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Allam AK, Anand A, Flores AR, Ropper AE. Computer Vision in Osteoporotic Vertebral Fracture Risk Prediction: A Systematic Review. Neurospine 2023; 20:1112-1123. [PMID: 38171281 PMCID: PMC10762393 DOI: 10.14245/ns.2347022.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/03/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Osteoporotic vertebral fractures (OVFs) are a significant health concern linked to increased morbidity, mortality, and diminished quality of life. Traditional OVF risk assessment tools like bone mineral density (BMD) only capture a fraction of the risk profile. Artificial intelligence, specifically computer vision, has revolutionized other fields of medicine through analysis of videos, histopathology slides and radiological scans. In this review, we provide an overview of computer vision algorithms and current computer vision models used in predicting OVF risk. We highlight the clinical applications, future directions and limitations of computer vision in OVF risk prediction.
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Affiliation(s)
- Anthony K. Allam
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Adrish Anand
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Alex R. Flores
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
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Ropper AE. Commentary on "Mini-Open Intercostal Retroperitoneal Approach for Upper Lumbar Spine Lateral Interbody Fusion". Neurospine 2023; 20:564-566. [PMID: 37401074 PMCID: PMC10323337 DOI: 10.14245/ns.2346594.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
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Anand A, Flores AR, McDonald MF, Gadot R, Xu DS, Ropper AE. A computer vision approach to identifying the manufacturer of posterior thoracolumbar instrumentation systems. J Neurosurg Spine 2022; 38:417-424. [PMID: 36681945 DOI: 10.3171/2022.11.spine221009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/17/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Knowledge of the manufacturer of the previously implanted pedicle screw systems prior to revision spinal surgery may facilitate faster and safer surgery. Often, this information is unavailable because patients are referred by other centers or because of missing information in the patients' records. Recently, machine learning and computer vision have gained wider use in clinical applications. The authors propose a computer vision approach to classify posterior thoracolumbar instrumentation systems. METHODS Lateral and anteroposterior (AP) radiographs obtained in patients undergoing posterior thoracolumbar pedicle screw implantation for any indication at the authors' institution (2015-2021) were obtained. DICOM images were cropped to include both the pedicle screws and rods. Images were labeled with the manufacturer according to the operative record. Multiple feature detection methods were tested (SURF, MESR, and Minimum Eigenvalues); however, the bag-of-visual-words technique with KAZE feature detection was ultimately used to construct a computer vision support vector machine (SVM) classifier for lateral, AP, and fused lateral and AP images. Accuracy was tested using an 80%/20% training/testing pseudorandom split over 100 iterations. Using a reader study, the authors compared the model performance with the current practice of surgeons and manufacturer representatives identifying spinal hardware by visual inspection. RESULTS Among the three image types, 355 lateral, 379 AP, and 338 fused radiographs were obtained. The five pedicle screw implants included in this study were the Globus Medical Creo, Medtronic Solera, NuVasive Reline, Stryker Xia, and DePuy Expedium. When the two most common manufacturers used at the authors' institution were binarily classified (Globus Medical and Medtronic), the accuracy rates for lateral, AP, and fused images were 93.15% ± 4.06%, 88.98% ± 4.08%, and 91.08% ± 5.30%, respectively. Classification accuracy decreased by approximately 10% with each additional manufacturer added. The multilevel five-way classification accuracy rates for lateral, AP, and fused images were 64.27% ± 5.13%, 60.95% ± 5.52%, and 65.90% ± 5.14%, respectively. In the reader study, the model performed five-way classification on 100 test images with 79% accuracy in 14 seconds, compared with an average of 44% accuracy in 20 minutes for two surgeons and three manufacturer representatives. CONCLUSIONS The authors developed a KAZE feature detector with an SVM classifier that successfully identified posterior thoracolumbar hardware at five-level classification. The model performed more accurately and efficiently than the method currently used in clinical practice. The relative computational simplicity of this model, from input to output, may facilitate future prospective studies in the clinical setting.
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Affiliation(s)
- Adrish Anand
- 1Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Alex R Flores
- 1Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Malcolm F McDonald
- 1Department of Neurosurgery, Baylor College of Medicine, Houston.,2Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas; and
| | - Ron Gadot
- 1Department of Neurosurgery, Baylor College of Medicine, Houston
| | - David S Xu
- 3Department of Neurosurgery, The Ohio State University School of Medicine, Columbus, Ohio
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Prablek M, Gadot R, Xu DS, Ropper AE. Neck Pain. Neurol Clin 2022; 41:77-85. [DOI: 10.1016/j.ncl.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lazaro TT, Katlowitz KA, Karas PJ, Srinivasan VM, Walls E, Collier G, Raza SM, Curry DJ, Ropper AE, Fuentes A, Gopinath SP, Rao G, Patel AJ. The impact of a night float system on operative experience in neurosurgery residency. J Neurosurg 2022; 138:1117-1123. [PMID: 36087325 DOI: 10.3171/2022.4.jns212612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions in 2003, many residency programs have adopted a night float system to comply with time constraints. However, some surgical subspecialities have been concerned that use of a night float system deprives residents of operative experience. In this study, the authors describe their training program's transition to a night float system and its impact on resident operative experience. METHODS The authors conducted a single-program study of resident surgical case volume before and after implementing the night float system at 3 of their 5 hospitals from 2014 to 2020. The authors obtained surgical case numbers from the ACGME case log database. RESULTS Junior residents received a concentrated educational experience, whereas senior residents saw a significant decrease from 112 calls/year to 17. Logged cases significantly increased after implementation of the night float system (8846 vs 10,547, p = 0.04), whereas cases at non-night float hospitals remained the same. This increase was concurrent with an increase in hospital cases. This difference was mainly driven by senior resident cases (p = 0.010), as junior and chief residents did not show significant differences in logged cases (p > 0.40). Lead resident cases increased significantly after implementation of the night float system (6852 vs 8860, p = 0.04). When normalized for increased hospital cases, resident case increases were not statistically significant. CONCLUSIONS Transitioning to a night float call system at the authors' institution increased overall resident operative cases, particularly for lead resident surgeons. Based on the results of this study, the authors recommend the use of a night float call system to consolidate night calls, which increases junior resident-level educational opportunities and senior resident cases.
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Affiliation(s)
- Tyler T Lazaro
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Patrick J Karas
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas
| | - Visish M Srinivasan
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Gina Collier
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Shaan M Raza
- 5University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel J Curry
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Alfonso Fuentes
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Ganesh Rao
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Akash J Patel
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,6Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas; and.,7Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
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Gadot R, Smith DN, Prablek M, Grochmal JK, Fuentes A, Ropper AE. Established and Emerging Therapies in Acute Spinal Cord Injury. Neurospine 2022; 19:283-296. [PMID: 35793931 PMCID: PMC9260540 DOI: 10.14245/ns.2244176.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/05/2022] [Indexed: 12/11/2022] Open
Abstract
Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.
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Affiliation(s)
- Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - David N. Smith
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Marc Prablek
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Joey K. Grochmal
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Alfonso Fuentes
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Alexander E. Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Corresponding Author Alexander E. Ropper Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St. Suite 9A, Houston, TX, USA
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Gadot R, Anand A, Verla T, Muir M, Winocour SJ, Reece EM, Ropper AE. Complex Wound Closure in Adult Spinal Deformity Surgery Reduces Complications in High-Risk Patients. World Neurosurg 2022; 162:e561-e567. [PMID: 35331948 DOI: 10.1016/j.wneu.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adult spinal deformity (ASD) surgery is becoming increasingly prevalent. Soft tissue defects arising from revision closure and impaired healing can predispose to wound complications including dehiscence and infection. Soft tissue coverage with local muscle flaps has been shown to minimize wound complications in high-risk patients. In this study we evaluate the role of complex wound closure in preventing wound complications in high-risk spinal deformity patients. METHODS The authors retrospectively reviewed charts of patients who underwent ASD surgery. Patients were stratified into muscle flap advancement (by neurosurgery or plastic surgery) closure versus primary approximation by neurosurgery. Relevant patient and operative factors were collected and summarized using descriptive statistics. Outcomes of interest included wound complication and revision surgery. RESULTS Ninety-four cases met inclusion criteria including 56 wounds closed by neurosurgery and 38 wounds closed by plastic surgery (PRS). Of the neurosurgery wounds, 31 and 25 were closed by primary approximation and muscular flap advancement, respectively. Patients operated on by PRS were higher risk than all patients operated on only by neurosurgery (P = 0.0037) but were not significantly higher risk than the neurosurgery performed flap cohort (P = 0.4914). In subgroup analysis, despite similar levels of risk, the PRS population experienced lower rates of any wound complication (P = 0.028) and specifically dehiscence (P = 0.029) compared with the neurosurgery performed flap closure cohort. CONCLUSIONS Prophylactic involvement of plastic surgery in ASD surgery wound closure may improve wound outcomes in higher risk patients. A multidisciplinary approach with plastic and spine surgeons may lessen the risk of wound complications in high-risk spine surgeries.
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Affiliation(s)
- Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adrish Anand
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Matthew Muir
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian J Winocour
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA; Divsion of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Edward M Reece
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA; Divsion of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA; Divsion of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
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Verla T, Huang AT, Sandulache VC, Ropper AE. Combined anterior cervical spine fusion and total laryngopharyngectomy with free flap reconstruction: A technical note. Interdisciplinary Neurosurgery 2021. [DOI: 10.1016/j.inat.2021.101238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Gadot R, Gopakumar S, Wagner K, Xu DS, Raper DMS, Burkhardt JK, Ropper AE. Foramen Magnum Dural Arteriovenous Fistula Presenting With Thoracic Myelopathy: Technical Case Report With 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E55-E59. [PMID: 33825904 DOI: 10.1093/ons/opab077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Dural arteriovenous fistulas (dAVFs) are vascular abnormalities of the central nervous system that can cause a wide array of neurological dysfunction depending on their location, flow, and propensity to rupture. Symptomatic dAVFs at the cranio-cervical junction usually result in hemorrhage or cervical myelopathy. Distantly located dAVFs of the foramen magnum are a rare cause of thoracic intrinsic myelopathy. CLINICAL PRESENTATION An 83-yr-old man presented with progressive lower extremity weakness, numbness, and difficulty walking along with episodes of bowel incontinence. Magnetic resonance imaging of the cervical spine demonstrated multilevel cervical disc disease with stenosis and longitudinal cervical cord signal change extending into the upper thoracic spinal cord. Cerebral and spinal angiography revealed a dAVF in the lateral foramen magnum region. Given the location, feeding vasculature, and morphology of the fistula, endovascular embolization was not attempted. Microsurgical resection with confirmative indocyanine green fluorescent imaging was performed with adequate obliteration of the fistula. The patient's neurological baseline was preserved postoperatively with improvement of lower extremity numbness. CONCLUSION We present a brief overview of this neuropathologic entity and demonstrate microsurgical resection of a foramen magnum dAVF through operative video. Craniocervical dAVFs should remain on the differential diagnosis of patients presenting with progressive thoracolumbar myelopathy.
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Verla T, Vedantam A, North RY, Xu DS, Raber MR, Fuentes A, Liou NE, Ropper AE. Surgical Management of Post-Radiation, Dropped Head Spinal Deformity in Head and Neck Cancer Patients. World Neurosurg 2021; 156:e1-e8. [PMID: 34245881 DOI: 10.1016/j.wneu.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dropped head syndrome is a morbid condition, which affects daily functionality, causing pain and dysphagia and respiratory compromise. Reported causes of dropped head syndrome include neuromuscular disorders, iatrogenic from cervical spine surgery, idiopathic and post-radiation for head and neck cancers. Management of this spinal disorder remains challenging, as the complication rates are high. We present our series of 7 patients who underwent surgical correction of dropped head syndrome, all resulting from radiation for head and neck cancers. METHODS Retrospective review of 7 patients who underwent surgery between 2016 and 2019 for dropped head syndrome secondary to post-radiation cervical spine deformity. Clinical variables were obtained from medical records. Radiographic parameters pre- and post-surgery including T1 slope, sagittal vertical axis, and C2-7 cervical lordosis were examined. RESULTS Seven patients were included in the study, with an average age 69 years. Two patients underwent traction pre-operatively. Five patients had posterior fixation and fusion only and two patients had a combined anterior and posterior fixation and fusion. Overall, there was improvement in average pre/post-op SVA (6.96cm to 3.04cm), T1 slope (33.61o to 24.34o) and C2-7 lordosis (-21.65o to -0.03o). CONCLUSION Surgical correction of post-radiation dropped head spinal deformity involving anterior and posterior fixation with osteotomies provides improvement in functional and radiographic outcomes as shown in our series. These cases are technically challenging and have a high rate of peri-operative complications. Approaches must be tailored to the patient with attention to their specific surgical and radiation history.
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Affiliation(s)
- Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA.
| | - Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Robert Y North
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Michael R Raber
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Alfonso Fuentes
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Nelson Eddie Liou
- Bobby R. Alford Department of Otolaryngology, Baylor College of Medicine, 1977 Butler Blvd. Suite E5.200. Houston, TX 77030
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
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Bohl MA, Reece EM, Farrokhi F, Davis MJ, Abu-Ghname A, Ropper AE. Vascularized Bone Grafts for Spinal Fusion-Part 3: The Occiput. Oper Neurosurg (Hagerstown) 2021; 20:502-507. [PMID: 33609121 DOI: 10.1093/ons/opab036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/21/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Obtaining successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. This challenge stems from the relatively hypermobile joints between the occipital condyles, the motion that occurs at C1 and C2, as well as the paucity of dorsal bony surfaces for posterior arthrodesis. While multiple different techniques for spinal fixation in this region have been well described, there has been little investigation into auxiliary methods to improve fusion rates. OBJECTIVE To describe the use of an occipital bone graft to augment bony arthrodesis in the supraaxial cervical spine using a multidisciplinary approach. METHODS We review the technique for harvesting and placing a vascularized occipital bone graft in 2 patients undergoing revision surgery at the craniocervical junction. RESULTS The differentiation from nonvascularized bone graft, either allograft or autograft, to a bone graft using vascularized tissue is a key principle of this technique. It has been well established that vascularized bone heals and fuses in the spine better than structural autogenous grafts. However, the morbidity and added operative time of harvesting a vascularized flap, such as from the fibula or rib, precludes its utility in most degenerative spine surgeries. CONCLUSION By adapting the standard neurosurgical procedure for a suboccipital craniectomy and utilizing the tenets of flap-based reconstructive surgery to maintain the periosteal and muscular blood supply, we describe the feasibility of using a vascularized and pedicled occipital bone graft to augment instrumented upper cervical spinal fusion. The use of this vascularized bone graft may increase fusion rates in complex spine surgeries.
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Affiliation(s)
- Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Farrokh Farrokhi
- Department of Neurosurgery, Virginia Mason Hospital, Seattle, Washington, USA
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Reece EM, Agrawal N, Wagner KM, Davis MJ, Abu-Ghname A, Shekher R, Raber MR, Winocour S, Bohl MA, Ropper AE. Vascularized Bone Grafts for Spinal Fusion-Part 2: The Rib. Oper Neurosurg (Hagerstown) 2021; 20:497-501. [PMID: 33609128 DOI: 10.1093/ons/opab035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/16/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pseudoarthrosis, or failure to achieve bony union, is a well-known complication of spinal fusion operations. Rates range from 5% to 40% and are influenced by both patient and technical factors. Patients who do not achieve complete fusion may experience a return or worsening of their preoperative pain. For patients with complicated pathologies, vascularized bone grafts (VBGs) have been shown to provide better outcomes than nonvascularized bone grafts (N-VBGs). OBJECTIVE To enhance an instrumented spinal fusion by the innovative technique presented herein that utilizes a rotated, pedicled VBG from the left eighth rib under the paraspinous musculature into the midlumbar posterolateral gutter. METHODS For posterior approaches, the rib can be easily accessed and rotated into the appropriate strut position. The rib is dissected out, identifying and preserving the neurovascular bundle medially. The rib is then tunneled medially and appropriately positioned as the spinal graft, with the curve providing anatomic kyphosis or lordosis, depending on the surgical location. It is then successfully fixated with plates and spinal screws. RESULTS In our limited experience to date, vascularized rib grafting procedures augment fusion and reduce operating room time and bleeding compared to free flap procedures. No patients have experienced complications related to these grafts. CONCLUSION Pedicled vascularized rib grafts can be utilized to provide the advantages of a vascularized bone flap in complicated pathologies requiring spinal fusion as far as the L2-L3 level, without the morbidity associated with free tissue transfer.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Nikhil Agrawal
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Kathryn M Wagner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Rohil Shekher
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Michael R Raber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Reece EM, Davis MJ, Abu-Ghname A, Chamata E, Holmes S, Winocour S, Hansen SL, Xu DS, Bohl MA, Ropper AE. Vascularized Bone Grafts for Spinal Fusion-Part 4: The Scapula. Oper Neurosurg (Hagerstown) 2021; 20:508-512. [PMID: 33616164 DOI: 10.1093/ons/opab034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/09/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Solid arthrodesis is the long-term goal of most spinal reconstruction surgeries. A multitube of biologics as well as autograft is commonly used to augment the bony fusion. Medial scapular vascularized bone grafts (S-VBGs) are a novel approach to supplement cervicothoracic arthrodesis in patients at high risk for failed fusion. OBJECTIVE To discuss the benefits of using a vascularized scapular graft, pedicled to the rhomboid minor, compared to both nonvascularized bone grafts and free vascularized bone grafts, as well as the surgical technique, feasibility, and nuances of the surgical experience with an S-VBG. METHODS The anatomic feasibility of this procedure has been established in cadaver studies. This technical note details the operative steps and presents the first surgery in which a vascularized scapular graft was used to supplement cervicothoracic arthrodesis. RESULTS A single patient with complex cervical deformity was successfully treated with this novel arthrodesis approach. CONCLUSION Vascularized scapula grafts, pedicled on the rhomboid minor, provides both structural support and a source of vascularized autograft to a cervicothoracic arthrodesis. It leverages the benefits of a free-flap bone with less operative time and morbidity.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Edward Chamata
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Scott Holmes
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Scott L Hansen
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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14
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Reece EM, Davis MJ, Wagner RD, Abu-Ghname A, Cruz A, Kaung G, Verla T, Winocour S, Ropper AE. Vascularized Bone Grafts for Spinal Fusion-Part 1: The Iliac Crest. Oper Neurosurg (Hagerstown) 2021; 20:493-496. [PMID: 33616183 DOI: 10.1093/ons/opab037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Iliac crest autograft has been the gold standard for harvest of fusion materials in spine surgery. The benefits of a vascularized version of this bone graft-including delivery of stem cells, ability to deliver antibiotics to the fusion bed, and relative ease of harvest-make this technique superior to free bone transfer in the achievement of augmented spinal fusion. OBJECTIVE To present a brief summary of similar existing concepts before describing the novel technique of this vascularized posterior iliac crest bone graft. METHODS Vascularized posterior iliac crest bone graft can be harvested from the same midline lumbar incision used for thoracolumbar spinal fusion, through lateral dissection around the paraspinals to the iliac crest. Recipient sites in the posterolateral bony spinal gutters may be as rostral as T12 and caudal as the sacrum. The ability to cover multiple lumbar levels can be achieved with desired lengths of the donor iliac crest. RESULTS Over 14 vascularized iliac crest bone grafts have been performed to augment lumbar fusion for salvage after pseudoarthrosis. Operative time and bleeding are reduced compared to free flap procedures, and no patients have experienced any complications related to these grafts. Indocyanine green (ICG) angiography has been utilized in a novel way to ensure the vascularity of the bone graft prior to arthrodesis. CONCLUSION While long-term follow-up will be required to fully characterize fusion rates and patient morbidity, this innovative surgical option augments spinal fusion in patients with, or at increased risk for, pseudoarthrosis.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Ryan D Wagner
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alex Cruz
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Geoffrey Kaung
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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15
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Prablek M, McGinnis J, Winocour SJ, Reece EM, Kakarla UK, Raber M, Ropper AE, Xu DS. Failures in Thoracic Spinal Fusions and Their Management. Semin Plast Surg 2021; 35:20-24. [PMID: 33994874 DOI: 10.1055/s-0041-1723832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Instrumented fixation and fusion of the thoracic spine present distinct challenges and complications including pseudarthrosis and junctional kyphosis. When complications arise, morbidity to the patient can be significant, involving neurologic injury, failure of instrumentation constructs, as well as iatrogenic spinal deformity. Causes of fusion failure are multifactorial, and incompletely understood. Most likely, a diverse set of biomechanical and biologic factors are at the heart of failures. Revision surgery for thoracic fusion failures is complex and often requires revision or extension of instrumentation, and frequently necessitates complex soft tissue manipulation to manage index level injury or to augment the changes of fusion.
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Affiliation(s)
- Marc Prablek
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - John McGinnis
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Department of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Department of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Udaya K Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael Raber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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16
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Verla T, Xu DS, Davis MJ, Reece EM, Kelly M, Nunez M, Winocour SJ, Ropper AE. Failure in Cervical Spinal Fusion and Current Management Modalities. Semin Plast Surg 2021; 35:10-13. [PMID: 33994872 DOI: 10.1055/s-0041-1722853] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Failed fusion in the cervical spine is a multifactorial problem stemming from a combination of patient and surgical factors. Patient-related risk factors such as steroid use, poor bone quality, and smoking can be optimized preoperatively. Age, prior radiation, prior surgery, and underlying genetics are nonmodifiable patient-centered risk factors. Surgical risks for failed fusion include the number of segments fused, anterior versus posterior approach for fusion, the type of bone graft, and the instrumentation utilized. Many symptomatic cases of failed fusion (pseudarthrosis) result in pain, neurological deficits, or loosened hardware necessitating a revision surgery consisting of extending the prior construct and utilizing additional allografts or autografts to augment the fusion. Given the relatively mobile nature of the cervical spine, pseudoarthrosis (either known or anticipated) must be recognized by the spine surgeon, and steps should be considered to optimize the likelihood of future fusion. This consists of both performing a rigid fixation and using appropriate bone graft to enhance the environment for arthrodesis. Vascularized bone grafts are a useful tool to augment fusion and provide added structural stability in cases at high risk of pseudoarthrosis.
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Affiliation(s)
- Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michelle Kelly
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Mervin Nunez
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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17
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Winocour SJ, Agrawal N, Wagner KM, Davis MJ, Abu-Ghname A, Shekher R, Raber MR, Bohl MA, Ropper AE, Reece EM. Vascularized Rib Bone Grafting: Indications, Techniques, and Clinical Outcomes. Semin Plast Surg 2021; 35:31-36. [PMID: 33994876 DOI: 10.1055/s-0041-1725985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pseudarthrosis is a difficult complication often seen in patients with complex spinal pathology. To supplement existing neurosurgical approaches to cervicothoracic spinal instrumentation and fusion, novel vascularized rib bone grafts can be utilized in patients at high risk for failed spinal fusion. In this article, we discuss the indications, benefits, surgical technique, feasibility, and limitations of using rib vascularized rib bone grafts to augment spinal fusion.
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Affiliation(s)
- Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nikhil Agrawal
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kathryn M Wagner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Rohil Shekher
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michael R Raber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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18
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Winocour SJ, Xue EY, Bohl MA, Farrokhi F, Davis MJ, Abu-Ghname A, Ropper AE, Reece EM. Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives. Semin Plast Surg 2021; 35:14-19. [PMID: 33994873 DOI: 10.1055/s-0041-1723834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. Different techniques for spinal fixation in this region have been well described, along with auxiliary methods to improve fusion rates. The occipital vascularized bone graft is a novel technique that can be used to augment bony arthrodesis in the supra-axial cervical spine. It provides the benefits of a vascularized autologous graft, such as accelerated healing, earlier fusion, and increased strength. This technique can be learned with relative ease and may be particularly helpful in cases with high risk of nonunion or pseudoarthrosis in the upper cervical spine.
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Affiliation(s)
- Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Erica Y Xue
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Farrokh Farrokhi
- Department of Neurosurgery, Virginia Mason Hospital, Seattle, Washington
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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19
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Reece EM, O'Neill RC, Davis MJ, Abu-Ghname A, Ropper AE, Bohl M, Xu DS, Winocour SJ. Vascularized Scapular Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives. Semin Plast Surg 2021; 35:25-30. [PMID: 33994875 DOI: 10.1055/s-0041-1723833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Spinal fusion can be challenging to obtain in patients with complex spinal pathology. Medial scapular vascularized bone grafts (S-VBGs) are a novel approach to supplement cervicothoracic arthrodesis in patients at high risk of failed spinal fusion. In this article, we discuss the benefits of using VBGs compared with both nonvascularized bone grafts and free vascularized bone flaps and the surgical technique, feasibility, and limitations specific to the S-VBG.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Rebecca C O'Neill
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Michael Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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20
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Do A, Davis MJ, Abu-Ghname A, Winocour SJ, Reece EM, Holmes S, Xu DS, Ropper AE, Hansen SL. The Historical Role of the Plastic Surgeon in Spine Reconstruction. Semin Plast Surg 2021; 35:3-9. [PMID: 33994871 DOI: 10.1055/s-0041-1722852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Wound complications occur in up to 19% of patients undergoing complex spine surgery. The role of the plastic surgeon in complex and redo spine surgery is important and evolving. Classically, plastic surgeons have been involved in the management of patients who develop wound complications following surgery. This involves reconstruction of posterior trunk defects with locoregional fasciocutaneous, muscle, and free tissue transfers. There has also been an increasing role for plastic surgeons to become involved in prophylactic closures of complex and/or redo spine surgeries for high-risk populations. Identification of patients with comorbidities and likelihood for multiple reoperations who are prophylactically treated with complex closure with or without local muscle flaps could significantly decrease the postoperative wound complications.
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Affiliation(s)
- Annie Do
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, California
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Scott Holmes
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Scott L Hansen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, California
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21
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Winocour SJ, Schultz KP, Davis MJ, Abu-Ghname A, Bohl M, Ropper AE, Maricevich M, Reece EM. Vascularized Posterior Iliac Crest Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives. Semin Plast Surg 2021; 35:37-40. [PMID: 33994877 DOI: 10.1055/s-0041-1725986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pseudarthrosis is a feared complication of spinal fusion procedures. Currently, the gold standard in prevention or treatment of pseudarthrosis is placement of nonvascularized iliac crest bone autograft. While rates of fusion are significantly higher in patients with use of nonvascularized bone autografts than with allografts, patients who have previously failed lumbar arthrodesis or those at a high risk for pseudarthrosis may benefit from a more robust, vascularized bone graft with enhanced osteogenicity. In this article, we discuss the use of iliac crest vascularized bone grafts as an adjunct for high-risk patients undergoing lumbosacral spine arthrodesis.
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Affiliation(s)
- Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kelly P Schultz
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Michael Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Marco Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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22
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Skochdopole AJ, Wagner RD, Davis MJ, Raj S, Winocour SJ, Ropper AE, Xu DS, Bohl MA, Reece EM. Vascularized Bone Grafts in Spinal Reconstruction: An Overview of Nomenclature and Indications. Semin Plast Surg 2021; 35:50-53. [PMID: 33994879 DOI: 10.1055/s-0041-1726101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Several vascularized bone grafts (VBGs) have been introduced for reconstruction and augmenting fusion of the spine. The expanding use of VBGs in the field of spinoplastic reconstruction, however, has highlighted the need to clarify the nomenclature for bony reconstruction as well as establish the position of VBGs on the bony reconstructive algorithm. In the current literature, the terms "flap" and "graft" are often applied inconsistently when describing vascularized bone transfer. Such inconsistency creates barriers in communication between physicians, confusion in interpreting the existing studies, and difficulty in comparing surgical techniques. VBGs are defined as bone segments transferred on their corresponding muscular attachments without a named major feeding vessel. The bone is directly vascularized by the muscle attachments and unnamed periosteal feeding vessels. VBGs are best positioned as a separate entity in the bony reconstruction algorithm between nonvascularized bone grafts (N-VBGs) and bone flaps. VBGs offer numerous advantages as they supply fully vascularized bone to the recipient site without the microsurgical techniques or pedicle dissection required for raising bone flaps. Multiple VBGs have been introduced in recent years to optimize these benefits for spinoplastic reconstruction.
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Affiliation(s)
- Anna J Skochdopole
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Ryan D Wagner
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Sarth Raj
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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23
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Cruz A, Ropper AE, Xu DS, Bohl M, Reece EM, Winocour SJ, Buchanan E, Kaung G. Failure in Lumbar Spinal Fusion and Current Management Modalities. Semin Plast Surg 2021; 35:54-62. [PMID: 33994880 DOI: 10.1055/s-0041-1726102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Lumbar spinal fusion is a commonly performed procedure to stabilize the spine, and the frequency with which this operation is performed is increasing. Multiple factors are involved in achieving successful arthrodesis. Systemic factors include patient medical comorbidities-such as rheumatoid arthritis and osteoporosis-and smoking status. Surgical site factors include choice of bone graft material, number of fusion levels, location of fusion bed, adequate preparation of fusion site, and biomechanical properties of the fusion construct. Rates of successful fusion can vary from 65 to 100%, depending on the aforementioned factors. Diagnosis of pseudoarthrosis is confirmed by imaging studies, often a combination of static and dynamic radiographs and computed tomography. Once pseudoarthrosis is identified, patient factors should be optimized whenever possible and a surgical plan implemented to provide the best chance of successful revision arthrodesis with the least amount of surgical risk.
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Affiliation(s)
- Alex Cruz
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | | | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Edward M Reece
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Geoffrey Kaung
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
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24
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Verla T, Simpson V, Ropper AE. Solitary Fibrous tumor of the lumbar spine mimicking a sequestered disc fragment. Radiol Case Rep 2020; 16:472-475. [PMID: 33363685 PMCID: PMC7753083 DOI: 10.1016/j.radcr.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022] Open
Abstract
Solitary fibrous tumor in the lumbar spine is a rare pathology with non-specific radiographic features, sometimes resulting in misdiagnosis. Our patient was a 41-year old female who presented with low back pain and bilateral leg pain. Initial MRI showed a lesion misdiagnosed for a sequestered disc at the mid L4-5 level, which was subsequently characterized appropriately and treated surgically, with resolution of symptoms. Pathologic diagnosis was most consistent with a solitary fibrous tumor due to STAT 6 and CD 34 reactivity. Long-term follow up is recommended in these patients to monitor tumor recurrence and evidence of metastasis.
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Affiliation(s)
- Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Venita Simpson
- Naval Medical Center Portsmouth. 620 John Paul Jones Circle, Portsmouth VA 23707
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
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25
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Ravindra VM, Mazur MD, Brockmeyer DL, Kraus KL, Ropper AE, Hanson DS, Dahl BT. Clinical Effectiveness of S2-Alar Iliac Screws in Spinopelvic Fixation in Pediatric Neuromuscular Scoliosis: Systematic Literature Review. Global Spine J 2020; 10:1066-1074. [PMID: 32875851 PMCID: PMC7645097 DOI: 10.1177/2192568219899658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVES To comprehensively review the S2-alar iliac (S2-AI) screw technique for pelvic fixation in pediatric neuromuscular scoliosis. METHODS Articles identified from the PubMed and EMBASE databases were reviewed for relevance and applicability, and the studies were summarized. RESULTS Eight articles met the inclusion criteria. A total of 277 pediatric patients underwent spinopelvic fixation using S2-AI fixation for neuromuscular scoliosis; the mean follow-up was 3 years (range = 0.75-6 years). Six articles had level III evidence (5 retrospective cohort studies, 1 observational study), and 2 articles had level IV evidence (case series). Wound complications occurred in 34 (12.2%) patients. Instrumentation complications occurred in 36 patients (13.0%), including lucency around the screw (6.5%), screw fracture (3.6%), disengaging of the set/screw or rod from the tulip head (2.8%), and screw displacement (0.7%). Three patients (1.1%) required reoperation for instrumentation failures. The overall reoperation rate-including 3 hardware replacements and 3 cases of L5-S1 pseudarthrosis-was 2.1%. The mean Cobb angle correction was 51.4°, and the mean pelvic obliquity correction was 14.8°; deformity correction was maintained at 3- and 5-year follow-ups. There were 10 (3.6%) cases of implant prominence/implant-related pain, 1 case of sacroiliac joint pain (resolved with longer screw placement), and no major neurological or vascular complications secondary to S2-AI screw placement. CONCLUSIONS This review suggests that the use of S2-AI screws in pediatric neuromuscular scoliosis is efficacious with a reasonable safety profile and provides a useful technique for pelvic fixation in children with scoliosis.
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Affiliation(s)
- Vijay M. Ravindra
- University of Utah, Salt Lake City, UT, USA,Baylor College of Medicine, Houston, TX, USA,Vijay M. Ravindra, Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT 84132, USA.
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Affiliation(s)
- Alexander E. Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX. 77030, USA
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Verla T, North R, Simpson V, Ropper AE. Osteomyelitis-Discitis at the Thoracolumbar Junction and the Development of Postinfectious Spinal Deformity: A Surgical Case Series. Int J Spine Surg 2020; 14:552-558. [PMID: 32986577 DOI: 10.14444/7073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Progressive spinal deformity and neural compromise are the main indications for surgical management of vertebral osteomyelitis-discitis. However, when such pathology presents at the thoracolumbar (TL) junction, it remains unclear what the appropriate intervention is. The therapeutic dilemmas of decompression with or without instrumented fusion, the need for circumferential decompression and reconstruction, as well as the prognostic factors for progression of kyphosis, all remained ill-defined in the literature. The objective of this study is to evaluate risk factors for instrumentation at TL junction in spinal osteomyelitis-discitis. METHODS A review of patients at a single center with osteomyelitis-discitis at the TL junction between 2014 and 2018 was performed. Patients were 18 years or older with infectious pathologies at T10 to L2. RESULTS Sixteen patients were included. Indication for instrumentation included progression of kyphosis following prior laminectomy/medical management. Of the 16 patients, 4 patients received laminectomy at initial treatment versus 12 patients receiving medical management alone. All 4 patients receiving laminectomy experienced progressive kyphosis requiring revision with instrumented fusion versus only 4 of 12 of the medically managed. Laminectomy, epidural compression, and vertebral body collapse were significant risk factors for kyphosis progression requiring instrumentation. The average time to surgical intervention for the indication of progressive kyphosis was 2.6 months after prior laminectomy and 6 months after initiation of medical management. CONCLUSIONS Given the proclivity for kyphotic deformity at the TL junction, patients may benefit from long segment instrumentation in addition to decompression at the initial surgery. Laminectomy alone may hasten kyphosis progression.
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Affiliation(s)
- Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Robert North
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Venita Simpson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Gopakumar S, Daou M, Gadot R, Ropper AE, Mandel J. Spinal meningioma in a patient with multiple sclerosis. Surg Neurol Int 2020; 11:196. [PMID: 32754367 PMCID: PMC7395551 DOI: 10.25259/sni_221_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Multiple sclerosis (MS) is the most common immune-mediated inflammatory demyelinating disease of the central nervous system. Multiple brain and spinal tumors have been linked to MS, but a causal relationship between the two has not been determined. Here, we report a case of spinal meningioma in a patient with MS and review literature discussing the possible connection between these two disease entities. Case Description: A 58-year-old female with MS presented with a 1-year history of progressively worsening back pain in conjunction with worsening right upper and lower extremity weakness. The patient was diagnosed with MS 19 months prior and had multiple known demyelinating plaques in her cervical spine. New MRI revealed an intradural extramedullary thoracic tumor with characteristics consistent with meningioma. She underwent T6- T8 laminectomies for tumor resection and pathology confirmed the radiological diagnosis. At 3-month follow- up, the patient reported complete resolution of her back pain and persistence of weakness-related gait issues. Conclusion: CNS neoplasms including meningioma should be considered in MS patients presenting with newly onset neurological symptoms not entirely consistent with demyelinating disease. Both disease processes should be addressed with appropriate long-term follow-up.
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Affiliation(s)
| | - Marc Daou
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center
| | - Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine
| | | | - Jacob Mandel
- Department of Neurology, Baylor College of Medicine, Houston, Texas, United States
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Gopakumar S, Gadgil N, McDonald MF, Gadot R, Ropper AE. Neurenteric Cyst: Case Report and Operative Video. Cureus 2020; 12:e8714. [PMID: 32699709 PMCID: PMC7372244 DOI: 10.7759/cureus.8714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Neurenteric cysts are rare, congenital lesions of the spinal axis composed of endodermal tissue arising from poor segmentation of the notochord. A 36-year-old patient presented with arm paresthesias and incontinence with imaging revealing a lesion in the C6-C7 region most consistent with neurenteric cyst. After partial resection of the lesion, the patient regained all neurological function. Here, we provide a brief overview of this rare neuropathologic entity and demonstrate surgical resection of neurenteric cyst through operative video.
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Affiliation(s)
| | - Nisha Gadgil
- Neurological Surgery, Baylor College of Medicine, Houston, USA
| | | | - Ron Gadot
- Neurological Surgery, Baylor College of Medicine, Houston, USA
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North RY, Verla T, Bartlett E, Reece E, Weiner HL, Ropper AE. Giant Symptomatic Meningocele as a Delayed, Adult Complication of Lipomyelomeningocele. World Neurosurg 2019; 134:532-535. [PMID: 31760189 DOI: 10.1016/j.wneu.2019.11.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND An expanding cohort of patients with spina bifida live well into adulthood and pose complex management challenges due to unique combinations of adult health issues overlying congenital problems. CASE DESCRIPTION We present a case of a 45-year-old woman with an expanding, disfiguring, painful lumbar meningocele more than 40 years after her only surgery as a 3-year-old child. A team of pediatric and adult neurosurgeons as well as plastic/reconstructive surgeons successfully performed surgery to obliterate the meningocele, with preservation of her baseline functional status, and no evidence of recurrence after more than 1 year of follow-up. CONCLUSIONS Symptomatic meningocele may present in a long-delayed fashion in adult patients with a history of spina bifida. Surgical treatment may provide symptomatic benefit.
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Affiliation(s)
- Robert Y North
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
| | - Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Erica Bartlett
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Edward Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA; Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Han IB, Thakor DK, Ropper AE, Yu D, Wang L, Kabatas S, Zeng X, Kim SW, Zafonte RD, Teng YD. Physical impacts of PLGA scaffolding on hMSCs: Recovery neurobiology insight for implant design to treat spinal cord injury. Exp Neurol 2019; 320:112980. [DOI: 10.1016/j.expneurol.2019.112980] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/05/2019] [Accepted: 06/19/2019] [Indexed: 12/22/2022]
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Han IB, Choi UY, Shin DE, Ropper AE, Choi DS, Ahn TK. Symptomatic posterior fossa and supratentorial subdural hygromas as a rare complication following transarticular screw fixation with posterior wiring for atlantoaxial instability: A case report. Medicine (Baltimore) 2019; 98:e14847. [PMID: 31305388 PMCID: PMC6641781 DOI: 10.1097/md.0000000000014847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Atlantoaxial transarticular screw fixation has been an effective and appealing method for inducing fusion of the C1-C2 complex. This technique is usually performed with Gallie fusion. In performing Gallie fusion using sublaminar wiring, a major concern is the risk of dural tear associated with passing sublaminar wires through the epidural space. We present the first report on symptomatic symptomatic subdural hygroma (SDH) due to transarticular screw fixation with posterior wiring. PATIENTS CONCERNS A 50-year-old man had sustained dens fracture 20 years ago and presented with severe neck pain following a recent traffic accident. The images showed atlantoaxial instability due to nonunion of the dens fracture and the patient underwent transarticular screw fixation with posterior sublaminar wiring using Gallie technique. When the U-shaped wire was passed under the arch of C1 from inferior to superior, a dural tear and cerebrospinal fluid (CSF) leak occurred. The site of dural tear was repaired by direct application of sutures. The patient was discharged in good condition. Fifteen day after surgery, the patient was readmitted with a history of a progressive headache associated with vomiting and vertigo. DIAGNONSIS Brain CT and MRI showed bilateral posterior fossa and a right-sided supratentorial SDH. INTERVENTIONS The patient underwent right occipital burr hole and evacuation of posterior fossa SDH due to deteriorating neurological status. OUTCOMES The patient's condition gradually improved after the operation and became asymptomatic at 3-year follow-up. LESSONS Posterior fossa and supratentorial SDH could occur resulting from any intraoperative dural tear and CSF leakage during posterior cervical spinal surgery. Symptomatic SDH after posterior cervical spinal surgery should be cautiously assessed and treated. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- In-Bo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Un Yong Choi
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Dong-Eun Shin
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | | | - Dae-Sung Choi
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | - Tae-Keun Ahn
- Department of Neurosurgery, Baylor College of Medicine, TX
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Reece EM, Vedantam A, Lee S, Bhadkamkar M, Kaufman M, Bohl MA, Chang SW, Porter RW, Theodore N, Kakarla UK, Ropper AE. Pedicled, vascularized occipital bone graft to supplement atlantoaxial arthrodesis for the treatment of pseudoarthrosis. J Clin Neurosci 2019; 74:205-209. [PMID: 31036507 DOI: 10.1016/j.jocn.2019.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/10/2019] [Accepted: 04/12/2019] [Indexed: 12/01/2022]
Abstract
Atlantoaxial pseudoarthrosis is a challenging postoperative complication. The use of a local, vascularized bone graft, without free tissue transfer, to support a revision atlantoaxial fusion has not been previously described. We report the first surgical patient who received a semispinalis capitis muscle pedicled, occipital bone graft for supplementation of a revision atlantoaxial arthrodesis. A 72-year-old female had a failed atlantoaxial fusion and developed neck pain from continued instability and fractured hardware. The fixation and fusion were revised and supplemented with a novel, pedicled occipital bone graft. A craniectomy was performed in the occipital bone while still attached to the semispinalis capitis muscle to provide graft vascularity. This graft was rotated inferiorly from the skull base to the C1 arch and C2 spinous process in order to supplement a revision atlantoaxial arthrodesis. The patient had excellent clinical recovery over 18-month clinical follow up. The bone graft harvesting and rotation were performed safely and without complication. The 6-month postoperative CT scan showed partial fusion into the graft. This novel surgical technique leverages the advantages of vascularized structural autograft without adding extensive time or morbidity to the procedure as observed in free-tissue transfers. It is a safe and useful salvage technique to supplement revision atlantoaxial fusion surgeries.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sungho Lee
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Mohin Bhadkamkar
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew Kaufman
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Steve W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Randall W Porter
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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Karikari I, Ghogawala Z, Ropper AE, Yavin D, Gabr M, Goodwin CR, Abd-El-Barr M, Veeravagu A, Wang MC. Utility of Cervical Collars Following Cervical Fusion Surgery. Does It Improve Fusion Rates or Outcomes? A Systematic Review. World Neurosurg 2018; 124:S1878-8750(18)32889-4. [PMID: 30593959 DOI: 10.1016/j.wneu.2018.12.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The use of postoperative cervical collars following cervical fusions is common practice. Its use has been purported to improve fusion rates and outcomes. There is a paucity in the strength of evidence to support its clinical benefit. Our objective is to critically evaluate the published literature to determine the strength of evidence supporting the use of postoperative cervical collar use following cervical fusions. METHODS A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (also known as PRISMA) was performed. An online search using Medline and Cochrane Central Register of Controlled Trials databases was used to query prospective and retrospective clinical trials evaluating cervical fusions with or without postoperative collar. RESULTS The search identified 894 articles in Medline and 65 articles in the Cochrane database. From these articles, 130 were selected based on procedure and collar use. Only 3 studies directly compared between collar use and no collar use. Our analysis of the mean improvement in neck disability index scores and improvement over time intervals did not show a statistically significant difference between collar versus no collar (P = 0.86). CONCLUSIONS We found no strong evidence to support the use of cervical collars after 1- and 2-level anterior cervical discectomy and fusion procedures, and no studies comparing collar use and no collar use after posterior cervical fusions. Given the cost and likely impact of collar use on driving and the return to work, our study shows that currently there is no proven benefit to routine use of postoperative cervical collar in patients undergoing 1- and 2-level anterior cervical discectomy and fusion for degenerative cervical pathologies.
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Affiliation(s)
- Isaac Karikari
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
| | - Zoher Ghogawala
- Division of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Alexander E Ropper
- Division of Neurosurgery, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Daniel Yavin
- Division of Neurosurgery, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Mostafa Gabr
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - C Rory Goodwin
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Muhammad Abd-El-Barr
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Anand Veeravagu
- Division of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Marjorie C Wang
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Guest JD, Moore SW, Aimetti AA, Kutikov AB, Santamaria AJ, Hofstetter CP, Ropper AE, Theodore N, Ulich TR, Layer RT. Internal decompression of the acutely contused spinal cord: Differential effects of irrigation only versus biodegradable scaffold implantation. Biomaterials 2018; 185:284-300. [DOI: 10.1016/j.biomaterials.2018.09.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 09/04/2018] [Accepted: 09/16/2018] [Indexed: 12/13/2022]
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Sellin JN, Mayer RR, Hoffman M, Ropper AE. Simultaneous lateral interbody fusion and pedicle screws (SLIPS) with CT-guided navigation. Clin Neurol Neurosurg 2018; 175:91-97. [DOI: 10.1016/j.clineuro.2018.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 11/26/2022]
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Ropper AE, Huang KT, Ho AL, Wong JM, Nalbach SV, Chi JH. Intraoperative Cerebrospinal Fluid Leak in Extradural Spinal Tumor Surgery. Neurospine 2018; 15:338-347. [PMID: 30531655 PMCID: PMC6347353 DOI: 10.14245/ns.1836042.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 08/28/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Patients with extradural spine tumors are at an increased risk for intraoperative cerebrospinal fluid (CSF) leaks and postoperative wound dehiscence due to radiotherapy and other comorbidities related to systemic cancer treatment. In this case series, we discuss our experience with the management of intraoperative durotomies and wound closure strategies for this complex surgical patient population. Methods We reviewed our recent single-center experience with spine surgery for primarily extradural tumors, with attention to intraoperative durotomy occurrence and postoperative wound-related complications.
Results A total of 105 patients underwent tumor resection and spinal reconstruction with instrumented fusion for a multitude of pathologies. Twelve of the 105 patients (11.4%) reviewed had intraoperative durotomies. Of these, 3 underwent reoperation for a delayed complication, including 1 epidural hematoma, 1 retained drain, and 1 wound infection. Of the 93 uncomplicated index operations, there were a total of 9 reoperations: 2 for epidural hematoma, 3 for wound infection, 2 for wound dehiscence, and 2 for recurrent primary disease. One patient was readmitted for a delayed spinal fluid leak. The average length of stay for patients with and without intraoperative durotomy was 7.3 and 5.9 days, respectively, with a nonsignificant trend for an increased length of stay in the durotomy cases (p=0.098).
Conclusion Surgery for extradural tumor resections can be complicated by CSF leaks due to the proximity of the tumor to the dura. When encountered, a variety of strategies may be employed to minimize subsequent morbidity.
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Affiliation(s)
- Alexander E Ropper
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin T Huang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Allen L Ho
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Judith M Wong
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen V Nalbach
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Beechar VB, Zinn PO, Heck KA, Fuller GN, Han I, Patel AJ, Ropper AE. Spinal Epidermoid Tumors: Case Report and Review of the Literature. Neurospine 2018; 15:117-122. [PMID: 29991240 PMCID: PMC6104727 DOI: 10.14245/ns.1836014.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/23/2018] [Indexed: 11/19/2022] Open
Abstract
Spinal epidermoid tumors are rare, benign tumors that are either acquired from trauma, surgery, or lumbar puncture or arise as congenital lesions, particularly spinal dysraphisms. We report a case of a massive spinal epidermoid tumor and review the literature with a focus on the surgical outcomes. A 71-year-old female patient presented after a fall with subsequent symptoms of severe back and hip pain, as well as loss of motor strength in the left leg. Her magnetic resonance imaging demonstrated a T2/short tau inversion recovery hyperintense mass extending from the level of the T10–11 disc caudally through S2. A biopsy was recommended to determine whether the tumor was radio- or chemo-sensitive. The patient underwent a L4 laminectomy and a pearly-white tumor was encountered, with a subsequent biopsy confirming it to be an epidermoid tumor. The following conclusions can be drawn from a review of the literature. Spinal epidermoid tumors are more common in women and tend to present in younger patients (median age of 23). The majority of patients had acquired lesions (46%). In terms of surgical outcomes for adherent tumors, gross total resection was found to provide optimal outcomes, with 90% of patients improving clinically after surgery.
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Affiliation(s)
- Vivek B Beechar
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Pascal O Zinn
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Kent A Heck
- Department of Pathology, Baylor College of Medicine, Houston, TX, USA
| | - Gregory N Fuller
- Department of Pathology, MD Anderson Cancer Center, Houston, TX, USA
| | - Inbo Han
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, Seongnam, Korea
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
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Ahn TK, Kim JO, Kumar H, Choi H, Jo MJ, Sohn S, Ropper AE, Kim NK, Han IB. Polymorphisms of miR-146a, miR-149, miR-196a2, and miR-499 are associated with osteoporotic vertebral compression fractures in Korean postmenopausal women. J Orthop Res 2018; 36:244-253. [PMID: 28741852 DOI: 10.1002/jor.23640] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/21/2017] [Indexed: 02/04/2023]
Abstract
Genetic factors have been shown to be a small but significant predictor for osteoporosis and osteoporotic fracture risk. We performed a case-control association study to determine the association between miR-146a, miR-149, miR-196a2, and miR-499 polymorphisms and osteoporotic vertebral compression fracture (OVCF) susceptibility. In total, 286 unrelated postmenopausal Korean women (57 with OVCFs, 55 with non-OVCFs, and 174 healthy controls) were recruited. All subjects underwent dual energy X-ray absorptiometry to determine BMD at the lumbar spine and femoral neck. We focused on four single nucleotide polymorphisms (SNPs) of pre-miRNA sequences including miR-146aC>G (rs2910164), miR-149T>C (rs2292832), miR-196a2T>C (rs11614913), and miR-499A>G (rs3746444). Genotype frequencies of these four SNPs were determined using polymerase chain reaction-restriction fragment length polymorphism analysis. The TT genotype of miR-149aT>C was less frequent in subjects with OVCFs, suggesting a protective effect against OVCF risk (Odds ratio [OR], 0.435; 95% confidence interval [CI], 0.22-0.85, p = 0.014), whereas the miR-146aCG/ miR-196a2TC combined genotype was more frequent in OVCF patients (OR, 5.163; 95%CI, 1.057-25.21, p = 0.043), suggesting an increase in OVCF risk. Additionally, combinations of miR-146a, -149, -196a2, and -449 showed a significant association with increased prevalence of OVCFs in postmenopausal women. In particular, the miR-146aG/-149T/-196a2C/-449G allele combination was significantly associated with an increased risk of OVCF (OR, 35.01; 95% CI, 1.919-638.6, p = 0.001). Our findings suggest that the TT genotype of miR-149aT>C may contribute to decreased susceptibility to OVCF in Korean postmenopausal women. Conversely, the miR-146aCG/ miR-196a2TC combined genotype and the miR-146aG/-149T/-196a2C/-449G allele combination may contribute to increased susceptibility to OVCF. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:244-253, 2018.
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Affiliation(s)
- Tae-Keun Ahn
- Department of Orthopedic Surgery, CHA University, CHA Bundang Medical Center, 59 Yaptapro, Seongnam-si, 13496, South Korea
| | - Jung-Oh Kim
- Department of Biomedical Science, College of Life Science, CHA University, 335 Pangyo-ro, Bundang-gu, Seongnam-si, 13488, Korea
| | - Hemant Kumar
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, 59 Yaptapro, Seongnam-si, 13496, South Korea
| | - Hyemi Choi
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, 59 Yaptapro, Seongnam-si, 13496, South Korea
| | - Min-Jae Jo
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, 59 Yaptapro, Seongnam-si, 13496, South Korea
| | - Seil Sohn
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, 59 Yaptapro, Seongnam-si, 13496, South Korea
| | | | - Nam-Keun Kim
- Department of Biomedical Science, College of Life Science, CHA University, 335 Pangyo-ro, Bundang-gu, Seongnam-si, 13488, Korea
| | - In-Bo Han
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, 59 Yaptapro, Seongnam-si, 13496, South Korea
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Neal MT, Hlubek RJ, Ropper AE, Kakarla UK. A novel duraplasty technique following fenestration of a massive lumbar arachnoid cyst in a patient with scoliosis: technical case report. J Neurosurg Spine 2017; 28:181-185. [PMID: 29219781 DOI: 10.3171/2017.6.spine17155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
When a dural defect is encountered during spine surgery, the dura mater must be reconstituted to minimize the occurrence of minor or major life-threatening sequelae. The neurosurgical literature lacks strategies for managing large dural defects encountered during surgery. The authors describe a 24-year-old man who developed cauda equina syndrome secondary to altered CSF flow in a large thoracolumbar arachnoid cyst. Surgical decompression and fenestration of the arachnoid cyst were performed, and the large dural defect was treated using a multilayer closure with collagen matrix, titanium mesh, and methylmethacrylate. At his 24-month postoperative follow-up, the patient had recovered full strength in his legs, and his sensory deficits and sexual dysfunction had resolved. His incision had healed well, and there were no signs of pseudomeningocele. He had no additional positional headaches. The defect was managed effectively with this technique. Although this technique is not a first-line strategy for dural closure in the spine, it can be considered in challenging cases when large dural defects are not amenable to traditional closure techniques.
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Kumar H, Ha DH, Lee EJ, Park JH, Shim JH, Ahn TK, Kim KT, Ropper AE, Sohn S, Kim CH, Thakor DK, Lee SH, Han IB. Safety and tolerability of intradiscal implantation of combined autologous adipose-derived mesenchymal stem cells and hyaluronic acid in patients with chronic discogenic low back pain: 1-year follow-up of a phase I study. Stem Cell Res Ther 2017; 8:262. [PMID: 29141662 PMCID: PMC5688755 DOI: 10.1186/s13287-017-0710-3] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/10/2017] [Accepted: 10/23/2017] [Indexed: 12/27/2022] Open
Abstract
Background Adipose tissue-derived mesenchymal stem cells (AT-MSCs) offer potential as a therapeutic option for chronic discogenic low back pain (LBP) because of their immunomodulatory functions and capacity for cartilage differentiation. The goal of this study was to assess the safety and tolerability of a single intradiscal implantation of combined AT-MSCs and hyaluronic acid (HA) derivative in patients with chronic discogenic LBP. Methods We performed a single-arm phase I clinical trial with a 12-month follow-up and enrolled 10 eligible chronic LBP patients. Chronic LBP had lasted for more than 3 months with a minimum intensity of 4/10 on a visual analogue scale (VAS) and disability level ≥ 30% on the Oswestry Disability Index (ODI). The 10 patients underwent a single intradiscal injection of combined HA derivative and AT-MSCs at a dose of 2 × 107 cells/disc (n = 5) or 4 × 107 cells/disc (n = 5). Safety and treatment outcomes were evaluated by assessing VAS, ODI, Short Form-36 (SF-36), and imaging (lumbar spine X-ray imaging and MRI) at regular intervals over 1 year. Results No patients were lost at any point during the 1-year clinical study. We observed no procedure or stem cell-related adverse events or serious adverse events during the 1-year follow-up period. VAS, ODI, and SF-36 scores significantly improved in both groups receiving both low (cases 2, 4, and 5) and high (cases 7, 8, and 9) cell doses, and did not differ significantly between the two groups. Among six patients who achieved significant improvement in VAS, ODI, and SF-36, three patients (cases 4, 8, and 9) were determined to have increased water content based on an increased apparent diffusion coefficient on diffusion MRI. Conclusions Combined implantation of AT-MSCs and HA derivative in chronic discogenic LBP is safe and tolerable. However, the efficacy of combined AT-MSCs and HA should be investigated in a randomized controlled trial in a larger population. Trial registration ClinicalTrials.gov NCT02338271. Registered 7 January 2015.
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Affiliation(s)
- Hemant Kumar
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Doo-Hoe Ha
- Department of Radiology, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Eun-Jong Lee
- CHA Biotec®, Seongnam-si, Gyeonggi-do, 13488, South Korea
| | - Jun Hee Park
- Department of Neurosurgery, Shim Jeong Hospital, Seoul, 151715, South Korea
| | - Jeong Hyun Shim
- Department of Neurosurgery, Shim Jeong Hospital, Seoul, 151715, South Korea
| | - Tae-Keun Ahn
- Department of Orthopedic Surgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, Kyungpook National University Hospital 130, Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Seil Sohn
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Chung-Hun Kim
- Department of Plastic and Reconstructive Surgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | | | - Soo-Hong Lee
- Department of Biomedical Science, CHA University, Seongnam-si, Gyeonggi-do, 13496, South Korea.
| | - In-Bo Han
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, South Korea.
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Theodore N, Hlubek R, Danielson J, Neff K, Vaickus L, Ulich TR, Ropper AE. First Human Implantation of a Bioresorbable Polymer Scaffold for Acute Traumatic Spinal Cord Injury: A Clinical Pilot Study for Safety and Feasibility. Neurosurgery 2017; 79:E305-12. [PMID: 27309344 DOI: 10.1227/neu.0000000000001283] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND IMPORTANCE A porous bioresorbable polymer scaffold has previously been tested in preclinical animal models of spinal cord contusion injury to promote appositional healing, spare white matter, decrease posttraumatic cysts, and normalize intraparenchymal tissue pressure. This is the first report of its human implantation in a spinal cord injury patient during a pilot study testing the safety and feasibility of this technique (ClinicalTrials.gov Identifier: NCT02138110). CLINICAL PRESENTATION A 25-year-old man had a T11-12 fracture dislocation sustained in a motocross accident that resulted in a T11 American Spinal Injury Association Impairment Scale (AIS) grade A traumatic spinal cord injury. He was treated with acute surgical decompression and spinal fixation with fusion, and enrolled in the spinal scaffold study. A 2 × 10 mm bioresorbable scaffold was placed in the spinal cord parenchyma at T12. The scaffold was implanted directly into the traumatic cavity within the spinal cord through a dorsal root entry zone myelotomy at the caudal extent of the contused area. By 3 months, his neurological examination improved to an L1 AIS grade C incomplete injury. At 6-month postoperative follow-up, there were no procedural complications or apparent safety issues related to the scaffold implantation. CONCLUSION Although longer-term follow-up and investigation are required, this case demonstrates that a polymer scaffold can be safely implanted into an acutely contused spinal cord. This is the first human surgical implantation, and future outcomes of other patients in this clinical trial will better elucidate the safety and possible efficacy profile of the scaffold. ABBREVIATIONS AIS, American Spinal Injury Association Impairment ScaleSCI, spinal cord injurytSCI, traumatic spinal cord injury.
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Affiliation(s)
- Nicholas Theodore
- *Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; ‡InVivo Therapeutics Corporation, Cambridge, Massachusetts; §akta Pharmaceutical Development, LLC, Boston, Massachusetts
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Beechar VB, Srinivasan VM, Reznik OE, Sen A, Klisch TJ, Ropper AE, Mandel JJ, Heck KA, Seipel TJ, Patel AJ. Intraventricular Cavernomas of the Third Ventricle: Report of 2 Cases and a Systematic Review of the Literature. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Affiliation(s)
- Alexander E Ropper
- From the Department of Neurosurgery, Baylor College of Medicine, Houston (A.E.R.)
| | - Allan H Ropper
- From the Department of Neurosurgery, Baylor College of Medicine, Houston (A.E.R.)
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Ropper AE, Thakor DK, Han I, Yu D, Zeng X, Anderson JE, Aljuboori Z, Kim SW, Wang H, Sidman RL, Zafonte RD, Teng YD. Defining recovery neurobiology of injured spinal cord by synthetic matrix-assisted hMSC implantation. Proc Natl Acad Sci U S A 2017; 114:E820-E829. [PMID: 28096400 PMCID: PMC5293074 DOI: 10.1073/pnas.1616340114] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Mesenchymal stromal stem cells (MSCs) isolated from adult tissues offer tangible potential for regenerative medicine, given their feasibility for autologous transplantation. MSC research shows encouraging results in experimental stroke, amyotrophic lateral sclerosis, and neurotrauma models. However, further translational progress has been hampered by poor MSC graft survival, jeopardizing cellular and molecular bases for neural repair in vivo. We have devised an adult human bone marrow MSC (hMSC) delivery formula by investigating molecular events involving hMSCs incorporated in a uniquely designed poly(lactic-co-glycolic) acid scaffold, a clinically safe polymer, following inflammatory exposures in a dorsal root ganglion organotypic coculture system. Also, in rat T9-T10 hemisection spinal cord injury (SCI), we demonstrated that the tailored scaffolding maintained hMSC stemness, engraftment, and led to robust motosensory improvement, neuropathic pain and tissue damage mitigation, and myelin preservation. The scaffolded nontransdifferentiated hMSCs exerted multimodal effects of neurotrophism, angiogenesis, neurogenesis, antiautoimmunity, and antiinflammation. Hindlimb locomotion was restored by reestablished integrity of submidbrain circuits of serotonergic reticulospinal innervation at lumbar levels, the propriospinal projection network, neuromuscular junction, and central pattern generator, providing a platform for investigating molecular events underlying the repair impact of nondifferentiated hMSCs. Our approach enabled investigation of recovery neurobiology components for injured adult mammalian spinal cord that are different from those involved in normal neural function. The uncovered neural circuits and their molecular and cellular targets offer a biological underpinning for development of clinical rehabilitation therapies to treat disabilities and complications of SCI.
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Affiliation(s)
- Alexander E Ropper
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Physical Medicine & Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Charlestown, MA 02129
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - Devang K Thakor
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Physical Medicine & Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Charlestown, MA 02129
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - InBo Han
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Physical Medicine & Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Charlestown, MA 02129
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - Dou Yu
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Physical Medicine & Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Charlestown, MA 02129
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - Xiang Zeng
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - Jamie E Anderson
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - Zaid Aljuboori
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
| | - Soo-Woo Kim
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130
| | - Hongjun Wang
- Biomedical Engineering, Chemistry, and Biological Sciences, Stevens Institute of Technology, Hoboken, NJ 07030
| | - Richard L Sidman
- Department of Neurology, Harvard Medical School/Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Ross D Zafonte
- Department of Physical Medicine & Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Charlestown, MA 02129
| | - Yang D Teng
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, MA 02130;
- Department of Physical Medicine & Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Charlestown, MA 02129
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, MA 02115
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Vasudeva VS, Ropper AE, Rodriguez S, Wu KC, Chi JH. Contralateral osteotomy of the pedicle and posterolateral elements for en bloc resection: a technique for oncological resection of posterolateral spinal tumors. J Neurosurg Spine 2016; 26:275-281. [PMID: 27791830 DOI: 10.3171/2016.8.spine16398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
En bloc resection of tumors involving the spinal column is technically challenging and is associated with high morbidity to the patient due to the proximity of critical neurological and vascular structures and the destabilizing nature of this surgery. Nevertheless, evidence has shown improved progression-free survival with en bloc resection for certain low-grade malignant and aggressive benign musculoskeletal tumors. To avoid the morbidity of en bloc spondylectomy in patients with tumors localized to the lateral and posterolateral spinal column, the authors have found that the goals of surgery can be accomplished through a contralateral osteotomy of the pedicle and posterolateral elements for en bloc resection (COPPER). They reviewed their series of 5 patients who underwent successful tumor removal through a COPPER approach. These patients were all found to harbor spinal column tumors involving the posterolateral elements that, based on pathology, would benefit from en bloc resection. Tumor pathology included chondrosarcoma, leiomyosarcoma, osteoblastoma, and liposarcoma. Resections were performed by completing ipsilateral facetectomies above and below the lesion and ipsilateral pedicle osteotomies from a contralateral approach following hemilaminectomy. By disarticulating the posterolateral elements while carefully protecting the thecal sac, the tumors were removed en bloc along with the affected lamina, pedicles, pars interarticularis, and spinous processes, allowing tumor-free margins. This technical report suggests that the COPPER approach is safe and effective for en bloc resection of tumors involving the posterolateral aspect of the spinal column with tumor-free margins and that it eliminates the need for anterior column reconstruction.
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Affiliation(s)
- Viren S Vasudeva
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Samuel Rodriguez
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California; and
| | - Kyle C Wu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Kumar H, Ropper AE, Lee SH, Han I. Propitious Therapeutic Modulators to Prevent Blood-Spinal Cord Barrier Disruption in Spinal Cord Injury. Mol Neurobiol 2016; 54:3578-3590. [PMID: 27194298 DOI: 10.1007/s12035-016-9910-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 05/03/2016] [Indexed: 01/09/2023]
Abstract
The blood-spinal cord barrier (BSCB) is a specialized protective barrier that regulates the movement of molecules between blood vessels and the spinal cord parenchyma. Analogous to the blood-brain barrier (BBB), the BSCB plays a crucial role in maintaining the homeostasis and internal environmental stability of the central nervous system (CNS). After spinal cord injury (SCI), BSCB disruption leads to inflammatory cell invasion such as neutrophils and macrophages, contributing to permanent neurological disability. In this review, we focus on the major proteins mediating the BSCB disruption or BSCB repair after SCI. This review is composed of three parts. Section 1. SCI and the BSCB of the review describes critical events involved in the pathophysiology of SCI and their correlation with BSCB integrity/disruption. Section 2. Major proteins involved in BSCB disruption in SCI focuses on the actions of matrix metalloproteinases (MMPs), tumor necrosis factor alpha (TNF-α), heme oxygenase-1 (HO-1), angiopoietins (Angs), bradykinin, nitric oxide (NO), and endothelins (ETs) in BSCB disruption and repair. Section 3. Therapeutic approaches discusses the major therapeutic compounds utilized to date for the prevention of BSCB disruption in animal model of SCI through modulation of several proteins.
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Affiliation(s)
- Hemant Kumar
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Soo-Hong Lee
- Department of Biomedical Science, CHA University, Seongnam-si, Gyeonggi-do, 13488, Republic of Korea.
| | - Inbo Han
- Department of Neurosurgery, CHA University, CHA Bundang Medical Center, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea.
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Ropper AE, Zeng X, Haragopal H, Anderson JE, Aljuboori Z, Han I, Abd-El-Barr M, Lee HJ, Sidman RL, Snyder EY, Viapiano MS, Kim SU, Chi JH, Teng YD. Targeted Treatment of Experimental Spinal Cord Glioma With Dual Gene-Engineered Human Neural Stem Cells. Neurosurgery 2015; 79:481-91. [DOI: 10.1227/neu.0000000000001174] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
There are currently no satisfactory treatments or experimental models showing autonomic dysfunction for intramedullary spinal cord gliomas (ISCG).
OBJECTIVE
To develop a rat model of ISCG and investigate whether genetically engineered human neural stem cells (F3.hNSCs) could be developed into effective therapies for ISCG.
METHODS
Immunodeficient/Rowett Nude rats received C6 implantation of G55 human glioblastoma cells (10K/each). F3.hNSCs engineered to express either cytosine deaminase gene only (i.e., F3.CD) or dual genes of CD and thymidine kinase (i.e., F3.CD-TK) converted benign 5-fluorocytosine and ganciclovir into oncolytic 5-fluorouracil and ganciclovir-triphosphate, respectively. ISCG rats received injection of F3.CD-TK, F3.CD, or F3.CD-TK debris near the tumor epicenter 7 days after G55 seeding, followed with 5-FC (500 mg/kg/5 mL) and ganciclovir administrations (25 mg/kg/1 mL/day × 5/each repeat, intraperitoneal injection). Per humane standards for animals, loss of weight-bearing stepping in the hindlimb was used to determine post-tumor survival. Also evaluated were autonomic functions and tumor growth rate in vivo.
RESULTS
ISCG rats with F3.CD-TK treatment survived significantly longer (37.5 ± 4.78 days) than those receiving F3.CD (21.5 ± 1.75 days) or F3.CD-TK debris (19.3 ± 0.85 days; n = 4/group; P <.05, median rank test), with significantly improved autonomic function and reduced tumor growth rate. F3.DC-TK cells migrated diffusively into ISCG clusters to mediate oncolytic effect.
CONCLUSION
Dual gene-engineered human neural stem cell regimen markedly prolonged survival in a rat model that emulates somatomotor and autonomic dysfunctions of human cervical ISCG. F3.CD-TK may provide a novel approach to treating clinical ISCG.
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Affiliation(s)
- Alexander E. Ropper
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Xiang Zeng
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Hariprakash Haragopal
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Jamie E. Anderson
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Zaid Aljuboori
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Inbo Han
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hong Jun Lee
- Medical Research Institute, Chung-Ang University College of Medicine, Seoul, Korea
| | - Richard L. Sidman
- Medical Research Institute, Chung-Ang University College of Medicine, Seoul, Korea
| | - Evan Y. Snyder
- Stem Cell Center, Sanford-Burnham Medical Research Institute, La Jolla, California
| | - Mariano S. Viapiano
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Seung U. Kim
- Medical Research Institute, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John H. Chi
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Yang D. Teng
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of SCI Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of PM&R, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
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Han I, Ropper AE, Konya D, Kabatas S, Toktas Z, Aljuboori Z, Zeng X, Chi JH, Zafonte R, Teng YD. Biological approaches to treating intervertebral disk degeneration: devising stem cell therapies. Cell Transplant 2015. [PMID: 26223943 DOI: 10.3727/096368915x688650] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intervertebral disk (IVD) degeneration is a common, chronic, and complex degeneration process that frequently leads to back pain and disability, resulting in a major public health issue. In this review we describe biological therapies under preclinical or clinical development with an emphasis on stem cell-based multimodal approaches that target prevention and treatment of IVD degeneration. Systematical review of the basic science and clinical literature was performed to summarize the current status of devising biological approaches to treating IVD degeneration. Since the exact mechanisms underlying IVD degeneration have not yet been fully elucidated and conservative managements appear to be mostly ineffective, current surgical treatment focuses on removal of the pathological disk tissues combined with spinal fusion. The treatment options, however, often produce insufficient efficacy and even serious complications. Therefore, there have been growing demands and endeavors for developing novel regenerative biology-guided strategies for repairing the IVD via delivery of exogenous growth factors, introduction of therapeutic genes, and transplantation of stem cells, or combinatorial therapies. Overall, the data suggest that when applied under a recovery neurobiology principle, multimodal regimens comprising ex vivo engineered stem cell-based disks hold a high potential promise for efficacious clinical translations.
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Affiliation(s)
- Inbo Han
- Department of Neurosurgery, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
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Abstract
OBJECT Moyamoya can cause cerebral ischemia and stroke in Down syndrome (DS) patients. In this study, the authors defined a surgically treated population of patients with DS and moyamoya and compared their clinical presentation, response to surgical treatment, and long-term prognosis with those of the general population of patients with moyamoya but without DS. METHODS This study was a retrospective review of a consecutive operative series of moyamoya patients with DS treated at Boston Children's Hospital from 1985 through 2012. RESULTS Thirty-two patients, average age 9.7 years (range 1.8-29.3 years), underwent surgery for moyamoya in association with DS. The majority presented with ischemic symptoms (87% stroke, 42% transient ischemic attacks). Twenty-four patients (75%) had congenital heart disease. Nineteen patients (59%) had bilateral moyamoya on presentation, and 13 presented with unilateral disease, of which 2 progressed to surgery on the opposite side at a later date. Patients were followed for a median of 7.5 years (1-20.2 years) after surgery, with no patients lost to follow-up. Follow-up arteriography demonstrated Matsushima Grade A collaterals in 29 of 39 (74%) hemispheres, Grade B in 5 (13%), and Grade C in 5 (13%). Complications included postoperative strokes in 2 patients, which occurred within 48 hours of surgery in both; one of these patients had arm weakness and the other confusion (both had recovered completely at follow-up). Seizures occurred in 5 patients perioperatively, including one who had a new seizure disorder related to hypocalcemia. CONCLUSIONS Moyamoya disease is a cause of stroke in patients with DS. Both the incidence of preoperative stroke (87% vs 67%) and the average age at diagnosis for children under age 21 (8.4 vs 6.5 years) were greater in patients with DS and moyamoya than in the general moyamoya surgical population, suggesting a possible delay in reaching a correct diagnosis of the cause of cerebral ischemia in the DS patient population. Pial synangiosis provided long-term protection from stroke in all patients treated.
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Affiliation(s)
| | | | | | - Richard L Robertson
- Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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