Fengliang Wu

Reconstruction of the Upper Cervical Spine Using a Personalized 3D-Printed Vertebral Body in an Adolescent With Ewing Sarcoma.

Study Design. Case report. Objective: To describe a three-dimensional (3D) printed axial vertebral body used in upper cervical spine reconstruction after a C2 Ewing sarcoma resection in an adolescent boy. Summary of Background Data. Ewing sarcoma is a malignant musculoskeletal neoplasm with a peak incidence in adolescents. Cervical spine as the primary site of the tumor has been related to a worse prognosis. Tumor resection is particularly challenging in the atlantoaxial region due to complexity of the anatomy, necessity for extensive resection according to oncological principles, and a lack of specialized implants for reconstruction. 3D printing refers to a process where 3D objects are created through successive layering of material under computer control. Although this technology potentially enables accurate fabrication of patient-specific orthopedic implants, literature on its utilization in this regard is rare. Methods. A 12-year-old boy with a C2 Ewing sarcoma underwent a staged spondylectomy. Wide resection of the posterior elements was first performed. Two weeks later, a high anterior retropharyngeal approach was taken to remove the remains of the C2 vertebra. A customized artificial vertebral body fabricated according to a computer model using titanium alloy powder was inserted to replace the defect between C1 and C3. The microstructure of the implant was optimized for better biomechanical stability and enhanced bone healing. Results. Patient had an uneventful recovery and began to ambulate on postoperative day 7. Adjuvant treatment commenced 3 weeks after the surgery. He was tumor-free at the 1-year follow-up. Computed tomography studies revealed evidence of implant osseointegration and no subsidence or displacement of the construct. Conclusion. This is a case example on the concept of personalized precision medicine in a surgical setting and demonstrates how 3D-printed, patient-specific implants may bring individualized solutions to rare problems wherein restoration of the specific anatomy of each patient is a key prognostic factor. Level of Evidence: 5

Different Approaches for Treating Multilevel Cervical Spondylotic Myelopathy: A Retrospective Study of 153 Cases from a Single Spinal Center.

Objective The optimal surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) remains controversial. This study compared the outcomes of three surgical approaches for MSCM treatment, focusing on the efficacy and safety of a combined approach. Methods This retrospective study included 153 consecutive MCSM patients (100 men, 53 women; mean age ± standard deviation, 55.7 ± 9.4 years) undergoing operations involving ≥3 intervertebral segments. The patients were divided into three groups according to surgical approach: anterior (n = 19), posterior (n = 76), and combined (n = 58). We assessed demographic variables, perioperative parameters, and clinical outcomes ≥12 months after surgery (20.5 ± 7.6 months), including Japanese Orthopaedic Association (JOA) score, improvement, recovery rate, and complications. Results The anterior group had the most favorable preoperative conditions, including the highest preoperative JOA score (12.95 ± 1.86, p = 0.046). In contrast, the combined group had the highest occupancy ratio (48.0% ± 11.6%, p = 0.002). All groups showed significant neurological improvement at final follow-ups, with JOA recovery rates of 59.7%, 54.6%, and 68.9% in the anterior, posterior, and combined groups, respectively (p = 0.163). After multivariable adjustments, the groups did not have significantly different clinical outcomes (postoperative JOA score, p = 0.424; improvement, p = 0.424; recovery rate, p = 0.080). Further, subgroup analyses of patients with occupancy ratios ≥50% showed similar functional outcomes following the posterior and combined approaches. Overall complication rates did not differ significantly among the three approaches (p = 0.600). Occupancy ratios did not have a significant negative influence on postoperative recovery following the posterior approach. Conclusions If applied appropriately, all three approaches are effective for treating MCSM. All three approaches had equivalent neurological outcomes, even in subgroups with high occupancy ratios. Further investigations of surgical approaches to MCSM are needed, particularly prospective multicenter studies with long-term follow-up.

An Approach to Primary Tumors of the Upper Cervical Spine With Spondylectomy Using a Combined Approach: Our Experience with 19 Cases

Study Design. A retrospective study. Objective. To examine the link between major complications, surgical techniques, and perioperative care in the intralesional spondylectomy of the upper cervical spine. Summary of Background Data. Spondylectomy has been demonstrated to prolong cancer-free survival in many patients with locally aggressive spinal tumors. However, the challenging nature of this surgical procedure and the potential for severe complications often limit its application in the upper cervical spine. Methods. Nineteen patients with primary upper cervical tumors were treated with spondylectomy from March 2005 to August 2009, using either the anterior-posterior or posterior-anterior approach. Anterior procedures were transmandibular, transoral, or high retropharyngeal. Anterior reconstructions were performed in plates with iliac crest strut grafts, plates with mesh cages, and Harms mesh cages alone. Occipitocervical fixation was performed with Halo-vest application for postoperative immobilization. Results. Vertebral artery injuries occurred unilaterally in 5 cases intraoperatively: 4 occurred in the anterior approach of anterior-posterior procedures. Fusion was achieved in 9 patients with intact internal instrumentation. Fusion with the anterior construct in a tilted position occurred in 3 patients, all of whom underwent anterior-posterior procedures with Halo-vest immobilization for less than 1 month. Nonunion occurred in 3 cases after the posterior-anterior procedure because of anterior bone graft absorption. Prolonged Halo-vest immobilization maintained postoperative stability. Failure of internal instrumentation occurred in 3 cases. Anterior construct dislocation and severe tilting occurred in 2 cases after the anterior-posterior procedure. Five patients had a local recurrence. All recurrent lesions were malignant tumors and occurred in regions where surgical exposure was inadequate with incomplete excision. Conclusion. The order of the surgical approach is a critical determinant of complications, fusion rates, choice of surgical technique, and reconstruction methods. The postoperative use of a Halo-vest is recommended. Local recurrence is associated with tumor malignancy and inadequate excision margin. Level of Evidence: 4

Cervical neurofibromatosis with tetraplegia: management by cervical suspensory traction.

Study Design. A case report. Objective. To describe a new method called “cervical suspensory traction” and to report its effect in the treatment of severe cervical kyphotic deformity with neurofibromatosis-1 (NF-1) in a teenager. Summary of Background Data. Cervical kyphotic deformity exceeding 100° due to NF-1 is a challenging surgical problem. Surgery alone may result in poor corrective efficiency, too long range of fusion, sacrificing more mobile segments. Methods. An 18-year-old teenager with NF-1 presented with tetraplegia. Radiographs of the cervical spine revealed that kyphotic deformity of C3–C6 was 125°. Spinal release surgery was undertaken in advance, followed by cervical suspensory traction and subsequent posterior instrumentation and fusion surgery. Results. During a 4-year follow-up, the patient made a full neurological recovery. Cervical curve of C3–C6 was improved with a residual kyphosis of 30°. Stable bone fusion was obtained in the lower cervical spine. No complication had occurred. Conclusion. Cervical suspensory traction is a viable and safe adjunct technique for applying gradual and sustained effort to maximize postoperative correction in the treatment of NF-1 patients with severely rigid and large curves. This report should contribute to expanding the alternative method for the staged treatment strategy to complex abnormalities.

Differences in calcification and osteogenic potential of herniated discs according to the severity of degeneration based on Pfirrmann grade: a cross-sectional study

BackgroundHerniated discs may exhibit calcification, and calcified discs may complicate surgical treatment. However, the osteogenic potential and expression of osteogenic markers in degenerative discs of different degenerative grades are still unclear. Our purposes are to study the differences in calcification rate and osteogenic potential of herniated discs according to different degenerative grades.MethodsFifty-eight lumbar intervertebral discs were removed from 41 patients. After grading according to the Pfirrmann scale, calcification was analyzed by micro computed tomography (μ-CT), and expression of osteogenic markers was analyzed by immunohistochemistry and real-time quantitative polymerase chain reaction (qPCR). Data from μ-CT scans were compared with the Kruskal–Wallis test. The Mann–Whitney test was applied to compare data between any two groups. Differences in osteogenic mRNA expression in different regions of the removed discs (posterior vs. anterior) were analyzed by paired t tests. Differences in the posterior portion of removed discs of different Pfirrmann grades were analyzed by one-way analysis of variance (ANOVA), and comparisons of data between discs of any two grades were completed with least significant difference (LSD) tests.ResultsSignificant differences in calcification according to μ-CT scanning were observed between discs of different degenerative grades. Nearly half of the discs of Pfirrmann grade V showed the highest degree of calcification compared to Pfirrman grade II discs. Bone morphogenetic protein (BMP)-2, Osterix, and Osteocalcin were detected histologically in discs of Pfirrmann grades III–V. Alkaline phosphatase (ALP) expression was observed in discs showing evidence of calcification. The qPCR analysis showed that BMP-2, Osterix, and Osteocalcin were expressed in most degenerated discs. We also observed greater expression of these osteogenic markers in the posterior portion of removed discs than in the anterior portion.ConclusionsThe osteogenic potential of degenerated intervertebral discs appears to increase with the severity of degeneration and to be greater in the tissue near the spinal canal than in tissue in the inner portion of the disc.

iASPP overexpression is associated with clinical outcome in spinal chordoma and influences cellular proliferation, invasion, and sensitivity to cisplatin in vitro

The oncogenetic function of inhibitory member of the apoptosis stimulating protein of p53 family (iASPP) in chordoma is unclear and remains to elucidate. The expression of iASPP in chordoma tissues and cells, its correlation to clinicopathological parameters and the effect on the patients’ prognosis were evaluated. Cellular proliferation, invasion and cisplatin-response were observed after the iASPP knockdown or overexpression in vitro. Co-Immunoprecipitation assay was used to explore the interaction between iASPP and p53. The regulation of miRNA-124 on the expression and apoptotic function of iASPP was explored after transiently transfecting cells with miRNA-124 mimics or inhibitor. Results indicated that iASPP overexpressed in chordoma tissues and cells. Its overexpression was associated with tumor invasion and local recurrence, and was predictive of patients’ poor prognosis. Cells with iASPP-silence showed a decreased ability of proliferation and invasion, but an increasing sensitivity to cisplatin. Besides, iASPP could combine with p53 in either endogenous or exogenous detection. Post-transcriptionally, miRNA-124 negatively regulated the expression of iASPP, which further led to the changes of apoptosis-related proteins. Thus, iASPP overexpression is associated with the clinical outcome in spinal chordoma and influences cellular proliferation, invasion, and the sensitivity to cisplatin.

Clinical features and treatment outcomes of Langerhans cell histiocytosis of the spine

BACKGROUND CONTEXT Langerhans cell histiocytosis (LCH) of the spine is a relatively rare condition with unknown etiology. The diagnosis and treatment protocols for spine LCH remain controversial. PURPOSE In this study, we evaluated the efficacy and safety of our proposed diagnosis and treatment protocol introduced in 2009. STUDY DESIGN This is a retrospective study. PATIENT SAMPLE A total of 110 patients with spine LCH who had been diagnosed and treated in our hospital from October 1997 to November 2015 were included in this study. OUTCOME MEASURES The age, gender, symptoms, neurologic function, lesion distribution, radiological features, pathology, treatment, outcome, and treatment complications of the patients were collected. Visual analog scale (VAS) for pain and Frankel scale for neurologic status were also documented. METHODS We retrospectively reviewed 110 patients with spine LCH who had been diagnosed and treated in our hospital from October 1997 to November 2015. The indications for computed tomography (CT)-guided biopsy and surgery for spine LCH have become more stringent since 2009. In cases of a solitary spinal lesion, immobilization and observation were usually first suggested. Chemotherapy was suggested for cases with multifocal LCH lesions, and low-dosage radiotherapy was restricted to recurrent solitary lesion. This project was supported by our hospital (No. Y71508-01) (¥ 400,000). RESULT This series included 69 male and 41 female patients (age range, 1-52 years). Pain was the most common symptom (93.6%, 103/110). Pathologic diagnosis was achieved in 72 cases (65.5%). CT-guided biopsies were performed in 91.3% (42/46) and 73.2% (41/56) of cases before and after 2009, respectively (p=.02). Ninety-eight cases (89.1%) were followed up for a mean 66.3 (range, 24-159) months. Immobilization and observation were performed in 25.9% (14/54) and 75.0% (42/56) of cases before and after 2009, respectively (p<.001). Approximately 35.2% (19/54) and 10.7% (6/56) of cases had surgery (p=.002) before and after 2009, respectively. During the follow-up, no significant difference was found in the outcomes between the two groups treated before and after 2009 (p=.64). CONCLUSION Biopsy is not mandatory for typical spine lesions of LCH. Given the self-healing tendency of spine LCH, immobilization and observation remain the first-choice treatments for LCH lesions. Conservative biopsy and treatment protocols might be more appropriate for spinal LCH.

Percutaneous radiofrequency ablation versus open surgical resection for spinal osteoid osteoma

BACKGROUND CONTEXT Both open surgical resection (OSR) and radiofrequency ablation (RFA) have been reported for spinal osteoid osteoma (OO). PURPOSE To verify the clinical safety and efficiency of RFA with OSR in treating spinal OO. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Twenty-eight consecutive patients with spinal OO who underwent either RFA or OSR in our institute between September 2006 and December 2016. OUTCOME MEASURES The age, gender, lesion distribution, surgical time, estimated blood loss, complications, local recurrence, visual analogue scale (VAS), and the modified Frankel grade were documented. METHODS We retrospectively reviewed 28 patients with spinal OO who had been treated in our hospital from September 2006 to December 2016. Patients were followed at 3, 6, 12, and 24 months after the index surgery. The minimum follow-up period was 12 months. This study was funded by Peking University Third Hospital (Y71508-01) (¥ 400,000). RESULTS Twelve and 16 patients were treated with CT-guided percutaneous RFA and OSR, respectively. Spinal OO locations were cervical in 4, thoracic in 4, lumbar in 3, and sacral vertebra in 1 in the RFA group and cervical in 12, thoracic in 1, and lumber in 3 in the OSR group. RFA showed shorter operating time, less blood loss, and less in-hospital stay than open surgery [105.0 ± 33.8 minutes vs. 186.4 ± 53.5 minutes (p < .001), 1 (0 to 5) ml vs. 125 (30-1200) ml (p < .001) and 1 (1-3) days vs. 6 (3-10) days (p < .001), respectively]. At last follow-up, one patient underwent a secondary RFA for recurrence. VAS improvement was 7.5 (3-10) and 6.5 (4-9) (p = .945) in the RFA and OSR groups, respectively. The overall complication rate was 8.3% (1/12) and 18.8% (3/16) in the RFA and OSR groups, respectively. CONCLUSIONS If there is sufficient cerebrospinal fluid between the spinal OO lesion and spinal cord/nerve root (more than 1 mm), RFA is effective and safe for treatment of well-selected spinal OO, showing reduced operating time, blood loss, in-hospital stay, and complications compared to OSR. However, OSR is still recommended in cases with spinal cord/nerve root compression.

Surgical approach selection for total spondylectomy for the treatment of giant cell tumors in the lumbar spine: A retrospective analysis of 12 patients from a single center

To describe the selection of the surgical approach used for total spondylectomy in the treatment of giant cell tumors of the lumbar spine.

A Cross-sectional Study on the Symptom Burden of Patients With Spinal Tumor: Validation of the Chinese Version of the M.D. Anderson Symptom Inventory—Spine Tumor Module

CONTEXT Tumors involving the spine are associated with unique symptoms affecting both patient survival and health-related quality of life. Currently, there is no disease-specific instrument in Chinese to assess the symptom burden of these patients. OBJECTIVES The objective of this study was to translate and validate a Chinese version of the M.D. Anderson Symptom Inventory-Spine Tumor Module (MDASI-SP-C) to assess the symptom burden of Chinese-speaking patients with spinal tumors. METHODS MDASI-SP-C was forward-and-backward translated according to standard protocols and administered to patients fulfilling study criteria at a major referral center of spine tumor between November 2014 and September 2015. The generic instruments of Short Form 36 Quality of Life Questionnaire (SF-36), Functional Assessment of Cancer Therapy-General Version (FACT-G), and Karnofsky Performance Scale were used along with MDASI-SP-C. Prevalence and severity distribution of each item were analyzed. Psychometric assessment and hierarchical cluster analysis were performed for the translated instrument. RESULTS One hundred forty-two patients were enrolled. High interdependency and relatively low intra-cluster distances were identified. Cronbachs alpha of the entire instrument, the symptom severity subscale, and the interference subscale was 0.93, 0.91, and 0.92, respectively. Principal axis factoring resulted in a four-factor solution, which was reduced to a three-factor (general symptoms, spine-specific symptoms, and gastrointestinal symptoms) solution on account of clinical interpretation. Correlation coefficients between MDASI-SP-C items and their corresponding domains in SF-36 and/or FACT-G were all greater than 0.3. MDASI-SP-C was able to distinguish patients with different Karnofsky Performance Scale levels. CONCLUSION MDASI-SP-C demonstrated satisfactory psychometric properties and could be used to better assess the symptom burden of Chinese-speaking patients with spine tumors for improved management of their medical needs.