Huajiang Chen

Comparison of 3 reconstructive techniques in the surgical management of multilevel cervical spondylotic myelopathy.

Study Design. A retrospective comparative study was performed in patients with 3-level cervical spondylotic myelopathy (CSM). Objective. To compare the clinical outcomes, radiological parameters, and complication incidence of 3 reconstructive techniques after the anterior decompression of multilevel CSM. Summary of Background Data. There has been growing interest in combination of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) for the treatment of multilevel CSM in recent years. However, the clinical efficacy and radiological outcomes of the hybrid decompression and fusion (HDF) have rarely been investigated. Methods. A total of 180 consecutive patients with 3-level CSM undergoing the anterior decompression and fusion procedures from January 2003 to July 2010 were retrospectively investigated. According to various reconstructive techniques, the patients were divided into 3 groups: HDF, ACDF, and ACCF groups. The clinical effects and improvements of cervical and segmental lordosis in each group were assessed. In addition, the fusion rate, postoperative complications, and radiographical adjacent-level changes regarding each group were also evaluated. Results. No statistical differences in clinical effects, restoration of cervical lordosis, and incidences of postoperative complications were found between the HDF and ACDF groups (P > 0.05). The ACCF group has achieved clinical effects similar to the ACDF or HDF group (P > 0.05), but it had more bleeding, lower fusion rate, and higher incidences of postoperative complications compared with the ACDF or HDF group (P < 0.05). The improvements of the cervical and segmental lordosis in the ACCF group were significantly less than the ACDF or HDF group (P < 0.05). There was no significant difference in radiographical adjacent-level changes among the 3 groups (P > 0.05). Conclusion. The HDF can be considered an effective and safe alternative procedure compared with ACDF in the treatment of the multilevel CSM, and ACCF should be the last option.

Cervical kinematics and radiological changes after Discover artificial disc replacement versus fusion

BACKGROUND CONTEXT The cervical disc arthroplasty has emerged as a promising alternative to the anterior cervical discectomy and fusion (ACDF) in patients with radiculopathy or myelopathy with disc degeneration disease. The advantages of this technique have been reported to preserve the cervical mobility and possibly reduce the adjacent segment degeneration. However, no studies have compared the clinical outcomes and radiological results in patients treated with Discover artificial disc replacement to those observed in matched group of patients that have undergone ACDF. PURPOSE We conducted this clinical study to compare the cervical kinematics and radiographic adjacent-level changes after Discover artificial disc replacement with ACDF. STUDY DESIGN Analysis and evaluation of data acquired in a comparative clinical study. PATIENT SAMPLE The number of patients in the Discover and ACDF group were 149 and 196, respectively. OUTCOME MEASURES The Neck Disability Index (NDI) and visual analog scale (VAS) pain score were evaluated. The range of movement (ROM) by the shell angle, the functional segment unit and global angles were measured, and the postoperative radiological changes at adjacents levels were observed. METHODS A total of 149 patients with symptomatic single or two-level cervical degenerative diseases received the Discover cervical artificial disc replacement from November 2008 to February 2010. During the same period, there were a total of 196 patients undergoing one or two-level ACDF. The average follow-up periods of the Discover disc group and ACDF group were 22.1 months and 22.5 months, respectively. Before surgery, patients were evaluated using static and dynamic cervical spine radiographs in addition to computerized tomography and magnetic resonance imaging. Static and dynamic cervical spine radiographs were obtained after surgery and then at 3- and 6-month follow-up. Then, the subsequent follow-up examinations were performed at every 6-month interval. The clinical results in terms of NDI and VAS scores, the parameters of cervical kinematics, postoperative radiological changes at adjacent levels, and complications in the two groups were statistically analyzed and compared. No funding was received for this study, and the authors report no potential conflict of interest-associated biases in the text. RESULTS Although the clinical improvements in terms of NDI and VAS scores were achieved in both the Discover and ACDF group, no significant difference was found between the two groups for both single- (VAS p=.13, NDI p=.49) and double-level surgeries (VAS p=.28, NDI p=.21). Significant differences of cervcial kinematics occurred between the Discover and the ACDF group for both the single- and double-level surgeries at the operative segments (p<.001). Except the upper adjacent levels for the single-level Discover and ACDF groups (p=.33), significant increases in adjacent segment motion were observed in the ACDF group compared with the minimal ROM changes in adjacent segment motion noted in the Discover group, and the differences between the two groups for both single and double-level procedures were statistically significant (p<.05). There were significant differences in the postoperative radiological changes at adjacent levels between the Discover and ACDF groups for the single-level surgery (p<.001, χ(2)=18.18) and the double-level surgery (p=.007, χ2=7.2). No significant difference of complications was found between the Discover and ACDF groups in both single (p=.25, χ2=1.32) and double-level cases (p=.4, χ2=0.69). CONCLUSIONS The adjacent segment ROM and the incidence of radiographic adjacent-level changes in patients undergoing ACDF were higher than those undergoing Discover artificial disc replacement. The cervical mobility was relatively well maintained in the Discover group compared with the ACDF group, and the Discover cervical disc arthroplasty can be an effective alternative to the fusion technique.

Preoperative scoring systems and prognostic factors for patients with spinal metastases from hepatocellular carcinoma.

Study Design. A retrospective study had been conducted to compare the existing preoperative scoring systems and to find useful prognostic factors for patients with spinal metastases from hepatocellular carcinoma (HCC). Objective. To evaluate different preoperative scoring systems and prognostic factors for patients with spinal metastases from HCC. Summary of Background Data. Different scoring systems for metastatic spinal tumor have been designed for prognostic evaluation. However, these scoring systems were formulated from many different types of tumors, so that their efficacy for a certain type of cancer needs to be validated. Furthermore, some serologic test results may enhance the accuracy of the scoring system. Methods. We conducted a retrospective study to evaluate 4 prognostic scoring systems and factors in a series of 41 cases with spinal metastases from HCC in a single center. These scoring systems include Tokuhashi revised score, Tomita score, Bauer score, and a revised van der Linden score by the authors. Serologic test items including serum albumin, aspartate aminotransferase, alanine transaminase, and lactate dehydrogenase (LDH) were also evaluated. Results. The revised Tokuhashi scoring system provided statistically significant differences in survival time between different groups (P = 0.012), while the Tomita and Bauer systems did not show statistically significant differences (P = 0.918 and P = 0.754, respectively). Significantly improved survival was found in patients with good performance status and no visceral metastases (Group C, P = 0.008) in revised van der Linden scores. Univariate and multivariate analyses showed serum albumin and LDH were independent prognostic factors for survival time. Conclusion. Revised Tokuhashi scoring system is practicable and highly predictive, while serum albumin and LDH also have prognostic value in patients with spinal metastases from HCC, especially those without visceral metastases. More accurate prognosis may be obtained if the scoring systems include clinical and laboratory data in future.

Inflammatory cytokines induce caveolin-1/β-catenin signalling in rat nucleus pulposus cell apoptosis through the p38 MAPK pathway.

Apoptosis of nucleus pulposus (NP) cells is a major cause of intervertebral disc degeneration. To elucidate relationships between caveolin‐1 and cytokine‐induced apoptosis, we investigated the role of caveolin‐1 in cytokine‐induced apoptosis in rat NP cells and the related signalling pathway.

Chondrosarcomas of the cervical and cervicothoracic spine: surgical management and long-term clinical outcome.

Study Design A retrospective review study. Objectives To estimate the clinical outcome of various resection protocols in patients with chondrosarcoma (CHS) at the challenging region of cervical and cervicothoracic spine (CCT). Summary of Background Data It is challenging to surgically manage CHS of the spine. Although total en-bloc resection has proven to be an ideal treatment, this option is not always feasible in the spine because of the constrains of critical neurovascular structures in the vicinity. Lesions at the CCT region pose even more difficulties, and few large clinical series concerning various protocols and long-term outcomes of these lesions exist at present. Methods Fifteen patients with CHS at the CCT region who underwent surgical management in our institute were retrospectively studied. Twelve piecemeal resections and 3 en-bloc resections were performed. Intraoperative local chemotherapy and postoperative cyberknife radiotherapy were given as adjuvant therapy. Neurologic status, local recurrence, distant metastasis, and treatment-related complications were evaluated. Results The mean follow-up time was 58.7 months (median 37 mo; ranging from 18 to 141 mo). Local recurrence was detected in 5 of 5 cases (100%) treated by intracapsular piecemeal resection, and in 1 of 7 cases (14.3%) treated by extracapsular piecemeal resection, whereas no recurrence was found in 3 cases treated by en-bloc resection. Of the 6 recurrent patients, 5 died of disease 24 to 46 months after present surgery, and the remaining patient was alive with disease in the final follow-up. There were no signs of recurrence in the remaining 9 patients. Conclusions For CHS at the CCT region, intralesional piecemeal resection has a poor prognosis and should be avoided. Oncologically, en-bloc resection remains the best form of disease management and should be the primary treatment of choice. For cases in which an uncontaminated en-bloc resection could not be achieved, the extracapsular piecemeal resection with adjuvant therapy including local chemotherapy and cyberknife radiotherapy is an effective and achievable option.

The impact of the depression and anxiety on prognosis of cervical total disc replacement.

Study Design. Prospective clinical study. Objective. To identify changes in depression and anxiety after cervical total disc replacement (CTDR) among patients with cervical spondylosis, and to investigate their effects on the prognosis. Summary of Background Data. Previous researches have reported relationships between mood disorders and lumbar surgery. There have been no previous studies on the effects of depressive and anxiety on the CTDR outcome at the 2-year postoperative phase. Methods. Eighty-five patients with cervical spondylosis who underwent CTDR were included. Patients were evaluated preoperatively and at 6 postoperative time points, including 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years. Depression and anxiety were evaluated by using the Zung Self-Rating Depression Scale and the Zung Self-Rating Anxiety Scale. Neurological function was evaluated by using the visual analogue scale and the Japanese Orthopaedic Association. The quality of life was assessed by a 36-item Short-Form Health Survey. A Spearman rank correlation analysis was used. Results. All patients had improvements in clinical symptoms and neurological function. Twelve (14.12%) patients had symptoms of depression and 21 (24.71%) patients had symptoms of anxiety. There was a significant difference between the preoperative and the postoperative Zung Self-Rating Anxiety Scale scores, whereas the Zung Self-Rating Depression Scale scores were not significantly different over time. For all patients, the visual analogue scale scores and the 36-item Short-Form Health Survey scores were associated with the postoperative level of depression and anxiety but not age or the Japanese Orthopaedic Association score. Conclusion. Some patients with cervical spondylosis have preoperative depression and/or anxiety. CTDR may provide some improvements in these psychological symptoms. The presence of depression and/or anxiety may have a negative influence on the patients prognosis. Level of Evidence: 3

Sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal-posterior approach: surgical technique and results in 11 patients.

BACKGROUND Surgical treatment of C2 tumors remains challenging. Because of the deep location and unique anatomical complexity, anterior exposure in this region is considered difficult and dangerous, and few reports concerning anterior tumor resection and reconstruction exist. OBJECTIVE To describe a technique of sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal–posterior approach. METHODS Eleven patients with C2 tumors underwent sequentially staged tumor resection and 2-column reconstruction in our institute. Eight primary lesions and 3 metastases were involved. Tumor resections and anterior reconstructions with conventional constructs were accomplished by an anterior retropharyngeal approach, and occipitocervical fusions through posterior access were performed in the same anesthesia. RESULTS No operative mortality occurred in this series. All patients experienced pain relief and neurological improvement after surgery. Except for 1 incidence of screw pullout, which was corrected by revision surgery, solid fusion was achieved in all patients. A follow-up period of 12 to 37 months was available for this study. Two patients with chordoma relapsed; 1 died of disease, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases. No evidence of local recurrence was found in the other patients. CONCLUSION The anterior retropharyngeal approach is a favorable route to treat tumor lesions of the C2 vertebral body that allows tumor resection and placement of anterior constructs between C1 and the subaxial vertebral body. Tumor resection and 2-column reconstruction could safely be accomplished simultaneously through the combined anterior retropharyngeal–posterior approach.

MiR-34a promotes Fas-mediated cartilage endplate chondrocyte apoptosis by targeting Bcl-2

Apoptosis of cartilage endplate (CEP) chondrocytes is associated with the pathogenesis of intervertebral disk degeneration (IDD). Recent studies have shown that miR-34a is crucially involved in chondrocyte apoptosis during osteoarthritic cartilage. Here, we investigated the involvement of miR-34a in CEP chondrocyte apoptosis in IDD. In human degenerated CEP chondrocytes, miRNA (miR)-34a was markedly elevated in association with increased apoptosis. Bioinformatics target prediction identified Bcl-2 as a putative target of miR-34a. Furthermore, miR-34a inhibited Bcl-2 expression by directly targeting their 3′-untranslated regions, and this inhibition was abolished by mutation of the miR-34a binding sites. In vitro, knockdown of miR-34a in human endplate chondrocytes resulted in overexpression of Bcl-2, whereas upregulation of miR-34a led to repression of Bcl-2. Fas-mediated apoptosis was decreased when antagonizing miR-34a with locked nucleotide analog-miR-34a in human endplate chondrocytes. Taken together, our results demonstrate that upregulated miR-34a potentiates Fas-mediated endplate chondrocyte apoptosis, which is associated with IDD.

Retrospective analysis of anterior correction and fusion for adolescent idiopathic thoracolumbar/lumbar scoliosis: the relationship between preserving mobile segments and trunk balance

The objective of this paper was to investigate the surgical strategy of the selection of the lowest instrumented vertebrae (LIV) in anterior correction for adolescent idiopathic scoliosis (AIS) and to discuss the relationship between the LIV and trunk balance. From 1998 to 2004, 28 patients with thoracolumbar/lumbar AIS (Lenke 5 type) were treated by anterior correction and fusion with a mean follow-up of 1.5 years. Specific radiographic parameters were observed respectively and the correlation between disc wedging immediately below the LIV and these parameters was analysed. The mean corrective rate of major curves was 74.84%. The preoperative disc angle distal to LIV was 2.96 ± 1.43° and postoperatively it was −3.60 ± 1.75°. The postoperative disc wedging was most correlated with LIV obliquity. The postoperative LIV–CSVL (centre sacral vertical line) distance, which reflects regional balance, was correlated with various preoperative parameters. LIV determination was correlated with multiple preoperative radiographic parameters. Disc wedging distal to LIV occurs most often when a short fusion excluding the lower end vertebra (LEV) and the subjacent disc are nearly parallel.RésuméL’objectif de cette étude est de mettre en évidence la meilleure stratégie chirurgicale lors de l’instrumentation des vertèbres lombaires dans la correction antérieure d’une scoliose idiopathique de l’adolescent, pour laquelle il est nécessaire de corréler l’instrumentation basse et la balance rachidienne. Méthode : De 1998 à 2004, 28 patients présentant une scoliose thoracolombaire ou lombaire idiopathique (Lenke type 5) ont été traités par correction avec fusion antérieure avec un recul minimum de 1.5 ans. Nous avons réalisé une évaluation radiologique très sévère avec une évaluation du disque immédiatement sous-jacent à l’arthrodèse. Résultats : la correction moyenne de la courbe principale a été de 74.84%. L’angulation préopératoire du disque immédiatement sous-jacent à la scoliose était de 2.96 et en post opératoire de 3.60. La distance post opératoire CSVL – LIV qui reflète la balance rachidienne était corrélée avec différents paramètres. En conclusion : la fusion distale de la courbure lombaire a lieu le plus souvent lorsque cette arthrodèse exclut les disques sous-jacents et lorsque celui-ci reste parallèle.

Combined Pre- and Retrovascular Extraoral Approach for Tumors at Lateral Mass of the Atlas

Study Design. A series of 9 patients surgically treated with a novel combined pre-and retrovascular extraoral approach to lateral mass of the atlas (LMA) is examined. Objective. To describe the efficacy of combined pre- and retrovascular extraoral approach in achieving a wide exposure and aggressive resection of tumors at the LMA. Summary of Background Data. The anatomic complexity and closeness to vital neurovascular structures raise technical difficulties in the surgical access to the LMA. Although various approaches, such as transoral approach, high anterior cervical approach, anterior lateral approach, and far lateral approach, have been reported in literature, wide exposure for the tumors at the LMA remains a unique challenge. Methods. For our experience in the surgical exposure of the upper cervical spine, we have developed a combined pre- and retrovascular extraoral approach to the atlas since 2001. Nine patients with neoplastic lesions at the LMA were surgically treated through this combined approach. Reconstruction of stability was achieved by a posterior occipitocervical fusion through a posterior approach under the same anesthesia. Results. This combined approach provided an excellent surgical field exposure to ensure the successful tumor resection while preventing the vertebral artery or nerve from injury. There was no operative mortality or severe morbidity in this series. Complications included 1 instance of transient dysphagia and 2 instances of transient trouble swallowing liquids. The symptoms of local pain and pharyngeal discomfort relieved, and patients suffering from spinal cord compression recovered well with 1 level of the Frankel scale when reevaluated 3 months after operation. With a follow-up period of 16 to 100 months, 1 patient with chondrosarcoma developed local recurrence at the 14th month of postoperation and died of respiratory and circulatory failure 39 months after surgery. No evidence of local recurrence was found in other patients. Conclusion. The combined pre- and retrovascular extraoral approach provides an advantageous alternative to previous reported approaches. For selected cases with tumor lesions at the LMA, this combined approach offers more benefits, through which a wide exposure with well-protected vertebral artery favoring radical excision could be achieved without complications normally associated with transoral surgery.