Shiro Imagama

Minocycline selectively inhibits M1 polarization of microglia

Minocycline is commonly used to inhibit microglial activation. It is widely accepted that activated microglia exert dual functions, that is, pro-inflammatory (M1) and anti-inflammatory (M2) functions. The in vivo status of activated microglia is probably on a continuum between these two extreme states. However, the mechanisms regulating microglial polarity remain elusive. Here, we addressed this question focusing on minocycline. We used SOD1G93A mice as a model, which exhibit the motor neuron-specific neurodegenerative disease, amyotrophic lateral sclerosis. Administration of minocycline attenuated the induction of the expression of M1 microglia markers during the progressive phase, whereas it did not affect the transient enhancement of expression of M2 microglia markers during the early pathogenesis phase. This selective inhibitory effect was confirmed using primary cultured microglia stimulated by lipopolysaccharide (LPS) or interleukin (IL)-4, which induced M1 or M2 polarization, respectively. Furthermore, minocycline inhibited the upregulation of NF-κB in the LPS-stimulated primary cultured microglia and in the spinal cord of SOD1G93A mice. On the other hand, IL-4 did not induce upregulation of NF-κB. This study indicates that minocycline selectively inhibits the microglia polarization to a proinflammatory state, and provides a basis for understanding pathogeneses of many diseases accompanied by microglial activation.

Human dental pulp-derived stem cells promote locomotor recovery after complete transection of the rat spinal cord by multiple neuro-regenerative mechanisms

Spinal cord injury (SCI) often leads to persistent functional deficits due to loss of neurons and glia and to limited axonal regeneration after injury. Here we report that transplantation of human dental pulp stem cells into the completely transected adult rat spinal cord resulted in marked recovery of hind limb locomotor functions. Transplantation of human bone marrow stromal cells or skin-derived fibroblasts led to substantially less recovery of locomotor function. The human dental pulp stem cells exhibited three major neuroregenerative activities. First, they inhibited the SCI-induced apoptosis of neurons, astrocytes, and oligodendrocytes, which improved the preservation of neuronal filaments and myelin sheaths. Second, they promoted the regeneration of transected axons by directly inhibiting multiple axon growth inhibitors, including chondroitin sulfate proteoglycan and myelin-associated glycoprotein, via paracrine mechanisms. Last, they replaced lost cells by differentiating into mature oligodendrocytes under the extreme conditions of SCI. Our data demonstrate that tooth-derived stem cells may provide therapeutic benefits for treating SCI through both cell-autonomous and paracrine neuroregenerative activities.

C5 palsy after cervical laminoplasty: A MULTICENTRE STUDY

We have reviewed 1858 patients who had undergone a cervical laminoplasty and identified 43 (2.3%) who had developed a C5 palsy with a MMT (MRC) grade of 0 to 2 in the deltoid, with or without involvement of the biceps, but with no loss of muscular strength in any other muscles. The clinical features and radiological findings of patients with (group P; 43 patients) and without (group C; 100 patients) C5 palsy were compared. CT scanning of group P revealed a significant narrowing of the intervertebral foramen of C5 (p < 0.005) and a larger superior articular process (p < 0.05). On MRI, the posterior shift of the spinal cord at C4-5 was significantly greater in group P, than in group C (p < 0.01). This study is the first to correlate impairment of the C5 nerve root with a C5 palsy. It may be that early foraminotomy in susceptible individuals and the avoidance of tethering of the cord by excessive laminoplasty may prevent a post-operative palsy of the C5 nerve root.

Segmental pedicle screwing for idiopathic scoliosis using computer-assisted surgery.

Study Design Retrospective clinical study. Objectives To evaluate the accuracy of computer-assisted surgery for idiopathic scoliosis. Summary of Background Data Segmental pedicle screw fixation has been proven to enable enhanced correction of scoliotic deformities. However, both neurovascular and visceral structures are at potential risk from screw misplacement due to pedicle drift. No reports exist on the accuracy and benefits of computer-assisted surgery for pedicle screwing in scoliosis surgery. Methods A total of 40 consecutive patients with idiopathic scoliosis were evaluated. Postoperative computed tomography was assessed for the accuracy of pedicle screw placement in 20 cases treated without a navigation system and 20 cases with a computed tomography-based navigation system. Correlations between registered levels and pedicle perforation were investigated. Results Pedicle violation was observed in 28.0% of the control group and 11.4% of the navigation group, with significant differences. No screw misplacements at the registered levels were seen, and the longer the distance between the registered level and level of screw insertion, the higher the rate of pedicle violation. No intraoperative complications caused by pedicle perforation occurred. Conclusions In the navigation group, a tendency to lateral perforation at the concave side and medial perforation at the convex side was noted, like in the control group. Use of the navigation system significantly reduced the screw misplacement rate for rotated vertebrae as compared with the control group. Separate registration is recommended for rotated vertebrae when possible.

Is local bone viable as a source of bone graft in posterior lumbar interbody fusion

Study Design. Radiographic evaluation of bony union and clinical outcome were investigated after posterior lumbar interbody fusion (PLIF) performed with only local bone. Objectives. To examine the viability of local bone for bone graft in PLIF. Summary of Background Data. Different sources of bone graft have been used for PLIF. Autologous iliac bone is most likely suitable for biologic bone healing ability, but there may be some questions such as donor site pain. Allograft and artificial bones are less effective for bone healing. Use of local bone could be a solution. However, the quality of local bone is still being questioned and there is hesitation to use local bone alone. Materials and Methods. Thirty-two patients underwent PLIF (24 single-level and 8 double-level) using the Brantigan I/F Carbon Cage filled with local bone and segmental pedicle screw fixation. At 3, 6, and 12 months after surgery, “parallel AP view radiograph” was obtained to evaluate bony union status. Average follow-up period was 26 months. Clinical outcome was also evaluated by the Japanese Orthopedic Association clinical score. Results. The bony union rate was 16.7%, 72.4%, and 100% at 3, 6, and 12 months after surgery, respectively. Clinically, the average of JOA scores was improved significantly (P < 0.001). The improvement rate was 72.9% (12 mo) and 76.8% (24 mo) on average. Conclusions. A 100% bony union rate was obtained 12 months after PLIF with only local bone. The results showed that clinical viability of local bone as a source of bone graft in PLIF.

Bone union rate with autologous iliac bone versus local bone graft in posterior lumbar interbody fusion.

Study Design. A retrospective clinical study with a long-term follow-up in a single facility. Objective. The purpose of this study is to compare bone union rate between autologous iliac crest bone graft and local bone graft in patients treated by posterior lumbar interbody fusion (PLIF) using carbon cage for single-level interbody fusion. Summary of Background Data. Recently, a number of authors have reported on local bone grafting using bone that is obtained from laminectomy, and have indicated that the achieved fusion rate is similar to that of autologous iliac bone grafting. However, there is no report comparing the fusion rates between autologous iliac bone and local bone graft with a detailed follow-up of fusion progression. Methods. The subjects were 101 patients whose course could be observed for at least 2 years. The diagnosis was lumbar spinal canal stenosis in 14 patients, herniated lumbar disc in 19 patients, and degenerative spondylolisthesis in 68 patients. Single interbody PLIF was performed using iliac bone graft in 54 patients and local bone graft in 47 patients. Existence of pseudarthrosis on X-P (anteroposterior and lateral view) was investigated during the same follow-up period. Results. No significant differences were found in operation time and blood loss. Significant differences were also not observed in fusion grade at any follow-up period or in fusion progression between the 2 groups. Donor site pain continued for more than 3 months in 6 cases (11%). The final fusion rate was 94.5% versus 95.8%. Conclusion. Fusion results from the local bone group and the autologous iliac bone group were nearly identical. Furthermore, fusion progression was nearly identical. Complications at donor sites were seen in 17% of the cases. From the aforementioned results, it was concluded that local bone graft is as beneficial as autologous iliac bone graft for PLIF at a single level.

Keratan Sulfate Restricts Neural Plasticity after Spinal Cord Injury

Chondroitin sulfate (CS) proteoglycans are strong inhibitors of structural rearrangement after injuries of the adult CNS. In addition to CS chains, keratan sulfate (KS) chains are also covalently attached to some proteoglycans. CS and KS sometimes share the same core protein, but exist as independent sugar chains. However, the biological significance of KS remains elusive. Here, we addressed the question of whether KS is involved in plasticity after spinal cord injury. Keratanase II (K-II) specifically degraded KS, i.e., not CS, in vivo. This enzyme digestion promoted the recovery of motor and sensory function after spinal cord injury in rats. Consistent with this, axonal regeneration/sprouting was enhanced in K-II-treated rats. K-II and the CS-degrading enzyme chondroitinase ABC exerted comparable effects in vivo and in vitro. However, these two enzymes worked neither additively nor synergistically. These data and further in vitro studies involving artificial proteoglycans (KS/CS-albumin) and heat-denatured or reduced/alkylated proteoglycans suggested that all three components of the proteoglycan moiety, i.e., the core protein, CS chains, and KS chains, were required for the inhibitory activity of proteoglycans. We conclude that KS is essential for, and has an impact comparable to that of CS on, postinjury plasticity. Our study also established that KS and CS are independent requirements for the proteoglycan-mediated inhibition of axonal regeneration/sprouting.

Multivariate analysis of C-5 palsy incidence after cervical posterior fusion with instrumentation

OBJECT Postoperative C-5 palsy is a significant complication resulting from cervical decompression procedures. Moreover, when cervical degenerative diseases are treated with a combination of decompression and posterior instrumented fusion, patients are at increased risk for C-5 palsy. However, the clinical and radiological features of this condition remain unclear. Therefore, the purpose of this study was to clarify the risk factors for developing postoperative C-5 palsy. METHODS Eighty-four patients (mean age 60.1 years) who had undergone posterior instrumented fusion using cervical pedicle screws to treat nontraumatic lesions were independently reviewed. The authors analyzed the medical records of some of these patients who developed postoperative C-5 palsy, paying particular attention to their plain radiographs, MRI studies, and CT scans. Risk factors for postoperative C-5 palsy were assessed using multivariate logistic regression analysis. The cutoff values for the pre- and postoperative width of the intervertebral foramen (C4-5) were determined by receiver operating characteristic curve analysis. RESULTS Ten (11.9%) of 84 patients developed postoperative C-5 palsy. Seven patients recovered fully from the neurological complications. The pre- and postoperative C4-5 angles showed significant kyphosis in the C-5 palsy group. The pre- and postoperative diameters of the C4-5 foramen on the palsy side were significantly smaller than those on the opposite side in the C-5 palsy group and those bilaterally in the non-C5 palsy group. Risk factors identified by multivariate logistic regression analysis were as follows: 1) ossification of the posterior longitudinal ligament (relative risk [RR] 7.22 [95% CI 1.03-50.55]); 2) posterior shift of the spinal cord (C4-5) (RR 1.73 [95% CI 1.00-2.98]); and 3) postoperative width of the C-5 intervertebral foramen (RR 0.33 [95% CI 0.14-0.79]). The cutoff values of the pre- and postoperative widths of the C-5 intervertebral foramen for C-5 palsy were 2.2 and 2.3 mm, respectively. CONCLUSIONS Patients with preoperative foraminal stenosis, posterior shift of the spinal cord, and additional iatrogenic foraminal stenosis due to cervical alignment correction were more likely to develop postoperative C-5 palsy after posterior instrumentation with fusion. Prophylactic foraminotomy at C4-5 might be useful when preoperative foraminal stenosis is present on CT. Furthermore, it might be useful for treating postoperative C-5 palsy. To prevent excessive posterior shift of the spinal cord, the authors recommend that appropriate kyphosis reduction should be considered carefully.

Surgical results of intramedullary spinal cord tumor with spinal cord monitoring to guide extent of resection.

OBJECT The authors investigated the outcome of intramedullary spinal cord tumor surgery, focusing on the effect of preoperative neurological status on postoperative mobility and the extent of tumor excision guided by intraoperative spinal cord monitoring prospectively. METHODS Intramedullary spinal cord tumor surgery was performed in 131 patients between 1997 and 2007. The authors compared the pre- and postoperative neurological status and examined the type of surgery in 106 of these patients. A modified McCormick Scale (Grades I-V) was used to assess ambulatory ability (I = normal ambulation; II = mild motor sensory deficit, independent without external aid; III = independent with external aid; IV = care required; and V = wheelchair required). The type of surgery was classified into 4 levels: total resection, subtotal resection, partial resection, and biopsy. RESULTS The 106 patients consisted of 47 females and 59 males, whose average age was 42.5 years (range 6-75 years). The mean follow-up period was 7.3 years (range 2.5 months-21 years). The tumor types included astrocytoma (12 cases), ependymoma (46 cases), hemangioblastoma (16 cases), cavernous hemangioma (17 cases), and others (15 cases overall: gangliocytoma, 1; germ cell tumor, 1; lymphoma, 3; neurinoma, 1; meningioma, 1; oligodendroglioma, 1; sarcoidosis, 2; glioma, 1; and unknown, 4). Initial total excision, subtotal resection, partial resection, biopsy, and duraplasty were performed in 59, 12, 22, 12, and 1 patients, respectively. According to the preoperative McCormick Scale, ambulatory status was classified as Grades I, II, III, IV, and V in 41(38%), 30 (28%), 14 (13%), 19 (19%), and 2 (2%) patients, respectively. Thirty-three (31%) of 106 patients suffered postoperative neurological deterioration. The number of patients who did not lose ambulatory ability or who achieved an ambulatory status of Grade I or II postoperatively was 33 (80%), 21 (70%), 10 (71%), 8 (42%), and 1 (50%) in patients with preoperative Grades I, II, III, IV, and V, respectively. Total excision was performed in 31 (79%) of 39 patients with preoperative Grade I, 12 (40%) of 30 patients with Grade II, 7 (50%) of 14 patients with Grade III, and 9 of 21 patients (38%) with Grade IV or V, indicating that the rate of total excision was significantly higher in patients with Grade I status. CONCLUSIONS The postoperative ambulatory ability was excellent in patients with a good preoperative neurological status. Total excision in patients with Grade I or II ambulation was associated with a good prognosis for postoperative mobility. However, the rate of postoperative deterioration was 31.5%, which is relatively high, and patients should be fully informed of this concern prior to intramedullary spinal cord tumor surgery.

N-Acetylglucosamine 6-O-Sulfotransferase-1-Deficient Mice Show Better Functional Recovery after Spinal Cord Injury

Neurons in the adult CNS do not spontaneously regenerate after injuries. The glycosaminoglycan keratan sulfate is induced after spinal cord injury, but its biological significance is not well understood. Here we investigated the role of keratan sulfate in functional recovery after spinal cord injury, using mice deficient in N-acetylglucosamine 6-O-sulfotransferase-1 that lack 5D4-reactive keratan sulfate in the CNS. We made contusion injuries at the 10th thoracic level. Expressions of N-acetylglucosamine 6-O-sulfotransferase-1 and keratan sulfate were induced after injury in wild-type mice, but not in the deficient mice. The wild-type and deficient mice showed similar degrees of chondroitin sulfate induction and of CD11b-positive inflammatory cell recruitment. However, motor function recovery, as assessed by the footfall test, footprint test, and Basso mouse scale locomotor scoring, was significantly better in the deficient mice. Moreover, the deficient mice showed a restoration of neuromuscular system function below the lesion after electrical stimulation at the occipito-cervical area. In addition, axonal regrowth of both the corticospinal and raphespinal tracts was promoted in the deficient mice. In vitro assays using primary cerebellar granule neurons demonstrated that keratan sulfate proteoglycans were required for the proteoglycan-mediated inhibition of neurite outgrowth. These data collectively indicate that keratan sulfate expression is closely associated with functional disturbance after spinal cord injury. N-acetylglucosamine 6-O-sulfotransferase-1-deficient mice are a good model to investigate the roles of keratan sulfate in the CNS.