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Shu-Guang Gao, Guang-Hua Lei, Hong-Bo He, Hua Liu, Wen-Feng Xiao, Ting Wen, Jie-Yu Liang, and Kang-Hua Li

Object

With the increasing advocacy for total disc replacement (TDR) as a potential alternative to fusion in the management of lumbar degenerative disc disease, intradiscal pressures (IDPs) and facet joint stresses at the adjacent levels of spine have generated considerable interest. The purpose of this study was to compare adjacent-level IDPs and facet joint stresses among TDR, discectomy, and fusion.

Methods

Ten fresh human cadaveric lumbar specimens (L2–S1) were subjected to an unconstrained load in axial torsion, lateral bending, flexion, and extension by using multidirectional flexibility test. Four surgical treatment modes—control (disc intact), discectomy, TDR, and fusion—were tested in sequential order at L4–5. During testing, the IDPs and facet forces following each treatment were calculated at the adjacent vertebral levels (L3–4 and L5–S1).

Results

Intradiscal pressures and facet force pressures were similar between the intact condition and the TDR reconstruction at the L3–4 and L5–S1 levels under all loading conditions (p > 0.05). Compared with the intact and TDR groups, the discectomy and fusion groups had higher IDPs at the L3–4 and L5–S1 levels under all loading conditions (p < 0.05). No significant difference in the facet force pressure was noted among the intact, discectomy, and TDR groups at the L3–4 and L5–S1 levels under any loading conditions (p > 0.05). However, the facet force pressure produced for fusion was significantly higher than the mean values obtained for the intact, discectomy, and TDR groups at the L3–4 and L5–S1 levels under all loading conditions (p < 0.05).

Conclusions

Lumbar TDR maintained adjacent-level IDPs and facet force pressures near the values for intact spines, whereas adjacent-level IDPs tended to increase after discectomy or fusion and facet forces tended to increase after fusion.

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Ming-Qiao Fang, Chong Wang, Guang-Heng Xiang, Chao Lou, Nai-Feng Tian, and Hua-Zi Xu

OBJECT

The aim of the present study was to retrospectively evaluate progressive correction of coronal and sagittal alignment and pelvic parameters in patients treated with a Chêneau brace.

METHODS

Thirty-two patients with adolescent idiopathic scoliosis (AIS) were assessed before initiation of bracing treatment and at the final follow-up. Each patient underwent radiological examinations, and coronal, sagittal, and pelvic parameters were measured.

RESULTS

No statistically significant modification of the Cobb angle was noted. The pelvic incidence remained unchanged in 59% of the cases and increased in 28% of the cases. The sacral slope decreased in 34% of the cases but remained unchanged in 50%. Thoracic kyphosis and lumbar lordosis were significantly decreased, whereas the sagittal vertical axis was significantly increased from a mean of -44.0 to -30.2 mm (p = 0.02). The mean pelvic tilt increased significantly from 4.5° to 8.3° (p = 0.002).

CONCLUSIONS

The Chêneau brace can be useful for preventing curvature progression in patients with AIS. However, the results of this study reveal high variability in the effect of brace treatment on sagittal and pelvic alignment. Treatment with the Chêneau brace may also influence sagittal global balance.

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Jiangkai Lin, Hua Feng, Fei Li, Bingmei Zhao, and Qiaonan Guo

✓ A 48-year-old man presented with a rare intraparenchymal schwannoma of the medulla oblongata. After he underwent gamma knife surgery, the patient's condition deteriorated and the mass, which at the time was thought to be a glioma, became larger on magnetic resonance images. The mass was resected through a suboccipital craniectomy via the transcerebellomedullary fissure approach. The tumor, which was moderately firm but distinct from the surrounding parenchyma, was removed totally. Postoperative histological and immunohistochemical examinations confirmed the diagnosis of a benign schwannoma. Brainstem schwannomas can be cured by microneurosurgery. It is important to distinguish these tumors from glioma. The main theories on the cause(s) of this lesion are briefly reviewed.

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Zhi Chen, Jingyu Chen, Hongpin Miao, Fei Li, Hua Feng, and Gang Zhu

Hemorrhagic events associated with cerebral paragonimiasis are not rare, especially in children and adolescents; however, angiographic evidence of cerebrovascular involvement has not been reported. The authors describe angiographic abnormalities of the cerebral arteries seen in 2 children in whom cerebral paragonimiasis was associated with hemorrhagic stroke. The patients presented with acute intracerebral and subarachnoid hemorrhage. Angiography revealed a beaded appearance and long segmental narrowing of arteries, consistent with arteritis. In both patients, involved vessels were seen in the area of the hemorrhage. The vascular changes and the hemorrhage, together with new lesions that developed close to the hemorrhage and improved after praziquantel treatment, were attributed to paragonimiasis. Further study of the frequency and mechanism of hemorrhagic cerebrovascular complications associated with cerebral paragonimiasis is needed.

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Hong-Qi Zhang, Ling-Qiang Chen, Shao-Hua Liu, Di Zhao, and Chao-Feng Guo

Object

The object of this study was to evaluate the efficacy and safety of posterior decompression with kyphosis correction for thoracic myelopathy due to ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL) at the same level.

Methods

Between January 2003 and December 2005, 11 patients (8 men and 3 women) with thoracic myelopathy due to OLF and OPLL at the same level underwent posterior decompressive laminectomy and excision of OLF. Posterior instrumentation was also performed for stabilization of the spine and reducing the thoracic kyphosis angle by approximately 5–15° (kyphosis correction), and spinal fusion was performed in all cases. The follow-up period ranged from 2 to 4 years (mean 2.8 years). The outcomes were evaluated using a recovery scale based on the Japanese Orthopaedic Association classification. The score of each patient was calculated before surgery, 1 year after surgery, and at the final follow-up visit.

Results

After surgery, the thoracic kyphosis in the stabilization area was reduced from 30.0 ± 4.02° to 20.8 ± 2.14° on average. The mean score on the Japanese Orthopaedic Association scale improved from 3.5 ± 1.69 preoperatively to 8.5 ± 1.63 at the final follow-up, with a recovery rate of 68.0%. The results were good in 9 patients and fair in 2 patients. Postoperative MR imaging showed that the spinal cord was shifted posteriorly and decompressed completely in all cases. Myelopathy was not aggravated in any case after surgery.

Conclusions

A considerable degree of neurological recovery was observed after posterior decompression and kyphosis correction. The procedure is easy to perform with a low risk of postoperative paralysis. The authors therefore suggest that the procedure is useful for patients whose spinal cords are severely impinged by OLF and OPLL at the same level.

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Feng-Ping Huang, Guohua Xi, Richard F. Keep, Ya Hua, Andrei Nemoianu, and Julian T. Hoff

Object. The mechanisms involved in brain edema formation following intracerebral hemorrhage (ICH) have not been fully elucidated. The authors have found that red blood cell lysis plays an important role in edema development after ICH. In the present study, they sought to determine whether degradation products of hemoglobin cause brain edema.

Methods. Hemoglobin, hemin, bilirubin, or FeCl2 were infused with stereotactic guidance into the right basal ganglia of Sprague—Dawley rats. The animals were killed 24 hours later to determine brain water and ion contents. Western blot analysis and immunohistochemistry were applied for heme oxygenase-1 (HO-1) measurement. The effects of an HO inhibitor, tin-protoporphyrin (SnPP), and the iron chelator deferoxamine, on hemoglobin-induced brain edema were also examined.

Intracerebral infusion of hemoglobin, hemin, bilirubin, or FeCl2 caused an increase in brain water content at 24 hours. The HO-1 was upregulated after hemoglobin infusion and HO inhibition by SnPP-attenuated hemoglobin-induced edema. Brain edema induced by hemoglobin was also attenuated by the intraperitoneal injection of 500 mg/kg deferoxamine.

Conclusions. Hemoglobin causes brain edema, at least in part, through its degradation products. Limiting hemoglobin degradation coupled with the use of iron chelators may be a novel therapeutic approach to limit brain edema after ICH.

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Guang-Heng Xiang, Chong Wang, Chao Lou, Ming-Qiao Fang, Nai-Feng Tian, and Hua-Zi Xu

OBJECT

The goal of this study was to evaluate the feasibility of the C-1 posterior arch crossing screw fixation technique in the pediatric age group.

METHODS

One hundred twenty-three pediatric patients were divided into 6 age groups. Computed tomography morphometric analysis of the C-1 posterior arch was performed. Measurements included height, width, and length. Statistical analysis was performed using the Student t-test and linear regression analysis.

RESULTS

The mean measurement of the posterior arch was height (6.35 ± 1.80 mm), width (Width 1: 4.48 ± 1.25 mm; Width 2: 4.42 ± 0.68 mm; Width 3: 4.42 ± 0.50 mm), and length (14.48 ± 1.67 mm). Seven (6.93%) of the 101 children in Groups 1–4 and 13 (59.1%) of the 22 children in Groups 5 and 6 could safely accommodate placement of C-1 posterior arch crossing screws.

CONCLUSIONS

This investigation found that a C-1 posterior arch crossing screw was feasible in this group of Chinese pediatric patients, particularly in those 13 years and older. Preoperative thin-cut CT is essential for identifying children in whom this technique is applicable and for planning screw placement.

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Lin-Feng Wang, Ying-Ze Zhang, Yong Shen, Yan-Ling Su, Jia-Xin Xu, Wen-Yuan Ding, and Ying-Hua Zhang

Object

The aim of this study was to investigate the clinical significance of both the signal intensity ratio obtained from MR imaging and clinical manifestations on the prognosis of patients with cervical ossification of the posterior longitudinal ligament.

Methods

The authors retrospectively reviewed the records of 58 patients with cervical ossification of the posterior longitudinal ligament who underwent cervical laminoplasty from February 1999 to July 2007. Magnetic resonance imaging (1.5-T) was performed in all patients before surgery. Sagittal T2-weighted images of the cervical spinal cord compressed by the ossified posterior longitudinal ligament showed increased intramedullary signal intensity, whereas the sagittal images obtained at the C7–T1 disc levels were of normal intensity. The signal intensity ratio between regions of intramedullary increased signal intensity and the normal C7–T1 disc level was calculated based on the signal intensity values generated from the MR imaging workstation. Patients were divided into 3 groups according to their signal intensity ratio (high, intermediate, and low signal intensity groups).

Results

There were significant differences between the 3 groups regarding recovery rate (p < 0.001), age (p = 0.022), duration of disease (p = 0.001), Babinski sign (p < 0.001), ankle clonus (p < 0.001), and both pre- and postoperative Japanese Orthopaedic Association score (p < 0.001). There was no significant difference in sex among the 3 groups (p = 0.391).

Conclusions

Patients with low signal intensity ratios that changed on T2-weighted imaging experienced a good surgical outcome. Low increased signal intensity might reflect mild neuropathological alteration in the spinal cord and greater recuperative potential. An increased signal intensity ratio with positive pyramidal signs indicates less recuperative potential of the spinal cord and a poor surgical outcome.

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Nai-Feng Tian, Ai-Min Wu, Li-Jun Wu, Xin-Lei Wu, Yao-Sen Wu, Xiao-Lei Zhang, Hua-Zi Xu, and Yong-Long Chi

Object

This study aimed to investigate the incidence rate of heterotopic ossification (HO) after implantation of Coflex interspinous devices. Possible risk factors associated with HO were evaluated.

Methods

The authors retrospectively analyzed patients who had undergone single-level (L4–5) implantation of a Coflex device for the treatment of lumbar spinal stenosis. Patient data recorded were age, sex, height, weight, body mass index, smoking habits, and surgical time. Heterotopic ossification was identified through lumbar anteroposterior and lateral view radiographs. The authors developed a simple classification for defining HO and compared HO-positive and HO-negative cases to identify possible risk factors.

Results

Among 32 patients with follow-up times of 24–57 months, HO was detectable in 26 (81.2%). Among these 26 patients, HO was in the lateral space of the spinous process but not in the interspinous space in 8, HO was in the interspinous space but did not bridge the adjacent spinous process in 16, and interspinous fusion occurred at the level of the device in 2. Occurrence of HO was not associated with patient age, sex, height, weight, body mass index, smoking habits, or surgical time.

Conclusions

A high incidence of HO has been detected after implantation of Coflex devices. Clinicians should be aware of this possible outcome, and more studies should be conducted to clarify the clinical effects of HO.

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Jingyu Chen, Zhi Chen, Fei Li, Jiangkai Lin, Hui Meng, and Hua Feng

Object

The purpose of this study was to review 14 rare cases of cerebral paragonimiasis that first manifested as intracranial hemorrhage (ICH), and to investigate the characteristics of clinical manifestation, diagnosis, and treatment of the disease.

Methods

The authors have encountered 14 cases of cerebral paragonimiasis in patients between the ages of 6 and 16 years (mean age 11.5 years) who presented with sudden headache, nausea, and vomiting. Three of them were affected with varying degrees of limb hemiplegia, and in 1 this was combined with high fever; the blood eosinophil count and enzyme-linked immunosorbent assay showed positive results too. The ICHs were observed with cranial CT and MR imaging, and lung lesions were also detected in 5 cases on chest CT scans. Ten of the diagnosed cases were treated with oral praziquantel. Three of these patients were given carbamazepine from the beginning of parasiticidal treatment to prevent seizures; 4 of the remaining 7 patients experienced epileptic seizures during the treatment process. Four patients needed surgery to remove the lesions, and these individuals received praziquantel treatment right after the surgery.

Results

Pathological examinations demonstrated eosinophilic granuloma in these patients. There was no disease recurrence or epilepsy in 11–40 months of follow-up; however, mild hemiplegia could still be observed in 2 cases after 12 months and 17 months of follow-up.

Conclusions

The possibility of cerebral paragonimiasis should be considered when ICH is detected in young patients who are either from an endemic area or have recently visited such an area; the relatively small amount of hemorrhage in cerebral paragonimiasis is often represented as small lesions surrounded by disproportionately larger edema on the imaging study. Preventive antiepileptic drugs should be used along with the administration of parasiticide.