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Jau-Ching Wu, Wen-Cheng Huang, Yun-An Tsai, Yu-Chun Chen and Henrich Cheng

Object

The aim of this study was to assess functional outcomes of nerve repair using acidic fibroblast growth factor (FGF) in patients with cervical spinal cord injury (SCI).

Methods

Nine patients who had cervical SCI for longer than 5 months were included in pre- and postoperative assessments of their neurological function. The assessments included evaluating activities of daily living, associated functional ability, and degree of spasticity, motor power, sensation, and pain perception. After the first set of assessments, the authors repaired the injured segment of the spinal cord using a total laminectomy followed by the application of fibrin glue containing acidic FGF. Clinical evaluations were conducted 1, 2, 3, 4, 5, and 6 months after the surgery. Preoperative versus postoperative differences in injury severity and grading of key muscle power and sensory points were calculated using the Wilcoxon signed-rank test.

Results

The preoperative degree of injury severity, as measured using the American Spinal Injury Association (ASIA) scoring system, showed that preoperative motor (52.4 ± 25.9 vs 68.6 ± 21.5), pinprick (61.0 ± 34.9 vs 71.6 ± 31.0), and light touch scores (57.3 ± 33.9 vs 71.9 ± 30.2) were significantly lower than the respective postoperative scores measured 6 months after surgery (p = 0.005, 0.012, and 0.008, respectively).

Conclusions

Based on the significant difference in ASIA motor and sensory scale scores between the preoperative status and the 6-month postoperative follow-up, this novel nerve repair strategy of using acidic FGF may have a role in the repair of human cervical SCI. Modest nerve regeneration occurred in all 9 patients after this procedure without any observed adverse effects. This repair strategy thus deserves further investigation, clinical consideration, and refinement.

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Michael G. Fehlings

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Jau-Ching Wu, Wen-Cheng Huang, Ming-Chao Huang, Yun-An Tsai, Yu-Chun Chen, Yang-Hsin Shih and Henrich Cheng

Object

In this study, the authors evaluated the efficacy of a new surgical strategy for reconnecting the injured brachial plexus with the spinal cord using fibrin glue containing acidic fibroblast growth factor as an adhesive and neurotrophic agent.

Methods

Eighteen patients with preganglionic brachial plexus injuries, each with varying degrees of upper limb dysfunction, underwent cervical laminectomy with or without sural nerve grafting. The treatment of each avulsed root varied according to the severity of the injury. Some patients also underwent a second-stage operation involving supraclavicular brachial plexus exploration for reconnection with the corresponding segment of cervical spinal cord at the trunk level. Muscle strength was graded both pre- and postoperatively with the British Medical Research Council scale, and the results were analyzed with the Friedman and Wilcoxon signed-rank tests.

Results

Muscle strength improvements were observed in 16 of the 18 patients after 24 months of follow-up. Significant improvements in mean muscle strength were observed in patients from all repair method groups at 12 and 24 months postoperatively (p < 0.05). Statistical significance was not reached in the groups with insufficient numbers of cases.

Conclusions

The authors' new surgical strategy yielded clinical improvement in muscle strength after preganglionic brachial plexus injury, such that nerve regeneration may have taken place. Reconnection of the brachial plexus to the cervical spinal cord is possible. Functional motor recovery, observed through increases in Medical Research Council–rated muscle strength in the affected arm, is likewise possible.

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Chin-Chu Ko, Hsiao-Wen Tsai, Wen-Cheng Huang, Jau-Ching Wu, Yu-Chun Chen, Yang-Hsin Shih, Hung-Chieh Chen, Ching-Lan Wu and Henrich Cheng

Object

Dynamic stabilization systems are used to stabilize degenerative lumbar spondylosis. Loosening of the pedicle screws in such nonfusion implants is predictable. This retrospective study evaluated the incidence of screw loosening and its effect on clinical outcomes.

Methods

Charts, radiographic films, and medical records of 71 consecutive patients who underwent decompression using Dynesys dynamic stabilization for 1- or 2-level lumbar spondylosis were reviewed. Radiographic films were evaluated and compared to detect screw loosening. A visual analog scale (VAS) for back pain and the Oswestry Disability Index (ODI) were used for measuring clinical outcome. Statistical analysis was conducted using the chisquare test and Student t-test.

Results

The 71 patients in the study sample had a mean age of 59.2 ± 11.65 years (range 23–80 years), with slight female predominance (39 women, 32 men). The mean follow-up duration was 16.6 months (range 8–29 months). There were loose screws in 14 of 71 patients (19.7%), for a rate of 4.6% per screw (17 of 368 screws). Most screw loosening occurred in patients ≥ 55 years old (13 of 14 patients) although age and sex had no effect on screw loosening (p = 0.233 and 0.109, respectively). Both the loose screw and solid screw groups experienced significant improvement after the surgery in VAS and ODI scores. On the VAS, scores improved from 5.9 ± 2.99 to 2.1 ± 2.14 in the loose screw group (p = 0.003), and from 5.7 ± 3.45 to 2.9 ± 2.68 in the solid screw group (p < 0.001). For the ODI scale, scores improved from 43.5 ± 16.78% to 28.0 ± 18.18% (p = 0.006) in the loose screw group, and from 52.1 ± 20.92% to 24.6 ± 19.78% (p < 0.001) in the solid screw group. There were no significant differences between the 2 groups (p = 0.334 for VAS, p = 0.567 for ODI).

Conclusions

The preliminary study of this pedicle-based dynamic stabilization device for 1- and 2-level lumbar spondylosis shows radiographic evidence of screw loosening in 19.7% of patients and 4.6% of screws. Nonetheless, the loosening of screws has no adverse effect on clinical improvement.

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Matthew B. Potts, Jau-Ching Wu, Nalin Gupta and Praveen V. Mummaneni

Object

Symptomatic tethered cord and associated anomalies such as diastematomyelia rarely present during adulthood but can cause significant pain as well as motor, sensory, and bladder dysfunction. As with children, studies have shown that surgical detethering may provide improvement in pain and neurological deficits. Typical surgical management involves an open laminectomy, sectioning of the filum terminale, and exploration of the split cord malformation. Such open approaches, however, cause significant paraspinous muscle trauma and scarring. Recent advances in minimally invasive techniques allow for access to the spine and thecal sac while minimizing associated muscular trauma. The authors present a comparison of open versus minimally invasive surgery to treat adult tethered cord syndrome.

Methods

Six adult patients underwent surgical release of a tethered spinal cord (2 of them also had diastematomyelia). The mean age of the patients was 47.78 years (range 31–64 years). All medical records and images were retrospectively reviewed. Three of the patients underwent traditional open laminectomies for detethering (open group) while the other 3 patients underwent minimally invasive (mini-open) spinal cord detethering. The length of the incision, length of stay, estimated blood loss, and complications were compared between the 2 groups.

Results

All 6 patients had tethered spinal cords, and 1 patient in each group had diastematomyelia. The mean estimated blood loss during surgery (300 ml in the open group vs 167 ml in the mini-open group, p = 0.313) and the mean length of stay (7 days in the open group vs 6.3 days in the mini-open group, p = 0.718) were similar between the 2 groups. The incision length was half as long in the mini-open group versus the open group. However, 1 patient in the mini-open group developed a postoperative pseudomeningocele requiring surgical revision, whereas the open group had no revision surgeries.

Conclusions

Cases of symptomatic diastematomyelia and tethered cord in adults can be safely and effectively explored through a mini-open approach. In this small case series, the authors did find that the mini-open group had an incision that was 50% smaller than the open group, but they did not find a significant clinical difference between the groups.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010

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Scott A. Meyer, Jau-Ching Wu and Praveen V. Mummaneni

Object

Two common causes of cervical myelopathy include degenerative stenosis and ossification of the posterior longitudinal ligament (OPLL). It has been postulated that patients with OPLL have more complications and worse outcomes than those with degenerative stenosis. The authors sought to compare the surgical results of laminoplasty in the treatment of cervical stenosis with myelopathy due to either degenerative changes or segmental OPLL.

Methods

The authors conducted a retrospective review of 40 instrumented laminoplasty cases performed at a single institution over a 4-year period to treat cervical myelopathy without kyphosis. Twelve of these patients had degenerative cervical stenotic myelopathy ([CSM]; degenerative group), and the remaining 28 had segmental OPLL (OPLL group). The 2 groups had statistically similar demographic characteristics and number of treated levels (mean 3.9 surgically treated levels; p > 0.05). The authors collected perioperative and follow-up data, including radiographic results.

Results

The overall clinical follow-up rate was 88%, and the mean clinical follow-up duration was 16.4 months. The mean radiographic follow-up rate was 83%, and the mean length of radiographic follow-up was 9.3 months. There were no significant differences in the estimated blood loss (EBL) or length of hospital stay (LOS) between the groups (p > 0.05). The mean EBL and LOS for the degenerative group were 206 ml and 3.7 days, respectively. The mean EBL and LOS for the OPLL group were 155 ml and 4 days, respectively. There was a statistically significant improvement of more than one grade in the Nurick score for both groups following surgery (p < 0.05). The Nurick score improvement was not statistically different between the groups (p > 0.05). The visual analog scale (VAS) neck pain scores were similar between groups pre- and postoperatively (p > 0.05). The complication rates were not statistically different between groups either (p > 0.05). Radiographically, both groups lost extension range of motion (ROM) following laminoplasty, but this change was not statistically significant (p > 0.05).

Conclusions

Patients with CSM due to either degenerative disease or segmental OPLL have similar perioperative results and neurological outcomes with laminoplasty. The VAS neck pain scores did not improve significantly with laminoplasty for either group. Laminoplasty may limit extension ROM.

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Jau-Ching Wu, Laura Liu, Yu-Chun Chen, Wen-Cheng Huang, Tzeng-Ji Chen and Henrich Cheng

Object

This study aimed to calculate the incidence and prevalence of ossification of the posterior longitudinal ligament (OPLL) in the cervical spine with its comorbid disability.

Methods

Using an 11-year nationwide database in Taiwan (National Health Insurance Research Database), this retrospective study cohort analyzed the incidences of cervical OPLL causing hospitalization. All patients admitted for the diagnosis of OPLL, regardless of surgery, were identified. Age- and sex-specific incidences, Poisson regression, and multivariate logistic regression analysis were conducted.

Results

Between 1997 and 2007 covering 241,800,725.8 person-years, 1651 patients were admitted for OPLL. The overall incidence of OPLL-related admission was 6.1 per 1 million person-years. Specifically, male sex and older age were associated with higher OPLL incidences (both p < 0.001). Among the 1651 OPLL patients, 542 (32.8%) received conservative management, 612 (37.1%) had anterior only surgery, 353 (21.4%) had posterior only surgery, and 144 (8.7%) had anterior and posterior surgery. Eighty-five patients were moderately to severely disabled (5.2% cumulative incidence rate). The incidences of disability varied by age, in a decreasing trend, except for the 60- to 69-year-old age group (p = 0.05). Patients who received posterior-only surgery were more likely to have disability.

Conclusions

In a large cohort of the Chinese population, the incidence of cervical OPLL-related admission is 6.1 per 1 million person-years, and the prevalence rate is 7.7 per 100,000 person-years. Higher incidences are observed in elderly and male patients, which implies the disease's degenerative nature. After adjustments for demographics, the incidences and trends of OPLL-related comorbid disability are associated with age and surgical approaches.

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Tsung-Hsi Tu, Jau-Ching Wu, Wen-Cheng Huang, Wan-Yuo Guo, Ching-Lan Wu, Yang-Hsin Shih and Henrich Cheng

Object

Heterotopic ossification (HO) after cervical total disc replacement (TDR) has been reported to impede artificial disc motion. In all previously reported cases of HO, assessment was based on plain radiographs. The authors hypothesized that CT scan is a more sensitive and accurate detector. The aims of this study were to assess the actual incidence of HO and its effect on outcome in a cohort of patients undergoing cervical TDR with the Bryan disc and to compare HO detection by means of plain radiographs and CT.

Methods

The authors retrospectively assessed data from medical records, radiological studies, and clinical evaluations of patients who underwent 1- or 2-level cervical TDR with the Bryan disc and were followed up for more than 12 months. The presence and grading of HO according to the McAfee classification were assessed by CT scan, and these findings were compared with findings on plain radiographs. Thirty-six patients (mean age 46.61 ± 7.24 years; range 29–60 years; 21 men and 15 women) who underwent Bryan TDR at 52 levels were included in the study. The mean duration of CT follow-up was 19.03 ± 4.64 months; the mean duration of clinical follow-up was 26.78 ± 7.20 months.

Results

On the basis of CT, HO was identified in 18 (50%) of 36 patients and 25 (48.1%) of 52 levels treated. Grade 1 HO was present in 9 of the levels treated (17.3%), Grade 2 in 13 levels (25.0%), Grade 3 in 2 levels (3.8%), and Grade 4 in 1 level (1.9%). Nineteen (76%) of the 25 affected levels were in patients who had undergone 2-level TDR. There was no significant association with patient sex or disc pathology. There was a tendency for HO development among older patients, but this finding was not statistically significant (mean age 48.8 ± 6.8 in patients with HO vs 44.4 ± 7.2 in those without HO, p = 0.065). Although HO was found in 25 levels, 96.2% of the treated levels (50 of 52) had segmental range of motion on dynamic (flexion and extension) radiographs. The concordance between HO grading by CT and radiography was high, with an intraclass correlation coefficient of 0.822 (lower limit of 95% CI: 0.710, p < 0.001). Patients who had HO had the same clinical success rate as those who did not (94.4% vs 94.4%, p = 1.00). The visual analog scale scores for neck and arm pain were significantly improved in both the HO and the non-HO group.

Conclusions

The rate of HO detected by CT scan in this cohort of patients undergoing cervical TDR with a Bryan disc was 48.1% per level treated and 50% per patient with minimal limitation of segmental motion (96.2% of levels remained mobile), but plain radiograph is an acceptable detection tool. Two-level surgery has a higher risk of HO, although development of HO does not affect clinical outcome.