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Liang Xu, Yong Qiu, Zhonghui Chen, Benlong Shi, Xi Chen, Song Li, Changzhi Du, Zezhang Zhu and Xu Sun

OBJECTIVE

This study aimed to evaluate the correction results of traditional dual growing rods (DGRs) on axial rotation using CT scans and to further explore the relationships between axial and torso deformities in patients with early-onset scoliosis (EOS).

METHODS

Patients with EOS who were treated with traditional DGRs between January 2006 and December 2014 were retrospectively reviewed. Plain radiographs were used to assess the degree of coronal and sagittal deformity. The apical vertebral rotation (AVR) and rib hump (RH) were measured on CT scans at the apical vertebra. Pearson or Spearman rank correlation analyses were used to analyze the associations between spinal and torso deformities.

RESULTS

A total of 27 patients (10 boys and 17 girls, average age 6.5 ± 1.7 years) were enrolled in this study. The average number of lengthenings per patient was 5.0 ± 1.9, with a mean follow-up duration of 52.9 ± 18.2 months. The apical vertebral translation, apical vertebral body–rib ratio (AVB-R), AVR, and RH parameters were significantly decreased after the initial surgery (p < 0.05) but showed notable progression at the latest follow-up evaluation (p < 0.05). The preoperative AVR and its correction after index surgery were significantly correlated with the preoperative values as well as with the corrections of the major Cobb angle, AVB-R, and RH. During the follow-up period, significant correlations were found between the deterioration of AVR and the AVB-R and also between the deterioration of AVR and the RH from the initial surgery to the latest follow-up.

CONCLUSIONS

Significant AVR correction can be achieved by DGR techniques after the initial surgery. However, this technique weakly prevents the deterioration of AVR during the follow-up period.

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Liang Xu, Zhonghui Chen, Yong Qiu, Xi Chen, Song Li, Changzhi Du, Qingshuang Zhou and Xu Sun

OBJECTIVE

As scoliosis in arthrogryposis multiplex congenita (AMC) is unusual and the number of cases reviewed in previous studies is also relatively small, no previous study exists that has directly compared the results of spinal deformity correction between AMC and adolescent idiopathic scoliosis (AIS) patients. The aim of this study was to compare the radiographic and clinical outcomes of surgical correction of spinal deformity associated with AMC versus AIS.

METHODS

Twenty-four adolescents with AMC were matched with 48 AIS patients in terms of Cobb angle of main curve, curve pattern, sex, age at surgery, Risser grade, and length of follow-up. Patients in both groups underwent posterior-only spinal correction and fusion procedures. The surgical outcomes and complications were analyzed and compared between the 2 groups.

RESULTS

In comparison to the AIS group, the AMC group had a significantly longer mean operation time (5.6 vs 4.4 hours, p = 0.002), more blood loss (1620 ± 250 ml vs 840 ± 260 ml, p < 0.001), and more fusion levels (14.1 ± 2.3 levels vs 12.4 ± 2.5 levels, p = 0.007) as well as a lower correction rate (44.3% ± 11.1% vs 70.8% ± 12.4%, p < 0.001) and a higher rate of loss of correction (5.0% ± 3.1% vs 2.1% ± 1.9%, p < 0.001). Nine patients in the AMC group had preoperative pelvic obliquity, which was corrected from a mean of 14.2° ± 8.4° to a mean of 4.3° ± 3.2° (p < 0.001) after the surgery. The thoracic lordosis and sagittal vertical axis were significantly improved in the AMC group. Notably, however, the AMC group was found to have higher rates of screw malpositioning (15.9% vs 9.5%, p = 0.002) and complications (8/24 [33.3%] vs 4/48 [8.3%], p = 0.016) as compared to the AIS group.

CONCLUSIONS

Correction of AMC-associated scoliosis tends to require a longer operating time and involve more fusion levels but results in less correction, more blood loss, and more complications, in comparison with AIS. In addition, more attention should be paid to pelvic obliquity and sagittal hyperlordosis in AMC patients.

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Zhonghui Chen, Song Li, Yong Qiu, Zezhang Zhu, Xi Chen, Liang Xu and Xu Sun

OBJECTIVE

Although the vertical expandable prosthetic titanium rib (VEPTR) and growing rod instrumentation (GRI) encourage spinal growth via regular lengthening, they can create different results because of their different fixation patterns and mechanisms in correcting scoliosis. Previous studies have focused comparisons on coronal plane deformity with minimal attention to the sagittal profile. In this retrospective study, the authors aimed to compare the evolution of the sagittal spinal profile in early-onset scoliosis (EOS) treated with VEPTR versus GRI.

METHODS

The data for 11 patients with VEPTR and 22 with GRI were reviewed. All patients had more than 2 years’ follow-up with more than 2 lengthening procedures. Radiographic measurements were performed before and after the index surgery and at the latest follow-up. The complications in both groups were recorded.

RESULTS

Patients in both groups had similar diagnoses, age at the index surgery, and number of lengthening procedures. The changes in the major coronal Cobb angle and T1–S1 spinal height were not significantly different between the 2 groups. Compared with the GRI group, the VEPTR group had less correction in thoracic kyphosis (23% ± 12% vs 44% ± 16%, p < 0.001) after the index surgery and experienced a greater correction loss in thoracic kyphosis (46% ± 18% vs 11% ± 8%, p < 0.001) at the latest follow-up. Although the increase in the proximal junctional angle was not significantly different (VEPTR: 7° ± 4° vs GRI: 8° ± 5°, p = 0.569), the incidence of proximal junctional kyphosis was relatively lower in the VEPTR group (VEPTR: 18.2% vs GRI: 22.7%). No significant changes in the spinopelvic parameters were observed, while the sagittal vertical axis showed a tendency toward a neutral position in both groups. The overall complication rate was higher in the VEPTR group than in the GRI group (72.7% vs 54.5%).

CONCLUSIONS

The VEPTR had coronal correction and spinal growth results similar to those with GRI. In the sagittal plane, however, the VEPTR was not comparable to the GRI in controlling thoracic kyphosis. Thus, for hyperkyphotic EOS patients, GRI is recommended over VEPTR.

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Jing Xu, Liang Xu, Ziheng Wu, Xianyi Chen, Jun Yu and Jianmin Zhang

OBJECT

P2 segment and distal aneurysms are rare lesions of the cerebrovascular system. The efficacy and safety of endovascular occlusion for these types of aneurysms remain controversial. The aim of this study was to reveal risk factors for endovascular parent artery occlusion of ruptured P2 segment and distal aneurysms.

METHODS

Between March 2010 and November 2012, 812 patients with a ruptured intracranial aneurysm were admitted to the authors' hospital. Among them, 11 patients presented with P2 segment and distal posterior cerebral artery (PCA) aneurysms. These patients were subjected to endovascular treatment. Periprocedural data and clinical and angiographic records were studied retrospectively.

RESULTS

Of the patients with a ruptured PCA aneurysm, 2 of them underwent selective aneurismal coiling, and the remaining patients were treated with simultaneous occlusion of the parent artery. Patients with an adult-type PCA (n = 6), treated with either selective coiling or simultaneous parent artery occlusion, had no serious neurological deficits on follow-up. Four patients with a fetal-type PCA that was also occluded intraoperatively exhibited newly developed permanent paralysis and hemianopsia. However, 1 patient with a fetal-type PCA aneurysm that was selectively coiled recovered without complications. No recanalization was observed in any of the treated aneurysms.

CONCLUSIONS

Endovascular occlusion of an aneurysm and its parent artery is a safe and effective method for managing adult-type P2 segment and distal aneurysms. However, the authors' clinical data suggest that this method is of high risk for patients with fetal-type PCA aneurysms.

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Xiaofeng Deng, Liang Wu, Chenlong Yang and Yulun Xu

Object

Neuropathic arthropathy (Charcot joint) caused by syringomyelia is rare and commonly misdiagnosed. Few cases have been reported by neurosurgeons. The aims of this study were to analyze the clinical and imaging presentations of neuropathic arthropathy and to discuss the effect of surgical management of the primary neurological deficits on neuropathic arthropathy.

Methods

The authors retrospectively reviewed clinical and imaging data of 12 patients with neuropathic arthropathy caused by syringomyelia who were referred to the department of neurosurgery between January 2003 and September 2012. Radiographs revealed destruction, dislocation, disorganization, and increased density or debris in the joints. Magnetic resonance imaging showed a syrinx of the spinal cord in all patients, with Chiari malformation in 11 patients and tethered spinal cord in 1 patient. Neurosurgical operations were performed in 5 of 12 patients, including posterior fossa decompression in 4 patients and syrinx-subarachnoidal shunt placement in 1 patient. Surgical management of the neuropathic joints was not performed in any of the patients. All patients were followed up, with a mean duration of 39 months.

Results

Sixteen joints were involved, including 10 elbows, 3 shoulders, 2 interphalangeal joints, and 1 wrist. The side of the syrinx on cervical axial MRI was consistent with the side of the affected limb in every patient. Five patients who underwent neurosurgical treatments stated improvement in neurological dysfunctions and no deterioration in symptoms related to neuropathic arthropathy. In the 7 patients without neurosurgical treatments, 5 reported aggravation of neuropathic arthropathy manifestations, with deterioration of neurological symptoms in 4 of the 5 patients. The condition of the other 2 patients remained stable.

Conclusions

The elbow is the most frequently involved joint in neuropathic arthropathy caused by syringomyelia, followed by the shoulder. The authors speculate that the side of the syrinx determines the side of the neuropathic arthropathy. A detailed medical history and a careful physical examination are crucial for differentiating neuropathic arthropathy from other joint lesions. This study suggests that early management of the primary neurological condition may play an important role in preventing the development of neuropathic arthropathy and avoiding disease progression.

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Liang Wu, Xiaofeng Deng, Chenlong Yang and Yulun Xu

Object

Intramedullary capillary hemangiomas are exceedingly rare lesions in the spinal cord, and have been previously reported in the literature as case reports. The authors review their experience in 5 surgically treated patients with intramedullary capillary hemangiomas and discuss the clinical features, radiological findings, and surgical outcomes.

Methods

Clinical and imaging data of 5 patients with intramedullary spinal capillary hemangiomas treated at a single institution were retrospectively analyzed.

Results

There were 4 men and 1 woman, and their ages ranged from 18 to 63 years (mean 47.2 years). The thoracic cord was affected in 4 patients, and the cervicothoracic cord in 1 patient. Four patients underwent a gross-total resection. One patient initially underwent a subtotal removal and then underwent a second surgery due to enlargement of the residual lesion. Long-term neurological function was improved in all patients and MRI showed no tumor recurrence.

Conclusions

Capillary hemangiomas should be considered in the differential diagnosis of intramedullary spinal vascular lesions. Complete resection is the treatment of choice for these lesions. When total resection cannot be achieved, subtotal or even partial removal of the tumor is advised and repeat removal of the lesion is indicated when residual tumor regrowth is associated with neurological deterioration.

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Tao Yang, Liang Wu, Jingyi Fang, Chenlong Yang, Xiaofeng Deng and Yulun Xu

OBJECT

Intramedullary neurenteric cysts (NECs) are exceedingly rare lesions and have been previously reported in case reports. The aim of this study was to determine the clinical manifestations, radiological features, and long-term prognosis of patients with such lesions.

METHODS

The authors retrospectively reviewed the records of 13 patients with an intramedullary NEC. Each patient underwent MRI, laminotomy, and microsurgery. The accurate diagnosis was based on imaging and pathology findings. Each patient's follow-up status was determined through individual office visits and a structured telephone interview.

RESULTS

The series included 7 male and 6 female patients. Progressive or intermittent motor deficit was the main symptom associated with or without pain or sensory disturbance. Five cysts were located in the cervical cord, 1 in the cervicothoracic cord, 3 in the thoracic cord, and 4 in the conus medullaris. Concurrent malformations included scoliosis (3 cases), fusion of rib (1 case), enlarged spinal canal (1 case), tethered spinal cord (1 case), and ectocardia (1 case). Gross-total resection of the cyst was achieved in 8 cases, and subtotal resection (STR) was achieved in 5 cases. All patients were followed up, with a mean duration of 66.5 months. Cyst recurrence was observed in 4 cases after STR. In 2 cases the patients underwent reoperation; the other 2 patients remained clinically stable and did not undergo reoperation. At the last evaluation, neurological function was improved in 11 patients and remained stable in 2 patients.

CONCLUSIONS

Intramedullary NECs should be considered in the differential diagnosis of a middle-aged patient with intermittent neurological symptoms and concurrent malformations. Early surgery is advocated to prevent permanent neurological deficits. When gross-total resection cannot be achieved, maximally safe removal under the protection of intraoperative neuromonitoring is advised. Because of the high risk of cyst recurrence, routine follow-up MRI is needed. If a residual cyst shows obvious regrowth and results in neurological deficits, timely reoperation with a goal of STR should be performed.

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Liang Xu, Benlong Shi, Yong Qiu, Zhonghui Chen, Xi Chen, Song Li, Changzhi Du, Qingshuang Zhou, Zezhang Zhu and Xu Sun

OBJECTIVE

This study aimed to quantify the response of the cervical spine to the surgical correction of Scheuermann’s kyphosis (SK) and to postoperative proximal junctional kyphosis (PJK).

METHODS

Fifty-nine patients (mean age 14.6 ± 2.3 years) were enrolled in the study: 35 patients in a thoracic SK (T-SK) group and 24 in a thoracolumbar SK (TL-SK) group. The mean follow-up period was 47.2 ± 17.6 months. Radiographic data, PJK-related complications, and patient-reported outcomes were compared between groups.

RESULTS

The global kyphosis significantly decreased postoperatively, and similar correction rates were observed between the two groups (mean 47.1% ± 8.6% [T-SK] vs 45.8% ± 9.4% [TL-SK], p = 0.585). The cervical lordosis (CL) in the T-SK group notably decreased from 21.4° ± 13.3° to 13.1° ± 12.4° after surgery and was maintained at 14.9° ± 10.7° at the latest follow-up, whereas in the TL-SK group, CL considerably increased from 7.2° ± 10.7° to 11.7° ± 11.1° after surgery and to 13.8° ± 8.9° at the latest follow-up. PJK was identified in 16 patients (27.1%). Its incidence in the TL-SK group was notably higher than it was in the T-SK group (41.6% [n = 10] vs 17.1% [n = 6], p = 0.037). Compared with non-PJK patients, PJK patients had greater CL and lower pain scores on the Scoliosis Research Society–22 questionnaire (p < 0.05).

CONCLUSIONS

Hyperkyphosis correction eventually resulted in reciprocal changes in the cervical spine, with CL notably decreased in the T-SK group but significantly increased in the TL-SK group. Patients developing PJK have increased CL, which seems to have a negative effect on patients’ health-related quality of life.

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Liang Chen, Huilin Yang, Tongqi Yang, Yaozeng Xu, Zhaohua Bao and Tiansi Tang

Object

The authors undertook a study in patients with traumatic central cord syndrome (TCCS) who underwent surgical intervention. They retrospectively assessed the motor score improvement and functional status and identified prognostic predictors of improvement.

Methods

Between March 1999 and May 2004, 49 patients with TCCS were surgically treated. Motor scores were collected at admission and follow-up using the American Spinal Injury Association (ASIA) Impairment Scale. The 36-Item Short Form Health Survey (SF-36) was administered. Other parameters including walking index, spasticity, bladder management, and neuropathic pain scores were recorded. Patients were asked to assess their level of satisfaction with their final symptoms.

Results

The average ASIA score, converted into numeric values, was increased from 54.9 at admission to 81.9 and 89.6 at 6 months and final follow-up, respectively. Significant improvement of ASIA score was achieved within the first 6 months of surgery. No significant difference was found between patients who underwent surgery within 4 days of injury or after 4 days of injury, adopting different approaches (anterior, posterior, or a combination), or with different pathological entities (acute disc herniation, fracture or dislocation, or multilevel degeneration). The ASIA score improvement had a positive correlation with the age at injury (r = 0.505, p = 0.023). The SF-36 data at 6 months and final follow-up were not as satisfactory as the improvement in ASIA scores, and almost one-third of patients expressed dissatisfaction with their final symptoms. For patients who were older than 65 years at injury, the mean follow-up Walking Index for Spinal Cord Injury (WISCI) score was statistically lower than it was in younger patients. The presence of spasticity or neuropathic pain at follow-up was not related to age, sex, ASIA motor score, or WISCI outcome.

Conclusions

Surgical intervention can be safely applied in patients with TCCS. Significant improvement of ASIA score was achieved during the first 6-month period of follow-up. Factors including type of lesion, timing of surgery within or after 4 days of injury, and surgical approach were not significantly associated with final ASIA score. The improvement in the ASIA motor score was positively correlated with age at injury. No significant correlation was found between or among the presence of spasticity, neuropathic pain, and ASIA score at final visit. Almost one-third of patients were not satisfied with their final symptoms.

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Fengping Zhu, Yi Qian, Bin Xu, Yuxiang Gu, Kaavya Karunanithi, Wei Zhu, Liang Chen, Ying Mao and Michael K. Morgan

OBJECTIVE

Although intracranial vessel remodeling has been observed in moyamoya disease, concerns remain regarding the effect of bypass surgery on hemodynamic changes within the internal carotid artery (ICA). The authors aimed to quantify the surgical effect of bypass surgery on bilateral ICAs in moyamoya disease and to estimate pressure drop (PD) along the length of the ICA to predict surgical outcomes.

METHODS

Records of patients who underwent bypass surgery for treatment of moyamoya disease and in whom flow rates were obtained pre- and postsurgery by quantitative MR angiography were retrospectively reviewed. Quantitative MR angiography and computational fluid dynamics were applied to measure morphological and hemodynamic changes during pre- and postbypass procedures. The results for vessel diameter, volumetric flow, PD, and mean wall shear stress along the length of the ICA were analyzed. Subgroup analysis was performed for the circle of Willis (CoW) configurations.

RESULTS

Twenty-three patients were included. The PD in ICAs on the surgical side (surgical ICAs) decreased by 21.18% (SD ± 30.1%) and increased by 11.75% (SD ± 28.6%) in ICAs on the nonsurgical side (contralateral ICAs) (p = 0.001). When the PD in contralateral ICAs was compared between patients with a complete or incomplete CoW, the authors found that the PDI in the former group decreased by 2.45% and increased by 20.88% in the latter (p = 0.05). Regression tests revealed that a greater postoperative decrease in PD corresponded to shrinking of ICAs (R2 = 0.22, p = 0.02).

CONCLUSIONS

PD may be used as a reliable biomechanical indicator for the assessment of surgical treatment outcomes. The vessel remodeling characteristics of contralateral ICA were related to CoW configurations.