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Jin Guo-Xin and Wang Huan

OBJECT

Atlantoaxial instability often requires surgery, and the current methods for fixation pose some risk to vascular and neurological tissues. Thus, new effective and safer methods are needed for salvage operations. This study sought to assess unilateral C-1 posterior arch screws (PASs) and C-2 laminar screws (LSs) combined with 1-side C1–2 pedicle screws (PSs) for posterior C1–2 fixation using biomechanical testing with bilateral C1–2 PSs in a cadaveric model.

METHODS

Six fresh ligamentous human cervical spines were evaluated for their biomechanics. The cadaveric specimens were tested in their intact condition, stabilization after injury, and after injury at 1.5 Nm of pure moment in 6 directions. The 3 groups tested were bilateral C1–2 PSs (Group A); left side C1–2 PSs with an ipsilateral C-1 PAS + C-2 laminar screw (Group B); and left side C1–2 PSs with a contralateral C-1 PAS + C-2 LS (Group C). During the testing, angular motion was measured using a motion capture platform. Data were recorded, and statistical analyses were performed.

RESULTS

Biomechanical testing showed that there was no significant difference among the stabilities of these fixation systems in flexion-extension and rotation control. In left lateral bending, the bilateral C1–2 PS group decreased flexibility by 71.9% compared with the intact condition, the unilateral C1–2 PS and ipsilateral PAS+LS group decreased flexibility by 77.6%, and the unilateral C1–2 PS and contralateral PAS+LS group by 70.0%. Each method significantly decreased C1–2 movements in right lateral bending compared with the intact condition, and the bilateral C1–2 PS system was more stable than the C1–2 PS and contralateral PAS+LS system (p = 0.036).

CONCLUSIONS

A unilateral C-1 PAS + C-2 LS combined with 1-side C-1 PSs provided the same acute stability as the PS, and no statistically significant difference in acute stability was found between the 2 screw techniques. These methods may constitute an alternative method for posterior atlantoaxial fixation.

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Ying-li Gu and Zhong-xin Zhao

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Sudhakar Vadivelu, Xin Xin, Tina Loven, Guillermo Restrepo, David J. Chalif and Avi Setton

The authors present the case of a patient who presented acutely with aneurysmal subarachnoid hemorrhage (SAH) and a contralateral iatrogenic dural arteriovenous fistula (DAVF). Diagnostic angiography was performed, revealing a right-sided middle cerebral artery (MCA) aneurysm and a left-sided DAVF immediately adjacent to the entry of the ventriculostomy and bur hole site. A craniotomy was performed for clipping of the ruptured MCA aneurysm, and the patient subsequently underwent endovascular obliteration of the DAVF 3 days later. The authors present their treatment of an iatrogenic DAVF in a patient with an aneurysmal SAH, considerations in management options, and a literature review on the development of iatrogenic DAVFs.

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Anqi Xiao, Jianguo Xu, Xin He and Chao You

Choroid plexus papilloma (CPP) is extremely rare in the brainstem. The authors report the case of a 10-year-old boy with a lesion in the pons that was misdiagnosed as a glioma preoperatively. The boy underwent partial resection of the lesion, which was diagnosed as a CPP based on histopathological findings. The authors review the MRI findings in this case and conclude that the presence of a well-defined boundary and no obvious cerebral edema are valuable features for distinguishing brainstem CPP from glioma. Although previous reports of parenchymal CPPs have described enhancement on contrast-enhanced T1-weighted MR images, the lesion in this case did not demonstrate significant enhancement. The authors note that the diagnosis of extraventricular CPP cannot be ruled out in a case of brainstem tumor without marked enhancement.

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KaiMing Gao, Jie Lao, Xin Zhao and YuDong Gu

Object

The intercostal nerves (ICNs) have been used to repair the triceps branch in some organizations in the world, but the reported results differ significantly. The effect of this procedure requires evaluation. Thus, this study aimed to evaluate the outcome of ICN transfer to the nerve of the long head of the triceps muscle and to determine the factors affecting the outcome of this procedure.

Methods

A retrospective review was conducted in 25 patients with global root avulsion brachial plexus injuries who underwent ICN transfer. The nerves of the long head of the triceps were the recipient nerves in all patients. The ICNs were used in 2 different ways: 2 ICNs were used as donor nerves in 18 patients, and 3 ICNs were used in 7 patients. The mean follow-up period was 5.6 years.

Results

The effective rate of motor recovery in the 25 patients was 56% for the function of the long head of the triceps. There was no significant difference in functional recovery between the patients with 2 or 3 ICN transfers. The outcome of this procedure was not altered if combined with phrenic nerve transfer to the biceps branch. Patients in whom surgery was delayed 6 months or less achieved better results.

Conclusions

The transfer of ICNs to the nerve of long head of the triceps is an effective procedure for treating global brachial plexus avulsion injuries, even if combined with phrenic nerve transfer to the biceps branch. Two ICNs appear to be sufficient for donation. The earlier the surgery is performed, the better are the results achieved.

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Yu Sun, Li-Xin Wang, Lei Wang, Si-Xin Sun, Xiao-Jian Cao, Peng Wang and Li Feng

Object

The effectiveness of the topical application of mitomycin C (MMC) or 5-fluorouracil (5FU) in preventing peridural adhesion after laminectomy was compared in this study.

Methods

Laminectomies were performed at L-1 in 30 rats. Cotton pads soaked with 0.1 mg/ml MMC, 25 mg/ml 5FU, or 9 mg/ml saline (control) were applied to the operative sites. To evaluate neurological deficits pre- and postoperatively, somatosensory evoked potentials were monitored and the Basso-Beattie-Bresnahan locomotion test was performed. Four weeks postlaminectomy the rats were killed, and peridural scar adhesion was evaluated histologically. The level of hydroxyproline, the area of peridural scar tissue, and the number of fibroblasts were determined. The degree of peridural adhesion was classified according to the Rydell standard.

Results

No obvious adhesion formed in the rats in the MMC group, but severe peridural adhesions were found in those in the 5FU and control groups. The content of hydroxyproline, the area of peridural scar tissue, and the number of fibroblasts in the MMC group were significantly lower than those in the 5FU and control groups.

Conclusions

The topical application of MMC rather than 5FU may be a successful method of preventing post-laminectomy peridural adhesions.

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Xin Wang, Zhiqi Mao, Zhiqiang Cui, Xin Xu, Longsheng Pan, Shuli Liang, Zhipei Ling and Xinguang Yu

OBJECTIVE

Primary Meige syndrome is characterized by blepharospasm and orofacial–cervical dystonia. Deep brain stimulation (DBS) is recognized as an effective therapy for patients with this condition, but previous studies have focused on clinical effects. This study explored the predictors of clinical outcome in patients with Meige syndrome who underwent DBS.

METHODS

Twenty patients who underwent DBS targeting the bilateral subthalamic nucleus (STN) or globus pallidus internus (GPi) at the Chinese People’s Liberation Army General Hospital from August 2013 to February 2018 were enrolled in the study. Their clinical outcomes were evaluated using the Burke–Fahn–Marsden Dystonia Rating Scale at baseline and at the follow-up visits; patients were accordingly divided into a good-outcome group and a poor-outcome group. Putative influential factors, such as age and course of disease, were examined separately, and the factors that reached statistical significance were subjected to logistic regression analysis to identify predictors of clinical outcomes.

RESULTS

Four factors showed significant differences between the good- and poor-outcome groups: 1) the DBS target (STN vs GPi); 2) whether symptoms first appeared at multiple sites or at a single site; 3) the sub-item scores of the mouth at baseline; and 4) the follow-up period (p < 0.05). Binary logistic regression analysis revealed that initial involvement of multiple sites and the mouth score were the only significant predictors of clinical outcome.

CONCLUSIONS

The severity of the disease in the initial stage and presurgical period was the only independent predictive factor of the clinical outcomes of DBS for the treatment of patients with Meige syndrome.

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Ming Luo, Wengang Wang, Mingkui Shen, Xin Luo and Lei Xia

OBJECTIVE

The radiographic and clinical outcomes of low-density (LD) versus high-density (HD) screw constructs in patients with adolescent idiopathic scoliosis (AIS) treated with all–pedicle screw constructs are still controversial. A systematic review and pooled analysis were performed to compare radiographic, perioperative, and quality-of-life (QOL) outcomes and complications in patients with moderate AIS treated with LD or HD screw constructs.

METHODS

The MEDLINE, Embase, and Web of Science databases were searched for English-language articles addressing LD versus HD screw constructs in AIS patients treated with all–pedicle screw constructs. The division of LD and HD groups was based on relative screw density and screw techniques. This systematic analysis strictly followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and all articles included in the analysis met the criteria specified in the guidelines. Two reviewers independently assessed the quality of the studies using the Newcastle-Ottawa Scale. Date on radiographic, perioperative, and QOL outcomes and complications were extracted from the included studies.

RESULTS

Twelve studies, involving a total of 827 patients (480 treated with LD constructs, 347 with HD), were analyzed—1 randomized controlled trial, 1 quasi-randomized controlled trial, and 10 retrospective studies. The patients' age at surgery, preoperative Cobb angle of the major curve, amount of thoracic kyphosis, and major curve flexibility were reasonably distributed, and no statistically significant differences were found. Regarding the outcomes at most recent follow-up, there were no significant differences in the Cobb angle of the major curve (mean difference 0.96°, 95% CI −0.06° to 1.98°, p = 0.06, I2 = 1%), major curve correction (mean difference −0.72%, 95% CI −2.96% to 1.52%, p = 0.53, I2 = 0%), thoracic kyphosis (mean difference −1.67°, 95% CI −4.59° to 1.25°, p = 0.26, I2 = 79%), complications (odds ratio [OR] 0.66, 95% CI 0.31–1.42, p = 0.29, I2 = 0%), and QOL outcomes. Reduced operative time (mean difference −48.56 minutes, 95% CI −82.69 to −14.43 minutes, p = 0.005, I2 = 87%), blood loss (mean difference −77.85 ml, 95% CI −153.10 to −2.60 ml, p = 0.04, I2 = 0%), and hospital charges (mean difference −$5.92K, 95% CI −$6.59K to −$5.26K, p < 0.00001, I2 = 0%) were found in the LD group, compared with the HD group.

CONCLUSIONS

LD and HD screw constructs are both associated with satisfactory radiographic and QOL outcomes with few complications. This study supports the use of LD screw constructs for the treatment of moderate AIS, because they resulted in reduced operative time, blood loss, and hospital charges while maintaining radiographic and QOL outcomes and complication rates similar to those achieved with HD screw constructs.

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Xin Hong, Kevin K. Nelson, Ana C. deCarvalho and Steven N. Kalkanis

Object

Mammalian heparanase has been shown to function in tumor progression, invasion, and angiogenesis. However, heparanase expression in gliomas has not been well analyzed. To clarify its expression in gliomas, human glioma tissues and glioma animal models were investigated.

Methods

The expression of heparanase mRNA was determined in 33 resected human glioma tissues by semiquantitative real-time polymerase chain reaction. Heparanase expression was verified with a Western blot assay and immunohistochemistry (IHC) staining. Primary neurospheres from human glioblastoma multiforme (GBM) were developed in vitro. Heparanase expression in murine astrocytoma and human primary neurosphere animal models was examined using IHC.

Results

The authors found that heparanase mRNA is greatly increased in gliomas including oligodendroglioma (9 samples), anaplastic astrocytoma (11 samples), and GBM (13 samples) as compared with healthy brain mRNA (3 samples). Note, however, that no significant difference was observed among the 3 tumor groups. Increased heparanase expression was also found in tumor tissues on Western blotting. Immunohistochemistry staining demonstrated that heparanase was expressed by neovessel endothelial cells, infiltrated neutrophils, and in some cases, by neoplastic cells. Heparanase-expressing cells, including GBM tumor cells and neovessel endothelial cells, exhibited decreased expression of CD44, a cell adhesion molecule on the cell membrane that is important for regulating tumor invasion. In addition, heparanase-expressing tumor cells showed an elevated density of the cell proliferation marker Ki 67, as compared with its density in non–heparanase-expressing tumor cells, suggesting that heparanase expression is correlated with enhanced tumor proliferation. Two animal glioma models were tested for heparanase expression. Both murine astrocytoma cells (Ast11.9-2) and cultured primary human GBM neurospheres expressed heparanase when grown in animal brain tissue.

Conclusions

Glioma tissues contain increased levels of heparanase. Multiple cell types contribute to the expression of heparanase, including neovessel endothelial cells, tumor cells, and infiltrated neutrophils. Heparanase plays an important role in the control of cell proliferation and invasion. Animal models using Ast11.9-2 and primary neurospheres are suitable for antitumor studies targeting heparanase.