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Hui Liu, Zemin Li, Sibei Li, Kuibo Zhang, Hao Yang, Jianru Wang, Xiang Li and Zhaomin Zheng

OBJECT

The aim of this study was to evaluate the effects of rod stiffness and implant density on coronal and sagittal plane correction in patients with main thoracic curve adolescent idiopathic scoliosis (AIS).

METHODS

The authors conducted a retrospective study of 77 consecutive cases involving 56 female and 21 male patients with Lenke Type 1 main thoracic curve AIS who underwent single-stage posterior correction and instrumented spinal fusion with pedicle screw fixation between July 2009 and July 2012. The patients' mean age at surgery was 15.79 ± 3.21 years. All patients had at least 1 year of follow-up. Radiological parameters in the coronal and sagittal planes, including Cobb angle of the major curve, side-bending Cobb angle of the major curve, thoracic kyphosis (TK), correction rates, and screw density, were measured and analyzed. Screw densities (calculated as number of screws per fusion segment × 2) of < 0.60 and ≥ 0.60 were defined as low and high density, respectively. Titanium rods of 5.5 mm and 6.35 mm diameter were defined as low and high stiffness, respectively. Patients were divided into 4 groups based on the type of rod and density of screw placement that had been used: Group A, low-stiffness rod with low density of screw placement; Group B, low-stiffness rod with high density of screw placement; Group C, high-stiffness rod with low density of screw placement; Group D, high-stiffness rod with high density of screw placement.

RESULTS

The mean coronal correction rate of the major curve, for all 77 patients, was (81.45% ± 7.51%), and no significant difference was found among the 4 groups (p > 0.05). Regarding sagittal plane correction, Group A showed a significant decrease in TK after surgery (p < 0.05), while Group D showed a significant increase (p < 0.05); Group B and C showed no significant postoperative changes in TK (p > 0.05). The TK restoration rate was highest in Group D and lowest in Group A (A, −39.32% ± 7.65%; B, −0.37% ± 8.25%; C, −4.04% ± 6.77%; D, 37.59% ± 8.53%). Screw density on the concave side was significantly higher than that on the convex side in all the groups (p < 0.05).

CONCLUSIONS

For flexible main thoracic curve AIS, both rods with high stiffness and those with low stiffness combined with high or low screw density could provide effective correction in the coronal plane; rods with high stiffness along with high screw density on the concave side could provide better outcome with respect to sagittal TK restoration.

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Jinqian Liang, Ran Ding, Sooyong Chua, Zheng Li and Jianxiong Shen

Object

The safety of spinal fusion has been poorly studied in children with surgically corrected congenital cardiac malformations (CCMs). The objective of this study was to evaluate the safety of spinal fusion in patients with CCMs following cardiac surgery.

Methods

A retrospective study was conducted on 32 patients with scoliosis who received surgical treatment for their CCMs (CCM group). Sixty-four age- and sex-matched patients with scoliosis and normal hearts who received spinal fusion served as the control group. These 2 groups were compared for demographic distribution, blood loss, transfusion requirements, and incidence of postoperative complications.

Results

The ages, curve pattern distributions, and number of levels fused were similar between the 2 groups before spinal fusion. Overall, a total of 7 patients in the CCM group (21.9%) and 5 (7.8%) in the control group had documented postoperative complications. The perioperative allogenic blood transfusion rate and mean red blood cell transfusion requirement in the CCM group were significantly higher than those found in patients in the control group (68.7% vs 28.1%, respectively, p = 0.000; and 2.68 ± 2.76 units/patient vs 0.76 ± 1.07 units/patient, respectively, p = 0.011). In the CCM group, a preoperative major curve magnitude ≥ 80° was the most accurate indicator of an increased risk for a major complication (p = 0.019), whereas no statistically significant correlation was noted between postoperative complications and age, type of congenital heart disease, operative duration, and estimated blood loss during the operation and transfusion.

Conclusions

Spinal fusion subsequent to prior cardiac surgery is relatively safe and effective in correcting the spinal deformity for patients with scoliosis and surgically corrected CCMs. A preoperative major curve magnitude ≥ 80° may be a risk factor in predicting postoperative complications in scoliotic patients with surgically corrected CCMs.

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Zhe-Feng Zhao, Li-Zhuang Yang, Chuan-Lu Jiang, Yong-Ri Zheng and Jin-Wei Zhang

Object

The authors' goal was to observe histopathological changes in the trigeminal nerve after Gamma Knife surgery (GKS) in rhesus monkeys, and to investigate the radiobiological mechanism of GKS for primary trigeminal neuralgia. The nerve length–dosage effect of irradiation is also discussed.

Methods

One of 5 rhesus monkeys randomly served as a control, and the other 4 monkeys were randomly administered a target radiation dose of 60, 70, 80, or 100 Gy (a different dose in each animal). The size of the collimator was 4 mm, and the target point was the trigeminal nerve root. In each experimental monkey, one side was exposed to single-target-point irradiation, and the contralateral side was exposed to double-target-point irradiation. After 6 months, the trigeminal nerve root was examined using light microscopy, transmission electron microscopy, and immunohistochemistry.

Results

At each radiation dose, the damage to the nerve tissue by single-target-point irradiation was identical to that caused by double-target-point irradiation. In the trigeminal nerve tissues of the monkeys irradiated with 60 and 70 Gy, there was limited nerve demyelination and degeneration, fragmentation, or loss of axons. In the trigeminal nerve tissue of the monkey irradiated with 80 Gy, the nerve tissue showed a disordered structure. In the trigeminal nerve tissue of the monkey irradiated with 100 Gy, there was severe derangement in the structure of the nerve tissue, and extensive demyelination, fragmentation, and loss of axons.

Conclusions

The target doses of 60 and 70 Gy have very little impact on the structure of the trigeminal nerve. Irradiation at 80 Gy can cause partial degeneration and loss of axons and demyelination. A 100-Gy dose can cause some necrosis of neurons. Comparing the single-target-point with the double-target-point irradiation, the extent of damage to the nerve tissue is identical, and no difference in the nerve length–dosage effect was found.

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Xinyu Liu, Suomao Yuan, Yonghao Tian, Lianlei Wang, Liangtai Gong, Yanping Zheng and Jianmin Li

OBJECTIVE

This study aimed to evaluate the clinical outcomes of percutaneous endoscopic transforaminal discectomy (PETD), microendoscopic discectomy (MED), and microdiscectomy (MD) for treatment of symptomatic lumbar disc herniation (LDH).

METHODS

One hundred ninety-two patients with symptomatic LDH at L3–4 and L4–5 were included in this study. The mean (± SD) age of patients was 34.2 ± 2.6 years (range 18–62 years). The patients were divided into groups as follows: group A was treated with PETD and included 60 patients (31 men and 29 women) with a mean age of 36.2 years; group B was treated with MED and included 63 patients (32 men and 31 women) with a mean age of 33.1 years; and group C was treated with MD and included 69 patients (36 men and 33 women) with a mean age of 34.0 years. The Japanese Orthopaedic Association (JOA) scale for low-back pain (LBP), Oswestry Disability Index (ODI), creatine phosphokinase activity 3 days after surgery, and visual analog scale (VAS) scores for LBP and leg pain were used for evaluation of clinical results.

RESULTS

There were no significant differences in mean preoperative JOA score, ODI score, and VAS scores for LBP and leg pain among groups A, B, and C. Incision length, duration of the operation, blood loss, creatine phosphokinase, length of hospital stay, and postoperative incision pain according to the VAS were best in the PETD group (p < 0.05). The number of seconds of intraoperative fluoroscopy was highest in the PETD group (p < 0.05), whereas there was no difference between the MED and MD groups. Three cases from the MED group and 2 cases from the MD group had an intraoperative durotomy. No CSF leakage was observed after surgery. One case from the MED group and 3 cases from the MD group had incision infections. There were no neurological deficits related to the surgeries in any of the groups. Fifty-five (91.6%), 59 (93.7%), and 62 patients (89.9%) had at least 2 years of follow-up in groups A, B, and C, respectively. At the last follow-up, JOA scores, VAS scores of LBP and leg pain, and ODI scores were significantly better than preoperative correlates in all groups. There were no differences among the 3 groups in JOA scores, JOA recovery rate, ODI scores, and VAS scores for leg pain. The VAS score for LBP was best in the PETD group (p < 0.05). No lumbar instability was observed in any group. Three cases (5.5%) in the PETD group had recurrent LDH, and 2 recurrent cases (3.4%) were confirmed in the MED group.

CONCLUSIONS

PETD, MED, and MD were all reliable techniques for the treatment of symptomatic LDH. With a restricted indication, PETD can result in rapid recovery and better clinical results after at least 2 years of follow-up.

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Xinyu Liu, Lianlei Wang, Suomao Yuan, Yonghao Tian, Yanping Zheng and Jianmin Li

OBJECT

Lumbar spondylolysis and isthmic spondylolisthesis occur most commonly at only one spinal level. The authors report on 13 cases of lumbar spondylolysis with spondylolisthesis at multiple levels.

METHODS

During July 2007–March 2012, multiple-level spondylolysis associated with spondylolisthesis was diagnosed in 13 patients (10 male, 3 female) at Qilu Hospital of Shandong University. The mean patient age was 43.5 ± 14.6 years. The duration of low-back pain was 11.7 ± 5.1 months. Spondylolysis occurred at L-2 in 2 patients, L-3 in 4 patients, L-4 in all patients, and L-5 in 5 patients. Spondylolysis occurred at 3 spinal levels in 3 patients and at 2 levels in 10 patients. All patients had spondylolisthesis at 1 or 2 levels. Japanese Orthopaedic Association and visual analog scale scores were used to evaluate preoperative and postoperative neurological function and low-back pain. All patients underwent pedicle screw fixation and interbody fusion or direct pars interarticularis repair.

RESULTS

Both low-back pain scores improved significantly after surgery (p < 0.05). Postoperative radiographs or CT scans showed satisfactory interbody fusion or pars interarticularis healing. No breakage, dislodging, or loosening of the pedicle screw hardware was observed for any patient.

CONCLUSIONS

Multiple-level lumbar spondylolysis and spondylolisthesis occurred more often in men. Most multiplelevel lumbar spondylolysis occurred at 2 spinal levels and was associated with sports, trauma, or heavy labor. Multiplelevel lumbar spondylolysis occurred mostly at L3–5; associated spondylolisthesis usually occurred at L-4 and L-5, mostly at L-4. The treatment principle was the same as that for single-level spondylolisthesis.

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Xinyu Liu, Suomao Yuan, Yonghao Tian, Lianlei Wang, Yanping Zheng and Jianmin Li

OBJECT

The purpose of this study was to determine the efficacy of a modified vertebral column resection for the treatment of thoracolumbar angular kyphosis.

METHODS

A total of 13 patients (8 male, 5 female) with thoracolumbar kyphosis (kyphotic angle > 60°) were included in this study (Group A). There were 3 patients with failure of spinal formation (Type 1 deformity), 6 patients with old thoracic or lumbar compression fracture, and 4 patients with old spinal tuberculosis (including 1 case of T3–5 vertebral malunion). The average preoperative kyphotic angle was 67.3° (range 62°–75°). Each patient underwent an expanded eggshell procedure combined with the closing-opening technique for the treatment of thoracolumbar angular kyphosis. Sixteen patients who were previously treated with a closing-opening wedge osteotomy in the same spine classification group (kyphotic angle > 60°) were used as a control group (Group B).

RESULTS

In Group A, the average (± SD) operative time was 400 ± 60 minutes, and the average blood loss was 960 ± 120 ml. There were no surgery-related complications observed during or after the operations. The average local kyphotic angle was 20.3° (range 18°–24.5°), and the average correction rate was 68.7%. In Group B, the average operative time was 470 ± 90 minutes, and the average blood loss was 2600 ± 1600 ml (range 1200–8200 ml). There were segmental vessels and spinal canal venous plexus injury in 1 case, spinal cord injury in 1 case, dural tearing in 2 cases, pleural rupture in 2 cases, and hemothorax and pneumothorax in 1 case. Each patient had more than 2 years of follow-up. At the latest follow-up examination, the average regional kyphotic angle was 19.9° ± 9.1° (range 19°–34°), and there was no significant loss of correction (p > 0.05). There was greater blood loss and a higher complication rate in Group B than in Group A (p < 0.05).

CONCLUSIONS

An expanded eggshell procedure combined with the closing-opening technique for the treatment of thoracolumbar angular kyphosis resulted in significant reduction of the kyphotic angle, few complications, and good follow-up results. However, a larger series of patients and long-term follow-up results is still required to verify the effectiveness and safety of this method.

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Jiangwei Tan, Yanping Zheng, Liangtai Gong, Xinyu Liu, Jianmin Li and Wei Du

Object

The authors report the short-term results of anterior cervical discectomy and interbody fusion performed via an endoscopic approach.

Methods

Thirty-six patients who underwent anterior cervical discectomy and fusion (ACDF) performed using endoscopic surgery were selected for this study. The indications for surgery were cervical disc herniation caused by neck injury, spondylotic myelopathy, cervical radiculopathy, and solitary ossification of the posterior longitudinal ligament (OPLL). The involved levels included C3–4, C4–5, C5–6, and C6–7. The working channel was inserted through a 20-mm transverse incision, the protruding discs or area of OPLL were excised for complete decompression, and then an appropriate intervertebral polyetheretherketone fusion cage was implanted.

Results

The time spent in surgery was 120 minutes on average (range 50–150 minutes), and the mean blood loss was 55 ml (range 20–140 ml). There were no intraoperative complications and no symptoms of irritation in the laryngopharynx after surgery. However, postoperative hemorrhage of the incision occurred in 1 case. The follow-up period ranged from 26–50 months (mean 38.5 months). Postoperative Japanese Orthopaedic Association and visual analog scale scores improved significantly.

Conclusions

Endoscopic surgery for ACDF can produce satisfactory results in patients with cervical disc herniation, cervical myelopathy, or radiculopathy. The optimal levels for this procedure are C4–5 and C5–6. Compared with a traditional approach, this technique has great advantages in terms of cosmetic results, intraoperative visualization, and postoperative recovery course. Nevertheless, every precaution should be taken to avoid possible complications, such as postoperative hemorrhage.

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Jian Zheng, Zhen Liu, Weishan Li, Jiaxin Tang, Dongwei Zhang and Xiaobo Tang

OBJECTIVE

Inflammation and apoptosis are two key factors contributing to secondary brain injury after intracerebral hemorrhage (ICH). The objective of this study was to evaluate the effects of lithium posttreatment on behavior, brain atrophy, inflammation, and perihematomal cell death. Furthermore, the authors aimed to determine the role of the pro-apoptotic glycogen synthase kinase-3β (GSK-3β) after experimental ICH.

METHODS

Male Sprague-Dawley rats (n = 108) were subjected to intracerebral infusion of semicoagulated autologous blood. Window of opportunity and dose optimization studies of lithium on ICH-induced injury were performed by measuring neurological deficits. Animals with ICH received vehicle administration or lithium posttreatment (60 mg/kg) for up to 21 days. Hemispheric atrophy was evaluated. Perihematomal cell death was quantified through terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick-end labeling (TUNEL). The number of myeloperoxidase (MPO)-positive neutrophils and OX42-positive microglia in the perihematomal areas were calculated. Western blotting was used for the quantification of GSK-3β, heat shock protein 70 (HSP70), nuclear factor-κB p65 (NF-κB p65), and cy-clooxygenase-2 (COX-2).

RESULTS

Lithium, at a dose of 60 mg/kg initiated from 2 hours after injury, exhibited the best effects of improving neurological outcomes 3, 5, 7, 14, 21, and 28 days after ICH, reduced the hemispheric atrophy at 42 days after surgery, and reduced the number of TUNEL-positive cells, MPO-positive neutrophils, and OX42-positive microglia in the perihematomal areas. Furthermore, lithium posttreatment modulated GSK-3β, increased HSP70, and decreased NF-κB p65 and COX-2 expression in the ipsilateral hemisphere.

CONCLUSIONS

Lithium posttreatment at a dose of 60 mg/kg, initiated beginning 2 hours after injury, improves functional and morphological outcomes, and inhibits inflammation and perihematomal cell death in a rat model of semicoagulated autologous blood ICH through inactivation of GSK-3β.

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Yanlu Zhang, Zheng Gang Zhang, Michael Chopp, Yuling Meng, Li Zhang, Asim Mahmood and Ye Xiong

OBJECTIVE

The authors' previous studies have suggested that thymosin beta 4 (Tβ4), a major actin-sequestering protein, improves functional recovery after neural injury. N-acetyl-seryl-aspartyl-lysyl-proline (AcSDKP) is an active peptide fragment of Tβ4. Its effect as a treatment of traumatic brain injury (TBI) has not been investigated. Thus, this study was designed to determine whether AcSDKP treatment improves functional recovery in rats after TBI.

METHODS

Young adult male Wistar rats were randomly divided into the following groups: 1) sham group (no injury); 2) TBI + vehicle group (0.01 N acetic acid); and 3) TBI + AcSDKP (0.8 mg/kg/day). TBI was induced by controlled cortical impact over the left parietal cortex. AcSDKP or vehicle was administered subcutaneously starting 1 hour postinjury and continuously for 3 days using an osmotic minipump. Sensorimotor function and spatial learning were assessed using a modified Neurological Severity Score and Morris water maze tests, respectively. Some of the animals were euthanized 1 day after injury, and their brains were processed for measurement of fibrin accumulation and neuroinflammation signaling pathways. The remaining animals were euthanized 35 days after injury, and brain sections were processed for measurement of lesion volume, hippocampal cell loss, angiogenesis, neurogenesis, and dendritic spine remodeling.

RESULTS

Compared with vehicle treatment, AcSDKP treatment initiated 1 hour postinjury significantly improved sensorimotor functional recovery (Days 7–35, p < 0.05) and spatial learning (Days 33–35, p < 0.05), reduced cortical lesion volume, and hippocampal neuronal cell loss, reduced fibrin accumulation and activation of microglia/macrophages, enhanced angiogenesis and neurogenesis, and increased the number of dendritic spines in the injured brain (p < 0.05). AcSDKP treatment also significantly inhibited the transforming growth factor–β1/nuclear factor–κB signaling pathway.

CONCLUSIONS

AcSDKP treatment initiated 1 hour postinjury provides neuroprotection and neurorestoration after TBI, indicating that this small tetrapeptide has promising therapeutic potential for treatment of TBI. Further investigation of the optimal dose and therapeutic window of AcSDKP treatment for TBI and the associated underlying mechanisms is therefore warranted.

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Jianxiong Shen, Jinqian Liang, Haiquan Yu, Guixing Qiu, Xuhong Xue and Zheng Li

Object

There are limited published data about the risk factors for the development of delayed infections after spinal fusion and instrumentation in the population with scoliosis. The objective of this study was to evaluate the predictive factors of development of delayed infections in patients with scoliosis who underwent surgical treatment.

Methods

A total of 17 patients with scoliosis and delayed infections were identified from 3463 patients with scoliosis who received surgical treatment. The control group was composed of 85 patients with scoliosis without infections, matched for sex, age, approximate date of surgery, and diagnosis. These 2 groups were compared for demographic distribution and clinical data to investigate the predictive factors of delayed infections.

Results

The overall incidence rate of delayed infections was 0.49%. The variables of age, body mass index, and number of levels fused were similar between the 2 groups. The average primary curve magnitude for the delayed infection and control (uninfected) groups was 80.4° ± 27.0° (range 47°–135°) and 66.3° ± 11.6° (range 42°–95°), respectively (p = 0.001). Operation time in the group with delayed infections was 384.7 ± 115.9 minutes versus 254.4 ± 79.2 minutes in the control group (p = 0.000), and estimated blood loss was 1342.2 ± 707.2 ml versus 833.9 ± 235.6 ml (p = 0.000) in these 2 groups, respectively. The perioperative mean red blood cell transfusion requirement in the delayed infection group was significantly higher than that found in patients without infections (2.8 ± 2.3 units/patient versus 1.1 ± 1.6 units/patient, respectively; p = 0.000). Logistic regression analysis showed that operation time and allogenic blood transfusion were the 2 independent predictors of delayed infections (odds ratio [OR] 1.021, 95% confidence interval [CI] 1.010–1.033, and OR 1.546, 95% CI 1.048–2.278, respectively).

Conclusions

The occurrence of a delayed infection in patients with scoliosis who undergo surgical treatment is most likely multifactorial and is related to surgical time and the use of allogenic blood transfusion.