Appropriate timing of surgical intervention for the proximal type of cervical spondylotic amyotrophy.

PURPOSE: The purposes of this study were to evaluate the clinical outcome after surgical treatment of patients with the proximal type of cervical spondylotic amyotrophy (CSA) and to explore the appropriate timing for surgical intervention. MATERIALS AND METHODS: A retrospective review was performed on a consecutive cohort of 41 patients who underwent surgical treatment for the proximal type of CSA between 1995 and 2011 at the Nagoya Spine Group Hospitals. We collected information regarding age, type of muscle atrophy, preoperative and final manual muscle test, duration of symptoms, high-intensity areas on T2-weighted MRI images, low-intensity areas on T1-weighted MRI images, levels of spinal canal stenosis, the compression lesion site, cervical kyphosis and surgical procedures (laminoplasty, anterior spinal fusion and posterior spinal fusion). Univariate analyses and multivariate logistic regression analysis were performed to identify correlates of a poor outcome. To explore the appropriate timing for performing surgery, we analyzed the data using receiver operating characteristic (ROC) analysis. RESULTS: The duration of CSA symptoms was 11.6 months on average. The surgical results were excellent for 25 patients, good for six, fair for nine and poor for one. On multivariate logistic regression analysis, the duration of symptoms was statistically associated with a poor surgical outcome (OR 1.393, p = 0.011). ROC analysis demonstrated that 4.3 months from the onset of CSA symptoms was the appropriate time to undergo surgery. CONCLUSIONS: Our results indicate that we should recommend surgical intervention to patients with the proximal type of CSA within about 4 months after the onset of symptoms if conservative treatment has not been successful.

Characteristics and surgical results of the distal type of cervical spondylotic amyotrophy.

OBJECT: Cervical spondylosis that causes upper-extremity muscle atrophy without gait disturbance is called cervical spondylotic amyotrophy (CSA). The distal type of CSA is characterized by weakness of the hand muscles. In this retrospective analysis, the authors describe the clinical features of the distal type of CSA and evaluate the results of surgical treatment. METHODS: The authors performed a retrospective review of 17 consecutive cases involving 16 men and 1 woman (mean age 56.3 years) who underwent surgical treatment for the distal type of CSA. The condition was diagnosed on the basis of cervical spondylosis in the presence of muscle impairment of the upper extremity (intrinsic muscle and/or finger extension muscles) without gait disturbance, and the presence of a compressive lesion involving the anterior horn of the spinal cord, the nerve root at the foramen, or both sites as seen on axial and sagittal views of MRI or CT myelography. The authors assessed spinal cord or nerve root impingement by MRI or CT myelography and evaluated surgical outcomes. RESULTS: The preoperative duration of symptoms averaged 11.8 months. There were 14 patients with impingement of the anterior horn of the spinal cord and 3 patients with both anterior horn and nerve root impingement. Twelve patients were treated with laminoplasty (plus foraminotomy in 1 case), 3 patients were treated with anterior cervical discectomy and fusion, and 2 patients were treated with posterior spinal fixation. The mean manual muscle testing grade was 2.4 (range 1-4) preoperatively and 3.4 (range 1-5) postoperatively. The surgical results were excellent in 7 patients, good in 2, and fair in 8. CONCLUSIONS: Most of the patients in this series of cases of the distal type of CSA suffered from impingement of the anterior horn of the spinal cord, and surgical outcome was fair in about half of the cases.

Risk factors for a poor outcome following surgical treatment of cervical spondylotic amyotrophy: a multicenter study.

INTRODUCTION: Cervical spondylotic amyotrophy (CSA) is characterized by muscle atrophy in the upper extremities without gait disturbance. However, the indications and outcomes of surgical treatment for CSA have not been clarified. The purpose of this study was to determine the risk factors for a poor outcome following surgical treatment of CSA. MATERIALS AND METHODS: We performed a retrospective review of CSA in patients from 1991 to 2010 through a multicenter study. We collected information regarding age, type of muscle atrophy, preoperative manual muscle test (MMT), duration of symptoms, high-intensity areas on T2-weighted MR images, low-intensity areas on T1-weighted MR images, levels of spinal canal stenosis, cervical kyphosis and surgical procedures (laminoplasty, anterior cervical discectomy and fusion and posterior spinal fusion), and calculated overall risk factors related to a poor outcome following surgery. Univariate analyses and multivariate logistic regression analysis were performed to identify correlates of a poor outcome. RESULTS: Fifty-nine patients, 95 % male (56 patients), were included in our analysis with a mean age of 59 years (range 32-78 years). Eighteen patients did not improve after surgery. Symptom duration (OR = 1.263), preoperative MMT grade (OR = 0.169) and distal type of CSA (OR = 9.223) were all associated with an increased risk of a poor surgical outcome. CONCLUSION: Early surgery is recommended for CSA patients in whom conservative treatment has not been successful. We also recommend surgery for patients who have severe preoperative muscle weakness or have the distal type of CSA.

Primary spinal cord tumors: review of 678 surgically treated patients in Japan. A multicenter study.

PURPOSE: To clarify the relative frequency of various histopathological primary spinal cord tumors and their features in Japanese people and to compare this data with other reports. METHODS: Primary spinal cord tumor surgical cases from 2000 to 2009, which were registered in our affiliated hospital database were collected. We examined age at surgery, sex, anatomical location, vertebral level of the tumor, and pathological diagnosis in each case. RESULTS: Of the 678 patients in our study, 377 patients (55.6 %) were males and 301 patients (44.4 %) were females (male/female ratio 1.25). The mean age at surgery was 52.4 years. Of these tumors, 123 cases (18.1 %) were intramedullary, 371 cases (54.7 %) were intradural extramedullary, 28 cases (4.1 %) were epidural, and 155 cases (22.9 %) were dumbbell tumors. The pathological diagnoses included 388 schwannomas (57.2 %), 79 meningiomas (11.6 %), 54 ependymomas (8.0 %), 27 hemangiomas (4.0 %), 23 hemangioblastomas (3.4 %), 23 neurofibromas (3.4 %), and 9 astrocytomas (1.3 %). The male/female ratios for schwannomas, meningiomas, ependymomas, hemangiomas, hemangioblastomas, neurofibromas, malignant lymphomas, and lipomas are 1.4, 0.34, 1.3, 1.5, 2.3, 1.3, 2.7 and 2.3, respectively. CONCLUSION: This is the first published research in English on the epidemiology of primary spinal cord tumors in Japanese people. Similar to other reports from Asian countries, our data indicates a higher male/female ratio overall for spinal cord tumors, a higher proportion of nerve sheath cell tumors, and a lower proportion of meningiomas and neuroepithelial tumors compared to reports from non-Asian countries. Data in the current study represent the characteristics of primary spinal cord tumors in Asian countries.

Comparison of the percutaneous screw placement precision of isocentric C-arm 3-dimensional fluoroscopy-navigated pedicle screw implantation and conventional fluoroscopy method with minimally invasive surgery.

STUDY DESIGN: Retrospective clinical study to compare the percutaneous screw placement precision of isocentric C-arm (Iso-C) 3-dimensional fluoroscopy-navigated pedicle screw implantation and conventional fluoroscopy. OBJECTIVE: The purpose of this study was to evaluate the accuracy of clinical percutaneous pedicle screw placement (PPSP) using Iso-C 3-dimensional fluoroscopy navigation. SUMMARY OF BACKGROUND DATA: The technique of PPSP recently has been applied to internal fixation for segmental lumbar instability as a form of minimally invasive spine surgery. The percutaneous insertion technique requires surgical skill and experience. The 3-dimensional fluoroscopy-based image-guidance navigation system has been proven to be effective in guiding accurate PPSP in the lumbar area of cadavers. However, there have been few clinical reports comparing the accuracy of Iso-C 3-dimensional fluoroscopy-navigated pedicle screw implantation and the conventional fluoroscopy method. METHODS: Here, 300 percutaneous pedicle screws were evaluated; half of them were inserted under Iso-C 3-dimensional navigation and the others under fluoroscopy. The accuracy of pedicle screw placement was examined postoperatively using an axial 2-mm slice computed tomography. Screw malpositioning was classified either as exposed screw (<50% of the screw outside the pedicle) or perforated pedicle (>50% of the screw outside the pedicle boundaries). RESULTS: Of the 150 pedicle screws placed with Iso-C 3-dimensional fluoroscopy-based image-guide assistance, 11 (7.3%) were classified as exposed screws and 0 (0%) as perforated pedicle. Of the 150 pedicle screws inserted under fluoroscopy, 18 (12%) were classified as exposed screw and 5 (3.3%) as perforated pedicle. The difference in frequency of screw misplacement between the procedure using Iso-C 3-dimensional fluoroscopy-based image-guide assistance and that using fluoroscopy was statistically significant (P<0.05; chi test). CONCLUSIONS: This study demonstrates the feasibility of placing percutaneous posterior lumbar pedicle screws with the assistance of Iso-C 3-dimensional navigation.

A histomorphologic study of scoliosis in pinealectomized chickens.

STUDY DESIGN: Pinealectomy was used to induce scoliosis in Broiler chickens, and a histologic investigation of the pinealectomized chickens was performed. OBJECTIVES: To investigate the incidence of scoliosis in pinealectomized Broiler chickens and to determine histologic changes in vertebrae in the pinealectomized chickens before the occurrence of a secondary vertebral wedging deformity due to scoliosis. SUMMARY OF BACKGROUND DATA: White Leghorn chickens have previously been used as an experimental model of scoliosis, but the occurrence of scoliosis in these chickens following pinealectomy has varied in different reports and is not always high. It is accepted that the development of scoliosis has a close association with growth, but the etiology and mechanism of the disease remain unknown. Histologic findings in vertebrae after the occurrence of scoliosis include those caused by secondary changes due to mechanical compression, and no histologic data for the period before the occurrence of scoliosis are available. METHODS: Study 1. A total of 100 female "Broiler" chickens were pinealectomized, and the frequency with which scoliosis occurred was investigated. Study 2. Sixty female Broiler chickens were divided into three groups: the control group (Group C, n = 20), the sham operation group (Group S, n = 20), and the pinealectomy group (Group P, n = 20). Each group was then subdivided into two groups according to the time of death: 3 days after the operation (Group 3-C, 3-S, 3-P, n = 10), and 6 days after the operation (Group 6-C, 6-S, 6-P, n = 10). Decalcified thin sagittal sections were made using a tartrate-resistant acid phosphatase (TRAP) stain. Histologic examinations of the growth plate, trabecular structure, and osteoclast number were performed. RESULTS: The incidence of scoliosis in the pinealectomized Broiler chickens was 93.6%. Nine of the 10 chickens in Group 6-P showed scoliosis deformity, while the presence of scoliosis was unclear in chickens in Group 3-P. The osteoclast number increased significantly in Group 3-P, compared with Groups 3-C and 3-S, and the trabecular thickness was greater in Group 3-P than in Groups 3-C and 3-S. There was no significant change in the growth plate or in other aspects of the trabecular structure, except for trabecular thickness, in any of the groups. CONCLUSIONS: The results show that the incidence of scoliosis using pinealectomized Broiler chickens is sufficient to study histologic changes of the vertebral body before onset of scoliosis. We found that the osteoclast number and trabecular thickness increased in pinealectomized chickens after 3 days after surgery, just before scoliosis began to develop, and that no change in the growth plate occurred. This suggests that there is no association between changes in the growth plate and the development of scoliosis. However, the change in osteoclast number may have an association with the development of scoliosis, through changes in bone modeling.

Uni-axial cyclic stretch induces the activation of transcription factor nuclear factor kappaB in human fibroblast cells.

The effect of uni-axial cyclic mechanical stretch on the activation of the transcription factor nuclear factor kappaB (NF-kappaB) was investigated in a human fibroblast cell line (TIG-1). In response to uni-axial cyclic stretch, NF-kappaB was found to be translocated into the nucleus. The NF-kappaB was first detectable 2 min after the onset of stretch and then peaked at 4 min and returned to the basal level within 10 min. To investigate whether NF-kappaB is activated following the translocation into the nucleus, we measured the luciferase activity in the cells transfected with pNF-kappaB-luciferase. The activity of luciferase increased 4 min after the initiation of cyclic stretch, peaked at 15 min (6.4-fold increase), and decreased gradually. We examined the involvement of the stretch-activated (SA) channel in the stretch-induced NF-kappaB activation. The application of Gd3+, a blocker of the SA channel, or the removal of extracellular Ca2+ inhibited both the translocation into the nucleus and the activation of NF-kB, which suggests that NF-kappaB is activated by uni-axial cyclic stretch via SA channel activation in human lung fibroblasts.