Bone Turnover Markers in Patients With Ossification of the Posterior Longitudinal Ligament in the Thoracic Spine.

STUDY DESIGN: A prospective, single-center, observational study. OBJECTIVE: To explore the association between serum levels of bone turnover markers and ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine. SUMMARY OF BACKGROUND DATA: The relationship between bone turnover markers, such as N-terminal propeptide of type I procollagen (PINP) or tartrate-resistant acid phosphate 5b (TRACP-5b), and OPLL has previously been examined. However, the correlation between these markers and thoracic OPLL, which is more severe than cervical-only OPLL, remains unclear. METHODS: This prospective study included 212 patients from a single institution with compressive spinal myelopathy and divided them into those without OPLL (Non-OPLL group, 73 patients) and those with OPLL (OPLL group, 139 patients). The OPLL group was further subdivided into cervical OPLL (C-OPLL, 92 patients) and thoracic OPLL (T-OPLL, 47 patients) groups. Patients' characteristics and biomarkers related to bone metabolism, such as calcium, inorganic phosphate (Pi), 25-hydroxyvitamin D, 1α,25 dihydroxyvitamin D, PINP, and TRACP-5b, were compared between the Non-OPLL and OPLL groups, as well as the C-OPLL and T-OPLL groups. Bone metabolism biomarkers were also compared after adjusting for age, sex, body mass index, and the presence of renal impairment using propensity score-matched analysis. RESULTS: The OPLL group had significantly lower serum levels of Pi and higher levels of PINP versus the Non-OPLL group as determined by propensity score-matched analysis. The comparison results between the C-OPLL and T-OPLL groups using a propensity score-matched analysis showed that T-OPLL patients had significantly higher concentrations of bone turnover markers, such as PINP and TRACP-5b, compared with C-OPLL patients. CONCLUSIONS: Increased systemic bone turnover may be associated with the presence of OPLL in the thoracic spine, and bone turnover markers such as PINP and TRACP-5b can help screen for thoracic OPLL.

Reliability and head-loading effects in imaging diagnosis of vertical subluxation in patients with rheumatoid arthritis.

OBJECTIVES: The purpose of this study was to examine the reproducibility of vertical subluxation (VS) parameters using X-ray, computed tomography (CT), and tomosynthesis (TS) while comparing the head-loading effects. METHODS: The VS parameters of 26 patients (retrospective review) were evaluated. Using the intra-class correlation coefficient, we statistically examined the intra-rater and inter-rater reliabilities of the parameters. Head-loaded and -unloaded imagings were compared using a Wilcoxon signed-rank test. RESULTS: The intra-rater reliability of TS and CT showed intra-class correlation coefficients of ≥0.8 (X-ray range: 0.6-0.8), with similar results for the inter-rater reliabilities. Furthermore, in head-loading imaging, the TS had significantly higher VS scores than that of CT (P < .05). CONCLUSIONS: In comparison with the X-ray, TS and CT were more accurate and reproducible. In terms of head loading, the VS values for TS were worse than those for CT, indicating that TS was more effective than CT in diagnosing VS.

Surgical outcomes of intraoperative O-arm versus C-arm fluoroscopy in occipitocervical fixation: a retrospective analysis.

PURPOSE: This study aims to compare the effect of using O-arm and C-arm fluoroscopy on the surgical outcomes of occipitocervical fixation. METHODS: The study included patients who underwent occipitocervical fixation using O-arm or C-arm between 2005 and 2021. Of 56 patients, 34 underwent O-arm-assisted surgery (O-group) and 22 underwent C-arm-assisted surgery (C-group). We assessed surgical outcomes, including operative time, intraoperative blood loss, perioperative complications, and bone union. RESULTS: Almost half of the patients had rheumatoid arthritis-related disorders in both groups. Sixteen cases (47.1%) in the O-group and 12 cases (54.5%) in the C-group were fixed from occipito (Oc) to C3, 12 cases (38.2%) in the O-group and 7 cases (31.8%) in the C-group from Oc to C4-7, 5 cases (14.7%) in the O-group, and 3 cases (13.6%) in the C-group from Oc to T2 (p = 0.929). There was no significant difference in operative time (p = 0.239) and intraoperative blood loss (p = 0.595) between the two groups. Dysphagia was the most common complication in both groups (O-group vs. C-group, 11.7% vs. 9.1%). Regarding implant-related complications, occipital plate dislodgement was observed in four cases (18.2%) in the C-group (p = 0.02). The bone union rate was 96.3% in the O-group and 93.3% in the C-group (P = 1). CONCLUSIONS: O-arm use is associated with a reduced rate of occipital plate dislodgment and has a similar complication incidence compared with C-arm-assisted surgery and does not prolong operative time despite the time needed for setting and scanning. Accordingly, an O-arm is safe and useful for occipitocervical fixation surgery.

Postoperative Complications and Survival Rate in Hemodialysis-Dependent Patients Undergoing Cervical Spine Surgery.

Introduction: Spine surgery is challenging in hemodialysis (HD)-dependent patients owing to their poor general condition. However, postoperative complications and the mortality and survival rates have not been specifically evaluated in a wide series. This study aimed to elucidate postoperative complications and the survival rate in cervical spine surgery in HD patients. Methods: This study included 109 HD patients (70 men, 39 women) who had undergone cervical spine surgery between July 1996 and May 2018. Based on radiological diagnosis, we divided them into the destructive spondyloarthropathy (DSA) and non-DSA groups. We investigated the causes of hemodialysis, postoperative complications, postoperative inpatient mortality rate, and survival rate. Results: The DSA and non-DSA groups included 100 surgeries in 89 patients and 21 surgeries in 20 patients, respectively. The mean age at surgery was 62.9 years for the DSA and 55.9 years for the non-DSA group (P=0.97). The DSA group had a shorter hemodialysis period at surgery compared with the non-DSA group (21.7 vs. 26.5 years, P<0.05). The two most common causes of HD in both groups were chronic glomerulonephritis (DSA, 45%; non-DSA, 57.1%) and diabetes (DSA, 11%; non-DSA, 14.5%). Postoperative complications were observed in 23% (23/100) and 19% (4/21) of surgeries in the DSA and non-DSA groups, respectively (P=0.782). The total in-hospital mortality rate was 2.5% (3/121). The 1-, 3-, 5-, and 10-year postoperative survival rates of all patients were 89.6%, 75.5%, 67.1%, and 44.7%, respectively. The survival rates did not depend on the group (DSA vs. non-DSA), pre- and postoperative Japanese Orthopedic Association score for cervical myelopathy, hemodialysis period, sex, and age (P>0.05). However, significantly low survival rates were observed in HD caused by diabetes compared with that by chronic glomerulonephritis (P<0.001) and other causes (P<0.001). Conclusions: Cervical spine surgery in HD patients is associated with postoperative complications. The postoperative survival rate was found to be low if the cause of hemodialysis was diabetes.

O-Arm Assisted Cervicothoracic Spine Pedicle Screw Placement Accuracy Is Higher Than C-Arm Fluoroscopy.

OBJECTIVE: We compared the accuracy of C-arm fluoroscopy versus O-arm-assisted pedicle screw (PS) placement in the cervicothoracic spinal junction (CTSJ). METHODS: Patients who underwent PS placement in the CTSJ (C7-T4) at our hospital were included in this study. Of 37 patients who underwent PS placement in the CTSJ, 20 underwent intraoperative C-arm fluoroscopy-assisted surgery (C Group) and 17 underwent intraoperative O-arm-assisted surgery (O Group). In total, 159 PSs were placed-73 in the C Group and 86 in the O Group. The accuracy of PS placement was compared between the C Group and O Group using the classification proposed by Gertzbein and Robbins to analyze pedicle violation. RESULTS: PS accuracy was higher in the O Group than C Group; PS placement evaluated as grade A, representing no perforation, was 95.3% (82/86) for the O Group, whereas it was 78.1% (57/73) for the C Group. There was a clear statistically significant difference in accuracy of PS placement between the groups (P = 0.0013). CONCLUSIONS: O-arm-assisted surgery improved the accuracy of PS placement in the CTSJ.

Comparison of Atlantoaxial Fusion with Transarticular Screws and C1 Lateral Mass-C2 Screws Using Intraoperative O-Arm Navigation.

OBJECTIVE: This study compared the surgical outcomes of atlantoaxial fusion with transarticular screws (TASs) and C1 lateral mass-C2 screws (screw-rod constructs [SRCs]) using the intraoperative O-arm navigation system (O-arm). METHODS: Among a total of 28 patients who underwent atlantoaxial fixation, 13 underwent TAS fixation and 15 underwent SRC fixation using the O-arm. All patients underwent Brooks procedure with iliac bone graft in addition to screw fixation. TAS fixation was performed for cases without high-riding vertebral artery (hVA). In the SRC group, pars or lamina screws were inserted for the side with a C2 hVA. Operative time, intraoperative bleeding, perioperative complications, screw accuracy, and bone union were evaluated. RESULTS: There were statistically significant differences in mean operative time between the 2 procedures (166 minutes in the TAS group vs. 212 minutes in the SRC group, P < 0.05) and in mean blood loss (80 vs. 185 mL, respectively; P < 0.01). Two patients developed temporary postoperative occipital neuralgia probably related to C2 nerve root in the SRC group. No screws violated the cortex in either group. Complete bone union was observed in all cases. CONCLUSIONS: O-arm-assisted TAS fixation had less intraoperative blood loss, shorter operative time, and fewer screw insertion complications than O-arm-assisted SRC fixation. O-arm-assisted TAS fixation is preferable for atlantoaxial fusion in patients without hVA.

Surgical Results of Intraoperative C-arm Fluoroscopy Versus O-arm in Transarticular Screw Fixation for Atlantoaxial Instability.

OBJECTIVE: This study compared the surgical results of transarticular screw (TAS) fixation for atlantoaxial instability between C-arm fluoroscopy and O-arm. METHODS: Of 58 patients who underwent TAS fixation for atlantoaxial instability, 35 underwent C-arm-assisted surgery (C-group) and 23 underwent O-arm-assisted surgery (O-group). In total, 78 TASs were placed: 39 in the C-group and 39 in the O-group. Unilateral and bilateral TAS fixation was performed in 38 and 20 patients, respectively. All patients underwent Brook's procedure with TAS. TAS fixation accuracy on postoperative computed tomography, operative time, intraoperative bleeding, perioperative complications, and bone union were evaluated. Screw accuracy was assessed using Neo's classification: grade (G) 0, no perforation; G1, perforation <2 mm; G2, perforation 2-4 mm; G3, perforation >4 mm. RESULTS: TAS fixation accuracy was greater in the O-group than the C-group: G0: 38, 97.4%; G1: 1, 2.6% (O-group) vs G0: 22, 56.4%; G1: 11, 28.2%; G2: 3, 7.7%; G3: 3, 7.7% (C-group) (P < 0.001). Median operative time and median blood loss were similar between both groups. Bone union rate was greater with bilateral than unilateral TAS fixation (P < 0.05). There were no complications regarding screw malposition. Deep wound infection was observed in 1 case in the C-group. CONCLUSIONS: O-arm use improved TAS fixation accuracy. Blood loss was equivalent between the groups. O-arm-assisted TAS fixation did not prolong operative time despite the time required for setting and scanning. The O-arm is safe and useful for TAS fixation in atlantoaxial instability.

Cervical Pedicle Screw Insertion Using O-Arm-Based 3D Navigation: Technical Advancement to Improve Accuracy of Screws.

OBJECTIVE: This study aimed to report the technical advancement to improve the accuracy of cervical pedicle screw (CPS) placement using O-arm-based 3D navigation. METHODS: Sixty-four patients who underwent CPS using O-arm in the spine level of C2 to C7 between June 2013 and February 2020 were involved. In the first phase, a reference frame was placed onto the spinous process of the cranial vertebrae and used it at a maximum of 3 vertebral levels. The navigation guide sleeve was used to drill a screw hole. In the second phase, a reference frame that can hold 3 vertebrae was introduced. In the third phase, a drill guide sleeve to minimize bending of the drill tip was developed. In the fourth phase, navigated surgical drill was introduced. Screw accuracy was assessed using Neo classification: grade (G) 0, no perforation; G1, perforation <2 mm; G2, perforation 2-4 mm; and G3, perforation >4 mm. RESULTS: Mean age at surgery was 67 (19-88) years. A total of 317 CPSs were inserted. In total, 83 screws were inserted in the first phase, 60 in the second phase, 87 in the third phase, and 87 in the fourth phase. The total proportion of malpositioning was 3.8% (12/317 screws) and all were G1; 6.0% (5/83 screws) in the first phase, 8.3% (5/60 screws) in the second phase, 1.2% (1/87 screws) in the third phase, and 1.2% (1/87 screws) in the fourth phase (P < 0.05). CONCLUSIONS: O-arm use improved CPS placement accuracy with the advancement of techniques and instruments.

Characterization of the asialoglycoprotein receptor under hypoxic conditions in primary cultured rat hepatocytes.

UNLABELLED: Hepatic ischemia/reperfusion injury occurs in numerous clinical situations including liver transplantation and hepatic resection. Therefore, accurate functional assessment of hepatocytes and prevention of ischemia/reperfusion injury to hepatocytes would be important. (99m)Tc-Galactosyl-human serum albumin is a liver scintigraphic agent that binds to asialoglycoprotein receptors (ASGP-R) on hepatocytes. We determined the number of ASGP-R during hypoxic conditions in primary cultured rat hepatocytes. METHODS: We used 3 durations of hypoxia (1, 2, and 3 h) for the cultured rat hepatocytes. The control incubation was performed under normoxic conditions (humidified 5% CO(2) in air) for the entire experiment. The maximal binding of (99m)Tc-galactosyl-human serum albumin (Bmax) to the hepatocytes (plasma membrane and endocytosis) and ketone body ratio (KBR) in the medium were estimated. RESULTS: The Bmax to hepatocytes and the KBR significantly decreased with time under the 3 different hypoxic conditions, whereas the cell counts of the hepatocytes did not decrease. Three hours after reoxygenation, the Bmax and KBR values that were decreased in the first 2 h of hypoxia reversed to control levels, but those Bmax and KBR values that were decreased after 3 h of hypoxia were irreversible. CONCLUSION: We conclude that the decrease in the number of ASGP-R per hepatocyte appears to be more significant than the decrease in the number of hepatocytes. Therefore, measurement of ASGP-R may provide an accurate assessment of hepatic function in the clinical setting of hepatic injury and recovery.

Impairment of activation of hepatocyte growth factor precursor into its mature form in rats with liver cirrhosis.

BACKGROUND: Hepatocyte growth factor (HGF) has a crucial role in liver regeneration following injury. The conversion of an inactive precursor form of HGF (proHGF) into a biologically active form (mature HGF) is essential, as HGF is involved in the recovery of liver damage. Liver regeneration is markedly poor in patients with liver cirrhosis after resection. We hypothesized that impairment of liver regeneration in cirrhosis is in part because of the absence of activation of proHGF to mature HGF. Studies were performed to clarify the molecular form of HGF in the liver of rats with fibrosis/cirrhosis before and after liver resection. METHODS: Rat models of liver fibrosis/cirrhosis were induced by intraperitoneal administration of dimethylnitrosamine, followed by 45% partial hepatectomy or sham operation. HGF was purified from the liver and plasma on a SP-Sepharose column and was analyzed by Western blotting. RESULTS: Production of proHGF in the liver increased in the following order: rats with normal liver, rats with fibrosis, and rats with cirrhosis. However, the levels of proHGF were similar after liver resection in the liver of these groups. A small but significant level of mature HGF was detected before resection in the fibrosis group, but not in the normal and cirrhosis groups. Liver resection increased the levels of mature HGF in the normal and fibrosis groups, but marginally in the cirrhosis group. CONCLUSIONS: These results demonstrate that the conversion of proHGF into mature HGF is impaired after liver resection in liver cirrhosis, while proHGF production is similar in the livers of normal, fibrosis, and cirrhosis groups. Acceleration of the processing of the HGF molecule may contribute to the improvement of liver dysfunction in cirrhosis.

Exogenously administered HGF activator augments liver regeneration through the production of biologically active HGF.

Hepatocyte growth factor (HGF) plays a crucial role in the recovery of injured liver. Liver functions are mostly impaired in patients with liver diseases including cirrhosis. However, a significant amount of inactive HGF precursor (proHGF) is reported in the plasma of these patients. proHGF is proteolytically converted to an active form (mature HGF) by HGF-activator. Thus conversion of proHGF into mature HGF presumably contributes to the recovery of liver functions. In this study, rats with a partial hepatectomy were used, as proHGF is accumulated in the remnant liver. Recombinant human HGF-activator was administered via the portal vein to investigate the effect on molecular forms of HGF and its biological signaling. rhHGF-activator promptly converted proHGF into mature HGF, reaching maximal levels at 5-10 min after the injection, while the decreased proHGF was quickly recovered to the initial levels in the liver. The HGF receptor/c-Met was found to be autophosphorylated in the liver treated with rhHGF-activator. Further, the proliferating cell nuclear antigen labeling index and the liver regeneration rate were significantly higher in rhHGF-activator group than in control animals. These results indicate that exogenously administered HGF-activator produces a biologically active HGF from its precursor form and increases the potential for liver regeneration in vivo.