Electromagnetic field-based image-guided spine surgery part one: results of a cadaveric study evaluating lumbar pedicle screw placement.

STUDY DESIGN: Human cadaveric. OBJECTIVES: Compare the accuracy of electromagnetic field (EMF)-based image-guided lumbar pedicle screw insertion to conventional techniques using anatomic landmarks, and fluoroscopy. BACKGROUND: Image-guided surgical systems that aid in spinal instrumentation seek to minimize radiation exposure and improve accuracy. EMF tracking-based image-guidance was developed in the hopes of eliminating line-of-sight restrictions seen with other systems. MATERIALS AND METHODS: Sixteen fresh-frozen human cadavers were randomly allocated into three groups. Pedicle screws were inserted from L1 to L5 using only anatomic landmarks in group 1, fluoroscopy in group 2, and image-guidance in group 3. Insertion and total fluoroscopic time were recorded. Anatomic dissections were performed to assess screw placement. RESULTS: Accuracy was 83%, 78%, and 95% for groups 1, 2, and 3, respectively. However, image-guided pedicle screw placement resulted in a 5% critical perforation rate whereas anatomic and fluoroscopic placement resulted in a 15% and 22% critical perforation rate, respectively. The average degree of perforation was 1.5 mm with image guidance, and 3.8 mm with fluoroscopic guidance (P < 0.05). Fluoroscopy time and insertion time per screw were not improved using image guidance. CONCLUSIONS: Our study has shown that when EMF tracking was used for image-guided lumbar pedicle screw placement, accuracy was improved and the incidence and degree of cortical perforations that may place neurovascular structures at risk was also reduced. Current system requirements for set-up and image acquisition, however, do add time to the procedure, and when factored in, do not yet result in a decrease in the use of fluoroscopy or screw insertion time.

Electromagnetic field-based image-guided spine surgery part two: results of a cadaveric study evaluating thoracic pedicle screw placement.

STUDY DESIGN: Human cadaveric. OBJECTIVES: Compare the accuracy of electromagnetic field (EMF)-based image-guided thoracic pedicle screw insertion to conventional techniques using anatomic landmarks and fluoroscopy. BACKGROUND: Image-guided surgical systems that aid in spinal instrumentation seek to minimize radiation exposure and improve accuracy. EMF image guidance was developed as an alternative to optical tracking to eliminate potential line of sight issues. MATERIALS AND METHODS: Four fresh-frozen human cadavers were randomly allocated into two groups. Pedicle screws were inserted from T1 to T12 using anatomic landmarks and fluoroscopy in group 1 and image guidance in group 2. Insertion and fluoroscopy time were recorded. Anatomic dissections were performed to assess screw placement. RESULTS: Image guidance placed 92% of thoracic pedicle screws safely, and conventional fluoroscopy placed 90% safely. The average degree of perforation was 2.4 mm with conventional fluoroscopy and 1.7 mm with image guidance (P = 0.055). Fluoroscopic time per screw was 5.9 seconds for conventional fluoroscopy and 3.6 seconds for image guidance (P = 0.045). Insertion time per screw was 4.35 minutes for conventional fluoroscopy and 2.98 minutes for image guidance (P = 0.007). However, when set-up time and image capture time were taken into account, the total insertion time per screw was not significantly different between the two groups. CONCLUSIONS: Our study has shown that EMF image-guided thoracic pedicle screw placement results in a similar incidence of safely placed screws as does conventional fluoroscopy. When set-up time and image-capture time were factored in for image guidance, the average time to insert a pedicle screw was equal for both techniques. The use of EMF image guidance significantly reduced fluoroscopic time and thus radiation exposure per screw compared with conventional fluoroscopic techniques.

Plantar-flexion tarsometatarsal joint injuries in children.

We are reporting a series of eight patients ranging in age from 3 to 10 years who sustained plantar-flexion injuries of the foot, resulting in injuries to the tarsometatarsal (TMT) interval. All injuries were identified within 3 days and treated with molded short leg immobilization. We evaluated all patients an average of 32 months after injury with physical examination and the Midfoot Functional Rating (MFR) score. Seven patients had no limitations in their activities of daily living or athletic endeavors. These seven patients had MFR scores of 100. One patient had complaints of midfoot pain with running for >5 min and radiographic evidence of degenerative changes across the TMT interval at 3-year follow-up. These results suggest that although indirect pediatric TMT injuries have a generally favorable prognosis, early degenerative changes can occur and may be responsible for chronic pain and activity limitation. Degenerative changes in this weight-bearing region in a young patient can have lifelong implications. Patients and parents may benefit from discussion of the potential for future midfoot compromise following this injury.

Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint.

Twenty volunteers (40 feet) with no prior foot injury underwent standardized abduction stress and standing AP radiographs. Subsequently, the Lisfranc and dorsal tarsometatarsal ligaments in nine feet from cadavers were sectioned in a varying sequential manner, and interval standardized radiographs of abduction stress and AP simulated weightbearing were obtained. On abduction stress radiographs in 39 of 40 feet of volunteers and nine of nine feet of cadavers before sectioning, a line tangential to the medial aspect of the navicular and medial cuneiform (medial column line) intersected the base of the first metatarsal. Combining the sectioning of the Lisfranc and dorsal tarsometatarsal ligaments produced a disruption of the medial column line in all feet from cadavers. Disruption of this medial column line may be a simple and valuable diagnostic tool for determining significant ligamentous injury to the tarsometatarsal interval.

Effects of sepiapterin and 6-acetyldihydrohomopterin on the guanosine triphosphate cyclohydrolase I of mouse, rat and the fruit-fly Drosophila.

The regulation of GTP cyclohydrolase I would lead to the regulation of tetrahydrobiopterin, an important cofactor for synthesis of neurotransmitters. In an attempt to extend a previous finding [Bellahsene, Dhondt, & Farriaux (1984) Biochem. J. 217, 59-65] that GTP cyclohydrolase I of rat liver is inhibited by subnanomolar concentrations of reduced biopterin and sepiapterin, we found that this could not be verified with the enzyme from mouse liver, fruit-fly (Drosophila) heads or, indeed, from rat liver. It was shown, however, that 12 microM-sepiapterin inhibited mouse liver GTP cyclohydrolase I. Another compound, namely 6-acetyldihydrohomopterin, was also employed in the present study to explore its effect on enzymes that lead to its synthesis in Drosophila and for effects on mammalian systems; at 2-5 microM this compound was shown to stimulate one form of mouse liver GTP cyclohydrolase I and then to inhibit at higher concentrations (40 microM). Neither sepiapterin nor 6-acetyldihydrohomopterin caused any effect on the Drosophila head enzyme. On the other hand, the sigmoid GTP concentration curve for the Drosophila enzyme may indicate a regulatory characteristic of this enzyme. Another report, on the lower level of GTP cyclohydrolase I in mutant mouse liver [McDonald, Cotton, Jennings, Ledley, Woo & Bode (1988) J. Neurochem. 50, 655-657], was confirmed and extended. Instead of having 10% activity, we find that the hph-1 mouse mutant has less than 2% activity in the liver. These studies demonstrate that micromolar levels of reduced pterins may have regulatory effects on GTP cyclohydrolase I and that a mouse mutant is available that has low enough activity to be considered as a model for human atypical phenylketonuria.

Partial purification of an oxygen scavenging cell membrane fraction for use in anaerobic biochemical reactions.

Anaerobic conditions are necessary to prevent the autoxidation of tetrahydrobiopterin. An enzymatic method for achieving such an anaerobic condition is shown to be obtained by a lactate oxidase activity in the membrane of Escherichia coli when the enzyme concentration exceeds 0.05 unit/ml. A procedure is described for partial purification of the membrane fragment that involves salt precipitation and gel sieve chromatography on Bio-Gel A-50m. The rate of removal of oxygen is used to define the enzyme activity, to determine stability during storage, and to define conditions for stabilization of tetrahydrobiopterin. A second assay procedure that measures the rate of reduction of resazurin is described and is useful when the enzyme concentration is low.