Posterior Thoracic Cage Interbody Fusion Offers Solid Bone Fusion with Sagittal Alignment Preservation for Decompression and Fusion Surgery in Lower Thoracic and Thoracolumbar Spine.

OBJECTIVE: It is challenging to make solid fusion by posterior screw fixation and laminectomy with posterolateral fusion (PLF) in thoracic and thoracolumbar (TL) diseases. In this study, we report our experience and follow-up results with a new surgical technique entitled posterior thoracic cage interbody fusion (PTCIF) for thoracic and TL spine in comparison with conventional PLF. METHODS: After institutional review board approval, a total of 57 patients who underwent PTCIF (n=30) and conventional PLF (n=27) for decompression and fusion in thoracic and TL spine between 2004 and 2019 were analyzed. Clinical outcomes and radiological parameters, including bone fusion, regional Cobb angle, and proximal junctional Cobb angle, were evaluated. RESULTS: In PTCIF and conventional PLF, the mean age was 61.2 and 58.2 years (p=0.46), and the numbers of levels fused were 2.8 and 3.1 (p=0.46), respectively. Every patient showed functional improvement except one case of PTCIF. Postoperative hematoma as a perioperative complication occurred in one and three cases, respectively. The mean difference in the regional Cobb angle immediately after surgery compared with that of the last follow-up was 1.4° in PTCIF and 7.6° in conventional PLF (p=0.003), respectively. The mean durations of postoperative follow-up were 35.6 months in PTCIF and 37.3 months in conventional PLF (p=0.86). CONCLUSION: PTCIF is an effective fusion method in decompression and fixation surgery with good clinical outcomes for various spinal diseases in the thoracic and TL spine. It provides more stable bone fusion than conventional PLF by anterior column support.

Clinical outcomes of posterior thoracic cage interbody fusion (PTCIF) to treat trauma and degenerative disease of the thoracic and thoracolumbar junctional spine.

Laminectomy followed by posterolateral fusion (PLF) is a standard procedure for thoracic and thoracolumbar (TL) compressive lesions. However, it is challenging to apply sufficient bone chips as the spinal cord is exposed after the laminectomy. Therefore, we performed posterior thoracic cage interbody fusion (PTCIF) as an alternative technique. A total of 25 patients operated with PTCIF technique between 2012 and 2017 were analyzed in our study. These patients required a posterior decompression and fusion in thoracic and TL spine for traumatic injury or degenerative disease. To evaluate the outcome of bone fusion, computed tomography (CT) was performed at least 3-4 months after PTCIF. The surgery was performed through insertion of screws and cages packed with autologous bone chips in a similar fashion to the posterior lumbar interbody fusion technique. Among 25 patients who underwent PTCIF, 22 patients were involved in our study. The mean age and follow-up interval were 58.6 (28-78) years and 27.1 (6-60) months, respectively. Traumatic spinal injury was diagnosed in 6 patients and degenerative disease in 16 patients. One level PTCIF was performed in 12 patients and 2 levels in 8 patients. After the operation, patients with degenerative disease showed neurological improvement, and trauma cases showed no neurological aggravation. Successful bone fusion was confirmed on CT for all patients. PTCIF is an effective treatment thereby we suggest this approach to be considered as an alternative procedure to decompression and fusion surgery in the thoracic and TL spine.

Practicality of using the figure-of-eight bandage to prevent fatal wound dehiscence after spinal tumor surgery for upper thoracic metastasis.

OBJECT: Serious postoperative wound problems can frequently develop after surgery with perioperative RT for upper thoracic metastatic lesions. The figure-of-eight bandage can restrict excessive shoulder motion, which could prevent wound dehiscence. The purpose of this study was to describe the efficacy of using the figure-of-eight bandage to prevent postoperative wound dehiscence. METHODS: Between February 2005 and July 2015, we retrospectively evaluated the medical records of cancer patients who underwent surgery with or without RT for spinal metastasis involving the upper thoracic spine. From January 2009, all patients received figure-of-eight bandaging immediately postoperatively, which was then maintained for 2 months. The outcome measures were the incidence and successful management of wound dehiscence following application of the figure-of-eight bandage. RESULTS: One hundred and fifteen patients (71 men and 44 women) were enrolled in the present study. A figure-of-eight bandage in conjunction with a thoracolumbosacral orthosis (TLSO) was applied to 78 patients, while only TLSO was applied to 37 patients. The overall rate of wound dehiscence was 4.34% and the mean duration before wound dehiscence was 27.0 days (range, 22-31 days) after surgery. In the TLSO-only group, wound dehiscence occurred in four patients (10.81%), meanwhile there was only one case (1.33%) of wound dehiscence in the group that had received the figure-of-eight bandage with TLSO. Three of four patients with wound dehiscence in the TLSO only group died from unresolved wound problems and another patient was treated with wound closure followed by the application of the figure-of-eight bandage. The only patient with wound dehiscence among the patients who received both the figure-of-eight bandage and TLSO was managed by primary wound closure without further complication. CONCLUSION: Current study suggests that the figure-of-eight bandage could prevent wound dehiscence and be used to treat wound problems easily.

Current Concept of Stem Cell Therapy for Spinal Cord Injury: A Review.

Spinal cord injury (SCI) is a catastrophic condition associated with significant neurological deficit, social, and financial burdens. Over the past decades, various treatments including medication, surgery, and rehabilitation therapy for SCI have been performed, but there were no definite treatment option to improve neurological function of patients with chronic SCI. Therefore, new treatment trials with stem cells have been studied to regenerate injured spinal cord. Among various types of stem cells, bone marrow derived mesenchymal stem cells is highly expected as candidates for the stem cell therapy. The result of the current research showed that direct intramedullary injection to the injured spinal cord site in subacute phase is most effective. Neurological examination, electrophysiologic studies, and magnetic resonance imaging are commonly used to assess the effectiveness of treatment. Diffusion tensor imaging visualizing white matter tract can be also alternative option to identify neuronal regeneration. Despite various challenging issues, stem cell therapy will open new perspectives for SCI treatment.

Analysis of equivalent parameters of two spinal cord injury devices: the New York University impactor versus the Infinite Horizon impactor.

BACKGROUND CONTEXT: The New York University (NYU) impactor and the Infinite Horizon (IH) impactor are used to create spinal cord injury (SCI) models. However, the parameters of these two devices that yield equivalent SCI severity remain unclear. PURPOSE: To identify equivalent parameters, rats with SCIs induced by either device set at various parameters were subjected to behavioral and histologic analyses. STUDY DESIGN: This is an animal laboratory study. METHODS: Groups of eight rats acquired SCIs by dropping a 10 g rod from a height of 25 mm or 50 mm by using the NYU device or by delivering a force of 150 kdyn, 175 kdyn, 200 kdyn, or 250 kdyn by using the IH impactor. All injured rats were tested weekly for 8 weeks by using the Basso, Beattie, and Bresnahan (BBB) test and the ladder rung test. On the 10th week, the lesion volume of each group was measured by using a 9.4 Tesla magnetic resonance imaging (MRI), and the spinal cords were subjected to histologic analysis using anterograde biotinylated dextran amine (BDA) tracing and immunofluorescence staining with an anti-protein kinase C-gamma (PKC-γ) antibody. RESULTS: Basso, Beattie, and Bresnahan test scores between the 25 mm and the 200 kdyn groups as well as between the 50 mm and and 250 kdyn groups were very similar. Although it was not statistically significant, the mean scores of the ladder rung test in the 200 kdyn group were higher than the 25 mm group at all assessment time points. There was a significantly different cavity volume only between the 50 mm and the 200 kdyn groups. Midline sagittal images of the spinal cord on the MRI revealed that the 25 mm group predominantly had dorsal injuries, whereas the 200 kdyn group had deeper injuries. Anterograde tracing with BDA showed that in the 200 kdyn group, the dorsal corticospinal tract of the caudal area of the lesion was labeled. Similar labeling was not observed in the 25 mm group. Immunofluorescence staining of PKC-γ also revealed strong staining of the dorsal corticospinal tract in the 200 kdyn group but not in the 25 mm group. CONCLUSIONS: The 25 mm injuries generated by the NYU impactor are generally equivalent to the 200 kdyn injuries generated by using the IH impactor. However, differences in the ladder rung test scores, MRI images, BDA traces, and PKC-γ staining demonstrate that the two devices exert qualitatively different impacts on the spinal cord.

A Phase III Clinical Trial Showing Limited Efficacy of Autologous Mesenchymal Stem Cell Therapy for Spinal Cord Injury.

BACKGROUND: In our previous report, 3 of 10 patients with spinal cord injury who were injected with autologous mesenchymal stem cells (MSCs) showed motor improvement in the upper extremities and in activities of daily living. OBJECTIVE: To report on the results of a phase III clinical trial of autologous MSCs therapy. METHODS: Patients were selected based on the following criteria: chronic American Spinal Injury Association B status patients who had more than 12 months of cervical injury, and no neurological changes during the recent 3 months of vigorous rehabilitation. We injected 1.6 × 10 autologous MSCs into the intramedullary area at the injured level and 3.2 × 10 autologous MSCs into the subdural space. Outcome data were collected over 6 months regarding neurological examination, magnetic resonance imaging with diffusion tensor imaging, and electrophysiological analyses. RESULTS: Among the 16 patients, only 2 showed improvement in neurological status (unilateral right C8 segment from grade 1 to grade 3 in 1 patient and bilateral C6 from grade 3 to grade 4 and unilateral right C8 from grade 0 to grade 1 in 1 patient). Both patients with neurological improvement showed the appearance of continuity in the spinal cord tract by diffusion tensor imaging. There were no adverse effects associated with MSCs injection. CONCLUSION: Single MSCs application to intramedullary and intradural space is safe, but has a very weak therapeutic effect compared with multiple MSCs injection. Further clinical trials to enhance the effect of MSCs injection are necessary.

Cauda equina lymphoma mimicking non-neoplastic hypertrophic neuropathy of the cauda equina: A case report.

Spinal cauda equina lymphoma (CEL) is very rare, with only about 14 cases reported in the English medical literature. Magnetic resonance image findings and the gross appearance of CEL at surgery are similar to those of non-neoplastic hypertrophic neuropathy of the cauda equina (HNCE); however, their prognosis and treatment are very different. We report a case of CEL and discuss the differences from non-neoplastic HNCE.