Complications of pedicle screw fixation in reconstructive surgery of the cervical spine

STUDY DESIGN

Retrospective evaluation of complications in 180 consecutive patients with cervical disorders who had been treated by using pedicle screw fixation systems.

OBJECTIVES

To determine the risks associated with pedicle screw fixation in the cervical spine and to emphasize the importance of preoperative planning and surgical techniques in reducing the risks of this procedure.

SUMMARY OF BACKGROUND DATA

Generally, pedicle screw fixation in the cervical spine has been considered too risky for the neurovascular structures. There have been several reports describing the complications of lateral mass screw-plate fixation. However, no studies have examined in detail the complications associated with cervical pedicle screw fixation.

METHODS

One hundred eighty patients who underwent cervical reconstructive surgery using cervical pedicle screw fixation were reviewed to clarify the complications associated with the pedicle screw fixation procedure. Cervical disorders were spinal injuries in 70 patients and nontraumatic lesions in 110 patients. Seven hundred twelve screws were inserted into the cervical pedicles, and the locations of 669 screws were radiologically evaluated.

RESULTS

Injury of the vertebral artery occurred in one patient. The bleeding was stopped by bone wax, and no neurologic complication developed after surgery. On computed tomographic (CT) scan, 45 screws (6.7%) were found to penetrate the pedicle, and 2 of 45 screws caused radiculopathy. Besides these three neurovascular complications directly attributed to screw insertion, radiculopathy caused by iatrogenic foraminal stenosis from excessive reduction of the translational deformity was observed in one patient.

CONCLUSIONS

The incidence of the clinically significant complications caused by pedicle screw insertion was low. Complications associated with cervical pedicle screw fixation can be minimized by sufficient preoperative imaging studies of the pedicles and strict control of screw insertion. Pedicle screw fixation is a useful procedure for reconstruction of the cervical spine in various kinds of disorders and can be performed safely.

Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report

Thirteen patients with fractures and/or dislocations of the middle and lower cervical spine were treated by transpedicular screw fixation using the Steffee variable screw placement system. Postoperative immobilization was either not used or simplified to short-term use of a soft neck collar. Recovery of nerve function and correction of kyphotic and/or translational deformities were satisfactory. All patients had solid fusion without loss of correction at the latest follow-up. There were no neurovascular complications. It was concluded that transpedicular screw fixation is as strong a fixation procedure for the cervical spine as it is for the thoracic and lumbar spine. This surgical procedure is associated with some risks of major neurovascular injuries; however, safety is adequate if the procedure is performed by experienced surgeons using meticulous surgical techniques.

Pedicle screw fixation for nontraumatic lesions of the cervical spine

STUDY DESIGN

This retrospective study was conducted to analyze the clinical results in 45 patients with nontraumatic lesions of the cervical spine treated by pedicle screw fixation.

OBJECTIVES

To evaluate the effectiveness of pedicle screw fixation in reconstructive surgery for nontraumatic cervical spinal disorders.

SUMMARY OF BACKGROUND DATA

Pedicle screw fixation for hangman's fracture of the axis and traumatic lesions of the middle and lower cervical spine has been reported; however, there have been no reports on pedicle screw fixation for nontraumatic lesions of the cervical spine.

METHODS

Forty-five patients with nontraumatic lesions of the cervical spine underwent reconstructive surgery including pedicle screw fixation and fusion. Five patients underwent occipitocervical fixation for the lesion of the upper cervical spine, and one patient underwent separate occipitocervical fixation and cervicothoracic fixation. Cervical or cervicothoracic fixation was performed in 39 patients. Twenty-six of these patients underwent simultaneous laminectomy or laminoplasty. Supplemental anterior surgery was conducted for 15 patients.

RESULTS

Solid fusion was obtained in all patients except eight with metastatic vertebral tumors who did not receive bone graft. Correction of kyphosis was adequate. There were no neurovascular complications, except one case of transient radiculopathy caused by screw threads.

CONCLUSIONS

Pedicle screw fixation is a useful procedure for posterior reconstruction of the cervical spine. This procedure does not require the lamina for stabilization, and should be especially valuable for simultaneous posterior decompression and fusion. The risk to neurovascular structures, however, cannot be completely eliminated.

Graft site morbidity with autogenous semitendinosus and gracilis tendons

To distinguish between morbidity caused by harvesting semitendinosus and gracilis tendons and morbidity associated with anterior cruciate ligament reconstruction surgery, we performed a prospective randomized study using 65 patients who underwent anterior cruciate ligament reconstruction using these tendons. The patients underwent either contralateral (N = 34) or ipsilateral (N = 31) graft harvest. For the nonoperated knees in the ipsilateral harvest group, isometric and isokinetic strength of the quadriceps and hamstring muscles increased to approximately 120% of the preoperative value at 12 months after surgery. Compared with these knees, the tendon harvest did not affect quadriceps muscle strength at all. However, harvest did decrease hamstring muscles strength for 9 months after surgery. The graft harvest in the knees with anterior cruciate ligament reconstruction also did not significantly affect quadriceps muscle strength, but it did significantly decrease hamstring muscles strength only at 1 month. Activity-related soreness at the donor site was rarely restricting and resolved by 3 months. This study demonstrated that the semitendinosus and gracilis tendon graft is a reasonable choice to minimize the donor site morbidity in ligament reconstruction using autografts.

Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems

STUDY DESIGN

This retrospective study was conducted to analyze the clinical results in 26 patients with lesions at the craniocervical junction that had been treated by occipitocervical reconstruction using pedicle screws in the cervical spine and occipitocervical rod systems.

OBJECTIVES

To evaluate the effectiveness of pedicle screw fixation in occipitocervical reconstructive surgery and to introduce surgical techniques.

SUMMARY OF BACKGROUND DATA

Many methods of occipitocervical reconstruction have been reported, but there have been no reports of occipitocervical reconstruction using pedicle screws and occipitocervical rod systems for reduction and fixation.

METHODS

Twenty-six patients with lesions at the craniocervical junction underwent reconstructive surgery using pedicle screws in the cervical spine and occipitocervical rod systems. The occipitocervical lesions were atlantoaxial subluxation associated with basilar invagination, which was caused by rheumatoid arthritis in 19 patients and other disorders in 7. The lowest cervical vertebra of fusion in 16 patients was C2, and the remaining 10 patients underwent fusion downward from C3 to C7. Flexion deformity of the occipitoatlantoaxial complex was corrected by application of extensional force, and upward migration of the odontoid process was reduced by application of combined force of extension and distraction between the occiput and the cervical pedicle screws.

RESULTS

Solid fusion was achieved in all patients except two with metastatic vertebral tumors who did not receive bone graft for fusion. Correction of malalignment at the craniocervical junction was adequate, and postoperative magnetic resonance imaging showed improvement of anterior compression of the medulla oblongata. There were no neurovascular complications of cervical pedicle screws.

CONCLUSIONS

Occipitocervical reconstruction by the combination of cervical pedicle screws and occipitocervical rod systems provided the high fusion rate and sufficient correction of malalignment in the occipitoatlantoaxial region. Results of this study showed the effectiveness of cervical pedicle screw as a fixation anchor for occipitocervical reconstruction.

Anterior decompression and stabilization with the Kaneda device for thoracolumbar burst fractures associated with neurological deficits

One hundred and fifty consecutive patients who had a burst fracture of the thoracolumbar spine and associated neurological deficits were managed with a single-stage anterior spinal decompression, strut-grafting, and Kaneda spinal instrumentation. At a mean of eight years (range, five years to twelve years and eleven months) after the operation, radiographs showed successful fusion of the injured spinal segment in 140 patients (93 per cent). Ten patients had a pseudarthrosis, and all were managed successfully with posterior spinal instrumentation and a posterolateral arthrodesis. The percentage of the canal that was obstructed, as measured on computed tomography, improved from a preoperative mean of 47 per cent (range, 24 to 92 per cent) to a postoperative mean of 2 per cent (range, 0 to 8 per cent). Despite breakage of the Kaneda device in nine patients, removal of the implant was not necessary in any patient. None of the patients had iatrogenic neurological deficits. After the anterior decompression, the neurological function of 142 (95 per cent) of the 150 patients improved by at least one grade, as measured with a modification of the grading scale of Frankel et al. Fifty-six (72 per cent) of the seventy-eight patients who had preoperative paralysis or dysfunction of the bladder recovered completely. One hundred and twenty-five (96 per cent) of the 130 patients who were employed before the injury returned to work after the operation, and 112 (86 per cent) of them returned to their previous job without restrictions. We concluded that anterior decompression, strut-grafting, and fixation with the Kaneda device in patients who had a burst fracture of the thoracolumbar spine and associated neurological deficits yielded good radiographic and functional results.

The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments

STUDY DESIGN

Change in lumbar lordosis was measured in patients that had undergone posterolateral lumbar fusions using transpedicular instrumentation. The biomechanical effects of postoperative lumbar malalignment were measured in cadaveric specimens.

OBJECTIVES

To determine the extent of postoperative lumbar sagittal malalignment caused by an intraoperative kneeling position with 90 degrees of hip and knee flexion, and to assess its effect on the mechanical loading of the instrumented and adjacent segments.

SUMMARY OF BACKGROUND DATA

The importance of maintaining the baseline lumbar lordosis after surgery has been stressed in the literature. However, there are few objective data to evaluate whether postoperative hypolordosis in the instrumented segments can increase the likelihood of junctional breakdown.

METHODS

Segmental lordosis was measured on preoperative standing, intraoperative prone, and postoperative standing radiographs. In human cadaveric spines, a lordosis loss of up to 8 degrees was created across L4-S1 using calibrated transpedicular devices. Specimens were tested in extension and under axial loading in the upright posture.

RESULTS

In patients who underwent L4-S1 fusions, the lordosis within the fusion decreased by 10 degrees intraoperatively and after surgery. Postoperative lordosis in the proximal (L2-L3 and L3-L4) segments increased by 2 degrees each, as compared with the preoperative measures. Hypolordosis in the instrumented segments increased the load across the posterior transpedicular devices, the posterior shear force, and the lamina strain at the adjacent level.

CONCLUSIONS

Hypolordosis in the instrumented segments caused increased loading of the posterior column of the adjacent segments. These biomechanical effects may explain the degenerative changes at the junctional level that have been observed as long-term consequences of lumbar fusion.

Risk factors and probability of vertebral body collapse in metastases of the thoracic and lumbar spine

STUDY DESIGN

The associations between vertebral body collapse and the size or location of the metastatic lesions were analyzed statistically to estimate the critical point of collapse.

OBJECTIVES

To determine risk factors for collapse, to estimate the predicted probability of collapse under various states of metastatic vertebral involvement, and to establish the criteria of impending collapse.

SUMMARY OF BACKGROUND DATA

Pathologic vertebral collapse brings about severe pain and paralysis in patients with cancer. Prevention of collapse plays a significant role in maintaining or improving their quality of life. Because no previous study has clarified the critical point of vertebral collapse, however, the optimum timing for prophylactic treatment has been unclear.

METHODS

The size and location of metastatic tumor from Th1 to L5 were evaluated radiologically for 100 thoracic and lumbar vertebrae with osteolytic lesions. The correlations between collapse and the following risk factors (x1-x4) were determined by means of a multivariate logistic regression model: x1, tumor size (the percentage of tumor occupancy in the vertebral body [% TO]); x2, pedicle destruction, x3, posterior element destruction; and x4, costovertebral joint destruction.

RESULTS

Significant risk factors were costovertebral joint destruction (odds ratio, 10.17; P = 0.021) and tumor size (odds ratio of every 10% increment in %TO, 2.44; P = 0.032) in the thoracic region (Th1-Th10), whereas, tumor size (odds ratio of every 10% increment in %TO, 4.35; P = 0.002) and pedicle destruction (odds ratio, 297.08; P = 0.009) were main factors in the thoracolumbar and lumbar spine (Th10-L5). The criteria of impending collapse were: 50-60% involvement of the vertebral body with no destruction of other structures, or 25-30% involvement with costovertebral joint destruction in the thoracic spine; and 35-40% involvement of vertebral body, or 20-25% involvement with posterior elements destruction in thoracolumbar and lumbar spine.

CONCLUSIONS

With respect to the timing and occurrence of vertebral collapse, there is a distinct discrepancy between the thoracic and thoracolumbar or lumbar spine. When a prophylactic treatment is required, the optimum timing and method of treatment should be selected according to the level and extent of the metastatic vertebral involvement.

Macrophage migration inhibitory factor up-regulates expression of matrix metalloproteinases in synovial fibroblasts of rheumatoid arthritis

Neutral matrix metalloproteinases (MMPs) are responsible for the pathological features of rheumatoid arthritis (RA) such as degradation of cartilage. We herein show the up-regulation of MMP-1 (interstitial collagenase) and MMP-3 (stromelysin) mRNAs of cultured synovial fibroblasts retrieved from rheumatoid arthritis (RA) patients in response to macrophage migration inhibitory factor (MIF). The elevation of MMP-1 and MMP-3 mRNA was dose-dependent and started at 6 h post-stimulation by MIF, reached the maximum level at 24 h, and was sustained at least up to 36 h. Interleukin (IL)-1beta mRNA was also up-regulated by MIF. These events were preceded by up-regulation of c-jun and c-fos mRNA. Tissue inhibitor of metalloproteinase (TIMP)-1, a common inhibitor of these proteases, was slightly up-regulated by MIF. Similarly, mRNA up-regulation of MMP-1 and MMP-3 was observed in the synovial fibroblasts of patients with osteoarthritis. However, their expression levels were much lower than those of RA synovial fibroblasts. The mRNA up-regulation by MIF was inhibited by the tyrosine kinase inhibitors genestein and herbimycin A, as well as the protein kinase C inhibitors staurosporine and H-7. On the other hand, the inhibition was not seen after the addition of the cyclic AMP-dependent kinase inhibitor, H-8. The mRNA up-regulation of MMPs was also inhibited by curcumin, an inhibitor of transcription factor AP-1, whereas interleukin-1 receptor antagonist, an IL-1 receptor antagonist, failed to inhibit the mRNA up-regulation. Considering these results, it is suggested that 1) MIF plays an important role in the tissue destruction of rheumatoid joints via induction of the proteinases, and 2) MIF up-regulates MMP-1 and MMP-3 via tyrosine kinase-, protein kinase C-, and AP-1- dependent pathways, bypassing IL-1beta signal transduction.

Lumbar trunk muscle endurance testing: an inexpensive alternative to a machine for evaluation

OBJECTIVES

The goals of this study were to verify the reliability and safety of new methods for evaluating trunk muscle endurance, and to compare the differences between healthy subjects and patients with chronic low-back pain.

DESIGN

Randomized and controlled study.

SETTING

A referral center and institutional practice, and outpatient care.

SUBJECTS

Ninety healthy subjects (37 men and 53 women average age 46.2 years) and 100 patients with CLBP (40 men and 60 women; average age 45.3 years) participated in this study.

MAIN OUTCOME MEASURES

During trunk flexor and extensor endurance tests, the subjects were asked to maintain the original positions for as long as possible. The performance time (seconds) for which subject could maintain the position was compared between two groups. Test-retest correlation (r) was also analyzed. The degree of lumbar lordosis was compared in conventional and new methods.

RESULTS

All test-retest correlations were significantly high in both groups (p < .01). The performance time was much longer in the healthy subjects than in the patients with CLBP during any procedures (p < .01). Lumbar lordosis was significantly less in our method than in the Kraus-Weber test (p < .01).

CONCLUSIONS

This study demonstrated that our methods for measuring trunk flexor and extensor endurance had high reliability, reproducibility, and safety, and were easy to perform, with no need for special equipment. This study also showed that trunk muscles in patients with CLBP were more easily fatigued, compared with those in healthy subjects.

Effects of initial graft tension on clinical outcome after anterior cruciate ligament reconstruction. Autogenous doubled hamstring tendons connected in series with polyester tapes

We conducted a prospective, randomized, short-term study to clarify the effects of initial graft tension on clinical outcome after arthroscopically assisted anterior cruciate ligament reconstruction with autogenous doubled semitendinosus and gracilis tendons connected in series with polyester tapes. Seventy Japanese patients with chronic, "isolated" anterior cruciate ligament tears were entered in the study. The patients were randomly divided into three groups based on initial graft tension: Group 1 (20 N), Group 2 (40 N), or Group 3 (80 N). No statistical differences were noted among the three groups with regard to their background factors. The patients were observed for 2 years or more after surgery. Postoperatively, the average side-to-side difference in anterior laxity was 2.2 +/- 2.4 mm in Group 1, 1.4 +/- 1.8 mm in Group 2, and 0.6 +/- 1.7 mm in Group 3. Analysis of variance testing showed that the postoperative laxity in Group 3 was significantly less than that in Group 1. Spearman's rank-order correlation analysis also demonstrated significant correlation between the magnitude of initial graft tension and the magnitude of the postoperative laxity. This study demonstrates that relatively high initial tension (up to 80 N) reduces the postoperative anterior laxity of the knee joint after anterior cruciate ligament reconstruction using the doubled autogenous hamstring tendons connected in series with polyester tapes.

Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation

Twenty-seven burst fractures with neurologic deficits of the thoracolumbar-lumbar spine were treated with an one-stage anterior operation consisting of anterior decompression through vertebrectomy, realignment and stabilization with Zielke instrumentation (12 patients), and our new anterior instrumentation (15 patients). Only two disc spaces directly related to the injury were fused. No patient showed neurologic deterioration after surgery. All 26 patients with incomplete lesions improved postoperatively, with 19 of them entering the next Frankel subgroup. The newly designed anterior instrumentation afforded enough stability to enable early ambulation with alignment and solid fusion.

Stability of posterior spinal instrumentation and its effects on adjacent motion segments in the lumbosacral spine

STUDY DESIGN

An in vitro biomechanical analysis of three anterior instability patterns was performed using calf lumbosacral spines. Stiffness of the constructs was compared, and segmental motion analyses were performed.

OBJECTIVES

To clarify the factors that alter the stability of the spinal instrumentation and to evaluate the influence of instrumentation on the residual intact motion segments.

SUMMARY OF BACKGROUND DATA

Recently, many adverse effects have been reported in fusion augmented with rigid instrumentation. Only few reports are available regarding biomechanical effects of stability provided by spinal instrumentation and its effects on residual adjacent motion segments in the lumbar-lumbosacral spine.

METHODS

Eighteen calf lumbosacral spine specimens were divided into three groups according to instability patterns--one-level, two-level, and three-level disc dissections. Six constructs were cyclically tested in rotation, flexion-extension, and lateral bending of intact spines, of destabilized spine, and of spines with four segmental posterior instrumentation systems used to extend the levels of instability (Cotrel-Dubousset compression hook and three transpedicular screw fixation systems). During each test, stiffness values and segmental displacements were measured.

RESULTS

The rigidity of the instrumented construct increased as the fixation range became more extensive. Although application of the instrumentation effectively reduced the segmental motion of the destabilized vertebral level, the motion at the destabilized level tended to increase as the number of unstable vertebral levels increased, and the fixation range of the instrumentation became more extensive. Instrumented constructs produced higher segmental displacement values at the upper residual intact motion segment when compared with those of the intact spine. In contrast, the instrumented constructs decreased their segmental displacement values at the lower residual intact motion segment with higher magnitude of the translational (shear) motion taking place compared with the intact spine in flexion-extension and lateral bending. These changes in the motion pattern became more distinct as the fixation range became more extensive.

CONCLUSIONS

As segmental spinal instrumentation progresses from one level to three levels, the overall torsional and flexural rigidity of the system increases. However, segmental displacement at the site of simulated instability becomes more obvious. Application of segmental instrumentation changes the motion pattern of the residual intact motion segments, and the changes in the motion pattern become more distinct as the fixation range becomes more extensive and as the rigidity of the construct increases.

Immunopathogenesis of delayed-type hypersensitivity

Cell-mediated immunity is defined as a beneficial host response characterized by an expanded population of specific T cells, which, in the presence of antigens, produce cytokines locally. The activation and recruitment of cells into an area of inflammation is a crucial step in the development of DTH responses. DTH is immunologically a process similar to cell-mediated immunity, involving T cells and cytokines. CD4 T helper (Th) 1 cells, differentiated from naive Th cells by IL-12 and IL-18 produced from macrophages, play a regulatory role in the expression of DTH and activation of macrophages via interferon gamma generated by Th1 and natural killer cells. Macrophages accumulate at the site of DTH and become activated through the CD4 Th1 cell-cytokine-macrophage axis. However, DTH leads to pathologic responses, such as granulomatous inflammation, calcification, caseation necrosis, and cavity formation. Granulomas usually form as a result of the persistence of a nondegradable product or as the result of DTH responses. DTH is also required for host defense against etiologic agents, such as Mycobacterium tuberculosis. The expression of cell-mediated immunity/DTH is a double-edged sword that may contribute to both clearance of the etiologic agent and tissue damage.

A novel extracellular cyclic lipopeptide which promotes flagellum-dependent and -independent spreading growth of Serratia marcescens

Serrawettin W2, a surface-active exolipid produced by nonpigmented Serratia marcescens NS 25, was examined for its chemical structure and physiological functions. The chemical structure was determined by degradation analyses, infrared spectroscopy, mass spectrometry, and proton magnetic resonance spectroscopy. Serrawettin W2 was shown to be a novel cyclodepsipeptide containing a fatty acid (3-hydroxydecanoic acid) and five amino acids. The peptide was proposed to be D-leucine (N-bonded to the carboxylate of the fatty acid)-L-serine-L-threonine-D-phenylalanine-L-isoleucine (bonded to the 3-hydroxyl group). By examining the effects of isolated serrawettin W2 on serrawettinless mutants, this lipopeptide was shown to be active in the promotion of flagellum-independent spreading growth of the bacteria on a hard agar surface. The parent strain NS 25 formed a giant colony with a self-similar characteristic after incubation for a relatively long time (1 to 2 weeks), similar to other fractal colony-producing strains of S. marcescens (producers of the different serrawettins W1 and W3). On a semisolid medium that permitted flagellum-dependent spreading growth, an external supply of serrawettin W2 accelerated surface translocation of a serrawettinless mutant during a short period (12 h) of observation. In contrast, bacterial translocation in the subsurface space of the semisolid agar was not enhanced by serrawettins. Thus, the extracellular lipids seem to contribute specifically to the surface translocation of the bacteria by exhibiting surfactant activity.

New anterior instrumentation for the management of thoracolumbar and lumbar scoliosis. Application of the Kaneda two-rod system

STUDY DESIGN

The Kaneda multisegmental instrumentation is a new anterior two-rod system for the correction of thoracolumbar and lumbar spine deformities. This system consists of a vertebral plate and two vertebral screws for individual vertebral bodies and two semirigid rods to interconnect the vertebral screws. Clinical results of 25 thoracolumbar and lumbar scoliosis patients treated with this new instrumentation were analyzed.

OBJECTIVES

To evaluate the efficacy of the new anterior instrumentation in correction and stabilization of thoracolumbar and lumbar scoliosis.

SUMMARY OF BACKGROUND DATA

Since Dwyer first introduced the concept of anterior spinal instrumentation and fusion for scoliosis, anterior surgery has gradually gained acceptance. In 1976, a useful modification for the anterior spinal instrumentation, which reportedly provided means of lordosation and vertebral body derotation, was described. However, some authors reported a high tendency of the implant breakage, loss of correction, progression of the kyphosis, and pseudoarthrosis as the major complications. To overcome the disadvantages of Zielke instrumentation, the authors have developed a new anterior spinal instrumentation (two-rod system) for the management of thoracolumbar and lumbar scoliosis.

METHODS

Anterior correction and fusion using Kaneda multisegmental instrumentation was performed in 25 patients with thoracolumbar or lumbar scoliosis. The average follow-up period was 3 years, 1 month (range, 2 years to 4 years, 7 months). There were 20 patients with idiopathic scoliosis (13 adolescents and seven adults) and five patients with other types of scoliosis, including congenital and other etiologies. All patients had correction of scoliosis by fusion within the major curve, and for 16 of the 25 patients, the most distal end vertebra was not included in the fusion (short fusion). Radiographic evaluations were performed to analyze frontal and sagittal alignments of the spine.

RESULTS

The average correction rate of scoliosis was 83%. Over the instrumented levels, the correction rate was 90%. Preoperative kyphosis of the instrumented levels of 7 degrees was corrected to 9 degrees of lordosis. Sagittal lordosis of the lumbosacral area beneath the fused segments averaged 51 degrees before surgery and was reduced to 34 degrees after surgery. The trunk shift was improved from 25 mm before surgery to 4 mm at final follow-up evaluation. The average improvement in the lower end vertebra tilt-angle was 97% in those patients whose lower end vertebra was included in the fusion and 83% in patients whose lower end vertebra was not included in the fusion. Apical vertebral rotation showed an average correction rate of 86%. At final follow-up evaluation, all patients demonstrated solid fusion without implant-related complications. There was 1.5 degrees of frontal plane and 1.5 degrees of sagittal plane correction loss within the instrumented area at final follow-up evaluation.

CONCLUSIONS

New anterior two-rod system showed excellent correction of the frontal curvature and sagittal alignment with extremely high correction capability of rotational deformities. Furthermore, correction of thoracolumbar kyphosis to physiologic lordosis was achieved. This system provides flexibility of the implant for smooth application to the deformed spine and overall rigidity to correct the deformity and maintain the fixation without a significant loss of correction or implant failure compared with conventional one-rod instrumentation systems in anterior scoliosis correction.

Correlation between histopathologic features and magnetic resonance images of spinal cord lesions

The authors report a correlation between histopathologic features and magnetic resonance images of spinal cord lesions in 19 human spinal cords with various types of lesions. Abnormally high T2-weighted image signal intensities appeared nonspecifically in mildly altered lesions or areas with edema. In the gray matter, a low T1-weighted image in addition to a high T2-weighted image signal intensity appeared in severely altered lesions with necrosis, myelomalacia, or spongiform change. In the white matter, abnormally high T1-weighted image intensities appeared in severely altered lesions. Based on these preliminary results, it appears that a correlation between the degree of histopathologic alteration of the spinal cord and magnetic resonance images in clinical cases can be made. This is the first study to clarify the correlation between histopathologic features and magnetic resonance images of the diseased human spinal cord.

The treatment of osteoporotic-posttraumatic vertebral collapse using the Kaneda device and a bioactive ceramic vertebral prosthesis

Twenty-two patients with neurologic deficit due to delayed posttraumatic vertebral collapse after osteoporotic compression fractures of the thoracolumbar spine underwent anterior decompression and reconstruction with bioactive Apatite-Wollastonite containing glass ceramic vertebral prosthesis and Kaneda instrumentation. Eighteen patients previously had minor trauma that resulted in a mild vertebral compression fracture without any neurologic involvement and were either conservatively treated or not treated at all. Four had no history of back injury. The preoperative neurologic status was incomplete paralysis in all patients. The average age at surgery was 66 (53-79) years. The average follow-up was 34 (20-58) months after surgery. All patients had returned to their daily living with neurologic recovery and stable spine. This type of anterior procedure is effective in the osteoporotic patients and there was a very low incidence of instrumentation failure and very low morbidity.

Relationship between traumatic spinal canal stenosis and neurologic deficits in thoracolumbar burst fractures

Using CT scans of 112 consecutive patients with thoracolumbar burst fractures, we investigated the relationship between traumatic spinal canal stenosis and neurologic deficits. We calculated the stenotic ratios of the area occupied by the retropulsed bony fragments to the estimated area of the original spinal canal. We also examined the shape of the narrowed canal and the disruption of spinal elements. Burst fractures having the following ratios are at significant risk of neurologic involvement: at T11 to T12 with 35% more, at L1 with 45% or more, and at L2 and below with 55% or more.

Role of Ionotropic Glutamatergic and GABAergic Inputs on the Firing Activity of Neurons in the External Pallidum in Awake Monkeys

The neurons in the external segment of the pallidum (GPe) in awake animals maintain a high level of firing activity. The level and pattern of the activity change with the development of basal ganglia disorders including parkinsonism and hemiballism. The GPe projects to most of the nuclei in the basal ganglia. Thus exploring the mechanisms controlling the firing activity is essential for understanding basal ganglia function in normal and pathological conditions. To explore the role of ionotropic glutamatergic and GABAergic inputs to the GPe, unit recordings combined with local injections of receptor antagonists were performed in awake monkeys. Observations on the effects of local application of the alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA)/kainate antagonist 1,2,3,4-tetrahydro-6-nitro-2, 3-dioxo-benzo[f]quinoxaline-7-sulfonamide, the N-methyl-d-aspartic acid (NMDA) antagonist 3-(2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid, and the GABAA antagonist gabazine as well as the effects of muscimol blockade of the subthalamic nucleus on the spontaneous firing rate, firing patterns, and cortical stimulation induced responses in the GPe suggested the following: sustained glutamatergic and GABAergic inputs control the level of the spontaneous firing of GPe neurons; both AMPA/kainate and NMDA receptors are activated by glutamatergic inputs; some GPe neurons receive glutamatergic inputs originating from areas other than the subthalamic nucleus; no GPe neurons became silent after a combined application of glutamate and GABA antagonists, suggesting that GPe neurons have intrinsic properties or nonionotropic glutamatergic tonic inputs that sustain a fast oscillatory firing or a combination of a fast and a slow oscillatory firing in GPe neurons.

In vitro migratory potential of rat quiescent hepatic stellate cells and its augmentation by cell activation

In liver injury, hepatic stellate cells are considered to depart from the sinusoidal wall and accumulate in the necrotic lesion through migration and proliferation. In this study, we investigated the migratory capacity of quiescent stellate cells in vitro and analyzed the relationship with proliferative response. Freshly isolated stellate cells that were seeded in the upper chamber of Cell Culture Insert (Becton Dickenson, Franklin Lakes, NJ) started to migrate to the lower chamber at 1 day and increased in migration index to 19% at 2 days. Cells in the lower chamber were stretched in shape with many lipid droplets and showed quiescent properties, i.e., negative expression of alpha-smooth muscle actin (alpha-SMA) or platelet-derived growth factor receptor-beta (PDGFR-beta). Migratory capacity in quiescent cells was also shown in the Matrigel-coated insert. Matrix metalloproteinase-2 (MMP-2) messenger RNA expression was low just after isolation, but was enhanced as migration became prominent. Migrating cells further showed higher proliferative activity than resting ones. The presence of PDGF/BB and Kupffer cells accelerated stellate cell migration by the chemotactic mechanism and concurrently augmented proliferation, whereas that of dexamethasone and interferon-gamma (IFN-gamma) attenuated migration as a result of general suppression effects. Compared with quiescent ones, alpha-SMA and PDGFR-beta-positive activated stellate cells obtained by 14-day culture exhibited more rapid and prominent migration, being regulated by mediators in a similar manner as described previously. These data indicate that quiescent stellate cells undergo migration, which is linked to proliferation and enhanced by PDGF/BB and Kupffer cells, suggesting the involvement of this function in the initial phase of development of postnecrotic fibrosis.

Correction of cervical kyphosis using pedicle screw fixation systems

STUDY DESIGN

This retrospective study was conducted to analyze the clinical results in 30 patients with cervical kyphosis that had been treated using cervical pedicle screw fixation systems.

OBJECTIVES

To evaluate the effectiveness of a pedicle screw fixation procedure in correction of cervical kyphosis.

SUMMARY OF BACKGROUND DATA

Correction of cervical kyphosis is a challenging problem in the field of spinal surgery. There have been several reports regarding surgical correction of cervical kyphosis; however, there have been no detailed reports on correction of cervical kyphosis using a pedicle screw fixation procedure.

METHODS

Thirty patients with cervical kyphosis underwent correction and fusion using cervical pedicle screw fixation. Seventeen of 30 patients with flexible kyphosis (Group I) were managed by a posterior procedure alone. The remaining 13 patients with rigid or fixed kyphosis (Group II) had a combined anterior and posterior procedure.

RESULTS

The average preoperative cervical kyphosis of 29.4 degrees improved to 2.3 degrees after surgery and was 2.8 degrees at the final follow-up. In Group I patients, preoperative kyphosis of 28.4 degrees improved to 5.1 degrees at the final follow-up. In contrast, preoperative kyphosis of 30.8 degrees in Group II patients improved to 0.5 degree at the final follow-up. Solid fusion was achieved in all patients. There were two patients with transient nerve root complications related to pedicle screw instrumentation.

CONCLUSION

Cervical kyphosis in 30 patients was effectively corrected using a pedicle screw fixation procedure with no serious complications. Flexible kyphosis with segmental motion can be satisfactorily corrected by a single posterior procedure using pedicle screw fixation. However, circumferential osteotomies combined with a posterior shortening procedure involving a pedicle screw system are required to achieve the best correction of fixed kyphosis by bony union. Cervical pedicle screw fixation is the most advantageous instrumentation in the correction of cervical kyphosis.

Prevention of rat hepatic fibrosis by the protease inhibitor, camostat mesilate, via reduced generation of active TGF-beta

BACKGROUND & AIMS

Proteolytic release and activation of latent transforming growth factor beta (TGF-beta) by the hepatic stellate cells (HSCs) are key events for pathogenesis of hepatic fibrosis, and protease inhibitors suppress TGF-beta generation by cultured HSCs, suggesting their potential use as antifibrogenic agents. We explored this idea using camostat mesilate, a serine protease inhibitor, to determine its effects and mechanisms of action in vivo.

METHODS

Camostat mesilate was either added to cultured rat HSCs or administered orally to rats during porcine serum treatment, followed by overexpression of urokinase. We measured cellular and hepatic levels of plasmin, TGF-beta, TGF-beta activity, activated HSC markers (increased cell number, morphologic change, and expression of both alpha-smooth muscle actin and collagen(alpha2)[I]), and fibrosis (Azan-staining and quantification of hydroxyproline content).

RESULTS

Camostat mesilate (500 micromol/L) inhibited generation of TGF-beta by suppressing plasmin activity and reduced the activity of TGF-beta, which blocked in vitro activation of HSCs. In the in vivo model, camostat mesilate (1-2 mg/g of diet) markedly attenuated an increase in hepatic plasmin and TGF-beta levels, HSC activation, and hepatic fibrosis without apparent systemic or local side effects, all of which were reverted by restoration of hepatic plasmin activity.

CONCLUSIONS

Camostat mesilate prevents porcine serum-induced rat hepatic fibrosis via a profound reduction in TGF-beta generation.

An unusual isopentenyl diphosphate isomerase found in the mevalonate pathway gene cluster from Streptomyces sp. strain CL190

A gene cluster encoding five enzymes of the mevalonate pathway had been cloned from Streptomyces sp. strain CL190. This gene cluster contained an additional ORF, orfD, encoding an unknown protein that was detected in some archaebacteria and some Gram-positive bacteria including Staphylococcus aureus. The recombinant product of orfD was purified as a soluble protein and characterized. The molecular mass of the enzyme was estimated to be 37 kDa by SDS-polyacrylamide gel electrophoresis and 155 kDa by gel filtration chromatography, suggesting that the enzyme is most likely to be a tetramer. The purified enzyme contained flavin mononucleotide (FMN) with the amount per tetramer being 1.4 to 1.6 mol/mol. The enzyme catalyzed the isomerization of isopentenyl diphosphate (IPP) to produce dimethylallyl diphosphate (DMAPP) in the presence of both FMN and NADPH. The Escherichia coli plasmid expressing orfD could complement the disrupted IPP isomerase gene in E. coli. These results indicate that orfD encodes an unusual IPP isomerase showing no sequence similarity to those of IPP isomerases identified to date. Based on the difference in enzymatic properties, we classify the IPP isomerases into two types: Type 2 for FMN- and NAD(P)H-dependent enzymes, and type 1 for the others. In view of the critical role of this isomerase in S. aureus and of the different enzymatic properties of mammalian (type 1) and S. aureus (type 2) isomerases, this unusual enzyme is considered to be a suitable molecular target for the screening of antibacterial drugs specific to S. aureus.

Biomechanical role of the posterior elements, costovertebral joints, and rib cage in the stability of the thoracic spine

STUDY DESIGN

This is a biomechanical study of the thoracic spine. Various ligaments and joints were resected sequentially and nondestructive cyclic loading tests were performed. Effects of each resection were analyzed biomechanically.

OBJECTIVES

To investigate the role of the posterior elements, costovertebral joints, and rib cage in the stability of the thoracic spine.

SUMMARY OF BACKGROUND DATA

There have been no experimental studies concerning the mechanical interaction between the thoracic spine and rib cage.

METHODS

Eight canine rib cage-thoracic spine complexes, consisting of the sixth to eighth ribs, sternum, and T5-T9 vertebrae, were used. Six pure moments along three axes were applied to the specimens, and angular deformation of T6-T7 was recorded. After testing the intact specimen, resection of the stabilizers was conducted incrementally in the following manner: 1) removal of the posterior elements at T6-T7, 2) resection of the bilateral seventh costovertebral joints, and finally, 3) destruction of the rib cage. The same loading tests were repeated at each stage. The ranges of motion and neutral zones were calculated by digitization.

RESULTS

A large increase in the range of motion in flexion-extension was observed after resection of the posterior elements and in lateral bending and axial rotation after resection of the costovertebral joints. A significant increase in the neutral zone in lateral bending and axial rotation was observed after bilateral resection of the costovertebral joints and destruction of the rib cage.

CONCLUSIONS

The costovertebral joints and rib cage play an important role in providing stability to the thoracic spine. The state of the costovertebral joints and rib cage should be assessed to evaluate the stability of the thoracic spine.