Recurrent ossification of the posterior longitudinal ligament in the upper thoracic region 10 years after initial decompression

Background: Posterior decompression surgery consisting of laminoplasty is generally considered be the treatment of choice for upper thoracic OPLL. Here, we describe a patient who, 10 years following a C3–T4 level laminectomy, developed recurrent OPLL at the T2–3 level with kyphosis requiring a posterior fusion. Case Description: A 64-year-old male with CT documented OPLL at the C3–4, C6–7, and T1–4 levels, originally underwent a cervicothoracic laminectomy with good results. However, 10 years later, when T2–3 OPLL recurred along with kyphosis, he warranted an additional posterior fusion. Conclusion: Due to the long-term risks of developing kyphotic deformity/instability, more patients undergoing initial decompressive surgery alone for upper thoracic OPLL should be considered for primary fusions.

The modified transmanubrial approach in thyroid malignant tumors: an optimal and less invasive surgical option.

- We retrospectively evaluated a large series of patients (n: 15) underwent a modified transmanubrial approach for wide mediastinal resection in case of malignance thyroid mass - In fourteen cases, also with thyroid tumor involving the middle line. A bilateral mTMA was necessary to perform a cava vein resection. - No major postoperative and cutaneous/sternum complications were detected. - mTMA allows an optimal exposure of the upper thoracic inlet achieving a complete radical oncological resection of the tumor/lymph-node and a safety vascular/tracheal control. - As a limitation, the modified mTMA is anatomically more demanding and not familiar for most surgeons in comparison to sternotomy

Reduced Reflex Autonomic Responses Following Intradetrusor OnabotulinumtoxinA Injections: A Pre-/Post-study in Individuals With Cervical and Upper Thoracic Spinal Cord Injury

Urodynamic studies (UDS) can provoke autonomic dysreflexia (AD) in individuals with spinal cord injury (SCI) at and above the sixth thoracic spinal segment potentially leading to profound vagally mediated heart rate (HR) reductions. In this study,1 we test the hypothesis that intradetrusor onabotulinumtoxinA injections will improve HR and its variability (HRV) responses to UDS in individuals with cervical and thoracic SCI. A total of 19 participants with chronic SCI (5 women, mean age 42.5 ± 7.9 years) with confirmed neurogenic detrusor overactivity underwent UDS before (i.e., baseline) and 1 month after intradetrusor onabotulinumtoxinA (200 U) injections (post-treatment). Continuous electrocardiography and blood pressure (BP) recordings were used to assess RR-interval, time, and frequency domain metrics of HRV (a surrogate marker of autonomic nervous system activity), and AD pre- and post-treatment. UDS pre-treatment resulted in increased RR-interval as well as time and frequency domain metrics of HRV. Vagally mediated increases in high-frequency (HF) power during UDS were larger in participants with cervical compared to upper thoracic SCI. Post-treatment, UDS had no effect on RR-interval and significantly reduced instances of bradycardia. Furthermore, intradetrusor onabotulinumtoxinA injections significantly reduced time domain metrics of HRV and HF power responses to UDS across all participants. Changes in HRV during UDS could be a potential indicator of improved autonomic cardiovascular function following interventions such as intradetrusor onabotulinumtoxinA injections.

Syrinx reduction due to spontaneous spinal cord tear: demonstration on 3 T MRI and review of the literature

A holocord syringomyelia due to Chiari 1.5 malformation (CM) in a 12-year-old girl was serially imaged with 3 T MRI over 4 years. The serial MRI showed reduction in size of the syrinx, without any surgical intervention or CM improvement, but rather due to spontaneous spinal cord tear. The tear was clearly demonstrated by evidence of flow signal across the tear between syrinx and subarachnoid space at the upper thoracic level. The tear showed spontaneous closure at follow-up. A medullary tear has been described in the adult population as one of the putative causes of spontaneous syringomyelia reduction, but its clear demonstration with modern high-resolution MRI has not been reported in the paediatric population. Moreover, this is the first reported case of syrinx reduction due to spontaneous fissuration in a paediatric patient.

The Preventive Effect of Cardiac Sympathetic Denervation Induced by 6-OHDA on Myocardial Ischemia–Reperfusion Injury: The Changes of lncRNA/circRNAs-miRNA-mRNA Network of the Upper Thoracic Spinal Cord in Rats

In this study, we investigated whether chemical 6-hydroxydopamine (6-OHDA) stimuli caused cardiac sympathetic denervation (SD), and we analyzed gene expression profiles to determine the changes in the lncRNA/circRNAs-miRNA-mRNA network in the affected spinal cord segments to identify putative target genes and molecular pathways in rats with myocardial ischemia–reperfusion injury (MIRI). Our results showed that cardiac sympathetic denervation induced by 6-OHDA alleviated MIRI. Compared with the ischemia reperfusion (IR, MIRI model) group, there were 148 upregulated and 51 downregulated mRNAs, 165 upregulated and 168 downregulated lncRNAs, 70 upregulated and 52 downregulated circRNAs, and 12 upregulated and 11 downregulated miRNAs in the upper thoracic spinal cord of the SD-IR group. Furthermore, we found that the differential genes related to cellular components were mainly enriched in extracellular and cortical cytoskeleton, and molecular functions were mainly enriched in chemokine activity. Pathway analysis showed that the differentially expressed genes were mainly related to the interaction of cytokines and cytokine receptors, sodium ion reabsorption, cysteine and methionine metabolism, mucoglycan biosynthesis, cGMP-PKG signaling pathway, and MAPK signaling pathway. In conclusion, the lncRNA/circRNAs-miRNA-mRNA networks in the upper thoracic spinal cord play an important role in the preventive effect of cardiac sympathetic denervation induced by 6-OHDA on MIRI, which offers new insights into the pathogenesis of MIRI and provides new targets for MIRI.

Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary?

Background While several studies report on accuracy rates of pedicle screws, risk factors associated with inaccurate pedicle screw positioning in patients with thoracolumbar fractures are reported rarely. CT scan as a routine postoperative control is advocated by various authors, however its necessity remains unclear. Methods Two hundred forty-five patients were included in this retrospective study. Percutaneous dorsal instrumentation was most commonly performed (n = 201). Classification of Zdichavsky et al. and Rao et al. were used to classify screw misplacement and anterior perforation was further evaluated according to the extent of perforation (< 2 mm; > 2 mm). Multivariate analysis was performed to identify risk factors for misplacement of screws. Results One thousand sixty-eight pedicle screws were inserted in 245 patients. Misplacement was found in 51 screws (4.8%) in 42 patients (17.1%) according to the classification of Zdichavsky et al. and in 75 screws (7.0%) in 64 patients (26.1%) according to the classification of Rao et al.. An anterior perforation of the vertebral cortex was found in 56 screws (5.2%). Multivariate analysis showed fracture location in the upper thoracic (p = 0.048) and lumbar spine (p = 0.013) to be the only independent predictors for screw misplacement. In addition a significant correlation between pedicle diameter and the occurrence of screw malposition was found (p = 0.003). No consequences were drawn from postoperative routine CT in asymptomatic patients. Conclusion An overall low rate of screw misplacement was found with fracture location in the upper thoracic and lumbar spine being the only factors independently associated with the risk of screw misplacement. No consequences were drawn from postoperative routine CT in asymptomatic patients. Therefore its use has to be discussed critically.

Upper Thoracic Spine Fractures Outcomes and Complications in King Abdul-Aziz Medical City, Riyadh

Introduction: Upper thoracic spine fractures (T1-T6) are not uncommon. They are often high-energy injuries complicated by multiple life-threatening comorbidities. There is a controversial discussion in the literature regarding the treatment choices. Thoracic pedicle screw fixation has replaced all other fixation techniques for its success rate and safety. Despite the number of studies discussing upper thoracic spine fractures, data on literature reporting postoperative complications are deficient. The aim of the study was to assess, in a series of patients, the impact of traumatic upper thoracic fractures on sagittal alignment, the incidence of possible complications, and the effect of associated injuries. Methodology: This retrospective chart review study included all adult cases diagnosed as traumatic upper thoracic spine fractures in KAMC in Riyadh. Data were obtained from the computerized database. The information reviewed included fracture characteristics, associated injuries, pre- and postoperative neurological status and sagittal alignment, follow-up duration, and the presence of complications. Result: A total of 19 patients were included in the study. Of them, 17 (89.5%) were injured secondary to a motor vehicle accident. There were three patients with a fixation level crossing the CT junction, more blood loss and procedure time was noticed with these cases. There was a notable improvement in upper thoracic kyphosis by 9º when measuring pre- and postop fracture Cobb's angle. The mean preop angle was 28.98 and the mean postop was 20.76. Of all the 19 cases involved in the study, 3 patients had developed surgical site infection as a complication. No other complication was reviewed. Conclusion: It is well-known in the literature that the correction of kyphosis and the absence of residual deformity postoperatively are indicators of the success and safety of the procedure used. Our findings correspond to the literature discussion that the current practice in managing traumatic upper thoracic spine fracture in KAMC in Riyadh is relatively safe and effective. Yet, further studies are needed to elaborate more on the relationship between the presence of other injuries and patients’ factors and postoperative outcomes.

Development of a Prognostic Nomogram and Risk Stratification System for Upper Thoracic Esophageal Squamous Cell Carcinoma

BackgroundEffective tools evaluating the prognosis for patients with upper thoracic esophageal carcinoma is lacking. We aimed to develop a nomogram model to predict overall survival (OS) and construct a risk stratification system of upper thoracic esophageal squamous cell carcinoma (ESCC) patients.MethodsNewly diagnosed 568 patients with upper thoracic ESCC at Fujian Medical University Cancer Hospital between February 2004 and December 2016 was taken as a training cohort, and additional 155 patients with upper ESCC from Sichuan Cancer Hospital Institute between January 2011 and December 2013 were used as a validation cohort. A nomogram was established using Cox proportional hazard regression to identify prognostic factors for OS. The predictive power of nomogram model was evaluated by using 4 indices: concordance statistics (C-index), time-dependent ROC (ROCt) curve, net reclassification index (NRI) and integrated discrimination improvement (IDI). Decision curve analysis (DCA) was used to evaluate clinical usefulness of prediction models. Patients were categorized into three risk groups by X-tile software on the survival scores of the training cohort.ResultsMultivariate analysis revealed that gender, clinical T stage, clinical N stage and primary gross tumor volume (GTVp) were independent prognostic factors for OS in the training cohort. The nomogram based on these factors showed favorable prognostic efficacy in the both training and validation cohorts, with C-index of 0.622, 0.713, and AUC value of 0.709, 0.739, respectively, which appeared superior to those of the American Joint Committee on Cancer (AJCC) staging system. In addition, NRI and IDI of the nomogram presented better discrimination ability to predict survival than those of AJCC staging. Furthermore, DCA curve of the nomogram exhibited greater clinical performance than that of AJCC staging. Finally, the nomogram fairly distinguished the OS rates among low, moderate, and high risk groups, whereas the OS curves of clinical stage could not be well separated among clinical AJCC stage. ConclusionsWe built an effective nomogram model for predict OS of upper thoracic ESCC, which may improve clinicians’ abilities to predict individualized survival and facilitate to further stratify the management of patients at risk.