Comparison between selective caudal fixed screw construct and all variable screw construct in anterior cervical discectomy and fusion

This retrospective comparative study aimed to compare the efficacy of selective caudal fixed screw constructs with all variable screw constructs in anterior cervical discectomy and fusion (ACDF). Thirty-five patients who underwent surgery using selective caudal fixed screw construct (SF group) were compared with 44 patients who underwent surgery using all variable constructs (AV group). The fusion rate, subsidence, adjacent level ossification development (ALOD), adjacent segmental disease (ASD), and plate-adjacent disc space distance were assessed. The one-year fusion rates assessed by computed tomography bone bridging and interspinous motion as well as the significant subsidence rate did not differ significantly between the AV and SF groups. The ALOD and ASD rates and plate-adjacent disc space distances did not significantly differ between the two groups at both the cranial and caudal adjacent levels. The number of operated levels was significantly associated with pseudarthrosis in the logistic regression analysis. The stability provided by the locking mechanism of the fixed screw did not lead to an increased fusion rate at the caudal level. Therefore, the screw type should be selected based on individual patient’s anatomy and surgeon’s experience without concern for increased complications caused by screw type.

Kisspeptin Neurons Excitability Is Not Modulate by Fasting

Kisspeptin is the most important neuromodulator of gonadotrophin releasing hormone neurons. Hypothalamic Kiss1-expressing neurons can be found in the anteroventral periventricular and rostral periventricular nuclei (AVPV/PeN) and in the arcuate nucleus of the hypothalamus (ARH). Food intake and energy balance are modulated by leptin, which acts primarily in the ARH. Leptin acts inhibiting orexigen neurotransmitters and stimulating anorectic neurotransmitters. Few ARH kisspeptin cells (10-15%) coexpress the leptin receptor and have their resting membrane potential (RMP) depolarized by leptin. Since the reproductive axis is sensitive to metabolic disorders, in the present study we used immunohistochemical and electrophysiological approach to understand the effects of fasting on kisspeptin neurons activity. To determine whether AVPV/PeN and ARH kisspeptin neurons activity are modulated by fasting, Kiss1/hrGFP female mice were fed regular chow ad libitum or fasted for 24 hours. Mice were euthanized after 24h. Fasting induced a significant increase of Fos protein on the ARH nucleus, as expected (rostral level of ARH, control: 19.3 ± 3.5 vs fasted: 81.3 ± 3.5 cells; caudal level, control: 15.7 ± 1.3 vs fasted: 103.3 ± 6.2 cells, P <0.0001, n=3/6 mice per group). Despite the significant increase of Fos-immunoreactive in the ARH nucleus, kisspeptin neurons did not co-express this neuronal marker. Next, we determined the RMP of kisspeptin cells obtained from control or fasted mice. Compared to the control group (AVPV/PeN, -56.5 ± 2.0 mV, n=13 cells from 4 animals; ARH, - 49.8 ± 2.4 mV, n= 9 cells from 6 animals), fasting was not sufficient to induce changes in RMP (AVPV/PeN, -56.1 ± 4.6 mV, n=6 cells from 3 animals, P=0.95; ARH, - 50.9 ± 2.6 mV, n=9 cells from 3 animals, P=0.11). The frequency (freq) and amplitude (amp) of the excitatory postsynaptic currents acting on kisspeptin neurons was further investigated. No significant difference was observed by comparing data obtained from control (AVPV/PeN: freq 0.76 ± 0.1 Hz, n=19; amp, 28.6 ± 1.8 pA, n=16; ARH: freq 0.36 ± 0.1 Hz, n=15; amp, 28.5 ± 2 pA, n=15) and fasted mice (AVPV/PeN: freq 0.7 ± 0.1 Hz, n=18; amp, 28.5 ± 1.1 pA; n=18; ARH: freq 0.5 ± 0.2 Hz, n=24; amp, 27.9 ± 1.3 pA; n=24; P > 0.5, 7/9 animals per group). Considering that 24hr fasting is not enough to inhibit estrous cyclicity, even though it is sufficient to induce a significant reduction of hypothalamic Kiss1 mRNA expression (unpublished data), our results suggest that prolonged periods of food restriction may be required to disturb excitatory inputs into kisspeptin cells.

Long-segment posterior cervical decompression and fusion: does caudal level affect revision rate?

OBJECTIVE Posterior cervical decompression and fusion (PCDF) is a commonly performed procedure to address cervical myelopathy. A significant number of these patients require revision surgery for adjacent-segment disease (ASD) or pseudarthrosis. Currently, there is no consensus among spine surgeons on the inclusion of proximal thoracic spine instrumentation. This study investigates the benefits of thoracic extension in long-segment cervical fusions and the potential drawbacks. The authors compare outcomes in long-segment subaxial cervical fusion for degenerative cervical myelopathy with caudal vertebral levels of C6, C7, and T1. METHODS A retrospective analysis identified 369 patients who underwent PCDF. Patients were grouped by caudal fusion level. Reoperation rates for ASD and pseudarthrosis, infection, and blood loss were examined. Data were analyzed with chi-square, 1-way ANOVA, and logistic regression. RESULTS The total reoperation rate for symptomatic pseudarthrosis or ASD was 4.8%. Reoperation rates, although not significant, were lower in the C3–6 group (2.6%, vs 8.3% for C3–7 and 3.8% for C3–T1; p = 0.129). Similarly, rates of infection were lower in the shorter-segment fusion without achieving statistical significance (2.6% for C3–6, vs 5.6% for C3–7 and 5.5% for C3–T1; p = 0.573). The mean blood loss was documented as 104, 125, and 224 mL for groups 1, 2, and 3, respectively (p < 0.001). CONCLUSIONS Given the lack of statistical difference in reoperation rates for long-segment cervical fusions ending at C6, C7, or T1, shorter fusions in high-risk surgical candidates or elderly patients may be performed without higher rates of reoperation.

Distribution of injectates in the thoracic paravertebral space of the dog and cat: A cadaveric study

Background: Thoracic paravertebral block (TPVB) entails injecting a local anesthetic inside the thoracic paravertebral space (TPVS). Loss of resistance to air injection (air-LOR) was the first technique described in humans to locate the TPVS. To date, no study has investigated the spread of any substance after injection into the TPVS using the air-LOR technique nor has described the cranial and caudal limits of the space. Aim: To identify the boundaries of the TPVS, to determine whether the air-LOR technique is reliable for the identification of the TPVS and to examine the relationship between the volume of injectate and its spread. Methods: After a preliminary phase, the thorax of five cat and five dog cadavers was accessed and eviscerated. After TPVS probing, the polyurethane foam was injected, and the cranial and caudal borders were recorded after its maximum spread. Different volumes of a mixture of new methylene blue and ioversol were injected in the TPVS after its localization with a Tuohy needle and air-LOR technique in fourteen dog and six cat cadavers. Lateral radiographs of the vertebral column were used to document needle positioning, spread pattern and extension. The thorax of these subjects was then accessed and eviscerated to observe and record the spread of the mixture. Results: Injecting a dye into the TPVS, localized by an air-LOR technique, resulted in multi-segmental and often bilateral subpleural staining of paravertebral, intercostal, and dorsal mediastinal structures in dog and cat cadavers. The lateral radiographs most often showed a mixed cloud-like and linear spread pattern, which could be a predictor of the longitudinal spread of the dye. The foam injected into the TPVS at the cranial and the caudal level revealed anatomical communication with the cervical, axillar, and lumbar paravertebral regions. Conclusion: TPVS localization by air-LOR technique and injection results in a longitudinal multi-segmental spread in dog and cat cadavers. The communication of the TPVS with the axillary and lumbar regions could be of clinical interest for the brachial plexus and the lumbar intercostal nerve blocks in a clinical setting.

Crossing the Cervico-Thoracic Junction in Long Posterior Cervical Fusions Reduces Caudal Adjacent Segment Pathology

Study Design: Retrospective case control. Objectives: The purpose of this study is to compare clinical outcomes and rates of symptomatic caudal adjacent segment pathology (ASP) in posterior cervical fusions (PCF) constructs with end-instrumented vertebrae in the cervical spine (EIV-C) to PCF constructs that end in the proximal thoracic spine (EIV-T). Methods: Retrospective review of 1714 consecutive cervical spinal fusion cases was done. Two groups were identified: 36 cervical end-instrumented vertebra patients (age56 ± 10 yrs) and 53 thoracic EIV patients (age 57 ± 9 yrs). Symptomatic ASP was defined as revision surgery or nerve root injection (or recommended surgery or injection) at the adjacent levels. Results: EIV-C patients had a significantly higher rate of caudal-level symptomatic ASP requiring intervention compared with EIV-T patients (39% vs 15%, p = 0.01). The development of caudal-level ASP was highest at C7 (41%), followed by C6 (40%). The overall complication rate and surgical revision rates, however, were similar between the groups. Neck Disability Index outcomes at 2 years postop were significantly better in the EIV-T group (24.5 vs. 34.0, p = 0.05). Conclusions: Long PCF that cross the C-T junction have superior clinical outcomes and reduced rates of caudal breakdown, at the expense of longer fusions and higher EBL, with no increase in the rate of complications. Crossing the C-T junction affords protection of the caudal adjacent levels without adding significant operative time or morbidity.

Comparison Between Selective Caudal Fixed Screw Construct and All Variable Screw Construct in Anterior Cervical Discectomy and Fusion

Objectives: This retrospective comparative study aimed to compare the efficacy of selective caudal fixed screw constructs with all variable screw constructs in anterior cervical discectomy and fusion (ACDF). Methods: Thirty-five patients who underwent surgery using selective caudal fixed screw construct (SF group) were compared with 44 patients who underwent surgery using all variable constructs (AV group). The fusion rate, subsidence, adjacent level ossification development (ALOD), adjacent segmental disease (ASD), and plate-adjacent disc space distance were assessed.Results: The one-year fusion rates assessed by computed tomography bone bridging and interspinous motion as well as the significant subsidence rate did not differ significantly between the AV and SF groups. The ALOD and ASD rates and plate-adjacent disc space distances did not significantly differ between the two groups at both the cranial and caudal adjacent levels. The number of operated levels was significantly associated with pseudarthrosis in the logistic regression analysis.Conclusion: The stability provided by the locking mechanism of the fixed screw did not lead to an increased fusion rate at the caudal level. Therefore, the screw type should be selected based on individual patient’s anatomy and surgeon’s experience without concern for increased complications caused by screw type.

Study of the Variation of Some Biochemical Parameters in Rattus norgevicus

The biochemical assessment in animals is of capital interest to define the diagnosis of many diseases. The variation of biochemical parameters (urea, glycemia, creatinemia, transaminases: GPT and GOT, total cholesterol, HDL-c, LDL-c, triglycerides and total lipids) is an indicator of the state of health of certain vital organs such as the kidney, liver, pancreas, veins, heart, etc... . For this study, to be able to determine the normal values of the rats, a set of batches of male and female Wistar rats was formed and acclimatized for 2 months. Each batch set consisted of thirty-nine (39) rats. Each rat was weighed and then sampled by venipuncture at the caudal level to collect their blood in a dry tube (red). The red tube was used to determine the biochemical parameters. The results of this study showed that some animals already had certain pathologies before the use of any beneficial or harmful substance on them. However, most of the animals used have normal biochemical parameters revealing the good state of their various vital functions (kidney, liver, heart, veins, pancreas, etc.). These values of determining standard biochemical parameters can form a basis for future tests.

Evaluation and prognosis of spinal cord injury

It is important to perform an accurate neurological assessment using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to judge the prognosis of spinal cord injury patients. We can gauge the prognosis for upper extremity function or gait ability according to the ISNCSCI results. ISNCSCI involves both sensory and motor examination, and it is performed with the patient in the supine position to enable a comparison between the initial and follow-up exams. The sensory exam is performed on the 28 key sensory points of dermatomes for light touch and pinprick. The motor exam is performed on 10 key muscles on each side. The sensory and motor levels for the right and left sides are determined according to the sensory and motor exam results. The neurological level of injury is the most caudal level of the cord at which both the motor and sensory functions are intact. Finally, the American Spinal Injury Association Impairment Scale (AIS) is determined. AIS A indicates complete injury, and AIS B, C, and D indicate incomplete injuries. Once the sensory and motor levels, neurological level of injury, and AIS scale of a spinal cord injury patient are determined through ISNCSCI, the patient's prognosis can be predicted based on those results. Furthermore, ISNCSCI performed at 72 hours after an injury yields the most significant prognostic factors.

Revision by S2-alar-iliac instrumentation reduces caudal screw loosening while improving sacroiliac joint pain—a group comparison study

Lumbosacral instrumentation continues to be challenging due to complex biomechanical force distributions and poor sacral bone quality. Various techniques have therefore been established. The aim of this study was to investigate the outcome of patients treated with S2-alar-iliac (S2AI), S2-alar (S2A), and iliac (I) instrumentation as the most caudal level. Sixty patients underwent one of the 3 techniques between January 2012 and June 2017 (S2AI 18 patients, S2A 20 patients, I 22 patients). Mean age was 70.4 ± 8.5 years. Screw loosening (SL) and sacroiliac joint (SIJ) pain were evaluated during the course at 3-month and maximum follow-up (FU). All patients completed 3-month FU, the mean FU period was 2.5 ± 1.5 years (p = 0.38), and a median of 5 segments was operated on (p = 0.26), respectively. Bone mineral density (BMD), derived opportunistically from computed tomography (CT), did not significantly differ between the groups (p = 0.66), but cages were more frequently implanted in patients of the S2A group (p = 0.04). SL of sacral or iliac screws was more common in patients of the S2A and I groups compared with the S2AI group (S2AI 16.7%, S2A 55.0%, I 27.3% of patients; p = 0.03). SIJ pain was more often improved in the S2AI group not only after 3 months but also at maximum FU (S2AI 61.1%, S2A 25.0%, I 22.7% of patients showing improvement; p = 0.02). Even in shorter or mid-length lumbar or thoracolumbar constructs, S2AI might be considered superior to S2A and I instrumentation due to showing lower incidences of caudal SL and SIJ pain.

Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter?

OBJECTIVEThree-column osteotomy (3CO) is a demanding technique that is performed to correct sagittal spinal malalignment. However, the impact of the 3CO level on pelvic or truncal sagittal correction remains unclear. In this study, the authors assessed the impact of 3CO level and postoperative apex of lumbar lordosis on sagittal alignment correction, complications, and revisions.METHODSIn this retrospective study of a multicenter spinal deformity database, radiographic data were analyzed at baseline and at 1- and 2-year follow-up to quantify spinopelvic alignment, apex of lordosis, and resection angle. The impact of 3CO level and apex level of lumbar lordosis on the sagittal correction was assessed. Logistic regression analyses were performed, controlling for cofounders, to investigate the effects of 3CO level and apex level on intraoperative and postoperative complications as well as on the need for subsequent revision surgery.RESULTSA total of 468 patients were included (mean age 60.8 years, mean body mass index 28.1 kg/m2); 70% of patients were female. The average 3CO resection angle was 25.1° and did not significantly differ with regard to 3CO level. There were no significant correlations between the 3CO level and amount of sagittal vertical axis or pelvic tilt correction. The postoperative apex level significantly correlated with greater correction of pelvic tilt (2° per more caudal level, R = −0.2, p = 0.006). Lower-level 3CO significantly correlated with revisions for pseudarthrosis (OR = 3.88, p = 0.001) and postoperative motor deficits (OR = 2.02, p = 0.026).CONCLUSIONSIn this study, a more caudal lumbar 3CO level did not lead to greater sagittal vertical axis correction. The postoperative apex of lumbar lordosis significantly impacted pelvic tilt. 3CO levels that were more caudal were associated with more postoperative motor deficits and revisions.