ObjectiveTo compare the fixation strength of optimum placed pedicle screw (OS) with re-directionally correctly placed pedicle screw (RS) following a violation of lateral pedicle. MethodsThirty fresh lumbar vertebrae (L1-5) were obtained from 6 pigs weighing 95-105 kg, male or female. Each vertebra was instrumented with a monoaxial pedicle screw into each pedicle using two different techniques. On one side, a perfect screw path was created using direct visualization and fluoroscopy. A pedicle screw of 5 mm in diameter and 35 mm in length was placed with a digital torque driver (OS). On the other side, a lateral pedicle wall violation was created at the pedicle-vertebral body junction with a guide wire, a cannulated tap, and a pedicle probe. This path was then redirected into a correct position, developed, and instrumented with a 5-mm-diameter by 35-mm-long pedicle screw (RS). For each pedicle screw, the maximal torque, seating torque, screw loosening force, and post-loosening axial pullout were measured. Screw loosening and axial pullout were assessed using an MTS machine. ResultsMaximal insertion torque was (111.4±8.2) N·cm and (78.9±6.4) N·cm for OS and RS respectively, showing significant difference (Z=3.038, P=0.002). The seating torque was (86.3±7.7) N·cm and (59.7±5.3) N·cm for OS and RS respectively, showing significant difference (Z=2.802, P=0.005). The screw loosening force was (76.3±6.2) N and (53.0±5.8) N for OS and RS respectively, showing significant difference (Z=2.861, P=0.004). The post-loosening axial pullout force was (343.0±12.6) N and (287.0±10.5) N for OS and RS respectively, showing significant difference (Z=2.964, P=0.003). ConclusionCompared with OS, RS placement after a lateral wall violation shows significantly decreased maximal insertion torque, seating torque, screw loosening force, and post-loosening axial pullout. On this occasion, RS augmentation is a probable option for remediation.
Objective To explore the influence of dexmedetomidine on wake-up test during spinal orthopaedic surgery. Methods All 80 patients taking spinal orthopaedic surgery were randomly divided into the trial group and the control group, with 40 cases in each group. The endotracheal intubation anesthesia was adopted in both groups with same anesthesia induction. Additionally, dexmedetomidine 0.8 μg/ (kg·h) was infused within 10 min in the trial group before anesthesia induction, and then another 0.5 μg/ (kg·h) was also infused from the intraoperation to suture of incision. For the control group, the same amount of normal saline was infused, and all the narcotics were stopped pumping 15 min before the wake-up test, but then were continued pumping after the wake-up test. Finally, the following indexes were analyzed: wake-up time, wake-up quality, hemodynamic changes at the time of 15 min before wake-up (T1), recovery of spontaneous breathing (T2), wake-up (T3) and 15 min after wake-up (T4), dosage of narcotics, and the incidence of adverse events. Results There was no significant difference in the operation time before wake-up between the two groups (P=0.07). For the trial group, the dosage of sevoflurane (P=0.03) and sufentanil (P=0.00) used before wake-up was significantly lower, the wake-up time (P=0.04) and bleeding amount during wake-up (P=0.00) were significantly less, the wake-up quality (P=0.03) was significantly higher, the blood pressure (P=0.00) and heart rate (P=0.00) when wake-up were significantly lower, and the incidence of adverse events (P=0.04) was significantly lower, compared with the control group. Conclusion Dexmedetomidine adopted in spinal orthopaedic surgery can significantly improve patient’s wake-up quality, shorten wake-up time, reduce bleeding amount when wake-up and adverse events after wake-up, and maintain the hemodynamic stability, so it has better protective effects.
Objective To establish the evidence-based treatment strategy for an advanced lung cancer case with spinal metastasis, regarding the patient’s condition and treatment expectations. Methods According to PICO principles, questions in the patient’s treatment were converted into a search strategy. The literature searching was performed in several databases. In accordance with the five evidence grading standards in evidence-based medicine, the best clinical evidence was interpreted to guide the treatment decisions. Results A total of 148 papers were detected and screened, of which 4 systematic reviews or meta-analyses were included finally. Four issues that patients concerned, including restoring spinal cord function (walking and sphincter function), local pain control, long-term survival, and treatment complications, were all supported by grade-1 evidence. The patient finally chose surgical decompression, which was of a higher complication risk, but better possibility of restoring nerve function, significant pain relief, and improved long-term survival. The patient obtained fully recovery and regained walking function after surgery. Conclusion The evidence-based treatment is able to provide reasonable treatment options for lung cancer patients with spinal metastasis. Decompression surgery for patients with walking dysfunction should be carried out as soon as possible, in order to early restore spinal marrow function, relieve pain and improve long-term survival. But both doctors and patients should fully acquaint themselves with the higher risk of surgical complications.
Objective To investigate the relation of spinal ventricular septal angle (SVSA) measured by computer tomographic pulmonary angiography (CTPA) and pulmonary vascular resistance (PVR) measured by right heart catheterization in patients with chronic thromboembolic pulmonary hypertension (CTEPH) .Methods Eighty-nine patients with CTEPH (male 57, female 32; 53.08 ±12.43 years) were recruited as a CTEPH group, and 89 patients without pulmonary artery hypertension and pulmonary embolismwere recruited as a control group. The CTEPH patients received CTPA before right-heart catheterization and pulmonary angiography. SVSA and pulmonary artery obstruction indexes including Qanadli Index and Mastora index were evaluated by two radiologists.Results SVSA was 65.13°±12.26°and 39.69°±5.84°in the CTEPH group and the control group respectively, with significant difference between two groups ( t =14.479, P = 0.000) . Qanadli index of the CTEPH patients was( 42.50 ±17.67) % , which had no correlation with SVSA ( r= 0.094, P = 0.552) . Mastora index was ( 30.02 ±15.53) % , which also had no correlation with SVSA ( r=0.025, P =0.873) . SVSA had a moderate positive correlation with PVR ( r =0.529, P =0.000) and a weak positive correlation with right atriumpressure ( r =0.270, P =0.010) . Area under ROC was 0.764 and sensitivity, specificity for PVR≥1000 dyne· s· cm- 5 was 0.714 and 0.778 respectively when SVSA≥67.55°. Conclusion SVSA measured by CTPA can be used as a better predictor for evaluating PVR in CTEPH patients.
Abstract： Objective To study the spinal cord protection effect of cerebrospinal fluid drainage （CSFD）for patients undergoing thoracoabdominal aortic aneurysm surgery. Methods We randomly allocated 30 patients undergoing thoracoabdominal aortic aneurysm surgery in Beijing Anzhen Hospital from December 2008 to August 2009 into a CSFD group with 15 patients（12 males, 3 females; average age of 45.0 years） and a control group with 15 patients（11 males, 4 females; average age at 45.8 years）by computer. All the patients underwent replacement of ascending aorta and aortic arch, implantation of descending aorta stent, or thoracoabdominal aorta replacement. Some patients underwent Bentall operation or replacement of half aortic arch. Patients in the CSFD group also underwent CSFD. Serum S100B, glial fibrillary acidic protein and neuron-specific enolase were measured at set intraoperative and postoperative times. All the patients were scored preoperatively, 72 hours postoperatively, and before discharge according to the National Institutes of Health Stroke Scale and International Standards for Neurological Classification of Spinal Cord Injury. Results Central nervous system injury occurred in four patients in the control group： one died of both brain damage and spinal cord damage; one patient had spinal cord injury and became better after treatment by early CSFD; two patients had brain damage（one patient died, another patient had concomitant acute renal failure and acute respiratory failure, recovered and was discharged after treatment）. In the CSFD group, only one patient died of acute respiratory failure and subsequent multiple organ system failure, and all other patients recovered very well. There was no late death during three months follow-up in both groups. The average serum S100B, glial fibrillary acidic protein，and neuron-specific enolase concentrations of the CSFD group patients were significantly lower than those of the control group （F=7.153，P=0.012；F=3.263，P=0.082；F=4.927，P=0.035）. Conclusion Selected CSFD is a safe, effective and feasible procedure to protect the spinal cord from ischemic damage during the perioperative period of thoracoabdominal aortic aneurysm surgery.
Objective To investigate the relationship between graded spinal cord ischemia/reperfusion injury and somatosensory evoked potentials(SEP),neurologic function score（NFS）and the histopathological changes of spinal cord. Methods Forty rabbits were randomized and equally divided into 4 groups: shamoperation group, ischemia for 30min, 45min and 60min groups. The spinal cord ischemiareperfusion injury model was created by occlusion of the abdominal aorta in rabbits. SEP was monitored before ischemia,5,10minutes after ischemia, 15, 30 minutes, 1,2, 24 and 48 hours after reperfusion. NFS was evaluated at 6,12,24 and 48 hours after reperfusion.The pathological changes of spinal cord were observed after reperfusion 48 hours. Results The pathological characters with mild,moderate and severe spinal cord ischemia/reperfusion injury could be simulated by declamping after 30， 45 and 60 minutes infrarenal aorta crossclamping. SEP amplitude returned to normal after reperfusion 15 minutes（Pgt;0.05）and SEP latency returned to normal after reperfusion 30 minutes（Pgt;0.05）during mild spinal cord ischemia/reperfusion injury.SEP amplitude returned to normal after reperfusion 30 minutes（Pgt;0.05）and SEP latency returned to normal after reperfusion 60 minutes（Pgt;0.05）during moderate spinal cord ischemia/reperfusion injury. SEP latency increased and SEP amplitude decreased during severe spinal cord ischemia/reperfusion injury,compared with other groups, there were significant differences in SEP latency and SEP amplitude by clamping the infrarenal aorta for 60min（Plt;0.01）. With graded spinal cord ischemia/reperfusion injury, compared with shamoperation group, spinal cord ischemiareperfusion groups had significant differences in NFS（Plt;0.01）. Conclusion SEP is much quicker in the recovery of amplitude than latency during spinal cord ischemia/reperfusion. SEP is a sensitive and accurate index for spinal cord function during ischemia/reperfusion injury. SEP monitoring spinal cord ischemia/reperfusion injury during operation provides experimental basis for clinical application.
Spinal cord injury is one of severe complications after thoracic aortic surgery. The degree and time of spinal cord ischemia during surgery, reconstruction of the blood supply of spinal cord ,biochemistry factors ,ischemiareperfusion injury, etc. are considered as factors influence on the complication of spinal cord after surgery. At present, to improve the surgical technique, to increase the blood supply of spinal cord, such as the mechanical dynamic blood perfusion, arterial shunt and cerebrospinal fluid shunt, to degrade the metabolic rate of spinal cord using hypothermia, and to prevent the ischemia-reperfusion injury using drugs are the methods for spinal cord protection during the aortic surgery. The feature of blood circulation of spinal cord, mechanisms of spinal cord injury and the latest progress of spinal cord protection is reviewed in this article.
Objective To investigate the influence of Nogo extracellular peptide residues 1-40 (NEP1-40) gene modification on the survival and differentiation of the neural stem cells (NSCs) after transplantation. Methods NSCs were isolated from the cortex tissue of rat embryo at the age of 18 days and identified by Nestin immunofluorescence. The lentiviruses were transduced to NSCs to construct NEP1-40 gene modified NSCs. The spinal cords of 30 Sprague Dawley rats were hemisected at T9 level. The rats were randomly assigned to 3 groups: group B (spinal cord injury, SCI), group C (NSCs), and group D (NEP1-40 gene modified NSCs). Cell culture medium, NSCs, and NEP1-40 gene modified NSCs were transplanted into the lesion site in groups B, C, and D, respectively at 7 days after injury. An additional 10 rats served as sham-operation group (group A), which only received laminectomy. At 8 weeks of transplantation, the survival and differentiation of transplanted cells were detected with counting neurofilament 200 (NF-200), glial fibrillary acidic portein (GFAP), and myelin basic protein (MBP) positive cells via immunohistochemical method; the quantity of horseradish peroxidase (HRP) positive nerve fiber was detected via HRP neural tracer technology. Results At 8 weeks after transplantation, HRP nerve trace showed the number of HRP-positive nerve fibers of group A (85.17 ± 6.97) was significantly more than that of group D (59.25 ± 7.75), group C (33.58 ± 5.47), and group B (12.17 ± 2.79) (P lt; 0.01); the number of groups C and D were significantly higher than that of group B, and the number of group D was significantly higher than that of group C (P lt; 0.01). Immunofluorescent staining for Nestin showed no obvious fluorescence signal in group A, a few scattered fluorescent signal in group B, and b fluorescence signal in groups C and D. The number of NF-200-positive cells and MBP integral absorbance value from high to low can be arranged as an order of group A, group D, group C, and group B (P lt; 0.05); the order of GFAP-positive cells from high to low was group B, group D, group C, and group A (P lt; 0.05); no significant difference was found in the percentage of NF-200, MBP, and GFAP-positive cells between group C and group D (P gt; 0.05). Conclusion NEP1-40 gene modification can significantly improve the survival and differentiation of NSCs after transplantation, but has no induction on cell differentiation. It can provide a new idea and reliable experimental base for the study of NSCs transplantation for SCI.
Objective To determine the surgical indications for posterior expansive open-door laminoplasty (EOLP) extended to the C1 level. Methods Seventeen patients undergoing C3-7 or C2-7 open-door laminoplasty were included as the case group between September 2005 and January 2010, whose spinal cord injury symptoms were not alleviated or aggravated again because of the cervical stenosis at C1-4 level, and the causes of the surgery itself were eliminated, all of these patients underwent reoperation with decompress upward to C1 level. Fifteen patients with cervical stenosis who underwent C2-7 laminoplasty and C1 laminectomy were selected as the control group. There was no significant difference in gender, age, and disease duration between 2 groups (P gt; 0.05). The pre- and post-operative cervical curvature and spinal cord compression were evaluated according to the patients’ imaging data; the pre- and post-operative neurological recovery situation was evaluated by Japanese Orthopaedic Association (JOA) 17 score and spinal cord function Frankel grade; the neurological recovery rate (according to Hirabayashi et al. method) was used to assess the postoperative neurological recovery situation. Results In the case group, 8 patients underwent primary C3-7 laminoplasty. In 3 of these patients, there was a cervical stenosis at C1, 2 level, and discontinuous cerebrospinal fluid around the spinal cord was observed; 5 of them with a compression mass which diameter was exceed 7.0 mm in the C2-4 segments. The remaining 9 patients in the case group underwent primary C2-7 laminoplasty, and the diameter of the compression mass was exceed 7.0 mm in the C2-4 segments. In all 17 patients of the case group, reoperation was performed with the decompression range extended to the C1 level, and the follow-up time was 35-61 months with an average of 45.6 months. Cervical curvature: there were 11 cases of cervical lordosis, 4 cases of straight spine, and 2 cases of cervical kyphosis before operation; but after operation, 2 cases of cervical lordosis became straight spine and 1 straight case became kyphosis. The postoperative neurological improvement was excellent in 8 cases, good in 7, and fair in 2. In the control group, all the patients had a compression mass which anteroposterior diameter was exceed 7.0 mm in the C2-4 segments before operation. The follow-up time was 30-58 months with an average of 38.7 months. Cervical curvature: there were 13 cases of cervical lordosis and 2 cases of straight spine before operation; but after operation, 1 case of cervical lordosis became straight spine. The postoperative neurological improvement was excellent in 8 cases, good in 6, and fair in 1. No significant difference was found in the JOA score at pre- and post-operation between 2 groups (P gt; 0.05); however, there were significant differences (P lt; 0.05) in the JOA score between at last follow-up and at preoperation. Conclusion The initially surgical indications which can be used as a reference for EOLP extended to C1 are as follows:① Upper cervical (C1, 2) spinal stenosis: C1 posterior arch above the lower edge part of cerebrospinal fluid around the spinal cord signal is not continuous, and the anteroposterior diameter of the spinal canal actual is less than 8.0 mm as judgment standard. ②There is a huge compression at the lower edge of C2-4 vertebrae, and the most prominent part of the diameter is exceed 7.0 mm, which can not be removed through the anterior cervical surgery, or the operation is high-risk.
Objective To investigate the effect of curcumin on calcitionin gene related peptide (CGRP) expression after spinal cord injury (SCI) in rats. Methods A total of 200 rats, weighing 250-300 g, were randomly divided into 4 groups (n=50): sham-operation group, normal saline (NS) group, low-dose curcumin group (30 mg/kg), and high-dose curcumin group (100 mg/kg). In sham-operation group, only vertebral lamina excision was performed without SCI; the SCI model was established in the other 3 groups. At immediate after modeling, 30 mg/kg and 100 mg/kg curcumin were injected intraperitoneally in 2 curcumin groups, equivalent NS was given in NS group (30 mg/kg), but no treatment in sham-operation group. At 1, 3, 7, 14, and 21 days after operation, the motor neural function was evaluated by the inclined plane test and Basso-Beattie-Bresnahan (BBB) scores; immunohistochemical staining and Western blot assay were used to observe CGRP expression. Results BBB score and inclined plane test score of NS group, low-dose curcumin group, and high-dose curcumin group were significantly lower than those of sham-operation group at each time point (P lt; 0.05). BBB score of low-dose curcumin group and high-dose curcumin group was significantly higher than that of NS group at 3, 7, 14, and 21 days after SCI (P lt; 0.05), and the score of high-dose group was significantly higher than that of low-dose curcumin group at 7, 14, and 21 days after SCI (P lt; 0.05). Inclined plane test score of low-dose curcumin group and high-dose curcumin group was significantly higher than that of NS group at 7, 14, and 21 days after SCI (P lt; 0.05), and the score of high-dose curcumin group was significantly higher than that of low-dose curcumin group at 7, 14, and 21 days after SCI (P lt; 0.05). Immunohistochemical staining results showed that the CGRP positive cells of sham-operation group was significantly more than those of the other 3 groups, and the CGRP positive cells of high-dose curcumin group were significantly more than those of low-dose curcumin group at each time point (P lt; 0.05); the CGRP positive cells of low- and high-dose curcumin groups were significantly more than those of NS group at 3, 7, 14, and 21 days after SCI (P lt; 0.05). Western blot assay results showed that the CGRP protein expressed at each time point after SCI in sham-operation group; the CGRP protein expression gradually decrease with time passing in NS group; but the CGRP protein expression gradually increased with time passing in low- and high-dose curcumin groups, and reached the peak at 14 days, then maintained a high level. Conclusion After SCI in rats, 30 mg/kg curcumin can improve rats’ motor function, and 100 mg/kg curcumin effect is more obvious, especially in promoting the expression of CGRP. That may be the mechanism of protection of the nervous system.