How Cervical Reconstruction Surgery Affects Global Spinal Alignment.

BACKGROUND:There have been no reports describing how cervical reconstruction surgery affects global spinal alignment (GSA). OBJECTIVE:To elucidate the effects of cervical reconstruction for GSA through a retrospective multicenter study. METHODS:Seventy-eight patients who underwent cervical reconstruction surgery for cervical kyphosis were divided into a Head-balanced group (n = 42) and a Trunk-balanced group (n = 36) according to the values of the C7 plumb line (PL). We also divided the patients into a cervical sagittal balanced group (CSB group, n = 18) and a cervical sagittal imbalanced group (CSI group, n = 60) based on the C2 PL-C7 PL distance. Various sagittal Cobb angles and the sagittal vertical axes were measured before and after surgery. RESULTS:Cervical alignment was improved to achieve occiput-trunk concordance (the distance between the center of gravity [COG] PL, which is considered the virtual gravity line of the entire body, and C7 PL < 30 mm) despite the location of COG PL and C7PL. A subsequent significant change in thoracolumbar alignment was observed in Head-balanced and CSI groups. However, no such significant change was observed in Trunk-balanced and CSB groups. We observed 1 case of transient and 1 case of residual neurological worsening. CONCLUSION:The primary goal of cervical reconstruction surgery is to achieve occiput-trunk concordance. Once it is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize GSA. Cervical reconstruction can restore both cervical deformity and GSA. However, surgeons must consider the risks and benefits in such challenging cases

Results at 24 months from the prospective, randomized, multicenter Investigational Device Exemption trial of ProDisc-C versus anterior cervical discectomy and fusion with 4-year follow-up and continued access patients.

BackgroundCervical total disk replacement (TDR) is intended to address pain and preserve motion between vertebral bodies in patients with symptomatic cervical disk disease. Two-year follow-up for the ProDisc-C (Synthes USA Products, LLC, West Chester, Pennsylvania) TDR clinical trial showed non-inferiority versus anterior cervical discectomy and fusion (ACDF), showing superiority in many clinical outcomes. We present the 4-year interim follow-up results.MethodsPatients were randomized (1:1) to ProDisc-C (PDC-R) or ACDF. Patients were assessed preoperatively, and postoperatively at 6 weeks and 3, 6, 12, 18, 24, 36, and 48 months. After the randomized portion, continued access (CA) patients also underwent ProDisc-C implantation, with follow-up visits up to 24 months. Evaluations included Neck Disability Index (NDI), Visual Analog Scale (VAS) for pain/satisfaction, and radiographic and physical/neurologic examinations.ResultsRandomized patients (103 PDC-R and 106 ACDF) and 136 CA patients were treated at 13 sites. VAS pain and NDI score improvements from baseline were significant for all patients (P < .0001) but did not differ among groups. VAS satisfaction was higher at all time points for PDC-R versus ACDF patients (P = .0499 at 48 months). The percentage of patients who responded yes to surgery again was 85.6% at 24 months and 88.9% at 48 months in the PDC-R group, 80.9% at 24 months and 81.0% at 48 months in the ACDF group, and 86.3% at 24 months in the CA group. Five PDC-R patients (48 months) and no CA patients (24 months) had index-level bridging bone. By 48 months, approximately 4-fold more ACDF patients required secondary surgery (3 of 103 PDC-R patients [2.9%] vs 12 of 106 ACDF patients [11.3%], P = .0292). Of these, 6 ACDF patients (5.6%) required procedures at adjacent levels. Three CA patients required secondary procedures (24 months).ConclusionsOur 4-year data support that ProDisc-C TDR and ACDF are viable surgical options for symptomatic cervical disk disease. Although ACDF patients may be at higher risk for additional surgical intervention, patients in both groups show good clinical results at longer-term follow-up

Quantitative Assessment of the Anatomical Footprint of the C1 Pedicle Relative to the Lateral Mass: A Guide for C1 Lateral Mass Fixation

Study Design: Anatomic study. Objectives: To determine the relationship of the anatomical footprint of the C1 pedicle relative to the lateral mass (LM). Methods: Anatomic measurements were made on fresh frozen human cadaveric C1 specimens: pedicle width/height, LM width/height (minimum/maximum), LM depth, distance between LM’s medial aspect and pedicle’s medial border, distance between LM’s lateral aspect to pedicle’s lateral border, distance between pedicle’s inferior aspect and LM’s inferior border, distance between arch’s midline and pedicle’s medial border. The percentage of LM medial to the pedicle and the distance from the center of the LM to the pedicle’s medial wall were calculated. Results: A total of 42 LM were analyzed. The C1 pedicle’s lateral aspect was nearly confluent with the LM’s lateral border. Average pedicle width was 9.0 ± 1.1 mm, and average pedicle height was 5.0 ± 1.1 mm. Average LM width and depth were 17.0 ± 1.6 and 17.2 ± 1.6 mm, respectively. There was 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle, which constituted 41% ± 9% of the LM’s width. The distance from C1 arch’s midline to the medial pedicle was 13.5 ± 2.0 mm. The LM’s center was 1.6 ± 1 mm lateral to the medial pedicle wall. There was on average 3.5 ± 0.6 mm of the LM inferior to the pedicle inferior border. Conclusions: The center of the lateral mass is 1.6 ± 1 mm lateral to the medial wall of the C1 pedicle and approximately 15 mm from the midline. There is 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle. Thus, the medial aspect of C1 pedicle may be used as an anatomic reference for locating the center of the C1 LM for screw fixation

Cost Analysis of Single-Level Lumbar Fusions

Study Design: Cost analysis of a retrospectively identified cohort of patients who had undergone primary single-level lumbar fusion at a single institution's orthopedic or neurosurgery department. Objective: The purpose of this article is to analyze the determinants of direct costs for single-level lumbar fusions and identify potential areas for cost reduction. Methods: Adult patients who underwent primary single-level lumbar fusion from fiscal years 2008 to 2012 were identified via administrative and departmental databases and were eligible for inclusion. Patients were excluded if they underwent multiple surgeries, had previous surgery at the same anatomic region, underwent corpectomy, kyphectomy, disc replacement, surgery for tumor or infection, or had incomplete cost data. Demographic data, surgical data, and direct cost data in the categories of supplies, services, room and care, and pharmacy, was collected for each patient. Results: The cohort included 532 patients. Direct costs ranged from $8286 to$73 727 (median = $21 781; mean =$22 890 +/- $6323). Surgical approach was an important determinant of cost. The mean direct cost was highest for the circumferential approach and lowest for posterior instrumented spinal fusions without an interbody cage. The difference in mean direct cost between transforaminal lumbar interbody fusions, anterior lumbar interbody fusions, and lateral transpsoas fusions was not statistically significant. Surgical supplies accounted for 44% of direct costs. Spinal implants were the primary component of supply costs (84.9%). Services accounted for 38% of direct costs and were highly dependent on operative time. Comorbidities were an important contributor to variance in the cost of care as evidenced by high variance in pharmacy costs and length of stay related to their management. Conclusion: The costs of spinal surgeries are highly variable. Important cost drivers in our analysis included surgical approach, implants, operating room time, and length of hospital stay. Areas of high cost and high variance offer potential targets for cost savings and quality improvements.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

PRL-3, a Metastasis Associated Tyrosine Phosphatase, Is Involved in FLT3-ITD Signaling and Implicated in Anti-AML Therapy

Combination with other small molecule drugs represents a promising strategy to improve therapeutic efficacy of FLT3 inhibitors in the clinic. We demonstrated that combining ABT-869, a FLT3 inhibitor, with SAHA, a HDAC inhibitor, led to synergistic killing of the AML cells with FLT3 mutations and suppression of colony formation. We identified a core gene signature that is uniquely induced by the combination treatment in 2 different leukemia cell lines. Among these, we showed that downregulation of PTP4A3 (PRL-3) played a role in this synergism. PRL-3 is downstream of FLT3 signaling and ectopic expression of PRL-3 conferred therapeutic resistance through upregulation of STAT (signal transducers and activators of transcription) pathway activity and anti-apoptotic Mcl-1 protein. PRL-3 interacts with HDAC4 and SAHA downregulates PRL-3 via a proteasome dependent pathway. In addition, PRL-3 protein was identified in 47% of AML cases, but was absent in myeloid cells in normal bone marrows. Our results suggest such combination therapies may significantly improve the therapeutic efficacy of FLT3 inhibitors. PRL-3 plays a potential pathological role in AML and it might be a useful therapeutic target in AML, and warrant clinical investigation

Effect of Co-60 gamma-ray irradiation on electrical properties of Ti/Au/GaAs1-xNx Schottky diodes

Current-voltage (I-V), capacitance-voltage-frequency (C-V-f) and conductance-voltage-frequency (G/ω-V-f) measurements at room temperature are used to study 50 kGy 60Co γ-ray electrical properties irradiation dependence of Ti/Au/GaAs1−xNx Schottky diodes with 0.2%; 0.4%; 0.8% and 1.2% nitrogen dilution. This γ-ray irradiation induces a permanent damage that has increased ideality factor and series resistance for all samples. It was accompanied by a decrease in Schottky barrier height with nitrogen content up to 0.4%N and remained constant thereafter. Radiation was also found to degrade the reverse leakage current. At high frequency (1 MHz), capacitance and conductance decreased after radiation due to a decrease in net doping concentration. Interface state density and series resistance were determined from C-V-f and G/ω-V-f characteristics using Hill-Coleman methods. Interface states density exponentially decreased with increasing frequency confirming the behavior of interface traps response to ac signal. Series resistance increases after irradiation is attributed to carrier's removal effect and mobility degradation. It has two peaks in the accumulation and inversion region for some diodes (0.4%N, 0.8%N). γ-ray irradiation produced traps levels and recombination centers that reduce relaxation time. An increase in %N content can impede irradiation damage with even some compensation when the percent of diluted nitrogen is high (1.2%N)

Physical Examination: ASIA Motor/Sensory Examination and Spinal Cord Injury Syndromes

I INTRODUCTION Traumatic spinal cord injury afflicts more than 8000 new patients per year (1). This figure will tend to increase over time as improved methods of transportation, lifesupport, and trauma care will allow for greater survival rates from high-energy trauma. The evaluation and management of patients with spinal injury are often complicated because it typically occurs in the context of polytrauma. In addition, the level of complexity in rehabilitating these patients is increased by the functional limitations placed upon the patient as a result of neurological injury. The most important part of the treatment of a patient with spinal cord injury begins with the initial assessment. The careful evaluation and clear documentation of the patient’s neurological status will allow the treating physician to best decide the appropriate initial treatment as well as to determine the prognosis for functional recovery and the long-term rehabilitation goals for each individual. This chapter will focus on the physical examination of the patient with spinal cord injury, with emphasis on the recommendations made by the American Spinal Injury Association (ASIA). It will also describe the various spinal cord syndromes that may be encountered by the treating physician

Autonomic dysreflexia caused by cervical stenosis

IntroductionAutonomic dysreflexia (AD) is a well-known sequela of high spinal cord injuries (SCI). The characteristic episodic presentation is one of increased sympathetic tone: diaphoresis, hypertension, tachycardia, or reflex bradycardia. The episodes are triggered by visceral sensations and can last days to weeks.Case presentationThis report presents the case of a 73-year-old male with cervical stenosis, with a longstanding history of "hot flashes" accompanied by dizziness, flushing and diaphoresis, and palpitations. The patient was evaluated extensively by cardiology, endocrinology, and neurology with no treatable pathology determined aside from the patient's cervical stenosis. The patient was diagnosed with autonomic dysreflexia caused by cervical spinal stenosis and underwent anterior cervical decompression and fusion (ACDF) at the stenotic C5-C6 level. He found near complete resolution of his autonomic symptoms.DiscussionWe hypothesize that the cervical compression caused a disruption in the regulatory control of the sympathetic preganglionic neurons resulting in the autonomic symptoms. Although numerous studies exist of patients with a traumatic onset of AD, to the best of our knowledge, this is the first case report in the literature of autonomic symptoms that stemmed from cervical stenosis. The purpose of this case report is to alert clinicians to a potential association between AD and spinal stenosis, which may exist outside the realm of SCI