జర్నల్ ఆఫ్ స్పైన్

Chronic back pain afflicts hundreds of millions of people worldwide. The most common early cause is deterioration of the intervertebral disc from trauma or aging. Current Therapies to treat back pain from nonsurgical techniques: ie. Physical medicine + pain management, and oral analgesics, are followed by various techniques of MIS and traditional disc surgery, but PREMATURELY ending in fusion.

Transplantation of autologous chondrocytes obtained from cellular culture constitutes one of the methods of the biological treatment of the degenerative disc disease (DDD). The study covered a group of 50 patients operated on for single-level lumbar discopathy in whom material for autologous chondrocyte culture was sampled from a removed fragment of an intervertebral disc. The chondrocytes obtained from the culture were next implanted into the pre-operated space with the use of the percutaneous method, the implantation being followed by a radiological and clinical evaluation. In two cases a repeated prolapse of a nucleus pulposus fragment was reported after an earlier transplantation. The patients were operated on again. The material obtained from the recurred nucleus pulposus hernia allowed for a biological evaluation of the effect of the transplantation on the structure of the intervertebral disc with a light and confocal microscope. The examination showed good integration of the transplanted cells with the cellular matrix and their correct production activity in the form of the generation of typical matrix components – type I, II, III, IX collagen, proteoglycans and aggrecan as well as type IV collagen, atypical for the matrix, the presence of which is a subject of further research works.

Background: Lumbar radicular pain may be caused by lumbar disc herniation, spinal stenosis, or degenerative spondylolisthesis. It is most often caused by lumbar disc herniation and presents as pain radiating from the back into the leg, usually in a dermatomal pattern corresponding to the compressed nerve root. In patients whose pain does not respond to epidural steroid injections, other treatment modalities can be considered. Minimally invasive disc decompression procedures have been developed to treat radicular pain caused by disc herniation. The Disc-FX system combines percutaneous manual discectomy using forceps, nuclear ablation, and annular modification using radiofrequency equipment. To our knowledge, no reports of a correlation between response to Disc-FX and type of lumbar disc herniation have been published. The aim of this study was to determine patients’ responses to and shortterm outcomes of Disc-FX procedures.
Methods: This single-center study enrolled 43 patients and followed them for 6 months. Disc-FX procedures were performed in the operating room using local anesthesia. Outcome measures were obtained with a numeric rating scale at 1 and 6 months post-treatment.
Results: Patients’ mean pain scores were significantly lower 1 and 6 months after treatment than before treatment. The percentage of patients who experienced pain relief (numeric rating scale scores less than 50% of baseline scores) was 55.8% at 1 month and 56.1% at 6 months after the procedure. There were no statistically significant correlations between pain relief and type of herniation, pain location (lower back and/or leg pain), pain duration, or presence of an annular tear.
Conclusion: Our results suggest that the Disc-FX procedure is a reasonable treatment option for carefully selected patients with lower back and radicular pain of discogenic origin.

Interspinous Posterior Devices (IPDs) are spinal implantable devices used to treat lumbar degenerative diseases, with lumbar stenosis as the main indication. They are defined as devices for dynamic stabilization, because their aim is to perform a decompression of the spinal canal in case of stenosis, while preserving biomechanical properties of the spinal metamere. Lumbar stenosis is considered as the last phase of the degenerative cascade, the process of degeneration of spinal motor unit described by Kirkaldy-Willis, which identified as primary cause the hypermobility of the vertebras.

We believed that the delivery of a moderate compression force to bone grafts in transforaminal lumbar interbody fusion (TLIF) was better for bony union and performed the TLIF using a pedicle screw with mobility. Using the Segmental Spinal Correction System for TLIF, we investigated 13 patients with a minimum postoperative follow-up of 1 year. A good bony union was observed and clinical results included an improvement rate of 76.8%. Recent spinal instruments are made from more rigid and break-resistant materials. Bony union is less likely to be achieved in TLIF unless segmental subsidence is tolerated to some extent. The use of pedicle screws with mobility may enhance bony union.
Background: TLIF using a rigid pedicle screw has become the gold standard in spinal fusion. However, do stronger instruments have advantages for bony union? Bone grafts in TLIF once undergo necrosis and the volume decreases over time. If the disc height does not decrease accordingly, it will create some space between the grafted bone and both upper and lower vertebral bodies, which is disadvantageous for bony union. Thus, we considered that a pedicle screw with mobility would provide moderate compression force to the bone grafts in TLIF and would be better for bony union. The Segmental Spinal Correction System (SSCS) was used for TLIF in this study.
Results: We investigated the clinical results of this method in 13 patients (6 male and 7 female, 56 to 79 y/o) with a minimum 1-year follow-up. The mean JOA score improved from 13.5 pre-OP to 25.4 post-OP. The mean improvement rate was 76.8%. Bony union was observed for all patients.
Conclusion: TLIF using a pedicle screw with mobility provides moderate compression force to the bone grafts in TLIF and bony union may be enhanced. This could be a new method in spinal fusion surgery.

We believed that the delivery of a moderate compression force to bone grafts in transforaminal lumbar interbody fusion (TLIF) was better for bony union and performed the TLIF using a pedicle screw with mobility. Using the Segmental Spinal Correction System for TLIF, we investigated 13 patients with a minimum postoperative follow-up of 1 year. A good bony union was observed and clinical results included an improvement rate of 76.8%. Recent spinal instruments are made from more rigid and break-resistant materials. Bony union is less likely to be achieved in TLIF unless segmental subsidence is tolerated to some extent. The use of pedicle screws with mobility may enhance bony union.
Background: TLIF using a rigid pedicle screw has become the gold standard in spinal fusion. However, do stronger instruments have advantages for bony union? Bone grafts in TLIF once undergo necrosis and the volume decreases over time. If the disc height does not decrease accordingly, it will create some space between the grafted bone and both upper and lower vertebral bodies, which is disadvantageous for bony union. Thus, we considered that a pedicle screw with mobility would provide moderate compression force to the bone grafts in TLIF and would be better for bony union. The Segmental Spinal Correction System (SSCS) was used for TLIF in this study.
Results: We investigated the clinical results of this method in 13 patients (6 male and 7 female, 56 to 79 y/o) with a minimum 1-year follow-up. The mean JOA score improved from 13.5 pre-OP to 25.4 post-OP. The mean improvement rate was 76.8%. Bony union was observed for all patients.
Conclusion: TLIF using a pedicle screw with mobility provides moderate compression force to the bone grafts in TLIF and bony union may be enhanced. This could be a new method in spinal fusion surgery.

Some rheumatic diseases, including ankylosing spondylitis, appear to be associated to an increased risk of cancer, in particular lymphoma. At the same time, a slightly higher risk of cancer has been associated to Tumour Necrosis Factor (TNF)-alpha antagonists, a widely used treatment for ankylosing spondylitis. A history of malignancy is generally considered a contraindication to TNF-alpha inhibitor and, if neoplasia is uncovered during treatment, therapy suspension is mandatory. Few data are available regarding the possibility of resuming treatment in the event of a flare up of this disease, even when exams monitoring the neoplastic disease are negative. Here we describe the case of a 56-year-old AS patient who developed a cutaneous B-cell non-Hodgkin lymphoma while undergoing treatment with a TNF-alpha inhibitor. The therapy was suspended while he was treated for the neoplasia, but it was resumed when there was a flare up of the disease, and the patient showed improvement.

Study Background: Os odontoideum is an anomaly of the cervical axis characterized by an independent ossicle of variable size separated from the hypoplastic dens that can present as an incidental radiographic finding to severe neck pain, torticollis, myelopathy, as well as seizures and syncope. Diagnosis is primarily made based on clinical presentation and extensive radiologic evaluation. In this review, we discuss the etiology, treatment, and management of this rare condition in the pediatric population and propose a treatment algorithm.
Methods: We performed a comprehensive retrospective review of English literature in PubMed on surgical approaches to treatment and stabilization of Os osontoideum in children.
Results: Asymptomatic children, who are diagnosed with Os odontoideum, but lack overt neurologic deficits, are advised to continue radiologic monitoring with lateral flexion-extension X-rays once a year and MRI evaluation once every five years. For symptomatic patients with significant atlantoaxial instability, neurologic deficits, or myelopathy, surgical treatment is recommended. In cases where the atlantoaxial joint is aligned properly without any kyphotic deformities and vertebral arteries abnormalities, transarticular C1-C2 screw fixation should be considered. If these requirements are not met, C1 lateral mass screws with C2 pars/pedicle screws method are advised. The transoral approach, odontoid screw fixation, and minimally invasive techniques are possible alternatives, but have not been studied enough to be considered standard treatments in pediatric population.
Conclusions: These recommendations are meant to initiate a “best practices” strategy for treatment of Os odontoideum in children. We anticipate further refinement of these recommendations as new research and reports arise in the field of minimally invasive neurosurgery.

Background: According to current literature, surgical management of Adult Scoliosis (AS) can benefit selected patients, especially when concurrent sagittal deformities are balanced.
This retrospective study analyzes this hypothesis by matching clinical and radiological results after AS surgical correction in selected cases. The study also analyzes the possible correlation between mechanical failure events and residual postoperative sagittal imbalance.

Materials and Methods: 12 patients, average aged 57 years, underwent AS surgical correction. Today, these patients have a follow up range from 24 months to 71 months (average 53.6 months).
Values related to scoliotic curve, lordosis, kyphosis and pelvic parameters (Pelvic Incidence, PI; Pelvic tilt, PT; Sacral Slope, SS; Sagittal Vertical Axis, SVA) were measured and registered pre-operatively and post-operatively.
Patients were examined at 3, 6, and 12 months after surgery and then every year through outpatient visits, where the degree of patient satisfaction was evaluated. Patients also received before the surgery and at 3, 6, 12 months follow up auto-administered validated questionnaires (Visual Analog Score, Oswestry Disability Index, Quality of Life) for the evaluation of clinical outcomes. Regarding patients’ responses to these questionnaires we have a follow up range of 3-20 months (average 8.4 months). Mechanical failure complications were also registered during the entire follow up period.

Results: Radiological results: scoliosis was corrected on average 27°; kyphosis changed in 10 patients, by an average increase of 11.33° in 6 patients and by an average reduction of 12.7° in 4 cases. The average correction of lordosis, compared to an ideal reference value, was 61.94% (41.89 – 86.42%). A pathological pelvic retroversion (PT>20°) affected 10 patients out of 12. After surgery this compensation vanished in 3 patients while it remained >20° in 7. Postoperative plumb line analysis showed that only five patients had a balanced postoperative profile.

Clinical results: Improvement of clinical conditions and patient’s satisfaction were obtained in 9 out of 12 patients.

Mechanical Failure: in our series, 4 patients (33%) experienced hardware failure.
Statistical analysis was performed using Kendall’s correlation test and Pearson’s correlation test.

Conclusions: This retrospective study evaluates medium and long term adult scoliosis surgical results, by matching clinical outcomes and postoperative balance. The complete rescue of physiological balance was demonstrated to reduce disability in all cases except one; according to our experience, also a partial reduction of the deformity could improve the clinical patient’s condition, especially in cases where deformity and disability were severe before the surgery. Statistically analysis showed a correlation between kyphosis changes following surgery and clinical outcomes trend. Despite the small sample size, we also observed that residual imbalance favored early mechanical hardware failure, confirming the trend reported in the literature.

Atlas fracture usually result from traumatic injury but only 3 cases of non-traumatic atlas fracture have described in the literature. The authors hereby describe a case of non-traumatic anterior atlas fracture following C1 laminectomy following the decompressive surgical procedure for the ossification of posterior longitudinal ligament. Originally droopy posture and iatrogenic disruption of the posterior arch with invading musculoligamentous structures from axis laminoplasty might increase the stress for anterior atlas. Due to the failure of bony fusion despite the use of an external orthosis, surgical intervention was necessary.

The Primary Central Nervous System Lymphoma is an uncommon disease and rarely affects the spinal cord. The authors present the case of a female patient, 67 year-old, with paresis of the left leg. Lumbosacral MRI depicts focal thickening of the cauda equina roots at L2 level, isointense on T1W and hyperintense on T2W with intense contrast enhancement. Immunohistochemistry analysis of a biopsied root confirmed the diagnosis of Diffuse Large B-cell Lymphoma. The PCNSL, generally represented by Large B-cells subtype, affects the spinal cord in less than one per cent of the cases and are generally associated with cytogenetic changes on BCL-6 gene. The appearance on MRI is not characteristic, evidencing the focal volumetric increase of the cauda equina roots, with intense contrast enhancement, being not possible to differentiate between lesions as schwannomas and meningiomas. For the diagnosis is necessary biopsy of the lesion and after intraoperative confirmation, resection should be suspended because it is not effective. The treatment is based on chemotherapy and radiotherapy, however, the prognosis is poor.

World Health Organization (WHO) in 2005 reported that cases of tuberculosis (TB) in the world occur more than 8 million annually and 5-10% was attacked in spine. The most effective treatment of spinal TB is evacuation of infected bone segments and fills with bone graft. It has been synthesized and characterized of Injectable Bone Substitute (IBS) paste based on hydroxyapatite, gelatin and streptomycin. IBS paste synthesized by mixing hydroxyapatite and gelatin 20% w/v with 75:25, 70:30, 65:35 and 60:40 ratio and streptomycin 10 wt%. The mixture was then added with hydroxypropyl methylcellulose (HPMC) 4% w/v as suspending agent. In vitro characterization performed includes acidity (pH), injectability test, setting time, cytotoxicity (MTT assay) and microbacterium test. Acidity test results indicate a fourth variation of the samples had pH values approaching normal body pH (7.3 to 7.6) and is able to maintain stability when measured in 7 days. Injectability test results indicate IBS paste is injectable with the highest percentage of the injectability value at 97.74% ± 0.19%. IBS paste has been setting within 30 minutes to 1 hour when injected on hydroxyapatite scaffold that resembles the bone cavity and is able to cover the pore scaffold seen from the Scanning Electron Microscope (SEM). Scaffold pore size is smaller from range of 780.8 to 835.4 μm into 225.2 μm. MTT assay results showed that IBS paste is not toxic and experiencing proliferation (viability >100%) that are expected to trigger osteoblast cell growth when applied. Microbacterium test results showed that IBS paste is an antibacterial seen from inhibition zone diameter of Staphylococcus aureus and has a high strength-sensitive antibacterial. Thus, hydroxyapatite, gelatin and streptomycin composites had qualified as injectable bone substitute which applied in cases of spinal tuberculosis.

Tubercle bacilli are tiny thin rod-shaped, non-spore-forming, non-motile obligate aerobic bacteria measuring 3 μm in length and 0.5 μm in width without pili for adherence and without producing adhesion molecule, and are acid-fast bacilli (AFB) with thick waxy cell wall having poorly developed porins, being present in the planktonic form. Tubercle bacilli are very slowly replicating (12 hours of generation time) only in presence of oxygen. Tuberculosis is a product of war between the host phagocytes and M tuberculosis in tissue. Phagocyte and M tuberculosis have very different cell wall composition, but both have very similar chemical weapons in them for fight and defense. Mycobacterium produces various mycolic acid compounds to form waxy cell wall and to defend it not to be digested by phagocytes, and not to be killed by the antituberculous drugs. Mycobacterium forms granuloma (tubercle) which is the specific reticuloendothelial tissue reaction to the specific type of irritants in normal person. It does not produce chondrolytic enzymes to destroy cartilage and disk, and does not adhere to any biomaterials. Thick waxy coat of Mycobacterium impedes the entry of nutrient through the poorly developed and scarce porins, and thus limits growth rate, but it also protects the bacilli from host defenses and antibiotics.