AANOS Annual Scientific Meeting Neurological and Orthopaedic Surgery Part 1

Management of Thoracolumbar Burst/Compression Fractures

Craig Clark, MD, PhD, Neurosurgeon, Greenwood Leflore Hospital, Carrollton, MS

The management of burst/compression fractures of the thoracolumbar spine remains controversial. Several recent studies have suggested that nonoperative treatment of these fractures allows reduction of complications and morbidity as well as costs. This is countered by advantages of operative intervention including immediate stability, better pain control, earlier mobility, avoidance of bracing and prevention of progressive deformity. Diagnostic criteria to aid in patient selection for nonoperative versus operative treatment will be presented, including a review of the AO criteria and the TLICS severity score, with an overall goal of optimizing patient safety and controlling costs of care.

Fractures of the Scaphoid. Case Study and Review of Treatment Options

Sudhir Rao, MD, Orthopaedic Surgeon

Big Rapids Orthopaedics PC, Big Rapids, MI

Fractures of the scaphoid continue to present a challenge. Up to a third of untreated fractures may fail to heal. Surgical treatment is often necessary for fresh fractures and almost always for non unions. There is general consensus in the treatment of uncomplicated non unions. The treatment options in complex situations such as persistent non union, avascular necrosis is varied and ill defined.

The goal of this presentation is to offer practical treatment options and outline strategies for difficult situations based on current understanding of the problems we face

Autologous Adipose Tissue-Derived Stem Cells Improved Cognitive Function in Alzheimer’s Disease

Hisakazu Yamagishi, MD, PhD, Professor, Kyoto Prefectural University of Medicine, Kyoto, Japan

We have been investigating the therapeutic potential of autologous adipose tissue-derived stem cells (ADSC) for several intractable neurodegenerative disease, including Alzheimer’s disease, Parkinson’s disease, ALS and multiple system atrophy.

ADSC are known to have neuronal repair, myelin repair, anti-inframatory function and blood flow improving effects in addition to their regenerative effects.

In this study, we compared 1) Cognitive assessment, 2)Amyloid-PET of the brain, and 3)

Amyloid-beta value of the peripheral blood pre- and post-administration of ADSC intravenously for 10 patients.

Conclusion:

Intravenous administration of ADSC could be safely repeated to cognitively disturved 　　　 patients.　

No adverse effects or no worsening of symptom was observed.

The cognitive function gradually improved for all patients. The amyloid-beta value of peripheral blood was increased for 4 patients, but the deposition of amyloid of PET scanning

was depends on patients.

AANOS Annual Scientific Meeting Neurological and Orthopaedic Surgery Part 2

Sarcopenia and Low Back Pain.

Amit Bhandarkar, MD, Orthopedic Spine and Pain Sugeon SSM Health Centralia IL., Wildwood, MO

Sarcopenia is defined as loss of function and mass of muscle. This paper investigates Sarcopenia in Perispinal muscles and how it correlates with different spinal pathologies and low back pain.

Sarcopenia was graded in all muscle groups and individual muscle groups. In addition, a new scoring system for assessing the grade of fat replacement of muscle- based on MRI was developed. The Scoring of 100 consecutive MRIs (axial sections -at the lower three-disc levels)of patients presenting to the spine clinic was done. Patients who had surgery were excluded. Correlation between the functional scores and grade of sarcopenia was done.

We seek to highlight the neglected problem of sarcopenia affecting the perispinal muscles and its relationship with low back pain.

We hypothesize patients with higher grades Sarcopenia are at increased risk of chronic low back pain and failed back surgery syndrome.

High Strength Suture Materials in Orthopedic Practice

Naga Cheppalli, MD, Assistant Professor of Orthopedic Surgery

University of New Mexico, Albuequerque, NM

The use of High Strength Suture Materials(HSSM) is increasing in frequency. In the market different HSSM are available for surgeons to choose from. Different HSSM have different mechanical, material properties. They have different strengths, stiffness, different knot holding ability, abrasion properties, and bacterial retention. Different suture materials might require for the tendons based on the shape ( round vs flat), load-bearing requirements(Quadriceps vs FDP), location (deep vs superficial),( intraarticular vs extra-articular) or tissues( Greater tuberosity vs rotator cuff). This presentation dives into different aspects of HSSM.

An Introduction to the American Board of Neurological and Neurosurgical Critical Care

Craig Clark, MD, PhD, Neurosurgeon, Greenwood Leflore Hospital,

Greenwood, MS, Carrollton, MS

The pre and postoperative care of critically ill neurosurgical patients has traditionally fallen within the training and practice of the neurological surgeon. As intensive care has become increasingly specialized and technology dependent, intensivists trained in pulmonary/critical care and neurologists/neurocritical care have claimed the ICU as their exclusive practice base, leading many hospital systems to CLOSE their ICUs with respect to credentialling. There is no specialty as uniquely qualified as neurosurgery regarding the particulars of traumatic brain injury, spinal cord injury, intracranial hemorrhage, and elevated intracranial pressure. Recognizing this problem, the American Federation for Medical Accreditation has developed a specialty Board Certification for Neurological and Neurosurgical Critical Care that provides evidence of special qualification in the care of the critically ill neurological patient. This certification is by examination and includes the areas of general patient care, neurological diseases and syndromes, ventilator management, ICP monitoring, CSF diversion and monitoring, critical care medicine and other related concepts. Sample questions and general information regarding the exam will be presented.

Juvenile Pilocytic Astrocytoma of Brain stem

Muhammad Janjua, MD, Assistant Professor University of Illinois Chicago, Poplar Grove, IL

Introduction:

Juvenile Pilocytic Astrocytoma (JPA) is the most common childhood brain tumor. Symptomatology can be diverse, and is dependent on tumor size and the location. Among posterior fossa, brainstem tumors can present with cranial neuropathies apart from generalized symptoms of ataxia, headaches with dizziness 8, 22. JPA has a favorable outcome, as gross surgical resection is curative. The main objective of this paper is to identify outcomes of different treatment modalities specific to pediatric brain stem JPA of brainstem.

Material and Methods:

A thorough literature review was conducted utilizing PubMed to identify published case reports on brainstem pediatric pilocytic astrocytoma (PA). With a focus on pediatric brainstem lesions, data was consolidated to identify the degree of tumor resection, outcome based on tumor treatment and location, and postoperative complications. Authors present a case of a 17-year-old female who presented with acute left sided facial numbness, right hemibody numbness, headache, and nausea while playing volleyball. Patient was diagnosed with a dorsal exophytic pontine PA which was resected using a retrosigmoid approach. Treatment strategy and outcome has been discussed.

Results:

Authors identified 11 studies for analysis, which included 480 cases of PA. Of 245 diagnosed cases of JPA where gender was specified, there were 126 females (51%) and 119 males (49%). Results for degree of initial resection, outcome, and brainstem location were detailed for 30 pediatric brainstem PA cases. 163 cases of pediatric PA in any location were analyzed to show favorable overall survival in these cases, as well as preference for cerebellar location. Outcomes supporting gross total resection (GTR) as the most efficacious treatment of PA was found based on analysis of 287 cases of PA in mixed adult and pediatric populations, without regards to tumor location. Authors’ patient recovered well after GTR, and had no surgical complications.

Conclusions:

GTR is the preferred treatment of JPA, yet it is not always feasible depending on tumor location. Sub-total resection (STR) is oftentimes achieved when GTR is not, but is correlated with lower progression free survival in pediatric and adult cases of PA. Regardless of surgical approach, great care must be taken to preserve surrounding eloquent structures and to minimize chance of surgical complication. Other prognostic factors, such as presence of tumor mutation(s) should be considered for future research of PA behavior, and may pose a potential target for non-invasive yet efficacious PA treatment strategies.

Correction of Sagittal Malalignment with L5 Pedicle Subtraction Osteotomy: A Cadaveric Study

Muhammad Janjua, MD, Clinical Assistant Professor of Neurosurgery, Poplar Grove, IL

Introduction:

Adult spinal deformity can be either results from progression of prior (childhood/adolescence) spinal kyphoscoliosis or deno vo or an iatrogenic degenerative spinal disease. Sagittal malalignment has been established with poor HRQOL. Planned osteotomies can help obtain an optimal sagittal correction. Author's objective is how a pedicle subtraction osteotomy (PSO) level can determine required degree of sagittal correction.

Methods:

12 freshly thawed cadaveric lumbopelvic articulated (previously prepared, and bonded) specimens were sought to determine the technique of L5 PSO. The surgical technique has been described in a step wise fashion for easy learning and reproducibility in the clinical setting. Radiographic sagittal lumbopelvic parameters were measured before and after the osteotomy. Moreover, state of art range of motion (flexion, extension, and lateral bending) was conducted and the data were analyzed to study the impact of level selection for higher grade osteotomy on fused and unfused lumbopelvic spine.

Results:

Sagittal focal lordotic angle was measured in intact as well as the post L5 PSO specimens to determine the impact of sagittal correction. This angle determined to be L4 - S1 (measured from inferior endplate of L4 to the superior end plate of S1). Mean lordotic angle in the intact specimens was measured to be mean±SEM [30.12±7.56]. Mean lordotic angle instrumented L2 - S1, specimens was measured to be mean±SEM [46.81±7.75]. Mean lordotic angle instrumented L2 - S1, and S1 Alar screws specimens was measured to be mean±SEM [46.76±7.63]. There is no statistical difference in focal (L4 - S1 angle) between the L2 - S1 or L2-S1 Alar group. All specimens were subjected to the range of motion (ROM) testing pre- and post-osteotomy. ROM testing was not different between L2 – S1 or L2 – S 1Alar with or without L5 PSO. One L2 – S1 instrumented specimen suffered type III sacral fracture during ROM testing.

Conclusion:

Pedicle subtraction osteotomy (PSO) is commonly utilized in gross malalignment, however, the most caudal lumbar level osteotomy (L5) provides maximal correction due to greatest contribution in overall spinoplevic sagittal alignment. Supplemental pelvic instrumentation has an additive role in stability of the hardware construct, and therefore is strongly recommended.

Management of Traumatic Sub-axial Cervical Facet Subluxation - Techniques and Approaches

Gazanfar Rahmathulla, (MBBS) MD, MBA, Assistant Professor of Neurosurgery, Medical Director of Neurosurgical Trauma,

University of Florida College of Medicine Jacksonville, Ponte Vedra Beach, FL

Cervical flexion distraction injuries are potentially devastating injuries. There is disruption of the posterior ligaments and bony elements of the spine. Management includes early reduction , re-alignment , possible decompression and stabilization.

Various approaches have been proposed and discussed including anterior, posterior and combined anterior-posterior approaches.

I will discuss the various approaches , with few representatives cases and discuss techniques that may help neurosurgeons deal with these challenging injuries.

The Role of Neuropeptide Agents in Intracerebral Injury Following Traumatic Brain Injury

Francis Samonte, MD, PhD, Senior Research Associate, National Institute of Health, San Diego, CA

Traumatic brain injury (TBI) is an important cause of mortality worldwide. Falls and road injuries were the leading causes of TBI, while it is estimated that more than 650,000 annual deaths worldwide have been attributed to head injuries. In low- to middle-income countries, access to proper health care infrastructure and timely neurosurgical intervention are key factors that contribute to poor outcomes following severe injuries. As a global burden of disease, the need to find safe and affordable medical intervention following TBI has important implications in the treatment and management worldwide. Over the years, the use of neuropeptide drugs (ND) in various forms of intracerebral injury following traumatic brain injury has led to decrease mortality while improving health care outcomes in developing countries and in poor resource settings. The need to expand current neurological interventions in the form of intravenous neuropeptide-based agents should be strongly considered and explored not only in poor resource settings but in emergency settings as a first line of intervention. We will also examine the use of neuropeptide drugs in developing countries as primary neurological intervention following TBI.