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Study Design A Retrospective Cohort Study.Objective To introduce a new Doppler sonography-assisted pedicle screw fixation technique that enables vertebral artery (VA) monitoring during surgery and compares the accuracies of Doppler sonography-assisted cervical pedicle screw fixation and the conventional technique.Methods This retrospective study was performed on 164 consecutive patients that underwent pedicle-based screw fixation from C2 to C6 between January 2013 and August 2020. Surgery was performed without intraoperative Doppler sonography in 84 cases (the Control group) or with intraoperative Doppler sonography in 80 cases (the Doppler group). Proper positioning of pedicle screws was graded, and the incidences of VA injury and screw breach in the Control and Doppler groups were compared.Results Three hundred and ninety-nine screws were placed in the 164 patients (Doppler, 186 screws; Control, 213 screws). The percentages of well-positioned screws in the two groups were significantly different (Doppler, 97.8%; Control, 85.0%). There were two cases of VA injury in the Control group, an incidence of 2.4%, but no case in the Doppler group.Conclusion Doppler sonography can be used intraoperatively to help guide the trajectory of the cervical pedicle screw insertion. It can detect the VA inside the screw trajectory and may reduce the risk of VA injury during cervical pedicle screw fixation.

•Failure to treat cerebrospinal fluid leakage can cause various complications, so it needs to be resolved as soon as possible.•In our experience, the use of prophylactic antibiotics is not essential when performing lumbar drainage.•Over-drainage can cause serious complications such as venous infarction, so be careful when performing the lumbar drainage procedure.•The lumbar drainage procedure is safe and effective when postoperative cerebrospinal fluid leakage is suspected.

Retrospective cross-sectional study To evaluate the validity and obtain optimal cutoff values of 3 radiologic measurements for the diagnosis of basilar invagination (BI). Two hundred seventy-six patients (46 patients who underwent atlantoaxial fusion for BI and 230 patients who were treated for minor cervical trauma) seen in a single institution from January 2010 to December 2016 were included in this study. Age, sex, and body mass index were adjusted for the patients. The Ranawat index (RI), modified Ranawat method (MRM), and Redlund-Johnell method (RJM) were used to diagnose BI on plain radiographs. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and diagnostic odds ratio of 3 radiologic measurements were compared. We also calculated the optimized cutoff values of 3 radiologic measurements using the receiver operating characteristic curve in our patients. The mean age of the 130 women and 146 men was 58.3 ± 14.5 years. The mean values of RI, MRM, and RJM in the BI group were 12.5 ± 3.3, 23.1 ± 3.8, and 27.3 ± 3.6 in women and 13.6 ± 2.6, 26.8 ± 4.2, and 34.7 ± 5.1 in men. There was a significant difference between the sexes (P < .05). The accuracies of RI, MRM, and RJM were 95%, 89.6%, and 92.3% in women and 93%, 68.2%, and 85.4% in men, respectively. The optimized cutoff values of RI, MRM, and RJM were 14, 26, and 32 mm in women and 15, 29, and 38 mm in men. Three radiologic measurements (RI, MRM, and RJM) are reliable for the diagnosis of BI even in the era of cross-sectional images. The validity of these measurements depends on sex and particular radiologic measurement. The optimized cutoff values of RI, MRM, and RJM were 14, 26, and 32 mm in women and 15, 29, and 37 mm in men. These cutoff values showed high validity when compared to the CT and MRI findings.

The simple proton-translocating inorganic pyrophosphatase (H+-PPase) found in plants and protists is an evolutionally conserved, essential enzyme that catalyzes the hydrolysis of pyrophosphate (PPi). Little is known about the functional contribution of H+-PPase to the cellular response to abiotic stresses, except its high salinity and drought stress. To investigate the role of H+-PPase during response to cellular stress, we isolated the cDNA of Arabidopsis thalianaH+-PPase (AVP1) and Oryza sativaH+-PPase (OVP1) and constructed transgenic Saccharomyces cerevisiaeand Escherichia colilines that express AVP1and OVP1. In S. cerevisiae, the expression of a chimeric derivative of the AVP1and OVP1alleviated the phenotype associated with ipp2-deficient cells in the presence of high salinity (NaCl) and metal stressors (Cd, Mn, and Zn). In E. coli, AVP1and OVP1overexpression conferred enhanced tolerance to abiotic stresses, including heat shock and H2O2, as well as NaCl, Cd, Mn, Zn, Ca, and Al. Interestingly, AVP1and OVP1overexpression resulted in hypersensitivity to menadione and cobalt. These results demonstrate the cellular capacity of AVP1- and OVP1-expressing transgenic yeast and E. coliin response to physiological, abiotic stresses. Moreover, our results suggest new ways of engineering stress-tolerant plants that are capable of responding to climate change. Here, we provide an outline of an experimental system to examine the alternative roles of plant H+-PPase.The simple proton-translocating inorganic pyrophosphatase (H+-PPase) found in plants and protists is an evolutionally conserved, essential enzyme that catalyzes the hydrolysis of pyrophosphate (PPi). Little is known about the functional contribution of H+-PPase to the cellular response to abiotic stresses, except its high salinity and drought stress. To investigate the role of H+-PPase during response to cellular stress, we isolated the cDNA of Arabidopsis thalianaH+-PPase (AVP1) and Oryza sativaH+-PPase (OVP1) and constructed transgenic Saccharomyces cerevisiaeand Escherichia colilines that express AVP1and OVP1. In S. cerevisiae, the expression of a chimeric derivative of the AVP1and OVP1alleviated the phenotype associated with ipp2-deficient cells in the presence of high salinity (NaCl) and metal stressors (Cd, Mn, and Zn). In E. coli, AVP1and OVP1overexpression conferred enhanced tolerance to abiotic stresses, including heat shock and H2O2, as well as NaCl, Cd, Mn, Zn, Ca, and Al. Interestingly, AVP1and OVP1overexpression resulted in hypersensitivity to menadione and cobalt. These results demonstrate the cellular capacity of AVP1- and OVP1-expressing transgenic yeast and E. coliin response to physiological, abiotic stresses. Moreover, our results suggest new ways of engineering stress-tolerant plants that are capable of responding to climate change. Here, we provide an outline of an experimental system to examine the alternative roles of plant H+-PPase.

Graphical Abstract

Graphical Abstract

Objective The upper cervical pathology is not an uncommon disease in the congenital anomaly, elderly population, and patients with rheumatoid. Newly developed operative techniques in high cervical region could be related to neurovascular injury. The objective of this study was to determine the anatomic relationship of the hypoglossal nerve (HN), internal carotid artery (ICA), bony structures, and hypoglossal canal and demonstrate the vulnerability of the neurovascular structures.Methods Eleven fresh cadavers (5 male and 6 female) were dissected bilaterally to expose neurovascular structures of the high anterior cervical region and hypoglossal canal. The anatomical relationship was evaluated between C1 bony structures (midline, lateral mass, and C1 transverse process) and the ICA and HN. The angle of the hypoglossal canal was also evaluated.Results The HN consistently traveled toward the midline at C2–3 and was safe caudal to C3–4. The HN is usually located lateral to the ICA. Relative anatomical relationship between the HN and surrounding bony structures at the level of C1 are as given below. The mean diameter of the HN was 2.4 mm (2–3.5 mm). The mean distance between the midline and the HN was 30.15 mm (24–35 mm). The mean distance between the margin of the C1 lateral mass (LM) and the HN was 4 mm (−3–11 mm). The mean distance between the C1 transverse process and the HN was 9.3 mm (3–16 mm). The transverse angle of the hypoglossal canal was between 31.6 and 55.5 degrees. The mean distance between the midline and the ICA was 26.06 mm (18–32 mm). In the cases of the medially displaced ICA, the HN is located more on the medial side relative to the LM. There was no reversed anatomical location of the HN and the ICA in the studied specimen.Conclusion On the basis of this study, spine surgeons can have enhanced knowledge of upper cervical anatomy. Although it has been rarely reported in the literature, the hypoglossal nerve and the ICA may be damaged during upper cervical spine surgery, especially in the cases with the ICA displaced medially.

Objective The aims of this study were to compare the parameters of spinal sagittal alignment between whole spine computed tomography (CT) scans in supine position and whole spine X-ray in standing position, and also to analyze the reciprocal and physiologic changes of the cervical spine in dynamic motion.Methods Data were obtained retrospectively in a single hospital. Radiographic data of 55 subjects were recruited about whole spine CT, whole spine X-ray, and cervical dynamic X-ray from November 2007 to May 2014. The mean age was 52.8 year (range, 17–85 years) and the female:male ratio was 31:24. Whole spine CT was checked in supine position and whole spine X-ray was checked in standing position. Cervical dynamic X-ray was checked in standing position. We included the subjects only with mild degenerative disease and simple back pain and excluded the subjects with severe scoliosis, severe deformity, and operation history. The radiological sagittal parameters on lateral paragraph were evaluated including C0–C7 Cobb angle (C0C7), C0–C2 Cobb angle (C0C2), C2–C7 Cobb angle (C2C7), T1 slope (T1S), neck tilt (NT), thoracic inlet angle (TIA), C2 tilt (C2T), C7 tilt (C7T), C2 sagittal vertical axis (C2SVA), C7 sagittal vertical axis (C7SVA), T1–T12 Cobb angle (T1T12), T1–T7 Cobb angle (T1T7), T7–T12 Cobb angle (T7T12), L1–S1 Cobb angle (L1S1), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Each parameter was analyzed statistically with paired ttest between CT and X-ray, and also assessed the relationships between all parameters with the Pearson correlation analysis.Results All corresponding parameters of spine alignment on X-ray were significantly correlated with those on CT. There was no significant difference in TIA (0.62 ± 3.41) and PI (0.62 ± 3.55) between CT and X-ray (p> 0.05). However, cervical lordosis, T1 slope (T1S), thoracic kyphosis, and lumbar lordosis (L1S1) on X-ray were significantly larger than those on CT. The differences of the means were 21.3 ± 15.6 degrees in C0C7, 3.8 ± 9.5 degrees in C0C2, 17.5 ± 12.3 degrees in C2C7, 7.8 ± 11.3 degrees in T1S, 14.3 ± 9.8 degrees in T1T12, 9.1 ± 8.4 degrees in T1T7, 5.2 ± 9.0 degrees in T7T12, and 4.8 ± 17.1 degrees in L1S1 (p< 0.05). Age significantly correlated with TIA (r = 0.382). Thoracic kyphosis (T1T12) had the significant correlation with T1S (r= 0.874 on CT, r= 0.425 on X-ray) and cervical lordosis (C0C7; r = 0.455 on CT, r= 0.405 on X-ray). Cervical tilt (C2T) and SVA (C2SVA) also had the significant correlations with T1S (C2T: r=  − 0.570 on CT, r=  − 0.550 on X-ray; C2SVA: r= 537 on CT, r= 0.498 on X-ray). T1S had the significant correlations with the TIA (r= 0.414 on CT, r= 0.368 on X-ray). T1S also had the significant correlations with cervical lordosis (C0C7: r= 0.367 on CT, r=  − 0.469 on X-ray), which mainly correlated with subaxial spine (C2C7: r= 0.355 on CT, r= 0.404 on X-ray) and not with upper cervical spine (C0C2). The changes of the cervical lordosis (C0C7) in dynamic motion (neutral, flexion, and extension) had highly evident correlations with subaxial spine (C2C7) than with upper cervical spine (C0C2). Pearson correlation coefficients (R) between C0C7 and C2C7 were 0.810 in neural, 0.766 in flexion, and 0.740 in extension, respectively (p< 0.01).Conclusion The difference of spine alignment between CT and X-ray should be because of the difference of the gravity stem from the posture. Upright posture may increase thoracic kyphosis, and cervical lordosis sequentially and reciprocally. Physiologic motions in the spine cause the cervical accommodations, in which subaxial spine is mainly and initially responsible for the reciprocal changes to other spinal parameters such as TIA and T1 slope. This finding may be the main reason of the subaxial cervical spine degeneration.

Purpose When C1 arch displaced laterally in C1 bursting fracture, anatomical change between displaced bone and surrounding neurovascular structures can make placing C1 screw more challenging. This study was to describe the effect of the C1 bursting fracture on the location of the internal carotid artery (ICA) around the atlas.Methods The authors analyzed the morphology of the atlas and the ICA in 15 patients with C1 bursting fracture and compared the anatomical parameters with control group (77 patients) without any bone fractures or pathologies. All patients were evaluated with CT angiography for the assessment of anatomical parameter. The laterality of the ICA was classified into the following four groups: group 1 (lateral to the C1 lateral mass), group 2 (lateral half of the lateral mass), group 3 (medial half of the lateral mass), and group 4 (medial to the lateral mass). The distances of the ICA from the midline, anterior tubercle, and ventral surface of the C1 lateral mass were compared between two groups. The distance between the lateral margin of the longus capitis muscle and the inner edge of the transverse foramen was also measured.Results Medially located ICA (laterality groups 2 and 3) was more common in the C1 bursting fracture group than control group (76.7 vs. 42.8%). There were no significant differences between two groups for the distance from the midline, the distance from the anterior tubercle, and the distance from the ventral surface of the C1 lateral mass, respectively. The distance of the longus capitis muscle to transverse foramen was 2.52 ± 2.09 and 4.15 ± 3.09 mm in each group, and there was statistically significant difference (p< 0.01).Conclusion Lateral displacement of the bony structure of C1 bursting fracture changes the relative location of the ICA medially, which increase the injury risk during the bicortical C1 screw insertion. These data suggest that CT angiography or enhanced CT scans may be essential study for C1 bursting fracture. These preoperative imaging studies can give information to choose the ideal fixation technique and the proper trajectory of the screws.