144S Proceedings of the NASS 23rd Annual Meeting / The Spine Journal 8 (2008) 1S–191S

P89. A Prospective Analysis of Prognostic Factors in the Patients

with Spinal Metastases Use of the Revised Tokuhashi Score

Takayuki Yamashita, MD, Krzysztof Siemionow, MD, Thomas Mroz, MD,

Isador Lieberman, MD, MBA, FRCS(C); Cleveland Clinic Foundation,

Cleveland, OH, USA

BACKGROUND CONTEXT: Approximately one third of cancer patients

develop metastases to the spinal column. The prognosis once spinal metas-

tases have been diagnosed and the most appropriate treatment still remains

controversial. Thus, spinal surgeons involved in treating patients with spi-

nal metastases have struggled to match the most appropriate treatment to

the life expectancy. The revised Tokuhashi score is one of the scoring sys-

tems used to assess the prognosis in patients with spinal metastases. This

score consists of the five variables ranging from 0 to 2 points (Karnofsky

performance status, extra spinal metastases, spinal metastases, major inter-

nal organ metastases, and Frankel grade) and the other variable ranging

from 0 to 5 points (primary cancer type). A recent review of the literature,

however, didn’t reveal any prospective studies using the revised Tokuhashi

score.

PURPOSE: To validate the Tokuhashi score‘s ability to predict survival

after developing spinal metastases.

STUDY DESIGN/ SETTING: Prospective non-intervention observa-

tional study, as such no intervention or treatment plan changes were asso-

ciated with this study.

PATIENT SAMPLE: All patients diagnosed with any form of spinal

metastases.

OUTCOME MEASURES: The revised Tokuhashi score was documented

in each variable, and the total score was calculated.

METHODS: All patients diagnosed with any form of spinal metastases,

who presented in the Taussig Cancer Institute or Center for Spine Health

at Cleveland Clinic, whether symptomatic or not, regardless of tumor bi-

ology were asked to enter the study. Demographic information and phys-

ical examination data were documented, and radiological studies were

reviewed at enrollment. The revised Tokuhashi score was documented in

each variable, and the total score was calculated.

RESULTS: Fifty-one (51) patients (Males 24, Females 27) were investi-

gated in this study. The mean age at enrollment was 58.9 years old (range:

35–84). The primary cancer types were breast (14), multiple myeloma

(11), lung (10), kidney (5), prostate (4), thyroid (2), and others (5). Of

the 51 patients, 34 patients survived for more than six months following

enrollment (long survival group), and 17 patients died within six months

(short survival group). Of the revised Tokuhashi score variables and the to-

tal score, there were significant differences between the two groups accord-

ing to primary cancer type (p50.011), major organ metastases (p50.001),

and the total score (p50.009). Of a total of 17 patients who had lung can-

cer (n510) or metastases to lung (n57), 13 (76.5%) patients died within

six months. Meantime, all the patients with multiple myeloma survived

for more than six months.

CONCLUSIONS: Severe cancer type, the existence of major organ me-

tastases, and less total revised Tokuhashi score demonstrated less survival

period in the patients with spinal metastases. Lung cancer and metastases

to lung were also related to less survival period. More accurate prediction

of prognosis will provide cancer patients with a better quality of life.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

doi:10.1016/j.spinee.2008.06.334

P90. Global Spinal Balance and Segmental Vertebral Body

Alignment Around the Vertical Pelvic Hip Axis: Rationale for Hip

Axis Coordinate Based Assessment

Roger Jackson, MD1, Anne McManus, RN2; 1North Kansas City Hospital,

North Kansas City, MO, USA; 2Midwest Spine Foundation, North Kansas

City, MO, USA

BACKGROUND CONTEXT: The center of gravity for balanced stand-

ing spinopelvic posture is over the pelvic Hip Axis (HA), as defined in the

literature.

PURPOSE: To study global balance in a Cartesian x-y-z axis coordinate

system and determine spatial vertebral body alignment around a vertical

z-axis centered on the HA.

STUDY DESIGN/ SETTING: Cohort of healthy adult volunteers

with no history of spinal surgery or back pain 6 months prior to the

study.

PATIENT SAMPLE: Volunteers (N5197) were recruited and each had

a standing 36’’ lateral film showing both hips. A subset of 62 volunteers

had a PA film taken that showed both hips.

OUTCOME MEASURES: Statistical analysis of the possible correlations

were done using independent student t tests and Pearson correlation

coefficients.

METHODS: The centroids for the vertebral bodies from C7 to S1 were

located and their perpendicular distances in space from the z-axis line

were measured on the films. The 62 with both films had top view polar

plots. Possible correlations for the centroid alignments around this z-axis

were then studied with respect to common spinopelvic radiographic pa-

rameters, including pelvic lordosis (PL), pelvic incidence (PI), pelvic ra-

dius angle (PRA) and the sagittal C7 vertical line, as defined in the

literature.

RESULTS: In 96% of subjects, the C7 line was posterior (mean �43 mm,

range 30 to �105 mm) to the z-axis line and, therefore, the HA and center

of gravity line for balance. PL and PI were very strongly correlated (r5.94,

p!.0001). These fixed pelvic parameters did not influence the position of

the C7 line with respect to the sacrum, HA or z-axis. In the sagittal and

transverse planes, the L4 centroid on average was closest to the z-axis

and its distance from this axis was strongly correlated with the PRA

(r5.79, p!.0001). In addition, the T4 centroid was always behind the

L4 centroid and the z-axis in both these planes. PRA correlated signifi-

cantly with PL and PI (r5.60, p!.0001; for both).

CONCLUSIONS: The vertical HA line (z-axis) and C7 line are dis-

tinctly different parameters for spinal balance. Because this HA line

can be considered superimposed on the z-axis in a Cartesian system,

and because of the close relationship previously reported for this axis

to the center of gravity line, the HA should be considered a key param-

eter for assessing standing spinopelvic posture in 3-planes. For compen-

sated balance, the T4 centroid should always be behind the L4 centroid

and the HA.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

doi:10.1016/j.spinee.2008.06.335

P91. Postoperative Outcomes of Anterior Cervical Decompression

and Fusion

Kevin Bell, MS1, Charise Shively, BS2, Erik Frazier, MS2,

Robert Hartman2, Joon Y. Lee, MD2, James Kang, MD2,

William Donaldson, III, MD2; 1Pittsburgh, PA, USA; 2University of

Pittsburgh, Pittsburgh, PA, USA

BACKGROUND CONTEXT: Anterior cervical decompression and fu-

sion (ACDF) is currently the most common surgical treatment option for

decompression of the cervical spine. However, the influence of number

of involved levels and the effect of timecourse postoperatively have not

been concretely quantified.

PURPOSE: The purpose of this research study is to compare cervical

range of motion (CROM) and Neck Disability Index (NDI) as a function

of postoperative time as well as the influence of number of fused levels

in patients who have undergone an ACDF procedure.

STUDY DESIGN/ SETTING: Case-controlled prospective clinical study

with age-matched cohort.

145SProceedings of the NASS 23rd Annual Meeting / The Spine Journal 8 (2008) 1S–191S

PATIENT SAMPLE: N541 subjects (ages 40 - 65), n512 asymptomatic

baseline subjects and n529 ACDF surgical patients (10, one-level; 12,

two-level, 4 three-level, and 3 four-level operations).

OUTCOME MEASURES: CROM measurements and the NDI were

recorded.

METHODS: The Nest of Birds electromagnetic tracking (EM), controlled

by Virtual Reality goggles (VR), was used to record 6-DOF CROM. The

subjects executed five consecutive cycles of flexion/extension (FE), axial

rotation (AR), lateral bending (LB), and circumduction. A Student’s t-test

(p5.05) was used for statistical analysis.

RESULTS: Timecourse data (Figure A) indicated motion restoration at

6–12 months after surgery compared to baseline. Conversely, 3–6

months and 12þ months post-op CROM was decreased. In Figure

1B, increasing the number of involved levels resulted in a trend of de-

creasing CROM. One-level procedures showed no statistical difference

compared to baseline. Significant correlations were also observed be-

tween NDI and CROM for extension (0.93), RAR (.955), and overall

motions (.960).

Figure

CONCLUSIONS: The results of this study (postoperative timecourse and

number of involved levels) were contrary to previous research (Hillibrand

et al, 2006). The addition of an age matched cohort and differences in

methods (EM/VR system) could account for these findings. Promising cor-

relations between CROM and NDI were also observed. Given these results,

a longitudinal prospective study is ongoing in our laboratory to further this

investigation.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

doi:10.1016/j.spinee.2008.06.336

P92. Osteogenic Differentiation of Adipose-derived Stromal Cells

Cultured on a Novel Three Dimensional Porous Polycaprolactone

Malatehydroxyapatite Composite Scaffold

Qing Zeng1, Yuqin Wan, PhD2, Xudong Li, MD, PhD2, Francis Shen, MD2;1Charlottesville, VA, USA; 2University of Virginia, Charlottesville, VA,

USA

BACKGROUND CONTEXT: According to tissue-engineering concepts,

it is possible to regenerate a variety of tissues through the use of living

cells and an appropriate scaffold. Along these lines, adipose derived stro-

mal (ADS) cells have been shown to be multipotential and under appropri-

ate conditions can differentiate in culture, or after in vivo implantation,

into osteoblasts, chondrocytes, adipocytes, myotubes, fibroblasts, and neu-

ronal cells and therefore into bone, cartilage, fat, myocardium, skin, and

neural tissue. We have developed a novel porous polyester material con-

sisting of poly (caprolactone malate)(PPCLM) composite material with

a hydroxyapatite (HA) content (15% by weight). Hydroxyapatite, a calcium

phosphate ceramic, is biocompatible and osteoconductive and is currently

used in a wide range of clinical applications.

PURPOSE: We evaluated the PPCLM composite with or without HA,

loaded the composite with cells for bone-tissue engineering and investi-

gated the osteoinductive potential of this material in vitro.

STUDY DESIGN/ SETTING: 90 PPCLM scaffolds with or without HA

were used for this study and divided into PPCLM/HA, experimental groups

and PPCLM, control groups. At days 7,14 and 21, scaffolds were removed

and characterized by histology, biochemical assay and gene expression.

PATIENT SAMPLE: ADS cells from the inguinal fat of adult Fisher rats

were isolated and maintained in culture medium containing Vitamin D.

METHODS: Biochemical assays were performed for the bone marker proteins

alkaline phosphatase (ALP) and osteocalcin (OC), MTS assay for cell prolifera-

tion, matrix mineralization by staining with Alizarin Red, Morphological analy-

sis was performed by scanning electron microscopy (SEM) and gene expression

of Cbfa1, ALP, collagen type I and OC were analyzed by Real Time PCR.

RESULTS: Based on the MTS assay, the number of cells at 1, 3, 7, and 14

days increased and the differences between and control and composite scaf-

folds were not statistically significant. At 21 day number of cells decreased

for both groups. SEM revealed that the pores of the PCCLM/HA scaffold

were predominantly covered by ADS cells and demonstrated the ability of

the cells to penetrate into the pore of the scaffold by 14 days. Staining with

Alizarin Red showed that calcium deposition increased with time and was

significantly greater at 14 and 21 days in the composite scaffolds with HA

compared to the scaffolds without HA and in the control group (p!0.05).

Similarly, ALP activity in cells in the experimental group was higher than

cells in the control group at all time points and was significantly enhanced

at day 14 (p! 0.05). OC increased significantly in the experimental group

compared with the control group at days 14 and 21 (p! 0.05). Gene expres-

sion of collagen type I and Cbfa1 in experimental group was higher than in

the control group at all time points; the differences were significant at day 14

for Cbfa1 and at 14 and 21 days for collagen type I (p! 0.05). OC gene ex-

pression on the composite was a statistically higher over the control at 14 and

21 days, while in ALP gene expression was greater at 14 days (p! 0.05).

CONCLUSIONS: Our results from cells proliferation assays, and an anal-

ysis of bone matrix proteins and the expression of their genes strongly sup-

port the hypothesis that the composite PPCLM/HA scaffold possesses not

only osteoinductive properties but also properties that potentiate osteo-

genic differentiation of rat ADS cells in vitro.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

doi:10.1016/j.spinee.2008.06.337

P93. Does CT Based Pedicle Morphology Correlate with Degree of

Curve Rotation Grade or Level of Apex?

John Czerwein, Jr., MD1, Beverly Thornhill, MD2, Terry Amaral, MD2,

Adam Wollowick, MD2, Alok Sharan, MD2, Vishal Sarwahi, MD2; 1Albert