Objective To survey the current clinical practice of chronic non-cancer pain (CNCP)management including opioid use in Chinese subgroup report of Current Practices of Cancer and Chronic Non-Cancer Pain Management:A Pan-Asian Study (ACHEON).Methods This questionnaire-based survey included 100 pain physicians and 250 patients experiencing CNCP in the period of September to December in 2013.Results CNCP management training was believed by 40％ of physicians,while 30％ reported adequate pain-relief training on opioid use.Opioids were not considered as the best choice for CNCP management by 65％ of physicians.The majority of location of pain with CNCP was legs/feet (59.2％) and neck (39.2％),arthritis (37.22％),overuse (26.91％),and poor posture (35.56％) were reported as the primary causes of pain.A portion (81.6％) of patients was under treatment,while 66.67％ of patients claimed to be satisfied with their current pain treatment.74.51％ of patients reported that CNCP management was effective pain-relief.Conclusions The Chinese physicians were insufficient cognition of CNCP management on opioid use.The CNCP education and cognition strengthening,CNCP management practice and patient's satisfaction are still necessary for Chinese physicians and patients.

Objectives: To reveal the possible role and mechanism of disc-facet angle in the occurrence and progress of Hirayama disease by analyzing the correlation of clinical appearance and the variation of disc-facet angle in Hirayama disease. Methods: 45 patients with Hirayama disease treated in the orthopedic de-partment of Peking University Third Hospital from October 2006 to January 2012 were reviewed. There were 44 males(97.8%) and 1 female(2.2%) with an average age of 19.33±3.89(range 13-37) years old. The onset age was 16.33±2.73 (range 10-27) years old and the duration of history was 35.64±23.24 (range 1 to 120) months. The disc-facet angle of C3-T1 was measured on PACS system. An extension line was made along the upper edge of objective vertebral body on the CT scan sagittal reconstruction image. An extension line was made along the joint surface of upper articular process of objective vertebra on the sagittal plane which crossed the midpoint of the facets. The blunt angle between two lines was the disc-facet angle. The cases were divided into unilateral affect and bilateral affected group according to history, spinal cord function and spinal cord lesion level. The correlation of above data and the variation of disc-facet angle were analyzed. Results: The duration of history in unilateral affected patients was significantly shorter than that of bilateral affected patients (P<0.05). The duration of history in sequential onset patients was significantly shorter than that of simultaneous onset in bilateral affected patients (P<0.05). The JOA score 17 and Chinese score 40 in unilateral affected patients were higher than those of bilateral affected patients. The C3-C7 disc-facet angle of affected side was bigger than that of normal side in unilateral affected patients, and C5, C6 had statistically significant difference (P<0.05). The spinal cord lesion level was mainly at C5 and C6 in unilateral affected group. The disc-facet angle had no difference on both sides in bilateral affected patients but the figures at C4 and C5 level were bigger than that of normal side in unilateral affected patients. The spinal cord lesion level was mainly at C4 and C5 in bilateral affected group. The stability of upper cervical spine segments was even worse in unilateral affected group and resulting in higher level of spinal cord lesion comparing with bi-lateral affected group. Conclusions: The disc-facet angle of C4, C5 is bigger in bilateral affected patients and may be correlated with higher level spinal cord lesion and more severe clinical symptoms. The C5, C6 disc-facet angle of affected side is significantly bigger than that of normal side in unilateral affected patients. This may be the key factor of spinal cord lesion mainly at C5 and C6 level on the same side.

Objectives: To study the morphological difference of luscka joints between Hirayama disease patients and non-Hirayama disease patients on CT scan and to provide a new possible mechanism of Hirayama disease. Methods: 32 patients(all males) with a mean age of 19.4±4.1(range 16-37 years) and with Hirayama disease were treated in our hospital from October 2006 to January 2012, the mean course of disease was 31.7±23.7 months(range, 1-120 months). 32 patients(all males) with a mean of age was 19.1±4.3 (range, 12-26 years) suffering from acute neck pain and having no Hirayama disease were reviewed as control. Both groups showed no age related difference. From the cervical CT coronal plane reconstruction images which passing through the transverse foramen center of C3-C7 in GE-PACS system, the following data were measured in both sides: ①The width of the uncinate process base: the distance between inner and outer margin of the uncinate process at the upper edge of the vertebral body. ②The height of the uncinate process:the vertical distance from the top of the uncinate process to the upper edge of the vertebral body. ③The distance between two uncinate processes: the distance between the tips of the bilateral uncinate processes. ④The inclination angle of the uncinate process: the angle between the uncinate process and the upper edge of the vertebral body. ⑤The inclination angle of the inferior endplate: the angle between the uncinate process:the vertical distance from the top of the uncinate process to the upper edge of the vertebral body. Results:There were no significant side-related differences on the width of the uncinate process base, the height of the uncinate process, the distance of the uncinate process, the inclination angle of the uncinate process and the inclination angle of the inferior endplate at the same segment from C3 to C7 in Hirayama disease patients(P>0.05). However, differences were found on the height of the uncinate process and the distance between two uncinate processes of C3-C7 (P<0.05), C6 and C4 had the highest and lowest height of the uncinate process as C6>C5>C7>C3>C4. The distance of the uncinate process gradually increased from C3 to C7. There were no significant differences on the width of the uncinate process base, the inclination angle of the uncinate pro-cess and the inclination angle of inferior endplate(except for C3) of C3-C7(P>0.05). Then, using the mean value of the left and right sides as the width of the base of uncinate process, the height of uncinate process, and calculating the sum of inclination angle of the uncinate process, the sum of inclination angle of inferior endplate of the upper vertebra and the difference between the sums (the sum of inclination angle of uncinate process - the sum of inclination angle of inferior endplate of the upper vertebra), then calculating the mean value and standard deviation. Compared with the non-Hirayama disease patients, there were no significant dif-ferences on the uncinate process base, the distance of the uncinate process and the sum of inclination angle of the uncinate process at the same segment of Hirayama disease patients (P>0.05), while the height of the uncinate process and the sum of inclination angle of uncinate process of Hirayama disease patients were sig-nificantly smaller than those of the control group, respectively(P<0.05), and the differences between the sums were larger than those of the control group (P<0.05). Conclusions: Hirayama disease patients may possess a dysplasia in the luscka joint, manifesting the nonuniform development of the uncinate indicators. Lower unci-nate process and smaller inclination angle of inferior endplate of the upper vertebra are common, The conse-quential cervical instability may play a significantly important role in the pathogenesis and progress of Hi-rayama disease.

Objective To investigate whether the hyperintensity on T2?weighted MRI affects the outcome of cervical ar?throplasty (CA) for cervical spondylotic myelopathy (CSM). Methods 69 patients with CSM who had undergone CA between June 2005 and December 2007 were retrospectively reviewed. They were divided into three groups according to the intensity of T2?weighted images:Group A, whose intensity of T2?weighted images in spinal cord compression spot was equisignal;Group B, hyper?intensity with obscure border; Group C, hyperintensity with clear border. There were 22 males and 19 females in group A aged from 27 to 63 years old, whose duration of disease was between 3 to 72 months, and there were 34 single?segment cases, 5 double?segment and 2 triple?segment cases. There were 9 males and 9 females in group B aged from 30 to 61 years old whose duration of disease was between 3 to 24 months, and there were 12 single?segment and 6 double?segment cases. There were 4 males and 6 fe?males in group C aged from 28 to 56 years old whose duration of disease was between 1 to 24 months, and there were 8 single?seg?ment and 2 double?segment cases. Two types of artificial cervical disc were used:Bryan Disc in 42 cases and Prodisc?C in 44 cas?es. The duration of Group A (24.7 ± 27.9 months) was significantly longer than that in Group B (6.6 ± 7.4 months) and Group C (11.1±9.5 months). The follow?up period was from 48 to 86 months with an average time of 61 months. The preoperative X?ray and MR as well as postoperative X?ray were collected. The history, compress ratio of MRI, the ROM of cervical segments pre and post?operatively were recorded and Japanese Orthopaedic Association (JOA) was used to evaluate the neurological function. Results Preoperative compress ratio of MRI were 43.3%± 15.2%, 42.4%± 10.7%and 41.9%± 14.8%respectively;preoperative segmental ROM were 9.6°±2.5°, 9.0°±1.7° and 9.1°±1.9° respectively. Preoperative JOA score were 13.6±1.2, 13.1±1.3 and 12.9±1.8, re?spectively. Postoperative JOA score at the latest follow?up were 16.2±1.0, 15.8±1.2 and 15.7±1.6 respectively. There was no statis?tic difference among these groups. Preoperative increased signal intensify on T2?weighted MRI in patients with cervical spondylot?ic myelopathy may not affect the outcome of cervical arthroplasty.

Objective To analysis the correlation between patient selection and heterotopic ossification (HO) after cervical artificial disc replacement.Methods Data of 48 patients with cervical spondylosis (34 cervical spondylotic myelopathy and 14 nerve-root type) who had undergone Bryan cervicadisc replacement from December 2003 to December 2008 were reviewed retrospectively,and all the patients had been followed up for more than 5 years.There were 21 males and 27 females with an average age of 42 years old (range,20-53 years).There were 38 single level replacement (C3-4 3 cases,C4-5 5 cases,C5-6 28 cases,C6-7 2 cases),9 double level replacement (C4-5,C5 6 4 cases;C5-6,C6-7 5 cases) and 1 three level replacement (C3-4,C4 5,C5-6) as a total of 59 surgical segments.The occurrence of HO was defined by McAfee classification on cervical lateral X-ray.Four factors were used in patient selection including gender,range of motion (ROM) of the target level,alignment of the functional spine unit (FSU) of the index level,and the disc height ratio between surgical level and the adjacent levels.The correlation between these four factors and HO was evaluated by logistic regression.The receiver operating characteristic (ROC) curve and area under the ROC curve were used to evaluate the significant result of logistic regression and the optimal diagnostic value.Results 48 patients were all followed up for an average period of 70.3 months (range,60-120 months).The occurrence rate in this study was 33.9％ (20/59 segments).Only one factor,the disc height ratio of the target level and its adjacent levels,presented statistical correlation with HO.ROC analysis showed that the area under the ROC curve of disc height ratio was 0.813 and the optimal diagnostic threshold was 0.9.Conclusion The disc height ratio of the target level and adjacent levels was the only patient selective factor correlated with the occurrence of HO.For those with disc height loss exceeding 10％ comparing to adjacent levels,it is not indicated for cervical artificial disc replacement with Bryan prosthesis.

Objectives To investigate influencing factors and pattern of posterior shifting of the spinal cord after cervical laminoplasty.Methods Forty three patients with compressive cervical myelopathy,including 32 males and 11 females,aged from 33 to 78 years (average,57.9 years),treated with open-door laminoplasty from C3 to C7 between February 2008 and October 2010,were enrolled in this study.There were 30 cases of cervical spondylotic myelopathy with developmental cervical stenosis and 13 cases of ossification of the posterior longitudinal ligament.Twenty one cases underwent modified open-door laminoplasty using anchor method,and the other 22 cases underwent laminoplasty with preservation of the unilateral muscular ligament complex.According to midsagittal T2-weighted MRI in the neutral position,several parameters indicating shift distance of the spinal cord and dural sac were measured at each level before operation and at 3 months after operation:shift of anterior margin of the spinal cord (SAMSC),shift of posterior margin of the spinal cord (SPMSC),shift of anterior margin of the dural sac (SAMDS) and shift of posterior margin of the dural sac (SPMDS).The line connecting the top of dens and posterior inferior angle of T1 was defined as E line and the length was E.The length of perpendicular line from each base point to E line was Px (x =1-6).The parameter (100×Px/E) was used to represent local curvature at each level,and the curvature index (CI)was used to represent the global curvature of the cervical spine.Then correlation analyses of the parameters above were performed.Results There was no significant change in SAMDS at different level after surgery,however SAMSC,SPMSC and SPMDS changed significantly and synchronously.At the level of C5 and C6,SPMSC was maximum,but not correlated to CI.Actually,SPMSC was correlated to the local curvature and highly correlated to SPMDS at the same level.Conclusion After cervical laminoplasty,posterior shifting of the spinal cord was highly correlated to posterior shifting of the dural sac at the same level,weakly correlated to local curvature and not correlated to the global curvature of the cervical spine.

Objective To investigate the technical methods for culturing and purifying the olfactory ensheathing cells(OECs) from the adult canine and human olfactory epithclium.To establish a basis for future studying the transplantation of peripheral(OECs) to repair the spinal cord injury in human. Methods Purifying the OECs from the olfactory epithelium of adult canine and man according to their different attachment time with other types of cells.Culturing for 25 days,observed at 6d,10d and 25d,and immunostained with NGFRp75 antibody to identify the OECs. Results The number of cultured olfactory epithelium OECs from both adult canine and man were increased much more after 10 days of culture,and its sharp showed to be bi-polar or tripe-polar and are immunopositive to NGFRp75 antibody.The in vitro OECs of canine grew better than that in man's in the present conditions.Conclusion\ The method of different attachment time seems available in purifying olfactory ensheathing cells from both the adult canine and man olfactory epithelium.

Objective:To retrospectively analyze the clinical data of the patients with reoperation for cervical myelopathy due to progressing ossification of the posterior longitudinal ligaments,with previous open-door expansive laminoplasty,and to evaluate the outcomes.Methods:From May 2006 to July 2012,a retrospective study was performed on a consecutive series of 17 patients with previous open-door expansive laminoplasty,who had received the reoperation for cervical myelopathy due to progressing ossi-fication of the posterior longitudinal ligaments.The reoperation was performed based on the clinical mani-festations and segments of responsibility.The anterior approaches were performed in 12 cases,and the posterior approaches in 5 cases.The correlation between the clinical factors and Japanese Orthopedic As-sociation (JOA)scores or the JOA recovery rate was evaluated by Pearson or Spearman correlation test. The pre-and post-operative JOA scores were analyzed by repeated measures ANOVA and the JOA recovery rates were compared with paired t test.Results:The mean follow-up was 137.5 months (range 60-348 months).There were no serious complications after surgical procedures.There was one case that had C5 palsy in the first operation and had recovery after one week.Another case had C5 palsy in the reoperation with posterior approach,which had recovery at the end of 6 months post-operation.Three cases had the cerebrospinal fluid leakage of the reoperation,with two cases in the anterior approaches and one case in the posterior approach.There was no significant correlation between the clinical variables and JOA scores or JOA recovery rates.The JOA scores of the patients in the first operation were improved from 9.4 ±4.1 to 12.8 ±2.8 (P<0.01),and the JOA recovery rate was 45.6%.The JOA scores of the reoperation were improved from 10.2 ±2.8 to 12.7 ±2.4 (P<0.05)at the end of 6 months and 14.3 ±1.9 (P<0.01)by the last follow-up.There were significant differences between the JOA recovery rates by the last follow-up (63 .2%)and at the end of 6 months (39 .3%)of the reoperation or 45 .6%of the first opera-tion (P<0.01).Conclusion:The reoperation for cervical myelopathy duo to progressing ossification of the posterior longitudinal ligaments can significantly promote the recovery of the spinal cord,based on the clinical manifestations combined with segments of responsibility of the imaging.

Objective To quantitatively compare the effect of preservation or removal of atlas posterior arch on cervical posterior decompression,so as to provide a basis for reasonable selection of upper cervical spine decompression range and determination of surgical indications for atlas posterior arch resection.Methods The data of 45 patients with posterior decompression of upper cervical spine were retrospectively analyzed.According to the decompression range,the patients were divided into C2-C7 group and C1-C7 group.There were 25 cases in the C2-C7 group,19 males and 6 females,with an average age of 56.3 years (40-71 years),4 cases of cervical spondylotic myelopathy and 21 cases of ossification of the posterior longitudinal ligament of cervical spine.All of the 25 patients underwent open-door laminoplasty:20 cases with hinge side anchoring procedure and 5 cases with preservation of the unilateral posterior muscular-ligament complex procedure (titanium cable procedure).There were 20 cases in C1-C7 group,12 males and 8 females,with an average age of 58A years (44-75 years).All of the 20 cases underwent atlas posterior arch resection as well as C2-C7 open-door laminoplasty,including anchoring procedure in 1 case,titanium miniplate procedure in 4 cases,and titanium cable procedure in 15 cases.Standardized vertebral-cord distance (SVCD) at each level from atlas to level C~ was measured on T2-weighted images of MR on the mid-sagittal plane in the neutral position pedormed 3-12 months postoperatively at each individual level.As the main outcomes,the SVCD values obtained at the same level of the two groups were compared between the two groups.Shapiro-Wilk normality test was performed on the SVCD values at C1.2 and C2 levels of two groups.The area under the normal distribution curve of SVCDs was used to calculate the corresponding residual compression rate with different magnitude of compression mass to further discover the difference of the decompression effect between the two groups.Results The SVCD obtained at the level of the anterior arch of atlas (C1),the junction of odontoid process and axis (C1,2) and the middle part of axis body (C2) in the C2-C7 group was 9.91±1.34 mm,8.35±1.27 mm,and 8.22 ±1.43 mm,respectively.The SVCD at the same levels was 11.02±1.60 mm,9.72±1.24 mm,and 9.12±1.11 mm,respectively.SVCDs differed significantly in the above range between the two groups.However,from level C2,3 to C6,7,there was no significant difference in SVCDs between the two groups.The JOA score of group C2-C7 was 11.8±2.7 preoperatively and increased significantly to 14.7±1.8 at 12 months postoperatively(t=-7.006,P＜0.001) with a recovery rate of 57.0％±32.2％.The JOA score of group C1-C7 was 11.7±2.8 preoperatively and increased significantly to 14.2±2.3 at 12 months postoperatively(t=-6.177,P＜0.001) with a recovery rate of 51.9％±32.1％.Conclusion Atlas posterior arch resection can significantly increase the decompression effect of posterior cervical surgery from the anterior arch of atlas to the middle part of axis body,but it would not increase the decompression effect at level C2.3 or below.When the magnitude of the ventral compression factor exceeds the decompression limit (8.5 mm) available with C2-C7 decompression in the range from atlas to the middle of the axis body,extending the decompression range by atlas posterior arch resection is an effective means to achieve adequate decompression.

Objective　To assess the mid-term clinical and radiological outcomes of anterior cervical internal fixation and fusion for the treatment of Hirayama disease and to evaluate the clinical significance and value of this procedure.Methods　All of 31 patients underwent anterior cervical internal fixation and fusion were retrospectively analyzed with a minimum of 5 years follow-up in our hospital between May 2008 and May 2011,whose disease progressively deteriorated after six-month's conservative therapy(neck collar)preoperatively.There were 30 males and 1 female with an average age of 19.0±2.7 years which ranged from 16 to 27.The clinical outcomes included forearm and hand muscle atrophy and strength.The radiological outcomes included range of motion(ROM)of the whole cervical spine and unstable segments,as well as venous flow empty phenomena and "snake eyes" sign on MRI in the flexed position.All were recorded at 3 month,1 year,3 year and 5-6 years follow-up time points after surgery.The preoperative and postoperative quantitative variables were analyzed by paired t test,and a P<0.05 was used to indicate statistical significance.Results　All the patients showed no further progression of symptoms of muscular weakness or atrophy.At the end of 5-6 years follow-up,24 of the 31 patients(77.4%)showed improved muscle strength and 16 of the 31 patients(51.6%)showed improved atrophy.Thirty-one patients had a forearm muscle strength of 4 to 5 at the last follow-up,with an average of 4.9±0.3,which was superior to preoperative 0 to 5(3.6±1.0);grip strength was 3 to 5 kg,with an average of 3.9±0.7 kg,significanthigher than 1 to 3.8 kg(2.5±0.8 kg)before surgery.Score of muscle strength of the 31 patients at the end of 5-6 years' follow-up was 4.9±0.3(4 to 5),which was significantly higher than preoperative.Postoperative X-rays at the end of 5-6 years' follow-up revealed that all the cases' internal fixation was at the proper position,and no losing or broken of the internal fixation were identified.Dynamic X-rays of cervical spine showed the range of motion(ROM)of the whole cervical spine was significantly decreased after the operation.The ROM of preoperation was 77.8o±12.70 and that of 5—6 years postoperation was 27.90±7.60.The unstable segments of cervical spine became stable postoperatively.The flexible position MRI of cervical spine showed the spinal cord was completely relieved,without new compression.Venous flow empty phenomena disappeared and no "snake eyes" sign was identified.Conclusion　Anterior cervical internal fixation and fusion is an effective surgical treatment for Hirayama disease and may provide preferable mid-term clinical and radiological outcomes.This procedure has clinical significance and value in terms of control of the progression and outcome of this disease.