Hiroshi Takahashi, 1 2 Yasuchika Aoki, 1 Arata Nakajima, 1. Masato Sonobe, 1 Fumiaki Terajima, 1 Masahiko Saito, 1 Masahiro Inoue, 1

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1 Reversible axonal damage is remarkable in patients with acutely worsening symptoms of compression myelopathy: analysis of human cerebrospinal fluid samples 1 Hiroshi Takahashi, 1 2 Yasuchika Aoki, 1 Arata Nakajima, 1 Masato Sonobe, 1 Fumiaki Terajima, 1 Masahiko Saito, 1 Masahiro Inoue, 1 Keita Koyama, 1 Keiichiro Yamamoto, 1 Koichi Nakagawa 1 Department of Orthopaedic Surgery, Toho University Sakura Medical Center 2 Department of Orthopaedic Surgery, Chiba Earstern Medical Center

2 EUROSPINE 2016 Disclosure of Conflict of Interest Hiroshi Takahashi, Yasuchika Aoki, Arata Nakajima, Masato Sonobe, Fumiaki Terajima, Masahiko Saito, Masahiro Inoue, Keita Koyama, Keiichiro Yamamoto, Koichi Nakagawa There is no COI to be disclosed with any companies.

3 Purpose To evaluate the proteins that reflect the damage to axon, myelin, astrocyte, and neuron in the CSF of patients with worsening symptoms of cervical compression myelopathy

4 Patients and samples Period: January, 2011 March, CSF samples obtained from patients at the time of myelography before spinal surgery in our hospital Exclusion criterior: Cervical spondylotic radiculopathy Cervical spondylotic amyotrophy Diagnosed as the double lesion like cervical and lumbar disorders This study was given approval by our university human ethics committee Informed consent was obtained from all patients

5 The causes of disorder Patients and samples Cervical compression myelopathy: 40 patients Acutely worsening symptoms (AM) group: 20 patients Chronic symptoms (CM) group: 20 patients Lumbar canal stenosis (LCS; control): 29 patients Acutely worsening symptoms of myelopathy were defined as that in which the JOA score of patients decreased by 2 points or more during a recent 1-month period (Sakuma, 2012)

6 Assay of proteins Material and methods pnf-h: reflects the axonal damage Tau: structures the microtubules of axon Myelin Basic Protein (MBP): reflects the demyelination S100-β: reflects the damage to astrocyte Neuron Specific Enolase (NSE) : reflects the damage to neuron Evaluation of neurological status In all patients with compression myelopathy (AM and CM groups) JOA score for cervical myelopathy The recovery rate of JOA score Evaluated before surgery and 1 year after surgery

7 Results: Patient characteristics AM CM LCS Number of cases Gender Age (years) Male Female ± ± ± 7.9 (45-79) (39-75) (55-86) pre-joa 9.25 ± ± 0.80 (6-14) (10-12) Surgical procedure Laminoplasty 4 2 Posterior decompression and fusion 1 2 Anterior corpectomy and fusion 3 2

S100-β (pg/ml) NSE (ng/ml) pnf-h (pg/ml) Tau (pg/ml) 3000 2000 pnf-h * * Results of the assays 500 400 300 # Tau * p<0.

8 S100-β (pg/ml) NSE (ng/ml) pnf-h (pg/ml) Tau (pg/ml) pnf-h * * Results of the assays # Tau * p<0.01 # p<0.05 (one factor ANOVA) AM CM LCS S100-β n.s. 0 4 AM CM LCS NSE * * AM CM LCS 0 AM CM LCS

9 JOA Score JOA Recovery Rate (%) Relults: Neurological Evaluation JOA recovery rate (AM and CM groups) JOA pre # acute chronic JOA post 1y Correlation of pnf-h level and JOA recovery rate ,0 2000,0 4000,0 pnf-h (pg/ml) # p<0.05 (one factor ANOVA) y= x (R=0.381, P=0.018)

10 Discussion Proteins pnf-h Tau MBP S100β NSE Damage to Axon Axon Myelin Astrocyte Neuron Acute Spinal Cord Injury (Cao 2008, Hayakawa 2012, Yokobori 2013) Acutely Worsening of Compression Myelopathy (Our study) The present results of assays suggest that axonal damage is remarkable compared with demyelination, astrocyte, and neuronal damage in acutely worsening compression myelopathy. The pathogenesis of acutely worsening of compression myelopathy is partially different from the secondary injury of acute spinal cord injury. The positive correlation between pnf-h level and JOA recovery rate indicates that the axonal damage is reversible and the better surgical outcome is expected in this timing.

11 Limitations The small number of sample size Bias in the degree of severity at the sampling of CSF The lack of healthy control subjects (because of ethical issues) Impossible to assess the changes of protein level over time

12 Conclusions The present results of assays suggest that axonal damage is remarkable compared with demyelination, astrocyte and neuronal damage in acutely worsening compression myelopathy. The better clinical outcome in acute worsening compression myelopathy indicates the reversible axonal damage to spinal cord. pnf-h can act as a predictive indicator for acutely worsening compression myelopathy.

Mitsuhiro Hashimto 1), Masashi Yamazaki 2), Macondo Mochizuki 3), Masatsune Yamagata 1), Yoshikazu Ikeda 1), Fumitake Nakajima 1)

Long-term results of anterior cervical corpectomy and arthrodesis for cervical degenerative diseases with more than ten years of follow-up Mitsuhiro Hashimto 1), Masashi Yamazaki 2), Macondo Mochizuki