Sodium MRI of the Lumbar Intervertebral Discs of the Human Spine: An Ex Vivo Study.

BACKGROUND: Lower back pain affects 75%-85% of people at some point in their lives. The detection of biochemical changes with sodium (23Na) MRI has potential to enable an earlier and more accurate diagnosis. PURPOSE: To measure 23Na relaxation times and apparent tissue sodium concentration (aTSC) in ex-vivo intervertebral discs (IVDs), and to investigate the relationship between aTSC and histological Thompson grade. STUDY TYPE: Ex-vivo. SPECIMEN: Thirty IVDs from the lumbar spines of 11 human body donors (4 female, 7 male, mean age 86 ± 8 years). FIELD STRENGTH/SEQUENCE: 3 T; density-adapted 3D radial sequence (DA-3D-RAD). ASSESSMENT: IVD 23Na longitudinal (T1), short and long transverse (T2s* and T2l*) relaxation times and the proportion of the short transverse relaxation (ps) were calculated for one IVD per spine sample (11 IVDs). Furthermore, aTSCs were calculated for all IVDs. The degradation of the IVDs was assessed via histological Thompson grading. STATISTICAL TESTS: A Kendall Tau correlation (τ) test was performed between the aTSCs and the Thompson grades. The significance level was set to P < 0.05. RESULTS: Mean 23Na relaxation parameters of a subset of 11 IVDs were T1 = 9.8 ± 1.3 msec, T2s* = 0.7 ± 0.1 msec, T2l* = 7.3 ± 1.1 msec, and ps = 32.7 ± 4.0%. A total of 30 IVDs were examined, of which 3 had Thompson grade 1, 4 had grade 2, 5 had grade 3, 5 had grade 4, and 13 had grade 5. The aTSC decreased with increasing degradation, being 274.6 ± 18.9 mM for Thompson grade 1 and 190.5 ± 29.5 mM for Thompson grade 5. The correlation between whole IVD aTSC and Thompson grade was significant and strongly negative (τ = -0.56). DATA CONCLUSION: This study showed a significant correlation between aTSC and degenerative IVD changes. Consequently, aTSC has potential to be useful as an indicator of degenerative spinal changes. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 1.

Acute or chronic pulmonary emphysema? Or both?-A contribution to the diagnosis of death due to violent asphyxiation in cases with pre-existing chronic emphysema.

The diagnosis of death due to violent asphyxiation may be challenging if external injuries are missing, and a typical acute emphysema (AE) "disappears" in pre-existing chronic emphysema (CE). Eighty-four autopsy cases were systematically investigated to identify a (histo-) morphological or immunohistochemical marker combination that enables the diagnosis of violent asphyxiation in cases with a pre-existing CE ("AE in CE"). The cases comprised four diagnostic groups, namely "AE", "CE", "acute and chronic emphysema (AE + CE)", and "no emphysema (NE)". Samples from all pulmonary lobes were investigated by conventional histological methods as well as with the immunohistochemical markers Aquaporin 5 (AQP-5) and Surfactant protein A1 (SP-A). Particular attention was paid to alveolar septum ends ("dead-ends") suspected as rupture spots, which were additionally analyzed by transmission electron microscopy. The findings in the four diagnostic groups were compared using multivariate analysis and 1-way ANOVA analysis. All morphological findings were found in all four groups. Based on histological and macroscopic findings, a multivariate analysis was able to predict the correct diagnosis "AE + CE" with a probability of 50%, and the diagnoses "AE" and "CE" with a probability of 86% each. Three types of "dead-ends" could be differentiated. One type ("fringed ends") was observed significantly more frequently in AE. The immunohistochemical markers AQP-5 and SP-A did not show significant differences among the examined groups. Though a reliable identification of AE in CE could not be achieved using the examined parameters, our findings suggest that considering many different findings from the macroscopical, histomorphological, and molecular level by multivariate analysis is an approach that should be followed.

Anatomical versus functional motor points of selected upper body muscles.

INTRODUCTION: In this study we aimed to identify nerve entry points (NEPs) of superficial skeletal muscles obtained by dissection of 20 human cadavers and compared them with motor points (MP) obtained previously by electrical stimulation. METHODS: The biceps brachii (BB), trapezius (TZ), latissimus dorsi (LD), pectoralis major (Pmaj), and pectoralis minor (Pmin) muscles were dissected from human cadavers. NEP data (mean ± standard deviation) from each muscle were calculated. F-tests with Bonferroni corrections were used to compare NEPs and MPs. RESULTS: The number of NEPs was 2 in BB, 1 in Pmin, 4 in TZ, and 3 in LD, whereas the total number in Pmaj varied from 3 to 5. NEPs and MPs were statistically equal only in Pmin and in the descending part of TZ. DISCUSSION: The findings show crucial differences between NEPs and MPs, possibly impacting the effectiveness of several medical treatment strategies. Muscle Nerve 57: 460-465, 2018.

Establishment and Characterization of a Novel Cell Line Derived from a Small Cell Neuroendocrine Carcinoma of the Anal Canal.

BACKGROUND: Gastroenteropancreatic neuroendocrine carcinomas (GEP-NECs) are biologically aggressive tumors, associated with a very poor survival. Due to their rarity, our knowledge on GEP-NEC biology is very limited. The aim of this study was to establish a GEP-NEC cell line model that might contribute to a better understanding of this rare malignant disease to further develop novel therapeutic approaches in preclinical studies. METHODS: Small cell neuroendocrine cancer cell line NEC-DUE3 was derived from a lymph node metastasis of a neuroendocrine carcinoma (NEC) located at the anal canal. Morphological characteristics and the expression of neuroendocrine markers were comprehensively investigated. For genetic profiling, NEC-DUE3 cells were analyzed by DNA fingerprinting. Chromosomal aberrations were mapped by array comparative genomic hybridization. NEC-DUE3 cell tumorigenicity was evaluated in vivo and the sensitivity to chemotherapeutic agents was assessed in vitro. RESULTS: NEC-DUE3 cells were characterized by the expression of molecular markers that are commonly observed in GEP-NECs, were sensitive to treatment with cisplatin, and able to form tumors in immunodeficient mice. CONCLUSION: We established and characterized the first small cell GEP-NEC cell line that may serve as a valuable tool to create a better understanding of the biology of these rare tumors and to develop novel treatment strategies.

Short-term results of the reverse Total Evolutive Shoulder System (TESS) in cuff tear arthropathy and revision arthroplasty cases.

INTRODUCTION: The aim of this study was to evaluate the clinical and radiological outcome of the Total Evolutive Shoulder System (TESS) in patients with cuff tear arthropathy and patients in need of a revision arthroplasty. METHODS: In this sequential study, 67 patients (56 non-stemmed, 11 stemmed) were evaluated after a mean follow-up of 17.5 months. The relative Constant and DASH scores, radiological joint geometry changes, complications and postoperative problems, which are not likely to affect the outcome, were evaluated. RESULTS: A significant increase was noticed for the relative Constant (11.3 vs. 78.8 %) and DASH scores (73.7 vs. 31.8) without significant differences between both etiology groups. Complication rates were similar to previous studies. An aseptic loosening of the non-stemmed humeral component was not noticed in the cuff tear arthropathy group, whereas one case with a loosening was noticed in the revision arthroplasty group. With nine cases (13.4 %), scapular notching rates were very low. On average, the acromiohumeral distance increased by 17 mm and the humeral offset by 13.9 mm; the height of the center of rotation decreased by 4.6 mm and the lateral glenohumeral offset by 6.1 mm, p < 0.05, respectively. CONCLUSION: Regarding the joint geometry, surgery with the TESS system provided adequate distalization and medialization of the humerus and the center of rotation. This corresponds to a good clinical outcome. The use of the surgical opportunity to implant the prosthesis with a relatively low neck-shaft angle might explain the low rates of scapular notching in our series. Regarding the case with a loosening of the humeral component, the surgeon should carefully indicate a stemless version for metaphyseal press-fit fixation in patients with revision arthroplasty.

Surgical treatment in a patient with Klippel-Feil syndrome and anterior cervical meningomyelocele: a case report and review of literature.

INTRODUCTION: Klippel-Feil syndrome (KFS) is considered a rare developmental disorder characterized by mono- or multisegmental fusion of the cervical vertebrae which is frequently associated with diverse non-osseous, e.g. neural, visceral, cardiopulmonary and genitourinary development anomalies. Anterior cervical meningomyelocele (MMC) in KFS has only been described in two previous patients, both with non-surgical treatment. CLINICAL PRESENTATION: We present the case of a 26-year-old female suffering from KFS, presenting with progressive bilateral C6 paraesthesias, C7 and C8 motor weakness and myelopathy. Radiological imaging revealed incomplete osseous fusion of the vertebrae C2-Th1. The spinal cord was displaced ventro-caudally through a large anterior MMC, apparently fixed at the dorsal oesophagus, severely stretching the cervical nerve roots. Surgery was indicated due to progression of the symptoms and was performed through a combined partial sternotomy and ventral anterolateral cervical approach. Intraoperatively, both division of oesophago-dural adhesions and intradural untethering of adhesions of the myelon with caudal parts of the cele were performed. Evoked somatosensory potentials improved immediately and 6-day postoperative MRI revealed a nearly complete reposition of the spinal cord in its physiological position. Genetic sequence analyses ruled out mutation of the growth and differentiation factor 6 (GDF6). Apart from slight intermittent paraesthesia, symptoms resolved almost completely within weeks after operation. Both radiological and neurological improvement remained stable at 16 months of follow-up. CONCLUSION: KFS with anterior cervical MMC is rarely seen and may require surgery in case of clincial signs of nerve root compression or myelopathy. Osseous decompression, untethering and adhesiolysis under electrophysiological monitoring can provide sufficient radiological and clinical improvement.

The chemicals between us-First results of the cluster analyses on anatomy embalming procedures in the German-speaking countries.

Hands-on courses utilizing preserved human tissues for educational training offer an important pathway to acquire basic anatomical knowledge. Owing to the reevaluation of formaldehyde limits by the European Commission, a joint approach was chosen by the German-speaking anatomies in Europe (Germany, Austria, Switzerland) to find commonalities among embalming protocols and infrastructure. A survey comprising 537 items was circulated to all anatomies in German-speaking Europe. Clusters were established for "ethanol"-, formaldehyde-based ("FA"), and "other" embalming procedures, depending on the chemicals considered the most relevant for each protocol. The logistical framework, volumes of chemicals, and infrastructure were found to be highly diverse between the groups and protocols. Formaldehyde quantities deployed per annum were three-fold higher in the "FA" (223 L/a) compared to the "ethanol" (71.0 L/a) group, but not for "other" (97.8 L/a), though the volumes injected per body were similar. "FA" was strongly related to table-borne air ventilation and total fixative volumes ≤1000 L. "Ethanol" was strongly related to total fixative volumes >1000 L, ceiling- and floor-borne air ventilation, and explosion-proof facilities. Air ventilation was found to be installed symmetrically in the mortuary and dissection facilities. Certain predictors exist for the interplay between the embalming used in a given infrastructure and technical measures. The here-established cluster analysis may serve as decision supportive tool when considering altering embalming protocols or establishing joint protocols between institutions, following a best practice approach to cater toward best-suited tissue characteristics for educational purposes, while simultaneously addressing future demands on exposure limits.

Approach-related lesions of the sympathetic chain in anterior correction and instrumentation of idiopathic scoliosis.

During anterior scoliosis instrumentation with a dual-rod system, the vertebrae are dissected anterolaterally. After surgery, some patients report a change in temperature perception and perspiration in the lower extremities. Sympathetic lesions might be an explanation for this. The aim of this clinical study was to investigate sympathetic function after anterior scoliosis instrumentation. A total of 24 female patients with idiopathic scoliosis (mean age at follow-up, 23.8 years) who had undergone anterior instrumentation on average 6.6 years earlier were included. Due to the suspected relevance of the sympathetic L2 ganglion, two groups were created: a T12 group, in which instrumentation down to T12 was carried out (n = 12), and an L3 group, in which instrumentation down to L3 was done (n = 12). Sympathetic function was assessed by measuring skin temperature at the back of the foot, a plantar ninhydrin sweat test and sympathetic skin responses (SSRs) following electrical stimulation. The side on which the surgical approach was carried out was compared with the contralateral, control side. Health-related quality of life was investigated using the Scoliosis Research Society SRS-22 patient questionnaire. In the T12 group, mean temperatures of 29.6 degrees C on the side of the approach versus 29.5 degrees C on the control side were measured (P > 0.05); in the L3 group, the mean temperatures were 33.2 degrees C on the approach side versus 30.5 degrees C on the control side (P = 0.001). A significant difference between the T12 group and the L3 group (P < 0.001) was observed on the approach side, but not on the control side (P = 0.15). The ninhydrin sweat test showed reduced perspiration in 11 of 12 patients in the L3 group on the approach side in comparison with the control side (P = 0.002). In the T12 group, no significant differences were noted between the left and right feet. SSRs differed significantly between the two groups (P = 0.005). They were detected in all nine analyzable patients in the T12 group on both sides. In the L3 group, they were found on the approach side only in 4 of 11 analyzable patients versus 11 patients on the control side. The results of the SRS-22 questionnaire did not show any significant differences between the two groups. In conclusion, anterior scoliosis instrumentation with a dual-rod system including vertebrae down to L3 regularly leads to lesions in the sympathetic trunk. These are detectable with an increase in temperature, reduced perspiration and reduced SSRs. The caudal level of instrumentation (T12 vs. L3) has an impact on the extent of impairment, supporting the suspected importance of the L2 ganglion. The clinical outcome does not seem to be significantly limited by sympathetic trunk lesions.

The effect of dynamic, semi-rigid implants on the range of motion of lumbar motion segments after decompression.

Undercutting decompression is a common surgical procedure for the therapy of lumbar spinal canal stenosis. Segmental instability, due to segmental degeneration or iatrogenic decompression is a typical problem that is clinically addressed by fusion, or more recently by semi-rigid stabilization devices. The objective of this experimental biomechanical study was to investigate the influence of spinal decompression alone, as well as in conjunction with two semi-rigid stabilizing implants (Wallis, Dynesys) on the range of motion (ROM) of lumbar spine segments. A total of 21 fresh-frozen human lumbar spine motion segments were obtained. Range of motion and neutral zone (NZ) were measured in flexion-extension (FE), lateral bending (LAT) and axial rotation (ROT) for each motion segment under four conditions: (1) with all stabilizing structures intact (PHY), (2) after bilateral undercutting decompression (UDC), (3) after additional implantation of Wallis (UDC-W) and (4) after removal of Wallis and subsequent implantation of Dynesys (UDC-D). Measurements were performed using a sensor-guided industrial robot in a pure-moment-loading mode. Range of motion was defined as the angle covered between loadings of -5 and +5 Nm during the last of three applied motion cycles. Untreated physiologic segments showed the following mean ROM: FE 6.6 degrees , LAT 7.4 degrees , ROT 3.9 degrees . After decompression, a significant increase of ROM was observed: 26% FE, 6% LAT, 12% ROT. After additional implantation of a semi-rigid device, a decrease in ROM compared to the situation after decompression alone was observed with a reduction of 66 and 75% in FE, 6 and 70% in LAT, and 5 and 22% in ROT being observed for the Wallis and Dynesys, respectively. When the flexion and extension contribution to ROM was separated, the Wallis implant restricted extension by 69% and flexion by 62%, the Dynesys by 73 and 75%, respectively. Compared to the intact status, instrumentation following decompression led to a ROM reduction of 58 and 68% in FE, 1 and 68% in LAT, -6 and 13% in ROT, 61 and 65% in extension and 54 and 70% in flexion for Wallis and Dynesys. The effect of the implants on NZ corresponded to that on ROM. In conclusion, implantation of the Wallis and Dynesys devices following decompression leads to a restriction of ROM in all motion planes investigated. Flexion-extension is most affected by both implants. The Dynesys implant leads to an additional strong restriction in lateral bending. Rotation is only mildly affected by both implants. Wallis and Dynesys restrict not only isolated extension, but also flexion. These biomechanical results support the hypothesis that postoperatively, the semi-rigid implants provide a primary stabilizing function directly. Whether they can improve the clinical outcome must still be verified in prospective clinical investigations.

Restoration of the joint geometry and outcome after stemless TESS shoulder arthroplasty.

AIM: To evaluate the joint geometry and the clinical outcome of stemless, anatomical shoulder arthroplasty with the TESS system. METHODS: Twenty-one shoulders with a mean follow-up 18 of months were included. On scaled digital radiographs the premorbid center of rotation (CoR) was assessed and compared to the CoR of the prosthesis by using the MediCAD® software. Additionally, the pre- and post-operative geometry of the CoR was assessed in relation to the glenoid, the acromion as well as to the proximal humerus. Radiological changes, such as radiolucencies, were also assessed. Clinical outcome was assessed with the Constant and DASH score. RESULTS: Both, the Constant and DASH scores improved significantly from 11% to 75% and from 70 to 30 points, P < 0.01 respectively. There were no significant differences regarding age, etiology, cemented or metal-backed glenoids, etc. (P > 0.05). The pre- and postoperative humeral offset, the lateral glenohumeral offset, the height of the CoR, the acromiohumeral distance as well as neck-shaft angle showed no significant changes (P > 0.05). The mean deviation of the CoR of the prosthesis from the anatomic center was 1.0 ± 2.8 mm. Three cases showed a medial deviation of more than 3 mm. These deviations of 5.1, 5.7 and 7.6 mm and were caused by an inaccurate humeral neck cut. These 3 patients showed a relatively poor outcome scoring. CONCLUSION: TESS arthroplasty allows an anatomical joint reconstruction with a very good outcome. Outliers described in this study sensitize the surgeon for an accurate humeral neck cut.

Periprosthetic bone density changes after MiniHipTM cementless femoral short stem: one-year results of dual-energy X-ray absorptiometry study.

INTRODUCTION: The purpose of the current study was to investigate the reaction of the femur to the implantation of the MiniHipTM in terms of: (1) bone density change during one year; (2) correlations between stem length, CCD (caput-collum-diaphyseal), femoral offset, T-value, and bone density; (3) other co-variables that influence the change of bone density. PATIENTS AND METHODS: MiniHipTM implant was performed for 62 patients. The age range of the patients who underwent treatment was 25-78 years. Periprothestic bone density was determined within two weeks postoperatively, after three, six, and twelve months utilizing the DEXA scan. RESULTS: The highest change was observed in the first three months post-implantation, while significant decrease in density was recorded at proximal Gruen zones 1, 2, and 7, and at distal Gruen zone 4. The decrease in density reached a plateau between the third and sixth months after operation. Afterwards, bone density recovered up to the 12th postoperative month. The correlation analysis showed significant difference between Gruen zone 1 and stem size and CCD. The same significant trend was not reached for Gruen zone 7. Femoral offset showed no correlation. Covariance analysis was unable to establish connection of the results with diagnosis, pairings, or gender. DISCUSSION: MiniHipTM densitometric results are promising and comparable to good results of the other representatives of the femoral neck partially-sustaining short stem prostheses with a lower proximal bone density reduction. Periprosthetic bone resorption is a multifactorial process where stem size, CCD angle, and patient-specific variables such as T-value have an impact on the periprosthetic bone remodeling. In particular, this applies to Gruen zone 1.

Intra-articular meniscoid folds in thoracic zygapophysial joints.

STUDY DESIGN: A descriptive morphologic anatomic study was performed. OBJECTIVE: The study aimed to investigate intra-articular meniscoids (folds) and cartilage quality in the thoracic zygapophysial joints (ZAJs), and to discuss them in the context of possible causes of thoracic back pain. SUMMARY OF BACKGROUND DATA: The clinical relevance of the intra-articular meniscoid structures described in the cervical and lumbar spine is unclear, particularly in relation to ZAJ blockades. Corresponding data for the thoracic joints are not available. METHODS: A total of 297 ZAJs between C7 and L1, obtained from 12 human cadavers (7 female, 5 male; mean age 81 years), were studied. The intra-articular folds were described and classified morphologically. The characteristics of the folds and their association with zygapophysial cartilage quality were investigated. Thirteen example folds were studied histologically. RESULTS: In all, 268 intra-articular meniscoid folds were found in 183 joints. Three types were identified: type 1 (90%; mean length 3.1 mm) were thin, solid folds originating from a connective-tissue base, with multiple vessels at the joint capsule, extending between the joint surfaces. Type 2 folds (6%) were soft structures of fat and loose connective tissue including multiple vessels, located in the joint recess and not extending between the joint surfaces. The remaining folds (type 3, 4%) were circumscribed thickenings of the joint capsule. Three folds showed chronic hemorrhage, with dilated vessels at the base, and this was associated with severe cartilage lesions. In 16 folds, the base had direct tissue connection to the fat tissue of the epidural space. CONCLUSION: This study for the first time systematically classifies intra-articular meniscoid folds in human thoracic ZAJs. These folds may represent an anatomic correlate for thoracic back pain. The chronic hemorrhage observed may be an important factor leading to arthritis.

The nerve supply of the human auricle.

Knowledge of the innervation of the outer ear is crucial for surgery in this region. The aim of this study was to describe the system of the auricular nerve supply. On 14 ears of seven cadavers the complete course of the nerve supply was exposed and categorized. A heterogeneous distribution of two cranial branchial nerves and two somatic cervical nerves was found. At the lateral as well as the medial surface the great auricular nerve prevails. No region with triple innervation was found.

The cartilage of the tibiofibular joint: a source for autologous osteochondral grafts without damaging weight-bearing joint surfaces.

Within the past few years, autologous osteochondral transplantation has become an established procedure in the therapy of articular cartilage defects of the knee. One significant disadvantage of this technique is the harvesting of grafts from the weight-bearing area. The tibiofibular articulation is less loaded. The purpose of this study was to evaluate the question of whether this joint is suitable as a donor site for osteochondral grafts. Ten fresh human knees were dissected to perform histology, immunohistochemistry, and thickness measurement of the tibiofibular cartilage. Favourable approaches and establishing of anatomical landmarks were investigated in 44 fixed tibiofibular joints. In knee extension, the shortest distance between the joint cleft and common fibular nerve was measured. A total of 389 bone specimens was analysed morphometrically (cartilage area, orientation of the joint line, signs of arthrosis). Histological and immunohistochemical examination showed hyaline cartilage and type II collagen. The area of cartilage amounted to 3.58 cm(2) (mean) at the tibia and at the fibula with a thickness of 1.6 mm (mean). The joint line is mainly orientated perpendicular to an axis course from craniomedioventral to caudolaterodorsal. Depending on the available instruments, two approaches are possible: from anteromedial or from posterolateral. The mean distance to the common fibular nerve was 19.5 mm. Signs of arthrosis were found in 1 of 10 fresh knee specimens and in 11.4% of the bone specimens. Transplantation into three patients showed no intra- or postoperative complications and a rapid and uneventful recovery. The proximal tibiofibular joint is an excellent donor site for autologous osteochondral grafts.