Ultrasound-Guided Blocks for Spine Surgery: Part 1-Cervix.

Postoperative pain is common following spine surgery, particularly complex procedures. The main anesthetic efforts are focused on applying multimodal analgesia beforehand, and regional anesthesia is a critical component of it. The purpose of this study is to examine the existing techniques for regional anesthesia in cervical spine surgery and to determine their effect and safety on pain reduction and postoperative patient's recovery. The electronic databases were searched for all literature pertaining to cervical nerve block procedures. The following peripheral, cervical nerve blocks were selected and described: paravertebral block, cervical plexus clock, paraspinal interfascial plane blocks such as multifidus cervicis, retrolaminar, inter-semispinal and interfacial, as well as erector spinae plane block and stellate ganglion block. Clinicians should choose more superficial techniques in the cervical region, as they have been shown to be comparably effective and less hazardous compared to paravertebral blocks.

Prophylaxis of occipital pressure sores in patients after elective spinal surgery in a pandemic condition.

Background: Occipital pressure sores (OPS) are complications of the use of cervical collars. Prophylaxis of OPS in patients after cervical spinal surgery (CCS) appears to be neglected. Material and methods: Cochrane Central, EMBASE, PubMed, SCOPUS, and Web of Science databases were searched for studies on OPS after CCS. Results: We present the case of a patient with rheumatic arthritis who was secured with a hard collar after revision CCS and was not seen by a health professional due to the COVID-19 outbreak. The result was an OPS leading to deep tissue infection. The patient required a prolonged hospital stay and long-term antibiotic therapy. We found a lack of literature on OPS prevention in patients after CCS. Conclusions: Patients with rheumatoid arthritis using collars after CCS are at risk of OPS. Protocols of prevention of OPS should be reviewed with respect to challenges resulting from epidemiological restrictions and accessibility of telemedical technologies.

Cytokines in the pathogenesis of hemophilic arthropathy.

Hemophilic arthropathy (HA) is one of the most common and typical manifestation in the course of recurrent bleeding episodes in patients with hemophilia. Clinical and subclinical joint bleeding episodes gradually lead to irreversible changes manifesting themselves as pain, progressing ankylosis, marked limitation of the range of motion, muscle atrophy and osteoporosis commonly concomitant with joint deformity resulting from chronic proliferative synovitis and both cartilage and bone degeneration leading to the final functional impairment of the joint. In spite of numerous studies, the pathophysiology of HA has not been fully elucidated, especially as regards immunopathological mechanisms which are associated with the subclinical and early stage of the disease and to be more precise, with chronic joint inflammation. It needs to be emphasized that the pathophysiological processes occurring in a joint with HA are most probably highly mediated by interactions within the cytokine network and other inflammatory mediators present in the tissues of affected joint. Among numerous compounds participating in the induction of an inflammatory process in the pathogenesis of HA, cytokines seem to play a leading role. The most important group controlling the disease seems to be well known inflammatory cytokines, including IL-1ß, TNFα and IL-6. The second group with antagonistic effect is formed by anti-inflammatory cytokines such as IL-4 and IL-10. The role of inflammatory and anti-inflammatory cytokines in the pathogenesis of HA with respect to cellular and intracellular signaling pathways is still under investigation. This review, summarizes and discusses the current knowledge about cytokine network in the pathogenesis of HA, indicating possible molecular and cellular mechanisms that may provide potential new therapeutic directions.

Rheumatoid arthritis bone marrow environment supports Th17 response.

BACKGROUND: Rheumatoid arthritis (RA) is a systemic, autoimmune disease leading to joint destruction and ultimately disability. Bone marrow (BM) is an important compartment in RA, where pathological processes from "outside the joint" can occur. IL-17 is a cytokine that exerts proinflammatory effects and participates in the process of bone destruction. It is believed that IL-17 is involved in pathogenesis of RA. However, little is known about the biology of this cytokine in BM. In the present study we investigated Th17-related cytokines in RA BM. METHODS: BM samples were obtained from RA and osteoarthritis (OA) patients during total hip replacement surgery. Levels of IL-17AF, IL-17AA, IL-17FF, IL-1ß, IL-6, IL-23, TGF-ß and CCL20 in BM plasma were determined by specific enzyme-linked immunosorbent assay tests. Percentage of IL-17-producing cells in BM was evaluated by flow cytometry. The effect of IL-15 stimulation on IL-17 production by BM mononuclear cells was examined in vitro. RESULTS: Increased levels of IL-17AF were observed in BM plasma of RA patients in comparison to OA patients. Increased concentrations of IL-1ß, IL-6 and CCL20 were observed in RA compared to OA BM plasma. Concordant with these findings, significantly increased percentages of CD3+CD4+IL-17+ and CD3+CD4+IL-17+IFN-γ+ cells were present in RA BM in comparison to OA BM samples. Finally, abundant in RA BM, IL-15 increased IL-17 production by cultured BM mononuclear cells. CONCLUSIONS: In the course of RA, the BM microenvironment can promote the development of Th17 cell responses and overproduction of IL-17AF that may lead to increased inflammation and tissue destruction in RA BM.

Different expression of chemokines in rheumatoid arthritis and osteoarthritis bone marrow.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic inflammatory disease leading to joint destruction. In addition to involvement of the joints, there is growing evidence that inflammatory/autoimmune processes take place in bone marrow, beginning the disease onset. Activated T and B cells accumulate in bone marrow, where also effective antigen presentation takes place. An increased number of activated T cells was observed in RA in comparison to osteoarthritis (OA) bone marrow. In the present study we analyzed the levels of chemokines that may be responsible for accumulation/retention of T-cells in the bone marrow of RA and OA patients. MATERIAL AND METHODS: Bone marrow samples were obtained from RA and OA patients during total hip replacement surgery, and bone marrow plasma was obtained by gradient centrifugation. Levels of the chemokines CX3CL1, CCL5, CCL2, CXCL12 and CXCL1 were measured in bone marrow plasma by specific ELISAs. Comparison between the groups of patients and statistical significance were analyzed by the two-tailed Mann-Whitney U test. RESULTS: Increased levels of CX3CL1 (818 ±431 pg/ml vs. 502 ±131 pg/ml, p < 0.0007) and CCL5 (5967 ±1680 pg/ml vs. 4878 ±2360 pg/ml, p < 0.05) respectively in bone marrow plasma from RA in comparison with OA patients were observed. In contrast, similar levels of CCL2, CXCL12 and CXCL1 in RA and OA bone marrow suggest that these cytokines do not play a significant role in the observed T cell accumulation in RA bone marrow. CONCLUSIONS: CX3CL1 and CCL5 overproduced in RA bone marrow may contribute to the accumulation of T cells observed in RA bone marrow.

Transforming growth factor Beta family: insight into the role of growth factors in regulation of fracture healing biology and potential clinical applications.

The transforming growth factor beta (TGF-ß) family forms a group of three isoforms, TGF-ß1, TGF-ß2, and TGF-ß3, with their structure formed by interrelated dimeric polypeptide chains. Pleiotropic and redundant functions of the TGF-ß family concern control of numerous aspects and effects of cell functions, including proliferation, differentiation, and migration, in all tissues of the human body. Amongst many cytokines and growth factors, the TGF-ß family is considered a group playing one of numerous key roles in control of physiological phenomena concerning maintenance of metabolic homeostasis in the bone tissue. By breaking the continuity of bone tissue, a spread-over-time and complex bone healing process is initiated, considered a recapitulation of embryonic intracartilaginous ossification. This process is a cascade of local and systemic phenomena spread over time, involving whole cell lineages and various cytokines and growth factors. Numerous in vivo and in vitro studies in various models analysing cytokines and growth factors' involvement have shown that TGF-ß has a leading role in the fracture healing process. This paper sums up current knowledge on the basis of available literature concerning the role of the TGF-ß family in the fracture healing process.

Syndromes with chronic non-bacterial osteomyelitis in the spine.

Chronic non-bacterial osteomyelitis (CNO) has been known for over of 40 years. It is an underrecognized entity due to the low number of described cases and poor propagation awareness of the problem. Chronic non-bacterial osteomyelitis is usually confused with infectious spondylodiscitis or malignant lesions, both primary and metastatic. Failing to consider CNO as one of possible lesions of the spine among an array of differential diagnoses may lead to a prolonged ineffective treatment increasing treatment-related morbidity. In this paper the authors describe these two syndromes, with a possible autoimmune background - chronic recurrent multifocal osteomyelitis (CRMO) and SAPHO syndrome - that include CNO being among the manifestations. The authors present the spinal symptomatology of CNO for both syndromes published so far to help spine clinicians organize the information for better usage in everyday clinical practice.

Comparison of trace element concentration in bone and intervertebral disc tissue by atomic absorption spectrometry techniques.

BACKGROUND: Trace element (TE) analysis in human tissue has the dual purpose of assessing environmental pollution and metabolism. In literature, bone TE analysis is common, but studies in intervertebral disc (IVD) tissue are lacking. The aim of the study was evaluation of the difference of TE concentration in intervertebral disc and bone in patients with degenerative changes. The comparison of the tissues differing in metabolism, blood perfusion, or separateness from adjoining tissues but playing similar biomechanical role and presenting some common morphological traits may shed new light on metabolism nuances, degenerative process, as well as accumulation potential of IVD in respect to bone. METHODS: In the study, we analyzed two types of samples: intervertebral disc (n =30, from 22 patients operated due to degenerative disc disease) and femoral bone (n =26, separately femoral head and neck, from 26 patients, acquired in total hip arthroplasty procedure in course of idiopathic osteoarthritis of the hip joint). In the samples we analyzed, with atomic absorption spectrometry, the concentrations of Pb, Ni, Mo, Cu, Mg, and Zn. RESULTS: The element concentrations identified in bone are comparable to those presented in the literature. In the case of Pb, Ni, Mo, Mg, and Zn, the concentration in the bone was 2 to 25.8 times higher than that observed in the disc. Only the Cu concentration was higher in disc tissue than in bone. In disc tissue, fewer samples had TE concentrations below the detection threshold. We found significant differences in TE profiles in the compared tissues. CONCLUSIONS: The results show that the disc could serve as a more stable compartment for evaluating TE concentration, especially for TEs that are environmentally related.

[Acquired musculoskeletal dysfunction syndromes in workers in the light of epidemiological studies]. / Nabyte zespoly dysfunkcji ukladu miesniowo-szkieletowego u pracowników w swietle badan epidemiologicznych.

Acquired musculoskeletal dysfunction syndromes (overload syndromes) that cause limitation of the system efficiency belong nowadays to the most serious problems in the medical care of workers. The etiology of overload syndromes is multifactorial, which means that occupational factors constitute only one of many causes fostering the development of those disorders. Occupational factors which increase the risk of musculoskeletal disorders include physical factors related to the work environment or the way the work is performed, such as body posture, value of exerted forces, movement repetitiveness, load handling, mechanical vibration or microclimate as well as psychosocial factors, such as quantitative and qualitative overload, lack of control, lack of social support or work insecurity. The consequence of musculoskeletal overload syndromes is the progressing reduction of its efficiency causing limitation or even loss of work ability, which results in premature exclusion from social and occupational activities. This article presents etiological factors of musculoskeletal complains and overload syndromes and their prevalence in workers.

Asp327Asn polymorphism of sex hormone-binding globulin gene is associated with systemic lupus erythematosus incidence.

Endogenous sex hormones have been observed to have a role in systemic lupus erythematosus (SLE) predisposition. Sex hormone-binding globulin (SHBG) regulates the bioavailability of sex hormones to target tissues. Therefore, we examined the distribution of the SHBG functional polymorphism Asp327Asn (rs6259) in SLE patients (n = 150) and controls (n = 150) in a Polish population. We found a contribution of the SHBG327Asn variant to the development of SLE. Women with the Asp/Asn and Asn/Asn genotypes displayed a 2.630-fold increased risk of SLE (95% CI = 1.561-4.433, P = 0.0003). SHBG has a much higher affinity for testosterone than estradiol, and the SHBG327Asn variant displays a reduction of estradiol clearance. Therefore we suggest that the opposing effects of estrogens and testosterone on the immune system and imbalance in the levels of these hormones in SLE patients can be enhanced by the SHBG327Asn protein variant.

The effect of the grade of degenerative changes in the spine on the outcomes of surgery for lumbar discopathy with a radicular syndrome.

BACKGROUND: The aim of the study was an evaluation of the influence of coexisting degenerative changes on surgical outcomes on patients with lumbar disc hernias (DH). MATERIAL AND METHODS: A total of randomly selected 132 patients undergoing surgery for DH (classic discectomy with fenestration of the yellow ligament) were examined. Radiographic and MRI scans of the lumbar spine were obtained in all patients, who were subsequently divided into 6 groups depending on the grade and/or extent of degenerative changes. The patients self-evaluated treatment outcomes using a visual analogue scale (VAS). The attending doctors carried out a more detailed assessment of the outcomes by separately determining pain intensity (using a 4-grade scale), motor weakness (using a 3-grade scale) and range of lumbar spine movement (using a 3-grade scale). RESULTS: In general, patient self-evaluation of treatment outcomes did not reveal statistically significant differences between subgroups. In doctors' detailed assessment, treatment outcomes related to pain and motor weakness were not significantly different between groups with and without spondylosis. The range of motion in the lumbar spine was greater in patients without spondylosis (p<0.05). CONCLUSIONS: According to both subjective and objective assessments of the therapeutic effects of surgery for lumbar disc hernias, even severe degenerative changes do not worsen the treatment outcome.

[Specific of pharmacotherapy management in back pain among the elderly]. / Specyfika leczenia farmakologicznego bólów krzyza u starszych chorych.

Back pain is one of the main reasons for physical disability among the elderly. The most frequent cause of the pain among this group is the degenerative disease. The larger part in causes of low back pain among the elderly has metabolic (osteoporosis) and neoplastic diseases. Pharmacological treatment of the back pain requires to take into consideration its etiology, course, specific biological features of the organism ageing, pain chronification features and extrasomatic influences. Environmental influences and additional diseases are not insignificant as well. The aforementioned factors determine limitations in using painkillers. The limitations concern quality area (e.g. medicine group, chosen pharmaceutical agents, way of medicine administration) and quantity area (e.g. drug dosage, time of application). The specified differences in etiology, course of low back pain and drug absorption and excretion among the elderly are not sufficiently taken into consideration. It becomes the cause of side effects of the used drugs, lack of treatment efficiency and as a result deterioration of life quality. To improve efficiency in low back pain treatment, the authors reviewed the literature and presented their own opinions on using different groups of drugs and limits of pharmacotherapy among the elderly.