Intradural lumbar disc herniation: A case report and literature review.

Study design and objection: Intradural disc herniation is a unusual disease associated with spinal surgery. The definitive diagnosis of intradural herniation depends on intraoperative findings. Summary of background data: We present the case of a 63-year-old woman with backache and left sciatica radiation for more than two months. The L2/3 laminectomy and discectomy were performed after magnetic resonance imaging (MRI) study; however, no disc rupture was noted during surgery. Follow-up lumbar spine MRI revealed one large, ruptured disc. The patient underwent revision surgery with durotomy. The large intradural disc was found and removed piece by piece. Methods Results and Conclusions: Intradural disc herniation, especially large herniation, is hard to diagnose specifically despite the progression of neuroradiologic imaging techniques. A durotomy procedure should be considered if there is a missing ruptured disc or a palpable intradural mass during surgery.

Comparison of anterior cervical discectomy and fusion versus artificial disc replacement for cervical spondylotic myelopathy: a meta-analysis.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) has long been regarded as a gold standard in the treatment of cervical myelopathy. Subsequently, cervical artificial disc replacement (c-ADR) was developed and provides the advantage of motion preservation at the level of the intervertebral disc surgical site, which may also reduce stress at adjacent levels. The goal of this study was to compare clinical and functional outcomes in patients undergoing ACDF with those in patients undergoing c-ADR for cervical spondylotic myelopathy (CSM). METHODS: A systematic literature review and meta-analysis were performed using the Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from database inception to November 21, 2021. The authors compared Neck Disability Index (NDI), SF-36, and Japanese Orthopaedic Association (JOA) scores; complication rates; and reoperation rates for these two surgical procedures in CSM patients. The Mantel-Haenszel method and variance-weighted means were used to analyze outcomes after identifying articles that met study inclusion criteria. RESULTS: More surgical time was consumed in the c-ADR surgery (p = 0.04). Shorter hospital stays were noted in patients who had undergone c-ADR (p = 0.04). Patients who had undergone c-ADR tended to have better NDI scores (p = 0.02) and SF-36 scores (p = 0.001). Comparable outcomes in terms of JOA scores (p = 0.24) and neurological success rate (p = 0.12) were noted after the surgery. There was no significant between-group difference in the overall complication rates (c-ADR: 18% vs ACDF: 25%, p = 0.17). However, patients in the ACDF group had a higher reoperation rate than patients in the c-ADR group (4.6% vs 1.5%, p = 0.02). CONCLUSIONS: At the midterm follow-up after treatment of CSM, better functional outcomes as reflected by NDI and SF-36 scores were noted in the c-ADR group than those in the ACDF group. c-ADR had the advantage of retaining range of motion at the level of the intervertebral disc surgical site without causing more complications. A large sample size with long-term follow-up studies may be required to confirm these findings in the future.

ProDisc-C versus anterior cervical discectomy and fusion for the surgical treatment of symptomatic cervical disc disease: two-year outcomes of Asian prospective randomized controlled multicentre study.

PURPOSE: Our study aimed to evaluate non-inferiority of ProDisc-C to anterior cervical discectomy and fusion (ACDF) in terms of clinical outcomes and incidence of adjacent segment disease (ASD) at 24-months post-surgery in Asian patients with symptomatic cervical disc disease (SCDD). METHODS: This multicentre, prospective, randomized controlled trial was initiated after ethics committee approval at nine centres (China/Hong Kong/Korea/Singapore/Taiwan). Patients with single-level SCDD involving C3-C7-vertebral segments were randomized (2:1) into: group-A treated with ProDisc-C and group-B with ACDF. Assessments were conducted at baseline, 6-weeks, 3/6/12/18/24-months post-surgery and annually thereafter till 84-months. Primary endpoint was overall success at 24-months, defined as composite of: (1) ≥ 20% improvement in neck disability index (NDI); (2) maintained/improved neurologic parameters; (3) no implant removal/revision/re-operation at index level; and (4) no adverse/severe/life-threatening events. RESULTS: Of 120 patients (80ProDisc-C,40ACDF), 76 and 37 were treated as per protocol (PP). Overall success (PP) was 76.5% in group-A and 81.8% in group-B at 24-months (p = 0.12), indicating no clear non-inferiority of ProDisc-C to ACDF. Secondary outcomes improved for both groups with no significant inter-group differences. Occurrence of ASD was higher in group-B with no significant between-group differences. Range of motion (ROM) was sustained with ProDisc-C but lost with ACDF at 24-months. CONCLUSION: Cervical TDR with ProDisc-C is feasible, safe, and effective for treatment of SCDD in Asians. No clear non-inferiority was demonstrated between ProDisc-C and ACDF. However, patients treated with ProDisc-C demonstrated significant improvement in NDI, neurologic success, pain scores, and 36-item-short-form survey, along with ROM preservation at 24-months. Enrolment difficulties resulted in inability to achieve pre-planned sample size to prove non-inferiority. Future Asian-focused, large-scale studies are needed to establish unbiased efficacy of ProDisc-C to ACDF.

Anticancer Effects of Midazolam on Lung and Breast Cancers by Inhibiting Cell Proliferation and Epithelial-Mesenchymal Transition.

Despite improvements in cancer treatments resulting in higher survival rates, the proliferation and metastasis of tumors still raise new questions in cancer therapy. Therefore, new drugs and strategies are still needed. Midazolam (MDZ) is a common sedative drug acting through the γ-aminobutyric acid receptor in the central nervous system and also binds to the peripheral benzodiazepine receptor (PBR) in peripheral tissues. Previous studies have shown that MDZ inhibits cancer cell proliferation but increases cancer cell apoptosis through different mechanisms. In this study, we investigated the possible anticancer mechanisms of MDZ on different cancer cell types. MDZ inhibited transforming growth factor ß (TGF-ß)-induced cancer cell proliferation of both A549 and MCF-7 cells. MDZ also inhibited TGF-ß-induced cell migration, invasion, epithelial-mesenchymal-transition, and Smad phosphorylation in both cancer cell lines. Inhibition of PBR by PK11195 rescued the MDZ-inhibited cell proliferation, suggesting that MDZ worked through PBR to inhibit TGF-ß pathway. Furthermore, MDZ inhibited proliferation, migration, invasion and levels of mesenchymal proteins in MDA-MD-231 triple-negative breast cancer cells. Together, MDZ inhibits cancer cell proliferation both in epithelial and mesenchymal types and EMT, indicating an important role for MDZ as a candidate to treat lung and breast cancers.

Post-surgery cholecystectomy, hepatectomy, and pancreatectomy patients increase the risk of osteoporotic vertebral fracture.

INTRODUCTION: Data is currently lacking regarding association between the cholecystectomy/hepatectomy/pancreatectomy and the development of osteoporotic fracture. A retrospective cohort study was conducted to investigate the relationship between cholecystectomy/hepatectomy/pancreatectomy and the subsequent risk of developing osteoporotic fracture. MATERIALS AND METHODS: Patients having undergone cholecystectomy, hepatectomy, or pancreatectomy between 2000 and 2012 were selected from the All Population Based Hospitalization File as the surgery cohort (n = 304,081), which was frequency matched with the control cohort (n = 304,081). The Cox proportional hazard model and Kaplan-Meier analysis were applied to measure the hazard ratios and the cumulative incidence of osteoporotic fracture. RESULTS: A total of 1136 patients in the surgery cohort and 1179 patients in the control cohort were newly diagnosed with osteoporotic fracture. The overall osteoporotic fracture risk in the surgery cohort was 1.12-fold higher [95% confidence interval (CI), 1.03-1.21]. Specifically, surgery cohort had higher vertebral fracture risk than non-surgery cohort [adjusted hazard ratio (aHR) 1.12, Cl, 1.03-1.22]. In addition, patients underwent cholecystectomy (includes open and laparoscopic approaches), hepatectomy (only open approach), and pancreatectomy group (only open approach) were 1.10 (95% CI, 1.01-1.19), 1.49 (95% CI, 1.10-2.01), and 1.88 (95% CI, 1.23-2.87) times more likely to develop osteoporotic fracture, respectively. No significant difference of osteoporotic fracture risk was observed between open and laparoscopic cholecystectomy. The risk of osteoporotic fracture was significantly increased in females, patients aged ≥ 40 years old, and patients with some comorbidity. CONCLUSIONS: Patients post cholecystectomy, hepatectomy, or pancreatectomy significantly increased risk of developing osteoporotic fracture, suggesting closer attention in post-operative care is needed.

Short-segment decompression and fixation for thoracolumbar osteoporotic fractures with neurological deficits.

Objective We assessed our results of short-segment decompression and fixation for osteoporotic thoracolumbar fractures with neurological deficits. Methods We evaluated 20 elderly patients (age, 60-89 years; mean, 73.2 years) with osteoporotic thoracolumbar fractures and neurological deficits. They underwent short-segment decompression and fixation and followed up for 40.6 (range, 24-68) months. A visual analog scale (VAS) and the Oswestry Disability Index (ODI) were used to measure back pain and disability. We also analyzed patients' radiologic findings and neurological status. Perioperative and postoperative complications were recorded. Results At the latest follow-up, the average VAS score for back pain and ODI scores had significantly improved. The radiologic assessment showed significant improvements in local kyphosis, anterior vertebral height, and the vertebral wedge angle compared with the original measures. Neurological function also improved in 18 of 20 patients. No major complications occurred perioperatively. Our techniques included preservation of the posterior ligament complex, decortication of facet joints for fusion, no tapping to increase the screw insertional torque, pre-contouring of the rods according to the "adaptive" curve obtained from postural reduction, and postoperative spinal bracing. Conclusions Posterior short-segment decompression and fixation could be an effective surgical option for osteoporotic thoracolumbar burst fractures with neurological deficits.

Epidemiological survey of the feasibility of broadband ultrasound attenuation measured using calcaneal quantitative ultrasound to predict the incidence of falls in the middle aged and elderly.

OBJECTIVES: We investigated whether calcaneal quantitative ultrasound (QUS-C) is a feasible tool for predicting the incidence of falls. DESIGN: Prospective epidemiological cohort study. SETTING: Community-dwelling people sampled in central western Taiwan. PARTICIPANTS: A cohort of community-dwelling people who were ≥40 years old (men: 524; women: 676) in 2009-2010. Follow-up questionnaires were completed by 186 men and 257 women in 2012. METHODS: Structured questionnaires and broadband ultrasound attenuation (BUA) data were obtained in 2009-2010 using QUS-C, and follow-up surveys were done in a telephone interview in 2012. Using a binary logistic regression model, the risk factors associated with a new fall during follow-up were analysed with all significant variables from the bivariate comparisons and theoretically important variables. PRIMARY OUTCOME MEASURES: The incidence of falls was determined when the first new fall occurred during the follow-up period. The mean follow-up time was 2.83 years. RESULTS: The total incidence of falls was 28.0 per 1000 person-years for the ≥40 year old group (all participants), 23.3 per 1000 person-years for the 40-70 year old group, and 45.6 per 1000 person-years for the ≥70 year old group. Using multiple logistic regression models, the independent factors were current smoking, living alone, psychiatric drug usage and lower BUA (OR 0.93; 95% CI 0.88 to 0.99, p<0.05) in the ≥70 year old group. CONCLUSIONS: The incidence of falls was highest in the ≥70 year old group. Using QUS-C-derived BUA is feasible for predicting the incidence of falls in community-dwelling elderly people aged ≥70 years.

Resection of giant invasive sacral schwannoma using image-based customized osteotomy tools.

BACKGROUND: Giant invasive sacral schwannomas are rare tumors. Surgical excision is the standard treatment and total resection is performed if feasible. Advances in three-dimensional (3D) imaging technology have facilitated treatment designs of complex surgical procedures. OBJECTIVE: Our aim was to evaluate virtual surgical planning, computer-aided design (CAD), and manufacturing with 3D printing technology of the customized osteotomy guiding device in giant invasive sacral schwannoma resection. METHODS: A digital 3D model of the sacrum, including the giant invasive sacral schwannoma, was rendered from patient computer tomography (CT) images. The surgeon chose excision margins of the tumor. Based on the virtual surgical planning, the customized guiding tool for osteotomy was designed and manufactured using the CAD and 3D printing. RESULTS: We used the guiding block to successfully excise a giant sacral schwannoma using only a posterior approach to achieve gross total resection. No augmented spinal instrumentation was used to prevent iatrogenic spinal instability. Clinical symptoms resolved dramatically after operation. No spinal instability occurred during follow-up. CONCLUSION: With the assistance of an image-based customized osteotomy guiding device, we achieved both goals of tumor resection and bone preservation in giant sacral schwannoma resection. With thorough surgical planning, this technology can be applied to the complex surgical procedures easily and reliably.

Palliative transpedicular partial corpectomy without anterior vertebral reconstruction in lower thoracic and thoracolumbar junction spinal metastases.

BACKGROUND: The thoracolumbar junction is the transition from a stiff (thoracic spine) to a mobile zone (lumbar spine) and is relatively unstable compared with the thoracic and lumbar portions of the spine. The need for anterior reconstruction after a corpectomy has been emphasized by several authors. However, for patients with a relatively short life expectancy, anterior reconstruction may be unnecessary. Posterior instrumentation alone may be sufficient to provide pain relief and stability for such patients. The goal of this study was to assess the postoperative outcomes and survival rates of patients with tumor metastases of the lower thoracic spine and thoracolumbar junction (T10-L1) who underwent transpedicular partial corpectomy without anterior vertebral reconstruction. METHODS: From November 2001 to February 2015, 29 patients diagnosed with symptomatic spinal cord compression caused by tumor metastasis involving T10 to L1 underwent palliative surgery that involved a posterolateral transpedicular partial corpectomy without anterior reconstruction. The surgical indication was neurologic progression. A follow-up was conducted for all of the patients, including reviewing medical records and performing an examination in the outpatient department. RESULTS: The patients ranged in age from 33 to 83 years (mean, 61.6 years). Neurologic improvement by at least one Frankel grade was noted in 75.9 % of the patients (N = 22). Neither intraoperative mortality nor implant failure was reported. The median survival rate was 7.43 months (range, 0.47-28 months). CONCLUSION: The results of this study suggest that the stability of implants can be maintained up to 28 months with satisfying functional outcome after a palliative posterolateral transpedicular partial corpectomy without anterior reconstruction.

Advances in noninvasive functional imaging of bone.

The demand for functional imaging in clinical medicine is comprehensive. Although the gold standard for the functional imaging of human bones in clinical settings is still radionuclide-based imaging modalities, nonionizing noninvasive imaging technology in small animals has greatly advanced in recent decades, especially the diffuse optical imaging to which Britton Chance made tremendous contributions. The evolution of imaging probes, instruments, and computation has facilitated exploration in the complicated biomedical research field by allowing longitudinal observation of molecular events in live cells and animals. These research-imaging tools are being used for clinical applications in various specialties, such as oncology, neuroscience, and dermatology. The Bone, a deeply located mineralized tissue, presents a challenge for noninvasive functional imaging in humans. Using nanoparticles (NP) with multiple favorable properties as bioimaging probes has provided orthopedics an opportunity to benefit from these noninvasive bone-imaging techniques. This review highlights the historical evolution of radionuclide-based imaging, computed tomography, positron emission tomography, and magnetic resonance imaging, diffuse optics-enabled in vivo technologies, vibrational spectroscopic imaging, and a greater potential for using NPs for biomedical imaging.

Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people.

UNLABELLED: The risk assessment of falls is important, but still unsatisfactory and time-consuming. Our objective was to assess quantitative ultrasound (QUS) in the risk assessment of falls. Our study was designed as epidemiological cross-sectional study occurring from March 2009 to February 2010 by community survey at a medical center. The participants were collected from systemic sample of 1,200 community-dwelling people (Male/Female = 524/676) 40 years old and over in Yunlin County, Mid-Taiwan. Structural questionnaires including socioeconomic status, living status, smoking and drinking habits, exercise and medical history were completed. Quantitative ultrasound (QUS) at the non-dominant distal radial area (QUS-R) and the left calcaneal area (QUS-C) were measured. The overall prevalence of falls was 19.8%. In men, the independently associated factors for falls were age (OR: 1.04; 95%CI: 1.01~1.06), fracture history (OR: 1.89; 95%CI: 1.12~3.19), osteoarthritis history (OR: 3.66; 95%CI: 1.15~11.64) and speed of sound (OR: 0.99; 95%CI: 0.99~1.00; p<0.05) by QUS-R. In women, the independently associated factors for falls were current drinking (OR: 3.54; 95%CI: 1.35∼9.31) and broadband ultrasound attenuation (OR: 0.98; 95%CI: 0.97~0.99; p<0.01) by QUS-C. The cutoffs at -2.5< T-score<-1 derived using QUS-R (OR: 2.85; 95%CI: 1.64~4.96; p<0.01) in men or T-score ≦-2.5 derived using QUS-C (OR: 2.72; 95%CI: 1.42~5.21; p<0.01) in women showed an independent association with falls. The lowest T-score derived using either QUS-R or QUS-C was also revealed as an independent factor for falls in both men (OR: 2.13; 95%CI: 1.03~4.43; p<0.05) and women (OR: 2.36; 95%CI: 1.13~4.91; p<0.05). CONCLUSIONS: Quantitative ultrasounds, measured either at the radial or calcaneal area, are convenient tools by which to assess the risk of falls in middle-aged and elderly people.

Bone marrow edema in vertebral compression fractures: detection with dual-energy CT.

PURPOSE: To assess the use of the dual-energy computed tomographic (CT) virtual noncalcium technique in the evaluation of bone marrow edema in vertebral compression fractures. MATERIALS AND METHODS: This prospective study was approved by the institutional review board; informed consent was obtained from all patients. Sixty-three consecutive patients with 112 thoracic and/or lumbar vertebral compression fractures were studied between January 2011 and April 2012. All patients underwent both dual-energy CT (100 kV and Sn140 kV, where Sn indicates the use of a 0.4-mm tin filter) and magnetic resonance (MR) imaging. Dual-energy CT data were postprocessed by using a three-material decomposition algorithm for generating noncalcium images of the collapsed bodies. Two radiologists evaluated for the presence of abnormal attenuation alterations in the bone marrow by using color-coded maps and measured CT numbers on noncalcium grayscale images. Bone sclerosis and intravertebral air were evaluated with CT scans. MR images served as the reference standard. CT numbers were subjected to receiver operating characteristic curve analysis. RESULTS: MR imaging depicted 46 edematous and 66 nonedematous vertebral compression fractures. Eighty-two bodies were classified as having less than 50% sclerosis and/or air. Significant differences in noncalcium CT numbers between edematous and nonedematous vertebral compression fractures were found for both readers (P < .0001). CT numbers for the diagnosis of bone marrow edema on the basis of MR imaging revealed areas under the receiver operating characteristic curve of 0.799 and 0.841 for readers 1 and 2, respectively (P = .56). Use of a cutoff value of -80 to differentiate edematous vertebral bodies resulted in a sensitivity of 96.3%, specificity of 98.2%, and accuracy of 97.6% in the group of vertebral bodies with less than 50% sclerosis and/or air. CONCLUSION: Dual-energy CT virtual noncalcium images were able to depict bone marrow in the collapsed vertebral bodies, especially in those with less than 50% sclerosis and/or air.

Developing functional workspace for the movement of trunk circumduction in healthy young subjects: a reliability study.

BACKGROUND: The lumbar range of motion has traditionally been used to assess disability in patients with low back disorders. Controversy exists about how movement ranges in static positions or in a single straight plane is related to the functional status of the patients. The trunk circumduction, as the result of neuromuscular coordination, is the integrated movements from three dimensions. The functional workspace stands for the volume of movement configuration from the trunk circumduction and represents all possible positions in three dimensions. By using single quantitative value, the functional workspace substitutes the complicated joint linear or angular motions. The aim of this study is to develop the functional workspace of the trunk circumduction (FWTC) considering possible functional positions in three dimensional planes. The reliability of the trunk circumduction is examined. METHODS: Test-retest reliability was performed with 18 healthy young subjects. A three-dimensional (3-D) Motion Analysis System was used to record the trunk circumduction. The FWTC was defined and calculated based on the volume of the cone that was formed as the resultant scanned area of markers, multiplied by the length of the body segment. The statistical analysis of correlation was performed to describe the relation of maximal displacements of trunk circumduction and straight planes: sagittal and coronal. RESULTS: The results of this study indicate that the movement of trunk circumduction measured by motion analysis instruments is a reliable tool. The ICC value is 0.90-0.96, and the means and standard deviations of the normalized workspace are: C7 0.425 (0.1162); L1 0.843 (0.2965); and knee 0.014 (0.0106). Little correlations between the maximal displacement of trunk circumduction and that of straight planes are shown and therefore suggest different movement patterns exist. CONCLUSIONS: This study demonstrates high statistical reliability for the FWTC, which is important for the potential development as the functional assessment technique. The FWTC provides a single integrated value to represent angular and linear measurements of different joints and planes. Future study is expected to carry out the FWTC to evaluate the amount of workspace for the functional status of patients with low back injuries or patients with spinal surgery.

IL-20 may contribute to the pathogenesis of human intervertebral disc herniation.

STUDY DESIGN: The gene expression of interleukin (IL)-20 on human herniated intervertebral disc. OBJECTIVE.: To elucidate the role of novel cytokine IL-20 in the pathogenesis of human intervertebral disc (IVD) herniation. SUMMARY OF BACKGROUND DATA: IL-20 is involved in inflammatory diseases such as psoriasis, atherosclerosis, and rheumatoid arthritis, etc. However, IL-20 is never reported to be associated with the pathogenesis of human disc herniation. METHODS: Twenty consecutive patients who were diagnosed with IVD herniation and received open discectomy were included in this study. The retrieved disc material specimens and the isolated primarily cultured disc cells were immunohistochemically stained to detect the expression of IL-20 and its receptor subunits (IL-20R1, IL-20R2, and IL-22R1). Besides, to investigate the in vitro response of IL-20 on human herniated intervertebral disc, we analyzed the effects of IL-20 alone, in combination with IL-1beta, and IL-1beta alone on the gene expression and protein levels of various cytokines, chemokines, matrix metalloproteinases (MMPs), etc. RESULTS: IL-20 and its receptors were detectable in human herniated disc tissues and isolated disc cells. In vitro, IL-1beta induced the expression of IL-20. Furthermore, IL-20 induced transcripts of IL-1beta, IL-6, vascular endothelial growth factor (VEGF), MMP-3, and monocyte chemoattractant protein (MCP-1) on primarily cultured human disc cells. IL-1beta induced transcripts of IL-1beta, IL-6, IL-8, VEGF, MMP3, and MCP-1. IL-20 combined with IL-1beta induced transcripts of tumor necrosis factor-alpha (TNF-alpha), IL-1beta, IL-6, IL-8, MMP-3, and MCP-1 to a level higher than those found in cells treated with IL-20 or IL-1beta alone.Enzyme-linked immunosorbent assay, analysis also showed that IL-20 combined with IL-1beta up-regulated the secretion of TNF-alpha, IL-6, IL-8, and MCP-1. CONCLUSION: IL-20 induces proinflammatory, chemotaxtic, and matrix degradative responses in IVD cells especially in combination with IL-1beta. Our study suggests that IL-20 plays an important role in the pathogenesis of disc herniation.

Mini-open anterior spine surgery for anterior lumbar diseases.

Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified "mini-open anterior spine surgery" (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24-52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12-L1, 18 at L1-L2, 18 at L2-L3, 22 at L3-L4 and 11 at L4-L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62-124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4-26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.

Langerhans cell histiocytosis as a possible differential diagnosis of painful scoliosis.

We report on a 5-year 8-month-old boy suffering from spinal Langerhans cell histiocytosis (LCH), who had initial symptoms of back and abdominal pain, as well as tilting of the shoulder that mimicked hemivertebra of T10 with scoliosis, as revealed by radiography. The LCH-involved vertebra did not demonstrate the classic radiographic picture of vertebra plana until the vertebral body symmetrically collapsed about 6 months later, when the patient's scoliosis disappeared. The delayed diagnosis of LCH was confirmed by biopsy after another 6 months. Polyostotic lesions affecting C6, T5, T9-12, and L2 were found. This case represented an unusual presentation of LCH as an early disease entity, which resulted in a misdiagnosis of painful scoliosis. We believe we are the first to report LCH as a differential diagnosis of painful scoliosis.

The in vivo biological effects of intradiscal recombinant human bone morphogenetic protein-2 on the injured intervertebral disc: an animal experiment.

STUDY DESIGN: Prospective analysis. OBJECTIVE: To investigate biologic influences of recombinant human bone morphogenetic protein (rhBMP)-2 on intervertebral discs after anular tears. SUMMARY OF BACKGROUND DATA: Treatments for intervertebral disc injury or degeneration are unsatisfactory. rhBMP-2, a high-potency osteoinductive and chondroinductive substance, is approved for use in anterior lumbar interbody fusions. rhBMP-2 stimulates the proliferation of rat disc cells and the secretion of extracellular matrix in vitro. In vivo responses in the intervertebral disc after anular tears are rarely studied. METHODS: Twenty New Zealand white rabbits received full-thickness anular tears and intradiscal injections of saline (control) and rhBMP-2 0.1 mg with and without coral grafts at L2-L3, L3-L4, and L4-L5, respectively. Three died or had infection. Therefore, 17 underwent radiography and sacrifice at 12 weeks. Spinal sections were stained with hematoxylin and eosin to examine responses to rhBMP-2. RESULTS: Radiographs revealed degenerative changes, such as disc space narrowing and irregularity, subchondral sclerosis, osteophyte formation, and hypertrophy of vertebral endplates in all groups. Degeneration was more frequent and severe with rhBMP-2 with (P < 0.01) and without (P < 0.05) coral than with saline. Two rabbits receiving rhBMP-2 and coral achieved solid interbody bony fusion. New bone formation was noted in 2 controls, in 3 animals treated with rhBMP-2, and in 4 treated with rhBMP-2 and coral. Vascularity and fibroblast proliferation increased with rhBMP-2 (n = 14) and rhBMP-2 with coral (n = 9) compared with control (n = 3; P < 0.01 and P = 0.03, respectively). Inflammatory infiltrates increased with rhBMP-2 (n = 8) compared with control (n = 2; P = 0.03). CONCLUSIONS: Degenerative changes were more frequent and severe in the groups treated with rhBMP-2 with or without coral in radiographic findings. In histopathologic findings, rhBMP-2 promoted hypervascularity and fibroblast proliferation of the intervertebral disc after an anular tear.

Histopathologic findings of retrieved specimens of vertebroplasty with polymethylmethacrylate cement: case control study.

STUDY DESIGN: Case control study. OBJECTIVE: To investigate the histopathologic findings of 2 retrieved specimens from failed vertebroplasty with polymethylmethacrylate (PMMA) cement. SUMMARY OF BACKGROUND DATA: Vertebroplasty using PMMA cement has been commonly used to treat debilitating back pain from compression fracture, angiomas, and metastatic cancer. However, there was concern about the unpredictable future results with PMMA cement. The histopathologic changes were rarely reported. METHODS: There were 2 PMMA augmented and 3 nonaugmented fractured vertebral bodies retrieved for histopathologic study. Between the 2 groups, we compared the findings of bone necrosis, foreign body reaction, fibrotic wall formation, and neovascularization. RESULTS: Bone necrosis was noted in the periphery of PMMA cement, which was surrounded by fibrotic tissues. In contrast, no fibrotic wall formation could be found in the nonaugmented control group. Foreign body reaction was only noted in PMMA augmented cases, and neovascularization was only noted in the control cases. CONCLUSION: PMMA cement might not be as bioinert as we considered. Therefore, the long-term safety of vertebroplasty should be further evaluated.

The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study.

BACKGROUND: Osteonecrosis of the femoral head is the most common diagnosis leading to total hip arthroplasty in young adults. Joint-preserving treatment options have been mainly surgical, with inconsistent results. Alendronate (a bisphosphonate agent) has been shown to lower the prevalence of vertebral compression fractures and could potentially retard the collapse of an osteonecrotic femoral head. The purpose of this study was to test the effect of alendronate in preventing early collapse of the femoral head in patients with nontraumatic osteonecrosis. METHODS: Forty patients with Steinberg stage-II or III nontraumatic osteonecrosis of the femoral head and a necrotic area of >30% (class C) were randomly divided into alendronate and control groups of twenty patients each. Patients in the alendronate group took 70 mg of alendronate orally per week for twenty-five weeks, while the patients in the control group did not receive this medication or a placebo. The patients were observed for a minimum of twenty-four months. Harris hip scores, plain radiographs, and magnetic resonance imaging scans were obtained. RESULTS: During the study period, only two of twenty-nine femoral heads in the alendronate group collapsed, whereas nineteen of twenty-five femoral heads in the control group collapsed (p < 0.001). One hip in the alendronate group underwent total hip arthroplasty, whereas sixteen hips in the control group underwent total hip arthroplasty (p < 0.001). CONCLUSIONS: Alendronate appeared to prevent early collapse of the femoral head in the hips with Steinberg stage-II or IIIC nontraumatic osteonecrosis. A longer duration of follow-up is needed to confirm whether alendronate prevents or only retards collapse. LEVEL OF EVIDENCE: Therapeutic Level I.