Chemogenetic stimulation of proprioceptors remodels lumbar interneuron excitability and promotes motor recovery after SCI.

Motor recovery after severe spinal cord injury (SCI) is limited due to the disruption of direct descending commands. Despite the absence of brain-derived descending inputs, sensory afferents below injury sites remain intact. Among them, proprioception acts as an important sensory source to modulate local spinal circuits and determine motor outputs. Yet, it remains unclear whether enhancing proprioceptive inputs promotes motor recovery after severe SCI. Here, we first established a viral system to selectively target lumbar proprioceptive neurons and then introduced the excitatory Gq-coupled Designer Receptors Exclusively Activated by Designer Drugs (DREADD) virus into proprioceptors to achieve specific activation of lumbar proprioceptive neurons upon CNO administration. We demonstrated that chronic activation of lumbar proprioceptive neurons promoted the recovery of hindlimb stepping ability in a bilateral hemisection SCI mouse model. We further revealed that chemogenetic proprioceptive stimulation led to coordinated activation of proprioception-receptive spinal interneurons and facilitated transmission of supraspinal commands to lumbar motor neurons, without affecting the regrowth of proprioceptive afferents or brain-derived descending axons. Moreover, application of 4-aminopyridine-3-methanol (4-AP-MeOH) that enhances nerve conductance further improved the transmission of supraspinal inputs and motor recovery in proprioception-stimulated mice. Our study demonstrates that proprioception-based combinatorial modality may be a promising strategy to restore the motor function after severe SCI.

Hypoxia inducible factor-1 (HIF-1α) reduced inflammation in spinal cord injury via miR-380-3p/ NLRP3 by Circ 0001723.

BACKGROUND: Spinal cord injury (SCI) is a severe central nervous system trauma. The present study aimed to evaluate the effect of HIF-1α on inflammation in spinal cord injury (SCI) to uncover the molecular mechanisms of anti-inflammation. RESULTS: HIF-1α was reduced in SCI model rats and HIF-1α activation reduced TNF-α, IL-1ß, IL-6 and IL-18 levels in SCI model rats. Meanwhile, Circ 0001723 expression was down-regulated and miR-380-3p expression was up-regulated in SCI model rats. In vitro model, down-regulation of Circ 0001723 promoted TNF-α, IL-1ß, IL-6 and IL-18 levels, compared with control negative group. However, over-expression of Circ 0001723 reduced TNF-α, IL-1ß, IL-6 and IL-18 levels in vitro model. Down-regulation of Circ 0001723 suppressed HIF-1α protein expressions and induced NLRP3 and Caspase-1 protein expressions in vitro model by up-regulation of miR-380-3p. Next, inactivation of HIF-1α reduced the pro-inflammation effects of Circ 0001723 in vitro model. Then, si-NLRP3 also inhibited the pro-inflammation effects of Circ 0001723 in vitro model via promotion of autophagy. CONCLUSIONS: We concluded that HIF-1α reduced inflammation in spinal cord injury via miR-380-3p/ NLRP3 by Circ 0001723.

Bone metastases from hepatocellular carcinoma: clinical features and prognostic factors.

BACKGROUND: Bone metastases (BMs) from hepatocellular carcinoma (HCC) is an increasingly common disease in Asia. We assessed the clinical features, prognostic factors, and differences in outcomes related to BMs among patients with different treatments for HCC. METHODS: Forty-three consecutive patients who were diagnosed with BMs from HCC between January 2010 and December 2014 were retrospectively enrolled. The clinical features were identified, the impacts of prognostic factors on survival were statistically analyzed, and clinical data were compared. RESULTS: The median patient age was 54 years; 38 patients were male and 5 female. The most common site for BMs was the trunk (69.3%). BMs with extension to the soft tissue were found in 14 patients (32.5%). Most (90.7%) of the lesions were mixed osteolytic and osteoblastic, and most (69.8%) patients presented with multiple BMs. The median survival after BMs diagnosis was 11 months. In multivariate analyses, survival after BM diagnosis was correlated with Karnofsky performance status (P=0.008) and the Child-Pugh classification (P<0.001); BM-free survival was correlated with progression beyond the University of California San Francisco criteria (P<0.001) and treatment of primary tumors (P<0.001). BMs with extension to soft tissue were less common in liver transplantation patients. During metastasis, the control of intrahepatic tumors was improved in liver transplantation and hepatectomy patients, compared to conservatively treated patients. CONCLUSIONS: The independent prognostic factors of survival after diagnosis of BMs were the Karnofsky performance status and Child-Pugh classification. HCC patients developed BMs may also benefit from liver transplantation or hepatectomy.

Treatment of Crowe Type-IV Hip Dysplasia Using Cementless Total Hip Arthroplasty and Double Chevron Subtrochanteric Shortening Osteotomy: A 5- to 10-Year Follow-Up Study.

BACKGROUND: The purpose of this study was to evaluate the functional and radiographic results of patients with Crowe type-IV hip dysplasia treated by cementless total hip arthroplasty and double chevron subtrochanteric osteotomy. METHODS: From January 2000 to February 2006, cementless total hip arthroplasty with a double chevron subtrochanteric shortening osteotomy was performed on 18 patients (22 hips) with Crowe type-IV dysplasia. The acetabular cup was placed in the position of the anatomic hip center, and subtrochanteric femoral shortening osteotomy was performed with the use of a double chevron design. The clinical and radiographic outcomes were reviewed with a mean follow-up of 6.5 years (5-10 years). RESULTS: The mean amount of femoral subtrochanteric shortening was 38 mm (25-60 mm). All osteotomy sites were healed by 3-6 months without complications. The mean Harris Hip Score improved significantly from 47 points (35-65 points) preoperatively to 88 points (75-97 points) at the final follow-up. The Trendelenburg sign was corrected from a positive preoperative status to a negative postoperative status in 12 of 22 hips. No acetabular and femoral components have loosened or required revision during the period of follow-up. CONCLUSION: Cementless total hip arthroplasty using double chevron subtrochanteric osteotomy allowed for restoration of anatomic hip center with safely functional limb lengthening, achieved correction of preoperative limp, and good functional and radiographic outcomes for 22 Crowe type-IV dislocation hips at the time of the 5- to 10-year follow-up.

Refracture of osteoporotic vertebral body concurrent with cement fragmentation at the previously treated vertebral level after balloon kyphoplasty: a case report.

Kyphoplasty has been shown to provide symptomatic relief of vertebral compression fractures refractory to medical therapy. However, few reports have focused on refracture of cemented vertebrae after kyphoplasty. The presence of cemented vertebrae refracture concurrent with cement fragmentation is an extremely rare condition. We reported an 86-year-old man with a T12 osteoporotic compression fracture undergoing the kyphoplasty treatment. The patient postoperatively continued to have back pain at the same level. The solid lumped polymethylmethacrylate (PMMA) mass and inadequate use and insufficient filling of PMMA cement were observed in postoperative radiographs and magnetic resonance image (MRI) examination. He refused to receive the surgical intervention, but had not strict compliance with oral anti-osteoporotic medications. Ten months postoperatively, refracture of osteoporotic vertebral body concurrent with cement fragmentation occurred at the previously kyphoplasty-treated vertebral level. Bone mineral analysis showed severe osteoporosis with a T-score of -4.0. The patient finally obtained therapeutic benefit of pain relief and bony union of T12 vertebral body by consistently adhering to anti-osteoporotic medication treatment. This case illustrated that patients who underwent kyphoplasty to treat osteoporotic vertebral compression fractures with intravertebral fracture should be strictly followed up and supervised in their anti-osteoporotic medication treatment. The interdigitation injection pattern of PMMA and sufficient PMMA filling with trabeculae in the kyphoplasty procedure also might prevent refracture of the cemented vertebrae concurrent with PMMA fragmentation.

Kyphoplasty versus vertebroplasty in the treatment of painful osteoporotic vertebral compression fractures: two-year follow-up in a prospective controlled study.

A total of 112 patients with a single-level osteoporotic vertebral compression fracture who did not respond to conservative therapy were included and allocated to either kyphoplasty or vertebroplasty treatment. The Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were used to assess back pain and disability. Anterior, midline, posterior vertebral body heights, and kyphotic angle at the fractured vertebra were measured for radiographic evaluation. Clinical and radiographic follow-up examinations were performed postoperatively at 3, 6, 12 and 24 months. Complications and patient satisfaction with the surgical procedure were also recorded. The follow-up rate was 73.3% in the kyphoplasty group and 80.8% in the vertebroplasty group (P = 0.737). There were no significant differences between the 2 groups with regard to improvement in VAS and ODI scores (P > 0.05) at all postoperative intervals. Both treatment groups achieved marked vertebral height restoration and kyphotic angle reduction, but the radiographic parameters were significantly better in the kyphoplasty group (P < 0.05). The incidence of asymptomatic cement leakage per treated vertebrae in the kyphoplasty group was 11.4% versus 31% in the vertebroplasty group (P < 0.001). Three adjacent level fractures in the kyphoplasty group and 2 in the vertebroplasty group occurred during 2-year follow-up, and no difference in patient satisfaction was detected between the 2 groups. Kyphoplasty and vertebroplasty achieved similar improvement of clinical outcomes and patient satisfaction at 2 years after surgery, albeit kyphoplasty had more ability to markedly reduce vertebral deformity and resulted in less cement leaks compared with vertebroplasty.

[Analyses of segment motor function in patients with degenerative lumbar disease on the treatment of WavefleX dynamic stabilization system].

OBJECTIVE: To explore the changes of range-of-motion (ROM) in patients with degenerative lumbar disease on the treatment of WavefleX dynamic stabilization system and examine the postoperative lumbar regularity and tendency of ROM. METHODS: Nine patients with degenerative lumbar disease on the treatment of WavefleX dynamic stabilization system were followed up with respect to ROMs at 5 timepoints within 12 months. Records of ROM were made for instrumented segments, adjacent segments and total lumbar. RESULTS: Compared with preoperation, ROMs in non-fusional segments with WavefleX dynamic stabilization system decreased statistical significantly (P < 0.05 or P < 0.01) at different timepoints; ROMs in adjacent segments increased at some levels without wide statistical significance. The exception was single L3/4 at Month 12 (P < 0.05) versus control group simultaneously at the levels of L3/4, L4/5 and L5/S1, ROMs decreased at Months 6 and 12 with wide statistical significance (P < 0.05 or P < 0.01). ROMs in total lumbar had statistical significant decrease (P < 0.01) in both group of non-fusional segments and hybrid group of non-fusion and fusion. The trends of continuous augments were observed during follow-ups. Statistically significant augments were also acquired at 4 timepoints as compared to control group (P < 0.01). CONCLUSION: The treatment of degenerative lumbar diseases with WavefleX dynamic stabilization system may limit excessive extension/inflexion and preserve some motor functions. Moreover, it can sustain physiological lordosis, decrease and transfer disc load in adjacent segments to prevent early degeneration of adjacent segment. Trends of motor function augment in total lumbar need to be confirmed during future long-term follow-ups.

Biochanin A attenuates spinal cord injury in rats during early stages by inhibiting oxidative stress and inflammasome activation.

JOURNAL/nrgr/04.03/01300535-202409000-00038/figure1/v/2024-01-16T170235Z/r/image-tiff Previous studies have shown that Biochanin A, a flavonoid compound with estrogenic effects, can serve as a neuroprotective agent in the context of cerebral ischemia/reperfusion injury; however, its effect on spinal cord injury is still unclear. In this study, a rat model of spinal cord injury was established using the heavy object impact method, and the rats were then treated with Biochanin A (40 mg/kg) via intraperitoneal injection for 14 consecutive days. The results showed that Biochanin A effectively alleviated spinal cord neuronal injury and spinal cord tissue injury, reduced inflammation and oxidative stress in spinal cord neurons, and reduced apoptosis and pyroptosis. In addition, Biochanin A inhibited the expression of inflammasome-related proteins (ASC, NLRP3, and GSDMD) and the Toll-like receptor 4/nuclear factor-κB pathway, activated the Nrf2/heme oxygenase 1 signaling pathway, and increased the expression of the autophagy markers LC3 II, Beclin-1, and P62. Moreover, the therapeutic effects of Biochanin A on early post-spinal cord injury were similar to those of methylprednisolone. These findings suggest that Biochanin A protected neurons in the injured spinal cord through the Toll-like receptor 4/nuclear factor κB and Nrf2/heme oxygenase 1 signaling pathways. These findings suggest that Biochanin A can alleviate post-spinal cord injury at an early stage.

Oblique Lumbar Interbody Fusion at L5-S1 Segment Through an Approach Between the Psoas Muscle and the Great Vessels.

Over the years, the oblique lateral interbody fusion (OLIF) technique has gained significant recognition for treating various spinal conditions in lumbar segments L2-L5. However, the adoption of OLIF for the L5-S1 segment has not been widely embraced by the spinal surgery community, given that significant concerns remain regarding the applicability of OLIF for lumbosacral fusion. In this study, a cohort of 20 patients underwent interbody fusion at the L5-S1 level using the OLIF technique through a single retroperitoneal oblique approach positioned between the Psoas muscle and the great vessels. The procedure involved discectomy and endplate preparation accomplished through a surgical window created on the anterolateral side of the L5-S1 disc. For secure interbody fusion cage placement, a supplementary cage insertion approach was employed. All patients were followed up for a minimum of 12 months. The mean preoperative visual analog scale (VAS) score for lower back pain was 6.3 ± 1.5 and experienced a significant reduction to 1.2 ± 0.8 at 12 months. The VAS score for lower limb pain significantly decreased from 5.6 ± 1.4 preoperatively to 0.8 ± 0.3 at 12 months after the surgery. Furthermore, the preoperative Oswestry disability index (ODI) improved from 82.4% ± 16.2% to 8.1% ± 2.0% at 12 months. Radiographic evaluations after surgery confirmed improved lumbosacral junction reconstruction for all patients. At the final follow-up, successful bony fusion was observed in all cases. Based on these findings, the OLIF technique for L5-S1 fusion represents an attainable approach for lumbosacral reconstruction. The procedure's success hinges on a comprehensive preoperative plan and precise intraoperative techniques.

The potential therapeutic roles of dental pulp stem cells in spinal cord injury.

Spinal cord injury (SCI) can lead to serious functional disorders, which have serious impacts on patients and society. The current traditional treatments of SCI are not effective the injured spinal cord is difficult to repair and regenerate. In recent years, stem cell transplantation for the treatment of SCI has been a hot research topic. Dental pulp stem cells have strong abilities of self-renewal and multi-directional differentiation, and have been applied for tissue engineering and regenerative medicine. And dental pulp stem cells have certain advantages in neuro-regenetation, bringing new hope to biotherapy for SCI. This article reviews the characteristics of dental pulp stem cells and their research progress in the treatment of SCI.

Cementless total hip arthroplasty with a double chevron subtrochanteric shortening osteotomy in patients with Crowe type-IV hip dysplasia.

The authors describe a modified double chevron subtrochanteric shortening osteotomy combined with cementless total hip arthroplasty for Crowe type-IV hip dysplasia. Shortening the femur allows to relax the shortened musculature. This operation was performed in 18 patients (22 hips) between January 2000 and February 2006. The mean follow-up period was 5.6 years (range: 3 to 8 years). The mean amount of femoral subtrochanteric shortening was 38 mm (range: 25 to 60 mm). The mean Harris hip score improved from 47 (range: 35 to 65) preoperatively to 88 points (range: 75 to 97) at final follow-up. The Trendelenburg sign was corrected from positive to negative in 12 of 22 hips. No acetabular or femoral components loosened or required revision during the follow-up period. All osteotomy sites healed in 3 to 6 months without complications. Cementless total hip arthroplasty using the modified double chevron subtrochanteric osteotomy provided good short- to midterm results in all 22 Crowe type-IV hip dislocations. Moreover, it restored the anatomic hip center and the limb length, which contributed to correction of the preoperative limp.

The effects of melatonin in the treatment of acute brachial plexus compression injury in rats.

Introduction: Brachial plexus injury (BPI) is one of the most destructive peripheral nerve injuries and there is still a lack of effective treatment. Methods: This study was conducted to evaluate the effects of melatonin in the treatment of acute brachial plexus compression injury in rats using histopathological, histomorphometric, immunohistochemical and electrophysiological methods. Forty-eight adult male Sprague Dawley rats were randomly allocated into three groups: sham, melatonin and vehicle groups. The brachial plexus compression injury model was performed by a vascular clamp. Melatonin group received intraperitoneal injection of melatonin at doses of 10 mg/kg for 21 days after crush injury. The conduction velocity and amplitude of compound muscle action potential (CAMP) in the regenerated nerve, and nerve histomorphometry, as well as levels of myelin protein zero (P0) protein of the crush region were assessed. Results: Compared with the vehicle group, the melatonin group which reported significant increased CMAP conduction velocity and amplitude also showed thicker myelin sheath and lower levels of P0 protein. Discussion: Our results suggest that melatonin effectively promotes nerve regeneration and improves the function of damaged nerves. Melatonin treatment is a promising strategy for the treatment of acute brachial plexus compression injury.

Comparison of kyphoplasty and vertebroplasty for treatment of painful osteoporotic vertebral compression fractures: twelve-month follow-up in a prospective nonrandomized comparative study.

STUDY DESIGN: A prospective nonrandomized comparative study. OBJECTIVE: To compare the efficacy and safety of kyphoplasty and vertebroplasty for treatment of painful osteoporotic vertebral compression fractures (VCFs) with respect to pain, functional outcome, radiomorphology, cement leakage, and incidence of new adjacent vertebral fracture. SUMMARY OF BACKGROUND DATA: Kyphoplasty and vertebroplasty have become common treatments for painful osteoporotic VCFs. Although the benefits of either kyphoplasty or vertebroplasty compared with conservative treatment have been frequently discussed, few clinical studies are available that directly compare the 2 procedures. METHODS: Ninety-six patients with painful osteoporotic VCFs less than 4 weeks old were included and nonrandomly assigned to undergo kyphoplasty or vertebroplasty treatment. Clinical outcomes were assessed using the visual analog scale and the Oswestry Disability Index. Plain radiographs were analyzed to quantify spinal deformity correction (vertebral body height and kyphotic angle), and evaluate cement leakage and new adjacent vertebral fractures. The follow-up time was 12 months. RESULTS: The baseline clinical and radiological characteristics of both groups were comparable. There were no significant differences between the 2 groups with regard to improvement in pain and functional scores at all postoperative intervals. Vertebral height restoration and kyphotic angle reduction were achieved in both groups, but the correction of spinal deformity was more significant in the kyphoplasty group. Asymptomatic cement leakage occurred in 9.1% and 34.6% of treated vertebrae for the kyphoplasty and vertebroplasty groups, respectively. Three adjacent fractures in the kyphoplasty group and 2 in the vertebroplasty group were identified during the follow-up time, and no major adverse events were observed. CONCLUSIONS: Kyphoplasty and vertebroplasty demonstrated similar good clinical outcomes during the 12-month follow-up. Kyphoplasty offers a higher degree of spinal deformity correction and results in less cement leakage than vertebroplasty. The benefits of these relative merits need to be ascertained in future long-term studies.

A multi-center retrospective comparative study of third generation Ceramic-on- Ceramic total hip arthroplasty in patients younger than 45 years with or without the sandwich liner: A ten-year minimum.

BACKGROUND: Ceramic-on-ceramic couplings are attractive alternative bearing surfaces that have been reported to eliminate or reduce problems related to polyethylene wear debris. However, the material in THA still remains one of the major concerns about the risk of fracture, due to its brittleness. OBJECTIVE: The present study aims at reporting the fracture rate of a series of ceramic-on-ceramic THAs with use of the sandwich liner combined with a ceramic femoral head, and attempt to detect the relative risk factors, possible cause and assesse the medium-term clinical results. METHODS: We retrospectively evaluated 282 patients (300 hips) with use of the sandwich liner ceramic-on-ceramic THA between 2001 and 2009 at three-centers. Patient assessment was based on demographic factors, including age, weight, gender and body-mass index. All patients were evaluated clinically and radio-graphically or computed tomography in consideration of dislocation, osteolysis, periprosthetic fracture, infection, loosening and implant fracture. RESULTS: five ceramic sandwich liners fracture (1.7%) were observed at an average of 7.3 years follow-up. These factors were irrelevant to the ceramic liner fracture, including age (p = 0.205), weight (p = 0.241), gender (p = 0.553), body-mass index (p = 0.736), inclination (p = 0.727), and anteversion (p = 0.606). The overall survival was 91.4% at 12 years with revision as the endpoint. Other complications included dislocation in two, perprosthetic fracture in two and osteolysis in eight hips. No hip had aseptic loosening of the implants was seen. CONCLUSIONS: We found that the sandwich liner may be lead to a high rate of alumina fracture and osteolysis. We have discontinued the use of sandwich liner with THA since 2009.

Mesoporous polydopamine nanoparticles for sustained release of rapamycin and reactive oxygen species scavenging to synergistically accelerate neurogenesis after spinal cord injury.

Spinal cord injury (SCI) is an intractable condition with complex pathological processes and poor prognosis. Reactive oxygen species (ROS) generation induced by the mammalian target of the rapamycin (mTOR) protein is one of the causes of secondary inflammation of SCI. Rapamycin (Rapa) is a pharmacological inhibitor of mTOR, which can inhibit ROS overproduction mediated by abnormal activation of the mTOR protein. Polydopamine, as a nanocarrier with excellent biological safety, has been reported to possess satisfactory ROS scavenging ability. Therefore, we designed a mesoporous polydopamine nanoparticle loaded with Rapa (mPDA@Rapa) for combination therapy, which simultaneously inhibited abnormally activated mTOR-mediated ROS production and eliminated already generated ROS. The synthesized mPDA nanoparticles could realize the effective encapsulation and sustained release of Rapa due to their mesoporous cavities and a hydrophobic benzene ring structure. In vitro experiments proved that mPDA@Rapa nanoparticles had a good ROS scavenging ability towards hydrogen peroxide and hydroxyl radicals. Furthermore, mPDA@Rapa also showed a good therapeutic effect in SCI model rats, which was evidenced by a smaller injury cavity, more coordinated hind limb movements, and a higher degree of neurogenesis and tissue regeneration. Our work provides a combined strategy to inhibit ROS overproduction and eliminate excess ROS, with potential applications not only in SCI, but also in other ROS-induced inflammations.

A new injectable quick hardening anti-collapse bone cement allows for improving biodegradation and bone repair.

The development of injectable cement-like biomaterials via a minimally invasive approach has always attracted considerable clinical interest for modern bone regeneration and repair. Although α-tricalcium phosphate (α-TCP) powders may readily react with water to form hydraulic calcium-deficient hydroxyapatite (CDHA) cement, its long setting time, poor anti-collapse properties, and low biodegradability are suboptimal for a variety of clinical applications. This study aimed to develop new injectable α-TCP-based bone cements via strontium doping, α-calcium sulfate hemihydrate (CSH) addition and liquid phase optimization. A combination of citric acid and chitosan was identified to facilitate the injectable and anti-washout properties, enabling higher resistance to structure collapse. Furthermore, CSH addition (5 %-15 %) was favorable for shortening the setting time (5-20 min) and maintaining the compressive strength (10-14 MPa) during incubation in an aqueous buffer medium. These α-TCP-based composites could also accelerate the biodegradation rate and new bone regeneration in rabbit lateral femoral bone defect models in vivo. Our studies demonstrate that foreign ion doping, secondary phase addition and liquid medium optimization could synergistically improve the physicochemical properties and biological performance of α-TCP-based bone cements, which will be promising biomaterials for repairing bone defects in situations of trauma and diseased bone.

The potential roles of dental pulp stem cells in peripheral nerve regeneration.

Peripheral nerve diseases are significantly correlated with severe fractures or trauma and surgeries, leading to poor life quality and impairment of physical and mental health. Human dental pulp stem cells (DPSCs) are neural crest stem cells with a strong multi-directional differentiation potential and proliferation capacity that provide a novel cell source for nerve regeneration. DPSCs are easily extracted from dental pulp tissue of human permanent or deciduous teeth. DPSCs can express neurotrophic and immunomodulatory factors and, subsequently, induce blood vessel formation and nerve regeneration. Therefore, DPSCs yield valuable therapeutic potential in the management of peripheral neuropathies. With the purpose of summarizing the advances in DPSCs and their potential applications in peripheral neuropathies, this article reviews the biological characteristics of DPSCs in association with the mechanisms of peripheral nerve regeneration.

Acute and chronic traumatic diaphragmatic hernia: 10 years' experience.

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

Surgical treatment of progressive cauda equina compression caused by spontaneous spinal subdural hematoma: A case report.

RATIONALE: Spontaneous spinal subdural hematoma (SSDH) without an underlying pathology is a very rare condition. The treatment protocol for SSDH is early diagnosis and treatment before irreversible damage to neural tissue. However, there is no agreement on the etiopathogenesis, as well as the need for surgery to treat spontaneous SSDH. Here, we report a rare case of spontaneous SSDH with progressive deterioration and symptoms of cauda equina syndrome after ineffective conservative treatment. PATIENT'S CONCERN: A 38-year-old male patient presented with sudden lower back and bilateral leg pain. DIAGNOSIS: A magnetic resonance imaging (MRI) scan on the third day after the onset of symptoms revealed a subdural hematoma from L1 to S1, presenting as hyperintensities on T1 weighted sequences and hypointensities to isointensities on T2 weighted sequences. INTERVENTION: Laminectomy and subdural evacuation were performed immediately. OUTCOMES: An abnormal ligamentum flavum was observed intraoperatively. A histological examination revealed extravasation of blood in the degenerated ligamentum flavum. Postoperatively, the lower limb pain improved immediately. At the 6-month follow-up, the pain and numbness of the lower limb disappeared, and the muscle strength of both legs recovered completely with normal gait. LESSONS: Spontaneous SSDH with ligamentum flavum hematoma was caused by a sudden increase of intravenous pressure, resulting from a marked surge in the intra-abdominal or intrathoracic pressure. Consecutive MRI scans provided valuable information, leading to a diagnosis of spontaneous SSDH. The treatment protocol for spontaneous SSDH should be determined based on the location and stage of the hematoma, as well as the subject's neurological status.

Neuroprotective effects of rapamycin on spinal cord injury in rats by increasing autophagy and Akt signaling.

Rapamycin treatment has been shown to increase autophagy activity and activate Akt phosphorylation, suppressing apoptosis in several models of ischemia reperfusion injury. However, little has been studied on the neuroprotective effects on spinal cord injury by activating Akt phosphorylation. We hypothesized that both effects of rapamycin, the increased autophagy activity and Akt signaling, would contribute to its neuroprotective properties. In this study, a compressive spinal cord injury model of rat was created by an aneurysm clip with a 30 g closing force. Rat models were intraperitoneally injected with rapamycin 1 mg/kg, followed by autophagy inhibitor 3-methyladenine 2.5 mg/kg and Akt inhibitor IV 1 µg/kg. Western blot assay, immunofluorescence staining and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling assay were used to observe the expression of neuronal autophagy molecule Beclin 1, apoptosis-related molecules Bcl-2, Bax, cytochrome c, caspase-3 and Akt signaling. Our results demonstrated that rapamycin inhibited the expression of mTOR in injured spinal cord tissue and up-regulated the expression of Beclin 1 and phosphorylated-Akt. Rapamycin prevented the decrease of bcl-2 expression in injured spinal cord tissue, reduced Bax, cytochrome c and caspase-3 expression levels and reduced the number of apoptotic neurons in injured spinal cord tissue 24 hours after spinal cord injury. 3-Methyladenine and Akt inhibitor IV intervention suppressed the expression of Beclin-1 and phosphorylated-Akt in injured spinal cord tissue and reduced the protective effect of rapamycin on apoptotic neurons. The above results indicate that the neuroprotective effect of rapamycin on spinal cord injury rats can be achieved by activating autophagy and the Akt signaling pathway.