The nucleus pulposus microenvironment in the intervertebral disc: the fountain of youth?

The intervertebral disc (IVD) is a complex tissue, and its degeneration remains a problem for patients, without significant improvement in treatment strategies. This mostly age-related disease predominantly affects the nucleus pulposus (NP), the central region of the IVD. The NP tissue, and especially its microenvironment, exhibit changes that may be involved at the outset or affect the progression of IVD pathology. The NP tissue microenvironment is unique and can be defined by a variety of specific factors and components characteristic of its physiology and function. NP progenitor cell interactions with their surrounding microenvironment may be a key factor for the regulation of cellular metabolism, phenotype, and stemness. Recently, celltransplantation approaches have been investigated for the treatment of degenerative disc disease, highlighting the need to better understand if and how transplanted cells can give rise to healthy NP tissue. Hence, understanding all the components of the NP microenvironment seems to be critical to better gauge the success and outcomes of approaches for tissue engineering and future clinical applications. Knowledge about the components of the NP microenvironment, how NP progenitor cells interact with them, and how changes in their surroundings can alter their function is summarised. Recent discoveries in NP tissue engineering linked to the microenvironment are also reviewed, meaning how crosstalk within the microenvironment can be adjusted to promote NP regeneration. Associated clinical problems are also considered, connecting bench-to-bedside in the context of IVD degeneration.

Anterior column reconstruction of the thoracolumbar spine with a new modular PEEK vertebral body replacement device: retrospective clinical and radiologic cohort analysis of 48 cases with 1.7-years follow-up.

PURPOSE: To evaluate whether a new PEEK vertebral body replacement can maintain the sagittal alignment as an anterior column reconstruction device in thoracic and lumbar spinal defects due to trauma or tumor. METHODS: Retrospective review of 48 patients who underwent a corpectomy between T5 and L5 due to trauma or tumor and were stabilized with the new PEEK vertebral body replacement, between 2013 and 2017. We excluded patients who underwent a corpectomy for infection or degenerative disease and patients without complete follow-up in our institution. The primary outcome was the bi-segmental kyphotic angle (BKA). Secondary outcomes were the assessment of pedicle screw loosening, cage height, and subsidence or tilting of the cage. The clinical outcomes were assessed through the COMI-Score, EuroQol-5D, and Karnofsky indexes. Bony fusion and complications were registered. RESULTS: After the surgery BKA decreased by 12.1° (p < 0.001). At the end of the follow-up, we observed a mean loss of reduction of 1.6° (p = 0.002). This was accompanied by an increase in subsidence of 2.1 mm (p < 0.001) and mean tilting of the cage of 1.4° (p = 0.003). The height of the cage and other parameters did not experience any changes. Clinically, the COMI-Score (p = 0.02) and the EuroQol-5D Index (p = 0.012) showed significant improvement, same as Karnofsky-Index (p = 0.015) at final follow-up. The fusion rate according to Bridwell was 92.1%. The 2% late complications were related to implant malpositioning. CONCLUSION: The new PEEK expandable vertebral body replacement is effective and safe in thoracic and lumbar anterior column reconstruction in tumor and trauma diseases.

[Resection at symptomatic cam impingement. Use of a minimally invasive antero-lateral approach]. / Offene Offsetkorrektur bei symptomatischem Cam-Impingement. Therapie über einen minimalinvasiven anterolateralen Zugang.

BACKGROUND: Surgical treatment of femoroacetabular impingement (FAI) is nowadays achieved by either open surgical hip dislocation or hip arthroscopy. However, drawbacks of both procedures include the invasiveness of the open procedure and a high learning curve to successfully perform arthroscopic treatment. In our institution, we established a minimally invasive, arthroscopically assisted, antero-lateral approach for the correction of cam type FAI. OBJECTIVES: The goal of the study was to describe the surgical technique and highlight the short-term clinical outcome in a consecutive series of patients operated between 2011 and 2014 in our institution. MATERIALS AND METHODS: In total, 77 patients were included in this study. The patients were allocated to two groups (Toennis = 0: Group I; Toennis 1 and 2: Group II). Clinical and radiographic follow up was obtained at 6 and 12 weeks postoperatively. Clinical outcome was assessed using the Hip-Outcome-Score. RESULTS: The mean age of patients in Group I was 25 (16-48) years and in Group II 38 (17-50) years respectively. Internal rotation (IR) in 90° flexion increased by 11 degrees from pre- to postoperatively in Group I (p < 0.001) and by 14° in Group II (p < 0.001). The Hip Outcome Score revealed the ability to perform sports with reduced pain at three months follow up. Subjectively, all patients benefitted in terms of pain and hip function in both groups (p < 0.001). There were no complications with long-term morbidity during the perioperative course. CONCLUSION: Arthroscopically assisted cam resection using a minimally invasive anterolateral approach is a safe technique for the treatment of FAI. At short term follow up, nearly all operated patients seem to benefit in terms of pain and hip function. The influence of progression of osteoarthritis still has to be shown.

Effective treatment of highest instability in a subacute fragility fracture of the pelvis (FFP IV) using a cement augmented transsacral screw only.

The highest instability in fragility fractures of the pelvis (FFP) is noted in presence of H-, U-type sacral fractures. Suggested surgical treatment options include uni- or bilateral sacroiliac or transsacral screw fixation at different levels or in combination, as well as lumbopelvic and bilateral triangular lumbopelvic stabilization. However, distinct treatment recommendations for this subset of injuries are scarce. We present a case sustaining rapid FFP crescendo instability following initial conservative treatment of a FFP type II injury resulting in a U-type spinopelvic dissociation. Fixation using one percutaneous cement augmented transsacral S1 screw resulted in perpetual clinical improvements in pain and mobility in presence of radiologic fracture consolidation.

Can handheld micropower impulse radar technology be used to detect pneumothorax? Initial experience in a European trauma centre.

BACKGROUND: Pneumothoraces are a common injury pattern in emergency medicine. Rapid and safe identification can reduce morbidity and mortality. A new handheld, battery powered device, the Pneumoscan (CE 561036, PneumoSonics Inc., Cleveland, OH, USA), using micropower impulse radar (MIR) technology, has recently been introduced in Europe for the rapid and reliable detection of PTX. However, this technology has not yet been tested in trauma patients. This is the first quality control evaluation to report on emergency room performance of a new device used in the trauma setting. MATERIAL AND METHODS: This study was performed at a Level I trauma centre in Switzerland. All patients with thoracic trauma and undergoing chest X-ray and CT-scan were eligible for the study. Readings were performed before the chest X-ray and CT scan. The patients had eight lung fields tested (four on each side). All readings with the Pneumoscan were performed by two junior residents in our department who had previously received an instructional tutorial of 15min. The qualitative MIR results were blinded, and stored on the device. We then compared the results of the MIR to those of the clinical examination, chest X-ray and CT-scan. RESULTS: 50 patients were included, with a mean age of 46 (SD 17) years. Seven patients presented with PTX diagnosed by CT; six of these were detected by Pneumoscan, leading to an overall sensitivity of 85.7 (95% confidence interval 42.1-99.6)%. Only two of seven PTX were found during clinical examination and on chest X-ray (sensitivity 28.6 (95% CI 3.7-71.0)%). Of the remaining 43 of 50 patients without PTX, one false-positive PTX was found by the Pneumoscan, resulting in a specificity of 97.7 (95% CI 87.7-99.9)%. DISCUSSION: The Pneumoscan is an easy to use handheld technology with reliable results. In this series, the sensitivity to detect a PTX by the Pneumoscan was higher than by clinical examination and chest X-ray. Further studies with higher case numbers and a prospective study design are needed to confirm our findings.

What is the incidence of intracranial bleeding in patients with mild traumatic brain injury? A retrospective study in 3088 Canadian CT head rule patients.

OBJECTIVE: Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI). METHODS: We retrospectively identified 3088 patients (mean age 41 range (7-99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the "Canadian CT head rules." Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson's correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins. RESULTS: 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (R = 0.11; P < 0.001; R = -0.06; P < 0.001). CONCLUSION: Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available.

Does Radar Technology Support the Diagnosis of Pneumothorax? PneumoScan-A Diagnostic Point-of-Care Tool.

Background. A nonrecognized pneumothorax (PTX) may become a life-threatening tension PTX. A reliable point-of-care diagnostic tool could help in reduce this risk. For this purpose, we investigated the feasibility of the use of the PneumoScan, an innovative device based on micropower impulse radar (MIR). Patients and Methods. addition to a standard diagnostic protocol including clinical examination, chest X-ray (CXR), and computed tomography (CT), 24 consecutive patients with chest trauma underwent PneumoScan testing in the shock trauma room to exclude a PTX. Results. The application of the PneumoScan was simple, quick, and reliable without functional disorder. Clinical examination and CXR each revealed one and PneumoScan three out of altogether four PTXs (sensitivity 75%, specificity 100%, positive predictive value 100%, and negative predictive value 95%). The undetected PTX did not require intervention. Conclusion. The PneumoScan as a point-of-care device offers additional diagnostic value in patient management following chest trauma. Further studies with more patients have to be performed to evaluate the diagnostic accuracy of the device.