Superior Cluneal Nerve Entrapment Syndrome: Thought to Be Spondylolysis.

A rare but typically overlooked diagnosis in the orthopaedic surgery community is superior cluneal nerve (SCN) entrapment syndrome. The cluneal nerves function as purely sensory fibers, and the SCNs provide cutaneous innervation to the posterior parasacral, gluteal, and posterolateral thigh regions. When irritated, this syndrome can cause acute and chronic lower back pain and lower extremity symptoms. A 14-year-old adolescent girl presented to the clinic for an evaluation of pain in the right side of her lower back. The patient's physical examination showed tenderness to palpation on the right posterior iliac crest seven centimeters from the midline. Her neurologic examination demonstrated normal deep tendon reflexes, muscle strength, and sensation in the L2-S1 dermatomal distribution. Although imaging showed evidence of a left L5 spondylolysis, she responded positively to a steroid injection over the posterior iliac crest but negatively to one over the L5 pars defect. She later underwent a right SCN decompression surgery. After the procedure, she reported at least 90% improvement in her pain and rated it as a one in severity, on a scale of 0 to 10. Research regarding SCN entrapment syndrome has increased in the past several years. However, most of these studies are limited to the adult population. Therefore, more reports highlighting the potential for this syndrome in adolescents are needed as well.

Novel Enhanced Recovery After Surgery Pathway Reduces Length of Stay and Postoperative Opioid Usage in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion.

PURPOSE: The goal of this study was to compare our institution's recently implemented enhanced recovery after surgery (ERAS) protocol to previous post-operative management for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion, specifically assessing length of stay, opioid consumption, and pain scores. METHODS: This is a retrospective analysis that compares the length of stay, opioid consumption, and pain scores of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Patients were analyzed prior to the implementation of our ERAS protocol, deemed the traditional pain pathway (TPP), to those who underwent the ERAS pathway. All patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis were included. Patients were excluded if they weighed less than 40kg, had significant comorbidities, or had non-idiopathic causes of scoliosis. RESULTS: We examined 22 patients in the TPP cohort and 20 in the ERAS cohort. Length of stay in the ERAS cohort was significantly reduced compared to the TPP by 1.7 days (P<0.01). Overall opioid consumption was also significantly reduced in the ERAS with 1.4 ± 0.7 morphine equivalents (ME)/kg compared to the TPP 2.4 ± 1.1 ME/kg (P < 0.01). We found no difference in pain scores between the two groups. CONCLUSION: Implementation of an ERAS pathway at our institution significantly reduced length of stay and opioid consumption in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. These outcomes reduce morbidity and costs associated with posterior spinal fusion and provide an overall improvement in the quality of care for our patients.

Cutoff Scores for MMPI-2 and MMPI-2-RF Cognitive-Somatic Validity Scales for Psychometrically Defined Malingering Groups in a Military Sample.

OBJECTIVE: This research examined cutoff scores for MMPI-2 and MMPI-2-RF validity scales specifically developed to assess non-credible reporting of cognitive and/or somatic symptoms. The validity scales examined included the Response Bias Scale (RBS), the Symptom Validity Scales (FBS, FBS-r), Infrequent Somatic Responses scale (Fs), and the Henry-Heilbronner Indexes (HHI, HHI-r). METHOD: Cutoffs were developed by comparing a psychometrically defined non-malingering group with three psychometrically defined malingering groups (probable, probable to definite, and definite malingering) and a group that combined all malingering groups. The participants in this research were drawn from a military sample consisting largely of patients with traumatic brain injury (mostly mild traumatic brain injury). RESULTS: Specificities for cutoffs of at least 0.90 are provided. Sensitivities, predictive values, and likelihood ratios are also provided. CONCLUSIONS: RBS had the largest mean effect size (d) when the malingering groups were compared to the non-malingering group (d range = 1.23-1.58).

Repeatable Battery for the Assessment of Neuropsychological Status: Effort Index Cutoff Scores for Psychometrically Defined Malingering Groups in a Military Sample.

OBJECTIVE: This research examined cutoff scores for the Effort Index (EI), an embedded measure of performance validity, for the Repeatable Battery for the Assessment of Neuropsychological Status. EI cutoffs were explored for an active-duty military sample composed mostly of patients with traumatic brain injury. METHOD: Four psychometrically defined malingering groups including a definite malingering, probable to definite malingering, probable malingering, and a combined group were formed based on the number of validity tests failed. RESULTS: Excellent specificities (0.97 or greater) were found for all cutoffs examined (EI ≥ 1 to EI ≥ 3). Excellent sensitivities (0.80 to 0.89) were also found for the definite malingering group. Sensitivities were 0.49 or below for the other groups. Positive and negative predictive values and likelihood ratios indicated that the cutoffs for EI were much stronger for ruling-in than ruling-out malingering. Analyses indicated the validity tests used to form the malingering groups were uncorrelated, which serves to enhance the validity of the formation of the malingering groups. CONCLUSIONS: Cutoffs were similar to other research using samples composed predominantly of head-injured individuals.

Victoria Symptom Validity Test: cutoff scores for psychometrically defined malingering groups in a military sample.

The Victoria Symptom Validity Test (VSVT) is one of the least widely used tests to assess performance validity on tests of neurocognitive functioning, but a meta-analysis has suggested that it is one of the more effective validity tests. The current research examined cutoffs for several different scores derived from the VSVT in an active duty military sample composed primarily of mild TBI patients. The results are consistent with previous research and provide additional evidence that much higher cutoffs scores than originally recommended for the VSVT by the developers based on binomial probability theory can produce excellent classification and diagnostic statistics when a psychometrically defined non-malingering group is compared with two psychometrically defined malingering groups (Probable and Probable to Definite). The utility of the difference score between the Easy and Hard Items is supported by this research. The results also indicate that reaction times have some utility, but they are constrained by a lack of sensitivity.

Test of memory malingering: cutoff scores for psychometrically defined malingering groups in a military sample.

This research examined cutoffs for the Test of Memory Malingering (TOMM) in a military sample composed primarily of mTBI patients. The results are consistent with previous research and provide additional evidence that cutoffs higher than those originally recommended for the TOMM can produce excellent classification and diagnostic statistics when a psychometrically defined non-malingering group is compared with three psychometrically defined malingering groups: Probable, Probable to Definite, and Definite Malingering. The groups were formed based on the number of symptom and performance validity tests passed or failed. Cutoffs that were 4-5 points higher for Trial 2 and the Retention Trial than originally recommended produced very low false positive rates (.0 to .06) and excellent positive predictive values (.75 to 1.00) for a base rate of malingering commonly found in TBI patients. Positive likelihood ratios were all above 10 for these two trials indicating excellent ability to rule in malingering. A range of cutoffs for Trial 1 were also examined, and classification and diagnostic statistics are presented for cutoffs ranging from 40 to 44 with results similar to the other TOMM trials.

Repair of large animal partial-thickness cartilage defects through intraarticular injection of matrix-rejuvenated synovium-derived stem cells.

Cartilage defects have a limited ability to self-heal. Stem cell treatment is a promising approach; however, replicative senescence is a challenge to acquiring large-quantity and high-quality stem cells for cartilage regeneration. Synovium-derived stem cells (SDSCs) are a tissue-specific stem cell for cartilage regeneration. Our recent findings suggest that decellularized stem cell matrix (DSCM) can rejuvenate expanded SDSCs in cell proliferation and chondrogenic potential. In this study, we were investigating (1) whether transforming growth factor (TGF)-ß1 and TGF-ß3 played a similar role in chondrogenic induction of SDSCs after expansion on either DSCM or plastic flasks (plastic), and (2) whether DSCM-expanded SDSCs had an enhanced capacity in repairing partial-thickness cartilage defects in a minipig model. SDSCs were isolated from synovium in two 3-month-old pigs and DSCM was prepared using SDSCs. Passage 2 SDSCs were expanded on either DSCM or plastic for one passage. The expanded cells were evaluated for cell morphology, chondrogenic capacity, and related mechanisms. TGF-ß1 and TGF-ß3 were compared for their role in chondrogenesis of SDSCs after expansion on either DSCM or plastic. The chondrogenic induction medium without TGF-ß served as a control. In 13 minipigs, we intraarticularly injected DSCM- or plastic-expanded SDSCs or saline into knee partial-thickness cartilage defects and assessed their repair using histology and immunohistochemistry. We found DSCM-expanded SDSCs were small, had a fibroblast-like shape, and grew quickly in a three-dimensional format with concomitant up-regulation of phosphocyclin D1 and TGF-ß receptor II. Plastic-expanded SDSCs exhibited higher mRNA levels of chondrogenic markers when incubated with TGF-ß3, while DSCM-expanded SDSCs displayed comparable chondrogenic potential when treated with either TGF-ß isotype. In the minipig model, DSCM-expanded SDSCs were better than plastic-expanded SDSCs in enhancing collagen II and sulfated glycosaminoglycan expression in repair of partial-thickness cartilage defects, but both groups were superior to the saline control group. Our observations suggested that DSCM is a promising cell expansion system that can promote cell proliferation and enhance expanded cell chondrogenic potential in vitro and in vivo. Our approach could lead to a tissue-specific cell expansion system providing large-quantity and high-quality stem cells for the treatment of cartilage defects.

Repeated computed tomographic scans in transferred trauma patients: Indications, costs, and radiation exposure.

BACKGROUND: Trauma patients are often transferred to regional Level I trauma centers from other institutions. At times, when the patient presents to the trauma center, radiologic studies performed at the previous institution are repeated. The aim of this study was to assess the proportion of computed tomographic (CT) scans repeated in trauma patients receiving CT scans before transfer and to obtain the indications for these repeats. This study also estimated the additional radiation dose and economic burden associated with repeated CT scans. METHODS: This prospective, observational cohort study collected data consecutively on transferred trauma patients who had received a CT scan at the transferring institution and investigated whether the CT scan was repeated at the receiving institution. Indications for repeating CT scans were obtained from the general surgery trauma service. The economic impacts were assessed using fee schedules from the hospital and the Center of Medicare and Medicaid Services. Effective dose radiation was estimated using the dose-length product method. RESULTS: Of the 211 patients who presented with a previous CT scan at the transferring institution, 82 had at least one repeated CT scan. Indications for repeating CT scans varied based on the body region. Additional hospital charges ranged from $728 to $5,892 with an average of $1,762.40 for patients having one or more repeated CT scans. The estimated additional effective dose radiation ranged from 1.2 mSv to 124 mSv with an average of 21.5 mSv. CONCLUSION: This study reveals the high rates of repeated CT scans in transferred trauma patients and the various indications that lead to them. Additional hospital charges and additional low levels of radiation exposure are a consequence of these repeats. LEVEL OF EVIDENCE: Diagnostic study, level IV.

Scores on the MMPI-2-RF scales as a function of increasing levels of failure on cognitive symptom validity tests in a military sample.

This research examined associations between the full range of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) validity and substantive scales and increasing levels of cognitive symptom validity test (SVT) failure in a sample of 501 military members who completed a neuropsychological evaluation primarily for mild traumatic brain injury resulting from a closed head injury and blast exposure or heat injury. SVT failure was associated with significant linear increases in all of the over-reporting MMPI-2-RF validity scales and most of the substantive scales. For the validity scales, all over-reporting scales had large effect sizes (ESs) when comparing a group that failed no SVTs with a group that failed three SVTs. A comparison between these two groups for the substantive scales revealed the largest ESs for scales related to somatic/cognitive complaints and emotional dysfunction. RBS (Response Bias Scale) had the largest ES of all scales (d = 1.69), followed by FBS-r (Symptom Validity Scale; d = 1.34), AXY (Anxiety, d = 1.21), and COG (Cognitive Complaints, d = 1.19). The scales related to behavioral dysfunction had the smallest ESs of all of the substantive scales, and there were no significant associations between the vast majority of these scales and SVT failure. With respect to clinically significant elevations, those who did not fail SVTs had clinically significant elevations only on COG and NUC (Neurological Complaints), and MLS (Malaise) approached clinical significance. For those who failed SVTs, RBS was the only over-reporting scale that was elevated across all failure groups. Those who failed any SVT had clinically significant elevations on COG, MLS, NUC, and AXY. Those who failed three SVTs had additional elevations on scales related to emotional dysfunction.

A comparison of selected MMPI-2 and MMPI-2-RF validity scales in assessing effort on cognitive tests in a military sample.

Using a relatively new statistical paradigm, Optimal Data Analysis (ODA; Yarnold & Soltysik, 2005), this research demonstrated that newly developed scales for the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and MMPI-2 Restructured Form (MMPI-2-RF) specifically designed to assess over-reporting of cognitive and/or somatic symptoms were more effective than the MMPI-2 F-family of scales in predicting effort status on tests of cognitive functioning in a sample of 288 military members. ODA demonstrated that when all scales were performing at their theoretical maximum possible level of classification accuracy, the Henry Heilbronner Index (HHI), Response Bias Scale (RBS), Fake Bad Scale (FBS), and the Symptom Validity Scale (FBS-r) outperformed the F-family of scales on a variety of ODA indexes of classification accuracy, including an omnibus measure (effect strength total, EST) of the descriptive and prognostic utility of ODA models developed for each scale. Based on the guidelines suggested by Yarnold and Soltysik for evaluating effect strengths for ODA models, the newly developed scales had effects sizes that were moderate in size (37.66 to 45.68), whereas the F-family scales had effects strengths that ranged from weak to moderate (15.42 to 32.80). In addition, traditional analysis demonstrated that HHI, RBS, FBS, and FBS-R had large effect sizes (0.98 to 1.16) based on Cohen's (1988) suggested categorization of effect size when comparing mean scores for adequate versus inadequate effort groups, whereas F-family of scales had small to medium effect sizes (0.25 to 0.76). The MMPI-2-RF Infrequent Somatic Responses Scale (F(S)) tended to perform in a fashion similar to F, the best performing F-family scale.

Investigating racial differences in coping with chronic osteoarthritis pain.

Osteoarthritis is a prevalent disease in older patients of all racial groups, and it is known to cause significant pain and functional disability. Racial differences in how patients cope with the chronic pain of knee or hip osteoarthritis may have implications for utilization of treatment modalities such as joint replacement. Therefore, we examined the relationships between patient race and pain coping strategies (diverting attention, reinterpreting pain, catastrophizing, ignoring sensations, hoping and praying, coping self-statements, and increasing behavior activities) for hip and knee osteoarthritis. This is a cross-sectional survey of 939 veterans 50 to 79 years old with chronic hip or knee osteoarthritis pain recruited from VA primary care clinics in Philadelphia and Pittsburgh. Patients had to have moderate to severe hip or knee osteoarthritis symptoms as measured by the WOMAC index. Standard, validated instruments were used to obtain information on attitudes and use of prayer, pain coping strategies, and arthritis self-efficacy. Analysis included separate multivariable models adjusting for demographic and clinical characteristics. Attitudes on prayer differed, with African Americans being more likely to perceive prayer as helpful (adjusted OR = 3.38, 95% CI 2.35 to 4.86) and to have tried prayer (adjusted OR = 2.28, 95% 1.66 to 3.13) to manage their osteoarthritis pain. Upon evaluating the coping strategies, we found that, compared to whites, African Americans had greater use of the hoping and praying method (beta = 0.74, 95% CI 0.50 to 0.99). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. This increased use of the hoping and praying coping strategy by African Americans may play a role in the decreased utilization of total joint arthroplasty among African Americans compared to whites. Further investigation of the role this coping strategy has on the decision making process for total joint arthroplasty should be explored.

An examination of three sets of MMPI-2 personality disorder scales.

Three sets of personality disorder scales (PD scales) can be scored for the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). Two sets (Levitt & Gotts, 1995; Morey, Waugh, & Blashfield, 1985) are derived from the MMPI (Hathaway & McKinley, 1983), and a third set (Somwaru & Ben-Porath, 1995) is based on the MMPI-2. There is no validity research for the Levitt and Gotts scale, and limited validity research is available for the Somwaru and Ben-Porath scales. There is a large body of research suggesting that the Morey et al. scales have good to excellent convergent validity when compared to a variety of other measures of personality disorders. Since the Morey et al. scales have established validity, there is a question if additional sets of PD scales are needed. The primary purpose of this research was to determine if the PD scales developed by Levitt and Gotts and those developed by Somwaru and Ben-Porath contribute incrementally to the scales developed by Morey et al. in predicting corresponding scales on the MCMI-II (Millon, 1987). In a sample of 494 individuals evaluated at an Army medical center, a hierarchical regression analysis demonstrated that the Somwaru and Ben-Porath Borderline, Antisocial, and Schizoid PD scales and the Levitt and Gotts Narcissistic and Histrionic scales contributed significantly and meaningfully to the Morey et al. scales in predicting the corresponding MCMI-II (Millon, 1987) scale. However, only the Somwaru and Ben-Porath scales demonstrated acceptable internal consistency and convergent validity.

TNF influences chemokine expression of macrophages in vitro and that of CD11b+ cells in vivo during Mycobacterium tuberculosis infection.

Granulomas, focal accumulations of immune cells, form in the lung during Mycobacterium tuberculosis infection. Chemokines, chemotactic cytokines, are logical candidates for inducing migration of T lymphocytes and monocytes to and within the lung. TNF influences chemokine expression in some models. TNF-deficient mice infected with M. tuberculosis are highly susceptible to disease, and granuloma formation is inhibited. Through in vitro assays, we demonstrate that neutralization of TNF in M. tuberculosis-infected macrophages led to a reduction in many inflammatory chemokines, such as C-C chemokine ligand 5, CXC ligand 9 (CXCL9), and CXCL10. In TNF-deficient mice, immune cells migrated to the lungs early after infection, but did not organize to form granulomas within the lung. Although chemokine expression, as measured in whole lung tissue, was not different, the expression of chemokines in the CD11b(+) subset of cells isolated ex vivo from the lungs of TNF-deficient mice had reduced expression of C-C chemokine ligand 5, CXCL9, and CXCL10 at early time points after TNF neutralization. Local expression of CXCR3-binding chemokines within the lungs, as determined by in situ hybridization, was also affected by TNF. Therefore, TNF affects the expression of chemokines by macrophages in vitro and CD11b(+) cells in vivo, which probably influences the local chemokine gradients and granuloma formation.