Long-term effects of local radiotherapy on growth and vertebral features in children with high-risk neuroblastoma.

BACKGROUND: To evaluate the effects of local radiotherapy (RT) on growth, we evaluated the chronological growth profiles and vertebral features of children with high-risk neuroblastoma. METHODS: Thirty-eight children who received local photon or proton beam therapy to the abdomen or retroperitoneum between January 2014 and September 2019 were included. Simple radiography of the thoracolumbar spine was performed before and every year after RT. The height and vertical length of the irradiated vertebral bodies (VBs) compared with the unirradiated VBs (vertebral body ratio, VBR) were analyzed using the linear mixed model. Shape feature analysis was performed to compare the irradiated and unirradiated vertebrae. RESULTS: The follow-up was a median of 53.5 months (range, 21-81 months) after RT. A decline in height z-scores was mainly found in the early phase after treatment. In the linear mixed model with height, the initial height (fixed, p < 0.001), sex (time interaction, p = 0.008), endocrine dysfunction (time interaction, 0.019), and age at diagnosis (fixed and time interaction, both p = 0.002) were significant. Unlike the trend in height, the change in VBR (ΔVBR) decreased gradually (p < 0.001). The ΔVBR in the group that received more than 30 Gy decreased more than in the group that received smaller doses. In the shape feature analysis, the irradiated VBs changed to a more irregular surface that were neither round nor rectangular. CONCLUSION: The irradiated VBs in children were gradually restricted compared to the unirradiated VBs in long-term follow-up, and higher RT doses were significantly affected. Radiation-induced irregular features of VBs were observed.

An easy way to determine bone mineral density and predict pelvic insufficiency fractures in patients treated with radiotherapy for cervical cancer.

PURPOSE: The aim of this study was to investigate whether bone mineral density (BMD) as measured in planning computed tomographies (CTs) by a new method is a risk factor for pelvic insufficiency fractures (PIF) after radio(chemo)therapy (R(C)T) for cervical cancer. METHODS: 62 patients with cervical cancer who received definitive or adjuvant radio(chemo)therapy between 2013 and 2017 were reviewed. The PIF were detected on follow-up magntic resonance imaging (MRI). The MRI of the PIF patients was registered to the planning CT and the PIF contoured. On the contralateral side of the fracture, a mirrored structure of the fracture was generated (mPIF). For the whole sacral bone, three lumbar vertebrae, the first and second sacral vertebrae, and the PIF, we analyzed the BMD (mg/cm3), V50Gy, Dmean, and Dmax. RESULTS: Out of 62 patients, 6 (9.7%) had a fracture. Two out of the 6 patients had a bilateral fracture with only one of them being symptomatic. PIF patients showed a significantly lower BMD in the sacral and the lumbar vertebrae (p < 0.05). The BMD of the contoured PIF, however, when comparing to the mPIF, did not reach significance (p < 0.49). The difference of the V50Gy of the sacrum in the PIF group compared to the other (OTH) patients, i.e. those without PIF, did not reach significance. CONCLUSION: The dose does not seem to have a relevant impact on the incidence of PIF in our patients. One of the predisposing factors for developing PIF after radiotherapy seems to be the low BMD. We presented an easy method to assess the BMD in planning CTs.

Lumbar vertebral osteoradionecrosis: a rare case report with 10-year follow-up and brief literature review.

BACKGROUND: Osteoradionecrosis (ORN) is a complication that occurs after radiotherapy for head or neck malignancies. ORN of the spine is rare, with only few cases affecting the cervical spine reported to date. To our knowledge, no case of lumbar ORN has been reported. We report a rare case of ORN in the lumbar spine that occurred 2 years after radiotherapy and perform a literature review. CASE PRESENTATION: We present a case of lumbar ORN that occurred 2 years after radiotherapy for gallbladder carcinoma. The patient was successfully treated conservatively and followed up for > 10 years. CONCLUSIONS: ORN of the spine is a rare complication of radiotherapy. Spinal ORN is clinically described as a chronic disease with a slow onset. The most common presenting symptom of spinal ORN is pain. However, as ORN progresses, spinal kyphosis and instability can lead to neurological compression and thus to induced myelopathy or radiculopathy. Treatment of spinal ORN is comprehensive, including orthosis, medication, hyperbaric oxygen therapy, surgery, and new treatment combinations of pentoxifylline and tocopherol. The surgical rate for spinal ORN is relatively high.

CT diagnostic reference levels: are they appropriately computed?

OBJECTIVES: To estimate the variability of CT diagnostic reference levels (DRLs) according to the methods used for computing collected data. METHODS: Dose-length products (DLP) were collected by our national nuclear control agency from the 250 devices installed in 140 medical centers in the country. In 2015, the number of head, thorax, abdomen, and lumbar spine examinations collected in these centers ranged from approximately 20,000 to 42,000. The impact on DRLs of the number of devices considered, as well as the differences in descriptive statistics (mean vs. median DLP) or methods of pooling DLP data (all devices vs. all patients), was investigated. Variability in DRLs was investigated using a bootstrapping method as a function of the numbers of devices and examinations per device. RESULTS: As expected, DRLs derived from means were higher than those from medians, with substantial differences between device- and patient-related DRLs. Depending on the numbers of devices and DLP data per device, the variability ranged from 10 to 40% but was stabilized at a level of 10-20% if the number of devices was higher than 50 to 60, regardless of the number of DLP data per device. CONCLUSION: Number of devices and of DLP data per device, descriptive statistics, and pooling data influence DRLs. As differences in methods of computing survey data can artificially influence DRLs, harmonization among national authorities should be recommended. KEY POINTS: • Due to CT dose variability, that of DRLs is at least of 10%. • DRLs derived from medians are lower than from means and differ from those obtained by pooling all patient data. • Fifty to 60 devices should be sufficient for estimating national DRLs, regardless of the number of data collected per device.

X-ray examination dose surveys: how accurate are my results?

OBJECTIVES: To determine the variabilities of dose-area-products (DAP) of frequent X-ray examinations collected for comparison with diagnostic reference levels (DRLs). METHODS: DAP values of chest, abdomen, and lumbar spine examinations obtained on devices from two manufacturers were collected in three centers over 1 to 2 years. The variability of the average DAP results defined as the 95% confidence interval in percentage of their median value was calculated for increasing sample sizes, each examination and center. We computed the sample sizes yielding variabilities lower or equal to 25% and 10%. The effect of narrowing patient selection based on body weight was also investigated (ranges of 67-73 Kg, or 60-80 Kg). RESULTS: DAP variabilities ranged from 75 to 170% of the median value when collecting small samples (10 to 20 DAP). To reduce this variability, larger samples are needed, collected over up to 2 years, regardless of the examination and center. A variability ≤ 10% could only be reached for chest X-rays, requiring up to 800 data. For the abdomen and lumbar spine, the lowest achievable variability was 25%, regardless of the body weight selection, requiring up to 400 data. CONCLUSION: Variabilities in DAP collected through small samples of ten data as recommended by authorities are very high, but can be reduced down to 25% (abdomen and lumbar spine) or even 10% (chest) through a substantial increase in sample sizes. Our findings could assist radiologists and regulatory authorities in estimating the reliability of the data obtained when performing X-ray dose surveys. KEY POINTS: • Low but reasonable variabilities cannot be reached with samples sized as recommended by regulatory authorities. Higher numbers of DAP values are required to reduce the variability. • Variabilities of 10% for the chest and 25% for abdomen and lumbar spine examinations are achievable, provided large samples of data are collected over 1 year. • Our results could help radiologists and authorities interpret X-rays dose surveys.

Intraoperative radiation exposure in spinal scoliosis surgery for pediatric patients using the O-arm® imaging system.

PURPOSE: The O-arm® navigation system allows intraoperative CT imaging that can facilitate highly accurate instrumentation surgery, but radiation exposure is higher than with X-ray radiography. This is a particular concern in pediatric surgery. The purpose of this study is to examine intraoperative radiation exposure in pediatric spinal scoliosis surgery using O-arm. METHODS: The subjects were 38 consecutive patients (mean age 12.9 years, range 10-17) with scoliosis who underwent spinal surgery with posterior instrumentation using O-arm. The mean number of fused vertebral levels was 11.0 (6-15). O-arm was performed before and after screw insertion, using an original protocol for the cervical, thoracic, and lumbar spine doses. RESULTS: The average scanning range was 6.9 (5-9) intervertebral levels per scan, with 2-7 scans per patient (mean 4.0 scans). Using O-arm, the dose per scan was 92.5 (44-130) mGy, and the mean total dose was 401 (170-826) mGy. This dose was 80.2% of the mean preoperative CT dose of 460 (231-736) mGy (P = 0.11). The total exposure dose and number of scans using intraoperative O-arm correlated strongly and significantly with the number of fused levels; however, there was no correlation with the patient's height. CONCLUSIONS: As the fused range became wider, several scans were required for O-arm, and the total radiation exposure became roughly the same as that in preoperative CT. Use of O-arm in our original protocol can contribute to reduction in radiation exposure.

Evaluation of the effects of photobiomodulation on vertebras in two rat models of experimental osteoporosis.

The aim of this study was to evaluate the effects of photobiomodulation (PBM) on cancellous bone in rat models of ovariectomized induced osteoporosis (OVX-D) and glucocorticoid-induced osteoporosis (GIOP). The experiment comprised of nine groups. A group of healthy rats was used for baseline evaluations. The OVX-D rats were further divided into groups as follows: control rats with osteoporosis, OVX-D rats that received alendronate (1 mg/kg 60 days), OVX-D rats treated with pulsed wave laser (890 nm, 80 Hz, 900 s, 0.0061 W/cm2, 5.5 J/cm2, three times a week, 60 days), and OVX-D rats treated with alendronate + pulsed laser. Dexamethasone was administered to the remaining rats that were split into four groups: control, alendronate-treated rats, laser-treated rats, and GIOP rats treated with alendronate + laser. T12, L1, L2, and L3 vertebrae were subjected to laser. Results of the current study demonstrated that OVX-D and GIOP significantly decreased some stereological parameters, and type 1 collagen gene expression compared to the healthy group. There was a significant increase in osteoclast number in both OVX-D and glucocorticoid administration compared to the healthy group. However, the detrimental effect of the OVX-D procedure on bone was more serious than glucocorticoid administration. Results showed that laser alone had a detrimental effect on trabecular bone volume, and cortical bone volume in groups GIOP and OVX-D compared to those in the healthy group. Alendronate significantly improved total vertebral bone volume, trabecular bone volume, and cortical bone volume, in GIOP and OVX-D groups compared to the laser-treated groups. Furthermore, the alendronate + laser in OVX-D rats and GIOP rats produced significantly increased osteoblast number and type 1 collagen gene expression and caused a significant decrease in osteoclast number compared to the controls.

Inter-observer and inter-examination variability of manual vertebral bone attenuation measurements on computed tomography.

OBJECTIVE: To determine inter-observer and inter-examination variability of manual attenuation measurements of the vertebrae in low-dose unenhanced chest computed tomography (CT). METHODS: Three hundred and sixty-seven lung cancer screening trial participants who underwent baseline and repeat unenhanced low-dose CT after 3 months because of an indeterminate lung nodule were included. The CT attenuation value of the first lumbar vertebrae (L1) was measured in all CTs by one observer to obtain inter-examination reliability. Six observers performed measurements in 100 randomly selected CTs to determine agreement with limits of agreement and Bland-Altman plots and reliability with intraclass correlation coefficients (ICCs). Reclassification analyses were performed using a threshold of 110 HU to define osteoporosis. RESULTS: Inter-examination reliability was excellent with an ICC of 0.92 (p < 0.001). Inter-examination limits of agreement ranged from -26 to 28 HU with a mean difference of 1 ± 14 HU. Inter-observer reliability ICCs ranged from 0.70 to 0.91. Inter-examination variability led to 11.2 % reclassification of participants and inter-observer variability led to 22.1 % reclassification. CONCLUSIONS: Vertebral attenuation values can be manually quantified with good to excellent inter-examination and inter-observer reliability on unenhanced low-dose chest CT. This information is valuable for early detection of osteoporosis on low-dose chest CT. KEY POINTS: • Vertebral attenuation values can be manually quantified on low-dose unenhanced CT reliably. • Vertebral attenuation measurements may be helpful in detecting subclinical low bone density. • This could become of importance in the detection of osteoporosis.

[Effects of 1.8 mT sinusoidal alternating electromagnetic fields of different frequencies on bone biomechanics of young rats].

Objective: To study the effects of 1.8 mT sinusoidal electromagnetic fields of different frequencies on bone mineral density (BMD) and biomechanical properties in young rats. Methods: A total of 32 female SD rats (6-week-old) were randomly divided into 4 groups (8 in each):control group, 10 Hz group, 25 Hz group and 40 Hz group. The experimental groups were given 1.8 mT sinusoidal electromagnetic field intervention 90 min per day. The whole body BMD of rats was detected with dual-energy X-ray absorptiometry after 4 and 8 weeks of intervention. After 8 weeks of intervention, all rats were sacrificed, and the BMD of femur and lumbar vertebra, the length and diameter of femur, the width between medial and lateral malleolus were measured. Electronic universal material testing machine was used to obtain biomechanical properties of femur and lumbar vertebra, and micro CT scan was performed to observe micro structures of tibial cancellous bone. Results: Compared with the control group, rats in 10 Hz and 40 Hz groups had higher whole body BMD, BMD of femur, maximum load and yield strength of femur, as well as maximum load and elastic modulus of lumbar vertebra (all P<0.05). But no significant differences in the length and diameter of femur, and the width between medial and lateral malleolus were observed between control group and experimental groups (all P>0.05). Micro CT scan showed that the trabecular number and separation degree, bone volume percentage were significantly increased in 10 Hz and 40 Hz groups (all P<0.01). Rats in 25 Hz group also had higher BMD and better in biomechanical properties than control group, but the differences were not statistically significant (all P>0.05). Conclusion: 10 and 40 Hz of 1.8 mT sinusoidal electromagnetic field can significantly improve the bone density, microstructure and biomechanical properties in young rats.

Radiation-induced camptocormia and dropped head syndrome: Review and case report of radiation-induced movement disorders.

BACKGROUND: In recent years, camptocormia and dropped head syndrome (DHS) have gained attention as particular forms of movement disorders. Camptocormia presents with involuntary forward flexion of the thoracolumbar spine that typically increases during walking or standing and may severely impede walking ability. DHS is characterized by weakness of the neck extensors and a consecutive inability to extend the neck; in severe cases the head is fixed in a "chin to chest position." Many diseases may underlie these conditions, and there have been some reports about radiation-induced camptocormia and DHS. METHODS: A PubMed search with the keywords "camptocormia," "dropped head syndrome," "radiation-induced myopathy," "radiation-induced neuropathy," and "radiation-induced movement disorder" was carried out to better characterize radiation-induced movement disorders and the radiation techniques involved. In addition, the case of a patient developing camptocormia 23 years after radiation therapy of a non-Hodgkin's lymphoma of the abdomen is described. RESULTS: In total, nine case series of radiation-induced DHS (n = 45 patients) and-including our case-three case reports (n = 3 patients) about radiogenic camptocormia were retrieved. Most cases (40/45 patients) occurred less than 15 years after radiotherapy involving extended fields for Hodgkin's disease. CONCLUSION: The use of wide radiation fields including many spinal segments with paraspinal muscles may lead to radiation-induced movement disorders. If paraspinal muscles and the thoracolumbar spine are involved, the clinical presentation can be that of camptocormia. DHS may result if there is involvement of the cervical spine. To prevent these disorders, sparing of the spine and paraspinal muscles is desirable.

Clinical curative effect of percutaneous vertebroplasty combined with 125I-seed implantation in treating spinal metastatic tumor.

This paper selected and studied 15 in-hospital patients to analyze and discuss the clinical curative effect of percutaneous vertebroplasty (PVP) combined with (125)I-seed implantation in treating spinal metastatic tumor. The evaluation of clinical curative effects was based on the observation of several factors, namely recovery conditions of vertebral body's leading edge and middle section before and after surgery, improvements of kyphosis Cobb angle, visual analog scale (VAS), and Barthel Index (BI). The paper found significant difference between preoperative VAS and postoperative VAS, and the same situation occurred to BI. However, compared to the loss rate of vertebral body's leading edge and middle section and the improvement of Cobb angle before operative, postoperative loss rate and Cobb angle did not show statistical difference. Thus the conclusion is that PVP combined with (125)I-seed implantation is a minimally invasive surgery for effectively treating spinal metastatic tumor, which does well in rapidly releasing pains, improving patients' daily life activities and life qualities.

Stability of spinal bone metastases in breast cancer after radiotherapy: a retrospective analysis of 157 cases.

PURPOSE: This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system. METHODS: The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated. RESULTS: Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years. CONCLUSION: The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.

A report from Fukushima: an assessment of bone health in an area affected by the Fukushima nuclear plant incident.

Bone health was assessed for inhabitants of an area affected by the Fukushima nuclear plant incident. Osteoporotic patients, who had been treated with active vitamin D3 and/or bisphosphonate at Soma Central Hospital before the Fukushima incident, were enrolled. Changes in bone turnover markers and bone mineral density were retrospectively analyzed. Serum levels of a bone resorption marker, serum type I collagen cross-linked N-telopeptide were decreased in all the treated groups, whereas those of a bone formation marker, bone-specific alkaline phosphatase, were increased. Accordingly, bone mineral density, estimated by dual-energy X-ray absorptiometry, was increased in the lumbar spine of all groups, but bone mass increase in the proximal femur was detected only in the group treated with the two agents in combination. From the degree of these parameter changes, the antiosteoporotic treatments looked effective and were equivalent to the expected potency of past observations. At this stage, the present study implies that the Fukushima nuclear incident did not bring an acute risk to bone health in the affected areas.

Dose absorption in lumbar and femoral dual energy X-ray absorptiometry examinations using three different scan modalities: an anthropomorphic phantom study.

The aim of this study was to measure the effective dose on an anthropomorphic phantom undergoing lumbar and femoral dual energy X-ray absorption (DXA) examinations, using 3 different scan modalities (fast-array [FA], array [A], high-definition [HD]), and assess the differences in the lifetime attributable risk (LAR) of cancer due to radiation. An anthropomorphic phantom was used. Thermoluminescent dosimeters were placed over 12 anatomic phantom regions and outside the room (to measure background radiation). Fifty scans on the femur and spine were performed for each mode. The dose relative to a single DXA scan for each dosimeter was measured (mean over the 50 scans) and the background radiation was then subtracted. The equivalent dose per organ was obtained. The total body effective dose was calculated by adding the equivalent doses. We estimated the lifetime dose absorption and LAR for cancer for a male and a female patient undergoing 36 DXA studies (18 lumbar, 18 femoral) every 21 months for 32 years. The effective dose for lumbar scans was FA = 17.79 µSv, A = 32.88 µSv, HD = 31.08 µSv; for femoral scans, FA = 5.29 µSv, A = 9.55 µSv, HD = 7.54 µSv. LAR estimation showed a minimal increase in cancer risk (range 4.55 × 10⁻4% [FA, femoral, male] to 4.02 × 10⁻³% [A, lumbar, female]). The lifetime dose absorption and LAR for cancer for a male and a female patient undergoing 36 DXA studies (18 lumbar, 18 femoral) every 21 months for 32 years were 0.756 mSv, 3.82 × 10(-3)% and 0.756 mSv, 5.11 × 10⁻³%, respectively. DXA examinations cause radiation levels that are comparable to the background radiation. Regardless of the scan modality or the anatomic site, a patient undergoing DXA scans for a lifetime has a negligible increased risk of developing cancer.

Two-stage, combined, three-level en bloc spondylectomy for a recurrent post-radiation sarcoma of the lumbar spine.

En bloc or extralesional resection means resection of the tumor in one piece together with a layer of healthy tissue: the margin is either marginal or wide. The prerequisite for an en bloc or extralesional spondylectomy is a tumor involvement of no more than one side of the posterior structures, so that a corridor can be created through which the spinal cord is released. This article presents a two-stage, combined anterior and posterolateral, three-level en bloc spondylectomy, and local flap wound coverage for a patient with a recurrent post-radiation sarcoma of the lumbar spine and infected wound after intralesional treatment. The patient had radiation therapy for an L4 Hodgkin's lymphoma 5 years before the development of the post-radiation sarcoma. Two-stage, three-level en bloc spondylectomy was done through a combined anterior and posterolateral approach. The resection margins were microscopically negative. Dural tear occurred intraoperatively because of tightly adherent dense scar tissue. Two years after spondylectomy, there was no evidence of tumor or infection recurrence; however, the patient died from her lymphoma. In surgically difficult spinal resections, we recommend the two-stage, combined anterior and posterolateral approach for en bloc spondylectomy. The staged procedure may provide for reduced perioperative complications and mortality, and meticulous dissection in the irradiated area, especially if infected. The combined approach provides for easier and safer dissection of the tumor and the spine from the anterior elements under direct visual control, and wide tumor resection.

[Morphological changes in the lumbar dorsal root ganglion of the domestic porcine after pulsed radiofrequency stimulation].

Pulsed radiofrequency (PRF) is a percutaneous minimal invasive procedure that can be used when conservative pain therapy methods have been ineffective. The effectiveness of PRF was demonstrated in various good quality randomized control studies, but mechanisms of action are still unclear. The aim of our study is to analyse the histological effects of PRF on the domestic porcine dorsal root ganglion (DRG), and evaluate the expression of biomarkers in gangliocytes. 3 domestic porcines were investigated. Under general anaesthesia and X-ray control, DRG PRF was performed. Four lumbar DRGs (L1, L2, L3, L4) were randomly treated. The opposite side DRGs was used as control. One month after the procedure the animal was euthanized. The lumbar region of the spine was placed in 10% formaldehyde for a month. After this fixation DRG samples were prepared for slide analysis. They were embedded in paraffin in order to obtain 3 microm thick sections, which were then cut by microtome and collected on slide glasses. Using standard immunohistochemical reactions, the materials were tinted to define biomarkers NF, GFAP, Hsp-70 expression and apoptosis by TUNEL kit. The number of cells with NF (26.0 +/- 3.0 vs 16.1 +/- 3.3; p < 0.05), GFAP (12.0 +/- 1.3 vs 3.2 +/- 0.9; p < 0.05) and Hsp-70 (10.0 +/- 1.6 vs 4.2 +/- 1.0; p < 0.05) expression, were larger in the PRF side comparing with the control side. Additionally, glial cells in spinal ganglia of both sides demonstrated immunoreactivity. The instances of apoptosis were not significantly different, in statistical terms, between the control and experimental sides (18.0 +/- 4.0 vs 20.0 +/- 4.0; p = 0.35). PRF in spinal gangliocytes of lumbar region increases neural tissue cytoskeleton factors like NF and GFAP suggesting about active regeneration processes into the cells 1 month after the procedure. Spinal gangliocytes one month after PRF treatment notably increases Hsp-70 expression suggesting about activation of cellular activity and inhibitory role reducing of oxidative stress. Similar number of apoptotic cells in spinal ganglia of lumbar region after PRF and control side suggests about inhibitory role of PRF on programmed cell death and stimulation of cell survival.

Beyond radiation therapy: photodynamic therapy maintains structural integrity of irradiated healthy and metastatically involved vertebrae in a pre-clinical in vivo model.

Spinal metastasis commonly occurs in advanced breast cancer. Treatment is often multimodal including radiation therapy (RT), bisphosphonates (BPs), and surgery, yet alternative minimally invasive local treatments are needed. Photodynamic therapy (PDT) has been shown to ablate tumor cells and enhance bone formation secondary to metastatic breast cancer, demonstrating potential as a treatment for spinal metastasis. Combined with previous BP treatment, bone formation was further enhanced by PDT. This study aimed to determine the effects of PDT in combination with previous RT on healthy and metastatically involved vertebrae. Forty-six athymic rats underwent RT (4 Gy on day-7), twenty-three of them were inoculated with MT-1 human breast cancer cells on day 0. Thirteen healthy and ten metastatically involved rats underwent PDT treatment on day 14. All rats were sacrificed on day 21. L2 vertebrae were analyzed using µCT imaging, mechanical testing, and histological methods. In healthy vertebrae, while modest increases in trabecular structure were found in RT + PDT compared to RT only, mechanical stability was negatively affected. The 4 Gy RT dose was found to ablate all tumor cells and prevent further vertebral metastasis. As such, in metastatically involved rats, no differences in stereological or mechanical properties were detected. RT + PDT and RT-only treatment resulted in greatly improved vertebral structural and mechanical properties versus untreated or PDT-only treatment in metastatically involved rats, due to early tumor destruction in RT-treated groups. Increased amounts of woven bone and osteoid volume were found in PDT-treated vertebrae. Further investigation is needed to understand if structural improvements seen in RT + PDT treatment can translate into longer-term improvements in strength to support the potential of PDT as a viable adjuvant treatment for spinal metastasis postradiation.

Prognostic factors in a series of 504 breast cancer patients with metastatic spinal cord compression.

BACKGROUND: This study was performed to identify new significant prognostic factors in breast cancer patients irradiated for metastatic spinal cord compression (MSCC). PATIENTS AND METHODS: The data of 504 patients with breast cancer patients with MSCC were retrospectively analyzed with respect to posttreatment motor function, local control of MSCC, and survival. The investigated potential prognostic factors included age, Eastern Cooperative Oncology Group (ECOG) performance score, number of involved vertebrae, other bone metastases, visceral metastases, pretreatment ambulatory status, interval from cancer diagnosis to radiotherapy of MSCC, time developing motor deficits before radiotherapy, and the radiation schedule. RESULTS: On multivariate analysis, better functional outcome was associated with ambulatory status prior to RT (estimate - 1.29, p < 0.001), no visceral metastases (estimate - 0.52, p = 0.020), and slower development of motor deficits (estimate + 2.47, p < 0.001). Improved local control was significantly associated with no other bone metastases (risk ratio (RR) 4.33, 95% confidence interval (CI) 1.36-14.02, p = 0.013) and no visceral metastases (RR 3.02, 95% CI 1.42-6.40, p = 0.005). Improved survival was significantly associated with involvement of only 1-2 vertebrae (RR 1.27, 95% CI 1.01-1.60, p = 0.044), ambulatory status before radiotherapy (RR 1.75, 95% CI 1.23-2.50, p = 0.002), no other bone metastases (RR 1.93, 95% CI 1.18-3.13, p = 0.009), no visceral metastases (RR 7.60, 95% CI 5.39-10.84, p < 0.001), and time developing motor deficits before radiotherapy (RR 1.55, 95% CI 1.30-1.86, p < 0.001). CONCLUSION: Several new independent prognostic factors were identified for treatment outcomes. These prognostic factors should be considered in future trials and may be used to develop prognostic scores for breast cancer patients with MSCC.

Severe spinal deformity and multiple vertebral collapses in juvenile Cushing Syndrome: a case report.

Cushing's Syndrome (CS) is rare in adolescence but the pathological effects of excessive circulating glucocorticoids concentration on bone during the developmental age still represent a challenge for orthopedists. Only few reports describe the gravity of early developed damages of spine in young affected by CS. A 18-years-old woman suffering from Cushing's Disease presented after many years treatment of the primary disease referring severe back pain and worsening back deformity. Radiological investigations showed vertebral collapses a devastating thoraco-lumbar scoliosis of 80° Cobb. Lumbar dual X-ray absorptiometry Z-score values were very low and consistent with severe osteoporosis. The patient was treated with bracing, antiresorptive therapy, calcium and vitamin D supplementation, and followed-up with imaging investigations to screen for further fractures. The bone mineral density will be monitored until its normalization will allow to plane surgical treatment in case of progression of spinal deformity and collapses. Early diagnosis and treatment of hypercortisolism, periodical clinical and radiographic follow-up, and treatment for the bone damage are mandatory to prevent the devastating sequelae of secondary osteoporosis.

A report of 3 soldiers returned to full duty after lumbar radiofrequency facet denervation in a theater of war.

OBJECTIVE: To provide the advanced interventional procedure of zygapophysial joint neurotomy to soldiers meeting the diagnostic criteria in a combat environment and thus reduce medical evacuations of soldiers from a theater of war. DESIGN: Retrospective chart review was performed on three consecutive soldiers who received neuroablation of the lumbar ZP joint. Patients received single MBB with 1 cc of 1% lidocaine at the b/l L3-L5 levels considered diagnostic if >50% analgesia was achieved concordant with duration of anesthetic. SETTING: All procedures were co-performed by the two authors at the Ibn Sina hospital in Baghdad, Iraq over a 3-month period. PATIENTS: Three consecutive patients with >50% pain relief from diagnostic medial branch blocks were treated with radiofrequency ablation of the bilateral L3-L4 medial branch nerves and L5 posterior primary ramus. INTERVENTIONS: Sensory test stimulation at 50 Hz and motor stimulation at 2 Hz were performed at each level. The nerves were then lesioned at 80° Centigrade for 90 seconds after injection of lidocaine and methylprednisolone. OUTCOME MEASURES: Procedure was considered successful if patients were able to wear body armour without significant discomfort (at least 1 hour/day). RESULTS AND CONCLUSIONS: Medical evacuation from Iraq was prevented and all soldiers returned to rigorous combat duties including the wearing of body armour daily. We believe to be the first to report on the use of RF nerve ablation in a war time setting and with this functional outcome.