Spinal medial branch nerve root block (MBNB) intervention compared to standard care-vertebroplasty (VP) for the treatment of painful osteoporotic vertebral fractures in frail, older hospitalised patients: a feasibility study.

Our study aimed to assess the feasibility outcomes comparing spinal medial branch nerve root block intervention to standard care vertebroplasty for the treatment of painful osteoporotic vertebral fractures in frail, hospitalised older patients. We found the study to be feasible and now propose a clinical effectiveness, cost effectiveness and safety evaluation. INTRODUCTION: Vertebroplasty (VP) is a key-hole procedure involving injection of bone cement into a fractured vertebral body, to reduce pain and increase vertebral body stability, although it is associated with a small risk of complications, particularly in frail, older hospitalised patients. Medial branch spinal nerve block (MBNB) may be an alternative treatment to alleviate pain symptoms, with less complications; however, no study has prospectively compared the clinical effectiveness, cost-effectiveness and safety of MBNB to VP, in frail, older hospitalised patients. The aim of our study was to conduct a 1st stage feasibility study, exploring recruitment, retention and several outcomes measures (means and SDs), together with qualitative interviews to assess participant and clinician views, to inform a definitive larger study. METHODS: We conducted a two-arm feasibility randomised controlled trial with participants allocated to continue with routine surgical care-VP or MBNB treatment, with an embedded qualitative study. Data was collected at baseline, week 1, 4, and week 8. RESULTS: Out of 40 eligible patients, 30 (75%) consented to take part in the study. The overall median time from randomisation to intervention was 3 days, IQR 1-7 days, 5 (1-7) days for VP and 2 (1-3) days for MBNB. Median (IQR) length of hospital stay for the VP group was 20 (8) days and for the MBNB 15(22) days. The proportion of completeness of outcome data collection at weeks 1, 4 and 8 was at least 77%: 14 (100%), 12 (85.7%) and 11(78.9%) for VP and 13 (100%), 12 (92.3%) and 10 (76.8%) for MBNB, respectively. There were no significant difference in the clinical outcomes or adverse events between the two groups. DISCUSSION: Our study was feasible in achieving is target recruitment, participants adhered to the randomisation and at least 77% completeness of data at the 8 week end-point (target 75%). We now plan to conduct a definitive clinical effectiveness, cost effectiveness and safety outcome study, comparing VP to MBNB in frail, older patients hospitalised with an acute vertebral osteoporotic fracture.

The influence of osteoporotic vertebral fractures on global sagittal alignment in elderly patients: a systematic review and meta-analysis.

BACKGROUND: Thoracic kyphosis, or loss of lumbar lordosis, is often equated with osteoporosis because vertebral fractures are assumed to be a major causative factor, in addition to degeneration related to age. Despite the few studies aiming to measure the natural change in global sagittal alignment (GSA) that occurs with advancing age, the overall effect of conservatively managed osteoporotic vertebral compression fractures (OVCF) on the GSA in the elderly remains poorly understood. OBJECTIVE: To systematically evaluate the relevant literature regarding the influence of OVCF on the GSA compared to patients of similar age without fractures using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spino-sacral Angle (SSA). METHODS: A systematic review of the English language literature dating up until October 2022, was undertaken utilizing the PRISMA guidelines. RESULTS: Of a total of 947 articles, 10 studies met the inclusion criteria (4 Level II, 4 level III and 2 level IV evidence) and were subsequently analyzed. Overall, 584 patients (8 studies) of mean age 73.7 years (69.3-77.1) had acute OVCF of one or more vertebra that were managed conservatively. The male to female ratio was 82:412. Five studies mentioned the number of fractured vertebrae, with a total of 393 in 269 patients (average of 1.4 fractured vertebrae per patient). Their pre-operative radiological parameters on standing X-rays showed a mean PI of 54.8°, PT 24°, LL 40.8°, TK 36.5°, PI-LL 14°, SVA 4.8 cm, and SSA 115°. In addition, 437 patients were used as a control group with osteoporosis without fractured vertebrae, (6 studies) with an average age of 72.4 years (67-77.8) and male to female ratio of 96:210 (5 studies). They all had upright X-rays to assess their global sagittal alignments. Radiological parameters showed an average PI of 54.3°, PT 17.3°, LL 43.4°, TK 31.25°, PI-LL 10.95°, SVA 1.27 cm and SSA 125°. A statistical analysis comparing the OVCF group with the control group (4 studies), showed a significant increase in PT of 5.97° (95%CI 2.63, 9.32; P < 0.0005), a significant increase in TK by 8.28° (95%CI 2.15, 14.4; P < 0.008), an increase in PI-LL by 6.72° (95%CI 3.39, 10.04; P < 0.0001), an increase in SVA by 1.35 cm (95%CI 0.88, 1.83; P < 0.00001), and a decrease in SSA by 10.2° (95%CI 10.3, 23.4; P < 0.00001). CONCLUSION: Osteoporotic vertebral compression fractures managed conservatively appear to be a significant causate factor of global sagittal imbalance.

Baastrup's Disease as a Rare Cause of Cauda Equina Syndrome: A Case Report.

CASE: "Baastrup's disease" is a relatively common anatomical condition, controversially recognized as a possible cause of back pain but frequently missed by clinicians of different specialties. We present a rare case of Baastrup's disease causing compression to the cauda equina nerves due to the formation of a large pseudotumoral epidural mass. The patient underwent a successful surgical decompression with remarkable improvement in her neurological presentation. The histopathological findings consisted of increased collagen deposition and chondroid metaplasia. CONCLUSION: Clinicians should be aware of possible cauda equina syndrome in rare cases of Baastrup's disease due to pseudotumoral mass compression in the lumbar spine.

The Acute VertEbRal AugmentaTion (AVERT) study: protocol for a randomised controlled, feasibility trial of spinal medial branch nerve block in hospitalised older patients with vertebral fragility fractures.

INTRODUCTION: Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture found in older people, resulting in increasing morbidity and excess mortality. These fractures can cause significant pain, requiring admission to hospital. Vertebroplasty (VP) is effective in reducing pain and allowing early mobilisation in hospitalised patients. However, it may be associated with complications such as cement leakage, infection, bleeding at the injection site and fracture of adjacent vertebrae. It is also costly and not readily accessible in many UK hospitals.A recent retrospective study reported that spinal medial branch nerve block (MBNB), typically used to treat facet arthropathy, had similar efficacy in terms of pain relief compared with VP for the treatment of painful VFF. However, to date, no study has prospectively compared MBNB to VP. We therefore propose a prospective feasibility randomised controlled trial (RCT) to compare the role of MBNB to VP, in hospitalised older patients. METHOD: A parallel, two-arm RCT with participants allocated on a 1:1 ratio to either standard care-VP or MBNB in hospitalised patients aged over 70 with acute osteoporotic vertebral fractures. Follow-up will be at weeks 1, 4 and 8 post intervention. The primary objective is to determine the feasibility and design of a future trial, including specific outcomes of recruitment, adherence to randomisation and safety. Embedded within the trial will be a health economic evaluation to understand resource utilisation and implications of the intervention and a qualitative study of the experiences and insights of trial participants and clinicians. Secondary outcomes will include pain scores, analgesia requirements, resource use and quality of life data. ETHICS AND DISSEMINATION: Ethical approval was granted by the Yorkshire & the Humber Research Ethics Committee (reference 21/YH/0065). AVERT (Acute VertEbRal AugmentaTion) has received approval by the Health Research Authority (reference IRAS 293210) and is sponsored by Nottingham University Hospitals NHS Trust (reference 21HC001). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals for publication on completion. TRIAL REGISTRATION NUMBER: ISRCTN18334053.

A Modified Self-Growing Rod Technique for Treatment of Early-Onset Scoliosis.

Surgical treatment of early-onset scoliosis (EOS) remains challenging as no definitive surgical technique has emerged as the single best option in this varied patient population1-3. Although the available surgical techniques may differ substantially, they all share the same goals of achieving and maintaining deformity correction, allowing physiological spinal growth, and reducing the number of operations and complications. Herein, we present a modified self-growing rod technique that represents a valid alternative to the existing surgical procedures for EOS. Description: The patient is positioned prone on a radiolucent table, and the spine is prepared and draped in a standard fashion. A posterior midline skin incision is made from the upper to the lower instrumented level. Subperiosteal exposure of the spine is carried out, ensuring that capsules of the facet joints are spared. Pedicle screws are inserted bilaterally at the cranial and caudal ends of the instrumentation. Fixation with pedicle screws of at least 3 levels at the top and bottom end is usually advised; in nonambulatory patients with pelvic obliquity, caudal fixation can be extended to the pelvis with bilateral iliac screws. Sublaminar wires are positioned bilaterally at every level between the cranial and caudal ends of the instrumentation and are passed as medially as possible to avoid damage to the facet joints. Four 5-mm cobalt-chromium rods are cut, contoured, and inserted at each end of the construct. Ipsilateral rods are secured with use of sublaminar wires, making sure that they overlap over a sufficient length to allow for the remaining spinal growth. Correction of the deformity is achieved with use of a combination of cantilever maneuvers and apical translation by progressive and sequential tightening of the sublaminar wires. The wound is closed in layers over a subfascial drain. The patient is allowed free mobilization after surgery. No postoperative brace is required. Alternatives: Nonoperative alternative treatment for EOS includes serial cast immobilization and bracing4. Alternative surgical treatments include traditional growing rods5, magnetically controlled growing rods6, the vertical expandable prosthetic titanium rib-expansion technique7, and the Shilla technique8. The use of compression-based systems (i.e., staples or tether)9 or early limited fusion has also been reported by other authors. Rationale: The main advantage of our technique is that it relies on physiological spinal growth and does not require surgery or external devices for rod lengthening, which is particularly beneficial in frail patients with a neuromuscular disease in whom repeated surgery is not advised. Segmental fixation by sublaminar wires allows good control of the deformity apex during growth. Concerns regarding early fusion of the spine have not been confirmed in our mid-term follow-up study10. Expected Outcomes: This technique allows correction of the deformity and continuous spinal growth in the years following surgery. At 6.0 years postoperatively, the average main curve correction was reported to be 61% and the average pelvic obliquity correction was 69%. The spine was reported to lengthen an average of 40.9 mm (range, 14.0 to 84.0 mm) immediately postoperatively, and the T1-S1 segment was reported to continue growing at 10.5 mm/year (range, 3.6 to 16.5 mm/year) thereafter10. The most common complication is rod breakage at the thoracolumbar junction, which seems to be more common in patients with idiopathic or cerebral palsy EOS and during the pubertal growth spurt10. Important Tips: Subperiosteal exposure of the spine should be carried out, making sure to preserve facet joints in the unfused area of the spine.Achieve segmental fixation with use of sublaminar wires at every level and pedicle screws at the top and bottom ends of the instrumentation.If pelvic imbalance is present and the patient is nonambulatory, pelvic fixation with iliac screws is advised.First round correction of the deformity is achieved with a cantilever technique; correction fine-tuning can be performed by tightening sublaminar wires.Consider utilizing thicker rods in cases of idiopathic or cerebral palsy EOS. Acronyms and Abbreviations: EOS = early-onset scoliosisAP = anteroposteriorEV = end vertebraSSEP = somatosensory evoked potentialsMEP = motor evoked potentialsPJK = proximal junctional kyphosisSMA = spinal muscular atrophyCP = cerebral palsyPACU = post-anesthesia care unit.

Dyspnoea due to spinal subarachnoid-pleural fistula.

We report a case of a 72-year-old woman who underwent transthoracic discectomy for a giant disc herniation at T9-T10 level causing significant cord compromise. Following removal of her non-suction chest drain, she was transferred to the acute spinal-orthogeriatric unit where she was under regular review by elderly care physicians as part of their spinal liaison role. Approximately four weeks after the operation, she started becoming dyspnoeic and her chest X-ray showed moderate left-sided pleural effusion which tested positive for ß2-transferrin, a sensitive marker of cerebrospinal fluid, supporting a diagnosis of subarachnoid-pleural fistula. This is a very unusual cause of breathlessness in a postoperative patient.

Rare, post-periodontitis spondylodiscitis caused by Fusobacterium nucleatum in a patient with multiple sclerosis: challenge of diagnosis and treatment.

Fusobacterium nucleatum is part of the commensal flora of the oral cavity, frequently associated with periodontal infections. We describe the case of a 49-year-old woman, on immunsuppressive therapy for multiple sclerosis, who presented with a 3-month history of debilitating back pain. She had a recent episode of periodontitis, and was under regular dental review. Her MRI scan demonstrated findings suggestive of L2-L3 spondylodiscitis. Her CT-guided biopsy yielded negative cultures and the patient failed two courses of empirical antibiotic treatment. With clinical and radiological disease progression, she underwent a percutaneous disc washout and biopsy, which subsequently grew F. nucleatum Treatment with clindamycin and metronidazole was commenced orally for 6 weeks. She improved gradually, and at 1 year follow-up was asymptomatic. The diagnosis of spondylodiscitis caused by F. nucleatum is challenging. The perseverance on identification by surgical biopsy, minimally invasive washout and targeted antibiotics are the mainstay of effective treatment.

Surgical complications and re-operation rates in spinal metastases surgery: a systematic review.

OBJECTIVE: The goal of this study was to review the incidence of complications and unplanned re-operations after surgery for metastatic spinal tumors. BACKGROUND: The spinal column is the most common osseous site for metastatic spread. The goals of the treatment of spinal metastases are largely palliative. The surgical aims include establishing a diagnosis, providing stability, relieving neurological compression and deterioration, decreasing pain and increasing patient independence. Patients with spinal metastases who undergo surgery are considered high risk, with higher morbidity and mortality rates. MATERIALS AND METHODS: A systematic review was undertaken; PubMed and Embase databases were searched between (2010-2020) for relevant publications in English language with the following search items: metastasis OR metastases AND spine AND surgery AND complications OR revision. Using a standard PRISMA template, 2293 articles were identified. Full-text articles of interest were assessed for inclusion criteria of greater than 30 patients. RESULTS: A final number of 19 articles fully met the search criteria. Four were level II evidence, and the remaining were level III/IV. Surgical site infection 6.5% (135/2088) was reported as the main complication following surgery for spinal metastases followed by neurological deterioration 3.3% (53/1595) and instrumentation failure 2.0% (30/1501). Re-operation rate was 8.3% (54/651), with SSI (27.8%) being the most common reason for revision surgery. CONCLUSION: Patients with spinal metastases frequently present with complex therapeutic challenges requiring multidisciplinary team assessment. Surgical site infection (6.5%) was the main reason for a re-operation in patients undergoing surgery for spinal metastases.

Mid-term results of a modified self-growing rod technique for the treatment of early-onset scoliosis.

AIMS: To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS). METHODS: We carried out a retrospective analysis of 16 consecutive patients with EOS treated with an SGR construct at a single hospital between September 2008 and December 2014. General demographics and deformity variables (i.e. major Cobb angle, T1 to T12 length, T1 to S1 length, pelvic obliquity, shoulder obliquity, and C7 plumb line) were recorded preoperatively, and postoperatively at yearly follow-up. Complications and revision procedures were also recorded. Only patients with a minimum follow-up of five years after surgery were included. RESULTS: A total of 16 patients were included. Six patients had an idiopathic EOS while ten patients had a neuromuscular or syndromic EOS (seven spinal muscular atrophy (SMA) and three with cerebral palsy or a syndrome). Their mean ages at surgery were 7.1 years (SD 2.2) and 13.3 years (SD 2.6) respectively at final follow-up. The mean preoperative Cobb angle of the major curve was 66.1° (SD 8.5°) and had improved to 25.5° (SD 9.9°) at final follow-up. The T1 to S1 length increased from 289.7 mm (SD 24.9) before surgery to 330.6 mm (SD 30.4) immediately after surgery. The mean T1 to S1 and T1 to T12 growth after surgery were 64.1 mm (SD 19.9) and 47.4 mm (SD 18.8), respectively, thus accounting for a mean T1 to S1 and T1 to T12 spinal growth after surgery of 10.5 mm/year (SD 3.7) and 7.8 mm/year (SD 3.3), respectively. A total of six patients (five idiopathic EOS, one cerebral palsy EOS) had broken rods during their growth spurt but were uneventfully revised with a fusion procedure. No other complications were noted. CONCLUSION: Our data show that SGR is a safe and effective technique for the treatment of EOS in nonambulatory hypotonic patients with a neuromuscular condition. Significant spinal growth can be expected after surgery and is comparable to other published techniques for EOS. While satisfactory correction of the deformity can be achieved and maintained with this technique, a high rate of rod breakage was seen in patients with an idiopathic or cerebral palsy EOS. Cite this article: Bone Joint J 2020;102-B(11):1560-1566.

A Personalized Medicine Approach for the Management of Spinal Metastases with Cord Compression: Development of a Novel Clinical Prediction Model for Postoperative Survival and Quality of Life.

Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.

Clinical outcomes of sacroplasty for metastatic sacral tumours: a systematic review and meta-analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: The purpose of this study was to evaluate the clinical outcome and safety of sacroplasty for patients with secondary metastatic lesions to the sacrum. METHODS: Several databases, including the Cochrane library, PubMed and EMBASE, were systematically searched to identify potentially eligible articles in English language. All the above databases were searched until December 2019. The search strategy was based on the combination of the following keywords: sacroplasty AND secondary tumours OR metastasis OR metastases. The reference list of the selected literature was also reviewed and a standard PRISMA template utilised. RESULTS: From a total of 102 articles initially identified, a final seven studies were identified as meeting the inclusion criteria. A total of 107 patients from these studies were included. The follow-up ranged from immediate post-operatively to 30.5 months. The mean preoperative VAS was 8.38 (range 6.9-9.3), which improved significantly to 3.01 (range 1.12-4.7) post-operatively (p < 0.001). The most frequent complication reported was cement leakage, which occurred in 26 patients (25.4%), but without any neurological or other adverse sequelae. CONCLUSIONS: Sacroplasty in the management of secondary sacral tumours is a safe procedure that can achieve a significant reduction in pain, as quantified by VAS scores, and low complication rate.

Impact of pedicle subtraction osteotomy on health-related quality of life (HRQOL) measures in patients undergoing surgery for adult spinal deformity: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. BACKGROUND: Three-column osteotomies (3-CO) have gained popularity in the last decade as part of the armamentarium for the surgical correction of sagittal imbalance in patients with adult spinal deformity (ASD). Three-column osteotomies in the form of pedicle subtraction osteotomy (PSO) may be necessary to achieve adequate correction for severe and rigid spinal deformity. Studies reporting improvement in health-related quality of life (HRQOL) with validated outcome measures after PSO surgery are sparse and currently consist of small series. OBJECTIVE: Evaluate the improvement in HRQOL measures following PSO for adult spinal deformity. METHODS: Two independent reviewers conducted a systematic review of the English literature between period 1996 and 2019 for articles reporting outcome of PSO in patients with ASD according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Inclusion criteria were studies consisting of patient-reported outcome Oswestry Disability Index (ODI) and Scoliosis Research Society 22 or 24 (SRS) outcomes after PSO surgery for adult spine deformity patients (18 years or older) with a minimum follow-up of 1 year. RESULTS: Eight studies with 431 PSOs were included in the meta-analysis. The results showed a statistically significant improvement in ODI in PSO (P < 0.0001), and the mean clinically important difference was achieved with both ODI (50.46 (45.5-55.4) preoperatively to 32.78 (29.7-39) postoperatively) and SRS (2.49 (2.38-2.7) preoperatively to 3.26 (2.8-4.1) postoperatively) scores. CONCLUSION: This meta-analysis did find improvements in the health-related quality of life in patients undergoing PSO surgery for adult spinal deformity.

Health-related quality of life in patients undergoing cervico-thoracic osteotomies for fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis.

PURPOSE: Ankylosing spondylitis (AS) can result in severe cervico-thoracic kyphotic deformity (CTKD). Few studies have addressed the relationship between cervico-thoracic osteotomies in AS and health-related quality of life scores. The aim of this study is to evaluate the impact of cervico-thoracic osteotomy (CTO) on improving quality of life for patients with fixed CTKD. METHODS: A database of all patients who underwent a CTO for CTKD in patients with AS was created. Data entered into the database consisted of patients' demographics and comorbidities, as well as surgical, clinical and radiological data. The outcome measures used in our study were Neck Disability Index (NDI), EuroQol 5D-5L (EQ-5D-5L) and Visual Analogue Scale. We also measured the following radiological parameters: chin-brow to vertical angle (CBVA), C7-Slope, C2-7 angle, Regional Kyphosis Angle, C2-C7 sagittal vertical axis (SVA) and C7-S1 SVA. RESULTS: A total of 13 male patients with AS were included in our study. The mean age was 57.5 years (40-74); and mean follow-up was 37.6 months (12-78). Following the C7-T1 osteotomy (10 Smith Peterson Osteotomies and 3 Pedicle Subtraction Osteotomies), NDI improved from a mean of 65.54 (SD 8.95) to a mean of 22.09 (SD 6.99). The EQ-5D-5L improved from a mean of 0.41 (SD 0.16) to 0.86 (SD 0.088). Pre-operative CBVA was on average 54° (40°-75°) and post-operative was 7° (2°-12°). There were no major complications, 1 superficial infection and 5 minor nerve root irritations. CONCLUSIONS: Cervical osteotomy for the management of fixed flexion deformity of cervical spine in ankylosing spondylitis is a safe procedure and can result in restoration of horizontal gaze and sagittal balance with significant improvement of the patient's health-related quality of life. These slides can be retrieved under Electronic Supplementary Material.

Molecular profile of major growth factors in lumbar intervertebral disc herniation: Correlation with patient clinical and epidemiological characteristics.

The involvement of growth factors (GFs) in the pathogenesis of lumbar intervertebral disc (ID) herniation and the spontaneous resorption of herniated ID fragments remains only partially elucidated. A simultaneous assessment of the transcript levels of numerous GFs and their association with clinical and epidemiological profiles of human ID herniation would provide valuable insight into the biology and clinical course of the disease. In the present study, we examined simultaneously the transcript levels of vascular endothelial growth factor (VEGF), transforming growth factor ß1 (TGF­ß1), basic fibroblast growth factor 2 (bFGF2), platelet derived growth factor (PDGF) isoforms and receptors, epidermal growth factor (EGF) and insulin growth factor­1 (IGF­1) in herniated and control ID specimens and investigated their correlation with the clinicopathological profiles of patients suffering from symptomatic lumbar ID herniation. GF mRNA expression levels were determined by RT-qPCR in 63 surgical specimens from lumbar herniated discs and 10 control ID specimens. Multiple positive correlations were observed between the transcript levels of the GFs examined in the ID herniation group. VEGF mRNA expression was significantly increased in the protruding compared with the extruded discs. Intense and acute pain significantly upregulated the PDGF transcript levels. Significant negative correlations were observed between the patient body mass index and the transcript levels of VEGF and PDGF receptors. Our findings support the hypothesis of the involvement of GFs in the natural history of ID herniation. GFs synergistically act in herniated IDs. Increased VEGF expression possibly induces the neovascularization process in the earliest stages of ID herniation. PDGF­C and ­D play a role in the acute phase of radiculopathy in a metabolic response for tissue healing. A molecular effect, in addition to the biomechanical effect of obesity in the pathogenesis of ID herniation is also implied.

Akt/PKB isoforms expression in the human lumbar herniated disc: correlation with clinical and MRI findings.

Intervertebral disc (IVD) degeneration suggests a complex process influenced by genetics, lifestyle and biomechanics, which accounts for the development of low back pain (LBP) and lumbar radiculopathy, a major cause of musculoskeletal disability in humans. The family of Akt/PKB kinases is a principal mediator in the signal transduction pathways, which contribute to transcriptional regulation, cell growth, proliferation, apoptosis, and survival ability. The purpose of this study was to evaluate the transcriptional profile of the AKT family genes in human herniated discs and the involvement of the PI3K-Akt signaling pathway in human IVD degeneration. Real-time PCR analysis was used to assess the mRNA expression pattern of the three Akt/PKB isoforms in 63 herniated and 10 control disc specimens. Our results showed a significant positive correlation between AKT1 and AKT3 mRNA in herniated discs suggesting a synergistic action between these isoforms in disc herniation. Interestingly, AKT2 mRNA was up-regulated in patients with acute pain during the first 12 months, indicating that AKT2 transcriptional activation may be associated with acute rather than chronic inflammation and phagocytosis. Finally, Akt1/PKB transcription presented a stepwise activation as disc herniation deteriorated. Our findings provide evidence on the transcriptional activation of the Akt/PKB pathway indicating that it is involved in lumbar disc degeneration. There is need for further studies to elucidate the exact role and down-stream signaling action of Akt/PKB isoforms in the pathogenesis of lumbar disc herniation.

Transcript levels of major MMPs and ADAMTS-4 in relation to the clinicopathological profile of patients with lumbar disc herniation.

The involvement of matrix metalloproteinases (MMPs) in both the pathogenesis of intervertebral disc (ID) herniation and the spontaneous regression of herniated ID fragments remains only partially elucidated. The purpose of the present study was to simultaneously examine the transcript levels of a large number of MMPs (-1, -3, -8, -9, -13 and -14) and ADAMTS-4 (a disintegrin and metalloproteinase with thrombospondin motifs) and to investigate their correlation with the clinicopathologic profile of patients suffering from symptomatic lumbar ID herniation. mRNA expression levels were determined by means of the real-time polymerase chain reaction in 63 herniated and 10 control ID specimens. Our results showed multiple positive correlations among all MMPs and ADAMTS-4 mRNA in herniated samples, indicating their possible synergistic effect in ID herniation. MMP-9 and -13 mRNA levels were significantly elevated in patients with chronic pain, presumably as a consequence of neovascularization and chronic inflammation. Smoking habits were found to have a negative dose-dependent effect on the transcript levels of MMP-3 and MMP-13 and a positive correlation with pain intensity, suggesting an unfavorable role for smoking in the regression process of herniated disc fragments. Our findings provide evidence of the molecular portrait of MMPs and ADAMTS-4 in lumbar ID herniation, as well as of its association with the clinicopathological profile of the patients included in this study, reinforcing the hypothesis of MMPs involvement in the natural history of ID herniation. However, further studies are necessary to elucidate the exact role of MMPs in the resorption process of herniated lumbar discs.

Thoracolumbar burst fractures: a systematic review of management.

The management of thoracolumbar burst fractures remains challenging. Ideally, it should effectively correct the deformity, induce neurological recovery, allow early mobilization and return to work, and be associated with minimal risk of complication. This article reviews the related studies reporting their clinical data for the management of thoracolumbar burst fractures, discusses the most suitable approach in cases such as these, highlights specific treatment recommendations, and proposes a treatment algorithm. Using PubMed and Scopus databases to search the term thoracolumbar burst fractures, abstracts and original articles in English investigating the treatment of thoracolumbar burst fractures were searched and analyzed.

Persistent sciatica induced by quadratus femoris muscle tear and treated by surgical decompression: a case report.

INTRODUCTION: Quadratus femoris tear is an uncommon injury, which is only rarely reported in the literature. In the majority of cases the correct diagnosis is delayed due to non-specific symptoms and signs. A magnetic resonance imaging scan is crucial in the differential diagnosis since injuries to contiguous soft tissues may present with similar symptoms. Presentation with sciatica is not reported in the few cases existing in the English literature and the reported treatment has always been conservative. CASE PRESENTATION: We report here on a case of quadratus femoris tear in a 22-year-old Greek woman who presented with persistent sciatica. She was unresponsive to conservative measures and so was treated with surgical decompression. CONCLUSION: The correct diagnosis of quadratus muscle tear is a challenge for physicians. The treatment is usually conservative, but in cases of persistent sciatica surgical decompression is an alternative option.

Combination of the AO-Magerl and load-sharing classifications for the management of thoracolumbar burst fractures.

The AO-Magerl classification is widely accepted for the appropriate management of patients with thoracolumbar burst fractures; however, it fails to assess the ability of the injured spine to withstand compressive loading and cannot predict instrumentation failure after short-segment posterior fixation. The load-sharing classification depends on the degree of comminution and apposition of bony fragments.We retrospectively classified according to both classifications 100 consecutive patients with 1-level thoracolumbar burst fractures treated nonoperatively or operatively within a 7-year period. Sixty neurologically intact patients (60%) were treated nonoperatively, 15 (15%) had short posterior instrumentation, 15 (15%) had short anterior instrumentation, and 10 (10%) had combined short posterior instrumentation and anterior strut grafting. Twenty-five of the 40 (60%) surgically treated patients had neurological impairment on admission. Clinical outcome was assessed using a pain and working ability scale. Mean follow-up was 52 months (range, 24-70 months). Function was satisfactory in 55 (92%) nonoperatively treated patients and in 33 (83%) surgically treated patients. Neurological improvement by American Spinal Injury Association (ASIA) grade was observed in patients with incomplete paraplegia (70% of neurologically impaired patients) who were treated operatively.The combination of AO-Magerl and load-sharing classifications provides for accurate selection of treatment, surgical approach, and length of instrumentation, and can guide the decision for additional anterior surgery.

Treatment of pathologic spinal fractures with combined radiofrequency ablation and balloon kyphoplasty.

BACKGROUND: In oncologic patients with metastatic spinal disease, the ideal treatment should be well tolerated, relieve the pain, and preserve or restore the neurological function.The combination of fluoroscopic guided radiofrequency ablation (RFA) and kyphoplasty may fulfill these criteria. METHODS: We describe three pathological vertebral fractures treated with a combination of fluoroscopic guided RFA and kyphoplasty in one session: a 62-year-old man suffering from a painful L4 pathological fracture due to a plasmocytoma, a 68-year-old man with a T12 pathological fracture from metastatic hepatocellular carcinoma, and a 71-year-old man with a Th12 and L1 pathological fracture from multiple myeloma. RESULTS: The choice of patients was carried out according to the classification of Tomita. Visual analog score (VAS) and Oswestry disability index (ODI) were used for the evaluation of the functional outcomes. The treatment was successful in all patients and no complications were reported. The mean follow-up was 6 months. Marked pain relief and functional restoration was observed. CONCLUSION: In our experience the treatment of pathologic spinal fractures with combined radiofrequency ablation and balloon kyphoplasty is safe and effective for immediate pain relief in painful spinal lesions in neurologically intact patients.