Fourth Lumbar Research Articles

Bilateral Iatrogenic Femoral Neuropathy.

Dear Editor, Postoperative femoral neuropathy is an uncommon complication associated with pelvic/abdominal surgery. The main mechanism underlying this neuropathy is stretching and/or prolonged compression of the nerve.1,2 The nerve compression can be caused by the self-retaining retractors that are sometimes used during surgery directly constricting the nerve against the pelvic sidewall and inducing ischemia.1 Symptoms of femoral neuropathy are weakness of ipsilateral hip flexion and knee extension, and sensory deficit on the anteromedial thigh. The prognosis is generally good, with partial or complete recovery being common. Postoperative femoral neuropathy is generally unilateral2,3,4; bilateral postoperative femoral neuropathy appears to be very rare.5,6 Herein we report a case of bilateral femoral nerve neuropathy that occurred in a patient undergoing abdominal surgery. A thin 44-year-old woman was diagnosed with rectosigmoid cancer and underwent a Hartmann surgical procedure, which involves resection of the rectosigmoid colon with creation of a colostomy bag. The presurgery general and neurological visits did not disclose any unexpected abnormalities. She had previously been physically healthy, with no underlying diseases such as hypertension, diabetes mellitus, or peripheral neuropathy. During the surgery, she was placed in a lithotomy position and a bilateral self-retaining retractor was used to facilitate the exploration of the surgical field. The surgery took about 2 hours. During recovery from the anesthesia, the patient complained of hypoesthesia over the anteromedial side of both thighs and proximal weakness in both lower limbs; in the immediate postoperative period she could neither stand nor get out of bed. A neurological examination revealed bilateral weakness of the knee extensor and hip flexor, hypoesthesia in the anteromedial thigh, and bilateral patellar areflexia. Muscle strength was assessed on both legs on the Medical Research Council scale: the iliopsoas and quadriceps muscles scored 2/5, while the adductor, hamstrings, and tibialis anterior muscles scored 5/5. An extensive diagnostic work-up was negative for abnormalities. Neurophysiological studies performed a few days after the onset of symptoms revealed bilateral femoral neuropathy (Table 1). The patient underwent physical therapy. Table 1 Electromyography (EMG) summary of lower limb muscles in the patient with bilateral femoral neuropathy At a 6-month follow-up the patient had only partially regained sensory and motor functions; she was able to walk with a double cane. Electromyography performed 1 year after symptom onset demonstrated persistent bilateral femoral nerve neuropathy. The femoral nerve originates from the posterior division of the ventral branch of the second to fourth lumbar roots behind the psoas muscle; it passes in the groove between the psoas and iliac muscles and descends into the thigh beneath the inguinal ligament. The pathophysiology of the nerve injury in abdominal/pelvic surgery includes compression, stretch, ischemia, and ileopsoas hematoma.1,2 The injury is often caused by the use of a self-retraining retractor directly compressing the nerve against the abdominal wall as it courses through the body of the psoas muscle, or compression of the iliac vessels, causing ischemia to the nerve.1 Individual patient factors such as comorbid conditions (e.g., diabetes or peripheral neuropathy), and factors related to the surgery (e.g., prolonged lithotomy position) might contribute to postoperative femoral neuropathy. This case represents a rare case of postsurgery bilateral femoral neuropathy. A review of the patient's clinical chart revealed that the duration of the intervention was about 2 hours, which is within the normal range for the Hartmann procedure, and that there were no surgery-related complications. This suggests that the bilateral nerve damage in this patient was most probably caused by improper retractor use. Neurologists and surgeons should be aware of this rare and potentially treacherous complication of the pelvic/abdominal surgery. Diagnosis should be prompt so that physical therapy is commenced as soon as is practicable.

Bone Density in Patients with Cervical Cancer or Endometrial Cancer in comparison with Healthy Control; According to the stages

Objective: To evaluate the bone mineral density (BMD) in the lumbar spine and femur in postmenopausal women with cervical cancer and endometrial cancer without bone metastasis in comparison with that in healthy control postmenopausal women, and to assess the loss of BMD according to the cancer stage.Materials and methods: We analyzed the BMD of the lumbar spine and femur using dual-energy X-ray absorptiometry (DXA) in 218 patients with cervical cancer, 85 patients with endometrial cancer, and 259 healthy controls. The serum levels of calcium (Ca), phosphorus (P), osteocalcin (OSC), and total alkaline phosphatase (ALP), and urine deoxypyridinoline(DPL) were measured in all participants.Results: Age, body mass index, parity, and time since menopause were not significantly different between the three groups. Serum Ca level was higher in the cervical cancer group (p = 0.000), however, urine DPL was lower in endometrial cancer group (p = 0.000). The T-scores of basal BMD at the second and fourth lumbar vertebra (L2, L4) were significantly lower in patients with cervical cancer (p = 0.038, 0.000, respectively) compared to those in the healthy control groups. Additionally, the incidence of osteoporosis and osteopenia basal status of bone mass was significantly higher in patients with cervical cancer compared to that in controls (p = 0.016). No differences in basal BMD of the lumbar spine and femur were observed between patients with cervical cancer according to their stages.Conclusion: Our results suggest that postmenopausal women with cervical cancer have a lower BMD and are at increased risk of osteoporosis in the lumbar spine before receiving anticancer treatment compared with postmenopausal women with endometrial cancer.

Association between the Number of Chondrocytes of Lumbar Intervertebral Discs and Age, Abdominal Aorta Atherosclerosis and Lumbar Artery Arteriosclerosis Descriptive Cross Sectional Study

Background: The effect of age, atherosclerotic changes of abdominal aorta and arteriosclerotic changes of lumbar arteries on number of chondrocytes of lumbar intervertebral discs has not been studied. Methods: A descriptive cross sectional post mortem study was carried out in Faculty of Medicine, University of Kelaniya, Sri Lanka to determine the association between the mean number of chondrocytes in the fifth lumbar intervertebral disc and age, the level of atherosclerotic changes of the lumbar abdominal aorta and arteriosclerotic changes of right and left, fourth lumbar arteries. The presence or absence of atherosclerotic plaques in the abdominal aorta lumbar region was studied. To assess arteriosclerotic changes, the Intima Media thickness (IMT) and the total thickness (TT) of lumbar arteries were measured and the ratio IMT/TT was calculated. Bivariant analysis and a multi variant analysis were done. Results: There were 51 samples in total. Their ages ranged from 18 to 96 years. The mean age (SD) was 43 (± 17.1) years. The samples were obtained from 38 males and 13 females. There was a significant negative association (P<0.001; Beta Coefficient=- 0.95) between the age of the subject and the mean number of chondrocytes in the intervertebral disc. There was no significant association between atherosclerotic changes of abdominal aorta and arteriosclerotic changes of lumbar arteries and the mean number of chondrocytes. Conclusion: Only the age had a significant negative association with the mean number of chondrocytes of the intervertebral disc.

First-in-man endovascular preconditioning of the paraspinal collateral network by segmental artery coil embolization to prevent ischemic spinal cord injury

Spinal cord injury remains an invincible complication affecting up to 1 of 5 patients after thoracoabdominal aortic aneurysm repair. A staged surgical approach has been suggested to eliminate paraplegia by induction of arteriogenesis within the paraspinal collateral network; however, its clinical implementation was deferred because it required 2 major procedures. First-in-man experience with minimally invasive, selective segmental artery endovascular coil embolization before Crawford type II and III thoracoabdominal aortic aneurysm repair for arteriogenic preconditioning of the collateral network is reported. A 45-year-old man received bilateral elective minimally invasive, selective segmental artery endovascular coil embolization of 2 unilateral lumbar segmental arteries 4 weeks before open surgical repair. A 67-year-old woman who was planned for total endovascular treatment received minimally invasive, selective segmental artery endovascular coil embolization at the fourth lumbar level and coil embolization of the inferior mesenteric artery 8 weeks before endovascular repair. Minimally invasive, selective segmental artery endovascular coil embolization was technically successful and did not result in any neurologic impairment. Both patients were discharged after 72 hours of clinical surveillance. Patient 1 returned for definite open single-stage thoracoabdominal aortic aneurysm repair after 4 weeks and left the hospital without any neurologic impairment on day 35 postoperatively. Patient 2 returned for total endovascular repair 8 weeks after she underwent minimally invasive, selective segmental artery endovascular coil embolization; she recovered well and was discharged without spinal cord injury 8days after extensive single-stage endovascular thoracoabdominal aortic aneurysm repair. Both patients are alive with no neurologic injury at 1-year follow-up. Minimally invasive, selective segmental artery endovascular coil embolization for arteriogenic preconditioning of the paraspinal arterial collateral network is clinically feasible and may eventually eliminate ischemic spinal cord injury to enable safe open or endovascular repair of extensive thoracoabdominal aortic aneurysms and prevent paraplegia altogether in the near future.

Identificación de puntos de referencia anatómicos para la valoración del equilibrio mediante dispositivos cinemáticos

ObjectiveThis paper has aimed to analyze the behavior of the spinal levels used most in the kinematic analysis and to define the best place for accelerometers to measure balance in adults. Material and methodA total of 71 healthy adults were evaluated. Most were women (92.96%), with an average age of 64.86 years (SD±7.63). Three tri-axial accelerometers were used to evaluate balance. One was placed on the sternum and two more on L4 and L5-S1. Kinematic data was obtained from two balance tests: eyes closed monopodal balance and monopodal dynamic balance.Exclusion criteria included inability to walk independently; to be unable to maintain bipodal static balance with eyes wide-open for 60seconds and the existence of contraindications to be tested. All the subjects performed the tests in bare feet with socks. ResultsThe results showed that the three reference locations analyzed during the balance tests proportionally increased to the distance to the center of gravity. Regarding the optimal devise placement point in the lumbar-pelvic regions, the results obtained did not show significant differences between the accelerometer on L4 and L5-S1. ConclusionsUsing the fourth lumbar vertebra for measurement is recommended because it limits the introduction of noise on the accelerometer signal due to pelvic girdle motion.

Deterioration of trabecular bone microarchitecture in the lumbar vertebrae in growing male mice following sciatic neurectomy

Sciatic nerve injury (SNI) can lead to significant bone loss in the lower extremities. However, the effects of SNI on the lumbar vertebrae are controversial. The present study aimed to evaluate the longitudinal effects of SNI on the lumbar vertebrae. Twenty-four 12-week-old male C57BL/6 mice (24.55±0.17 g) were randomly assigned to 3 groups (8 mice each) and underwent unilateral sciatic neurectomy (USN group), bilateral sciatic neurectomy (BSN group), or no surgery (CON group). The third (L3) and fourth (L4) lumbar vertebrae were scanned by in-vivo micro-computed tomography (iCT) preoperatively and at 14 and 28 days postoperatively. Using μCT images, structural parameters and bone mineralization density distribution of the trabecular bone were analyzed among the 3 groups. In the BSN group, structural and material properties of L3 and L4 worsened after 14 days. Deterioration in the structural properties of L3 was observed at 28 days in the USN group, whereas no changes were observed in L4. These results implied that SNI can cause considerable deterioration in the microarchitecture of trabecular bone in the lumbar vertebrae. However, differences in the magnitude and rate of the deterioration and its onset period are observed between cases of unilateral and bilateral SNI.

L4 fractures, biomechanics of cure foretold

Objectives: To analyze the clinical and radiographic outcomes in fracture of the fourth lumbar vertebra, under conservative or surgical treatment. Methods: Patients diagnosed with L4 fracture with or without neurological injury were studied and to whom conservative or surgical treatment was provided. Radiographic measurements were performed taking into account the kyphosis angle, the sagittal index, loss of vertebral body height, percentage of canal occlusion and height compression percentage. Results: Twenty-five patients were treated, five conservatively and 20 surgically. The vertebral kyphosis angle in both groups was 12&amp;#176;, no regional kyphosis was present, the sagittal index was 11.9 (Farcy), the loss of vertebral body height was 53.17%, the percentage of canal occlusion was 23% and the height compression percentage was 38.06%. The residual pain according to the visual analog scale was two in both groups. Conclusions: Patients with a fractured L4 have a satisfactory outcome with both treatments, the height of the vertebral body remains the same, the lordosis is preserved and therefore the sagittal balance, allowing recovering the mechanical functions of the spine as opposed to other segment fractures.

Risk factors for a persistent type 2 endoleak after endovascular aneurysm repair.

To investigate the natural course of type 2 endoleaks (T2Es) and to identify the risk factors associated with a persistent T2E after endovascular aneurysm repair (EVAR). The medical records of patients who underwent EVAR for the treatment of an atherosclerotic abdominal aortic aneurysm between October 2006 and December 2011 at our institute were reviewed. T2Es were diagnosed by contrast-enhanced computed tomography within 4 weeks of EVAR, and patients were followed up at 6 and 12 months. In cases where a T2E was detected, the blood vessels responsible for the T2E were identified and statistically analyzed for their association with a persistent T2E. We identified T2Es in 111 of 469 patients within 4 weeks of undergoing EVAR. During the follow-up, 41 patients (36.9 %) showed spontaneous resolution of their T2E. The percentage of patients with a T2E was 75.4, 69.2 and 58.0 % at 6, 12 and 24 months, respectively. T2E caused by defects in multiple vessels and T2E associated with the fourth lumbar artery were identified as risk factors associated with a persistent T2E in the univariate analysis. In the multivariate analysis, T2E caused by multiple vessels was identified as the only independent risk factor for a persistent T2E. We identified T2E caused by multiple vessel failure as an independent risk factor for persistent T2E.

Cyanidin 3-O-β-D-Glucoside Improves Bone Indices.

Oxidative stress (OS) promotes bone loss after menopause, and there is evidence that dietary antioxidants may reduce the level of OS in vivo. This study examined dose-dependent effects of blackberries (BBs) containing mainly cyanidin 3-O-β-d-glucoside (C3G) in preventing bone loss in an ovariectomized (Ovx) rat model. Nine-month-old female (N=38) Sprague-Dawley rats were scanned using dual-energy X-ray absorptiometry for baseline whole body, bone mineral content (BMC), and bone mineral density (BMD). One group was sham operated (Sham) and three groups were ovariectomized (Ovx). The groups and corresponding diets were Sham+control diet (n=12), Ovx+control diet (n=12), Ovx+5% BB (n=7), and Ovx+10% BB (n=7). Control diet was AIN-93M rodent diet, and the Ovx+5% BB and Ovx+10% BB were a diet modified to contain powdered, freeze-dried BB at levels of 5% and 10% (w/w). Following 100 days of treatment, whole body BMC and BMD were reassessed and bone specimens, blood, and 24-h urine samples were collected for analyses. Findings indicate that ovariectomy (Ovx) compromised whole body BMC and trabecular microarchitecture of the proximal tibia and fourth lumbar vertebra. C3G-rich BB at the level of 5% modestly protected BMDs, loss of the tibia, lumbar vertebra, and femur by 2.4%, 2.7%, and 4.3% (P<.0013; .0437; .0004), respectively. BB 5% treatment significantly prevented loss of tibial trabecular bone volume and trabecular number by 37% and 21%, respectively (P<.05), and also significantly prevented tibial trabecular separation by 22%. We conclude that C3G-rich BB treatment at the level of 5% (w/w) but not at 10% (w/w) may modestly reduce Ovx-induced bone loss evident by improved tibial, vertebral, and femoral BMD values, and tibial bone microstructural parameters. Bone protective effects may be as a result of the synergistic effects of phenolic compounds; however, further work is required to determine BBs' specific mechanisms of action.

Effect of muscle mass on toxicity and survival in patients with colon cancer undergoing adjuvant chemotherapy.

The purpose of this study was to elucidate the effect of decreased muscle mass on the toxicity and survival of patients with colon cancer treated with adjuvant chemotherapy after surgery. We reviewed the data of 229 consecutive patients with stage III colon cancer who received adjuvant oxaliplatin, 5-fluorouracil, and leucovorin chemotherapy at a single center between 2003 and 2010. Baseline muscle mass was assessed by measuring the cross-sectional area of the psoas muscle at the level of the fourth lumbar vertebra on computed tomography images. Effects of muscle mass on toxicity of chemotherapy and survival were assessed. The median age of the 229 patients was 61 years (range, 28-80) and 134 (58.5 %) were men. The mean psoas muscle mass index (PI, psoas muscle area divided by height(2) [mm(2)/m(2)]) was 548.3. A 1 SD decrement in the PI was associated with an increase in all grade 3-4 toxicities in univariate (OR = 1.69, 95 % CI = 1.18-2.27) and multivariate (OR = 1.56, 95 % CI = 1.05-2.38) analyses. In univariate analysis, the PI was not associated with overall survival. However, multivariate analysis showed that a 1 SD decrement in the PI increased the hazard of overall mortality by 85 % (HR = 1.85, 95 % CI = 1.10-3.13). This effect of the PI on mortality was maintained in subgroup analyses, especially in older and obese patients. Decreased muscle mass was associated with increased risk of grade 3-4 toxicity and poor prognosis in patients with stage III colon cancer.

The Effects of Locally Injected Triamcinolone on Entrapment Neuropathy in a Rat Chronic Constriction Injury Model

Patients with idiopathic carpal tunnel syndrome are commonly treated by steroid injections into the carpal tunnel. We administered triamcinolone (Tr) to chronic constriction injury model rats. We hypothesized that Tr administration would have both favorable behavioral effects and quantifiable immunohistological effects on compressed nerves. Thirty-six male Wister rats were used. For rats to be treated with Tr, we loosely ligated their right sciatic nerves at 4 sites. Sham rats had their nerves exposed without ligation. On postoperative day 7, we reexposed their ligated nerves, after which we delivered either 0.1 mg of Tr (0.1-mg group), 0.5 mg of Tr (0.5-mg group), or normal saline (saline group) around the nerve fibers at the injured sites. Gait was analyzed, and allodynia was assessed with von Frey hairs, before surgery and on postoperative days 3, 7, 10, 14, and 21. The right sciatic nerve was resected and stained using hematoxylin-eosin, and the fourth and fifth lumbar dorsal root ganglia (DRG) were removed and assessed by immunohistochemistry for calcitonin gene-related peptide (CGRP) and activating transcription factor 3 (ATF3) on postoperative day 21. In addition, interleukin-1β (IL-1β) in sciatic nerve was quantified using enzyme-linked immunosorbent assays. Mechanical allodynia was significantly decreased in the 0.5-mg group compared with the saline group. In hematoxylin-eosin sections, the extent of inflammation-induced edema between the nerve fibers and infiltration of inflammatory cells was significantly reduced in the 0.5-mg group compared with the saline group. IL-1β levels at the sciatic nerve in the 0.5-mg group were significantly lower than those in the saline group. Tr-treated chronic constriction injury rats exhibited significant alleviation of sensory disturbance, edema, inflammation, and pain-related peptide upregulation. These phenomena suggest the validity of Tr administration as a treatment affecting the nerve itself. Therapeutic I.

Sigma-1 receptor antagonism restores injury-induced decrease of voltage-gated Ca2+ current in sensory neurons.

Sigma-1 receptor (σ1R), an endoplasmic reticulum-chaperone protein, can modulate painful response after peripheral nerve injury. We have demonstrated that voltage-gated calcium current is inhibited in axotomized sensory neurons. We examined whether σ1R contributes to the sensory dysfunction of voltage-gated calcium channel (VGCC) after peripheral nerve injury through electrophysiological approach in dissociated rat dorsal root ganglion (DRG) neurons. Animals received either skin incision (Control) or spinal nerve ligation (SNL). Both σ1R agonists, (+)pentazocine (PTZ) and DTG [1,3-di-(2-tolyl)guanidine], dose dependently inhibited calcium current (ICa) with Ba(2+) as charge carrier in control sensory neurons. The inhibitory effect of σ1R agonists on ICa was blocked by σ1R antagonist, BD1063 (1-[2-(3,4-dichlorophenyl)ethyl]-4-m​ethylpiperazine dihydrochloride) or BD1047 (N-[2-(3,4-dichlorophenyl)ethyl]-N-m​ethyl-2-(dimethylamino)ethylamine dihydrobromide). PTZ and DTG showed similar effect on ICa in axotomized fifth DRG neurons (SNL L5). Both PTZ and DTG shifted the voltage-dependent activation and steady-state inactivation of VGCC to the left and accelerated VGCC inactivation rate in both Control and axotomized L5 SNL DRG neurons. The σ1R antagonist, BD1063 (10 μM), increases ICa in SNL L5 neurons but had no effect on Control and noninjured fourth lumbar neurons in SNL rats. Together, the findings suggest that activation of σR1 decreases ICa in sensory neurons and may play a pivotal role in pain generation.

Penetration Approach for Repeat Vertebroplasty Through the Previously Impacted Bone Cement

Dear Editor, Vertebroplasty (VP) and kyphoplasty (KP) are effective treatments for painful vertebral compression fractures (VCFs) [1,2]. Although not common, subsequent refracture in the previously augmented vertebra causes persistent or recurrent pain [3]. Some reports have shown that repeat VP can control pain caused by refractures [3–5]. However, repeat VP is challenging because the previously impacted bone cement blocks the fluoroscopic views and access of procedure needles. A 57-year-old woman presented with severe pain (visual analog scale [VAS] 8/10) in her lower back and both thighs, which left her unable to sit or walk. She had a history of rectal cancer that had metastasized to the liver and lungs. Six months previously, metastasis to the fourth lumbar vertebra was detected and KP was performed (Figure ⇓). After the procedure, her pain reduced from VAS 8 to 2, but it recurred a week before her visit to our clinic. Magnetic resonance imaging (MRI) revealed further metastatic progression in the L4 vertebral body, and bone cement was located in front of the left pedicle (Figure ⇓). After the failure of conservative treatments, we undertook repeat VP with a …

Foot drop after a suicide attempt

A 33-year-old male presented with a 2-month history of left foot drop, starting upon waking up 3 days after a suicide attempt with ingestion of high doses of phenobarbital, clonazepam, and alcohol. Painful left drop foot, trophic changes in the lower extremities, and bilateral Achilles areflexia were noted. Magnetic resonance neurography (MRN) of the lumbosacral plexus and left thigh showed thickening and signal intensity (SI) abnormality in the left sciatic nerve along the pelvic outlet and proximal thigh (Fig. 1). Denervation of the lumbosacral plexus affecting the quadratus femoris, piriformis, obturator, and adductor muscles with areas without contrast enhancement consistent with myonecrosis was seen on the pelvis, while denervation of the hamstring muscles related to sciatic neuropathy was seen on the thigh (Fig. 2). Electroneuromyography showed complete motor and sensitive axonal impairment of the left peroneal nerve, partial impairment of the left tibial nerve (with reinnervation), and partial impairment of the left femoral nerve. A compressive-ischemic mechanism after a long-term sideways position during unconsciousness was indicated as the cause of the clinical and imaging findings in this case. Sciatic neuropathy is the second most common cause in the legs, after peroneal neuropathy, and may be caused by acute or chronic compression, stretching, ischemia, laceration, or toxic injury (injections) as well as iatrogenic lesions (hip arthroplasty). Increased pressure on the nerve can cause injury either directly or indirectly as a result of compression of the vasa nervorum if the ischemia is prolonged, which was the most likely mechanism in our case [1, 2]. The sciatic nerve derives from the fourth and fifth lumbar and first and second sacral roots, coursing down deeper to the piriformis muscle with anatomical variations. It continues posteromedially to the hip and distally deep in the thigh before dividing into the tibial and common peroneal nerves above the popliteal fossa [2, 3]. MR imaging patterns vary depending on the muscle denervation stage: acute and subacutely denervated muscles show high SI on fluid-sensitive images and normal SI on T1-weighted images; in chronic denervation, muscle atrophy and fatty infiltration demonstrate high SI on T1-weighted images in association with volume loss [4]. On the other hand, myonecrosis is revealed by high SI on T1-weighted images, heterogeneously high SI on T2weighted images, and rim enhancement on contrastenhanced images [5]. A possible overlap of denervation No related papers from the same study have been published or submitted.

Mo1925 Prognostic Significance of CT Muscle Density in Upper GI Cancer

Introduction: Upper gastrointestinal (UGI) surgery is by definition high risk and frequently performed in malnourished patients with a significant incidence of sarcopenia (age-associated loss of skeletal muscle mass and function). Nutritional support is an integral component of enhanced recovery protocols (ERP) to mitigate post-operative risk, and the aim of this study was to investigate the prognostic significance of sarcopenia as defined by CT density of muscle mass in UGI cancer. Methods: One hundred and seven consecutive patients undergoing surgery for UGI cancer [median age 66 yr, 79 m, 55 esophageal (46 ACA, 9 SCC), 52 gastric cancer] were studied prospectively. The axial CT slice at the upper border of the fourth lumbar vertebra was identified and a region of interest was drawn around each psoas muscle. The mean psoas muscle CT density (PMD) was calculated within the region in Hounsfield units (HU) by the Agfa PACS system, and the greater of the two density measurements was used for analysis. The primary outcome measure was survival. Results: Median PMD was 49.25 (range -5.55 to 73.73) HU. Nineteen patients (17.8%) had low PMD ( 40 HU 70.4%, p<0.001). On multivariate analysis only rTNM stage was independently associated with survival (HR 2.157, 95% CI 1.450-3.209, p<0.001). Conclusion: CT defined psoas muscle density (PMD) and by implication sarcopenia, is an important and new prognostic indicator in UGI cancer. Patients identified as such should enter targeted strategic ERP protocols.

Mo1926 Selenium Supplement Ameliorates Chemotherapy-Induced Mucositis in Rat Small Intestine

Introduction: Upper gastrointestinal (UGI) surgery is by definition high risk and frequently performed in malnourished patients with a significant incidence of sarcopenia (age-associated loss of skeletal muscle mass and function). Nutritional support is an integral component of enhanced recovery protocols (ERP) to mitigate post-operative risk, and the aim of this study was to investigate the prognostic significance of sarcopenia as defined by CT density of muscle mass in UGI cancer. Methods: One hundred and seven consecutive patients undergoing surgery for UGI cancer [median age 66 yr, 79 m, 55 esophageal (46 ACA, 9 SCC), 52 gastric cancer] were studied prospectively. The axial CT slice at the upper border of the fourth lumbar vertebra was identified and a region of interest was drawn around each psoas muscle. The mean psoas muscle CT density (PMD) was calculated within the region in Hounsfield units (HU) by the Agfa PACS system, and the greater of the two density measurements was used for analysis. The primary outcome measure was survival. Results: Median PMD was 49.25 (range -5.55 to 73.73) HU. Nineteen patients (17.8%) had low PMD ( 40 HU 70.4%, p<0.001). On multivariate analysis only rTNM stage was independently associated with survival (HR 2.157, 95% CI 1.450-3.209, p<0.001). Conclusion: CT defined psoas muscle density (PMD) and by implication sarcopenia, is an important and new prognostic indicator in UGI cancer. Patients identified as such should enter targeted strategic ERP protocols.

Epithelioid angiosarcoma of the spine: A case report of a rare bone tumor.

Epithelioid angiosarcoma (EA) is an extremely rare subtype of angiosarcoma, which is characterized by large cells with an epithelioid morphology. EA typically arises in deep soft tissues, including the adrenal gland, skin and thyroid, however, EA rarely arises in the spine. The current study presents a case of osteolytic lesions involving the fourth lumbar (L4) level of the spine. Preoperatively, the patient was misdiagnosed with metastatic carcinoma, however, a radiological examination detected the presence of osteolytic or destructive lesions in the vertebrae, which extended into the pedicles. Histopathological and immunohistochemical evaluations were performed on the tumor tissue obtained from a decompression specimen of the L4 vertebra. A bone lesion composed of sheet-like malignant cells exhibiting atypical epithelioid morphology with vascular formation was observed. The presence of anastomosing vascular channels lined by epithelioid endothelial cells also indicated that focal endothelial differentiation had occurred. In addition, immunohistochemistry assays revealed that the lesion was positive for the endothelial cell markers, CD31, CD34 and vimentin. The tumor was treated with decompression of the L4 vertebra, followed by posterior stabilization. The patient subsequently refused chemotherapy and radiotherapy but completed six months of follow-up. At the time of writing, the tumor remains under control and the patient is asymptomatic. This case highlights the difficulty of diagnosing EA, which requires careful pathological examination and immunophenotype labeling. At present, CD31 is the most sensitive marker for detecting EA.

Bone Structure and Strength are Enhanced in Rats Programmed by Early Overfeeding

Childhood obesity is growing in prevalence. Obesity and bone dysfunctions may be related disorders, and therefore our aim was to study the impact of the early overfeeding (EO) in offspring bone health since weaning up to adulthood. To induce EO during lactation, litter size was adjusted to 3 male rats per litter (SL). Litter containing 10 pups per mother was the control (NL). Bone tissue was evaluated by dual-energy X-ray absorptiometry, computed tomography, microcomputed tomography, biomechanical tests, and serum analyses. SL offspring presented higher body weight, fat mass, lean mass from 21 up to 180 days, hyperphagia, and higher visceral fat mass. Bone analysis showed that SL offspring presented higher total bone mineral density (BMD) only at 180 days, and higher total bone mineral content and higher bone area from 21 until 180 days. At 180 days, SL offspring presented higher femur BMD and fourth lumbar vertebra (LV4) BMD, higher femoral head radiodensity and LV4 vertebral body radiodensity, lower trabecular pattern factor and trabecular separation, however with higher trabecular number, higher maximal load, resilience, stiffness and break load, and lower break deformation. SL group had, at 180 days, higher osteocalcin and lower C-terminal cross-linked telopeptide of type I collagen (CTX I). We have shown that the excess of fat mass contributed to an increased bone mass, and hypothesized that this increase could be mediated by the hypothyroidism and previous higher thyroid hormone action and hyperleptinemia at weaning. Furthermore, the increased biomechanical loading due to increased body weight probably help us to understand the protective effects obesity exerts upon bone health.

Effect of Low Level Laser Therapy on Chronic Compression of the Dorsal Root Ganglion

Dorsal root ganglia (DRG) are vulnerable to physical injury of the intervertebral foramen, and chronic compression of the DRG (CCD) an result in nerve root damage with persistent morbidity. The purpose of this study was to evaluate the effects of low level laser therapy (LLLT) on the DRG in a CCD model and to determine the mechanisms underlying these effects. CCD rats had L-shaped stainless-steel rods inserted into the fourth and fifth lumbar intervertebral foramen, and the rats were then subjected to 0 or 8 J/cm2 LLLT for 8 consecutive days following CCD surgery. Pain and heat stimuli were applied to test for hyperalgesia following CCD. The levels of TNF-α, IL-1β and growth-associated protein-43 (GAP-43) messenger RNA (mRNA) expression were measured via real-time PCR, and protein expression levels were analyzed through immunohistochemical analyses. Our data indicate that LLLT significantly decreased the tolerable sensitivity to pain and heat stimuli in the CCD groups. The expression levels of the pro-inflammatory cytokines TNF-α and IL-1β were increased following CCD, and we found that these increases could be reduced by the application of LLLT. Furthermore, the expression of GAP-43 was enhanced by LLLT. In conclusion, LLLT was able to enhance neural regeneration in rats following CCD and improve rat ambulatory behavior. The therapeutic effects of LLLT on the DRG during CCD may be exerted through suppression of the inflammatory response and induction of neuronal repair genes. These results suggest potential clinical applications for LLLT in the treatment of compression-induced neuronal disorders.

Monostotic Fibrous Dysplasia of the Lumbar Vertebra: A Case Report and Review of the Literature.

Fibrous dysplasia (FD) is an uncommon benign fibro-osseous lesion of the bone, characterized by the replacement of normal cancellous bone with fibroblastic tissue that contains irregularly shaped metaplastic woven bone1. This disease has different forms: monostotic (MFD), polyostotic (PFD), or variable with cutaneous and endocrine abnormalities (McCune-Albright syndrome)2. MFD most commonly affects the ribs, femur, tibia, jaws, calvarium, and humerus3,4. Spine involvement in MFD is exceedingly rare, particularly in the lumbar spine. To our knowledge, there have been only fifteen cases of lumbar MFD previously described in the literature4-18. We present a rare case of MFD of the fourth lumbar vertebra and review the relevant literature. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A thirty-seven-year-old woman presented with right-sided low back pain of five years’ duration. One month before admission, she developed bilateral leg pain and numbness, which was more prominent on the right side. The pain became worse at night and forced her to be confined to bed. No history of trauma was reported. The family history was unremarkable. Conservative treatment, including the use of nonsteroidal anti-inflammatory drugs and bracing, failed. Physical examination revealed tenderness over the right paravertebral area of L4. The spinal range of motion was impaired. The straight leg raise test was positive at 40° on the right side and 50° on the left side. Sensation to pinprick was diminished between the L4 and L5 dermatomes on both sides, but especially on the right side. There were motor deficits. No endocrinological dysfunction or skin pigmentation was present. Deep tendon reflexes were symmetrical. Laboratory investigation, including total blood-cell count, hormone levels, erythrocyte sedimentation rate, C-reactive protein level, cancer marker (alpha-fetoprotein [AFP], CA10, carcinoembroyonic antigen …