L5 Vertebral Body Research Articles

Serum C-reactive protein in dogs with paraplegia secondary to acute intervertebral disc extrusion.

BackgroundApart from the absence of nociception, there is no readily available prognostic test for dogs presenting with paraplegia secondary to acute intervertebral disc extrusion (IVDE).ObjectiveTo assess if serum C‐reactive protein (CRP) can predict the postoperative outcome in paraplegic dogs undergoing surgery for IVDE and to assess the association between serum CRP and presence/absence of nociception on admission, and serum CRP and presence/absence of intramedullary changes seen on magnetic resonance imaging (MRI).AnimalsOne hundred dogs that underwent surgery at our hospital between 2018 and 2020 because of acute paraplegia secondary to IVDE and in which serum CRP was measured.MethodsRetrospective observational cohort study. Dogs were classified as 4 or 5 according to the modified Frankel score (MFS) depending on presence/absence of nociception, respectively. MRI images were reviewed and the T2‐weighted hyperintensity: L2 vertebral body length was measured. Postoperative outcome was defined as positive if nociception, ambulation or both returned after decompressive surgery.ResultsThe median (95% CI) serum CRP was 4 (4‐5) and 6 (4‐7) mg/L in MSF4 and MSF5, respectively (P = .03). A weak linear relationship (R 2 = 0.049, P = .03) was found between CRP and the T2‐weighted hyperintensity: L2 vertebral length. Outcome data was available for 85 dogs: CRP was 4 (4‐5) and 5 (4‐10) mg/L in positive and negative outcome dogs, respectively (P = .32).Conclusion and Clinical ImportanceSerum CRP did not predict outcome after surgery in dogs with paraplegia secondary to IVDE.

Case series and a systematic review concerning the level of the aortic bifurcation.

The aim of this study is to present the level of aortic bifurcation in a sample of Greek origin (case series) and to perform an up-to-date systematic review in the existing literature. Seventy-six formalin-fixed adult cadavers were dissected and studied in order to research the level of aortic bifurcation. Additionally, PubMed and Google Scholar databases were searched for eligible articles concerning the level of aortic bifurcation for the period up to February 2020. The mean level of aortic bifurcation according to our case series was the lower third of the L4 vertebral body (21/76, 27.6%). The level of aortic bifurcation ranged between the lower third of the L3 vertebral body and the lower third of the L5 body. No statistically significant correlation was found between the two sexes. The systematic review of the literature revealed 31 articles which were considered eligible and a total number of 3537 specimens were retracted. According to the recorded findings the most common mean level of aortic bifurcation was the body of L4 vertebra (1495/3537 cases, 42.2%), while the range of aortic bifurcation was described to occur from upper third of L3 vertebrae to the upper third of the S1 vertebrae in the 52.8% of the cases (1866/3537). The mean level of AA corresponds to the body of L4 and presents a great range (form L3U to S1U). Knowledge of the mean level of aortic bifurcation and its probable ranges is of great significance for interventional radiologists and especially vascular surgeons that deal with aneurism proximal to the aortic bifurcation.

MRI-based early diagnosis: a diabetic Charcot spine case report

BackgroundSpinal neuroarthropathy (SNA), also known as Charcot spine, is an uncommon aggressive arthropathy, secondary to loss of proprioceptive and nociceptive feedback from the spine. A diagnosis of SNA is frequently delayed due to the scarcity of symptoms in its early stages, leading to significant neurological deterioration. Therefore, prompt suspicion of the disease is critical to providing better outcomes. This case assembles two rare characteristics of SNA: diabetic aetiology and a precocious time of diagnosis, and aims to highlight the magnetic resonance imaging (MRI) findings that allowed for the diagnosis.Case presentationA 44-year-old woman, with long-term type 1 diabetes, presented with a two-month history of progressive lumbar pain, difficulty in maintaining an upright position, and discrete trunk forward-leaning. Diabetes-related vasculopathy and nephropathy were already known, and laboratory test results did not show any new abnormalities. A lumbar MRI revealed extensive signal intensity changes of the L2 and L3 vertebral bodies associated with marginal areas of enhancement and the involvement of regions adjacent to interapophyseal articulations and spinous processes from L2–L3 to L5–S1, in association with degenerative changes of the thoracolumbar spine. These findings were identified by the radiologist as suggestive of SNA. To rule out neoplastic and infectious disease, a bone biopsy at the L2–L3 level was executed. The pathology report revealed intervertebral disc material and fragments of fibrous tissue, with a complete absence of inflammatory cells. It was decided to perform a six-month MRI follow-up, which showed stability of the findings, confirming the hypothesis of Charcot spine. The patient was under clinical and radiological follow-up and did not require surgical fixation at the moment of diagnosis. After 2.5 years from the initial diagnosis, a new MRI revealed progression of the lesions with oedema and enlarged paravertebral soft tissues; these findings are compatible with the patient’s latest complaints of lumbar pain recurrence.ConclusionTo the best of our knowledge, this is the first case report of an MRI-based early diagnosis of diabetic SNA, a rare disease with nonspecific symptoms in its initial stages and a wide spectrum of differential diagnoses. The MRI findings, distinctly the involvement of both anterior and posterior spinal elements, were the key to allowing for the proper diagnosis. A precocious diagnosis, although challenging, is fundamental to providing early intervention and to preventing further neurological impairment.

Radiotherapy-Associated Pelvic Insufficiency Fracture Treated by Romosozumab: Course of L1 and L5 Vertebral Body CT Attenuation

Background: Radiotherapy is a risk factor for osteoporosis and insufficiency fractures via osteoblast apoptosis and vascular injury. PTH analogs teriparatide and abaloparatide are contraindicated in patients with prior exposure to radiotherapy crossing bone due to the increased risk of osteosarcoma. Patients with radiotherapy-associated fractures or osteoporosis were eligible only for antiresorptive agents until romosozumab was recently FDA-approved. Current International Society for Clinical Densitometry (ISCD) guidelines include assessment of “opportunistic CT” as a surrogate for DXA scan using L1 vertebral body attenuation: >150 Hounsfield units (HU) is normal and <100 HU signifies osteoporosis.Clinical Case: A 60 year old female patient with history of endometrial cancer diagnosed at age of 57 and treated with hysterectomy and bilateral salpingo-oophorectomy, chemotherapy, then pelvic radiotherapy, was referred to endocrinology for pelvic insufficiency fractures evaluation. Two years after completing chemoradiotherapy, she complained of right groin and low back pain with difficulty walking. MRI pelvis showed bilateral sacral ala and right pubic ramus insufficiency fractures. She had normal serum mineral concentration, 25-OH vitamin D sufficiency, normal PTH, eGFR, liver function tests and 24-hour urine calcium excretion. Screening for celiac disease and multiple myeloma was negative. DXA scan BMD T-score showed osteoporosis, -3.0 at the right femoral neck. L1-L4 T-score was +0.4 but unreliable due to presence of degenerative changes. Four months after onset of pain, patient started romosozumab 210mg SQ monthly for a total of 12 doses, after which she started oral alendronate. Pain essentially resolved within 6 months of romosozumab therapy. C-telopeptide (CTX) and procollagen type 1 N-terminal propeptide (P1NP) were obtained at baseline, 3 and 12 months after romosozumab initiation. CTX was 362, 247 and 258 pg/mL (reference range, >49 years: not established), and P1NP was 82, 178 and 62 mcg/L (reference range, 20 - 108), respectively. Attenuation of L1 and L5 vertebral body was measured using CT abdomen and pelvis scans before and 5 months after radiotherapy, and before and after completion of romosozumab therapy. L1 attenuation measured 161, 132, 127 and 179 HU, and L5 measured 150, 46, 50 and 86 HU, respectively.Conclusion: Pelvic radiotherapy was associated with a decline in L1 CT attenuation and even greater magnitude of decrease at L5. Romosozumab was associated with clinical improvement, restoration of L1 CT attenuation and diminishment of regain at L5. Although L5 attenuation has not been previously assessed for osteoporosis, this site may be of predictive value in patients who receive pelvic radiotherapy.

Low back pain with lumbar subcutaneous edema successfully treated using traditional Chinese medicine, including radix astragali

Abstract Introduction: Lumbar subcutaneous edema (LSE) is incidentally found in obese patients during the course of evaluating the cause of low back pain using magnetic resonance imaging (MRI). However, there is no established treatment for LSE, and the mechanism underlying its development is unknown. Patient concerns: A 77- year- old woman presented with chronic low back pain that had persisted for several years. Her BMI was 25.1 kg/m2, which indicates obesity in Japan. Diagnosis: MRI revealed LSE, which extended from the level of the L2 vertebral body to the sacrum. Interventions: We prescribed Maxing Yigan (MYG), a traditional Chinese medicine formula, to which we added powdered cinnamon bark and processed aconite root (hereafter referred to as modified MYG). Outcomes: This treatment was ineffective for six months. We then added Radix Astragali (RA) to the modified MYG. One month later, her low back pain was found to have markedly improved. MRI also confirmed that the LSE decreased remarkably. Conclusions: According to the clinical and MRI findings, modified MYG, including RA, was effective for the treatment of low back pain and LSE. The mechanism underlying the development of LSE could be lymphatic pooling due to perilymphatic inflammation associated with obesity. Modified MYG, including RA, might suppress perilymphatic inflammation and thereby improve lymphatic drainage. Further investigations are required to support this hypothesis.

Transposition of the Inferior Vena Cava (IVC) in a Patient with an Infrarenal Abdominal Aortic Aneurysm (AAA)

Computed tomography angiography in a 65 year old complaining of right sided abdominal pain with a palpable expansile mass revealed a 5 cm abdominal aortic aneurysm (AAA) and hydronephrotic right kidney secondary to calculus. Transposition of the inferior vena cava (IVC) was noted (A, white arrow). The confluence of the common iliac veins gives rise to the IVC at the level of L5 vertebral body. The left sided IVC crosses the aorta at the level of the left renal vein obscuring the aneurysm neck (B, white arrow). This anomaly has a prevalence of 0.3% and is significant at open repair as IVC transection and reconstruction may be required. Endovascular repair negates this challenge.Image 1

Biomechanical Changes of Adjacent and Fixed Segments Through Cortical Bone Trajectory Screw Fixation versus Traditional Trajectory Screw Fixation in the Lumbar Spine: A Finite Element Analysis

The finite element method was used to investigate the biomechanical adjustments of adjacent and fixed segments after lumbar fusion and fixation with traditional trajectory (TT) and cortical bone trajectory (CBT) screws. The model used was a validated nonlinearly L3-S1 finite element model. Interbody fusion cages and 2 types of screws were used to work on the L4-L5. To simulate flexion, extension, lateral bending, and axial rotation, all models were loaded in 3 planes with a compressive pre-load of 400 N and a bending moment of 7.5 N/m. Under various loading conditions, the range of motion (ROM), peak Von Mises stress of the vertebral body, stress of the intervertebral disc, stress of the facet joints, stress of the endplate, and stress of internal fixation were compared. In all instrumentation models, the ROM at fixed segments decreased. At adjacent segments, the ROM of the CBT model was greater than that of the TT model. The CBT model had a greater peak Von Mises stress of the L4 and L5 vertebral bodies, as well as greater stress of internal fixation, than the TT model. Furthermore, as compared with the TT model, the CBT model's facet joint and endplate stress were lower at fixed segments but higher at adjacent segments. The stress on the L3-L4 and L5-S1 intervertebral discs in the CBT and TT models, on the other hand, was nearly equivalent. At the fixed section, CBT may provide slightly better stability, endplate tension, and facet joint stress than TT. The greater ROM, endplate stress, and facet joint stress of CBT in adjacent segments, on the other hand, should be taken into account in the future.

Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study.

Emergency laparotomy is a considerable component of a colorectal surgeon's workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65s who underwent emergency laparotomy and emergency colorectal resection. An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann-Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3. Nine-hundred and forty-four over-65s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76years (IQR 70-82years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91). PML3 is an accurate predictor of mortality in over-65s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction.

Association of Lumbar Paraspinal Muscle Morphometry with Degenerative Spondylolisthesis.

The objective of this study was to assess the cross-sectional areas (CSA) of lumbar paraspinal muscles and their fatty degeneration in adults with degenerative lumbar spondylolisthesis (DLS) diagnosed with chronic radiculopathy, compare them with those of the same age- and sex-related groups with radiculopathy, and evaluate their correlations and the changes observed on magnetic resonance imaging (MRI). This retrospective study included 62 female patients aged 65–85 years, who were diagnosed with lumbar polyradiculopathy. The patients were divided into two groups: 30 patients with spondylolisthesis and 32 patients without spondylolisthesis. We calculated the CSA and fatty degeneration of the erector spinae (ES) and multifidus (MF) on axial T2-weighted magnetic resonance (MR) images from the inferior end plate of the L4 vertebral body levels. The functional CSA (FCSA): CSA ratio, skeletal muscle index (SMI), and MF CSA: ES CSA ratio were calculated and compared between the two groups using an independent t-test. We performed logistic regression analysis using spondylolisthesis as the dependent variable and SMI, FCSA, rFCSA, fat infiltration rate as independent variables. The result showed more fat infiltration of MF in patients with DLS (56.33 vs. 44.66%; p = 0.001). The mean FCSA (783.33 vs. 666.22 mm2; p = 0.028) of ES muscle was a statistically larger in the patients with DLS. The ES FCSA / total CSA was an independent predictor of lumbar spondylolisthesis (odd ratio =1.092, p = 0.016), while the MF FCSA / total CSA was an independent protective factor (odd ratio =0.898, p = 0.002)

A Rare Case of Intramuscular Schwannoma of Dorsal Ramus Nerve: A Case Report

Schwannoma is a benign, expansile neoplasm that originates from nerve sheaths. Intramuscular schwannoma is a rare tumor presenting as a slow-growing soft-tissue mass that may or may not has associated neurological symptoms. We present a rare case of intramuscular schwannoma of the dorsal ramus nerve in a 50-year-old female patient who presented with a single, firm, and well-defined swelling over the back region. On magnetic resonance imaging, a 54 mm × 23 mm × 20 mm, well-defined altered signal intensity lesion at the left posterior paraspinal region extending from the superior endplate of D12 to the inferior endplate of L1 vertebral bodies was noted which was suggestive of neurogenic tumor/ hemangioma. The swelling was excised and sent for histopathological examination (HPE). A diagnosis of intramuscular schwannoma was confirmed on HPE. Hence, all soft-tissue tumors should be sent for HPE for confirmation of the diagnosis and its further management.

Microwave Radiometry (MWR) temperature measurement is related to symptom severity in patients with Low Back Pain (LBP)

Microwave Radiometry (MWR) has the advantage that measurements of internal (i.e. deep) tissue temperature may be obtained non-invasively by measuring naturally emitted radiation in GHz range. The goal of the present study is to further the development of MWR for clinical application in assessment of patients with Low Back Pain (LBP). In particular, a protocol was developed in which MWR was used to measure internal temperature at the level of the spinous processes of the L1 to L5 vertebral bodies along median and left and right para-vertebral lines. The protocol was used to study 48 patients with clinically confirmed acute or sub-acute LBP and 27 Controls. Analysis revealed there to be a significant increase in deep tissue temperature with increasing pain severity as measured by using a Visual Analogue Scale (VAS) in patients with LBP (p < 0.05). In conclusion, MWR potentially allows for objective assessment of the magnitude of clinical symptoms in patients with LBP and shows promise for measuring pain severity.

Management of Neural Tube Defect: A Single-Center Experience

Objective: Neural tube defects are a heterogeneous and complex group of congenital central nervous system anomalies involving that involve the failed closure of the vertebral column. The spinal cord is frequently affected, and neural tube defects substantially increase the risk of disability and death within the first year of life. Neural malformations are often associated with abnormalities in other organ systems. This study presents our clinical experiences regarding the development and comorbidities of infants with neural tube defect and compares them with the literature.&#x0D; Materials and Methods: This retrospective study included 47 patients (24 females, 23 males) who underwent surgical treatment for neural tube defect in the neurosurgery department of Sivas Cumhuriyet University Faculty of Medicine Training and Research Hospital between 2000 and 2020.&#x0D; Results: Of the 47 patients, 34 (72.34%) had myelomeningocele and 13 (27.65%) had meningocele. Lesion location was thoracolumbar in 38 patients (80.85%), lumbar in 5 (10.63%), lumbosacral in 3 (6.38%), and cervical in 1 patient (2.12%). Twenty-seven patients (57.44%) underwent ventriculoperitoneal shunting due to hydrocephalus. Thirty patients (63.82%) had Chiari malformation type II, 13 (27.65%) had cranial anomalies, and 1 (2.12%) had Down syndrome. In 9 patients, the conus medullaris terminated at or below the L3 vertebral body (19.14%). Two patients (4.25%) died.&#x0D; Conclusion: Because of their multidimensional nature, neural tube defects have various effects on individuals, families, society, and the field of medicine. This study represents a small group of patients with neural tube defects. Cases should be included from other centers to compile more comprehensive data about patients with neural tube defects in Turkey.

Sarcopenia predicts perioperative adverse events following complex revision surgery for the thoracolumbar spine

Background ContextSarcopenia measured by psoas muscle index (PMI) has been shown to predict perioperative mortality and adverse events (AEs) after various surgical procedures. However, this relationship has not been studied in complex revision thoracolumbar spine surgery. PurposeThis study aimed to determine the relationship between sarcopenia and perioperative AEs among patients undergoing complex revision thoracolumbar spine surgery. Study DesignRetrospective cohort study Patient SampleA retrospective analysis was performed at a single institution between May 2016 and February 2020 of patients undergoing complex revision thoracolumbar spine surgery by three board certified fellowship-trained orthopaedic spine surgeons. Outcome MeasuresPerioperative adverse events including postoperative anemia requiring transfusion, cardiac complication, sepsis, wound complication, delirium, intra-operative dural tear, acute kidney injury, pneumonia, urinary tract infection, urinary retention, epidural hematoma, and deep vein thrombosis. Secondary outcome measures were 30-day readmission rates, 30-day re-operation rates, in-hospital mortality rates, discharge disposition, and postoperative length of stay (LOS). MethodsSarcopenia was analyzed using PMI, calculated at the L3 vertebral body measured on preoperative magnetic resonance imaging (MRI) or computed tomography (CT) normalized to height2 (mm2/m2). Receiver operating characteristic (ROC) curve analysis and Youden index were used to determine gender-specific PMI cut-off values for predicting perioperative AEs. Sarcopenia was defined as PMI below the cut-off values. Complex revision surgery was defined as Spine Surgical Invasiveness Index >10. ResultsA total of 114 consecutive patients were included in the study. ROC curve analysis demonstrated PMI <500 mm2/m2 for males and <412 mm2/m2 for females as predictors for perioperative AEs. 49 patients were in the sarcopenia cohort and 65 patients in the nonsarcopenia cohort. The sarcopenia group had higher overall perioperative AEs (75.5% vs 27.7%, p<.001) and individual AEs including: postoperative anemia requiring transfusion, wound complication, delirium, acute kidney injury, pneumonia, urinary tract infection, and deep vein thrombosis. The sarcopenia group had higher 30-day reoperation rate (14.3% vs 3.1%, p=.037), 30-day readmission rate (16.3% vs 3.1%, p=.018), rate of discharge to a facility (83.7% vs 50.8%, p<.001), and longer length of stay (LOS) (7.3±4.2 days vs 5.6±3.5 days, p=.023). ConclusionsSarcopenia measured by PMI is associated with higher perioperative AEs, 30-day readmission rates, 30-day reoperation rates, rate of discharge to a facility, and longer LOS among patients undergoing complex revision thoracolumbar spine surgery.

Effect of combined treatment with pulsed electromagnetic field stimulation and sclerostin monoclonal antibody on changes in bone metabolism and pedicle screw augmentation in rabbits with ovariectomy-induced osteoporosis.

Both pulsed electromagnetic field (PEMF) stimulation and sclerostin monoclonal antibody are useful for treating osteoporosis, but whether the two therapies have synergistic effects on both screw fixation quality and bone metabolism of ovariectomy-induced osteoporosis has not been reported. We used ovariectomy to create a rabbit model of postmenopausal osteoporosis. Then, specimens were fixed with pedicle screws in the L4 vertebral body. Rabbits were randomly divided into an OVX control group, PEMF group, Scl-Ab group, and PEMF+Scl-Ab group. The PEMF group was given PEMF magnetic therapy, the Scl-Ab group was administered a subcutaneous Scl-Ab injection, and the PEMF+SclAb group received both therapies. The OVX group was injected subcutaneously with the same dose of saline instead. After eight weeks of treatment, the bone metabolism index, bone mineral density (BMD), and bone microstructural, biological, and biomechanical parameters were evaluated. BMD significantly decreased six months post-ovariectomy. Compared with that of the OVX group, the BMD of the PEMF, Scl-Ab, and PEMF+Scl-Ab groups increased by 20.3%, 19.9%, and 35.0%, respectively. The maximum pulling force of pedicle screws increased by 14.0%,15.0% and 19.1%, and the maximum failure power consumption of pedicle screws increased by 27.9%, 27.2% and 33.6%, respectively; these differences were statistically significant (P<0.05). The bone metabolism index and bone microstructure parameters of the PEMF+Scl-Ab group were more optimal than those in the single treatment group. Both Scl-Ab and PEMF therapy can enhance the BMD and the mechanical strength of pedicle screws in osteoporotic bones of rabbits with postmenopausal osteoporosis. However, combination of the two measures has achieved even better results, yielding potential clinical application value.

A Rare Case of Extensive Spondylodiscitis

A 71-year-old man with a history of diabetes mellitus was admitted to our hospital with a 2-week history of fever and low back pain. Physical examination showed fever (38.1°C), painful palpation of the lower lumbar vertebrae and right lower limb paresis. Blood examination revealed an increased white blood cell count (16700x109/L) and C- reactive protein (22,39 mg/dL). Magnetic resonance imaging showed extensive spondylodiscitis, with osteomyelitis of the L5, S1 and S2 vertebral bodies, discitis, large epidural empyema, paraspinal and epidural abscesses. Patient was submitted to surgical treatment and was started on empirical antimicrobial therapy. Blood and intraoperative cultures were negative. Brucellosis and tuberculosis testing was negative. A 10- week course of antimicrobial therapy was performed with progressive decline of acute-phase reactants, reduction in pain and improvement of the neurological deficit. At 1-year follow up with light residual lower back pain and no neurological deficit.

Biomechanical properties of a novel nonfusion artificial vertebral body for anterior lumbar vertebra resection and internal fixation

The aim of the study was to evaluate the biomechanical properties of a novel nonfused artificial vertebral body in treating lumbar diseases and to compare with those of the fusion artificial vertebral body. An intact finite element model of the L1–L5 lumbar spine was constructed and validated. Then, the finite element models of the fusion group and nonfusion group were constructed by replacing the L3 vertebral body and adjacent intervertebral discs with prostheses. For all finite element models, an axial preload of 500 N and another 10 N m imposed on the superior surface of L1. The range of motion and stress peaks in the adjacent discs, endplates, and facet joints were compared among the three groups. The ranges of motion of the L1–2 and L4–5 discs in flexion, extension, left lateral bending, right lateral bending, left rotation and right rotation were greater in the fusion group than those in the intact group and nonfusion group. The fusion group induced the greatest stress peaks in the adjacent discs and adjacent facet joints compared to the intact group and nonfusion group. The nonfused artificial vertebral body could better retain mobility of the surgical site after implantation (3.6°–8.7°), avoid increased mobility and stress of the adjacent discs and facet joints.

Clinical significance of skeletal muscle density and sarcopenia in patients with pancreatic cancer undergoing first-line chemotherapy: a retrospective observational study

BackgroundTo investigate the clinical impact of sarcopenia and skeletal muscle density (SMD) among patients with metastatic pancreatic adenocarcinoma who underwent palliative first line gemcitabine-based chemotherapy.MethodsA total of 330 patients treated with first line gemcitabine-based chemotherapy between January 2010 and March 2017 were included. CT scans before chemotherapy and after 8±2 weeks were evaluated. The L3 skeletal muscle index (SMI) was used to detect sarcopenia and calculated as the total area of the L3 skeletal muscle divided by the height-squared (cm2/m2). SMD was quantified as the mean muscle radiation attenuation of the muscle cross-sectional area across the L3 vertebral body level and was assessed between − 29 and + 150 Hounsfield units.ResultsA SMI to SMD comparison revealed a positive correlation (R2 = 0.058, P < 0.001). Compared with high SMD, the risks of low SMI were 1.516 (95% confidence interval [CI]: 1.164–1.973) among patients with low SMD. Kaplan–Meier analysis showed that the low SMD was related to poor overall survival (OS, median, 6.1 versus [vs.] 7.9 months, P = 0.010). Multivariate analysis using Cox regression showed that low SMI (hazard ratio [HR]: 1.35, 95% CI: 1.03–1.78, P = 0.032) and low SMD (HR: 1.45, 95% CI: 1.09–1.93, P = 0.011) were poor prognostic factors for OS, respectively. Co-presence of low SMI and low SMD had more powerful prognostic implication for OS (HR: 1.58, 95% CI: 1.12–2.23, P = 0.010). Grade 3 or higher toxicity of chemotherapy was more frequently observed in patients who have a low SMI (43% vs. 59%, P = 0.019) and low SMD (44% vs. 60%, P = 0.023). OS was not related to SMD status among patients who were chemotherapy responders (complete or partial responses). However, among non-responders (stable or progressive disease), low SMD groups had significantly poorer OS in comparison with high SMD groups (median, 5.6 vs 7.4 months, P = 0.006).ConclusionsSarcopenia and SMD status can be considered a prognostic factor in patients with metastatic pancreatic adenocarcinoma who received palliative first line gemcitabine-based chemotherapy. Severe chemotherapy toxicity occurred in the sarcopenia and low SMD groups. Our data suggest that a comprehensive assessment of skeletal muscle parameters may be more useful prognostic factors.

Evaluation of a rabbit model of adjacent intervertebral disc degeneration after fixation and fusion and maintenance in an upright feeding cage

ABSTRACT Purpose: To establish an animal model of adjacent intervertebral disc degeneration by performing spinal fixation and fusion after percutaneous needle puncture and removal of the intervertebral disc or percutaneous needling of the vertebral body without removal of the intervertebral disc. Methods: We established a model of adjacent intervertebral disc degeneration after spinal fixation and fusion of rabbits maintained in upright feeding cages. Twenty-five healthy New Zealand rabbits were used. In the experimental group, the L3-4 intervertebral disc was percutaneously punctured with an 18-G needle under fluoroscopic guidance. Once degeneration occurred, the L3-4 disc was excised, and interbody fusion was performed. The changes in the adjacent intervertebral discs were observed periodically via X-ray and MRI. In the control group, the L3 vertebral body was percutaneously needled with an 18-G needle under fluoroscopic guidance. The changes in the adjacent intervertebral discs were observed on X-ray and MRI at 4, 8, and 12 weeks after puncture in both groups. At 12 weeks postoperatively, the animals were euthanized, and the histopathologic changes of the adjacent intervertebral discs were assessed using hematoxylin-eosin and TdT-mediated dUTP nick end labeling (TUNEL) staining. The mRNA and protein expressions of aggrecanase-1 were measured by real-time quantitative PCR and Western blot analysis. The product of aggrecan degradation, Aggrecan ARGxx, was measured by Western blot analysis. Results: The degeneration of the intervertebral discs in the adjacent segments in the experimental group increased over time. The mRNA and protein expressions of aggrecanase-1 and the expression of Aggrecan ARGxx in the experimental group were significantly increased after puncture, fixation, and fusion (P<0.05). The adjacent intervertebral disc sections had a significantly lower cell density and significantly higher TUNEL-positive cell rate in the experimental group than the control group (P<0.05). Conclusion: The results suggest that the occurrence of intervertebral disc degeneration in adjacent segments may begin with the degeneration of the punctured intervertebral disc.

Impact of paravertebral muscle in thoracolumbar and lower lumbar regions on outcomes following osteoporotic vertebral fracture: a multicenter cohort study.

Paravertebral muscle (PVM) is an important component of the spinal column. However, its role in the healing process after osteoporotic vertebral fracture (OVF) is unclear. This study aimed to clarify the effect of PVM in thoracolumbar and lower lumbar regions on OVF clinical and radiological outcomes. This was a multicenter prospective cohort study from 2012 to 2015. Patients ≥ 65 years old who presented within 2 weeks after fracture onset were followed up for 6 months. PVM was measured at the upper edge of the L1 and L5 vertebral body in the magnetic resonance imaging (MRI) T2-axial position at registration. The cross-sectional area (CSA), relative CSA (rCSA), and fat infiltration percentage (FI%) were measured. Severe vertebral compression, delayed union, new OVF, and remaining low back pain (LBP) were analyzed. Among 153 patients who were followed up for 6 months, 117 with measurable PVM were analyzed. Their average age was 79.1 ± 7.2 years, and 94 were women (80.3%). There were 48 cases of severe vertebral compression, 21 delayed unions, 11 new OVF, and 27 remaining LBP. Among all poor prognoses, only the FI% of the PVM was significantly associated with new OVF (p = 0.047) in the thoracolumbar region and remaining LBP (p = 0.042) in the lumbar region. The occurrence of additional OVF in the thoracolumbar region and remaining LBP in the lumbar region was significantly related to the FI% of the PVM. Physicians should be aware that patients with such fatty degeneration shown in acute MRI may require stronger treatment.

HELICAL COMPUTERIZED TOMOGRAPHY CAN MEASURE SUBCUTANEOUS, VISCERAL AND TOTAL FAT AREAS?

ABSTRACT Background:Abdominal obesity or android obesity, that is, the increase in adipose tissue in the abdominal region, is considered a risk factor for several morbidities. Different ways of quantifying it have been proposed, one method is the measurement of the abdominal fat area by computed tomography. Aim:To establish correspondence between the groups defined by degree of obesity in relation to the total, subcutaneous and visceral fat area. Methods:Cross-sectional observational study carried out through the analysis of tomographic examinations. Horos v3.3.5 medical image visualization software was used, with abdominal tomography in a single cut including the L4 vertebral body and the umbilical scar, to obtain the areas of total, visceral and subcutaneous fat. Results:Of the 40 patients, 10 had grade II obesity, 23 grade III and 7 superobese. The amount of total fat showed an increase in relation to the degree of obesity. Visceral fat did not show significant differences between the degrees of obesity, but the data showed a lower average in the group of obesity grade II. The area of subcutaneous fat, as well as total fat, showed an increase in its measurements, according to the progression of the patients’ BMI, but there was no statistical significance in this difference between the groups of grade II and super-obese individuals. Conclusion:The area of total and subcutaneous fat showed an increase in its measurements according to the progression of the BMI groups, which did not happen with visceral fat.