Paleopathology of skeletal fluorosis

Co-emissions of fluoride ion, fluorinated greenhouse gases, and per- and polyfluoroalkyl substances (PFAS) from different fluorochemical production processes

Fluorochemical industry is an emerging industry leading to environmental emissions of fluoride ion, fluorinated greenhouse gases (GHGs) and per- and polyfluoroalkyl substances (PFASs) globally. Chlorofluorocarbon (CFCs) and hydrochlorofluorocarbon (HCFCs) are the primary causes of ozone layer depletion, and together with hydrofluorocarbons (HFCs), they contribute to global climate warming. PFAS are emerging persistent organic pollutants, comprising thousands of materials including perfluoroalkyl acids (PFAAs), perfluoroalkane sulfonamides (FASAs), and fluoropolymers.As the implementation of the Montreal Protocol and the Stockholm Convention makes progress, fluorochemical industry is searching for alternatives like HFCs, perfluoroalkyl ether carboxylic acids (PFECAs) and etc. Even though studies on chemical processes and environmental influences of the fluorochemical industry are plentiful, research on emissions of fluorine chemicals from different fluorochemical industry is still scarce. In this study, we conducted on-site sampling to analyze the distribution of fluorine chemicals in the surrounding environment of the fluorochemical industrial sites. The sampling sites represent different stages of fluorochemical industry production, including fluorite mining, synthesis of fluorochemical raw materials like fluorocarbons, and fine fluorine product processing which is mostly PFAS. Results show that at the fluorite mining stage, concurrent emissions of fluoride ion and CFC-12 contribute to the primary environmental issue. Perfluorooctanoic acid (PFOA) and some short-chain PFASs like perfluorobutanoic acid (PFBA), perfluoropentanoic acid (PFPeA), perfluoroheptanoic acid (PFHpA), and perfluorobutanesulfonic acid (PFBS) are the main pollutants from fluocarbons production, accompanied by emissions of fluorinated GHGs such as HFC-32, and HCFC-22. At the fine fluorine product synthesis stage where produces fluoropolymers, perfluoropolyethers and fluorinated surfactants, PFAS especially for emerging alternatives PFECAs like hexafluoropropylene oxide dimer acid (HFPODA) and Perfluoro-4-oxapentanoic acid (PF4OPeA), as well as fluorinated GHGs like HFC-23 and HFC-227ea, require increasing attention.

Diffuse Idiopathic Skeletal Hyperostosis (DISH): New evidence from micro-XCT scanning

OBJECTIVE

To observe and describe the development and underlying structure of the spinal manifestations of individuals osteologically diagnosed with DISH (Diffuse Idiopathic Skeletal Hyperostosis), using micro-XCT imaging.

MATERIALS

A total of 72 individuals with DISH were identified in two modern skeletal collections in South Africa.

METHODS

Vertebral columns affected by DISH were scanned at the micro-focus x-ray computed tomography facility at the Nuclear Energy Corporation of South Africa. Four features were macroscopically examined: (1) the origin of the new bone growth; (2) retention of the original vertebral cortex at the site of the new bone formation associated with DISH; (3) evidence of trabecular bone with or without sclerosis on the anterolateral surface of affected vertebrae; and (4) abnormal areas of osteosclerosis beyond features associated with DISH.

RESULTS

Considerable variation across and between the four recorded features was found. Of note, 81% (n = 58) of individuals had both developed trabecular bone within the flowing new bone formation (feature 3), without retention of the original vertebral cortex (feature 2).

CONCLUSIONS

Possible localised erosive/inflammatory processes destroyed the original cortex of the vertebral body and resulted in the expansion of trabeculae with new bone formation.

SIGNIFICANCE

Micro-XCT imaging shed new light on the development of DISH, adding to literature suggesting that it could be an inflammatory disease.

LIMITATIONS

Clinical histories of the individuals were not known.

SUGGESTIONS FOR FURTHER RESEARCH

The role of chronic inflammatory disease in the development of DISH should be further explored including both the extra-spinal and spinal manifestations.

Identifying treponemal disease in early East Asia

Objectives

Historic records suggest that a virulent form of treponematosis, sexually transmitted syphilis was introduced to Asia from Europe by the da Gama crew, who landed in India in 1498. Our objective is to assess the gross pathology of human skeletal remains from the Tang dynasty of China to test the presence of treponemal infection in East Asia before 1498. We interpret this paleopathological evidence in the context of site ecology and sociocultural changes during the Tang dynasty.

Materials and methods

We examined the gross pathology of 1598 human skeletons from Xingfulindai (AD 618 to AD 1279) archeological site located on the Central Plain of China. Using the modified diagnostic criteria defined by Hackett's classical work, we classify the pathology as consistent, strongly suggestive, or pathognomonic for treponemal infection.

Results

Twelve adult individuals from Xingfulindai had bone lesions suggestive of systemic pathology. Two of these individuals displayed a combination of lesion patterns pathognomonic of treponemal disease and one had lesions consistent with treponematosis. The radiocarbon dates for the bone samples from these skeletons place them before AD 1200.

Conclusions

The location of Xingfulindai in a continental climatic zone is not typical for yaws and bejel ecology, because these strains occur in the tropics, or in hot, dry environments, respectively. The urban setting, where there is documented evidence for increased interaction between multiple ethnic groups and a developed institution of courtesans during the Tang dynasty, favors sexually transmitted syphilis as the more likely diagnosis. This study supports an earlier spread of syphilis to China than 1498.

High concentration of sodium fluoride in drinking water induce hypertrophy versus atrophy in mouse skeletal muscle via modulation of sarcomeric proteins

Fluoride at high doses is a well-known toxic agent for the musculoskeletal system, primarily in bone and cartilage cells. Research on fluoride toxicity concerning particularly on the skeletal muscle is scanty. We hypothesized that during skeletal fluorosis, along with bone, muscle is also affected, so we have evaluated the effects of Sodium fluoride (NaF) on mouse skeletal muscles. Sodium fluoride (80 ppm) was administered to 5-week-old C57BL6 mice drinking water for 15 and 60 days, respectively. We carried out histology, primary culture, molecular and proteomic analysis of fluoride administered mouse skeletal muscles. Results indicated an increase in the muscle mass (hypertrophy) in vivo and myotubes ex vivo by activating the IGF1/PI3/Akt/mTOR signalling pathway due to short term NaF exposure. The long-term exposure of mice to NaF caused loss of muscle proteins leading to muscle atrophy due to activation of the ubiquitin-proteasome pathway. Differentially expressed proteins were characterized and mapped using a proteomic approach. Moreover, the factors responsible for protein synthesis and PI3/Akt/mTOR pathway were upregulated, leading to muscle hypertrophy during the short term NaF exposure. Long term exposure to NaF resulted in down-regulation of metabolic pathways. Elevated myostatin resulted in the up-regulation of the muscle-specific E3 ligases-MuRF1, promoting the ubiquitination and proteasome-mediated degradation of critical sarcomeric proteins.

Spotted bones in an osteopoikilosis-related disease (Buschke Ollendorff Syndrome): Identifying this rare condition from the lab to the field

OBJECTIVE

To improve the differential diagnosis of osteopoikilosis in past populations using a clinical case as an example of this rare condition.

MATERIALS

A patient referred to our Genetic Service with suspected Buschke Ollendorff Syndrome after finding a connective nevus.

METHODS

Radiological images from different body regions were accompanied by a genetic study using next-generation sequencing.

RESULTS

Small circular-to-ellipsoid sclerotic lesions were found in the epiphysis and metaphysis of long bones, as well as in the pelvis. These lesions were bilaterally distributed and with well-defined margins, compatible with the characteristics of Buschke Ollendorff Syndrome, bone manifestation osteopoikilosis. A heterozygous mutation on LEMD3 (NM_001167614:c.1918 + 1G > C) was identified by next-generation sequencing. Based on this confirmed case, we have discussed the most probable causes of similar bone lesions found in the archaeological record.

CONCLUSION

It has been demonstrated how a current case of a rare disease can provide useful tools to improve the differential diagnosis of this disease in ancient skeletons.

SIGNIFICANCE

This work underlines the great need for multidisciplinary platforms that integrates clinical research into paleopathology in order to successfully address the study of rare diseases from the past.

LIMITATIONS

Since OPK is only detected by X-rays, suspected cases of this bone lesion will only be identified when radiographs are taken for other purposes.

SUGGESTIONS FOR FURTHER RESEARCH

Retrospective and large-scale studies of radiographs from other research in past populations.

The Osteosclerosis Challenge Toothpaste Unveiling Secrets

The patient, then a 35-year-old female, presented with an 18-month history of bilateral hip and groin pain, limiting her ability to ambulate. The pain appeared upon rest and exertion, and responded poorly to simple analgesics. No other systemic complaints were present.

Lactobacillus johnsonii BS15 improves intestinal environment against fluoride-induced memory impairment in mice-a study based on the gut-brain axis hypothesis

Background

Excessive fluoride can lead to chronic neurodegeneration characterized by neuron and myelin loss and memory dysfunction. The gut–brain axis hypothesis suggests that gut microbiota plays a crucial role in regulating brain function. Thus, using probiotics to adjust the gut microenvironment may be a potential therapy for mental diseases.

Methods

Mice in the prob group were administrated with Lactobacillus johnsonii BS15 for 28 days prior to and throughout a 70-day exposure to sodium fluoride. The drinking water of all groups (F and prob groups) except the control group were replaced by high-fluoride water (100 mg NaF/L) on day 28. Animals in each group were divided into two subsets: one underwent behavioral test, and the other was sacrificed for sampling. The mRNA expression level and protein content related to inflammatory reaction in the ileum and hippocampus were respectively detected by reverse transcription quantitative polymerase chain reaction (RT-qPCR) and enzyme-linked immunosorbent assay (ELISA). The mRNA expression levels of proteins related to myelin structure, apoptosis, and memory in the hippocampus and tight junction proteins in the ileum were determined by RT-qPCR and/or immunohistochemistry. Gut permeability markers (D-lactate and diamine oxidase (DAO)) in the serum were also examined by ELISA.

Results

The results showed that fluoride exposure induced a lower spontaneous exploration (P < 0.05) in T-maze test, which indicated an impairment of memory. Spontaneous exploration of BS15-treated mice was significantly higher (P < 0.05) than that in F group. Fluoride reduced (P < 0.05) levels of myelin structural protein (proteolipid protein) and neurogenesis-associated proteins (brain-derived neurotrophic factor and cAMP/Ca²⁺ responsive element-binding protein), induced disordered inflammatory cytokines (TNF-α, IFN-γ, and IL-6; P < 0.05), increased pro-apoptotic genes (caspase-3; P < 0.05), and decreased anti-apoptotic genes (Bcl-2; P < 0.05) in the hippocampus, of which the influences were reversed by BS15. BS15 treatment exerted significant preventive effects on reversing the gut inflammation induced by excessive fluoride intake by reducing (P < 0.05) the levels of pro-inflammatory cytokines (tumor necrosis factor-alpha (TNF-α) and interferon-gamma (IFN-γ)) and remarkably increasing (P < 0.05) the level of anti-inflammatory cytokines (IL-10). Moreover, the serum DAO activity and D-lactate concentration significantly increased by fluoride were also reduced (P < 0.05) by BS15. This result indicated the profitable effect of BS15 on gut permeability.

Conclusion

L. johnsonii BS15 intake could benefit the neuroinflammation and demyelination in the hippocampus by improving the gut environment and ameliorating fluorine-induced memory dysfunction.

Increasing fluoride content deteriorates rat bone mechanical properties

Elevation of bone fluoride levels due to drinking beverages with high fluoride content or other means such as inhalation can result in skeletal fluorosis and lead to increased joint pain, skeletal deformities, and fracture. Because skeletal fluorosis alters bone's mineral composition, it is likely to affect bone's tissue-level mechanical properties with consequent effects on whole bone mechanical behavior. To investigate this, we determined whether incubation with in vitro sodium fluoride (NaF) altered bone's mechanical behavior at both the tissue- and whole bone-levels using cyclic reference point indentation (cRPI) and traditional 3-point bending, respectively. Forty-two ulnas from female adult rats (5-6 months) were randomly divided into 5 groups (vehicle, 0.05 M NaF, 0.25 M NaF, 0.75 M NaF, and 1.5 M NaF). Bones were washed in a detergent solution to remove organic barriers to ion exchange and incubated in respective treatment solutions (12 h, 23 °C). Cortical tissue mineral density (TMD) and geometry at the mid-diaphysis were determined by microCT. cRPI was performed on the distal diaphysis (9 N, 2 Hz, 10 cycles), and then bones were tested in 3-point bending to assess whole bone mechanical properties. The incubations in vehicle (0 M) up to 1.5 M in vitro NaF concentrations achieved bone fluoride levels ranging from approximately 0.70 to 15.8 ppm. NaF-incubated bones had significantly greater indentation distances, higher displacement-to-maximum force, and lower estimated elastic modulus, ultimate stress, and bending rigidity with increasing NaF concentration compared to vehicle-incubated bones. cRPI variables were moderately correlated to whole bone mechanical properties such that higher indentation distances were associated with lower estimated elastic modulus, ultimate stress, and bending rigidity. In conclusion, in vitro NaF incubation mostly has a deleterious effect on bone mechanical behavior with increasing NaF levels that is independent of bone turnover and reflected, in part, by less resistance of the tissue to cRPI-based indentation.

Using teeth as tools: Investigating the mother-infant dyad and developmental origins of health and disease hypothesis using vitamin D deficiency

OBJECTIVES

With a growing interest in the mother-infant dyad and the Developmental Origins of Health and Disease hypothesis among biological and medical anthropologists, this study set out to provide all the information required to evaluate if mineralization defects in dentine might be caused by vitamin D deficiency in the critical first 1000 days of life.

MATERIALS AND METHODS

Information was compiled on dentine formation in utero to approximately 18 years, and a method for determining the location of the neonatal line in dentine was devised, allowing the assessment of the prenatal and early life period. Re-evaluation of previously analyzed teeth (n = 61) was undertaken with detailed examination of n = 5/22 first permanent molars forming in the prenatal and critical early life periods.

RESULTS

First permanent molars and all deciduous teeth give information on intrauterine development and on the first 1000 days postnatally providing a direct window on maternal and fetal health. Three archaeological individuals had interglobular dentine that formed prenatally suggesting that their mothers experienced vitamin D deficiency at the time dentine was forming and all other individuals had a deficiency during the first 1000 days of life. Conditions that could cause systemic mineralization defects were determined, and in each, case they were found to be consistent with vitamin D deficiency.

DISCUSSION

The neonatal line serves as a clear baseline for determining prenatal and postnatal events, particularly those related to vitamin D, calcium, and phosphate metabolism, and can be used to investigate the maternal-infant dyad for both past and present communities.

Evidence of Skeletal Fluorosis at the Ray Site, Illinois, USA: a pathological assessment and discussion of environmental factors

OBJECTIVE

To carefully assess skeletal lesions in close environment context in order to evaluate whether skeletal fluorosis was present in individuals living in the prehistoric Midwest, USA.

MATERIALS

Skeletal remains from minimally 117 individuals recovered from the Ray Site, located in western Illinois (USA) and dated to the Middle/early Late Woodland periods (50 BC-AD 400).

METHODS

Macroscopic evaluation of all recovered skeletal elements.

RESULTS

Eight individuals display a constellation of abnormal bony changes, including osteosclerosis, a high frequency of fractures, and dental abnormalities.

CONCLUSIONS

The osteosclerotic changes along with the naturally high fluoride content of west central Illinois soil and water suggests the presence of skeletal fluorosis.

SIGNIFICANCE

This is the first report of skeletal fluorosis from archaeologically recovered human remains from North America.

LIMITATIONS

The ambiguous nature of the skeletal changes associated with fluorosis, especially in the less severe stages of the disease, renders determination of the etiology difficult.

SUGGESTIONS FOR FURTHER RESEARCH

The continuation of paleopathological investigations of fluoride toxicity within archaeological communities recovered from this region with emphasis on the incorporation of biomedical and environmental data. Furthermore, complementary analyses of the chemical composition and the histological presentation of the skeletons could provide support for this diagnosis.

The antiquity of the spondyloarthritides: Presentation of one of the oldest Neolithic cases in Western Europe

In humans, little is yet known about the origins of the inflammatory rheumatisms of the spondyloarthritides group, especially regarding the period of their emergence. However, a better knowledge of their history would help to clarify their aetiology. We report a paleopathological case of European origin, dated from the late Neolithic (3621-3023 cal BC), consisting of an isolated vertebral block combining erosion, ossification and severe anterior and posterior ankylosis. The lesional presentation is very suggestive of a severe form of axial spondyloarthritis. This specimen and some other rare cases from the same period found in Western Europe suggest that these diseases appeared, in this geographical region, in evolving groups of humans as part of the demographic and epidemiological transition that constituted the Neolithic period. The emergence of infectious agents and the profound dietary changes that occurred during this period of human history may have favoured the appearance of the spondyloarthritides.

Is differential diagnosis attainable in disarticulated pathological bone remains? A case-study from a late 19th/early 20th century necropolis from Juncal (Porto de Mós, Portugal)

Differential diagnosis is a fundamental step in every palaeopathological study. It is a challenging exercise since many intrinsic and extrinsic factors may negatively impact the accurate interpretation of bone changes in human skeletal remains. Among these, the completeness and preservation of skeletal elements plays a significant role. This study aims to explore the limits of differential diagnosis in the analysis of disarticulated, fragmented bones. The sample consists of twelve adult bone fragments with noticeable changes. The remains were identified in a dis-articulated skeletal assemblage from the former necropolis of Juncal (Porto de Mós, Portugal), which probably closed in the late 19th century/early 20th century. They were analysed visually and with X-radiography, and the changes carefully described prior to differential diagnosis. Six bones presented signs of healed bone trauma and one showed features compatible with leg amputation. Periosteal reactions were observed in several bones, one of them resembling changes consistent with an overlying skin ulcer. Two bone fragments were identified as belonging to the same individual due to the matching bone changes. Despite the incomplete remains, a broader diagnosis was possible for most cases, which facilitated a discussion of health, medical and social care among the inhabitants of the region.

Subsistence strategy changes: the evidence of entheseal changes

Changes in subsistence strategy have caused some of the profoundest changes to the structure and health of humans. This study aims to test whether these changes have reduced work-load as assessed by entheseal changes. Entheseal changes, formerly called musculoskeletal stress markers, are thought to reflect muscle usage throughout life, although it is widely agreed that they have a multifactorial origin. This paper uses a meta-analysis of comparable published data to plot trends in time by muscle, enthesis type and sex. The results show that agriculturalists have the lowest scores for entheseal changes, with hunte-gatherers next highest and those working in industry the highest. These findings are the same for males and females, for most muscles and muscle groups. However, entheseal changes are highly correlated with increased age and the age distributions of the samples analysed could not be compared. It is, therefore, possible that differences in age distribution of the samples are one of the reasons for this finding. Recommendations are provided to reduce this and other limitations for future meta-analyses.

Dental fluorosis linked to degassing of Ambrym volcano, Vanuatu: a novel exposure pathway

Ambrym in Vanuatu is a persistently degassing island volcano whose inhabitants harvest rainwater for their potable water needs. The findings from this study indicate that dental fluorosis is prevalent in the population due to fluoride contamination of rainwater by the volcanic plume. A dental survey was undertaken of 835 children aged 6-18 years using the Dean's Index of Fluorosis. Prevalence of dental fluorosis was found to be 96% in the target area of West Ambrym, 71% in North Ambrym, and 61% in Southeast Ambrym. This spatial distribution appears to reflect the prevailing winds and rainfall patterns on the island. Severe cases were predominantly in West Ambrym, the most arid part of the island, and the most commonly affected by the volcanic plume. Over 50 km downwind, on a portion of Malakula Island, the dental fluorosis prevalence was 85%, with 36% prevalence on Tongoa Island, an area rarely affected by volcanic emissions. Drinking water samples from West Ambrym contained fluoride levels from 0.7 to 9.5 ppm F (average 4.2 ppm F, n = 158) with 99% exceeding the recommended concentration of 1.0 ppm F. The pathway of fluoride-enriched rainwater impacting upon human health as identified in this study has not previously been recognised in the aetiology of fluorosis. This is an important consideration for populations in the vicinity of degassing volcanoes, particularly where rainwater comprises the primary potable water supply for humans or animals.

Enduring fluoride health hazard for the Vesuvius area population: the case of AD 79 Herculaneum

BACKGROUND

The study of ancient skeletal pathologies can be adopted as a key tool in assessing and tracing several diseases from past to present times. Skeletal fluorosis, a chronic metabolic bone and joint disease causing excessive ossification and joint ankylosis, has been only rarely considered in differential diagnoses of palaeopathological lesions. Even today its early stages are misdiagnosed in endemic areas.

METHODOLOGY/PRINCIPAL FINDINGS

Endemic fluorosis induced by high concentrations of fluoride in water and soils is a major health problem in several countries, particularly in volcanic areas. Here we describe for the first time the features of endemic fluorosis in the Herculaneum victims of the 79 AD eruption, resulting from long-term exposure to high levels of environmental fluoride which still occur today.

CONCLUSIONS/SIGNIFICANCE

Our observations on morphological, radiological, histological and chemical skeletal and dental features of this ancient population now suggest that in this area fluorosis was already endemic in Roman times. This evidence merged with currently available epidemiologic data reveal for the Vesuvius area population a permanent fluoride health hazard, whose public health and socio-economic impact is currently underestimated. The present guidelines for fluoridated tap water might be reconsidered accordingly, particularly around Mt Vesuvius and in other fluoride hazard areas with high natural fluoride levels.

Thoracic ossification of ligamentum flavum caused by skeletal fluorosis

Thoracic ossification of ligamentum flavum (OLF) caused by skeletal fluorosis is rare. Only six patients had been reported in the English literature. This study reports findings from the first clinical series of this disease. This was a retrospective study of patients with thoracic OLF due to skeletal fluorosis who underwent surgical management at the authors' hospital between 1993 and 2003. Diagnosis of skeletal fluorosis was made based on the epidemic history, clinical symptoms, radiographic findings, and urinalysis. En bloc laminectomy decompression of the involved thoracic levels was performed in all cases. Cervical open door decompression or lumbar laminectomy decompression was performed if relevant stenosis was present. Neurological status was evaluated preoperatively, at the third day postoperatively, and at the end point of follow-up using the Japanese Orthopaedic Association (JOA) scoring system of motor function of the lower extremities. A total of 23 cases were enrolled, 16 (69.6%) males and 7 (30.4%) females, age ranging from 42 to 72 years (mean 54.8 years). All patients came from a high-fluoride area, and 22 (95.7%) had dental fluorosis. Medical imaging showed OLF together with ossification of many ligaments and interosseous membranes, including interosseous membranes of the forearm (18/23 patients 78.3%), leg (14/23 patients 60.9%), and ribs (11/23 patients 47.8%). OLF was classified into five types based on MRI findings: localized (4/23 patients 17.4%), continued (12/23 patients 52.2%), skip (3/23 patients 13.0%), combining with anterior pressure (2/23 patients 8.7%), and combining with cervical and/or lumbar stenosis (2/23 patients, 8.7%). Urinalysis showed a markedly high urinary fluoride level in 14 of 23 patients (60.9%). Patients were followed up for an average duration of 4 years, 5 months. Paired t-test showed that the JOA score was slightly but nonsignificantly increased relative to preoperative measurement 3 days after surgery (P = 0.0829) and significantly increased at the end of follow-up (P = 0.0001). In conclusion, Fluorosis can cause ossification of thoracic ligamentum flavum, as well as other ligaments. Comparing with other OLF series, a larger number of spinal segments were involved. The diagnosis of skeletal fluorosis was made by the epidemic history, clinical symptom, imaging study findings, and urinalysis. En bloc laminectomy decompression was an effective method.

Thoracic myelopathy caused by ossification of ligamentum flavum of which fluorosis as an etiology factor

PURPOSE

To evaluate the clinical feature, operative method and prognosis of thoracic ossification of ligamentum flavum caused by skeletal fluorosis.

METHODS

All the patients with thoracic OLF, who underwent surgical management in the authors' hospital from 1993-2003, were retrospectively studied. The diagnosis of skeletal fluorosis was made by the epidemic history, clinical symptoms, radiographic findings, and urinalysis. En bloc laminectomy decompression of the involved thoracic levels was performed in all cases. Cervical open door decompression or lumbar laminectomy decompression was performed if relevant stenosis existed. The neurological statuses were evaluated with the Japanese Orthopaedic Association (JOA) scoring system preoperatively and at the end point of follow up. Also, the recovery rate was calculated.

RESULTS

23 cases have been enrolled in this study. Imaging study findings showed all the cases have ossification of ligamentum flavum together with ossification of many other ligaments and interosseous membranes, i.e. interosseous membranes of the forearm in 18 of 23 (78.3%), of the leg in 14 of 23 (60.1%) and of the ribs in 11 of 23 (47.8%). Urinalysis showed markedly increased urinary fluoride in 14 of 23 patients (60.9%). All the patients were followed up from 12 months to 9 years and 3 months, with an average of 4 years and 5 months. The JOA score increased significantly at the end of follow up (P = 0.0001). The recovery rate was 51.83 +/- 32.36%. Multiple regression analysis revealed that the preoperative JOA score was an important predictor of surgical outcome (p = 0.0022, r = 0.60628). ANOVA analysis showed that patients with acute onset or too long duration had worse surgical result (P = 0.0003).

CONCLUSION

Fluorosis can cause ossification of thoracic ligamentum flavum, as well as other ligaments. En bloc laminectomy decompression was an effective method. Preoperative JOA score was the most important predictor of surgical outcome. Patients with acute onset or too long duration had worse surgical outcome.