Is the anterior approach still superior to posterior correction in AIS regarding correction, fusion levels and kyphosis when modern posterior systems are used?

PURPOSE

The aim of our study is to compare anterior and posterior corrections of thoracic (Lenke I) and lumbar (Lenke V) curves when modern posterior pedicle screw systems with vertebral derotation techniques are used. Curves that could not be corrected with both systems were excluded.

METHODS

A thoracic group (N = 56) of Lenke I AIS patients (18 anterior and 38 posterior) and a lumbar group (N = 42) of Lenke V patients (14 anterior and 28 posterior) with similar curves < 65° were identified.

RESULTS

Thoracic group The mean postoperative correction (POC) was 68 ± 13.4% in the anterior and 72 ± 10.5% in the posterior group. The postoperative change in thoracic kyphosis was +4° and +5° respectively. The median length of fusion was eight segments in the posterior and seven segments in the anterior groups. In 89% the LIV was EV or shorter in the anterior, and in 71% of the posterior corrections. Lumbar group The mean POC was 75 ± 18.3% (anterior) and 72 ± 8.5% (posterior). The postoperative gain in lumbar lordosis was 0.8° (anterior) and 4° (posterior). The median length of fusion was five segments in both groups and there was no difference in relation of the LIV to the EV.

CONCLUSION

With modern implants and derotation techniques, the posterior approach can achieve similar coronal correction, apical derotation and thoracic kyphosis with similar length of fusion and better lumbar lordosis restoration.

The indication of fusion to the pelvis in neuromuscular scoliosis is based on the underlying disease rather than on pelvic obliquity

INTRODUCTION

The decision to instrument to L5 or ilium, in NMS, is usually based on radiologic factors, including pelvic obliquity (PO) > 15°, apex of curvature < L3, and Cobb angle > 60°. Since scoliosis in these patients is caused by a neurologic disease, we based our decision to stop at L5 on the presence of spasticity or flaccidity.

PATIENTS & METHODS

The senior author did 109 primary fusions in NMS. Of those with DMD or SMA only 16% were instrumented to the ilium. The main factor for our decision was the correction potential of the truncal shift and PO in the supine traction radiographs and the absence of severe spasticity.

RESULTS

The 57 patients with DMD/SMA had a mean preoperative curvature of 68°, PO of 17°, and truncal shift of 20°. 74% should have been instrumented to the pelvis, but only 16% were. Those instrumented shorter as the rule, were corrected from 74° to 26° and had a postoperative PO of 8°. There was no significant difference in postoperative correction and PO compared to those instrumented to L5 on standard protocol. Subsequent extension to the pelvis was needed in 1 CP patient. There were no significant changes after 2 years. Of the 20 patients instrumented to the pelvis 11 had cerebral palsy and a preop curvature of 89°, a PO of 21° and a truncal shift of 25°.

DISCUSSION

The decision on instrumentation length should take flexibility and disease into consideration. If the trunk is centred over the pelvis, deterioration will not occur in absence of spasticity.

Derotation screws provide no advantage over polyaxial screws regarding coronal & sagittal correction in thoracic curves of AIS patients

PURPOSE

We compared two techniques for thoracic apical derotation; one using conventional reduction screws (Single-Innie-SI) and one requiring special derotation screws that can be converted to monoaxial screws to enhance dorotation (Dual-Innie-DI) for coronal and sagittal correction and.

METHODS

A total of 200 patients with thoracic AIS have been included. In the SI-Group (n = 127) the convex rod was applied first. Vertebral derotation was done by translation to the concave rod with the convex rod being in place and center of rotation (COR). In the DI-Group (n = 73) correction started with translation on the concave side as well but now followed by derotation around the concave rod using the DI-mechanism.

RESULTS

The mean rotation according to Raimondi and coronal correction was not sig. affected (72 (± 12) % in the SI-Group versus 68 (± 15) % in the DI-Group), even when flexibility was respected (Cincinnati Correction Index CCI was 2.9 (± 4.9) versus 3.5 (± 4.4). (p < 0.01). The gain of kyphosis was sig greater (2.7°) in the SI-group, but not clinical relevant.

CONCLUSION

The use of DI screws for apical derotation did not provide an advantage for coronal correction or derotation in thoracic curves. Presumably after translation is performed in the DI-group, there was too much tension and friction in the construct impeding further derotation. Simultaneous translation and derotation in the SI-group, with the convex rod being the COR, yielded similar correction with better kyphosis and was faster and more economic.

AI Prediction of Neuropathic Pain after Lumbar Disc Herniation—Machine Learning Reveals Influencing Factors

The treatment options for neuropathic pain caused by lumbar disc herniation have been debated controversially in the literature. Whether surgical or conservative therapy makes more sense in individual cases can hardly be answered. We have investigated whether a machine learning-based prediction of outcome, regarding neuropathic pain development, after lumbar disc herniation treatment is possible. The extensive datasets of 123 consecutive patients were used to predict the development of neuropathic pain, measured by a visual analogue scale (VAS) for leg pain and the Oswestry Disability Index (ODI), at 6 weeks, 6 months and 1 year after treatment of lumbar disc herniation in a machine learning approach. Using a decision tree regressor algorithm, a prediction quality within the limits of the minimum clinically important difference for the VAS and ODI value could be achieved. An analysis of the influencing factors of the algorithm reveals the important role of psychological factors as well as body weight and age with pre-existing conditions for an accurate prediction of neuropathic pain. The machine learning algorithm developed here can enable an assessment of the course of treatment after lumbar disc herniation. The early, comparative individual prediction of a therapy outcome is important to avoid unnecessary surgical therapies as well as insufficient conservative therapies and prevent the chronification of neuropathic pain.

Open versus minimally invasive TLIF: literature review and meta-analysis

Study design

This study is a comparative, literature review.

Objective

The aim of this study is to provide a comparative analysis of open vs. minimally invasive TLIF using a literature review and a meta-analysis.

Summary of background data

Lumbar interbody fusion is a well-established surgical procedure for treating several spinal disorders. Transforaminal lumbar interbody fusion (TLIF) was initially introduced in the early 1980s. To reduce approach-related morbidity associated with traditional open TLIF (OTLIF), minimally invasive TLIF (MITLIF) was developed. We aimed to provide a comparative analysis of open vs. minimally invasive TLIF using a literature review.

Methods

We searched the online database PubMed (2005–2017), which yielded an initial 194 studies. We first searched the articles’ abstracts. Based on our inclusion criteria, we excluded 162 studies and included 32 studies: 18 prospective, 13 retrospective, and a single randomized controlled trial. Operative time, blood loss, length of hospital stay, radiation exposure time, complication rate, and pain scores (visual analogue scale, Oswestry Disability Index) for both techniques were recorded and presented as means. We then performed a meta-analysis.

Results

The meta-analysis for all outcomes showed reduced blood loss (P < 0.00001) and length of hospital stay (P < 0.00001) for MITLIF compared with OTLIF, but with increased radiation exposure time with MITLIF (P < 0.00001). There was no significant difference in operative time between techniques (P = 0.78). The complication rate was lower with MITLIF (11.3%) vs. OTLIF (14.2%), but not statistically significantly different (P = 0.05). No significant differences were found in visual analogue scores (back and leg) and Oswestry Disability Index scores between techniques, at the final follow-up.

Conclusion

MITLIF and OTLIF provide equivalent long-term clinical outcomes. MITLIF had less tissue injury, blood loss, and length of hospital stay. MITLIF is also a safe alternative in obese patients and, in experienced hands, can also be used safely in select cases of spondylodiscitis even with epidural abscess. MITLIF is also a cost-saving procedure associated with reduced hospital and social costs. Long-term studies are required to better evaluate controversial items such as operative time.

[Spondylolisthesis in the growing spine]

BACKGROUND

Spondylolisthesis (Greek for sliding vertebra) in children is usually the result of a defect (=lysis) or an elongation of the interarticular portion. The cause can be a congenital dysplasia of the dorsal stabilizing structures or pressure of the facet on the interarticular portion. This is a consequence of lumbar lordosis which is necessary for an upright posture.

TREATMENT

The treatment depends on the symptoms and the risk of progression. This is related to the sliding distance, the degree of secondary dysplasia of the vertebral bodies and the sagittal profile, which is considered in the Mac-Thiong classification. For low-grade olistheses, conservative therapy is an option; for a symptomatic lysis without disc degeneration, pars repair should be considered. In higher-grade olistheses, repositioning and spondylodesis are usually recommended. Repositioning improves the fusion rate and sagittal profile, but increases the risk of nerve root damage, so complete repositioning should not be forced.

Panobinostat mediated cell death: a novel therapeutic approach for osteosarcoma

Osteosarcoma is an aggressive cancer with a poor long term prognosis. Neo-adjuvant poly-chemotherapy followed by surgical resection remains the standard treatment, which is restricted by multi-drug resistance. If first-line therapy fails, disease control and patient survival rate drop dramatically. We aimed to identify alternative apoptotic mechanisms induced by the histone deacetylase inhibitor panobinostat in osteosarcoma cells. Saos-2, MG63 and U2-OS osteosarcoma cell lines, the immortalized human osteoblast line hFOB and the mouse embryo osteoblasts (MC3T3-E1) were treated with panobinostat. Real time viability and FACS confirmed the cytotoxicity of panobinostat. Cell stress/death related factors were analysed by RT-qPCR and western blot. Cell morphology was assessed by electron microscopy. 10 nM panobinostat caused cell viability arrest and death in all osteosarcoma and osteoblast cells. P21 up-regulation was observed in osteosarcoma cells, while over-expression of p73 was restricted to Saos-2 (TP53^-/-). Survivin and Bcl-2 were suppressed by panobinostat. Endoplasmic reticulum (ER) stress markers BiP, CHOP, ATF4 and ATF6 were induced in osteosarcoma cells. The un-spliced Xbp was no further detectable after treatment. Autophagy players Beclin1, Map1LC3B and UVRAG transcripts over-expressed after 6 hours. Protein levels of Beclin1, Map1LC3B and p62 were up-regulated at 72 hours. DRAM1 was stable. Electron micrographs revealed the fragmentation and the disappearance of the ER and the statistically significant increase of autophagosome vesiculation after treatment. Panobinostat showed a synergistic suppression of survival and promotion of cell death in osteosarcoma cells. Panobinostat offers new perspectives for the treatment of osteosarcoma and other malignant bone tumours.

Interstitial cells of Cajal: crucial for the development of megacolon in human Chagas' disease?

AIM

Megacolon, chronic dilation of a colonic segment,is accompanied by extensive myenteric neuron loss. However, this fails to explain unequivocally the formation of megacolon. We aimed to study further enteric structures that are directly or indirectly involved in colonic motility.

METHOD

From surgically removed megacolon segments of seven Chagasic patients, three sets of cryosections from oral, megacolonic and anal zones were immunohistochemically quadruple-stained for smooth-muscle actin (SMA), synaptophysin (SYN, for nerve fibres), S100 (glia) and c-Kit (interstitial cells of Cajal, ICCs). Values of area measurements were related to the appropriate muscle layer areas and these proportions were compared with those of seven non-Chagasic control patients.

RESULTS

Whereas nerve and glia profile proportions did not mirror unequivocally the changes of Chagasic colon calibre (nondilation/dilation/nondilation), the proportions of SMA (i.e. muscle tissue density) and c-Kit (i.e. ICC density) did so: they decreased from the oral to the megacolonic segment but increased to the anal zones (muscle tissue density: control 68.3%, oral 54.3%, mega 42.1%, anal 47.6%; ICC-density: control 1.8%, oral 1.1%, mega 0.4, anal 0.8%).

CONCLUSION

Of the parameters evaluated, muscle tissue and ICC densities may be involved in the formation of Chagasic megacolon, although the mechanism of destruction cannot be deduced.

Mucosal layers and related nerve fibres in non-chagasic and chagasic human colon--a quantitative immunohistochemical study

Chagasic megacolon is accompanied by extensive myenteric and, simultaneously, moderate submucosal neuron loss. Here, we examined changes of the innervation pattern of the lamina propria (LP) and muscularis mucosae (MM). Two alternating sets of cryosections were taken from seven non-chagasic colonic and seven chagasic megacolonic specimens (the latter included both the dilated megacolonic and the non-dilated transitional oral and anal zones) and were immunohistochemically triple-stained for smooth-muscle actin (SMA), synaptophysin (SYN) and glial acid protein S100 and, alternatively, for SMA, vasoactive intestinal peptide (VIP) and somatostatin (SOM). Subsequent image analysis and statistical evaluation of nervous tissue profile areas revealed that, in LP, the most extreme differences (i.e. increase in thickness or decrease in nerve, glia and muscle tissue profile area, respectively) compared with control values occurred in the dilated megacolonic zone itself. In contrast, the most extreme differences in the MM were in the anal-to-megacolonic zone (except the profile area of muscle tissue, which was lowest in the megacolonic zone). This parallels our previous results in the external muscle coat. A partial and selective survival of VIP-immunoreactive in contrast to SOM-immunoreactive nerve fibres was observed in both mucosal layers investigated. Thus, VIPergic nerve elements might be crucial for the maintenance of the mucosal barrier. The differential changes of neural tissue parameters in LP and MM might reflect a multifactorial rather than a pure neurogenic development of megacolon in chronic Chagas' disease.

Anterior cruciate ligament reconstruction using quadriceps tendon autograft for adolescents with open physes- a technical note

Background

One major concern in the treatment of ACL lesions in children and adolescents with open physes is the risk of iatrogenic damage to the physes and a possibly resulting growth disturbance.

Purpose

The primary purpose of this article is to describe our technique of a transphyseal ACL reconstruction using quadriceps tendon-bone autograft in children and adolescents with open growth plates. The secondary aim is to report our early results in terms of postoperative growth disturbances which are considered to be a major concern in this challenging group of patients. It was our hypothesis that with our proposed technique no significant growth disturbances would occur.

Methods

From January 1997 to December 2007 49 consecutive children and adolescents with open growth plates were treated for a torn ACL using the aforementioned surgical technique. The patients (28 males and 21 females) with a median age at surgery of 13 (range 8-15) years were retrospectively evaluated. Outcome measures were follow-up radiographs (weight-bearing long leg radiographs of the injured and uninjured knee, anteroposterior and lateral views, a tangential view of the patella and a tunnel view of the injured knee) and follow-up notes (6 weeks, 3, 6, 12 months and until closing of physes) for occurrence of any tibial and/or femoral growth changes.

Results: All of the 49 patients had a sufficient clinical and radiological follow-up (minimum 5 years, rate 100%). 48 cases did not show any clinical and radiological growth disturbance. One case of growth disturbance in a 10.5 years old girl was observed. She developed a progressive valgus-flexion deformity which was attributed to a malplacement of the autograft bone block within the femoral posterolateral epiphyseal plate leading to an early localized growth stop. None of the patients were reoperated due to ACL graft failure. Five of the patients underwent revision ACL surgery due to another adequate sports trauma after the growth-stop. The tibial fixation screw had to be removed under local anaesthesia in 10 patients.

Conclusions

The described ACL reconstruction technique represents a promising alternative to previously described procedures in the treatment of children and adolescents with open growth plates. Using quadriceps tendon future graft availability is not compromised, as the most frequently used autograft-source, ipsilateral hamstring tendons, remains untouched.

Thymoquinone hydrazone derivatives cause cell cycle arrest in p53-competent colorectal cancer cells

Thymoquinone (TQ), the major compound of black seed oil, has been shown to induce pro-apoptotic signaling pathways in various human cancer models. Although TQ is commonly used in traditional medicine, its use in humans is limited due to its chemical properties and poor membrane penetration capacity. We therefore attached saturated and unsaturated fatty acid residues to TQ and evaluated the effect on cell proliferation, apoptosis and underlying signaling pathways in HCT116 and HCT116(p53-/-) colon cancer and HepG2 hepatoma cells in vitro. Treatment with thymoquinone-4-α-linolenoylhydrazone (TQ-H-10) or thymoquinone-4-palmitoylhydrazone (TQ-H-11) induced a cytostatic effect, particularly in p53-competent HCT116 cells, mediated by an up-regulation of p21(cip1/waf1) and a down-regulation of cyclin E, and associated with an S/G(2) arrest of the cell cycle. Cells lacking p53 (HCT116(p53-/-)) or HepG2 liver cancer cells showed only a minor response to TQ-H-10. These findings demonstrate that derivatives of TQ inhibit cell proliferation dependent on p53 status by activating the cell cycle inhibitor p21(cip1/waf1) at lower concentrations than unmodified TQ. Structural modifications can therefore contribute to the further clinical development of TQ.