Hardware failure and spinal pseudoarthrosis causing autonomic dysreflexia: a report of two cases.

STUDY DESIGN: Case report. OBJECTIVES: To describe two cases of hardware failure with pseudoarthrosis causing autonomic dysreflexia. The first patient was a 24-year-old woman with T3 ASIA (American Spinal Injury Association)-A paraplegia who developed complete failure and breakage of the Luque rods at the T11-12 region. The second woman was a 36-year-old T5 ASIA-A complete paraplegic who fractured her Harrington rods at T12 and L1 bilaterally. SETTING: Saskatoon City Hospital, Saskatchewan, Canada. METHODS AND RESULTS: Both patients underwent operation for surgical fixation. In both cases, stabilization and fusion of the spinal deformity abolished the autonomic dysreflexia. CONCLUSION: Owing to the failure of spine-stabilizing hardware, sitting upright may cause an afferent stimulus that triggers the onset and worsening of symptoms associated with autonomic dysreflexia. Therefore, in contrast to current acute treatment regimes, lying down may be preferred to sitting upright (to decrease blood pressure) as a means to relieve the afferent stimulus. Surgical correction and hardware replacement alleviated the symptoms in these two patients.

Parallel induction of epithelial surface-associated chemokine and proteoglycan by cellular hypoxia: implications for neutrophil activation.

Neutrophil-induced damage to the protective epithelium has been implicated in mucosal disorders associated with hypoxia, and such damage may be initiated by epithelial-derived chemokines. Because chemokines can bind to membrane proteoglycans, we hypothesized that chemokines may associate with epithelial surfaces and activate polymorphonuclear neutrophils (PMN). Epithelial hypoxia (pO2 20 torr) resulted in a time-dependent induction of interleukin-8 (IL-8) mRNA, soluble protein, as well as surface protein. Such surface IL-8 expression was demonstrated to be dependent on heparinase III expression, and extensions of these experiments indicated that hypoxia induces epithelial perlecan expression in parallel with IL-8. Finally, co-incubation of post-hypoxic epithelia with human PMN induced IL-8-dependent expression of the PMN beta2-integrin CD11b/18. These data indicate that chemokines liberated from epithelia may exist in a surface-bound, bioactive form and that hypoxia may regulate proteoglycan expression.

Endothelial cell injury in cardiac surgery: salicylate may be protective by reducing expression of endothelial adhesion molecules.

OBJECTIVE: Cardiac surgery with cardiopulmonary bypass induces ischemia to the heart, hypoxemia to various tissues and release of endotoxins. The endothelial cell may suffer from hypoxia and trigger cascades of adverse reactions by activation of neutrophils through adhesion molecules. The authors measured expression of intercellular adhesion molecule-1 (ICAM-1), during hypoxia and normoxia and hypothesized that salicylate, which inhibits the nuclear factor-kappaB (NFkappaB), an hypoxia-dependent transmission factor, could reduce this expression. METHODS: Human umbilical vein endothelial cells were cultured and exposed to normoxia and hypoxia in the presence of lipopolysaccharide (LPS). The endothelial cells were thereafter treated with salicylate or indomethacin under the same conditions. The surface expression of ICAM-1 was measured by whole cell enzyme-linked immunosorbent assay (ELISA) and the NFkappaB expression by Western blotting. RESULTS: In the presence of LPS and under hypoxic conditions, the endothelial cells produced a 300 +/- 41% increased expression of ICAM-1 compared with normoxia. The addition of salicylate (0.02-20 mM) completely inhibited the enhanced expression of ICAM-1, the addition of indomethacin at equivalent concentrations did not reduce ICAM-1 expression under either condition. CONCLUSION: ICAM-1 expression is greatly enhanced by the hypoxic endothelial cell in the presence of circulating endotoxin. Pre-treatment with salicylate completely abolishes the enhanced expression. The study suggests that salicylate administered before cardiopulmonary bypass might protect the heart against ischemic/reperfusion injuries and reduce the load of the overall inflammatory reaction.

A study of the diagnostic accuracy and reliability of the Scoliometer and Adam's forward bend test.

STUDY DESIGN: Study of the diagnostic accuracy and interexaminer reliability of scoliosis diagnostic tests. OBJECTIVES: To estimate the sensitivity, specificity, and predictive value of the Scoliometer (National Scoliosis Foundation, Watertown, MA) and Adam's forward bend test in diagnosing scoliosis, and to determine the interexaminer reliability of the Scoliometer and Adam's forward bend test. SUMMARY OF BACKGROUND DATA: Exposure to diagnostic radiation in patients with adolescent idiopathic scoliosis may result in a small but significant increase in cancer rates. The full-spine radiographic examination remains the standard procedure for the assessment of scoliosis. There is a need for a valid and reliable noinvasive test to assess scoliosis. METHODS: Two examiners independently assessed 105 patients presenting to a scoliosis clinic for trunk asymmetry with Adam's forward bend test and axial trunk rotation with the Scoliometer. The Cobb method served as the gold standard. RESULTS: The interexaminer agreement for the Scoliometer is excellent in the thoracic spine and substantial in the lumbar spine. The interexaminer measurement error shows poor precision for thoracic and lumbar Scoliometer measurements. The interexaminer agreement for Adam's forward bend test is substantial in the thoracic spine and poor in the lumbar spine. Adam's forward bend test is more sensitive than the Scoliometer in detecting thoracic curves measuring 20 degrees or more by the Cobb method. Receiver operating characteristic curve analysis suggests that the use of the Scoliometer marginally improves the ability of diagnosing a scoliosis in the thoracic spine. CONCLUSIONS: The Scoliometer and Adam's forward bend tests have adequate interexaminer reliability for the assessment of thoracic curves. The Scoliometer has better interexaminer agreement in the lumbar spine. However, the Scoliometer has a high level of interexaminer measurement error that limits its use as an outcome instrument. Because Adam's forward bend test is more sensitive than the Scoliometer, the authors believe that it remains the best noninvasive clinical test to evaluate scoliosis.

Autocrine regulation of epithelial permeability by hypoxia: role for polarized release of tumor necrosis factor alpha.

BACKGROUND & AIMS: The intestinal mucosa is lined by a monolayer of protective epithelial cells. This barrier is regulated by immune-derived factors such as interferon gamma (IFN-gamma). Because of the high volume of blood flow, the intestine is a primary target for hypoxic damage. We hypothesize that epithelial cytokine responses are regulated by hypoxia. METHODS: T84 intestinal epithelial cells were used to assess alterations in permeability, major histocompatibility complex class II induction, cytokine receptor expression, and cytokine release in response to combinations of IFN-gamma and cellular hypoxia. RESULTS: Hypoxia potentiated the influence of IFN-gamma on epithelial barrier function. Such responses were conferrable in a >/=10-kilodalton conditioned media fraction from hypoxic epithelia. Subsequent experiments identified this factor as epithelium-derived tumor necrosis factor alpha (TNF-alpha). Add-back of recombinant TNF-alpha in combination with IFN-gamma to normoxic epithelia recapitulated hypoxia and identified basolaterally polarized TNF-alpha receptor types I and II on intestinal epithelia. A similar pattern of TNF-alpha-receptor expression was observed on native intestinal epithelia. Specific inhibition of TNF-alpha using neutralizing antibody or alpha-N-phthalimidoglutarimide (thalidomide) resulted in reversal of the hypoxia-evoked responses. CONCLUSIONS: These studies indicate that during hypoxia, epithelium-derived mediators such as TNF-alpha have the potential to regulate permeability through autocrine pathways.

Hypoxia enhances induction of endothelial ICAM-1: role for metabolic acidosis and proteasomes.

Intercellular adhesion molecule 1 (ICAM-1) is an important molecule in promotion of polymorphonuclear neutrophil transendothelial migration during inflammation. Coincident with many inflammatory diseases is tissue hypoxia. Thus we hypothesized that combinations of hypoxia and inflammatory stimuli may differentially regulate expression of endothelial ICAM-1. Human endothelial cells were exposed to hypoxia in the presence or absence of added lipopolysaccharide (LPS) and examined for expression of functional ICAM-1. Although hypoxia alone did not induce ICAM-1, the combination of LPS and hypoxia enhanced (3 +/- 0.4-fold over normoxia) ICAM-1 expression. Combinations of hypoxia and LPS significantly increased lymphocyte binding, and such increases were inhibited by addition of anti-ICAM-1 antibodies or antisense oligonucleotides. Hypoxic endothelia showed a > 10-fold increase in sensitivity to inhibitors of proteasome activation, and combinations of hypoxia and LPS enhanced proteasome-dependent cytoplasmic-to-nuclear localization of the nuclear transcription factor-kappa B p65 (Rel A) subunit. Such proteasome activation correlated with hypoxia-evoked decreases in both extracellular and intracellular pH. We conclude from these studies that endothelial hypoxia provides a novel, proteasome-dependent stimulus for ICAM-1 induction.

Altered loading patterns and femoral bone mineral density in children with unilateral Legg-Calvé-Perthes disease.

Maximization of bone accrual during the growing years is thought to be an important factor in minimizing fracture risk in old age. Mechanical loading through physical activity has been recommended as a modality for the conservation of bone mineral in adults; however, few studies have evaluated the impact of different loading regimes in growing children. The purpose of this study was to compare bone mineral density (BMD) in weight-bearing and non-weight-bearing limbs in 17 children with unilateral Legg Calvé Perthes Disease (LCPD). Children with this condition have an altered weight-bearing pattern whereby there is increased mechanical loading on the noninvolved normal hip and reduced loading on the involved painful hip. Thus, these children provide a unique opportunity to study the impact of differential mechanical loading on BMD during the growing years while controlling for genetic disposition. BMD at four regions of the proximal femur (trochanter, intertrochanter, femoral neck, total of the regions) was measured using dual energy x-ray absorptiometry (DXA), and the values were compared between the involved and noninvolved sides of the children with LCPD. The BMD of the both sides also were compared with normative values based on both chronological and skeletal age data. A significantly higher BMD was found on the noninvolved side over the involved side for all regions (P < 0.01 and percentage differences of 12-15%) except at the femoral neck (percentage difference of 3.9%). The BMD (at all regions) of the noninvolved side also was significantly greater (P < 0.01) than either the chronological or skeletal age based norms for all sites except the trochanter. The results support the concept that mechanical loading of the skeleton during the growing years is an important factor in BMD accrual.

Epithelial exposure to hypoxia modulates neutrophil transepithelial migration.

Polymorphonuclear leukocytes (PMN) are central to the pathogenesis of a number of intestinal diseases. PMN-induced damage to the protective epithelium occurs in hemorrhagic shock, necrotizing enterocolitis and conditions resulting in intestinal reperfusion injury. In such diseases, tissue hypoxia has been implicated as a pathophysiologic mediator. Thus, we hypothesized that exposure of intestinal epithelia to hypoxia may modulate PMN-epithelial interactions. In this study, T84 cell monolayers, a human intestinal crypt cell line, and isolated human PMN were used to examine the influence of hypoxia/reoxygenation (H/R) on PMN transepithelial migration. Confluent T84 cell monolayers were exposed to hypoxia (range 2-21% O2 for 0-72 h) and reoxygenated with buffer containing PMN. Transmigration of PMN (basolateral to apical orientation) was driven by a transepithelial gradient of the chemotactic peptide tMLP. In response to hypoxia/reoxygenation (H/R), transmigration into, and across epithelial monolayer was increased in a dose- (EC50 approximately 7% O2) and time-dependent fashion (3.5 +/- 0.3-fold increase at 2% O2 for 48 h, P < 0.001). Such conditions of H/R were not toxic to epithelia and did not influence epithelial barrier function. The influence of H/R on PMN transmigration was protein synthesis-dependent (> 80% decreased in the presence of cycloheximide) and could be inhibited by addition of functionally inhibitory antibodies to the PMN beta 2 integrin CD11b/18 (> 80% attenuated) and to CD47 (> 90% decreased compared to control). Hypoxia induced epithelial production and basolateral release of the PMN activating chemokine interleukin-8 (IL-8, nearly sixfold increase over normoxic control) which remained avidly associated with the epithelial matrix. Treatment of epithelial cells with IL-8 antisense oligonucleotides resulted in decreased monolayer-associated PMN but did not influence PMN transmigration, suggesting that epithelial IL-8 production may serve as a recruitment signal for PMN to the basal surface of polarized epithelia. The present observations indicate that H/R provides a relevant stimulus for novel biochemical crosstalk between epithelia and PMN.

Hypoxia enhances stimulus-dependent induction of E-selectin on aortic endothelial cells.

In many diseases, tissue hypoxia occurs in conjunction with other inflammatory processes. Since previous studies have demonstrated a role for leukocytes in ischemia/reperfusion injury, we hypothesized that endothelial hypoxia may "superinduce" expression of an important leukocyte adhesion molecule, E-selectin (ELAM-1, CD62E). Bovine aortic endothelial monolayers were exposed to hypoxia in the presence or absence of tumor-necrosis factor alpha (TNF-alpha) or lipopolysaccharide (LPS). Cell surface E-selectin was quantitated by whole cell ELISA or by immunoprecipitation using polyclonal anti-E-selectin sera. Endothelial mRNA levels were assessed using ribonuclease protection assays. Hypoxia alone did not induce endothelial E-selectin expression. However, enhanced induction of E-selectin was observed with the combination of hypoxia and TNF-alpha (270% increase over normoxia and TNF-alpha) or hypoxia and LPS (190% increase over normoxia and LPS). These studies revealed that a mechanism for such enhancement may be hypoxia-elicited decrements in endothelial intracellular levels of cAMP (<50% compared with normoxia). Addition of forskolin and isobutyl-methyl-xanthine during hypoxia resulted in reversal of cAMP decreases and a loss of enhanced E-selectin surface expression with the combination of TNF-alpha and hypoxia. We conclude that endothelial hypoxia may provide a novel signal for superinduction of E-selectin during states of inflammation.

Scheuermann's juvenile kyphosis.

OBJECTIVE: Two cases are discussed to illustrate two different presentations, progressions and treatments of Scheuermann's juvenile kyphosis. CLINICAL FEATURES: In one case, a 13-yr-old boy suffered from a 2-yr history of lower back pain. Radiographs demonstrated irregularity of the upper lumbar vertebral endplates, associated with Schmorl's nodes. The second case is one of a 14-yr-old boy who was seen in an orthopedic outpatient clinic. Radiographs revealed wedging of the anterior border of T6, T7, and T8 vertebrae with a thoracic spine kyphotic deformity measuring 72 degrees. INTERVENTION AND OUTCOME: The first case was treated conservatively. The patient maintained his improvement at 6 month follow-up. The second case was initially treated with a brace that the patient did not wear regularly as directed. The kyphotic deformity progressed from 72 degrees to 92 degrees. An operation was performed to reduce the kyphotic curve and prevent further progression. On review 6 yr later, the patient was well without back pain or other complications. The kyphotic curve measured 65 degrees. CONCLUSION: Scheuermann's juvenile kyphosis is a common spinal deformity in the adolescent. A radiographic appearance of wedging of the anterior portion of the vertebral bodies with marked kyphotic deformity suggests the diagnosis of classical Scheuermann's disease. However, the lumbar type of Scheuermann's disease should be considered in young patient with radiographic evidence of irregular vertebral endplates, Schmorl's nodes and a decreased disc space without wedging. Nevertheless, significant progression of the curve in both the typical and atypical types of Scheuermann's disease is rare, but can occur. An algorithm is presented to facilitate decision making in the management of Scheuermann's juvenile kyphosis.

Interleukin-4 and interleukin-13 differentially regulate epithelial chloride secretion.

Intestinal epithelia are in intimate contact with subepithelial and intraepithelial lymphocytes. When stimulated, mucosal lymphocytes generate cytokines that act locally and influence functional aspects of many cell types. We have previously defined functional epithelial receptors for interferon-gamma, interleukin (IL)-4, and a recently described IL-4-like cytokine IL-13. In this study, we examine the ion transport properties of T84 cells, a crypt-like epithelial cell line, following exposure to IL-4 and IL-13. Basolateral exposure of epithelial monolayers to both IL-4 and IL-13 attenuated epithelial barrier function and increased paracellular flux of a dextran marker by greater than 65% in a dose- and time-dependent fashion. Stimulated Cl- secretion, as measured by epithelial short circuit current, however, was diminished only by IL-4 and not IL-13, demonstrating cytokine specificity in this epithelial function. Decreased Cl- secretion following IL-4 exposure was associated with diminished Cl- channel activity and IL-4 pretreatment of epithelia decreased expression of the cystic fibrosis transmembrane regulator. Finally, stimulated fluid transport across cultured epithelia was diminished following exposure to IL-4, but not IL-13. These results indicate that while post-receptor signaling events induced by IL-13 and IL-4 may be similar, end point function is cytokine-specific.

Hypoxic stress alone does not modulate endothelial surface expression of bovine E-selectin and intercellular adhesion molecule-1 (ICAM-1).

UNLABELLED: Hypoxemia is a common event in many vascular diseases, especially vascular ischemia. Since endothelial cells of blood vessels are exposed to conditions within the vascular space and leucocytes play a key role in ischemia/reperfusion injury, we hypothesized that endothelial exposure to hypoxia may regulate expression of surface proteins important in leucocyte-endothelial interactions, such as E-selectin and intercellular adhesion molecule (ICAM-1). In this study, we used isolated bovine aortic endothelial monolayers to examine endothelial surface alterations of E-selectin and ICAM-1 induced by tumor necrosis factor-alpha (TNF-alpha), lipopolysaccharide (LPS) and hypoxia using a whole cell enzyme-linked immunosorbent assay (ELISA). Bovine endothelial exposure to TNF-alpha (50 ng/mL) induced a time dependent increase (range 0-24h) in specific E-selection surface expression. Endothelial exposure to hypoxia alone (pO2 approximately 3 mmHg, range 0-24 h), however, failed to elicit endothelial E-selectin expression. Endothelial exposure to LPS brought about a dose- and time-dependent (range 0.5 ng/mL and 2-8 h) increase in specific ICAM-1 surface expression (max. 3.5 +/- 0.15-fold increase over no cytokine control at 10 ng/mL, 4 h). Hypoxia (pO2 approximately 3 mmHg, 8h), however, did not induce ICAM-1 surface expression over normoxia levels. IN CONCLUSION: i) bovine endothelial E-selectin and ICAM-1 surface expression are regulated molecules, ii) hypoxia, per se, does not regulate surface expression of either E-selectin or ICAM-1. These results suggest that hypoxic endothelia may require additional external signals for generation of adaptive inflammatory responses.

Spondyloepiphyseal dysplasia tarda.

OBJECTIVE: To present a case of spondyloepiphyseal dysplasia (SED) tarda in a 14-yr-old boy. CLINICAL FEATURES: The patient suffered from chronic bilateral hip pain and range of movement was decreased. Radiographic examination showed findings consistent with skeletal dysplasia tarda. INTERVENTION AND OUTCOME: The patient was given specific stretching exercises and encouragement to stay active. Physiotherapy was provided to strengthen the hip adductor muscles. CONCLUSION: The presence of short stature, symmetrical hip dysplasia and abnormal vertebral bodies should raise the suspicion of a skeletal dysplasia, specifically spondyloepiphyseal dysplasia.

Ganglioneuroma of the thoracic spine presenting as adolescent idiopathic scoliosis: a case report.

Ganglioneuromas are rare soft-tissue tumors that can present as painless spinal deformities. The surgical outcome is usually satisfactory when complete excision is achieved. A case of spinal ganglioneuroma presenting as adolescent idiopathic scoliosis is presented to illustrate the illusive nature of this condition.

Spinal cord astrocytoma presenting as torticollis and scoliosis.

OBJECTIVE: To illustrate the importance of a careful differential diagnosis in children presenting with torticollis. CLINICAL FEATURES: A 14-yr-old boy presented with a 6-month history of neck pain, torticollis and increasing neurological deficit. Past physiotherapy and chiropractic treatment had not helped. A myelogram and MRI scan revealed a large intramedullary lesion. INTERVENTION AND OUTCOME: He was treated by laminectomy with partial excision of the lesion, followed by radiotherapy. Pathology confirmed the diagnosis of astrocytoma. The patient developed postlaminectomy instability and required spinal fusion. CONCLUSION: The differential diagnosis of torticollis in children is extensive and should always include spinal tumor.

Osteoblastoma: experience with 23 patients.

A retrospective review of 23 patients with osteoblastoma was undertaken in an attempt to answer questions concerning the aggressiveness and potential malignancy of this tumour. Demographic information confirmed that recorded in the literature. There was no suggestion of malignant potential, but, significantly, one tumour persisted, with local recurrence after 11 operations over a period of 27 years. A second tumour, a spinal lesion, occurred (still in a benign form) after a symptom-free period of 17 years. Recognition of aggressive features clinically, radiologically and histologically suggests the need for more aggressive surgical treatment, and late recurrence indicates the need for a more guarded prognosis and longer follow-up.

Osteoid osteomata of the distal phalanx.

Osteoid osteomata are rarely found in the distal phalanges of the hand. The 23 cases in the English language literature are discussed and two additional cases are described. The usual presenting features are chronic pain, nail enlargement and increase in size of the terminal part of the digit. Diagnosis is difficult but surgical excision is effective for treating the patients' pain.