Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome.

OBJECTIVES: To increase the clinical awareness of piriformis muscle syndrome (PMs) by reporting cross-sectional imaging findings, the clinical impact of imaging studies and treatment outcome. METHODS: Within a 10-year-period, 116 patients referred for radiological evaluation of clinically suspected PMs, with excluded lumbar pathology related to symptomatology, were prospectively studied with MRI and/or computed tomography (CT). Piriformis muscle (PM), sciatic nerve (SN), piriformis region and sacroiliac joints were evaluated. PMs was categorised into primary/secondary, according to a reported classification system. Treatment decisions were recorded. Outcome was categorised using a 3-point-scale. RESULTS: Seventy-four patients (63.8%) exhibited pathologies related to PMs. Primary causes were detected in 12 and secondary in 62 patients. PM enlargement was found in 45.9% of patients, abnormal PM signal intensity/density in 40.5% and sciatic neuritis in 25.7%. Space-occupying lesions represented the most common related pathology. Treatment proved effective in 5/8 patients with primary and 34/51 patients with secondary PMs. In 34 patients, imaging revealed an unknown underlying medical condition and altered treatment planning. CONCLUSIONS: Secondary PMs aetiologies appear to prevail. In suspected PMs, PM enlargement represented the most common imaging finding and space-occupying lesions the leading cause. Imaging had the potential to alter treatment decisions. KEY POINTS: • In clinically suspected PMs cross-sectional imaging may reveal variable pathology. • Secondary PMs aetiologies appeared to be more common than primary. • PM enlargement represented the most common imaging finding in clinically suspected PMs. • Space-occupying lesions in the piriformis region represented the leading cause of PMs. • In clinically suspected PMs cross-sectional imaging may alter treatment planning.

Molecular profile of major growth factors in lumbar intervertebral disc herniation: Correlation with patient clinical and epidemiological characteristics.

The involvement of growth factors (GFs) in the pathogenesis of lumbar intervertebral disc (ID) herniation and the spontaneous resorption of herniated ID fragments remains only partially elucidated. A simultaneous assessment of the transcript levels of numerous GFs and their association with clinical and epidemiological profiles of human ID herniation would provide valuable insight into the biology and clinical course of the disease. In the present study, we examined simultaneously the transcript levels of vascular endothelial growth factor (VEGF), transforming growth factor ß1 (TGF­ß1), basic fibroblast growth factor 2 (bFGF2), platelet derived growth factor (PDGF) isoforms and receptors, epidermal growth factor (EGF) and insulin growth factor­1 (IGF­1) in herniated and control ID specimens and investigated their correlation with the clinicopathological profiles of patients suffering from symptomatic lumbar ID herniation. GF mRNA expression levels were determined by RT-qPCR in 63 surgical specimens from lumbar herniated discs and 10 control ID specimens. Multiple positive correlations were observed between the transcript levels of the GFs examined in the ID herniation group. VEGF mRNA expression was significantly increased in the protruding compared with the extruded discs. Intense and acute pain significantly upregulated the PDGF transcript levels. Significant negative correlations were observed between the patient body mass index and the transcript levels of VEGF and PDGF receptors. Our findings support the hypothesis of the involvement of GFs in the natural history of ID herniation. GFs synergistically act in herniated IDs. Increased VEGF expression possibly induces the neovascularization process in the earliest stages of ID herniation. PDGF­C and ­D play a role in the acute phase of radiculopathy in a metabolic response for tissue healing. A molecular effect, in addition to the biomechanical effect of obesity in the pathogenesis of ID herniation is also implied.

Evaluation of the reliability of a new non-invasive method for assessing the functionality and mobility of the spine.

UNLABELLED: For the evaluation of the functionality and mobility of the spine, several methods have been developed. The purpose of this study was to estimate the test-retest reliability of the Spinal Mouse, a new, non-invasive, computer-assisted wireless telemetry device for the assessment of the curvatures, the mobility and the functionality of the spine. MATERIALS AND METHODS: the test-retest reliability was evaluated in 50 adults with back or low back pain. Twenty four parameters were studied in the sagittal and frontal plane. For the characterization of the precision, the intraclass correlation coefficient and the standard error of measurement were used. RESULTS: in the sagittal plane, 22 of the 24 parameters showed high and good reliability, while only two fair and poor. In the frontal plane, 17 parameters showed high and good reliability, five fair and two poor. DISCUSSION: the Spinal Mouse showed excellent test-retest reliability in the sagittal plane, while a slightly inferior performance in the frontal plane, for the evaluation of curvatures, deformation and mobility of the spine.

The study of the thrombin generation mechanism and the effect of low molecular weight heparin as thromboprophylaxis in patients undergoing total knee and hip replacement.

INTRODUCTION: The recommended duration of post-operative Low-Molecular-Weight-Heparins (LMWHs) thromboprophylaxis in Total-Hip-Replacement (THR) and Total-Knee-Replacement (TKR) surgery is controversial. Our aim is to study the thrombin generation (TG) modifications induced by surgery and to evaluate the effect of LMWH on TG during and after the recommended duration. PATIENTS/METHODS: Thirty-one patients received 4000IU anti-Xa/day of enoxaparin, 8-hours post-operatively (15 THR for 30-days and 16 TKR for 15-days). TG assay sensitive to enoxaparin was performed, pre-operatively (D0), 7-hours post-surgery (D1), 8-days post-surgery (D8), and 2-days after thromboprophylaxis withdrawal (D32 and D17), evaluating: lag-time, endogenous thrombin potential (ETP), peak amount of generated thrombin (Peak), time-to-Peak (tt-Peak), and the Mean-Rate-Index [MRI=Peak/(tt-Peak-lag-time)]. RESULTS: TKR surgery decreased lag-time and tt-Peak and increased MRI on D1 vs D0 (p<0.05). In contrast, THR did not significantly modify TG. Enoxaparin effectively reduced thrombin generation in both groups. Thromboprophylaxis withdrawal resulted in rebound increase of TG in the TKR patients (ETP, Peak & MRI significantly increased on D17 vs D0; p<0.05, and vs. D1; p<0.05) but not in THR patients. Variability in the response to enoxaparin was observed among patients of the same group. CONCLUSIONS: TKR surgery is more thrombogenic than THR surgery. In THR patients TG was efficiently inhibited by 30-day thromboprophylaxis, whereas, in TKR patients treated for 15-days TG was not effectively inhibited. Individual variability of the response to enoxaparin was observed in both groups revealing some form of biological resistance to enoxaparin. TG assay may represent the breakthrough step to efficient antithrombotic strategy in clinical settings with high thrombotic risk.

Safety and effectiveness of retrorectal presacral approach for lumbosacral axial instrumentation. A clinical study.

This prospective study aimed to quantify the risks and complications associated with AxiaLIF in a series of 29 patients. AxiaLIF is a fusion technique using a percutaneous retrorectal, presacral corridor approach to access the L5-S1 and L4-L5 intervertebral spaces transaxially, through the body of S1 and L5 vertebrae. The fusion rate in the present series was 92% and the reported results ranged from 68% to 100%. The only serious complication in the authors' series was one presacral haematoma (1/29, or 35%). Symptomatic subsidence occurred in the stand alone group, resulting in foraminal stenosis and radiculopathy in two patients (7%) and back pain in one (3.5%). Painful radiolucent halo around the rod was noted in a spondylolytic case (1/29, or 3.5%); it resolved after transpedicular instrumentation. AxiaLIF is a novel truly minimally invasive technique not requiring blood transfusion and can be safely performed as a day surgery. Retroperitoneal haematoma, ureteral and vascular injuries can be avoided by respecting the regional anatomical landmarks as guided by accurate fluoroscopy. Only expanding haematomas may have to be drained. Bowel perforation can be prevented by gently sweeping away the rectum from the sacrum before inserting the guide probe.

Impaired clearance of apoptotic cells leads to HMGB1 release in the bone marrow of patients with myelodysplastic syndromes and induces TLR4-mediated cytokine production.

Excessive pro-inflammatory cytokine production in the bone marrow has been associated with the pathogenesis of myelodysplastic syndromes. We herein investigated the involvement of toll-like receptors and their endogenous ligands in the induction/maintenance of the inflammatory process in the marrow of patients with myelodysplastic syndromes. We evaluated the expression of toll-like receptors in marrow monocytes of patients (n=27) and healthy controls (n=25) by flow-cytometry and also assessed the activation of the respective signaling using a real-time polymerase chain reaction-based array. We measured the high mobility group box-1 protein, a toll-like receptor-4 ligand, in marrow plasma and long-term bone marrow culture supernatants by an enzyme-linked immunosorbent assay and we performed cross-over experiments using marrow plasma from patients and controls in the presence/absence of a toll-like receptor-4 inhibitor to evaluate the pro-inflammatory cytokine production by chemiluminescence. We assessed the apoptotic cell clearance capacity of patients' macrophages using a fluorescence microscopy-based assay. We found over-expression of toll-like receptor-4 in patients' marrow monocytes compared to that in controls; this over-expression was associated with up-modulation of 53 genes related to the respective signaling. Incubation of patients' monocytes with autologous, but not with normal, marrow plasma resulted in over-production of pro-inflammatory cytokines, an effect that was abrogated by the toll-like receptor-4 inhibitor suggesting that the pro-inflammatory cytokine production in myelodysplastic syndromes is largely mediated through toll-like receptor-4. The levels of high mobility group box-1 protein were increased in patients' marrow plasma and culture supernatants compared to the levels in controls. Patients' macrophages displayed an impaired capacity to engulf apoptotic cells and this defect was associated with excessive release of high mobility group box-1 protein by dying cells. A primary apoptotic cell clearance defect of marrow macrophages in myelodysplastic syndromes may contribute to the induction/maintenance of the inflammatory process through aberrant release of molecules inducing toll-like receptor-4 such as high mobility group box-1 protein.

Study of the quantitative, functional, cytogenetic, and immunoregulatory properties of bone marrow mesenchymal stem cells in patients with B-cell chronic lymphocytic leukemia.

The bone marrow (BM) microenvironment has clearly been implicated in the pathogenesis of B-cell chronic lymphocytic leukemia (B-CLL). However, the potential involvement of BM stromal progenitors, the mesenchymal stem cells (MSCs), in the pathophysiology of the disease has not been extensively investigated. We expanded in vitro BM-MSCs from B-CLL patients (n=11) and healthy individuals (n=16) and comparatively assessed their reserves, proliferative potential, differentiation capacity, and immunoregulatory effects on T- and B-cells. We also evaluated the anti-apoptotic effect of patient-derived MSCs on leukemic cells and studied their cytogenetic characteristics in comparison to BM hematopoietic cells. B-CLL-derived BM MSCs exhibit a similar phenotype, differentiation potential, and ability to suppress T-cell proliferative responses as compared with MSCs from normal controls. Furthermore, they do not carry the cytogenetic abnormalities of the leukemic clone, and they exert a similar anti-apoptotic effect on leukemic cells and healthy donor-derived B-cells, as their normal counterparts. On the other hand, MSCs from B-CLL patients significantly promote normal B-cell proliferation and IgG production, in contrast to healthy-donor-derived MSCs. Furthermore, they have impaired reserves, defective cellular growth due to increased apoptotic cell death and exhibit aberrant production of stromal cell-derived factor 1, B-cell activating factor, a proliferation inducing ligand, and transforming growth factor ß1, cytokines that are crucial for the survival/nourishing of the leukemic cells. We conclude that ex vivo expanded B-CLL-derived MSCs harbor intrinsic qualitative and quantitative abnormalities that may be implicated in disease development and/or progression.

Sliding screw implants for extracapsular hip fractures.

Hip fractures are associated with significant mortality and morbidity for the patients, more dependent residual status, and increased socio-economic cost. Many hip-fracture patients experience severe functional impairment, and most never recover their pre-fracture level of function. Current research has sought to identify the most effective treatments to reduce the incidence of hip fractures, improve survival and quality of life, and minimize complications and disability. The treatment of these fractures in the elderly aims to return these people to their pre-fracture mobility and functional level. This article reviews the surgical treatment options for extracapsular hip fractures and discusses their associated advantages, disadvantages, and complications. Two types of implants are currently available: the dynamic hip screw (DHS), and the intramedullary hip nail with one or two sliding screws. In this review, no clear advantage of one implant over another for the treatment of extracapsular hip fractures was evident. Both the DHS and hip nails can be used successfully for the treatment of stable hip fractures; for unstable fractures and low subtrochanteric fractures, hip nails are preferred. Although hip nails are associated with limited exposure, lower blood loss and transfusion requirements, and shorter operative time, complications are more common with hip nails. Long-term survival and function are similar in the two approaches. Hip nails with two sliding screws do not seem to make the difference in clinical practice that is reported in biomechanical studies.

Respiratory effects, hemodynamic changes and cement leakage during multilevel cement balloon kyphoplasty.

PURPOSE: The purpose of this study is to evaluate the effects of multilevel balloon kyphoplasty (BK) on blood pressure, blood gases and cement leakage. METHODS: This is a prospective study of 63 patients: 31 were treated for osteoporotic vertebral compressive fractures (OVCF) and 32 for osteolytic tumors (OT). Twenty-six patients were treated at 1 level, 15 at 2, 2 at 3, 6 at 4, 3 at 5, 4 at 6, 5 at 7 and 2 at 8. PPMA was used in 43 patients and calcium phosphate in 20. All patients were treated under general anesthesia with continuous invasive monitoring of hemodynamic changes, arterial blood gases and peripheral and regional cerebral oxygen saturation. RESULTS: Two patients had a transient drop in blood pressure between 21 and 42 % during simultaneous inflation of all four balloons at two levels and three more patients during cement injection (two PMMA, one calcium phosphate). Five patients had a cement leak (7.9 %), which was unrelated to the cement type or number of levels. Blood pressure, end-tidal carbon dioxide partial pressure and arterial oxygen partial pressure decreased statistically, but without any clinical significance after cement insertion. Peripheral and regional cerebral oxygen saturation remained unchanged. One-way ANOVA revealed no difference between these changes when clustered by the groups single level, two levels and three or more levels. CONCLUSION: BK performed under general anesthesia appears to be safe when applied in multiple levels in the same seating provided the balloons are inflated sequentially and not simultaneously and the cement is inserted slowly in a very doughy state. Close monitoring of cardiorespiratory factors is valuable. Its rare circulatory effects are unrelated to the number of levels or the cement type.

Spinal cord ischemia after endovascular embolization of a type II endoleak following endovascular aneurysm repair.

BACKGROUND: We report a rare case of severe spinal cord ischemia with neurological consequences in a patient who presented after endovascular treatment of a type II endoleak following endovascular aneurysm repair. METHODS AND RESULTS: An enlarging abdominal aortic aneurysm post-endovascular aneurysm repair was detected owing to a persistent type II endoleak caused by a communication between the iliolumbar and L4 lumbar artery for which the patient underwent supraselective embolization with particles and coils. Immediately after the procedure, the patient experienced an acute onset of neurological symptoms in the right lower limb while limb arterial perfusion remained unaffected. Magnetic resonance imaging-magnetic resonance angiography revealed an acute ischemic process at the L2-L4 level. Further follow-up revealed persistence of the endoleak, and the patient was referred to our institution for open surgical treatment. CONCLUSIONS: To the best of our knowledge, this is the first report of severe spinal cord ischemia after transcatheter embolization of the feeding iliolumbar branches of a type II endoleak. Care must be taken during embolization of the feeding artery of type II endoleaks, which may also supply the spinal cord, to minimize the risk of possible spinal cord ischemia.

Predictive value of Tokuhashi and Tomita scores in patients with metastatic spine disease.

OBJECTIVE: Our aim was to determine the best preoperative prognostic score to safely propose operative intervention for patients with metastatic spinal disease. METHODS: This prospective cohort study included 52 consecutive patients who underwent surgery between 1997 and 2007 to alleviate pain and preserve or restore neurological function. All patients were prospectively evaluated with the Tokuhashi score and retrospectively with the Tomita score to compare their surgery indications. The relationship between the scores and overall survival time were compared. P values of less than 0.05 were considered significant. RESULTS: In predicting survival time, the Tokuhashi score was statistically significant (r=0.574, p=0.01), and the Tomita score borderline significant (r=-0.394, p=0.05). For overall survival after initial diagnosis, the Tokuhashi score was borderline significant for survival (r=0.380, p=0.05) and the Tomita score was not significant. CONCLUSION: The prognostic Tokuhashi score appears to be more valuable for surgical indications than the Tomita score in patients with spinal metastases.

Knee joint anterior malalignment and patellofemoral osteoarthritis: an MRI study.

OBJECTIVES: To evaluate patellofemoral congruency measurements on MRI and correlate the findings with severity of ipsilateral osteoarthritis. METHODS: We retrospectively reviewed 650 consecutive knee MRI examinations from 622 patients divided into two age groups: ≤50 and >50 year-old. The femoral sulcus angle (SA) and depth (SD), lateral patellar displacement (LPD), lateral patellofemoral angle (LPFA), tibial tubercle-trochlear groove (TT-TG) distance and Insall-Salvati index as well as the grade of focal cartilage defects (ranging from I to IV) in the patellofemoral region were assessed in each subject on axial and sagittal fat-saturated intermediate-w MR images. RESULTS: A significant difference exists between normal and knees with patellofemoral joint osteoarthritis regarding SA (p = 0.0002 and <0.0001), SD (p = 0.0004 and <0.0001), LPD (p = 0.0014 and 0.0009) and LPFA (p = 0.0002 and 0.0003) in both age groups (≤50 and >50 respectively). Significant correlation was found between grading of cartilage defects and SA (rho = 0.21, p = 0.0001 and 0.443, <0.0001), SD (rho = -0.198, p = 0.0003 and -0.418, <0.0001), LPD (rho = 0.176, p = 0.0013 and 0.251, 0.0002) and LPFA (rho = -0.204, p = 0.0002 and -0.239, 0.0005) in both age groups. CONCLUSIONS: Knee joint anterior malalignment is multivariably associated with patellofemoral osteoarthritis. KEY POINTS: • MRI is an excellent method to evaluate knee alignment and articular cartilage damage. • Significant associations exist between alignment parameters and osteoarthritis of the patellofemoral joint. • The "sulcus angle" and "sulcus depth" were the most valuable osteoarthritic markers.

Non-operative treatment of peroneal split syndrome: a case report.

Peroneal split syndrome refers to longitudinal tearing of the peroneus brevis tendon at the level of the retrofibular groove. It is an increasingly recognized, albeit frequently overlooked, cause of lateral ankle pain. Several surgical options have been documented for managing this entity, however there are no reports emphasizing the role of conservative treatment. A 48-year-old male patient presented to our department with persistent lateral ankle and hindfoot pain over the past 9 months, following an inversion injury to his right ankle. Magnetic Resonance Imaging demonstrated a longitudinal split of the peroneus brevis tendon. Following peroneus brevis targeted physical therapy, the patient remains symptom free 34 months after his injury. Diagnostic diligence is required in order to direct treatment to the diseased peroneus brevis tendon, thus avoiding prolonged morbidity. A trial of conservative treatment in lower-demand middle aged patients should be considered.

Bacterial wound contamination during simple and complex spinal procedures. A prospective clinical study.

BACKGROUND CONTEXT: Spinal procedures have a potential of intraoperative contamination. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been used to diagnose postoperative infections after spinal surgery. However, it has not been demonstrated if there is an association between surgical site contamination and clinical manifestation of postoperative infection based on inflammatory markers and patients' clinical course. PURPOSE: The purpose of this prospective study was to evaluate the association between surgical site contamination and the development of a postoperative infection in simple and complex surgical procedures. C-reactive protein and ESR levels were observed. The correlation between their values, surgical time, type of surgical procedures, and contaminated surgical sites was investigated. STUDY DESIGN: Prospective clinical study. PATIENT SAMPLE: The study consisted of 40 patients divided into two groups. Group A included 20 patients (mean age, 46.2 years; 12 women and 8 men) who underwent an open discectomy for a lumbar herniated disc. Group B consisted of 20 patients (mean age, 67.9 years; 11 women and 9 men) who underwent a decompression and instrumented fusion for lumbar spinal stenosis. They were followed up for an average of 26.7 months (range, 11-40 months). OUTCOME MEASURES: Samples were obtained for cultures in standard time intervals during surgery. The types of bacteria cultured were evaluated, and CRP and ESR levels were measured. METHODS: Simple lumbar discectomy (Group A, 20 patients) and instrumented lumbar decompression for degenerative lumbar stenosis (Group B, 20 patients) were performed in a prospective consecutive series of patients. All patients were operated by the same surgeon in the same operating room. Surgical site preparation in each patient was done by a standard manner. Samples were obtained for cultures in standard time intervals during surgery. C-reactive protein and ESR levels were measured preoperatively on the 3rd, 7th, and 21st postoperative days, and the clinical course of each patient was recorded. RESULTS: From 40 patients, three patients in Group A and five patients in Group B, a total of eight patients (20%) had positive cultures for bacteria. There was no statistical significance between contamination and duration of surgery in both groups. None of the patients with positive intraoperative cultures developed any clinical signs of superficial or deep postoperative spinal infection, and no additional antibiotic treatment was administered. Three patients with negative cultures developed a postoperative infection. There were no differences in CRP and ESR values between patients with contamination and noncontamination in both groups. C-reactive protein and ESR levels were significantly elevated in complex procedures (Group B) than in simple procedures (Group A). Statistical analysis of CRP and ESR values in both groups and types of bacteria cultured intraoperatively are presented. CONCLUSIONS: The results of this study demonstrate that intraoperative contamination can occur during simple and complex spinal procedures. In the absence of postoperative signs of infection in patients with intraoperative contamination, there is no need of continuing antibiotic treatment. Postoperative kinetics of CRP and ESR showed to be the same in patients with and without intraoperative contamination. Higher levels of inflammatory markers were noted in complex spinal procedures where instrumentation was applied.

Pathophysiology and biomechanics of the aging spine.

AGING OF THE SPINE IS CHARACTERIZED BY TWO PARALLEL BUT INDEPENDENT PROCESSES: the reduction of bone mineral density and the development of degenerative changes. The combination of degeneration and bone mass reduction contribute, to a different degree, to the development of a variety of lesions. This results in a number of painful and often debilitating disorders. The present review constitutes a synopsis of the pathophysiological processes that take place in the aging spine as well as of the consequences these changes have on the biomechanics of the spine. The authors hope to present a thorough yet brief overview of the process of aging of the human spine.

Low molecular weight heparin inhibits melanoma cell adhesion and migration through a PKCa/JNK signaling pathway inducing actin cytoskeleton changes.

Low molecular weight heparin (LMWH) has significant antimetastatic capabilities and affects cancer progression in humans through, not fully defined mechanisms. Here we evaluated its activity at the intracellular level and how it is correlated with melanoma cell adhesion and migration. LMWH inhibited M5 and A375 melanoma cell adhesion and migration in a dose-dependent manner (p⩽0.01). Treatment of M5 melanoma cells with LMWH caused a marked down regulation of constitutive as well as the FN-induced phosphorylation (p⩽0.01) of protein kinase C alpha (PKCa). This was associated with a profound decrease in the cytoplasmic pPKCa (p⩽0.05) and a simultaneous enhancement of nuclear pPKCa localization (p⩽0.01). A significant decrease in the levels of pJNK (p⩽0.01), which is a downstream effector of PKCa, was also demonstrated in the LMWH-treated cells. Furthermore, LMWH-treated cells had disorganized actin stress fibers correlated to a strong decrease in cell-substratum interface area (p⩽0.05) and altered morphology. The decrease in the activation of PKCa, which is an important regulator of cell motility, was directly correlated to the reduced ability of the LMWH-treated melanoma cells to adhere onto and migrate towards the fibronectin (FN) substrate (p⩽0.01). The lineage activation of PKCa-JNK/p38 and their correlation to M5 cell adhesion was confirmed with the utilization of specific inhibitors. In conclusion, LMWH through the downregulation of pPKCa and redistribution to nuclear region attenuates JNK activation, which in turn induces cytoskeleton changes correlated to M5 cell decreased adhesion/migration. This may provide clues for the pharmacological targeting of melanoma.

Reversal of tetraplegia in a patient with haematogenous cervical epidural abscess.

Pyogenic haematogenous cervical epidural abscess complicated by tetraplegia is an uncommon entity, but its clinical importance overshadows its rarity. Predisposing risk factors for spinal epidural abscess include diabetes, intravenous drug abuse, liver disease, renal failure, malignancy, HIV, infection elsewhere, rheumatoid conditions, trauma and a number of spinal interventions. Lack of recovery and death are much more frequent when complete paralysis exists since more than 24 to 48 hours. Most authors combine decompressive laminectomy and antibiotics. Anterior decompression and needle aspiration are rarely used, the former more specifically in case of anterior abscess formation. A high index of suspicion along with reliance on gadolinium-enhanced MRI is essential to diagnose the pathology and institute appropriate treatment on an individual basis. The authors report on a diabetic male patient who developed a cervical epidural abscess with tetraplegia after dental extraction. He was treated within six hours by one stage anterior/posterior decompression and fusion, with complete recovery.

Role of receptor for hyaluronic acid-mediated motility (RHAMM) in low molecular weight hyaluronan (LMWHA)-mediated fibrosarcoma cell adhesion.

Hyaluronan (HA) modulates key cancer cell functions through interaction with its CD44 and receptor for hyaluronic acid-mediated motility (RHAMM) receptors. HA was recently found to regulate the migration of fibrosarcoma cells in a manner specifically dependent on its size. Here, we investigated the effect of HA/RHAMM signaling on the ability of HT1080 fibrosarcoma cells to adhere onto fibronectin. Low molecular weight HA (LMWHA) significantly increased (p ≤ 0.01) the adhesion capacity of HT1080 cells, which high molecular weight HA inhibited. The ability of HT1080 RHAMM-deficient cells, but not of CD44-deficient ones, to adhere was significantly decreased (p ≤ 0.001) as compared with control cells. Importantly, the effect of LMWHA on HT1080 cell adhesion was completely attenuated in RHAMM-deficient cells. In contrast, adhesion of RHAMM-deficient cells was not sensitive to high molecular weight HA treatment, which identifies RHAMM as a specific conduit of the LMWHA effect. Western blot and real time-PCR analyses indicated that LMWHA significantly increased RHAMM transcript (p ≤ 0.05) and protein isoform levels (53%, 95 kDa; 37%, 73 kDa) in fibrosarcoma cells. Moreover, Western blot analyses showed that LMWHA in a RHAMM-dependent manner enhanced basal and adhesion-dependent ERK1/2 and focal adhesion kinase (FAK) phosphorylation in HT1080 cells. Utilization of a specific ERK1/2 inhibitor completely inhibited (p ≤ 0.001) LMWHA-dependent adhesion, suggesting that ERK1/2 is a downstream effector of LMWHA/RHAMM signaling. Likewise, the utilization of the specific ERK1 inhibitor resulted in a strong down-regulation of FAK activation in HT1080 cells, which identifies ERK1/2 as a FAK upstream activator. In conclusion, our results suggest that RHAMM/HA interaction regulates fibrosarcoma cell adhesion via the activation of FAK and ERK1/2 signaling pathways.

Parathyroid hormone affects the fibroblast growth factor-proteoglycan signaling axis to regulate osteosarcoma cell migration.

Parathyroid hormone (PTH)(1-34), which has been established to have a dual effect on bone metabolism, was recently found to regulate osteosarcoma cell migration. A significant part of the bone anabolic action of PTH(1-34) is attributed to fibroblast growth factor (FGF)-2 stimulation. Furthermore, it was recently suggested that the FGF-proteoglycan axis may form an extracellular matrix-related regulatory feedback loop that controls osteoblastic lineage cell proliferation and execution of the osteogenic program. In this study, we investigated the possible participation of FGF-2 signaling in PTH(1-34)-dependent osteosarcoma cell migration. FGF-2 treatment of osteosarcoma cells resulted in a significant increase (P ≤ 0.01) in MG63 cell migration, similar to that caused by PTH(1-34). mRNA expression analysis of cells treated with PTH(1-34) showed a strong increase in FGF-2 transcript levels (P = 0.0015). Interestingly, the addition of FGF-2 to MG63 cells led to significant downregulation of small leucine-rich proteoglycan biglycan expression at both the mRNA (P ≤ 0.0001) and protein (60%) levels. In order to examine the significance of biglycan on MG63 cell migration, transfection with short interfering RNA specific for biglycan was performed, resulting in a significant increase (P ≤ 0.01) in the migration capacity of biglycan-deficient MG63 cells. In contrast, exogenous human recombinant biglycan strongly inhibited the migration of these cells (P ≤ 0.01). Finally, a direct correlation between PTH(1-34) action and biglycan expression was established by the finding of a significant decrease (P ≤ 0.01) in biglycan transcript levels in PTH(1-34)-treated cells. To summarize, the present study demonstrates a novel cooperative mechanism of PTH(1-34) and FGF-2 action that results in specific alteration of the biglycan extracellular matrix content to regulate osteosarcoma cell migration.