Septic Arthritis of Cervical Spine Facet Joints: A Case Report and Review of Imaging.

BACKGROUND Septic arthritis of the facet joint (SAFJ) has been considered a rare type of spinal infection. However, because of the aging of the population, the increase in compromised hosts, and the increase in MRI use in recent years, the number of reports has been increasing. We report the clinical progress of a rare case of septic arthritis of the cervical facet joint (SACFJ) with some imaging considerations, and we compare our findings with existing reports of SACFJ. CASE REPORT A 73-year-old Japanese woman presented with fever, paralytic symptoms, and paresthesia of the upper limbs. Here, we report a case of SACFJ in which MRI findings allowed early diagnosis, and a favorable course was obtained by conservative treatment with antibiotics. Although MRI performed 93 days after the initiation of treatment showed a slight residual signal change in the facet joints, no symptoms had recurred by the sixth month after hospital discharge. CONCLUSIONS If a patient develops neurological symptoms such as paralysis with fever and increased inflammatory response, the physician must consider the possibility of pyogenic spondylitis, including SACFJ, and order an MRI. Epidural abscess is almost inevitable in SACFJ, and surgical treatment, including abscess drainage, is required if spinal cord or paralytic symptoms progress. For patients with SACFJ, as well as pyogenic spondylitis, MRI may not be useful in determining treatment efficacy.

Randomized trial of granulocyte colony-stimulating factor for spinal cord injury.

Attenuation of the secondary injury of spinal cord injury (SCI) can suppress the spread of spinal cord tissue damage, possibly resulting in spinal cord sparing that can improve functional prognoses. Granulocyte colony-stimulating factor (G-CSF) is a haematological cytokine commonly used to treat neutropenia. Previous reports have shown that G-CSF promotes functional recovery in rodent models of SCI. Based on preclinical results, we conducted early phase clinical trials, showing safety/feasibility and suggestive efficacy. These lines of evidence demonstrate that G-CSF might have therapeutic benefits for acute SCI in humans. To confirm this efficacy and to obtain strong evidence for pharmaceutical approval of G-CSF therapy for SCI, we conducted a phase 3 clinical trial designed as a prospective, randomized, double-blinded and placebo-controlled comparative trial. The current trial included cervical SCI [severity of American Spinal Injury Association (ASIA) Impairment Scale (AIS) B or C] within 48 h after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group was administered 400 µg/m2/day × 5 days of G-CSF in normal saline via intravenous infusion for five consecutive days. The placebo group was similarly administered a placebo. Allocation was concealed between blinded evaluators of efficacy/safety and those for laboratory data, as G-CSF markedly increases white blood cell counts that can reveal patient treatment. Efficacy and safety were evaluated by blinded observer. Our primary end point was changes in ASIA motor scores from baseline to 3 months after drug administration. Each group includes 44 patients (88 total patients). Our protocol was approved by the Pharmaceuticals and Medical Device Agency in Japan and this trial is funded by the Center for Clinical Trials, Japan Medical Association. There was no significant difference in the primary end point between the G-CSF and the placebo control groups. In contrast, one of the secondary end points showed that the ASIA motor score 6 months (P = 0.062) and 1 year (P = 0.073) after drug administration tend to be higher in the G-CSF group compared with the placebo control group. Moreover, in patients aged over 65 years old, motor recovery 6 months after drug administration showed a strong trend towards a better recovery in the G-CSF treated group (P = 0.056) compared with the control group. The present trial failed to show a significant effect of G-CSF in primary end point although the subanalyses of the present trial suggested potential G-CSF benefits for specific population.

Bone formation at Ti-6Al-7Nb scaffolds consisting of 3D honeycomb frame and diamond-like carbon coating implanted into the femur of beagles.

We fabricated Ti-6Al-7Nb bone scaffolds with 5 mm diameter and 20 mm length comprise of a three-dimensional (3D) honeycomb frame structure of truncated octahedra created by selective laser sintering 3D printing. The honeycomb frame was then coated with 0.1 µm thick diamond-like carbon (DLC) to increase biocompatibility. A round rod of Ti-6Al-7Nb alloy (ASTM F1295) was as a control material. They were implanted into the femur bones of beagles to evaluate bone morphometrics and to investigate changes in the transcriptome of the new bone tissue using DNA microarray analysis and real-time polymerase chain reaction (PCR). In the present report, the 3D honeycomb material with and without DLC film consisting of a-C:H is referred to as 3D_a-C:H and 3D_non, respectively. At 3 weeks after implantation, the 3D_non had more contact between the new and artificial bones compared with the control, and the 3D_a-C:H had more contact between the new and artificial bones compared with the control and 3D_non. Furthermore, 3D_a-C:H showed even more new bone compared with the control and 3D_non. At 8 weeks after implantation, more appeared lamellar bone with the 3D_a-C:H implant than those with the control and 3D_non. The real-time PCR results at 1 week of implantation revealed higher expression levels of VEGF, RANKL, and NOTCH2 expression with 3D_a-C:H than with 3D_non and control. As a result of real-time PCR at 2 weeks of implantation, OPN and CTSK expressions were found to be higher with 3D_a-C:H and 3D_non than that with the control.

Evaluation of Antibacterial and Cytotoxic Properties of a Fluorinated Diamond-Like Carbon Coating for the Development of Antibacterial Medical Implants.

Peri-implant infection is a serious complication in surgical procedures involving implants. We conducted an in vitro study to determine whether the use of a fluorinated diamond-like carbon (F-DLC) coating on a titanium alloy surface can prevent peri-implant infection. After applying the F-DLC, we evaluated its antibacterial and cytotoxic properties. The coating groups, containing controlled fluorine concentrations of 5.44%, 17.43%, 24.09%, and 30%, were examined for the presence of Staphylococcus aureus and Escherichia coli according to ISO 22196 for the measurement of antibacterial activity on plastics and other nonporous surfaces. Biological toxicity was evaluated using Chinese hamster V79 cells according to ISO 10993-5 for the biological evaluation of medical devices. In the control group, populations of S. aureus and E. coli substantially increased from 2.4 × 104 to (1.45 ± 1.11) × 106 colony-forming units (CFUs) and from 2.54 × 104 to (4.04 ± 0.44) × 106 CFUs, respectively. However, no bacteria colonies were detected in any F-DLC group with a fluorine concentration of ≥ 17.43%. In the biological toxicity study, an F-DLC coating with a fluorine concentration of 30% showed a colony formation rate of 105.8 ± 24.1%, which did not differ significantly from the colony formation rate of 107.5 ± 31.1% in the nontoxic control group. An F-DLC coating on titanium alloy discs showed excellent in vitro antibacterial activity with no biological toxicity.

Case report of surgical treatment of scoliosis caused by neurofibroma located posterior mediastinum.

BACKGROUND: Neurofibromatosis type 1 (NF-1) is often associated with various orthopedic disorders, especially scoliosis. Spinal deformity in patients with NF-1 can be induced by localized neurofibromas. CASE PRESENTATION: Scoliosis can be induced by a localized neurofibroma. A 12-year-old boy diagnosed with neurofibromatosis type 1 had severe scoliosis caused by a neurofibroma located in the posterior mediastinum. We performed two-stage procedure involving the extirpation of the neurofibroma in the lateral position, and posterior spinal fusion with segmental spinal instrumentation for the scoliosis in the prone position. DISCUSSION: The optimum surgical approach for the extirpation of neurofibroma located in the posterior mediastinal remains to be established. It may be difficult to extirpate a tumor in this position via a posterior approach alone, as the tumor is surrounded by several tissue, e.g. azygos vein, trachea and esophagus. In our case, we first extirpated the tumor located in the posterior mediastinum via a posterolateral incision in the right lateral position. With this approach, it may be easy to confirm the safe relationship between the tumor and surrounding tissue. CONCLUSIONS: We safely performed a two-stage procedure involving the extirpation of a neurofibroma in the lateral position, and posterior spinal fusion with segmental spinal instrumentation for scoliosis in the prone position.

Study protocol for the G-SPIRIT trial: a randomised, placebo-controlled, double-blinded phase III trial of granulocyte colony-stimulating factor-mediated neuroprotection for acute spinal cord injury.

INTRODUCTION: Granulocyte colony-stimulating factor (G-CSF) is generally used for neutropaenia. Previous experimental studies revealed that G-CSF promoted neurological recovery after spinal cord injury (SCI). Next, we moved to early phase of clinical trials. In a phase I/IIa trial, no adverse events were observed. Next, we conducted a non-randomised, non-blinded, comparative trial, which suggested the efficacy of G-CSF for promoting neurological recovery. Based on those results, we are now performing a phase III trial. METHODS AND ANALYSIS: The objective of this study is to evaluate the efficacy of G-CSF for acute SCI. The study design is a prospective, multicentre, randomised, double-blinded, placebo-controlled comparative study. The current trial includes cervical SCI (severity of American Spinal Injury Association (ASIA) Impairment Scale B/C) within 48 hours after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group is administered 400 µg/m2/day×5 days of G-CSF in normal saline via intravenous infusion for 5 consecutive days. The placebo group is similarly administered a placebo. Our primary endpoint is changes in ASIA motor scores from baseline to 3 months. Each group includes 44 patients (88 total patients). ETHICS AND DISSEMINATION: The study will be conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Japanese Medical Research Involving Human Subjects Act and other guidelines, regulations and Acts. Results of the clinical study will be submitted to the head of the respective clinical study site as a report after conclusion of the clinical study by the sponsor-investigator. Even if the results are not favourable despite conducting the clinical study properly, the data will be published as a paper. TRIAL REGISTRATION NUMBER: UMIN000018752.

CSF tau protein is a useful marker for effective treatment of superficial siderosis of the central nervous system: two case reports.

We report two cases of superficial siderosis (SS) of the central nervous system (CNS), which is caused by chronic haemorrhaging into the subarachnoid space with haemosiderin deposition in the superficial portion of the CNS. Patient 1 had fluid collection in the spinal canal, which was reported as the source of the chronic bleeding. Patient 2 was bleeding from thickened dura at the level of the sacral vertebrae. Both of the patients had xanthochromic cerebrospinal fluid. We surgically repaired the sources of bleeding. Subsequently the cerebrospinal fluid (CSF) cleared and their symptoms were not aggravated for about 1 year. We measured several CSF markers of SS before and after surgery. Total tau protein (CSF-t-tau), phosphorylated tau protein (CSF-p-tau), iron (CSF-iron) and ferritin (CSF-ferritin) in the CSF were highly elevated at diagnosis. After surgery, the levels of CSF-t-tau and CSF-p-tau were markedly reduced while CSF-iron and CSF-ferritin had not decreased. It is suggested that CSF-t-tau and CSF-p-tau reflected the neural damage in SS and were useful to evaluate the effectiveness of SS therapies.

Cervicothoracic giant cell tumor expanding into the superior mediastinum: total excision by combined anterior-posterior approach.

This article describes a case of cervicothoracic giant cell tumor expanding into the superior mediastinum treated by total spondylectomy. A 42-year-old-man presented with back pain and paraparesis. Magnetic resonance imaging revealed the collapse of the T2 vertebral body. The spinal cord was severely compressed by the tumor mass. The tumor had spread from T2 to the mediastinum, so that the tumor was in contact with many vital structures. To resect the tumor completely, total spondylectomy from T1 to T3 was performed through a combined anterior-posterior approach. The tumor was dissected from the vital structures using an anterior low cervical approach and splitting one-third of the sternum. En bloc vertebral resection from Th1 to Th3, including the tumor pseudocapsule, was possible through a posterior approach. The tumor around the nerve roots or dura was resected piece by piece since it was possible to separate the capsulated tumor from the dura. Splitting one-third of the sternum allowed separation of the tumor from the anterior vital structures, under direct vision. This allowed en bloc vertebral resection of the tumor that had spread to the mediastinum from T2 and in the craniocaudal direction from T1 to T3. Although giant cell tumor is benign, it can be locally aggressive. Complete excision of a giant cell tumor is the best treatment option even for the cervicothoracic spine, to protect the vital structures or neural function.