Cortical bone trajectory for lumbar pedicle screws.

BACKGROUND CONTEXT: Achieving solid implant fixation to osteoporotic bone presents a clinical challenge. New techniques and devices are being designed to increase screw-bone purchase of pedicle screws in the lumbar spine via a novel cortical bone trajectory that may improve holding screw strength and minimize loosening. Preliminary clinical evidence suggests that this new trajectory provides screw interference that is equivalent to the more traditionally directed trajectory for lumbar pedicle screws. However, a biomechanical study has not been performed to substantiate the early clinical results. PURPOSE: Evaluate the mechanical competence of lumbar pedicle screws using a more medial-to-lateral path (ie, "cortical bone trajectory") than the traditionally used path. STUDY DESIGN: Human cadaveric biomechanical study. METHODS: Each vertebral level (L1-L5) was dual-energy X-ray absorptiometry (DXA) scanned and had two pedicle screws inserted. On one side, the traditional medially directed trajectory was drilled and tapped. On the contralateral side, the newly proposed cortical bone trajectory was drilled and tapped. After qCT scanning, screws were inserted into their respective trajectories and pullout and toggle testing ensued. In uniaxial pullout, the pedicle screw was withdrawn vertically from the constrained bone until failure occurred. The contralateral side was tested in the same manner. In screw toggle testing, the vertebral body was rigidly constrained and a longitudinal rod was attached to each screw head. The rod was grasped using a hydraulic grip and a quasi-static, upward displacement was implemented until construct failure. The contralateral pedicle screw was tested in the same manner. Yield pullout (N) and stiffness (N/mm) as well as failure moment (N-m) were compared and bone mineral content and bone density data were correlated with the yield pullout force. RESULTS: New cortical trajectory screws demonstrated a 30% increase in uniaxial yield pullout load relative to the traditional pedicle screws (p=0.080), although mixed loading demonstrated equivalency between the two trajectories. No significant difference in construct stiffness was noted between the two screw trajectories in either biomechanical test or were differences in failure moments (p=0.354). Pedicle screw fixation did not appear to depend on bone quality (DXA) yet positive correlations were demonstrated between trajectory and bone density scans (qCT) and pullout force for both pedicle screws. CONCLUSIONS: The current study demonstrated that the new cortical trajectory and screw design have equivalent pullout and toggle characteristics compared with the traditional trajectory pedicle screw, thus confirming preliminary clinical evidence. The 30% increase in failure load of the cortical trajectory screw in uniaxial pullout and its juxtaposition to higher quality bone justify its use in patients with poor trabecular bone quality.

Lower cervical spine facet cartilage thickness mapping.

OBJECTIVE: Finite element (FE) models of the cervical spine have been used with increasing geometric fidelity to predict load transfer and range of motion (ROM) for normal, injured, and treated spines. However, FE modelers frequently treat the facet cartilage as a simple slab of constant thickness, impeding the accuracy of FE analyzes of spine kinematics and kinetics. Accurate prediction of facet joint contact forces and stresses, ROM, load transfer, and the effects of facet arthrosis require accurate representation of the geometry of the articular cartilage of the posterior facets. Previous research has described the orientations of the facet surfaces, their size and aspect ratio, and mean and maximum thickness. However, the perimeter shape of the cartilaginous region and the three-dimensional distribution of cartilage thickness remain ill-defined. As such, it was the intent of this research to further quantify these parameters. METHOD: Vertebrae from seven fresh-frozen unembalmed human cadavers were serially sectioned and the osteochondral interface and the articulating surface of each facet on each slice were identified. The cartilage thickness was recorded at nine equidistant points along the length of each facet. It was observed that facets tended to have elliptic or ovoid shapes, and best-fit ovoid perimeter shapes were calculated for each facet. The thickness distribution data were used to represent the entire three-dimensional cartilage distribution as a function of one variable, and a thickness distribution function was optimized to fit the thickness distribution. The antero-posterior and medial/lateral shifts of the thickness center relative to the geometric were calculated and reported. RESULTS: High correlation was observed between the ovoid perimeter shapes and the measured facet shapes in radial coordinates, indicating that the ovoid approximation is able to accurately represent the range of facet geometries observed. High correlation between the measured and fitted thickness distributions indicates that the fitting function used is able to accurately represent the range of cartilage thickness distributions observed. CONCLUSION: Utilization of a more physiologic cartilage thickness distribution in FE models will result in improved representation of cervical spine kinematics and increased predictive power. The consistency observed in the thickness distribution function in this study indicates that such a representation can be generated relatively easily.

Recurrent headache in adolescents: nonreferred versus clinic population.

OBJECTIVE: To compare headache activity, psychosocial measures, and cold pressor response between referred and nonreferred adolescents with frequent headache. DESIGN: Thirteen boys and 19 girls with a mean age of 13.4 +/- 0.9 years who had been referred to a hospital-based behavioral treatment program for recurrent headache were compared with an age- and sex-matched school-based population of nonreferred students consisting of 31 adolescents with frequent headaches and 32 adolescents with infrequent or no headaches. All subjects completed the Spielberger State-Trait Anxiety Inventory/Trait form, the Children's Depression Inventory, the Childhood Somatization Inventory, and measures of headache activity and related functional disability. Additionally, all subjects reported interval discomfort scores on a 40-second cold pressor test with arm immersion in a 10 degrees +/- 1 degree C cold water bath. RESULTS: Subjects from both headache groups reported significantly more anxiety than those with infrequent or no headaches. The school-based nonreferred adolescents reported more depressive symptoms than the clinic-based referred subjects. In addition, the latter group reported headaches of longer duration and more school days missed due to headaches than both other groups. Whereas school-based subjects and those with infrequent or no headaches reported relatively low initial cold pressor test scores and gradually reported increasing scores with time, clinic-based subjects rated their discomfort as high at the initial interval report and maintained high levels throughout the test. No differences in somatization were found among groups. CONCLUSION: Although adolescents who seek behavioral treatment for recurrent headache do not report more psychological symptoms than nonreferred adolescents with frequent headaches, they report headaches of longer duration, miss more school days due to headache, and report higher initial sustained discomfort scores to a standardized noxious stimulus.

Variation in opioid use during PCA in adolescents.

The objective of this investigation was to determine if the variability in the use of opioids for pain following surgery is related to variability in blood concentration of opioids used for pain relief. We measured morphine use and morphine blood concentration in a group of otherwise healthy adolescent girls following spinal surgery. There was considerable variability in morphine use and morphine blood levels as indicated by a large range of values and a moderately large standard deviation. Morphine blood concentration correlated with morphine use. Neither morphine use nor morphine concentration correlated with pain scores. The data indicate that there is considerable variability among patients in the amount of opioid needed to achieve comfort and in the blood concentration associated with comfort. The cause of this variability does not appear to be related to metabolism of opioid, but may be related to psychological differences, differences in pain tolerance and threshold, or differences in the way patients use PCA.

Lung protection against paraquat is calcium dependent.

Isolated, perfused, and ventilated rat lungs were challenged by paraquat (0.01 M) in the presence of 2.5 mM Ca2+, 2.5 mM Ca2+ with trifluoperazine (100 microM), 0.025 mM Ca2+, or 0.025 mM Ca2+ with sodium metavanadate (10 microM) to establish the effect of varying calcium concentration or calcium-dependent enzyme activities on injury induced by paraquat. Segmental vascular resistances, microvascular permeability (as assessed by the capillary filtration coefficient), lung tissue oxidized glutathione, and lung paraquat accumulation were measured. Exposure to paraquat for 2.5 h did not increase microvascular permeability or pulmonary vascular resistance in the presence of either normal extracellular calcium or low extracellular calcium and sodium metavanadate. Lungs exposed to paraquat were injured (as assessed by increased filtration coefficient) only in the presence of low extracellular calcium or after trifluoperazine was added. This injury was associated with decreased levels of oxidized glutathione and increased paraquat accumulation, suggesting that calcium's protective effect was both by inhibition of paraquat accumulation and maintenance of NADPH. Pulmonary vascular resistance was not increased with paraquat challenge.

Villous motility and unstirred water layers in canine intestine.

The possibility that villous motility reduces the mucosal unstirred water layer by mechanical stirring was examined. The frequency of contraction of villi was measured by using videomicroscopic techniques while a segment of anesthetized canine jejunum or ileum with its nerve and blood supply intact was maintained in a sealed chamber through which Tyrode solution was perfused. Radioisotopically labeled inulin, H2O, and butyric and lauric acid were used to measure net and/or unidirectional fluxes from the chamber. The unidirectional absorptive transport of H2O and butyric acid but not lauric acid by jejunal segments was significantly correlated with flow through the chamber. Plasma volume expansion increased villous motility but decreased the absorption of H2O and lauric acid. Absorption of butyric acid from the ileum was little different than from the jejunum although the degree of villous motility was less and net water absorption was greater from the ileum. Absorption of butyric acid into dead tissue indicated that passive diffusion into the tissue accounted for between 7 and 25%, depending on flow rate, of the absorption in intact tissue and that nonspecific binding was low. It was concluded that villous motility did not stir the unstirred water layers and was not directly associated with altered transport.

Symptomatic mitral valve prolapse in children and adolescents: catecholamines, anxiety, and biofeedback.

It has been proposed that symptomatic mitral valve prolapse may be associated with a hyperadrenergic state and/or increased anxiety. To test this hypothesis, Spielberger State-Trait Anxiety (STAI) scores and 24-hour urinary catecholamine collections were gathered from 11 children and adolescents without mitral valve prolapse, 6 with asymptomatic mitral valve prolapse, and 14 who had chest pain (some with additional symptoms of shortness of breath, palpitations, and fatigue). STAI scores and catecholamine excretion values were not significantly different between groups. Ten symptomatic patients were randomly assigned to either eight sessions of skin temperature biofeedback with daily home practice of relaxation-mental imagery techniques or an attention-placebo condition. Change in 24-hour urinary catecholamine excretion values and STAI scores from baseline to end of treatment did not differ significantly between treatment and placebo conditions. Although not evident at the end of treatment, a significant decrease in chest pain was found in the biofeedback group at 6-month follow-up evaluation. In summary, results of this study did not show evidence of increased sympathetic tone or levels of anxiety in symptomatic pediatric patients with mitral valve prolapse. A behavioral treatment program using biofeedback and relaxation-mental imagery techniques was associated with decreased chest pain at 6-month follow-up.

Hypnotizability does not predict outcome of behavioral treatment in pediatric headache.

Several adult studies suggest that recurrent headache patients who are highly hypnotizable benefit most from behavioral treatment. We examined the relationship between intrinsic patient factors and clinical outcome in 100 children and adolescents with recurrent headache who were enrolled in our behavioral treatment program. We found no correlation between age, sex, headache type, hypnotizability, and clinical outcome.

Hypnotic versus active cognitive strategies for alleviation of procedural distress in pediatric oncology patients.

This study provided a differential comparison of the efficacy of standardized instruction in hypnosis or active cognitive strategy for provision of relief from procedurally induced pain and anxiety. Subjects were instructed to self-direct in the use of strategies during medical procedures. Twenty pediatric oncology patients participated in the study. They were not informed that hypnosis was one of the strategies. Subjects were screened for hypnotizability and randomly assigned to treatments. Demographic data were collected. Pre-strategy training observations were made during a Bone Marrow Aspiration or Lumbar Puncture (BMA/LP) using visual analog scales, the McGill Pain Questionnaire, State-Trait Anxiety Inventory, pulse and temperature readings, and interview. Following strategy training, data were collected during a second BMA/LP using the same measures as employed pre-intervention. Results indicated that both strategies were effective in providing pain reduction. Neither technique provided for anxiety reduction. Hypnotizability scale scores failed to correlate with degree of pain reduction.

Assessment and management of recurrent pain in adolescence.

The pediatrician presented with an adolescent complaining of recurrent or chronic pain should assess the antecedents, sustainers and consequences of the pain syndrome. Particular attention should be paid to the developmental tasks of adolescence and the presence of psychosocial stress in the adolescent's family, school, peer relationships or community. Regardless of its etiology, effective management of recurrent or chronic pain in adolescence involves a balance of cognitive, behavioral and pharmacologic interventions.

Neurohumoral control of villous motility.

A quantitative videomicroscopic method was used to examine neurohumoral control of villous motility. Intraduodenal instillation of saline, 0.4% hydrochloric acid, or acidified predigested food did not cause a significant change in villous contraction frequency in an isolated segment of jejunum. Villous motility in the jejunum of fed dogs, from which the chyme had been removed, was not greater than that in fasted dogs (2.9 +/- 0.3 vs. 3.4 +/- 0.5 contractions/min). Furthermore, acid extracts of the duodenal mucosa did not produce an increase in jejunal villous motility when injected intravenously. These data argue against the existence of a humoral stimulant of villous motility (villikinin). Vagotomy caused only a small (20%) and transient (10 min) decline in villous motility. Vagal stimulation at 5, 10, and 20 Hz caused villous motility to increase by 24 +/- 7, 23 +/- 9, and 32 +/- 10%, respectively. Atropine blocked the effects of vagal stimulation. Section of the periarterial (sympathetic) nerves did not alter villous contractile activity. Stimulation of the periarterial nerves at 5, 10, and 20 Hz caused villous contraction frequency to decline by 41 +/- 5, 45 +/- 5, and 38 +/- 10%, respectively. This inhibition appears to involve both alpha- and beta-adrenergic receptors and a reduction in blood flow. Neither atropine, alpha-blockade, nor beta-blockade produced a sustained alteration in basal contraction frequency.

Villous motility: relationship to lymph flow and blood flow in the dog jejunum.

Villous contraction frequency, lymph flow, blood flow, and arteriovenous oxygen difference were measured in dog jejunum. Venous pressure elevation and plasma dilution were used to increase capillary fluid filtration. Both perturbations produced concomitant increases in villous contraction frequency and lymph flow. A highly significant correlation (r = 0.83, p less than 0.001) was obtained between villous contraction frequency and lymph flow. This finding, coupled with the observation that stimulation of net fluid absorption increases villous contraction frequency, suggests that villous motility is increased by a myogenic response elicited by increments in interstitial fluid pressure. In another series of experiments local arterial pressure was reduced in 20-mmHg steps from 120 to 20 mmHg. Although blood flow fell proportionately to arterial pressure, villous contraction frequency and oxygen uptake were maintained at a normal level when arterial pressure was between 120 and 60 mmHg. Villous motility and oxygen consumption fell progressively as arterial pressure was reduced below 60 mmHg. This observation indicates that ischemia does not alter villous contraction frequency unless blood flow is reduced below the level necessary to maintain normal tissue oxygenation.

Microsphere estimates of blood flow: methodological considerations.

The microsphere technique is a standard method for measuring blood flow in experimental animals. Sporadic reports have appeared outlining the limitations of this method. In this study we have systematically assessed the effect of blood withdrawals for reference sampling, microsphere numbers, and anesthesia on blood flow estimates using radioactive microspheres in dogs. Experiments were performed on 18 conscious and 12 anesthetized dogs. Four blood flow estimates were performed over 120 min using 1 X 10(6) microspheres (15 microns) each time. The effects of excessive numbers of microspheres (13 million), pentobarbital sodium anesthesia (30 mg/kg), and replacement of volume loss for reference samples with dextran 70 were assessed. In both conscious and anesthetized dogs a progressive decrease in gastric mucosal blood flow and cardiac output was observed over 120 min. This was also observed in the pancreas in conscious dogs. The major factor responsible for these changes was the volume loss due to reference sample withdrawals. Replacement of the withdrawn blood with dextran 70 led to stable blood flows to all organs. The injection of excessive numbers of microspheres did not modify hemodynamics to a greater extent than did the injection of 4 million microspheres. Anesthesia exerted no influence on blood flow other than raising coronary flow. We conclude that although blood flow to the gastric mucosa and the pancreas is sensitive to the minor hemodynamic changes associated with the microsphere technique, replacement of volume loss for reference samples ensures stable blood flow to all organs over a 120-min period.

Stress management techniques in childhood and adolescence. Relaxation training, meditation, hypnosis, and biofeedback: appropriate clinical applications.

Many childhood and adolescent stress-related symptoms have a psychophysiological component that involves muscular tension and/or autonomic nervous system dysfunction. Examples of this include recurrent headache, chest pain, abdominal pain, syncope, and dizziness. After a careful medical and psychosocial evaluation, the clinician may identify many patients who are appropriate for the application of stress reduction techniques such as progressive muscular relaxation, meditation, biofeedback, and relaxation/mental imagery (self-hypnosis). This review describes these techniques and their application with selected children and adolescents.

Importance of collateral circulation in the vascularly occluded feline intestine.

The aim of this study was to assess the extent of collateral blood flow provided by the celiac and inferior mesenteric arteries to the intestines during total occlusion of the superior mesenteric artery (SMA). In anesthetized cats, blood flow to the pancreas, duodenum, jejunum, ileum, and colon was measured with radioactive micropheres (15 microns in diameter) before and during occlusion of the SMA. Superior mesenteric artery occlusion significantly decreased (by 63%) blood flow to the head of the pancreas. Flow to the neck and tail of the pancreas was not altered. Blood flow to the proximal and distal duodenum was significantly reduced by 35% and 61%, respectively. Along the entire jejunum and ileum, SMA occlusion markedly decreased blood flow by an average of 71%. In the proximal colon, blood flow decreased by 63%, whereas flow to the middle and distal colon was not affected by SMA occlusion. Reduction in total wall blood flow to the small and large intestines was largely due to a marked reduction in mucosa/submucosa blood flow; muscularis/serosa flow was not affected. The results of this study suggest that total occlusion of the SMA does not compromise blood flow to the neck and tail of the pancreas and middle and distal colon (tissues that are normally perfused with blood from either the celiac or inferior mesenteric arteries). Perfusion through collaterals maintains flow to the head of the pancreas and gut (from duodenum to proximal colon) to within 30%-65% of control (preocclusion) flow. An important new observation of this study is that collateral blood vessels are much more effective in preventing ischemia in the muscularis/serosa than in the mucosa/submucosa after SMA occlusion.

Quantitative assessment of villous motility.

A videomicroscopic method was used to quantitatively analyze villous motility in the dog small intestine. The frequency and duration of villous contractions (retractions) were measured in the duodenum, midjejunum, and distal ileum under controlled conditions. A pronounced gradient of villous motility was evident along the bowel. The duodenum exhibited the highest frequency (7.3 +/- 0.1/min) and longest duration (2.6 +/- 0.1 s) of contraction; the jejunum exhibited an intermediate frequency and duration of contraction (4.0 +/- 0.1/min, 2.1 +/- 0.1 s), and the lowest values were measured in the ileum (2.0 +/- 0.1/min and 1.8 +/- 0.1 s). In contrast to the retraction movements, the frequency of pendular villous movements (whipping, swaying movements without shortening) was highest in the jejunum and lowest in the duodenum. The frequency and duration of villous contractions (retractions) remained relatively constant over a 2-h observation period. Reducing mucosal surface temperature from 38 to 30 degrees C caused the frequency of contraction to fall by 33% and the duration to increase by 106%. Varying the suffusate pH within the physiological range of 5.0-7.4 produced no significant effects on jejunal villous motility. Suffusion with glucose (140 and 280 mM) failed to alter villous motility. However, amino acid (15 and 30 mM) and fatty acid (10 mM) solutions significantly increased contraction frequency by 30-50% and 90%, respectively. The videomicroscopic method provides useful quantitative information, which should extend current knowledge regarding the regulation and physiological importance of villous motility.

Collateral blood flow in segmental intestinal ischemia: effects of vasoactive agents.

We evaluated the effects of common vasoactive agents on collateral blood flow to an ischemic segment of small intestine and on the hemodynamic determinants of that flow. Two adjacent canine jejunal segments were isolated together, and the artery to each was cannulated for autoperfusion from a femoral and a carotid artery, respectively. Arterial pressure, arterial blood flow into, and venous outflow from each segment was measured separately. Venous pressure was zero. Vascular resistances were calculated. After clamping the arterial circuit to one segment, designated "ischemic," its steady-state venous outflow was taken as the collateral blood flow from the nonischemic into the ischemic segment. Without drugs, collateral blood flow was equal to 29 +/- 4 ml/min X 100 gm or, 56% +/- 8% of normal, well above the level needed to sustain oxygen consumption and thereby prevent ischemic injury. Local intra-arterial infusion of the vasodilators isoproterenol and papaverine not only failed to increase collateral flow but actually caused a small but (with isoproterenol) significant reduction, caused by vasodilation in the nonischemic bed, and a resulting drop in arterial pressure distal to the occlusion in the ischemic segment (i.e., a steal phenomenon). The vasoconstrictors levarterenol and vasopressin also reduced collateral flow but by direct and preferential vasoconstriction of the dilated ischemic bed. These findings suggest that collateral blood flow may be optimal without drugs and is decreased only by vasoactive agents, including vasodilators. This contradicts the rationale for vasodilator therapy for the direct augmentation of collateral blood flow in acute occlusive intestinal ischemia.

Chronic portal hypertension: effects on gastrointestinal blood flow distribution.

The intramural distribution of blood flow in the gastrointestinal tract was measured in shamoperated control and portal vein-stenosed rats. Total organ blood flow, measured via the radioactive microsphere technique, was elevated in the esophagus (66%), stomach (102%), duodenum (42%), jejunum (52%), ileum (54%), and colon (79%) of portal-hypertensive rats. Histological evaluation of carbonized nonradioactive 15-microns microspheres allowed for fractionation of blood flow within the wall (mucosa, submucosa, and muscularis externa) of each organ. The microsphere distribution pattern indicates that intramural blood flow distribution in all organs was not dramatically affected by chronic portal hypertension. These findings further define the characteristics of the factors responsible for the gastrointestinal hyperemia produced by chronic portal hypertension.