Potential roles of cytokines and chemokines in human intervertebral disc degeneration: interleukin-1 is a master regulator of catabolic processes.

OBJECTIVE: These studies investigated cytokine and chemokine receptor profiles in nucleus pulposus (NP) cells, and the effects of receptor stimulation on mRNA levels of extracellular matrix (ECM) components, degrading enzymes and cytokine and chemokine expression. METHOD: Immunohistochemistry (IHC) was performed to localise expression of CD4, CCR1, CXCR1 and CXCR2 in human NP tissue samples. Effects of cytokine and chemokine stimulation was performed to investigate effects related to ECM remodelling and modulation of cytokine and chemokine mRNA expression. RESULTS: IHC identified CD4, CCR1, CXCR1 and CXCR2 expression by NP cells. Differential expression profiles were observed for CD4 and CXCR2 in tissue samples from degenerate and infiltrated IVDs. In vitro stimulations of primary human NP cultures with IL-16, CCL2, CCL3, CCL7 or CXCL8 did not identify any modulatory effects on parameters associated with ECM remodelling or expression of other cytokines and chemokines. Conversely, IL-1 was seen to modulate ECM remodelling and expression of all other cytokines and chemokines investigated. CONCLUSION: This study demonstrates for the first time that NP cells express a number of cytokine and chemokine receptors and thus could respond in an autocrine or paracrine manner to cytokines and chemokines produced by NP cells, particularly during tissue degeneration. However, this study failed to demonstrate regulatory effects on ECM genes and degradative enzymes or other cytokines and chemokines for any target investigated, with the exception of IL-1. This suggests that IL-1 is a master regulator within the IVD and may exert regulatory potential over a plethora of other cytokines and chemokines.

A prospective, randomised trial of immediate exercise following lumbar microdiscectomy: a preliminary study.

OBJECTIVE: To investigate whether immediate commencement of exercises after lumbar microdiscectomy enabled patients to become independently mobile more rapidly with no increase in risk of complications. STUDY DESIGN: Randomised, single-blind, controlled trial. SETTING: One secondary care teaching hospital in the UK. PARTICIPANTS: Thirty patients were recruited. The follow-up rate was 28 (93%) at 4 weeks and 23 (77%) at 3 months. INTERVENTIONS: Patients were randomised to an intervention group commencing exercises within 2 hours after surgery, or a control group commencing exercises on the first postoperative day. MAIN OUTCOME MEASURES: Primary outcome measures included the time taken for the patient to become independently mobile and attain discharge criteria following surgery. Secondary outcome measures were disability and pain scores collected before surgery, and 4 weeks and 3 months after surgery; and return to work rates. RESULTS: The two groups were similar at baseline. The results indicated significantly reduced time to independent mobility [median 7 vs 19 hours, median difference 9 hours, 95% confidence interval (CI) 1.25 to 14.5, P=0.009] and return to work (median 6 vs 8 weeks, median difference 2 weeks, 95% CI 0 to 6, P=0.002) in the intervention group compared with the control group. At 15 hours after surgery, independent mobility was attained in 80 and 40% of the intervention and control groups, respectively. There were no significant differences in disability and pain scores at 4 weeks and 3 months. CONCLUSIONS: Immediate commencement of exercises following first-time single-level lumbar microdiscectomy enabled patients to become independently mobile more rapidly and return to work sooner. Immediate commencement of exercises may enable patients to be discharged earlier, with associated cost benefits to health care and no increase in the rate of revision surgery.

Traumatic occipitocervical disruption: a new technique for stabilisation. Case report and literature review.

Traumatic atlanto-occipital dislocation in adults is usually fatal and survival without neurological deficit is rare. The surgical management of those who do survive is difficult and controversial. Most authorities recommend posterior occipitoaxial fusion, but this compromises cervical rotation. We describe a case in which a patient with a traumatic atlanto-occipital disruption but no neurological deficit was treated by atlanto-occipital fusion using a new technique consisting of cancellous bone autografting supported by an occipital plate linked by rods to lateral mass screws in the atlas. The technique is described in detail. At one year the neck was stable, radiological fusion had been achieved, and atlantoaxial rotation preserved. The rationale behind this approach is discussed and the relevant literature reviewed. We recommend the technique for injuries of this type.

Personalised image-based templates for intra-operative guidance.

The high rate of unplanned perforation, poor fixation, and nerve injury with freehand pedicle screw insertion has led to the use of image-guided navigation systems. Although these improve accuracy, they have several drawbacks that could be overcome by using image-based drilling guide templates. The accuracy of such templates was tested in a cadaveric study of screw placement in the lumbar, thoracic, and cervical regions of the spine. The dimensional stability with autoclaving of duraform polyamide, to be used for manufacturing the guides, was first determined using test specimens. Computed tomography (CT) images were acquired of 4 cadaveric spines, and placement of 4 cervical, 32 thoracic, and 14 lumbar screws was planned. Eighteen personalized drilling guide templates, in four different designs, were built. Orthopaedic surgeons experienced in the freehand techniques used the templates. CT images were acquired to assess placement position with respect to the pedicle. Duraform polyamide was found to be unaffected by sterilization. Two of the template designs facilitated the placement of 20/20 screws without error. Templates can lead to successful screw placement, even in small pedicles, providing their design is optimized for the application area, e.g. with enhanced rotational stabilization.

A new technique for delayed primary closure of fasciotomy wounds.

Fasciotomy for compartment syndrome in the lower limb is a surgical emergency to preserve future limb function. The advised standard procedure involves both medial and lateral dermotomy in addition to the fasciotomy. There is often concern before and after performing fasciotomy about the cosmetic appearance and prolonged hospital stay if split skin grafting is required to cover the resultant skin defect. This is the case in over 50% of lower limb fasciotomies. We have used a technique of subcuticular prolene suture, first described for the delayed primary closure of contaminated abdominal wounds, in six patients who had undergone lower limb fasciotomies. In all of these cases delayed primary closure was easily achieved without the need for skin grafting. Experiments using a synthetic skin model have shown a 60% reduction in suture tension when compared with interrupted vertical mattress suturing. The subcutaneous prolene suture has the advantage of being both the method of approximation and final closure whilst spreading tension evenly across the wound edges without causing skin edge necrosis. It appears to be simpler and more economical than any technique so far described for the successful delayed primary closure of fasciotomy wounds.

Rhabdomyolysis with renal dysfunction in a hypothermic man.

We describe a case of rhabdomyolysis with renal dysfunction in a 41-year-old previously healthy man with hypothermia. We believe this to be the first case of rhabdomyolysis and hypothermia so far described in the UK.