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Superior mesenteric artery syndrome (SMAS) is a rare and unpredictable complication after correction spine surgery for adolescent idiopathic scoliosis (AIS). The management of this condition is poorly investigated, with controversial outcomes. This investigation systematically reviewed current evidence on pathogenesis, risk factors, management, and outcomes of SMAS following correction spine surgery for AIS. The present systematic review was conducted according to the 2020 PRISMA statement. All the included investigations reported SMAS presentation following scoliosis correction surgery in AIS. 29 articles with 61 eligible patients were included in this review. The mean age of the patients was 15.8 ± 7.2 years. The mean weight was 45.3 ± 8.0 kg, the mean height 159.6 ± 13.6 cm, and the mean BMI 16.5 ± 2.9 kg/m2. The mean duration of the treatment for SMAS was 21.6 ± 10.3 days. The mean interval between spine surgery and symptoms of SAMS was 69 days, with high between-studies variability (3 days to 4 years). Prompt identification of risk factors and an early diagnosis are necessary to manage SMAS and reduce the risk of complications. Additional investigations are required to establish risk factors and diagnostic criteria.

Purpose: Congenital kyphosis (CK) is an uncommon condition that develops due to a defect of formation or segmentation of one or more vertebrae during the first weeks of embryonic life and can be frequently associated with abnormalities of the spinal cord. Meningocele manqué(MM) is a rare congenital malformation consisting of intradural fibrous bands tethering the spinal cord, oftentimes in combination with a split cord malformation. The aim of this manuscript is to describe combined surgical management of a rare case of CK associated with double spinal cord tethering. Study design: Case report. Methods: We report the case of a 4-year-old boy presenting with a combination of congenital kyphosis due to L2 fully segmented posterior hemivertebra and double spinal cord tethering, at the level of the filum terminale and at L1-L2 due to an intradural ventral fibrous band. Results: Spinal cord detethering and L2 hemivertebra resection with kyphosis correction were achieved with a single stage procedure. Segmental kyphosis was corrected from 45° to 11° post-operatively. Apart from a transitory sensory impairment, no immediate or delayed complications were noted and, at 2 years follow-up, correction and spinal alignment were stable. Conclusion: To the best of our knowledge, this is the first case to report the simultaneous occurrence of congenital kyphosis and double spinal cord tethering due to MM and tethering of the filum terminale. Our case report shows that surgical correction of the deformity and spinal cord detethering can be safely and effectively achieved during the same surgical procedure.

AimsTo report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).MethodsWe carried out a retrospective analysis of 16 consecutive patients with EOS treated with an SGR construct at a single hospital between September 2008 and December 2014. General demographics and deformity variables (i.e. major Cobb angle, T1 to T12 length, T1 to S1 length, pelvic obliquity, shoulder obliquity, and C7 plumb line) were recorded preoperatively, and postoperatively at yearly follow-up. Complications and revision procedures were also recorded. Only patients with a minimum follow-up of five years after surgery were included.ResultsA total of 16 patients were included. Six patients had an idiopathic EOS while ten patients had a neuromuscular or syndromic EOS (seven spinal muscular atrophy (SMA) and three with cerebral palsy or a syndrome). Their mean ages at surgery were 7.1 years (SD 2.2) and 13.3 years (SD 2.6) respectively at final follow-up. The mean preoperative Cobb angle of the major curve was 66.1° (SD 8.5°) and had improved to 25.5° (SD 9.9°) at final follow-up. The T1 to S1 length increased from 289.7 mm (SD 24.9) before surgery to 330.6 mm (SD 30.4) immediately after surgery. The mean T1 to S1 and T1 to T12 growth after surgery were 64.1 mm (SD 19.9) and 47.4 mm (SD 18.8), respectively, thus accounting for a mean T1 to S1 and T1 to T12 spinal growth after surgery of 10.5 mm/year (SD 3.7) and 7.8 mm/year (SD 3.3), respectively. A total of six patients (five idiopathic EOS, one cerebral palsy EOS) had broken rods during their growth spurt but were uneventfully revised with a fusion procedure. No other complications were noted.ConclusionOur data show that SGR is a safe and effective technique for the treatment of EOS in nonambulatory hypotonic patients with a neuromuscular condition. Significant spinal growth can be expected after surgery and is comparable to other published techniques for EOS. While satisfactory correction of the deformity can be achieved and maintained with this technique, a high rate of rod breakage was seen in patients with an idiopathic or cerebral palsy EOS.Cite this article: Bone Joint J2020;102-B(11):1560–1566.

Implantable intramedullary nail lengthening devices (e.g., PRECICE 2 system) have been proposed as alternative method to external fixation for lower limb lengthening surgery. The aim of this study was to analyse our outcomes and complications using the PRECICE 2 (P2) nail system and review them in light of the existing literature. A retrospective multicentre study was conducted on patients <18 years, who were treated for limb lengthening using the P2 system. The inclusion criteria were a limb length discrepancy ≥ 30 mm and a follow-up ≥6 months after the end of treatment. A total of 26 (15 males) patients were included, average age was 14.7 ± 2.3 years; 26 nails (21 femur, 5 tibia) were implanted. The average goal lengthening was 49.4 ± 12.4 mm, while average achieved lengthening was 44.4 ± 11.6 mm. Average distraction and consolidation indexes were 11.9 ± 2.1 days/cm and 25.1 ± 8.1 days/cm, respectively. Nail accuracy and reliability were 91.1% and 88.5%, respectively. A total of five problems (joint contractures), one obstacle (femur fracture) and three complications (hip joint subluxation, deep infection and nail running back) were encountered. The P2 nail system is a valid alternative to external fixator for limb lengthening in young patients with no significant angular or rotation deformities. Our study confirms a favourable complication rate and available evidence from literature suggests a lower complication rate than external fixator systems. Nevertheless, surgeons should keep a watchful eye on risk of joint subluxation and mechanical complications with intramedullary lengthening.

Study Design: Prospective observational cohort study.Objectives: To analyze clinical and economic results in patients with degenerative disc disease in the lumbar area for patients who received combined anterior and posterior fusion or total disc replacement (TDR).Methods: The study included 75 patients, 38 in the fusion group and 37 in the TDR group, who received either anterior/posterior fusion or TDR for lumbar disc disease from January 2005 to December 2008 with a minimum follow-up of 24 months. We collected data with regard to clinical parameters, demographics, visual analogue scale scores, Oswestry Disability Index scores, SF-36 and SF-6D data, surgery time, amount of blood loss, transfusion of blood products, number of levels, duration of hospital stay, and complications. For cost analysis, general infrastructure, theatre costs, as well as implant costs were examined, leading to primary hospital costs. Furthermore, average revision costs were examined, based on the actual data. Statistical analysis was performed using ttests for normal contribution and Mann-Whitney test for skew distributed values. The significance level was set to .05.Results: There was a higher surgery time, more blood loss, and longer hospital stay for the fusion group, compared with the TDR group. In addition, the hospital costs for the primary procedure and revision were 35% higher in the fusion group. The clinical data in terms of SF-36 and SF-6D showed no difference between these 2 groups.Conclusions: TDR is a good alternative to anterior and posterior lumbar fusion in terms of short follow-up analysis for clinical data and cost analysis. General advice cannot be given due to missing data for long-term costs in terms of surgical treatment of adjacent level or further fusion techniques.

ABSTRACTThe similarity of stromal-like Wilms tumor (str-WT) cells with mesenchymal stem cells (MSC), suggests their relevant role in the interplay with immune cells in the tumor microenvironment. We investigated the interaction between str-WT cells and NK cells. We observed that str-WT cells expressed some major ligands for activating and inhibitory NK cell receptors. Moreover, they expressed inhibitory checkpoint molecules involved in the negative regulation of anti-tumor immune response. The analysis of the interaction between str-WT cells and NK lymphocytes revealed that activated NK cells could efficiently degranulate upon interaction with str-WT cells. On the other hand, str-WT cells could exert potent inhibitory effects on cytokine-induced activation of NK cell proliferation and phenotype, which were mediated by the production of IDO and PGE2 inhibitory factors. Our data provide insight into the molecular interactions between str-WT cells and NK lymphocytes that may result in different outcomes possibly occurring in the WT microenvironment.

Introduction Low back pain is a chronic health problem. It is the most common cause of limited activity. 90% of people worldwide will develop low back pain during their life. It is due, in the most cases, to the intervertebral disc degeneration (IDD). The first cause of IDD is aging. In all tissues aging is a condition characterized by mutations and genome instability, mitochondrial dysfunction, oxidative damage and consequential decline of cellular functions. Decline in tissues function is related to the loss of stem cells. These characteristics translate into different pathologies, with increasing costs for the healthcare system. In 2050 around 2 billion people worldwide will be older than 65. People are living longer but they are not healthier. Worldwide research is focused on identify the molecular pathways that can regulate expression of pro-survival networks. The purpose of this study was to determinate whether blood chimerism with a young wild type mouse (WT) could delay or reverse aging in a prematurely aging mouse model (Ercc1-/Δ). Blood chimerism was obtained by way of parabiosis, an experimental method in which two animals are surgically connected and develop a united circulation.Material and Methods 3 kinds of parabiotic pairs were generated: WT + WT at 40 days old (hisochronic parabiosis), Ercc1-/Δ + Ercc1-/Δ at 64 days old (hisochronic parabiosis) and WT + Ercc1-/Δ (heterochronic parabiosis). After surgery the couples develop anastomosis that make possible the blood chimerism. Administration of a dye (Evans blue) and fluorescent nano-beads into a single symbiont animal were used to test shared circulation in the parabiosis couples. Mice were sacrificed after 4 weeks; entire intervertebral discs were removed from the surrounding vertebral bodies by an incision along the endplate. Lumbar discs from each mouse were analyzed histologically and for nucleous polposus protein content. Expression of pro-survival networks in senescent cells and in stem cells were analyzed.Results Compared with the hisochronic controls, Ercc1-/Δ mice heterochronically paired with young WT mice had a significally improved protein content in the disc (95% CI). Histological analysis (EE & SaffO) revealed an improvement in the disc for the Ercc1-/Δ individual in the heterochronic pair relative to the hisochronic ones. We observed a reactivation of stem cells when exposed to younger serum and a migration of young stem cells to the old mice (using GFP protein expressed in the younger mouse). Furthermore µCT highlighted an improvement of the bone quality.Conclusion These results indicate that spine of the progeroid mice were rejuvenated in the older mice when exposed to a serum derived from younger organism. Senescent cells secrete pro-inflammatory cytokines, and chemokines, which together constitute the senescence-associated secretory phenotype. We believe that stem cells are quiescent in old organism and that the environment can reactivate them. Moreover this factor can attract young stem cells from the young mice. The factor responsible for this, this elixir of youthful, although currently unidentified, could potentially be used as an effective treatment to rescue IDD as well other pathologies connected to aging.

Introduction Type II dens fracture is the most common cervical spine fracture type in elderly patients. Treatment options for this common injury include conservative management (i.e., hard collar or Halo Vest immobilization) or surgery. Delayed union or non-union is a frequent complication in elderly patients and is associated with an increased morbidity and mortality due to prolonged immobilization and hospitalization. The rhPTH1–34 (Teriparatide) is the recombinant form of the biologically active component of the human parathyroid hormone, currently approved for treatment of severe post-menopausal osteoporosis. However many in vitro studies have also demonstrated the efficacy of rhPTH1–34 in stimulating osteogenesis and bone healing and a few case reports have been published on its use in humans for treatment of fracture non-unions. The aim of this study is to report our successful experience with the use of rhPTH1–34 in the treatment of 5 cases of dens fracture non-union in elderly patients.Material and Methods Five patients (age > 70, all females) diagnosed with type II C2 dens fracture non-union (no neurological compromise) were enrolled in this study. Fracture non-union was defined as non- healing at 9 months after injury and radiographic evidence of failed healing progression over the last 3 months. All patients had been treated conservatively with a hard collar. Patients were started on anabolic drug therapy with daily subcutaneous injection of rhPTH1–34 (Teriparatide, 20 ng/die) for 3 months. Regular clinical assessments and monitoring of serum levels of calcium, phosphorus, vitamin D, and alkaline phosphatase were undertaken throughout the treatment period. We describe the evolution of our cases over time with serial CT scan imaging as well as HRQoL questionnaires (VAS, SF-12, and Eq. 5D).Results Successful complete fracture healing was achieved in all patients at 74.5 ± 4.4 weeks after the injury and at 10.2 ± 3.8 weeks after the start of the anabolic therapy. Mean VAS score at the end of the treatment was 2.4 ± 1.3 (from a baseline value of 6.8 ± 2, p< 0.02) in all patients, while the average SF-12 score was 42 ± 3.7 (PCS) and 61.5 ± 2.11 (MCS) (from a baseline value of 25.1 ± 2.12 and 43.2 ± 1.49, p< 0.04) and Eq. 5D was 0.798 ± 0.044 (from a baseline value of 0.396 ± 0.198, p< 0.03). Patients had normal serum calcium level (9.1 ± 0.9 mg/dl). No side effects related to the use of the anabolic therapy were noted in our patients.Conclusion Our case series shows that rhPTH1–34 has induced successful bone healing in all our cases of type II dens fracture non-union. Bone healing has been demonstrated through CT imaging and also confirmed by clinical improvement of HRQoL measures. This is a potentially groundbreaking finding in management of elderly patients with upper cervical injuries and will deserve further study in future.

Introduction Osteoporosis is a highly prevalent and one of the most debilitating and costly chronic diseases worldwide and it is also responsible for approximately 1.5 million vertebral fragility fractures (VCFs) a year.1,2,3Most of the patients experiencing an osteoporotic VCFs remain asymptomatic or minimally symptomatic; however, a large part of these patients do experience significant pain, resulting in decreased quality of life and disability and mortality too.4The consequences of these fractures include pain and, in many cases, progressive vertebral collapse with resultant spinal kyphosis. Minimally invasive procedures, namely, kyphoplasty and vertebroplasty, represent a recent advance to the treatment of osteoporotic VCFs.5,6,7The aim of this study is to compare effects in terms of recovery and quality of life and to compare deformity prevention efficacy of kyphoplasty and conservative treatment in postmenopausal women with an osteoporotic VCF. The aim of this study is to provide an efficacy assessment of kyphoplasty as compared with standard conservative treatment in postmenopausal women (bracing immobilization).8,9,10Patients and Methods We designed a retrospective case–control study on 110 postmenopausal women. Included in this study were patients who were diagnosed with postmenopausal osteoporosis according to National Osteoporosis Foundation (NOF) guidelines, with a recent (< 2 weeks) symptomatic osteoporotic vertebral compression fracture (VCF), no more than two (if any) old VCFs with no resultant kyphotic deformity, and whose treatment starts no later than 15 days from the VCF time. Study population was split in a surgery cohort and a conservative cohort according to the provided treatment. All patients were asked to fill in VAS, SF-12, and Eq. 5D questionnaires at different time points up to 12 months after treatment. Segmental kyphosis at fracture level was also measured for our analysis.Results Kyphoplasty-treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients (p< 0.05). Eq. 5D questionnaire also showed a better quality of life at 1 month for surgically treated patients (p< 0.05). As for the SF-12 no significant difference was observed. At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average.Conclusion Kyphoplasty seems to be a safe and effective procedure in reducing back pain due to painful VCF. The kyphosis restoring effect is also extremely interesting and can be achieved only in the first days after fracture time. In conclusion, kyphoplasty is a procedure that offers a fast recovery and a better quality of life at 1 month after treatment, helping restoring segmental kyphosis after VCFs.11,12,13Acknowledgments There was no external funding source and no funding source played a role in the investigation. References Who are candidates for prevention and treatment for osteoporosis? Osteoporos Int 1997;7(1):1–6 Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17(12):1726–1733 Iqbal MM, Sobhan T. Osteoporosis: a review. Mo Med 2002;99(1):19–24 Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone 1996;18(3, Suppl):185S–189S Jarvik JG, Kallmes DF. Point of view. Efficacy of vertebroplasty and kyphoplasty. Spine 2009;34(6):613–614 Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009;361(6):569–579 Weinstein JN. Balancing science and informed choice in decisions about vertebroplasty. N Engl J Med 2009;361(6):619–621 Lyritis GP, Mayasis B, Tsakalakos N, et al. The natural history of the osteoporotic vertebral fracture. Clin Rheumatol 1989;8(2, Suppl 2):66–69 Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury 2007;38(3, Suppl 3):S40–S48 Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001;26(14):1511–1515 Ledlie JT, Renfro M. Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and activity levels. J Neurosurg 2003;98(1, Suppl):36–42 Voggenreiter G. Balloon kyphoplasty is effective in deformity correction of osteoporotic vertebral compression fractures. Spine 2005;30(24):2806–2812 Pradhan BB, Bae HW, Kropf MA, Patel VV, Delamarter RB. Kyphoplasty reduction of osteoporotic vertebral compression fractures: correction of local kyphosis versus overall sagittal alignment. Spine 2006;31(4):435–441