Jörn Lange

Nerve Root Sedimentation Sign : Evaluation of a New Radiological Sign in Lumbar Spinal Stenosis

Study Design. Retrospective case-referent study. Objective. To assess whether the new sedimentation sign discriminates between nonspecific low back pain (LBP) and symptomatic lumbar spinal stenosis (LSS). Summary of Background Data. In the diagnosis of LSS, radiologic findings do not always correlate with clinical symptoms, and additional diagnostic signs are needed. In patients without LSS, we observe the sedimentation of lumbar nerve roots to the dorsal part of the dural sac on supine magnetic resonance image scans. In patients with symptomatic and morphologic central LSS, this sedimentation is rarely seen. We named this phenomenon “sedimentation sign” and defined the absence of sedimenting nerve roots as positive sedimentation sign for the diagnosis of LSS. Methods. This study included 200 patients. Patients in the LSS group (n = 100) showed claudication with or without LBP and leg pain, a cross-sectional area <80 mm2, and a walking distance <200 m; patients in the LBP group (n = 100) had LBP, no leg pain, no claudication, a cross-sectional area of the dural sac >120 mm2, and a walking distance >1000 m. The frequency of a positive sedimentation sign was compared between the 2 groups, and intraobserver and interobserver reliability were assessed in a random subsample (n = 20). Results. A positive sedimentation sign was identified in 94 patients in the LSS group (94%; 95% confidence interval, 90%–99%) but none in the LBP group (0%; 95% confidence interval, 0%–4%). Reliability was kappa = 1.0 (intraobserver) and kappa = 0.93 (interobserver), respectively. There was no difference in the detection of the sign between segmental levels L1–L5 in the LSS group. Conclusion. A positive sedimentation sign exclusively and reliably occurs in patients with LSS, suggesting its usefulness in clinical practice. Future accuracy studies will address its sensitivity and specificity. If they confirm the signs high specificity, a positive sedimentation sign can rule in LSS, and, with a high sensitivity, a negative sedimentation sign can rule out LSS.

Histomorphometric and radiographical changes after lumbar implantation of the PEEK nonfusion interspinous device in the BB.4S rat model

Study Design. An experimental animal study. Objective. To investigate histomorphometric and radiographical changes in the BB.4S rat model after PEEK (polyetheretherketone) nonfusion interspinous device implantation. Summary of Background Data. Clinical effectiveness of the PEEK nonfusion spine implant Wallis (Abbott, Bordeaux, France; now Zimmer, Warsaw, IN) is well documented. However, there is a lack of evidence on the long-term effects of this implant on bone, in particular its influence on structural changes of bone elements of the lumbar spine. Methods. Twenty-four male BB.4S rats aged 11 weeks underwent surgery for implantation of a PEEK nonfusion interspinous device or for a sham procedure in 3 groups of 8 animals each: 1) implantation at level L4–L5; 2) implantation at level L5–L6; and 3) sham surgery. Eleven weeks postoperatively osteolyses at the implant-bone interface were measured via radiograph, bone mineral density of vertebral bodies was analyzed using osteodensitometry, and bone mineral content as well as resorption of the spinous processes were examined by histomorphometry. Results. Resorption of the spinous processes at the site of the interspinous implant was found in all treated segments. There was no significant difference in either bone density of vertebral bodies or histomorphometric structure of the spinous processes between adjacent vertebral bodies, between treated and untreated segments and between groups. Conclusion. These findings indicate that resorption of spinous processes because of a result of implant loosening, inhibit the targeted load redistribution through the PEEK nonfusion interspinous device in the lumbar spinal segment of the rat. This leads to reduced long-term stability of the implant in the animal model. These results suggest that PEEK nonfusion interspinous devices like the Wallis implants may have time-limited effects and should only be used for specified indications.

Needle decompression of tension pneumothorax: Population-based epidemiologic approach to adequate needle length in healthy volunteers in Northeast Germany.

BACKGROUND Tension pneumothorax is one of the leading causes of preventable death in both military and civilian trauma patients. Needle decompression is recommended in trauma guidelines as an emergency procedure to relieve increased intrapleural pressure. The main reason for decompression failure is reported to be insufficient needle length in proportion to the chest wall thickness (CWT). So far, population-based epidemiologic data on CWT are missing. Therefore, it was the aim of this work to investigate the CWT in the second intercostal space, midclavicular line, based on magnetic resonance imaging data of a large population-based sample. The second aim of this study was to explore the potential risk of iatrogenic lesions caused by the proximity of the intended puncture track to the internal mammary artery. METHODS A total of 2,574 healthy volunteers (mean [SD] age, 53.3 [13.9] years; range, 21–89 years) from the population-based cohort Study of Health in Pomerania (SHIP) were enrolled. CWT and the distance from the intended puncture track to the internal mammary artery were investigated with the chest sequences of a standardized 1.5-T whole-body magnetic resonance imaging. RESULTS For all 5,148 measured sites in 2,574 volunteers, the mean (SD) CWT was 5.1 (1.4) cm. The mean body mass index was determined to be 27.7 kg/m2. The CWT correlated significantly with body weight and body mass index. The internal mammary artery was located medial to the intended puncture site in all participants; the mean (SD) distance was 5.7 (0.7) cm on the right and 5.5 (0.7) cm on the left side. CONCLUSION Based on the population-based epidemiologic data presented in this study, the use of a needle of 7 cm in length is recommended to decompress a tension pneumothorax in the second intercostal space in the midclavicular line, which might successfully decompress more than 90% of the participants in this study. When using this anterior approach at the anatomically correct puncture site, safety margin to the internal mammary artery is sufficient so that the risk of iatrogenic lesion of the internal mammary artery should be minimal. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Phenotypic and gene expression differences between DA, BN and WOKW rats.

Background Because inbred rat strains are widely used as laboratory models, knowledge of phenotypic and genetic variations between strains will be useful to obtain insight into the relationship between different strains. Methods and Results We studied phenotypic traits: of each strain – BN/K, DA/K and WOKW –10 male rats were studied for body weight and serum constituents at an age of 10 and 30 weeks. In addition, a total of 95 rats were studied for life expectancy. At an age of 30 weeks, these male rats were killed by an overdose of anesthetic (Sevofluran, Abbott), and the subcutaneous and visceral adipose tissue as well as bone tissue were removed to study the expression of 20 genes. There were significant differences in body weight, serum lipids and leptin at an age of 30 weeks between strains. Regarding life expectancy, BN rats lived longest (1072±228d). The highest gene expression was found in bone of BN rats. In adipose tissues, Nfkb1 is only expressed in subcutaneous adipocytes, and 5 genes, Col2a1, Mmp9, Tnfa, Ins1 and Cyp24a1, are not expressed in adipocytes. The ranking BN = DA>WOKW was observed in only one gene in subcutaneous (Fto) and visceral adipocytes (Col6a1). There were no significant differences in gene expression of one gene in subcutaneous adipocytes and of 3 genes in visceral adipocytes. Comparing the gene expression in visceral and subcutaneous adipocytes, only one gene showed a comparable behavior (Bmp1). Conclusion From these results, it can be concluded that obvious phenotypic differences are caused by genetic differences between three rat strains, BN, DA and WOKW, as supported by gene expression studies in bone and adipose tissues. Especially BN rats can be used to study the genetic basis of long life.

Light rhythm and diet differently influence facets of the metabolic syndrome in WOKW rats

It has previously been shown that high-calorie diet alters the function of the mammalian circadian clock and that obesity has an influence on circadian organization of hormone secretion. That prompted us to test whether inbred Wistar Ottawa Karlsburg W (RT1u) (WOKW) rats developing facets of the metabolic syndrome show changes in their metabolic profiles under different feeding conditions (high-fat, high-sugar versus control diet) and under two different 12 h:12 h light–dark (LD) cycles. At the age of four weeks, these rats were divided into four groups. Groups 1 and 2 were kept under initial LD cycle (lights on at 05:00 h). Group 1 was fed with a normal rat diet while group 2 received a high-fat, high-sugar diet from 10 up to the age of 21 weeks. Groups 3 and 4 were kept under a shifted LD cycle (lights on at 11:00 h). Group 3 was given a normal diet while group 4 received a high-fat, high-sugar diet from an age like groups 1 and 2. Several metabolic traits were studied during the observation period of 21 weeks. The blood samples were obtained 2 h before lights off. Body weight gain (P < 0.001), leptin (P < 0.001), triglycerides (P < 0.001) and cholesterol (P < 0.05) were significantly reduced in group 4 versus group 2, but comparable between control groups (1 versus 3). The insulin concentrations were reduced in groups 3 and 4 versus groups 1 and 2 without effect of diet. In conclusion, the results provide evidence that light conditions influence diet induced changes in phenotypic traits like body weight gain, lipids as well as hormone levels (insulin and leptin) in WOKW rats.