Historical overview of spinal deformities in ancient Greece

Little is known about the history of spinal deformities in ancient Greece. The present study summarizes what we know today for diagnosis and management of spinal deformities in ancient Greece, mainly from the medical treatises of Hippocrates and Galen. Hippocrates, through accurate observation and logical reasoning was led to accurate conclusions firstly for the structure of the spine and secondly for its diseases. He introduced the terms kyphosis and scoliosis and wrote in depth about diagnosis and treatment of kyphosis and less about scoliosis. The innovation of the board, the application of axial traction and even the principle of trans-abdominal correction for correction of spinal deformities have their origin in Hippocrates. Galen, who lived nearly five centuries later impressively described scoliosis, lordosis and kyphosis, provided aetiologic implications and used the same principles with Hippocrates for their management, while his studies influenced medical practice on spinal deformities for more than 1500 years

Advantages of the Ilizarov external fixation in the management of intra-articular fractures of the distal tibia

<p>Abstract</p> <p>Background</p> <p>Treatment of distal tibial intra-articular fractures is challenging due to the difficulties in achieving anatomical reduction of the articular surface and the instability which may occur due to ligamentous and soft tissue injury. The purpose of this study is to present an algorithm in the application of external fixation in the management of intra-articular fractures of the distal tibia either from axial compression or from torsional forces.</p> <p>Materials and methods</p> <p>Thirty two patients with intra-articular fractures of the distal tibia have been studied. Based on the mechanism of injury they were divided into two groups. Group I includes 17 fractures due to axial compression and group II 15 fractures due to torsional force. An Ilizarov external fixation was used in 15 patients (11 of group I and 4 of group II). In 17 cases (6 of group I and 11 of group II) a unilateral hinged external fixator was used. In 7 out of 17 fractures of group I an additional fixation of the fibula was performed.</p> <p>Results</p> <p>All fractures were healed. The mean time of removal of the external fixator was 11 weeks for group I and 10 weeks for group II. In group I, 5 patients had radiological osteoarthritic lesions (grade III and IV) but only 2 were symptomatic. Delayed union occurred in 3 patients of group I with fixed fibula. Other complications included one patient of group II with subluxation of the ankle joint after removal of the hinged external fixator, in 2 patients reduction found to be insufficient during the postoperative follow up and were revised and 6 patients had a residual pain. The range of ankle joint motion was larger in group II.</p> <p>Conclusion</p> <p>Intra-articular fractures of the distal tibia due to axial compression are usually complicated with cartilaginous problems and are requiring anatomical reduction of the articular surface. Fractures due to torsional forces are complicated with ankle instability and reduction should be augmented with ligament repair, in order to restore normal movement of talus against the mortise. Both Ilizarov and hinged external fixators are unable to restore ligamentous stability. External fixation is recommended only for fractures of the ankle joint caused by axial compression because it is biomechanically superior and has a lower complication rate.</p

Expression of matrix metalloproteinase-1 (MMP-1) in Wistar rat's intervertebral disc after experimentally induced scoliotic deformity

<p>Abstract</p> <p>Introduction</p> <p>A scoliotic deformity on intervertebral discs may accelerate degeneration at a molecular level with the production of metalloproteinases (MMPs). In the present experimental study we evaluated the presence of MMP-1 immunohistochemically after application of asymmetric forces in a rat intervertebral disc and the impact of the degree of the deformity on MMP-1 expression.</p> <p>Material-Method</p> <p>Thirty female Wistar rats (aged 2 months old, weighted 200 ± 10 grams) were used. All animals were age, weight and height matched. A mini Ilizarov external fixator was applied at the base of a rat tail under anaesthesia in order to create a scoliotic deformity of the intervertebral disc between the 9^thand 10^thvertebrae. Rats were divided into three groups according to the degree of the deformity. In group I, the deformity was 10°, in group II 30° and in group III 50°. The rats were killed 35 days after surgery. The discs were removed along with the neighbouring vertebral bodies, prepared histologically and stained immunohistochemically. Immunopositivity of disc's cells for MMP-1 was determined using a semi-quantitative scored system.</p> <p>Results</p> <p>MMP-1 immunopositivity was detected in disc cells of annulus fibrosus of all intervertebral disc specimens examined. The percentage of MMP-1 positive disc cells in annulus fibrosus in group I, II and III were 20%, 43% and 75%, respectively. MMP-1 positivity was significantly correlated with the degree of the deformity (p < 0,001). An increase of chondrocyte-like disc cells was observed in the outer annulus fibrosus and at the margin of the intervertebral disc adjacent to the vertebral end plates. The difference in the proportion of MMP-1 positive disc cells between the convex and the concave side was statistically not significant in group I (p = 0,6), in group II this difference was statistically significant (p < 0,01). In group III the concave side showed a remarkable reduction in the number of disc's cells and a severe degeneration of matrix microstructure.</p> <p>Conclusion</p> <p>The present study showed that an experimentally induced scoliotic deformity on a rat tail intervertebral disc results in over-expression of MMP-1, which is dependent on the degree of the deformity and follows a dissimilar distribution between the convex and the concave side.</p

Surgical and conservative treatment of patients with congenital scoliosis: α search for long-term results

<p>Abstract</p> <p>Background</p> <p>In view of the limited data available on the conservative treatment of patients with congenital scoliosis (CS), early surgery is suggested in mild cases with formation failures. Patients with segmentation failures will not benefit from conservative treatment. The purpose of this review is to identify the mid- or long-term results of spinal fusion surgery in patients with congenital scoliosis.</p> <p>Methods</p> <p>Retrospective and prospective studies were included, reporting on the outcome of surgery in patients with congenital scoliosis. Studies concerning a small numbers of cases treated conservatively were included too. We analyzed mid-term (5 to 7 years) and long-term results (7 years or more), both as regards the maintenance of the correction of scoliosis and the safety of instrumentation, the early and late complications of surgery and their effect on quality of life.</p> <p>Results</p> <p>A small number of studies of surgically treated patients were found, contained follow-up periods of 4-6 years that in the most cases, skeletal maturity was not yet reached, and few with follow-up of 36-44 years. The results of bracing in children with congenital scoliosis, mainly in cases with failure of formation, were also studied.</p> <p>Discussion</p> <p>Spinal surgery in patients with congenital scoliosis is regarded in short as a safe procedure and should be performed. On the other hand, early and late complications are also described, concerning not only intraoperative and immediate postoperative problems, but also the safety and efficacy of the spinal instrumentation and the possibility of developing neurological disorders and the long-term effect these may have on both lung function and the quality of life of children.</p> <p>Conclusions</p> <p>Few cases indicate the long-term results of surgical techniques, in the natural progression of scoliosis. Similarly, few cases have been reported on the influence of conservative treatment.</p> <p>In conclusion, patients with segmentation failures should be treated surgically early, according to the rate of deformity formation and certainly before the pubertal growth spurt to try to avoid cor- pulmonale, even though there is lack of evidence for that in the long-term. Furthermore, in patients with formation failures, further investigation is needed to document where a conservative approach would be necessary.</p

Relatively lower body mass index is associated with an excess of severe truncal asymmetry in healthy adolescents: Do white adipose tissue, leptin, hypothalamus and sympathetic nervous system influence truncal growth asymmetry?

<p>Abstract</p> <p>Background</p> <p>In healthy adolescents normal back shape asymmetry, here termed truncal asymmetry (TA), is evaluated by higher and lower subsets of BMI. The study was initiated after research on girls with adolescent idiopathic scoliosis (AIS) showed that higher and lower BMI subsets discriminated patterns of skeletal maturation and asymmetry unexplained by existing theories of pathogenesis leading to a new interpretation which has therapeutic implications <it>(double neuro-osseous theory)</it>.</p> <p>Methods</p> <p>5953 adolescents age 11–17 years (boys 2939, girls 3014) were examined in a school screening program in two standard positions, standing forward bending (FB) and sitting FB. The sitting FB position is thought to reveal intrinsic TA free from back humps induced by any leg-length inequality. TA was measured in both positions using a Pruijs scoliometer as angle of trunk inclinations (ATIs) across the back at each of three spinal regions, thoracic, thoracolumbar and lumbar. Abnormality of ATIs was defined as being outside 2 standard deviations for each age group, gender, position and spinal region, and termed <it>severe </it>TA.</p> <p>Results</p> <p>In the sitting FB position after correcting for age,<it>relatively lower BMIs </it>are statistically associated with a greater number of severe TAs than with relatively higher BMIs in both girls (thoracolumbar region) and boys (thoracolumbar and lumbar regions).</p> <p>The relative frequency of severe TAs is significantly higher in girls than boys for each of the right thoracic (56.76%) and thoracolumbar (58.82%) regions (p = 0.006, 0.006, respectively). After correcting for age, smaller BMIs are associated with more <it>severe TAs </it>in boys and girls.</p> <p>Discussion</p> <p>BMI is a surrogate measure for body fat and circulating leptin levels. The finding that girls with relatively lower BMI have significantly later menarche, and a significant excess of TAs, suggests a relation to energy homeostasis through the hypothalamus. The hypothesis we suggest for the pathogenesis of severe TA in girls and boys has the same mechanism as that proposed recently for AIS girls, namely: severe TAs are initiated by a <it>genetically-determined selectively </it>increased hypothalamic sensitivity (up-regulation, i.e. increased sensitivity) to leptin with asymmetry as an adverse response to stress (hormesis), mediated bilaterally mainly to the growing trunk via the sympathetic nervous system <it>(leptin-hypothalamic-sympathetic nervous system (LHS) concept)</it>. The putative autonomic dysfunction is thought to be increased by any lower circulating leptin levels associated with relatively lower BMIs. Sympathetic nervous system activation with asymmetry leads to asymmetries in ribs and/or vertebrae producing severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk. A test of this hypothesis testing skin sympathetic responses, as in the Rett syndrome, is suggested.</p

Research on the osteogenic regulatory effect of the growth factor Pleiotrophin (PTN) and its receptor Receptor Tyrosine Phosphatase beta/zeta (RPTPβ/ζ) in the growth plate during mechanical loading in a rat model

Objectives: Mechanical loading of the spine is a major causative factor of degenerative changes and causes molecular and structural changes in the intervertebral disc (IVD) and the vertebrae end plate (EP). Pleiotrophin (PTN) is a growth factor with a putative role in bone remodelling through its receptor protein tyrosine phosphatase beta/zeta (RPTPβ/ζ).Aim of the study: The present study investigates the effects of strain on PTN and RPTPβ/ζ protein expression in vivo. Materials and Methods: Tails of eight weeks old Sprague-Dawley rats were subjected to mechanical loading using a mini Ilizarov external apparatus. Rat tails untreated (control) or after 0 degrees of compression and 100, 300 and 500 of angulation (groups 0, I, II and III respectively) were studied. PTN and RPTPβ/ζ expression were evaluated using immunohistochemistry and Western blot analysis. Results: In the control group, PTN was expressed only by the EP hypertrophic chondrocytes. In groups 0 to II, PTN was detected in the chondrocytes of hypertrophic and proliferating zones, as well as in osteocytes, osteoblast-like and bone lining cells of the ossification zone. In group III, only limited PTN expression was observed in EP chondrocytes and osteocytes. RPTPβ/ζ expression was increased in groups 0 and I, in EP chondrocytes of the hypertrophic and proliferative zones, osteoblast-like cells and IVD chondrocytes of the annulus fibrosus periphery. Low intensity RPTPβ/ζ immunostaining was observed in groups II and III. Conclusions: PTN and RPTPβ/ζ are expressed in spinal deformities caused by mechanical loading, and their expression depends on the type and severity of the applied strain.Υπόβαθρο: Η πλειοτροπίνη (ΡΤΝ) είναι ένας αυξητικός παράγοντας με υψηλή συγγένεια για την ηπαρίνη. Η ΡΤΝ εκφράζεται στον εμβρυικό και νεανικό χόνδρο, καθώς και στις επιφύσεις των οστών σε πειραματόζωα. Επιπλέον εκφράζεται και σε κύτταρα του μεσοσπονδύλιου δίσκου in vitro. Ασκεί τις βιολογικές της δράσεις με την σύνδεσή της στον υποδοχέα της Receptor Protein Tyrosine Phosphatase β/ζ (RPTPβ/ζ). Παρόλα αυτά ο ρόλος της παραμένει ακόμα ασαφής.Σκοπός: Σκοπός της έρευνάς μας είναι να μελετήσουμε την έκφραση της ΡΤΝ και του υποδοχέα της RPTPβ/ζ στην λειτουργική μονάδα τελικής πλάκας-μεσοσπονδύλιου δίσκου, κατά την ανάπτυξη σπονδυλικών παραμορφώσεων, που οφείλονται στην διαταραχή του μηχανικού περιβάλλοντος της σπονδυλικής στήλης.Υλικό και Μέθοδοι: Χρησιμοποιήθηκαν 64 επίμυες Sprague-Dawley, ηλικίας 8 εβδομάδων, εκ των οποίων 4 χρησιμοποιήθηκαν ως υγιείς μάρτυρες. Στις ουρές των πειραματόζωων εφαρμόστηκε μηχανική φόρτιση με την χρήση μιας mini συσκευής εξωτερική οστεοσύνθεσης τύπου Ilizarov. Η φόρτιση αντιστοιχούσε με 0 μοίρες μέτριας αξονικής συμπίεσης της τάξης των 5mm, και 10 , 30 και 50 μοιρών που ταξινομήθηκαν στις ομάδες 0, Ι, ΙΙ και ΙΙΙ, αντίστοιχα. Η έκφραση της ΡΤΝ, του RPTPβ/ζ και των πιθανόν αλληλεπιδράσεων μεταξύ τους ερευνήθηκαν με Western blot ανάλυση καθώς και με ανοσοϊστοχημικές μεθόδους.Αποτελέσματα: Η έκφραση της ΡΤΝ, στο control group, ήταν περιορισμένη στα χονδροκύτταρα της υπερτροφικής ζώνης της τελικής πλάκας. Στα group 0 – ΙΙ, η έκφραση της ΡΤΝ αυξάνονταν και εντοπίζονταν στα χονδροκύτταρα της υπερτροφικής ζώνης, της ζώνης πολλαπλασιασμού και στα οστεοκύτταρα και οσστεοβλαστικά κύτταρα της ζώνης οστεοποίησης των τελικών πλακών. Αύξηση της έκφρασης της ΡΤΝ παρατηρήθηκε και στα χονδροκύτταρα της περιφέρειας του ινώδους δακτυλίου. Στο group ΙΙΙ μόνο περιορισμένη έκφραση της ΡΤΝ παρατηρήθηκε κυρίως στα οστεοκύτταρα. Ο υποδοχέας RPTPβ/ζ εκφράστηκε με τις τρεις ισομορφές των > 250 kDa, 130 και 85 kDa. Η έκφραση του RPTPβ/ζ παρουσίαζε αύξηση κυρίως στο group 0 σε όλους τους τύπους των κυττάρων. Μικρής έντασης ανοσοχρώση για τον RPTPβ/ζ παρατηρήθηκε στα groups I και II, ενώ στο group ΙΙΙ η έκφρασή του ελαχιστοποιήθηκε.Συμπεράσματα: Η ΡΤΝ και ο υποδοχέας της RPTPβ/ζ εκφράζονται κατά την ανάπτυξη των σπονδυλικών παραμορφώσεων που οφείλονται στην άσκηση μηχανικής φόρτισης. Το ποσό της έκφρασή τους εξαρτάται από τον τύπο και την σοβαρότητα της παραμόρφωσης. Τα ανωτέρω τους καθιστούν σημαντικά μόρια στην παθοφυσιολογία της πάθησης αλλά και ως ενδιαφέροντες υποψήφιους στόχους για την ανάπτυξη θεραπευτικής προσέγγισης της νόσου

Perinatal Risk Factors and Genu Valgum Conducive to the Onset of Growing Pains in Early Childhood

The most prevalent musculoskeletal disorder of childhood with unclear aetiology is growing pains (GPs). Anatomic deformities and factors that change bone turnover are implicated in GP pathophysiology. Perinatal risk factors alter the bone metabolism affecting the bone mineral density and content. The aim of our study was to analyze the relationship between GPs, knock knees and perinatal factors. The examined population consisted of 276 children aged 3–7 years. Among them, ten pairs of dizygotic twins were evaluated. The data were collected by using a combination of semi-structured questionnaires, clinical examinations and medical charts of the children and the obstetric history of the mothers. A total of 78 children presenting GPs met Peterson’s criteria. Genu valgum severity was a significant factor for GP manifestation and for their increased frequency and intensity. Subsequently, perinatal factors regarding gestational age, Apgar score, head circumference (lower than 33 cm) and birth length or weight (smaller than 50 cm and 3000 g, respectively) made a remarkable contribution to the development of GPs. Conversely, antenatal corticosteroid treatment, increased maternal age and maternal smoking during pregnancy were not predictive of the disorder. Our data are potentially supportive for the “bone strength” theory and for the contribution of anatomical disturbances in GP appearance

Sclerostin and Its Involvement in the Pathogenesis of Idiopathic Scoliosis

Idiopathic scoliosis is a disorder of unknown etiology. Bone biopsies from idiopathic scoliosis patients revealed changes at cellular and molecular level. Osteocytic sclerostin is downregulated, and serum level of sclerostin is decreased. Osteocytes in idiopathic scoliosis appear to be less active with abnormal canaliculi network. Differentiation of osteoblasts to osteocytes is decelerated, while Wnt/beta-catenin signaling pathway is overactivated and affects normal bone mineralization that leads to inferior mechanical properties of the bone, which becomes susceptible to asymmetrical forces and causes deformity of the spinal column. Targeting bone metabolism during growth by stimulating sclerostin secretion from osteocytes and restoring normal function of Wnt/beta-catenin signaling pathway could, in theory, increase bone strength and prevent deterioration of the scoliotic deformity