A case of thoracic disc herniation characterized by marked posture-related dynamic changes in neurological symptoms

Thoracic disc herniation is less common than lumbar and cervical disc herniations. It is usually accompanied by severe myelopathy, which often leads to surgery. Because the thoracic spine is less mobile, thoracic disc herniation is considered to be minimally affected by dynamic spine factors in cases with myelopathy. We experienced a case of thoracic disc herniation (T4/5 and T6/7) characterized by posture-related dynamic changes in neurological symptoms; that is, numbness extending from the trunk to the entire lower limbs was deteriorated in the standing and sitting positions, was relieved in the supine position, and disappeared in the prone position. In addition, the patient reported dysuria with a delay when attempting to urinate in the standing position. Computed tomographic myelography revealed diffuse idiopathic skeletal hyperostosis extending from T3 to T11, and the kyphosis angles at T1 to T11 levels were 68 degrees in the half-sitting position and 58 degrees in the prone position, showing posture-related changes. The patient underwent the posterior fusion in the prone position, by which symptoms disappeared, without undergoing disc herniotomy or laminectomy, and favorable outcomes were achieved. Thoracic disc herniation with marked posture-related neurological symptoms is extremely rare. Here we report a case presentation and literature review of pathophysiology observed in our patient

Visualization of walking speed variation-induced synchronized dynamic changes in lower limb joint angles and activity of trunk and lower limb muscles with a newly developed gait analysis system

Purpose:To evaluate a newly developed system for dynamic analysis of gait kinematics and muscle activity.Methods:We recruited 10 healthy men into this study. Analyses of three-dimensional motion and wireless surface electromyogram (EMG) were integrated to achieve synchronous measurement. The participants walked continuously for 10 min under two conditions: comfortable and quick pace. Outcome measures were joint angles of the lower limbs determined from reflective markers and myoelectric activity of trunk and lower limbs determined from EMG sensors, comparing comfortable and quick gait pace.Results:Lower limb joint angle was significantly greater at the quick pace (maximum flexion of the hip joint: 4.1°, maximum extension of hip joint: 2.3°, and maximum flexion of the knee joint while standing: 7.4°). The period of maximum flexion of the ankle joint during a walking cycle was 2.5% longer at a quick pace. EMG amplitudes of all trunk muscles significantly increased during the period of support by two legs (cervical paraspinal: 55.1%, latissimus dorsi: 31.3%, and erector spinae: 32.6%). EMG amplitudes of quadriceps, femoral biceps, and tibialis anterior increased significantly by 223%, 60.9%, and 67.4%, respectively, between the periods of heel contact and loading response. EMG amplitude of the gastrocnemius significantly increased by 102% during the heel-off period.Conclusion:Our gait analysis synchronizing three-dimensional motion and wireless surface EMG successfully visualized dynamic changes in lower limb joint angles and activity of trunk and lower limb muscles induced by various walking speeds

Cervical restenosis caused by progressive ossification of the posterior longitudinal ligament in patients following laminoplasty: Two case reports

We report two cases of restenosis caused by the progression of thickness of ossification of the posterior longitudinal ligament (OPLL) seven and more years after laminoplasty, resulting in neurological deterioration needed for revision anterior decompressive surgeries. Neurological recovery after revision anterior excision of OPLL was poor. In both cases, the patients had progressive OPLL, with a non-ossified segment of the ossification foci, in common. After laminoplasty, they also both exhibited osseous fusion of the elevated laminae, but there was discontinuity at the interlaminar space at the peak level of OPLL. Discontinuity of the osseous fusion in the elevated laminae might cause mechanical stress increases at the non-ossified segment of the OPLL and could lead to the progression of OPLL. The present cases showed that long-term progression of OPLL can induce neurological deterioration even after sufficient posterior decompression by laminoplasty. Therefore, when considering risk factors that may be predictive of the progression of OPLL after laminoplasty, it is important to perform strict follow-up examination to check for progression to reduce the risk of myelopathy symptoms that are indicative of neurological deterioration

Initial hospitalization with rigorous bed rest followed by bracing and rehabilitation as an option of conservative treatment for osteoporotic vertebral fractures in elderly patients: a pilot one arm safety and feasibility study

SummaryWe assessed the safety and feasibility of a unified conservative treatment protocol for osteoporotic vertebral fractures in the elderly patients with a 24-week follow-up. Our results showed that initial hospitalization with rigorous bed rest followed by a rehabilitation program using a Jewett brace was safe and feasible in managing patients.PurposeThe purpose of this study was to prove the safety and feasibility of a unified conservative treatment protocol, which included initial hospitalization with rigorous bed rest followed by a rehabilitation program with Jewett brace for osteoporotic vertebral fractures (OVFs) in the elderly patients with a 24-week follow-up.MethodsBetween April 2012 and Mach 2015, one hundred fifty-four patients met the eligibility for this study. Radiological findings at the 3-week, 6~8-week, 24-week assessment were evaluated. Among these, 11 patients underwent early surgery within the first 2 weeks after admission and 19 patients lost follow-up. Therefore, 124 patients were assessed at the final follow-up visit.ResultsThe average vertebral instability in all the present series was 4.9 ± 4.8° at 3-week, 2.9 ± 3.5° at 6~8-week, and 1.8 ± 3.0° at 24-week follow-up visit. Delayed union was observed in 16 patients on the 24-week follow-up visit. Therefore, the present conservative treatment protocol resulted in bony union in 98 out of 124 patients (79.0%, per protocol set analysis) and 98 out of 154 patients including drop-out (63.6%, intention-to-treat analysis). There was no severe adverse event related to initial bed rest. The vertebral instability at 3-week assessment was significantly higher in the delayed union group when compared with that in the union group. Univariate analyses followed by multivariate logistic regression analysis revealed that T2-weighted image of confined high intensity on MRI and having more than 5° of vertebral instability on dynamic X-ray at 3-week assessment are the independent risk factors for delayed union of conservative treatment in the present series.ConclusionsOur results showed that initial hospitalization with rigorous bed rest followed by a rehabilitation program using a Jewett brace was safe and feasible. Therefore, the present conservative treatment protocol can be one of the acceptable treatment options in managing OVF patients

To Be or Not to Be a Flatworm: The Acoel Controversy

Since first described, acoels were considered members of the flatworms (Platyhelminthes). However, no clear synapomorphies among the three large flatworm taxa - the Catenulida, the Acoelomorpha and the Rhabditophora - have been characterized to date. Molecular phylogenies, on the other hand, commonly positioned acoels separate from other flatworms. Accordingly, our own multi-locus phylogenetic analysis using 43 genes and 23 animal species places the acoel flatworm Isodiametra pulchra at the base of all Bilateria, distant from other flatworms. By contrast, novel data on the distribution and proliferation of stem cells and the specific mode of epidermal replacement constitute a strong synapomorphy for the Acoela plus the major group of flatworms, the Rhabditophora. The expression of a piwi-like gene not only in gonadal, but also in adult somatic stem cells is another unique feature among bilaterians. These two independent stem-cell-related characters put the Acoela into the Platyhelminthes-Lophotrochozoa clade and account for the most parsimonious evolutionary explanation of epidermal cell renewal in the Bilateria. Most available multigene analyses produce conflicting results regarding the position of the acoels in the tree of life. Given these phylogenomic conflicts and the contradiction of developmental and morphological data with phylogenomic results, the monophyly of the phylum Platyhelminthes and the position of the Acoela remain unresolved. By these data, both the inclusion of Acoela within Platyhelminthes, and their separation from flatworms as basal bilaterians are well-supported alternatives

Hyponatremia Associated with Congestive Heart Failure: Involvement of Vasopressin and Efficacy of Vasopressin Receptor Antagonists

Hyponatremia is frequently found in patients with congestive heart failure. A reduction in effective circulatory blood volume in a volume-expanded patient with decreased cardiac output is linked to a baroreceptor-mediated non-osmotic release of arginine vasopressin (AVP). The increased production of AVP and salt and water retention in the proximal and distal tubules of the kidney by humoral, hemodynamic, and neural mechanisms increase circulatory blood volume and contribute to hyponatremia. Recent studies have indicated that hyponatremia predicts the short-term and long-term prognosis of heart failure by increasing cardiac death and rehospitalization. In addition, the early development of hyponatremia in acute myocardial infarction also predicts the long-term prognosis of worsening heart failure. AVP V2 receptor antagonism may relieve water retention, but it is unknown whether the V2 receptor inhibitor, tolvaptan, improves the long-term prognosis of congestive heart failure. The newly identified natriuretic factor in renal salt wasting has the potential of improving clinical outcomes when combined with a distal diuretic

Intraprocedural left ventricular free wall rupture diagnosed by left ventriculogram in a patient with infero-posterior myocardial infarction and severe aortic stenosis

Background: Left ventricular wall rupture remains a major lethal complication of acute myocardial infarction and hypertension is a well-known predisposing factor of cardiac rupture after myocardial infarction. Case presentation: An 87-year-old man was admitted to our hospital, diagnosed as acute myocardial infarction (AMI). The echocardiogram showed 0.67-cm2 aortic valve, consistent with severe aortic stenosis (AS). A coronary angiography showed a chronic occlusion of the proximal left circumflex artery and a 99 % stenosis and thrombus in the mid right coronary artery. During percutaneous angioplasty of the latter, transient hypotension and bradycardia developed at the time of balloon inflation, and low doses of noradrenaline and etilefrine were intravenously administered as needed. The patient suddenly lost consciousness and developed electro-mechanical dissociation. Cardio-pulmonary resuscitation followed by insertion of an intra-aortic balloon pump (IABP) and percutaneous cardiopulmonary support were initiated. The echocardiogram revealed moderate pericardial effusion, though the site of free wall rupture was not distinctly visible. A left ventriculogram clearly showed an infero-posterior apical wall rupture. Surgical treatment was withheld because of the interim development of brain death. Conclusions: In this patient, who presented with severe AS, the administration of catecholamine to stabilize the blood pressure probably increased the intraventricular pressures considerably despite apparently normal measurements of the central aortic pressure. IABP, temporary pacemaker, or both are recommended instead of intravenous catecholamines for patients with AMI complicated with significant AS to stabilize hemodynamic function during angioplasty

Surgical Repair of Acetabular Fracture Using Unidirectional Porous β-Tricalcium Phosphate

We report a case of an acetabular fracture treated using a unidirectional porous β-tricalcium phosphate artificial bone (Affinos®) to surgically repair bone defects. An 82-year-old man sustained an acetabular fracture on the left side and presented with shock on arrival along with impaired vital signs and systolic blood pressure. Upon stabilization, we performed an open reduction and internal fixation. However, there were significant bone defects, which were then fixed using Affinos® (both blocks and granules), an artificial β-tricalcium phosphate bone with a porosity of 57% (pore size: 25–300 μm), characterized by a novel unidirectional porous structure. By 18 months postoperatively, the patient was able to perform stair climbing and absorption and bone fusion around the artificial bone were observed. Affinos® has a frost-like structure, which endows it with good tissue-invasive properties because of the capillary effect. Moreover, it has excellent osteoconduction capability. In this case, both Affinos® blocks and granules showed good affinity, absorption, and bone substitution. Further prospective studies are required to confirm our findings