Pneumothorax by Penetrating Endplate Screw for Diffuse Idiopathic Skeletal Hyperostosis-Related Thoracolumbar Fracture

Pneumothorax is a rare surgical complication in spinal surgery with thoracic pedicle screws. The penetrating endplate screw (PES) technique has been developed as a strong alternative spinal anchor to conventional pedicle screws for diffuse idiopathic skeletal hyperostosis (DISH). We present an intraoperative pneumothorax without deviation to the thoracic during the maneuver of the PES. A 56-year-old male who presented with non-union of DISH-related T12 vertebral fracture underwent T12 kyphoplasty and T10-L2 posterior fixation using the PES technique. The left pneumothorax was developed postoperatively without screw deviation to the thorax throughout screw insertion. Postoperative CT suggested that a displaced rib head by the lateral misposition of the screw at the inserting point and the pedicle level might injure the pleura. Spine surgeons should know that the lateral insertion of PES has a potential risk for pneumothorax by the displacement of the rib head because of screw trajectory from caudal to cranial apart from conventional pedicle screw.

Treatment of thigh abscess caused by retroperitoneal perforation of cecal cancer: A case report

Introduction and importance

Iliopsoas and iliacus abscesses are caused by hematogenous and lymphatic infections and the spread of inflammation in neighboring organs. A small number of cases have been reported in which inflammation spread not only within the iliopsoas muscle but also to the thigh. Here we report a case of retroperitoneal infiltration and perforation of cecal cancer that caused extensive abscess formation from the iliacus muscle to the thigh.

Case presentation

An 80-year-old man who had undergone chemotherapy for cecal cancer had abdominal pain and right thigh pain without any particular attraction. CT images showed extensive abscess formation from the iliacus muscle to the subcutaneous part of the thigh due to retroperitoneal infiltration and perforation of cecal cancer. Ileocecal resection, colostomy, and retroperitoneal abscess drainage were performed for perforation of cecal cancer and pelvic abscess. Although the thigh was initially drained by a small incision, the infection did not heal. Extensive debridement and drainage were required for all of the contaminated areas, and after all the infection was completely cured.

Clinical discussion

The optimal treatment for an abscess that has spread from the inguinal region to the thigh is unclear. In this case, active debridement and drainage of the infected area were effective and should have been done early.

Conclusion

We believed that debridement and drainage should have been performed from the time of the first surgery not only by the small incision drainage but also for all of the contaminated areas when the infection had been widespread.

•

・The iliopsoas abscess may spread to the surrounding area in case its diagnosis is delayed.

•

・The optimal treatment for an abscess spreading from the inguinal region to the thigh is still controversial.

•

・Drainage by the small incision is not helpful when the infection has been spreading to the thigh, and all of the contaminated areas should also be exposed and active debridement and drainage are required.

Role of irisin in effects of chronic exercise on muscle and bone in ovariectomized mice

INTRODUCTION

Exercise is beneficial for the prevention and treatment of osteoporosis. Skeletal muscle affects other tissues via myokines, the release of which is regulated by acute exercise. However, the effects of chronic exercise on myokines linking muscle to bone have not been fully elucidated. Therefore, we investigated the effects of chronic exercise on bone and myokines using ovariectomized (OVX) mice.

MATERIALS AND METHODS

Treadmill exercise with moderate intensity was performed for 8 weeks after OVX or sham surgery. We measured bone mineral density (BMD) at the femurs and tibias of mice by quantitative computed tomography and myokine mRNA levels in the gastrocnemius and soleus muscles.

RESULTS

Treadmill exercise ameliorated decreases in trabecular and cortical BMD in the femurs of OVX mice. Irisin is a proteolytic product of fibronectin type III domain-containing 5 (Fndc5). Among the myokines examined, treadmill exercise increased irisin protein and Fndc5 mRNA levels in the gastrocnemius and soleus muscles of sham and OVX mice. Treadmill exercise increased peroxisome proliferator-activated receptor γ coactivator-1α mRNA levels in the gastrocnemius muscles of mice. Fndc5 mRNA levels in the gastrocnemius muscles positively correlated with trabecular BMD, but not with cortical BMD, at the femurs and tibias of mice in simple regression analyses.

CONCLUSIONS

We demonstrated that chronic exercise elevated irisin expression in the gastrocnemius and soleus muscles of estrogen-deficient mice. Irisin might be related to increases in trabecular BMD in mice; however, further studies are needed to clarify the involvement of irisin in the effects of chronic exercise on muscle/bone interactions.

Role of Dkk2 in the Muscle/bone Interaction of Androgen-Deficient Mice

Androgen deficiency is known to cause both osteoporosis and sarcopenia. Myokines, humoral factors secreted from the skeletal muscles, have recently been getting attention as the key factors related to the interactions between muscle and bone. Dickkopf (Dkk) 2 is known as an inhibitor of canonical Wnt/β-catenin signaling, and Wnt/β-catenin signaling is crucial for the maintenance of muscle and bone. The present study was therefore performed to investigate the roles of Dkk2 in the alterations of muscle and bone of androgen-deficient mice with orchidectomy (ORX). ORX significantly enhanced Dkk2 mRNA levels, but not other Dkks and secreted frizzled related proteins, in the soleus muscles of mice. Moreover, ORX enhanced serum Dkk2 levels, but not Dkk2 mRNA levels in the tibial bone tissues, the white adipose tissues and liver of mice. In simple regression analyses, serum Dkk2 levels were negatively related to trabecular bone mineral density at the tibias in mice employed in the experiments. In vitro experiments, testosterone suppressed Dkk2 mRNA levels in mouse muscle C2C12 cells. In conclusion, we showed that androgen deficiency enhances Dkk2 expression and secretion in the muscles of mice. Dkk2 might be involved in androgen deficiency-induced muscle wasting and osteopenia as a myokine linking muscle to bone.

Roles of Dkk2 in the Linkage from Muscle to Bone during Mechanical Unloading in Mice

Mechanical unloading simultaneously induces muscle and bone loss, but its mechanisms are not fully understood. The interactions between skeletal muscle and bone have been recently noted. Although canonical wingless-related integration site (Wnt)/β-catenin signaling is crucial for bone metabolism, its roles in the muscle and bone interactions have remained unknown. Here, we performed comprehensive DNA microarray analyses to clarify humoral factors linking muscle to bone in response to mechanical unloading and hypergravity with 3 g in mice. We identified Dickkopf (Dkk) 2, a Wnt/β-catenin signaling inhibitor, as a gene whose expression was increased by hindlimb unloading (HU) and reduced by hypergravity in the soleus muscle of mice. HU significantly elevated serum Dkk2 levels and Dkk2 mRNA levels in the soleus muscle of mice whereas hypergravity significantly decreased those Dkk2 levels. In the simple regression analyses, serum Dkk2 levels were negatively and positively related to trabecular bone mineral density and mRNA levels of receptor activator of nuclear factor-kappa B ligand (RANKL) in the tibia of mice, respectively. Moreover, shear stress significantly suppressed Dkk2 mRNA levels in C2C12 cells, and cyclooxygenase inhibitors significantly antagonized the effects of shear stress on Dkk2 expression. On the other hand, Dkk2 suppressed the mRNA levels of osteogenic genes, alkaline phosphatase activity and mineralization, and it increased RANKL mRNA levels in mouse osteoblasts. In conclusion, we showed that muscle and serum Dkk2 levels are positively and negatively regulated during mechanical unloading and hypergravity in mice, respectively. An increase in Dkk2 expression in the skeletal muscle might contribute to disuse- and microgravity-induced bone and muscle loss.

Role of irisin in androgen-deficient muscle wasting and osteopenia in mice

Androgen deficiency plays a crucial role in the pathogenesis of male osteoporosis and sarcopenia. Myokines have recently been identified as humoral factors that are involved in the interactions between muscle and bone; however, the influence of androgen deficiency on these interactions remains unclear. Therefore, we herein investigated the roles of humoral factors linking muscle to bone using orchidectomized mice with sarcopenia and osteopenia. Orchidectomy (ORX) significantly reduced muscle mass, grip strength, and trabecular bone mineral density (BMD) in mice. Among the myokines examined, ORX only significantly reduced fibronectin type III domain-containing 5 (Fndc5) mRNA levels in both the soleus and gastrocnemius muscles of mice. In simple regression analyses, Fndc5 mRNA levels in the soleus muscle positively correlated with trabecular BMD, but not cortical BMD. The administration of irisin, a product of Fndc5, significantly protected against the decrease induced in trabecular BMD, but not muscle mass, by androgen deficiency in mice. In conclusion, the present results demonstrated that androgen deficiency decreases the expression of irisin in the skeletal muscle of mice. Irisin may be involved in muscle/bone relationships negatively affected by androgen deficiency.

Salmonella Osteomyelitis of the Distal Tibia in a Healthy Woman

Salmonella osteomyelitis is extremely rare; only a few cases have been reported in healthy adults. We describe a case of salmonella osteomyelitis in an otherwise healthy 20-year-old Japanese woman who presented with distal tibial pain. X-ray and magnetic resonance imaging showed a lesion suspected to be a bone cyst. Osteomyelitis was diagnosed when pus was observed during an open biopsy. The bacterial culture examination yielded salmonella. Surgical drainage and antibiotic treatment were performed, after which no recurrence was observed. To our best knowledge, this is the first report of salmonella osteomyelitis of the distal tibia in an otherwise healthy individual.

Clinical outcomes of patients with primary malignant bone and soft tissue tumor aged 65 years or older

The number of elderly patients with sarcoma (65 years or older) has increased with the rise in the aging of society. As it is difficult to treat elderly sarcoma patients in the same manner as younger patients, the present study sought to compare treatment options currently available for elderly patients. The present study was comprised 34 Japanese patients (21 men and 13 women) with malignant bone or soft tissue tumors who underwent surgery in our department from September 2004 to March 2014. The median patient age was 72 years (range, 65-86 years). Histologically, 23 cases were categorized as high-grade and 11 as low-grade. Treatments included surgery with adequate margins (25 cases), surgery with inadequate margins and radiotherapy (4 cases), surgery with inadequate margins and chemotherapy (3 cases) and intralesional resection (2 cases). The postoperative follow-up period ranged from 7 to 112 months (average, 49 months). The 5-year survival rates were determined and compared using the Kaplan-Meier method and log-rank test, respectively. Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and Anesthesiologists-Physical Status (ASA-PS) scores were also determined. The overall 5-year survival rate was 86.02%; it differed significantly between patients with high-grade (100%) vs. low-grade (74.3%) neoplasms P<0.001), but not between patients aged 65-69 (76.9%) vs. ≥70 (90.2%) years-old (P=0.65). Tumor status was classified as follows: i) Continuously disease-free, n=24 cases; ii) alive with disease, n=3 cases; iii) and dead of disease, n=7 cases. The ECOG-PS status scores were 0 in 9 cases, 1 in 21 cases, and 2 in 4 cases. ASA-PS scores were also I in 9 cases and II in 23 cases. Thus, the primary treatment for elderly patients with sarcoma should be surgery alone as no additional benefits were obtained when radiotherapy or chemotherapy was also performed. Adequate margins should be confirmed along with the histology of surgical specimens.

Control of AIF-mediated cell death by antagonistic functions of CHIP ubiquitin E3 ligase and USP2 deubiquitinating enzyme

Apoptosis inducing factor (AIF) is a mitochondrial oxidoreductase that scavenges reactive oxygen species under normal conditions. Under certain stresses, such as exposure to N-methyl-N'-nitro-N'-nitrosoguanidine (MNNG), AIF is truncated and released from the mitochondria and translocated into the nucleus, where the truncated AIF (tAIF) induces caspase-independent cell death. However, it is unknown how cells decide to kill themselves or operate ways to survive when they encounter stresses that induce the release of tAIF. Here, we demonstrated that USP2 and CHIP contribute to the control of tAIF stability. USP2 deubiquitinated and stabilized tAIF, thus promoting AIF-mediated cell death. In contrast, CHIP ubiquitinated and destabilized tAIF, thus preventing the cell death. Consistently, CHIP-deficient cells showed an increased sensitivity to MNNG. On the other hand, knockdown of USP2 attenuated MNNG-induced cell death. Moreover, exposure to MNNG caused a dramatic decrease in CHIP level, but not that of USP2, concurrent with cell shrinkage and chromatin condensation. These findings indicate that CHIP and USP2 show antagonistic functions in the control of AIF-mediated cell death, and implicate the role of the enzymes as a switch for cells to live or die under stresses that cause tAIF release.

Follistatin inhibits the function of the oocyte-derived factor BMP-15

Recent studies have highlighted the importance of a novel oocyte-derived growth factor, bone morphogenetic protein-15 (BMP-15) in the regulation of proliferation and differentiation of granulosa cells in the ovary. Namely, BMP-15 stimulates granulosa cell mitosis and inhibits follicle-stimulating hormone (FSH) receptor mRNA expression in granulosa cell, thereby playing a critical role in the elaborate mechanism controlling ovarian folliculogenesis. At present, however, nothing is known about molecules which may regulate the biological activity of BMP-15. Here we demonstrate evidence that follistatin can form an inactive complex with BMP-15, through which follistatin inhibits BMP-15 bioactivities. The binding of follistatin to BMP-15 was directly demonstrated by a surface plasmon resonance biosensor, and the ability of follistatin to inhibit BMP-15 functions was determined by established BMP-15 bioassays using primary rat granulosa cells. Specifically, follistatin attenuated BMP-15 stimulation of granulosa cell proliferation and reversed BMP-15 inhibition of FSH receptor mRNA expression leading to the suppression of FSH-induced progesterone synthesis. This is the first demonstration of the biochemical interaction and biological antagonism of follistatin and BMP-15, which may be involved in the complex yet well-controlled mechanism of the regulation of follicle growth and development.

Bone morphogenetic protein 2 stimulates osteoclast differentiation and survival supported by receptor activator of nuclear factor-kappaB ligand

Bone is a major storage site for TGFbeta superfamily members, including TGFbeta and bone morphogenetic proteins. It is believed that these cytokines are released from bone during bone resorption. Recent studies have shown that both RANKL and macrophage colony-stimulating factor are two essential factors produced by osteoblasts for inducing osteoclast differentiation. In the present study we examined the effects of bone morphogenetic protein-2 on osteoclast differentiation and survival supported by RANKL and/or macrophage colony-stimulating factor. Mouse bone marrow-derived macrophages differentiated into osteoclasts in the presence of RANKL and macrophage colony-stimulating factor. TGFbeta superfamily members such as bone morphogenetic protein-2, TGFbeta, and activin A markedly enhanced osteoclast differentiation induced by RANKL and macrophage colony-stimulating factor, although each cytokine alone failed to induce osteoclast differentiation in the absence of RANKL. Addition of a soluble form of bone morphogenetic protein receptor type IA to the culture markedly inhibited not only osteoclast formation induced by RANKL and bone morphogenetic protein-2, but also the basal osteoclast formation supported by RANKL alone. Either RANKL or macrophage colony-stimulating factor stimulated the survival of purified osteoclasts. Bone morphogenetic protein-2 enhanced the survival of purified osteoclasts supported by RANKL, but not by macrophage colony-stimulating factor. Both bone marrow macrophages and mature osteoclasts expressed bone morphogenetic protein-2 and bone morphogenetic protein receptor type IA mRNAs. An EMSA revealed that RANKL activated nuclear factor-kappaB in purified osteoclasts. Bone morphogenetic protein-2 alone did not activate nuclear factor-kappaB, but rather inhibited the activation of nuclear factor-kappaB induced by RANKL in purified osteoclasts. These findings suggest that bone morphogenetic protein-mediated signals cross-communicate with RANKL-mediated ones in inducing osteoclast differentiation and survival. The enhancement of RANKL-induced survival of osteoclasts by bone morphogenetic protein-2 appears unrelated to nuclear factor-kappaB activation.

Dorsal spinal cord inhibits oligodendrocyte development

Oligodendrocytes are the myelinating cells of the mammalian central nervous system. In the mouse spinal cord, oligodendrocytes are generated from strictly restricted regions of the ventral ventricular zone. To investigate how they originate from these specific regions, we used an explant culture system of the E12 mouse cervical spinal cord and hindbrain. In this culture system O4(+) cells were first detected along the ventral midline of the explant and were subsequently expanded to the dorsal region similar to in vivo. When we cultured the ventral and dorsal spinal cords separately, a robust increase in the number of O4(+) cells was observed in the ventral fragment. The number of both progenitor cells and mature cells also increased in the ventral fragment. This phenomenon suggests the presence of inhibitory factor for oligodendrocyte development from dorsal spinal cord. BMP4, a strong candidate for this factor that is secreted from the dorsal spinal cord, did not affect oligodendrocyte development. Previous studies demonstrated that signals from the notochord and ventral spinal cord, such as sonic hedgehog and neuregulin, promote the ventral region-specific development of oligodendrocytes. Our present study demonstrates that the dorsal spinal cord negatively regulates oligodendrocyte development.

Characterization of follistatin isoforms in early Xenopus embryogenesis

Follistatin is expressed in Spemann's organizer in the Xenopus gastrula and mimics the activity of the organizer, inducing a neural fate directly in the ectoderm. We have previously shown that follistatin inhibits BMP activity through a direct interaction. In this study, we have characterized the localization and function of two follistatin isoforms to examine the functional differences between them. One notable difference, previously described, is that the shorter form (xFSS or xFS319) but not the C-terminally extended long form (xFSL) associates with cell-surface matrices. Here, we show that the spatial-temporal expression pattern of xFSL and xFSS is indistinguishable. Interestingly, however, xFSS was found to have a more potent inhibitory activity against BMP-4 than xFSL. Furthermore, using a surface plasmon resonance biosensor, xFSS was shown to have a higher binding capacity for BMP subtypes. The diffusion rates of xFSS and xFSL ectopically expressed in Xenopus embryos were similar. Taken together, our results suggest that the difference in BMP-inhibiting activity of the two follistatin isoforms is mainly attributable to a difference in their BMP binding properties rather than to their diffusion rates.

Isolation and characterization of bone morphogenetic protein-binding proteins from the early Xenopus embryo

Using a surface plasmon resonance biosensor as a sensitive and specific monitor, we have isolated two distinct bone morphogenetic protein (BMP)-binding proteins, and identified them as lipovitellin 1 and Ep45, respectively. Lipovitellin 1 is an egg yolk protein that is processed from vitellogenin. Both vitellogenin and Ep45 are synthesized under estrogen control in the liver, secreted, and taken up by developing oocytes. In this paper, we have shown that of the TGF-beta family members tested, Ep45 can bind only to BMP-4, whereas lipovitellin 1 can bind to both BMP-4 and activin A. Because of this difference in specificity, we have focused on and further studied Ep45. Kinetic parameters were determined by surface plasmon resonance studies and showed that Ep45 associated rapidly with BMP-4 (k(a) = 1.06 x 10(4) M(-1)s(-1)) and dissociated slowly (k(d) = 1.6 x 10(-4) s(-1)). In Xenopus embryos microinjected with Ep45 mRNA, Ep45 blocked the ability of follistatin to inhibit BMP activity and to induce a secondary body axis in a dose-dependent manner, whereas it had no effect on other BMP antagonists, chordin and noggin. These results support the possibility that Ep45 interacts with BMP to modulate its activities in vivo.

A functional bone morphogenetic protein system in the ovary

Bone morphogenetic proteins (BMPs) comprise a large group of polypeptides in the transforming growth factor beta superfamily with essential physiological functions in morphogenesis and organogenesis in both vertebrates and invertebrates. At present, the role of BMPs in the reproductive system of any species is poorly understood. Here, we have established the existence of a functional BMP system in the ovary, replete with ligand, receptor, and novel cellular functions. In situ hybridization histochemistry identified strong mRNA labeling for BMP-4 and -7 in the theca cells and BMP receptor types IA, IB, and II in the granulosa cells and oocytes of most follicles in ovaries of normal cycling rats. To explore the paracrine function of this BMP system, we examined the effects of recombinant BMP-4 and -7 on FSH (follicle-stimulating hormone)-induced rat granulosa cytodifferentiation in serum-free medium. Both BMP-4 and -7 regulated FSH action in positive and negative ways. Specifically, physiological concentrations of the BMPs enhanced and attenuated the stimulatory action of FSH on estradiol and progesterone production, respectively. These effects were dose- and time-dependent. Furthermore, the BMPs increased granulosa cell sensitivity to FSH. Thus, BMPs have now been identified as molecules that differentially regulate FSH-dependent estradiol and progesterone production in a way that reflects steroidogenesis during the normal estrous cycle. As such, it can be hypothesized that BMPs might be the long-sought "luteinization inhibitor" in Graafian follicles during their growth and development.

Direct binding of follistatin to a complex of bone-morphogenetic protein and its receptor inhibits ventral and epidermal cell fates in early Xenopus embryo

In early development of Xenopus laevis, it is known that activities of polypeptide growth factors are negatively regulated by their binding proteins. In this study, follistatin, originally known as an activin-binding protein, was shown to inhibit all aspects of bone morphogenetic protein (BMP) activity in early Xenopus embryos. Furthermore, using a surface plasmon resonance biosensor, we demonstrated that follistatin can directly interact with multiple BMPs at significantly high affinities. Interestingly, follistatin was found to be noncompetitive with the BMP receptor for ligand binding and to form a trimeric complex with BMP and its receptor. The results suggest that follistatin acts as an organizer factor in early amphibian embryogenesis by inhibiting BMP activities by a different mechanism from that used by chordin and noggin.

Interaction between soluble type I receptor for bone morphogenetic protein and bone morphogenetic protein-4

Bone morphogenetic proteins (BMPs) are multifunctional proteins that comprise the largest subfamily of the transforming growth factor-beta. These proteins bind to types I and II serine/threonine kinase receptors. Ligand-induced heteromeric dimerization of these receptors is the key event in initiation of biological responses. We report here large-scale expression and purification of extracellular domain of the type I receptor for BMP-2/4, using a silkworm expression system. This soluble form of BMP receptor (sBMPR) was in monomer form in solution and bound to BMP-4 but not to activin or transforming growth factor-beta1. Surface plasmon resonance studies showed that kinetic parameters of sBMPR for BMP-4 consisted of a relatively rapid association rate constant (ka = 3.81 +/- 0.19 x 10(4) s-1 M-1) and an extremely slow dissociation rate constant (kd = 3.69 +/- 0.26 x 10(-4) s-1). From these two kinetic parameters, affinity was determined to be similar to that of the intact membrane-associated receptor expressed on COS cells. sBMPR inhibited the alkaline phosphatase activity in BMP responsive cell lines such as mouse osteoblastic cell MC3T3-E1 and bone marrow stromal cell ST2. These data indicate that the extracellular domain of type I receptor for BMP-2 and BMP-4 is sufficient for high-affinity binding to its ligands and should prove useful in understanding the role of BMP-2/4 in vivo, because a suitable high-affinity anti-BMP antibody has yet to be developed.