Immunodeficiency, Centromeric Region Instability, and Facial Anomalies Syndrome (ICF) in a Boy with Variable Clinical and Immunological Presentations

Immunodeficiency, centromeric instability, and facial anomalies (ICF) syndrome is a rare primary immunodeficiency disorder characterized by recurrent infections and low immunoglobulin levels due to variable combined immunodeficiency, and centromeric region instability, and facial dysmorphism. We describe a 12-year-old boy with recurrent respiratory tract infections, facial anomalies, scoliosis, and psychomotor retardation. He had recurrent pneumonia with low serum IgG and IgM levels during infancy and preschool age. Later at the age of 10, he developed recurrent ear infections. An IgA and IgM deficiency was found accompanied by a normal B-cell and T-cell count as well as an impaired candida-induced T-cell proliferation. Further evaluations revealed a missense mutation in the DNMT3B gene on chromosome 20. Chromosomal analysis showed a sunburst multi-radial feature on chromosome 1, which is a hallmark of ICF syndrome. The genetic mutation and chromosomal abnormality along with clinical findings are compatible with the diagnosis of ICF syndrome. To the best of our knowledge, this is the first time that scoliosis is observed in an ICF patient. The additional variable clinical symptoms in the case were the presence of spastic gait as well as hypogammaglobulinemia with immunoglobulin isotype switch at different ages.

Abnormal lacuno-canalicular network and negative correlation between serum osteocalcin and Cobb angle indicate abnormal osteocyte function in adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) is a prevalent spinal deformity occurring during peripubertal growth period that affects 1-4% of adolescents globally without clear etiopathogenetic mechanism. Low bone mineral density is an independent and significant prognostic factor for curve progression. Currently, the cause underlying low bone mass in AIS remains elusive. Osteocytes play an important role in bone metabolism and mineral homeostasis, but its role in AIS has not been studied. In the present study, iliac bone tissues were harvested from 21 patients with AIS (mean age of 14.3 ± 2.20 yr old) with a mean Cobb angle of 55.6 ± 10.61° and 13 non-AIS controls (mean age of 16.5 ± 4.79 yr old) intraoperatively. Acid-etched scanning electron microscopy (SEM) images of AIS demonstrated abnormal osteocytes that were more rounded and cobblestone-like in shape and were aligned in irregular clusters with shorter and disorganized canaliculi. Further quantitative analysis with FITC-Imaris technique showed a significant reduction in the canalicular number and length as well as an increase in lacunar volume and area in AIS. SEM with energy-dispersive X-ray spectroscopy analysis demonstrated a lower calcium-to-phosphorus ratio at the perilacunar/canalicular region. Moreover, microindentaion results revealed lower values of Vickers hardness and elastic modulus in AIS when compared with controls. In addition, in the parallel study of 99 AIS (27 with severe Cobb angle of 65.8 ± 14.1° and 72 with mild Cobb angle of 26.6 ± 9.1°) with different curve severity, the serum osteocalcin level was found to be significantly and negatively associated with the Cobb angle. In summary, the findings in this series of studies demonstrated the potential link of abnormal osteocyte lacuno-canalicular network structure and function to the observed abnormal bone mineralization in AIS, which may shed light on etiopathogenesis of AIS.-Chen, H., Zhang, J., Wang, Y., Cheuk, K.-Y., Hung, A. L. H., Lam, T.-P., Qiu, Y., Feng, J. Q., Lee, W. Y. W., Cheng, J. C. Y. Abnormal lacuno-canalicular network and negative correlation between serum osteocalcin and Cobb angle indicate abnormal osteocyte function in adolescent idiopathic scoliosis.

Changes in circulating cell-free nuclear DNA and mitochondrial DNA of patients with adolescent idiopathic scoliosis

BACKGROUND

Adolescent idiopathic scoliosis (AIS) which characterized by complex three-dimensional deformity of spine has been difficult to cure because of the unknown etiopathology and uncertainty of progression. Nowadays, circulating cell-free (ccf) DNA was found to be a potential biomarker for several benign and malignant diseases. However, whether ccf DNA can be a biomarker for AIS has not been reported yet. In this study, we investigate the circulating cell-free nuclear DNA (ccf n-DNA) and mitochondrial DNA (ccf mt-DNA) concentrations in the plasma of patients with AIS and controls (CT), and the changed plasma ccf n-DNA and ccf mt-DNA levels and their association with clinical parameters were assessed.

METHODS

The plasma of peripheral blood from 69 AIS patients and 21 age-matched CT was collected for ccf DNA analysis. Quantitative PCR was used to detect ccf n-DNA and ccf mt-DNA levels, and correlation analyses between the ccf n-DNA and ccf mt-DNA levels and clinical characteristics were conducted. Receiver operator curves (ROC) were used to analyze the sensitivity and specificity of ccf n-DNA and ccf mt-DNA levels to different characteristics.

RESULTS

The plasma ccf n-DNA levels of both GAPDH and ACTB were significantly decreased in AIS patients compared with those in controls, while the plasma ccf mt-DNA levels did not changed. According to sex-related analyses, the ccf n-DNA levels in male CT-M was higher than that in female CT and male AIS, but the ccf n-DNA levels in female AIS was not significantly changed when compared with male AIS or female CT. However, the concentration of ccf mt-DNA in female AIS increased significantly when compared with male AIS. Surprisingly, Lenke type-related analyses suggested that Lenke type 1 patients had lower ccf n-DNA levels, whereas Lenke type 5 patients had higher ccf mt-DNA levels compared with those of controls. However, a lower sensitivity and specificity of AIS predicted by ccf n-DNA or ccf mt-DNA levels was observed, whether in total, by sex, or by Lenke type.

CONCLUSION

Although with no/little predictive accuracy of AIS/progressed AIS by ccf DNA levels, significantly changed plasma ccf DNA levels were observed in AIS patients compared with those in controls.

Hemoglobin Levels Pre- and Posttreatment as a Surrogate for Disease Severity in Early-Onset Scoliosis

STUDY DESIGN

Prospective cohort.

OBJECTIVE

To compare preoperative hemoglobin levels to postoperative hemoglobin levels in patients with early-onset scoliosis (EOS).

SUMMARY OF BACKGROUND DATA

Elevated hemoglobin (Hgb) may be a marker for preoperative hypoxia in patients with EOS and thoracic insufficiency syndrome (TIS). The changes in Hgb level after treatment may be a surrogate marker for improved oxygenation.

METHODS

Because normal levels of Hgb vary with patient age, Hgb z scores were calculated by dividing age-adjusted mean Hgb levels by the age-adjusted standard deviation. Elevated Hgb was defined by a hemoglobin z score >1. Patients with a baseline Hgb value measured before initial implantation with at least one follow-up measurement, at 6, 12, or 18 months, were included in longitudinal analysis. Change in Hgb z score as well as change in curve magnitude over time was assessed using piecewise linear mixed modeling for patients with elevated Hgb and those without.

RESULTS

Two hundred sixty-seven patients with EOS were treated surgically over the study period. Average age at initial implantation was 6.8 years. Forty-eight (18%; 95% confidence interval = 13.7%, 23.2%) subjects had an elevated Hgb (z score > 1) level before implantation procedure. Hgb levels decreased in subjects with elevated Hgb from implantation to 6 months (p < .001) with no change in Hgb from 6 to 12 months (p = .46) or from 12 to 18 months (p = .59), but an overall decrease from preoperative to 18 months (p < .001). There was no change in Hgb levels for subjects without elevated Hgb from implantation to 6 months (p = .94), from 6 to 12 months (p = .61), or from 12 to 18 months (p = .78).

CONCLUSIONS

In some patients with EOS and TIS, there appears to be significant positive impact on oxygenation from distraction instrumentation as evidenced by a meaningful proxy measurement: improvement in abnormal preoperative Hgb levels after surgery.

LEVEL OF EVIDENCE

III.

Association of Circulating YKL-40 Levels and CHI3L1 Variants with the Risk of Spinal Deformity Progression in Adolescent Idiopathic Scoliosis

The cellular and molecular mechanisms underlying spinal deformity progression in adolescent idiopathic scoliosis (AIS) remain poorly understood. In this study, 804 French-Canadian patients and 278 age- and sex-matched controls were enrolled and genotyped for 12 single nucleotide polymorphisms (SNPs) in the chitinase 3-like 1 (CHI3L1) gene or its promoter. The plasma YKL-40 levels were determined by ELISA. We showed that elevation of circulating YKL-40 levels was correlated with a reduction of spinal deformity progression risk. We further identified significant associations of multiple CHI3L1 SNPs and their haplotypes with plasma YKL-40 levels and scoliosis severity as a function of their classification in a specific endophenotype. In the endophenotype FG3 group, we found that patients harboring the haplotype G-G-A-G-G-A (rs880633|rs1538372|rs4950881|rs10399805|rs6691378|rs946261), which presented in 48% of the cases, showed a positive correlation with the plasma YKL-40 levels (P = 7.6 × 10-6 and coefficient = 36). Conversely, the haplotype A-A-G-G-G-G, which presented in 15% of the analyzed subjects, showed a strong negative association with the plasma YKL-40 levels (P = 2 × 10-9 and coefficient = -9.56). We found that this haplotype showed the strongest association with AIS patients in endophenotype FG2 (P = 9.9 × 10-6 and coefficient = -13.53), who more often develop severe scoliosis compared to those classified in the other two endophenotypes. Of note, it showed stronger association in females (P = 1.6 × 10-7 and coefficient = -10.08) than males (P = 0.0021 and coefficient = -9.01). At the functional level, we showed that YKL-40 treatments rescued Gi-coupled receptor signalling dysfunction occurring in primary AIS osteoblasts. Collectively, our findings reveal a novel role for YKL-40 in AIS pathogenesis and a new molecular mechanism interfering with spinal deformity progression.

Alterations of the gut microbiome and plasma proteome in Chinese patients with adolescent idiopathic scoliosis

The etiology of adolescent idiopathic scoliosis (AIS), the most common rotational deformity of the spine, is still unclear. Emerging evidence suggests that gut microbiota dysbiosis influences musculoskeletal diseases such as arthritis and osteoporosis. However, the alterations of the fecal microbiome in AIS remain unknown. Thus, the current study was conducted to explore the gut microbiota compositions of Chinese AIS patients. Microbiota communities in the feces of 51 AIS patients and 34 age- and sex-matched healthy individuals were investigated using 16S rRNA sequencing. Meanwhile, the changes in the plasma proteome were detected using tandem mass tag (TMT) labeling coupled with liquid chromatography-mass spectrometry (LC-MS). The relationship between gut microbiota and AIS clinical characteristics as well as the correlation between gut microbiota and the changes in plasma proteins were analyzed. The structure of the gut microbiota differed between the AIS and healthy groups, however, the richness was similar. The genera Prevotella, Gelria, and Desulfovibrio were enriched in the feces of AIS patients. In contrast, the abundance of Parasutterella, Tyzzerella, and Phascolarctobacterium was decreased in the AIS group. More remarkably, a positive correlation between the abundance of the fecal genera Prevotella and the Cobb angles of the AIS patients was observed. Moreover, the major differential plasma proteins related to AIS were Fibronectin 1 (FN1), voltage-dependent anion channel 1 (VDAC1), Ras homolog family member A (RHOA), and AHNAK nucleoprotein (AHNAK). Additionally, the positive correlations between fecal Prevotella and the expression of host plasma FN1 as well as the negative relationships between fecal Prevotella and the expression of host VDAC1 and AHNAK were confirmed. Elucidating these differences in the gut microbiota will provide a foundation to improve our understanding of the pathogenesis of AIS and to support potential therapeutic options based on modifying the gut microbiota.

Preliminary Analysis of Factors Associated with Blood Loss in Neuromuscular Scoliosis Surgery

STUDY DESIGN

A retrospective review was conducted of 57 consecutive patients (26 female; mean age: 16.6 years) who underwent posterior or combined anterior-posterior spinal fusion for neuromuscular scoliosis (NMS) from 2006 and 2007.

OBJECTIVES

We aimed to assess which patient and surgical factors are predictive of increased blood loss and transfusion requirements during spinal fusion for NMS.

BACKGROUND

Spinal fusion surgery in patients with NMS has been associated with significant intraoperative blood loss and transfusion requirements. Specific factors predictive of greater blood loss have not been delineated; recognizing these factors will assist predicting the need for blood products and antifibrinolytics.

METHODS

Data gathered included demographic, operative (operative time, levels fused, estimated blood loss, cell saver transfused, IV fluids transfused, and units transfused), and laboratory parameters (hemoglobin, hematocrit, platelet count, prothrombin time, partial prothrombin time, and international normalized ratio). Multivariate linear regression was used to identify parameters associated with greater intraoperative blood loss and transfusion requirements.

RESULTS

Eighty-three percent of patients underwent primary surgery with mean levels fused of 13.5. Regression analysis showed a statistically significant increase in blood loss with age (p = 0.00), operative time (p = 0.00), and postoperative platelets (p = 0.016). Each year of increasing age corresponded with an increase of 50 cc of estimated blood loss (EBL). Each additional hour of operative time was associated with an additional EBL of 147.7 cc. Each additional unit of postoperative platelets was associated with an EBL decrease of 2.8 cc. Units transfused increased with age (p = 0.00): each year of increasing age corresponded with an increase of 0.04 units of blood transfused.

CONCLUSIONS

Patients with NMS remain a challenging group of patients to treat. We find that age, operative time, and postoperative platelets are predictive of increased blood loss while only age was related to greater transfused units. Our findings may predict the need for blood products and antifibrinolytic agents preoperatively in this heterogeneous population, especially as patients age.

Circulating miRNAs as diagnostic biomarkers for adolescent idiopathic scoliosis

The aetiology of adolescent idiopathic scoliosis (AIS) has been linked to many factors, such as asymmetric growth, neuromuscular condition, bone strength and genetic background. Recently, epigenetic factors have been proposed as contributors of AIS physiopathology, but information about the molecular mechanisms and pathways involved is scarce. Regarding epigenetic factors, microRNAs (miRNAs) are molecules that contribute to gene expression modulation by regulating important cellular pathways. We herein used Next-Generation Sequencing to discover a series of circulating miRNAs detected in the blood samples of AIS patients, which yielded a unique miRNA biomarker signature that diagnoses AIS with high sensitivity and specificity. We propose that these miRNAs participate in the epigenetic control of signalling pathways by regulating osteoblast and osteoclast differentiation, thus modulating the genetic background of AIS patients. Our study yielded two relevant results: 1) evidence for the deregulated miRNAs that participate in osteoblast/osteoclast differentiation mechanisms in AIS; 2) this miRNA-signature can be potentially used as a clinical tool for molecular AIS diagnosis. Using miRNAs as biomarkers for AIS diagnostics is especially relevant since miRNAs can serve for early diagnoses and for evaluating the positive effects of applied therapies to therefore reduce the need of high-risk surgical interventions.

Prevalence of Vitamin D Deficiency in Pediatric Patients With Scoliosis Preparing for Spinal Surgery

BACKGROUND

Establishing prevalence of vitamin D deficiency in elective scoliosis surgery may impact clinical outcomes. The objectives of this study were to document vitamin D status of patients with scoliosis preparing for surgical intervention in order to establish frequency of deficiency and determine characteristics influencing levels.

METHODS

Records were queried for patients with scoliosis diagnosis who underwent posterior spinal fusion or initial growing rod placement and had serum vitamin 25 hydroxyvitamin D (D25) recorded in the preoperative period. Demographic data (gender, age, body mass index [BMI], race, scoliosis type, spine surgery procedure, and season of the year) were extracted. Chi-square analysis and multivariate modeling were used to evaluate deficiency status among various demographic categories and determine the demographic factors impacting D25.

RESULTS

A total of 217 patients with a mean age of 13.6 ± 3.6 years had vitamin D levels drawn a mean of 38.7 ± 20.6 days prior to surgery. The majority of the sample presented with a diagnosis of idiopathic scoliosis (n = 126), and most patients were scheduled for spinal fusion surgery (n = 192). Nearly 75% of the study population (n = 162) demonstrated D25 values below normal. African Americans presented with greater risk of deficiency (p < .0002) compared to Caucasians, as did patients preparing for spinal fusion versus growing rod placement (p < .03). Severe hypovitaminosis D was more common in winter than any other season (p < .005). Patients with neuromuscular scoliosis demonstrated significantly higher D25 levels over the idiopathic diagnosis type (p < .0002). Gender, BMI, and age did not impact D25.

CONCLUSION

Low D25 levels are reported in pediatric patients with scoliosis preparing for corrective spinal surgery. Population subsets most at risk for deficiency in this limited study include African American children, those presenting for spinal fusion surgery, and patients admitted in winter season.

Vitamin D receptor gene (VDR) transcripts in bone, cartilage, muscles and blood and microarray analysis of vitamin D responsive genes expression in paravertebral muscles of juvenile and adolescent idiopathic scoliosis patients

BACKGROUND

VDR may be considered as a candidate gene potentially related to idiopathic scoliosis susceptibility and natural history. Transcriptional profile of VDR mRNA isoforms might be changed in the structural tissues of the scoliotic spine and potentially influence the expression of VDR responsive genes. The purpose of the study was to determine differences in mRNA abundance of VDR isoforms in bone, cartilage and paravertebral muscles between tissues from curve concavity and convexity, between JIS and AIS and to identify VDR responsive genes differentiating juvenile and adolescent idiopathic scoliosis in paravertebral muscles.

METHODS

In a group of 29 patients with JIS and AIS, specimens of bone, cartilage, paravertebral muscles were harvested at the both sides of the curve apex together with peripheral blood samples. Extracted total RNA served as a matrix for VDRs and VDRl mRNA quantification by QRT PCR. Subsequent microarray analysis of paravertebral muscular tissue samples was performed with HG U133A chips (Affymetrix). Quantitative data were compared by a nonparametric Mann Whitney U test. Microarray results were analyzed with GeneSpring 11GX application. Matrix plot of normalized log-intensities visualized the degree of differentiation between muscular tissue transcriptomes of JIS and AIS group. Fold Change Analysis with cutoff of Fold Change ≥2 identified differentially expressed VDR responsive genes in paravertebral muscles of JIS and AIS.

RESULTS

No significant differences in transcript abundance of VDR isoforms between tissues of the curve concavity and convexity were found. Statistically significant difference between JIS and AIS group in mRNA abundance of VDRl isoform was found in paravertebral muscles of curve concavity. Higher degree of muscular transcriptome differentiation between curve concavity and convexity was visualized in JIS group. In paravertebral muscles Tob2 and MED13 were selected as genes differentially expressed in JIS and AIS group.

CONCLUSIONS

In Idiopathic Scolioses transcriptional activity and alternative splicing of VDR mRNA in osseous, cartilaginous, and paravertebral muscular tissues are tissue specific and equal on both sides of the curve. The number of mRNA copies of VDRl izoform in concave paravertebral muscles might be one of the factors differentiating JIS and AIS. In paravertebral muscles Tob2 and Med13 genes differentiate Adolescent and Juvenile type of Idiopathic Scoliosis.

Posterior spinal fusion in adolescent idiopathic scoliosis with or without intraoperative cell salvage system: a retrospective comparison

This study investigates efficacy and safety of routine cell salvage system use in adolescent idiopathic scoliosis patients undergoing primary posterior spinal fusion surgery with segmental spinal instrumentation. Forty-five consecutive adolescent idiopathic scoliosis patients undergoing posterior spinal fusion by two surgeons at a single hospital were studied. Intraoperative cell salvage system was used in 23 patients, and the control group was 22 patients who underwent surgery without cell salvage system. The cell salvage system was the Haemonetics Cell Saver 5. The primary outcome measures were intraoperative and perioperative allogeneic transfusion rate, difference between preoperative and discharge Hg and Hct levels. Average patient age was 14.65 ± 1.49 in cell saver group and 13.86 ± 2.0 in control group. In cell saver group, average intraoperative autotransfusion was 382.1 ± 175 ml. Average perioperative allogeneic blood transfusion need was 1.04 ± 0.7 unit in cell saver group and 2.5 ± 1.14 unit in control group. No transfusion reactions occurred in either group. Average hemoglobin level in cell saver group was 10.7 ± 0.86 and average hemoglobin level in control group was 10.7 ± 0.82 on discharge. Cell saver reduces perioperative transfusion rate in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis.

Role of high central leptin activity in a scoliosis model created in bipedal amputated mice

Significantly lower circulating leptin level has been reported in adolescent idiopathic scoliosis (AIS) compared to healthy adolescents. It was hypothesized that leptin dysfunction might be involved in the etiopathogenesis of AIS. In this study, a scoliosis model of bipedal amputated mice with high central leptin activity was established to validate this hypothesis. Three days after bipedal amputation, the mice were randomly divided into two groups: then 8 mice were injected in the hypothalamus with lentivirus vectors which expressed leptin, whereas the remaining 8 were injected with lentivirus vectors expressing GFP (control vector). X-rays were obtained at 20th week to determine the development of spinal deformity. After that all mice were sacrificed, and blood samples were collected. Then peripheral leptin levels were measured by an ELISA kit. Comparisons for the incidence of scoliosis and the severity of the curves were performed between groups. The body weight was found to be slightly lower in the leptin-vector-treated C3H/HeJ mice when compared with control mice. Significantly higher peripheral serum leptin level was found in leptin-vector-treated mice than control mice. Scoliosis was observed in all leptin-vector-treated mice with an average Cobb angle of 28.2°, and in 4/8 of control with an average Cobb angle of 23.5°. The incidence of scoliosis was significantly higher in leptin-vector-treated mice than in control group, although no significant difference was found in terms of curve severity. The results of this study indicated that the high central leptin activity might not only increase the risk of developing a scoliosis in bipedal mice but also contribute to the progression of scoliosis. The high central leptin activity might play an important role in the etiopathogenesis of scoliosis.

Activity of platelet hemostasis in children with spinal deformities

An increase of adhesion and aggregation functions of platelets in vivo and in vitro was detected in 5-6-year-old children with scoliosis. These disorders were caused by hyperproduction of von Willebrand's factor in the vascular wall and intensification of thromboxane production in blood platelets. Activation of thromboxane formation is the main cause of platelet hyperactivity in children with scoliosis. Correction of platelet hemostasis may include pathogenetically substantiated complex of therapeutic exercises, swimming, and massage.

[Decreased circulating matrilin-1 levels in adolescent idiopathic scoliosis]

OBJECTIVE

To determine the circulating matrilin-1 levels in adolescent idiopathic scoliosis (AIS), and to investigate its potential role in etiopathogenisis of AIS.

METHODS

This study population consisted of 25 patients with AIS from June 2006 to March 2007 and 25 age-matched normal controls. All subjects of the study met the following criteria: no evidence of bone diseases, metabolic diseases or growth disturbances; no evidence of systemic illness or other condition known to affect bone metabolism; and no history of recent steroid intake and surgery of congenital cardiopathy. The maximum Cobb angle and curve pattern of AIS group were recorded. All AIS patients were categorized by progressive and non-progressive groups. Progression to a severe curve was defined per usual clinical criteria (progression to a > 40 degrees curve in an individual still growing or progression to a > 50 degrees curve in an adult). Measurements of genotype by PCR-RFLP methods and circulating matrilin-1 by ELISA assay were performed in both AIS and control groups. The circulating matrilin-1 levels were compared between AIS and control groups, and also among different genotype individuals. The relationship between matrilin-1 levels and cure progression were also analyzed.

RESULTS

Compared with control group, a marked decrease of plasma matrilin-1 levels was found in AIS groups (P = 0.0002). Matrilin-1 levels of both AIS and control groups with GG genotype tended to be lower than with AA and AG genotypes, and this trend was stronger in AIS groups. Compared with non-progressive AIS group, plasma matrilin-1 levels in progressive AIS group were significantly lower.

CONCLUSIONS

There is an association between matrilin-1 levels and curve progression. Measurement of circulating matrilin-1 levels is helpful for early screening and diagnosis of AIS, and it may be considered as an independent index to predict curve progression.

Human platelet Ca2+-ATPases: New markers of cell differentiation as illustrated in idiopathic scoliosis

The aetiology of adolescent idiopathic scoliosis (AIS), the most common form of scoliosis, is unclear. Previous studies showed controversial platelet abnormalities including intracellular calcium. Platelet Ca2+ homeostasis is controlled by a multi-Ca2+-ATPase system including SERCA (sarco/endoplasmic reticulum Ca2+-ATPase) and PMCA (plasma membrane Ca2+-ATPase) isoforms. Here, we first investigated the expression of PMCA4b, SERCA3a and SERCA2b isoforms in platelets of 17 patients with AIS. Patients presenting thoracic curves were found to present a higher PMCA4b expression coupled to a lower SERCA3a one in agreement with an abnormality in platelet maturation. Indeed, using PMA-treated MEG 01 cells, an in vitro model of megakaryocytopoiesis, we found an increase in SERCA3a expression, associated to a caspase-3 mediated C terminal proteolysis of PMCA4b. To look whether platelets reflect a basic defect in cell differentiation, we next identified osteoblast Ca2+-ATPases and studied their expressions in AIS. Major expressions of PMCA4b and SERCA2b were found in normal osteoblasts. Comparing platelets and osteoblasts in two additional patients with AIS, we found opposite and concerted regulations of the expressions of PMCA4b and caspase-3 substrate, PARP in both cell types. A systemic defect in cell differentiation involving caspase-3 can be proposed as a novel mechanism in the etiopathogenesis of the most frequent type of AIS. *R. Bredoux and E. Corvazier contributed equally to this work.

Serum melatonin levels in adolescent idiopathic scoliosis prediction and prevention for curve progression--a prospective study

The correlation of serum melatonin levels and curve progression in adolescent idiopathic scoliosis, and the effects of melatonin therapy in scoliotic patients with reduced levels of endogenous melatonin were studied in 40 adolescent patients with moderate to severe idiopathic scoliosis. Of the scoliotic subjects, 28 had stable scoliosis and 12 had progressive scoliosis. Normal melatonin levels were derived from 25 age-matched control patients. Serum melatonin levels were monitored yearly in scoloiotic patients for a period ranging from 3 to 6 yr, revealing a diurnal pattern with low values during the day and high at night. Scoliotic patients with normal levels were not treated or were treated with a brace, and all but two patients with low endogenous melatonin were treated with oral supplements of the indole. Of the 22 patients with a normal melatonin level, 16 had stable scoliosis and six had progressive scoliosis. Of the 16 patients treated for a low melatonin level, 12 had stable scoliosis and four had a progressive course. The two untreated cases had a progressive course. Of the 12 patients who had progressive scoliosis, nine had >35 degrees of curve at initial examination. These findings suggest that melatonin deficiency plays a role in the prognosis of idiopathic scoliosis. Therefore, melatonin supplements may prevent the progression of scoliosis, especially in mild cases with less than a 35 degrees curve.

The concentrations of testosterone and estradiol in girls with adolescent idiopathic scoliosis

AIM

The role of hormones in development and progression of scoliosis, although suggested, remains unclear. The purpose of this study was to evaluate the level of steroid sex hormones in girls with adolescent idiopathic scoliosis (AIS).

METHODS

A group of 27 girls, aged 12-17 years (mean+/-SD = 14.8+/-1.5 years) in whom right thoracic scoliosis was diagnosed (Cobb angle was from 10 degrees to 55 degrees, mean+/-SD = 30+/-13.8 degrees; Risser test was in the range from 2 to 4, mean+/-SD = 3.7+/-0.2) was examined. The control group included 7 girls, aged 13-17 years (mean+/-SD = 14.3+/-1.8 years) with slight lumbar functional scoliosis 10 degrees to 20 degrees to the left (mean+/-SD = 11.4+/-3.8 degrees). In both groups the concentrations testosterone was tested on 8th day of menstrual cycle, whereas estrogen concentrations were measured on 8th and 20th day of the cycle.

RESULTS

Increased testosterone level above the reference values was found in girls with AIS. The observed differences in both groups in estrogen levels in folicular and luteal phase were not statistically significant.

CONCLUSIONS

Possibly, the evaluation of testosterone level could be an important prognostic factor for scoliosis progression. The studies to be continued.

Elevated soluble receptor activator of nuclear factor-kappaB ligand and reduced bone mineral density in patients with adolescent idiopathic scoliosis

Generalized low bone mass and osteopenia in both axial and peripheral skeleton in adolescent idiopathic scoliosis (AIS) have been reported in literature. However, the exact mechanisms and causes of the bone loss in AIS are not identified yet. Therefore, this study examined the relationship between serum concentration of soluble receptor activator of nuclear factor-kappaB ligand (RANKL), serum level of osteoprotegerin (OPG) and bone mass in 72 patients with AIS and compared to those of 64 age- and gender-matched healthy controls. The mean lumbar spinal bone mineral density (LSBMD) and femoral neck BMD (FNBMD) in patients with AIS were decreased compared with that in control individuals, respectively (P = 0.0029 and P = 0.0192, respectively). The mean RANKL and RANKL to OPG ratio in patients with AIS were increased compared with that in control subjects, respectively (P = 0.0004 and P = 0.0032, respectively). The RANKL and RANKL to OPG ratios were negatively correlated to the LSBMD and serum OPG levels in both groups. Serum OPG levels were positively correlated to the LSBMD and FNBMD in both groups. These findings mean that the imbalance and the disturbed interaction of RANKL and OPG may be an important cause and pathogenesis in reduced BMD in AIS.

[Association between circulating leptin level and anthropometric parameters in girls with adolescent idiopathic scoliosis]

OBJECTIVE

To investigate the correlation between the circulating leptin level and the anthropometric parameters and parameters related to pubertal growth, and to explore the role of leptin in the abnormal growth pattern in girls with adolescent idiopathic scoliosis (AIS).

METHODS

One hundred and twenty AIS girls selected randomly from the out-patient and in-patient departments, divided into 2 groups: Group A1 (n = 73, aged 10 - 13) and Group A2 (n = 47, aged 14 - 17), and 80 14 - 17 year-old healthy girl students receiving physical examination underwent measurement of body height and weight. Body mass index (BMI) was calculated. Peripheral fasting blood samples were collected to detect the level of leptin. The anthropometric data, pubertal status, and circulating leptin level were compared between the AIS girls and the controls. The relationships between leptin and age, menstrual status, body weight, height, BMI and Risser sign were analyzed in the AIS girls.

RESULTS

Eighty-eight AIS girls (73%) and 14 healthy girls (18%) had a BMI score less than 18.0. The mean leptin level of Group A1 was 6.2 microg/L, significantly lower than of Group A2 (8.6 microg/L, P = 0.024). Compared with the healthy controls, the AIS girls had significantly greater corrected height (162.7 cm vs. 160.2 cm, P = 0.026), lower weight (44.3 kg vs. 53.6 kg, P = 0.01), lower BMI (17.5 kg/m(2) vs. 20.9 kg/m(2), P = 0.01), and lower circulating leptin (8.6 microg/L vs. 14.9 microg/L), even after the adjustment for age and menstrual status. An inverse correlation was observed between the leptin level and the age at menarche (AIS, r = -0.428, P < 0.001; controls, r = -0.280, P = 0.013). Whereas, positive correlations were found between leptin and age, menstrual status, body weight, height, BMI, and Risser sign (r = 0.234 - 0.506, P = 0.01 - < 0.001).

CONCLUSION

AIS girls have markedly decreased circulating leptin level. Circulating leptin level is associated with body weight, BMI, and other growth parameters, suggesting that leptin may play an important role in the lower body mass in AIS girls.

Fibrinogen levels following Amicar in surgery for idiopathic scoliosis

STUDY DESIGN

Prospective evaluation of fibrinogen levels before surgery and after surgery in patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) who received Amicar to decrease perioperative blood loss.

OBJECTIVES

To assess a possible association between postoperative fibrinogen levels and Amicar administration.

SUMMARY OF BACKGROUND DATA

Our previous randomized, double-blind (Amicar and control) study demonstrated a rise in fibrinogen levels on the first postoperative day in the Amicar group, but not in the control group. Fibrinogen levels were not measured on the remaining postoperative days. We subsequently measured fibrinogen levels on all postoperative days in 21 consecutive patients with idiopathic scoliosis and found a dramatic increase throughout the postoperative hospitalization. This study is a continuation of our analysis of postoperative fibrinogen levels.

METHODS

We analyzed fibrinogen levels before surgery and on all postoperative days (4 or 5 days) until discharge in 51 consecutive patients, including our 21 previously reported patients, who received Amicar and underwent a PSF and SSI. We also analyzed the same factors with respect to perioperative blood loss as in our previous Amicar studies.

RESULTS

There were 41 females and 10 males with a mean age at surgery of 14.2 +/- 1.8 years. Their mean hospitalization was 4.6 +/- 0.8 days. Their mean estimated intraoperative blood loss was 766 +/- 308 mL and postoperative suction drainage 532 +/- 186 mL for a total perioperative blood loss of 1297 +/- 311 mL. The perioperative transfusion requirements were 0.5 +/- 0.6 U per patient. The preoperative fibrinogen was 255.5 +/- 58.3 mg/dL, and it rose steadily throughout the postoperative period to 680.9 +/- 111.9 mg/dL on the fifth postoperative day. There were no complications related to the use of Amicar.

CONCLUSIONS

Fibrinogen levels rise steadily throughout the postoperative period. The significance of this increase is unknown. Was it due to the use of Amicar or just the effects of surgery itself? Further investigations will be necessary.

Correlates of the peak height velocity in girls with idiopathic scoliosis

STUDY DESIGN

Prospective longitudinal.

OBJECTIVE

Determine correlates of the peak height velocity (PHV) in girls with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Only identifiable retrospectively, the PHV is the most useful known maturity marker in idiopathic scoliosis. Clinically useful correlates are needed to make PHV timing helpful.

METHODS

A total of 24 immature girls with idiopathic scoliosis were followed with serial heights, sexual staging, skeletal ages, spinal radiographs, insulin-like growth factor (IGF)-1, IGF binding protein-3, dehydroepiandrosterone sulfate, estradiol, bone-specific alkaline phosphatase, and osteocalcin levels. These markers were correlated to PHV timing.

RESULTS

There were 14 girls who had identifiable growth peaks that averaged 10.5 +/- 1.8 cm/y at age 11.7 +/- 1 years. At the PHV, all girls were Risser 0 with open triradiate cartilages. On a skeletal age radiograph, digital uncapped phalangeal epiphyses were indicative of pre-PHV and fused epiphyses of post-PHV. Capped but unfused epiphyses were indeterminate. Tanner stage 1 for breast strongly indicates pre-PHV. Stage 3 for breast and pubic hair occurred at or after the PHV, and stage 4 always occurred after PHV. Higher IGF-1 and estradiol levels after PHV are potentially discriminatory.

CONCLUSIONS

The PHV occurs during Risser 0 with open triradiate cartilages. If triradiate cartilages are open, then Tanner stages, IGF-1, estradiol levels, and the appearance of the epiphyses on a skeletal age radiograph are useful in determining status before or after PHV.

Changes in melatonin receptors in relation to the development of scoliosis in pinealectomized chickens

STUDY DESIGN

The 2[125I]iodomelatonin binding assay was used to investigate the involvement of melatonin receptors in the development of scoliosis in pinealectomized chickens.

OBJECTIVE

To compare the binding properties of melatonin receptors in the thoracic spinal cord between pinealectomized chickens that had scoliosis develop and those that did not.

SUMMARY OF BACKGROUND DATA

Surgical pinealectomy in young chickens induced scoliosis with a reported incidence of 50% to 100%. The factors regulating the development of scoliosis in this animal model are unclear. Melatonin receptors have been shown in the spinal cord of chickens, but their functions are still unknown. This study addresses the question as to whether spinal cord melatonin receptors are related to the pathogenesis of scoliosis in pinealectomized chickens.

METHOD

Control and pinealectomized chickens were kept under controlled lighting conditions and monitored for scoliosis development. At 9-11 weeks after pinealectomy, thoracic spinal cords were removed for 2[125I]iodomelatonin binding assay, and blood was collected for serum melatonin assay at either the middle of the light period or middle of the dark period.

RESULTS

Pinealectomy in young chickens produced: (1) loss of diurnal variations in serum melatonin levels, (2) 50% incidence of scoliosis, and (3) attenuation in the diurnal variations in the receptor affinity to melatonin. No differences were detected in the serum melatonin levels or binding of spinal cord melatonin receptors between the pinealectomized chickens that had scoliosis develop and those that did not.

CONCLUSION

Changes are detected in melatonin receptor binding after pinealectomy. However, these changes cannot account for the reason why scoliosis develops in some chickens after pinealectomy, while it does not in others. Neither low melatonin serum level nor changes in spinal cord melatonin binding can be a sole etiologic factor in the pathogenesis of scoliosis in pinealectomized chickens.

Recombinant coagulation factor VIIa--a novel haemostatic agent in scoliosis surgery?

Spinal fusion surgery in children and adolescents with idiopathic scoliosis is often associated with severe haemorrhage. Recombinant coagulation factor VIIa (rFVIIa) has previously been shown to be an effective haemostatic treatment for severe bleeding associated with a variety of coagulopathic and non-coagulopathic indications. The aim of this retrospective study was to assess the safety and haemostatic efficacy of rFVIIa in a series of 26 consecutive adolescent patients with scoliosis (22 females; mean age 16.6 years) undergoing correctional surgery. A second series of 26 consecutive patients (20 females; mean age 16.2 years) who received standard therapy during surgery, represented historical controls. Blood loss, transfusion requirements, duration of surgery, and peri-operative measurements of coagulation parameters were compared between the two groups. Intra-operative and combined intra-operative and post-operative blood losses were significantly smaller in the rFVIIa-treatment group than in the historical controls (P=0.003 and 0.032, respectively); rFVIIa-treated patients also demonstrated significantly reduced blood loss per vertebral segment fused (P=0.032) and per hour of surgery (P<0.001). Intra-operative requirements for packed red blood cells were also significantly lower in the treatment group (P=0.042). Patients in the treatment group demonstrated rapid and maintained reduction of prothrombin time and international normalised ratio; values among rFVIIa-treated patients remained significantly lower than those in the control group at all time points evaluated (P<0.001). There were no deaths and no adverse events. These results suggest that rFVIIa is a safe and effective haemostatic agent for use during spinal fusion surgery in adolescent patients with idiopathic scoliosis; however, further research and randomised, placebo-controlled trials are needed to confirm these findings.

Platelet calmodulin levels in adolescent idiopathic scoliosis (AIS): can they predict curve progression and severity? Summary of an electronic focus group debate of the IBSE

There is no generally accepted scientific theory for the etiology of idiopathic scoliosis. As part of its mission to widen understanding of scoliosis etiology, the International Federated Body on Scoliosis Etiology (IBSE) introduced the electronic focus group (EFG) as a means of increasing debate of extant knowledge on important topics. This has been designated as an on-line Delphi discussion. The text for this EFG was written by Professor Thomas G Lowe MD and drawn from research carried out by himself and his co-workers on platelet calmodulin levels in patients with adolescent idiopathic scoliosis. To explain the relationship of platelet calmodulin levels to scoliosis curve changes in AIS brought about spontaneously, by brace treatment, or surgery Dr Lowe attributes the platelet calmodulin changes to paraspinous muscle activity and suggests that the calmodulin acts as a systemic mediator of tissues having a contractile system (actin and myosin). Controversy includes: 1) the lack of normal data and the large variability in baseline levels of platelet calmodulin, necessitating the use of the AIS subjects as their own controls; 2) calmodulin is not usually used as a marker of platelet activation; 3) whether the platelet calmodulin changes which appear to reflect an abnormality of a portion of the spine are related to local and/or regional changes in muscles, nervous system, or immature vertebrae. What is not controversial is the need for more research on platelets and the immature deforming skeleton in relation to etiology and prognosis.

Effect of melatonin suppression on scoliosis development in chickens by either constant light or surgical pinealectomy

STUDY DESIGN

This study was designed to compare the effect of suppression of melatonin secretion by bright light in chickens with that of surgical pinealectomy.

OBJECTIVE

To determine whether suppression of melatonin secretion without surgery in chickens can result in scoliosis development.

SUMMARY OF BACKGROUND DATA

Pinealectomy in chickens consistently produces scoliosis with anatomic characteristics similar to those of human idiopathic scoliosis. Conversely, cutting of the pineal stalk without removal of the pineal gland will also result in scoliosis. This study addresses the question of whether constant bright light can induce scoliosis formation, because it is well known that 24-hour bright lighting conditions can suppress the secretion of melatonin to an equivalent level as pinealectomy.

MATERIALS AND METHOD

Seventy-seven newborn Nihon chickens were separated into three groups. A control group (n = 21) with no surgery performed; a pinealectomy group (n = 15) that served as surgical controls; and a constant light group (n = 41). The first two groups were kept together in a strict 12-hour light-dark cycle, whereas the third group was separately kept with constant lighting conditions (>100 lux). All the chickens were radiographed at two weekly intervals, and blood was taken during the middle of the light and dark cycles for serum melatonin assay using ELISA.

RESULTS

Fifty-four percent of the pinealectomized chickens had scoliosis develop by 6 weeks. None of the constant-light chickens or controls had scoliosis develop for up to 11 weeks. Measurements of serum melatonin levels of the constant light group confirm that secretion is suppressed.

CONCLUSION

This study suggests that for scoliosis to develop in chickens, the surgical operation itself is important and challenges the role of melatonin as an isolated etiological factor in the development of scoliosis.

Idiopathic scoliosis and concentrations of zinc, copper, and selenium in blood plasma

The concentration of zinc, copper, selenium, albumin, and ceruloplasmin in blood plasma and the activity of superoxide dismutase and glutathione peroxidase in erythrocytes were determined in a set of patients with idiopathic scoliosis (n=51). A significant decrease of selenium concentration (0.50 +/- 0.16 micromol/L) was found when compared with a control group (0.69 +/- 0.07 micromol/L) (p<0.01). The same levels of significance were found out for selenium levels corrected for albumin content. In a group of patients with a curvature over 45 degrees indicated for a surgical correction, the average plasma concentrations of selenium were significantly lower (p < 0.05) in comparison with a group of patients with a curvature below 45 degrees treated conservatively. The GSH-Px activity in erythrocytes was the same in both sets. In comparison with the controls, no significant differences were revealed in all of the other parameters. The detection of the decreased blood plasma concentration of selenium has suggested possible disturbance of well-proportioned distribution and of general optimal availability of selenium in the organism of patients with idiopathic scoliosis with likely effects on the process of synthesis and maturation of collagen affecting the axial skeleton stability.

Jet ventilation for anterior paediatric scoliosis surgery

Single-lung anaesthesia for thoracotomy is usually achieved with endobronchial intubation, a double-lumen tube or an endobronchial blocker. High-frequency jet ventilation (HFJV) is seldom described for thoracotomy in children, although it is used for both laryngology procedures in the operating room and as a ventilation mode in intensive care. HFJV was used in three children, aged 10-12 years, who presented for scoliosis correction involving thoracotomy. The jet ventilation catheter was passed through a tracheal tube to reduce the risk of outflow obstruction and allow a smooth conversion to intermittent positive-pressure ventilation when required. Mean airway pressures measured at the tip of the HFJV catheter were at or below 4 cmH2O. Surgical opening of the nondependent lung pleura resulted in sufficient collapse of the pulmonary parenchyma with the patient in the lateral decubitus position for the surgical procedure. Arterial blood gas analyses performed during thoracotomy were within normal limits, with no CO2 retention. HFJV is an alternative ventilation strategy for thoracotomy in children because of its unique ability to deliver small tidal volumes at low mean airway pressures via a narrow catheter.

Scoliosis correction with shape-memory metal: results of an experimental study

The biocompatibility and functionality of a new scoliosis correction device, based on the properties of the shape-memory metal nickel-titanium alloy, were studied. With this device, the shape recovery forces of a shape-memory metal rod are used to achieve a gradual three-dimensional scoliosis correction. In the experimental study the action of the new device was inverted: the device was used to induce a scoliotic curve instead of correcting one. Surgical procedures were performed in six pigs. An originally curved squared rod, in the cold condition, was straightened and fixed to the spine with pedicle screws. Peroperatively, the memory effect of the rod was activated by heating the rod to 50 degrees C by a low-voltage, high-frequency current. After 3 and after 6 months the animals were sacrificed. The first radiographs, obtained immediately after surgery, showed in all animals an induced curve of about 40 degrees Cobb angle - the original curve of the rod. This curve remained constant during the follow-up. The postoperative serum nickel measurements were around the detection limit, and were not significantly higher compared to the preoperative nickel concentration. Macroscopic inspection after 3 and 6 months showed that the device was almost overgrown with newly formed bone. Corrosion and fretting processes were not observed. Histologic examination of the sections of the surrounding tissues and sections of the lung, liver, spleen and kidney showed no evidence of a foreign body response. In view of the initiation of the scoliotic deformation, it is expected that the shape-memory metal based scoliosis correction device also has the capacity to correct a scoliotic curve. Moreover, it is expected that the new device will show good biocompatibility in clinical application. Extensive fatigue testing of the whole system should be performed before clinical trials are initiated.

Correlation between the age of pinealectomy and the development of scoliosis in chickens

STUDY DESIGN

Pinealectomy induces experimental scoliosis in chickens. This study analyzed the correlation between the age at which pinealectomy was performed and the development of scoliosis in chickens.

OBJECTIVE

To investigate the differences in the rate or magnitude of scoliosis and the type of curvature in chickens pinealectomized at different times after hatching.

SUMMARY OF BACKGROUND DATA

Scoliosis develops in almost all chickens pinealectomized within 3 days after hatching, but there are no data on whether the condition will develop in chickens pinealectomized earlier or later after hatching.

METHODS

In this study, 106 female white leghorn chickens were divided into six groups: four pinealectomy groups (pinealectomy was performed 2, 4, 11, or 18 days after hatching in Groups P-2, P-4, P-11, and P-18, respectively), a control group (Group C), and a sham operation group (Group S). Ventrodorsal radiographs of the spine were taken at 4-week intervals until the age of 12 weeks. At 12 weeks, a 1-mL sample of blood was taken from the heart at the middle of the dark cycle, and the serum melatonin concentration was measured by radioimmunoassay.

RESULTS

At the age of 12 weeks, scoliosis was present in 63.6% of the chickens in Group P-2, 72.7% in Group P-4, 81% in Group P-11, and 70% in Group P-18, and the Cobb angles in the scoliotic chickens averaged 32.6, 29.8, 23.8, and 22.3 degrees in the respective groups. There were no significant differences in the rate or magnitude of scoliosis and the type of curvature among the pinealectomy groups at the age of 12 weeks. At the age of 12 weeks, the serum melatonin levels at the middle of the dark cycle in the pinealectomized chickens were significantly lower than those of chickens in Groups C and S. However, there were no differences in the serum melatonin levels between scoliotic and nonscoliotic pinealectomized chickens.

CONCLUSIONS

Findings from this study show that scoliosis develops in 60% to 80% of chickens pinealectomized within 18 days after hatching, and that scoliotic development is not influenced by the age at which pinealectomy is performed. However, this study suggests that melatonin plays a complicated role in spinal development, inasmuch as the serum melatonin levels after pinealectomy approximated zero. Yet scoliosis did not develop in all pinealectomized chickens.

Pineal transplantation after pinealectomy in young chickens has no effect on the development of scoliosis

STUDY DESIGN

Three experimental groups and one control group of chickens underwent different surgical procedures to determine the effects of pineal gland transplantation on the development of scoliosis.

OBJECTIVE

To determine whether transplantation of the pineal gland to the body wall musculature maintains serum melatonin levels at normal values and prevents the development of scoliosis.

SUMMARY OF BACKGROUND DATA

Scoliosis occurs consistently after pinealectomy in young chickens. Many characteristics of this scoliosis are similar to those seen in patients with adolescent idiopathic scoliosis. It is not clear whether the underlying mechanism is dependent on reduced levels of serum melatonin or some other aspect of the extensive surgery.

METHODS

Four groups of chickens were selected: normal chickens, pinealectomized chickens, chickens that underwent simple cutting of the pineal stalk, and chickens that underwent transplantation of the pineal gland into the body wall. Development of scoliosis was determined from measurement of the Cobb angle from weekly radiographs.

RESULTS

All of the experimental groups showed the same levels of incidence and the same patterns of scoliosis development. Serum melatonin levels were reduced to nearly zero in all the experimental groups for the duration of the experiment. Scoliosis developed in none of the normal chickens.

CONCLUSIONS

Neither transplantation of the pineal gland into the body wall musculature nor simple cutting of the pineal stalk was able to maintain normal levels of serum melatonin because both procedures reduced levels to nearly zero. The incidence and pattern of scoliosis development in these groups were the same as those for the pinealectomized group. Reduction of serum melatonin levels remains a prerequisite for scoliosis development in young chickens.

The critical stage of pinealectomy surgery after which scoliosis is produced in young chickens

STUDY DESIGN

Stages of the surgical procedure for pinealectomy in chickens were identified. Groups of chickens were selected for each stage. Scoliosis development was identified from radiographs.

OBJECTIVES

To determine the critical stage of surgery for pinealectomy after which scoliosis develops in young chickens.

SUMMARY OF BACKGROUND DATA

Pinealectomy in young chickens consistently produces scoliosis in young chickens that has many characteristics similar to those seen in patients with adolescent idiopathic scoliosis. The mechanism behind this phenomenon remains unknown.

METHODS

Five distinct stages in the pinealectomy surgery were identified. Groups of chickens were selected to undergo surgery to represent these five stages. Scoliosis was determined from weekly radiographs.

RESULTS

Cutting the pineal stalk was identified as the critical stage in the surgery after which scoliosis developed. The incidence of scoliosis did not increase after more extensive surgery in which the pineal bulb was removed from the skull. This stage was also correlated with a significant reduction of serum melatonin levels.

CONCLUSIONS

Cutting the pineal stalk was identified as the critical stage of pinealectomy surgery after which scoliosis may develop. This stage was also correlated with the significant reduction of average serum melatonin levels. These results allow the focus of attention into the mechanism behind this phenomenon to center on the consequences of cutting the pineal stalk rather than total removal of the pineal gland.

[Metabolic indices for the bone tissue organic base metabolism and its mineral metabolism in patients with scoliosis]

The biochemical findings secured in the examination of 55 pediatric patients presenting with a progressing form of scoliosis suggested to us abnormalities of metabolism in the osseous tissue organic base and of the mineral metabolism. Indices capable of reflecting in the most unbiassed fashion the osseous tissue metabolic states include Ca/Cr, Ca/fr OP, Ph/Cr, Ph/fr OP ratios. Collagen and mineral metabolic disturbances result in structural changes in the vertebral osseous tissue organic base that may have an important part in the development of scoliotic disease.

Adolescent idiopathic scoliosis. Is low melatonin a cause?

BACKGROUND

Although the cause of adolescent idiopathic scoliosis remains unclear, pinealectomy is followed by the development of scoliosis in chickens. Melatonin is the only hormone secreted by pineal gland.

OBJECTIVE

To assess serum melatonin levels in adolescents with idiopathic scoliosis.

METHODS

Serum melatonin was assayed once, at 12:00 hours, in each of 20 adolescents with idiopathic scoliosis and 10 age-matched siblings. In the patient group, mean age was 14.3 years and the mean Cobb angle was 54.5 degrees (range, 20 degrees-110 degrees). Mean age in the control group was 14 years.

RESULTS

Serum melatonin was significantly lower in the patients (mean, 7.7 pg/mL; range, 4 to 13 pg/mL) than in the controls (mean, 29.9 pg/mL; range, 19.3 to 46 pg/mL) (P < 0.00001). The 12 surgically treated patients had a mean melatonin level of 8.1 pg/mL, versus 7.2 pg/mL in the eight other patients (nonsignificant P and regression coefficient values). Serum melatonin was not significantly correlated with the Cobb's angle (regression coefficient, 0.18; P < 0.44).

CONCLUSION

Our data suggest that serum melatonin levels may contribute to the pathogenesis of idiopathic scoliosis.

Fibrinogen, fibrin and its degradation products in drained blood after major orthopaedic surgery

The aim of this study was to evaluate the fibrinogen enzymatic conversion in blood collected postoperatively from a surgical wound. Ten otherwise healthy patients (aged 11-28 years) in need of surgical treatment for thoracic scoliosis were included in the study. Arterial blood preoperatively and at wound closure were compared with samples of drained blood from the wound at closure and from a collection system for autologous transfusion 2.8 +/- 1.1 h later. There was a decrease in the fibrinogen content in arterial blood from 2.17 +/- 0.35 g/l to 1.23 +/- 0.42 g/l, which followed a 40% haemodilution estimated from the blood loss of 1.6 +/- 0.9 l during the operation. Drained blood contained high concentrations of D-dimer (85 +/- 53 mg/l from the wound and 121 +/- 47 mg/l from the collection system), but no clottable fibrinogen. The Western immunoblots all visualized the same patterns; in drained blood there were split-products mainly from cross-linked fibrin, in contrast to arterial blood which contained only normal fibrinogen. This indicates a strong fibrinolysis in the surgical wound after closure, with concentrations of fibrin degradation products that may impair local coagulation, and if infused, might interfere with general haemostasis.

Effects of deamino-8-D-arginin vasopressin on blood loss and coagulation factors in scoliosis surgery. A double-blind randomized clinical trial

STUDY DESIGN

A double-blind, randomized, prospective clinical study was performed to evaluate the efficacy of deamino-8-D-arginin vasopressin in reducing blood loss in major scoliosis surgery.

OBJECTIVES

To evaluate whether desmopressin has any effect on reducing blood loss in spinal surgery, to identify the probable mechanisms of effectiveness via blood coagulation factors, and to outline any adverse effect associated with the use of deamino-8-D-arginin vasopressin.

SUMMARY OF BACKGROUND DATA

Scoliosis surgery is known to be associated with major blood loss. Because of major drawbacks of homologous blood transfusion, many alternative methods have been used to counter the blood loss. Only a few studies exist, with controversial results, on the use of deamino-8-D-arginin vasopressin.

METHODS

The study population included 40 operations on 35 consecutive patients undergoing reconstructive surgery for either idiopathic (n = 26) or congenital (n = 9) scoliosis. Operations were randomized into deamino-8-D-arginin vasopressin (0.3 microgram/kg body weight; maximum, 20 micrograms) (n = 18) or placebo (n = 22) groups and stratified according to the diagnosis and the type of surgery performed (i.e., anterior versus posterior versus anterior and posterior sequential). Parameters of blood loss, serum levels of blood coagulation factors at different time intervals, and urinary output were measured.

RESULTS

Findings indicated that blood loss per kilogram of body weight, blood loss per surgically treated spinal level, urinary output per kilogram of body weight and serum levels of fibrinogen, von Willebrand factor (vWF) activity, tissue type plasminogen activator activity, and plasminogen activator inhibitor activity were not sensitive to the administration of deamino-8-D-arginin vasopressin at any time interval during surgery or at 24 hours after surgery (P > 0.05). Only factor VIII:C levels exhibited significant elevations at 30 minutes and at 24 hours (P < 0.05).

CONCLUSIONS

This study could not demonstrate any significant effect of deamino-8-D-arginin vasopressin on the amount of blood loss in a group of patients with idiopathic or congenital scoliosis. Findings indicate that for most of the coagulation factors, any changes in serum levels induced by deamino-8-D-arginin vasopressin were much like those expected from surgery itself. This study also failed to demonstrate any significant effects altering the urinary output that may be attributed to the use of deamino-8-D-arginin vasopressin.

The cytokines IL-1beta and IL-1 receptor antagonist, IL-2 and IL-2 soluble receptor-alpha, IL-6 and IL-6 soluble receptor, TNF-alpha and TNF soluble receptor I, and IL10 in drained and systemic blood after major orthopaedic surgery

OBJECTIVE

To measure the concentration of the cytokines interleukin-1beta (IL-1beta), interleukin-2 (IL-2), interleukin-6 (IL-6), interleukin-10 (IL-10), and tumour necrosis factor-alpha (TNF-alpha) and the modulators of their function interleukin-1 receptor antagonist (IL-1Ra), interleukin-2 soluble receptor alpha (IL-2 sRalpha), interleukin-6 soluble receptor (IL-6sR) and soluble tumour necrosis factor receptor I (sTNFR-I) in systemic and drained blood for the first six hours after a major orthopaedic operation.

DESIGN

Prospective study.

SETTING

University hospital, Oslo.

PATIENTS

8 patients operated on for thoracic scoliosis.

MAIN OUTCOME MEASURE

Concentrations of IL-1beta, IL-2, IL-6, IL-10, TNF-alpha, IL-1Ra, IL-2 sRalpha , IL-6sR, and sTNFR-I were measured together with haemoglobin (Hb) concentration, white cell count (WCC), and differential count in arterial and drained blood at wound closure and 1, 2, 4, and 6 hours postoperatively.

RESULTS

IL-1beta and IL-6 concentrations increased significantly in drained blood, whereas that of TNF-alpha increased only in arterial blood. The modulating factors IL-1Ra, sTNFR-I, and IL-10 were increased both in arterial and drained blood. IL-6sR had decreased slightly at 6 hours in drained blood. No IL-2 was found and IL-2 sRalpha decreased simultaneously with the haemodilution. In arterial blood there was a granulocytosis and in drained blood a relative lymphocytosis.

CONCLUSION

Cytokine responses to surgical trauma include modulating factors such as soluble receptors and receptor antagonists that have different responses systemically and locally.

Complement activation and increased systemic and pulmonary vascular resistance indices during infusion of postoperatively drained untreated blood

In nine healthy young patients, operated on for thoracic scoliosis, a pulmonary artery catheter was inserted for the study of haemodynamic variables and blood sampling during autologous transfusion of postoperatively drained blood. At 1-3 h after wound closure, 10 ml kg/body weight of drained untreated blood from the wound was collected and recirculated over a l-h period. The concentration of the complement activation product, C3bc, increased from a mean of 5.4 (SD 1.5) AU ml-1 before infusion to 11.1 (3.9) AU ml-1 during infusion and then returned to 7.8 (2.8) AU ml-1 after infusion. The concentration of the terminal complement complex (TCC) increased from 0.5 (0.2) to 1.3 (0.5) AU ml-1 and was reduced to 0.7 (0.3) AU ml-1 after infusion. Only TCC exceeded the reference values which are 14 AU ml-1 for C3bc and 1.0 AU ml-1 for TCC. Pulmonary vascular resistance index concomitantly increased from a mean of 130 (SD 52) to 195 (88) dyn s cm-5 m-2 and was reduced to 170 (86) dyn s cm-5 m-2 after infusion. Systemic vascular resistance index increased from a mean of 1238 (SD 403) to 1349 (473) dyn s cm-5 m-2 and returned to 1196 (401) dyn s cm-5 m-2 after infusion. White blood cell count (WCC) increased from 14.4 (4.3) x 10(9) litre-1 before infusion to 17.8 (7.2) x 10(9) litre-1 during and after infusion. No change in platelet count during infusion was observed. There were no differences in WCC or platelet count between mixed venous or peripheral arterial blood. Pulmonary and systemic vascular resistance indices may be influenced by activated complement in drained untreated blood when it is recirculated.

The production of scoliosis after pinealectomy in young chickens, rats, and hamsters

STUDY DESIGN

This study involved weekly radiographic examination of pinealectomized rats, hamsters, and chickens to observe the development of scoliosis.

OBJECTIVES

To determine whether pinealectomy produces scoliosis in animals more closely related phylogenetically to humans than to chickens, namely rats and hamsters, which are representative of mammals.

SUMMARY OF BACKGROUND DATA

Pinealectomy in 3-day-old chickens has consistently resulted in the development of scoliosis with many characteristics similar to those seen in patients with adolescent idiopathic scoliosis. It has not been determined whether this phenomenon is restricted solely to chickens or is applicable to other animals, especially those more closely related to humans.

METHODS

The pineal gland was removed from young rats, hamsters, and chickens. All animals underwent radiography weekly to detect the development of any scoliosis. Weight and length measurements were also taken weekly, and serum melatonin levels were determined at the time the animals were killed.

RESULTS

Scoliosis was not observed in either the rats or the hamsters. In contrast, scoliosis developed in 10 of 21 chickens. Serum melatonin levels in all pinealectomized animals were zero.

CONCLUSIONS

In contrast to the chickens, pinealectomy does not seem to cause scoliosis in either young rats or hamsters. The reasons for this discrepancy may include differences in the physiology and spinal morphology of the rat and hamster in comparison with the chicken. In the pinealectomized chickens, the results also suggest that future scoliosis development might be indicated by a significant increase in size when they are compared with pinealectomized chickens that do not develop scoliosis. Such differences in growth rates also distinguish patients with adolescent idiopathic scoliosis.

Changes in serum melatonin levels in response to pinealectomy in the chicken and its correlation with development of scoliosis

STUDY DESIGN

Normal, sham, and groups of chickens subjected to pinealectomy from which serum melatonin levels were measured and correlated with scoliosis development in a period of 5 weeks.

OBJECTIVES

To measure serum melatonin levels in chickens subjected to pinealectomy and control chickens and correlate findings with development of scoliosis.

SUMMARY OF BACKGROUND DATA

In a previous study by others, scoliosis developed in 100% of chickens subjected to pinealectomy, and serum melatonin levels were found to be reduced. Previous results in a study by the authors showed scoliosis developing in only approximately 55% of chickens that underwent pinealectomy.

METHODS

Young chickens were subjected to pinealectomy. Control groups consisted of sham operation and normal groups. Radiographs and blood samples were taken at weekly intervals to monitor scoliosis development and measure serum melatonin levels using radioimmunoassay techniques.

RESULTS

Scoliosis developed in only 52% of chickens that underwent pinealectomy, but all had low levels of serum melatonin and no circadian rhythm. The chickens in the two control groups maintained normal serum melatonin levels and rhythms.

CONCLUSIONS

Pinealectomy in young chickens reduces serum melatonin levels and eliminates the melatonin circadian rhythm. It can also produce scoliosis, but low levels of serum melatonin are a poor predictor of development of scoliosis.

Immunological suppression after surgery in scoliosis patients

This is a prospective study to analyze the postoperative immunological changes in scoliosis surgery. Twenty-eight patients who underwent Harrington instrumentation were analyzed. Seven patients who underwent arthroscopic surgery were analyzed as a control group. The objective of this study is to determine whether surgery and surgical stress (minor versus major surgery) changed the immune capability of patients as indicated by the ratio of lymphocyte cell types and interferon induction. Pre- and postoperative blood from scoliosis and knee arthroscopy patients was analyzed at various times using antisera and two-color flow cytometry with monoclonal antibodies. Both scoliosis and knee arthroscopy patients had a postoperative decrease in the population of B-lymphocytes (Leu 12+) and a transient increase in the natural killer cells (Leu 4-/Leu 19+) and the cytotoxic T-lymphocytes (Leu 2a++/Leu 15-). These changes were significantly greater in the scoliosis patients, who also experienced a prolonged decrease in the inducer T-lymphocytes (Leu 8+/Leu 3a+) for 3 weeks following surgery. Production of interferon-alpha and interferon-gamma by lymphocytes was suppressed postoperatively and returned to preoperative levels within 3 weeks. Immunological depressive changes occurred postoperatively and lasted at least 1 week. These effects are more pronounced with longer surgeries, suggesting greater postoperative vigilance for infections in these cases.

Melatonin levels in idiopathic scoliosis. Diurnal and nocturnal serum melatonin levels in girls with adolescent idiopathic scoliosis

STUDY DESIGN

Matched pairs of adolescent girls were used to compare serum melatonin levels in adolescent patients and control subjects with idiopathic scoliosis during the day and in the middle of the night.

OBJECTIVES

To compare serum melatonin levels in patients with adolescent idiopathic scoliosis and matched control subjects during the day and in the middle of the night.

SUMMARY OF BACKGROUND DATA

Recent studies using the chick as the animal model have suggested that the pineal gland and its main product, melatonin, might be involved in the cause of scoliosis. There have been no studies of melatonin levels in patients with adolescent idiopathic scoliosis.

METHODS

Blood was collected from seven adolescent girls with idiopathic scoliosis and a group of seven age-matched control subjects. Two samples were collected, one in the middle of the day and one in the middle of the night, to examine the diurnal variation of melatonin production. Serum melatonin levels were measured using a radioimmunoassay technique.

RESULTS

No significant differences were found in serum melatonin levels between experimental and control groups either during the day, when melatonin levels were low, or during the night, when melatonin levels were high.

CONCLUSIONS

Whereas pinealectomy in young chickens leads to reduced melatonin levels and the development of scoliosis, the results of this study suggest that melatonin levels in mature patients who already have severe scoliosis do not differ from healthy subjects. Whether melatonin levels differ in humans between healthy subjects and patients with scoliosis at the time of onset of the disease remains to be seen.

Effects of inspiratory pressure support on oxygenation and central haemodynamics in the normal heart during the postoperative period

Ten patients without cardiac disease or pulmonary dysfunction were exposed to an inspiratory pressure of 0, 10 and 20 cmH2O, in random order, via a nasal mask during the first postoperative day after scoliotic surgery. These patients were in the supine position, and a BiPAP respiratory assist device was used. Arterial oxygen saturation increased significantly during the application of 10 and 20 cmH2O, while none of the haemodynamic parameters (cardiac output, central venous pressure, right ventricular ejection fraction, right ventricular end diastolic volume, mean pulmonary artery pressure, pulmonary artery wedge pressure, pulmonary vascular resistance) changed significantly, contrary to the findings during continuous positive airways pressure treatment. In addition, the BiPAP was generally well tolerated by the patients.

[The Harrington scoliosis operation: the anesthesiological problems in the perioperative phase]

85 histories of scoliosis patients who had the operation with Harrington rod instrumentation were analysed retrospectively in order to reveal perioperative anaesthesiological problems. The cardiovascular and pulmonary alterations represented in addition to the length and the area involved eo ipso was a risk during narcosis. The neurolept analgesia in combination with inhalation anaesthetics after introduction with a barbiturate proved to be a safe procedure. The tachycardia turned out to be the main cardiovascular postoperative complication, which also characterised the situation after one week. In contrast, the blood pressure remained relatively stable. The average blood loss of 1.75 l was responsible for a postoperative anaemia, whilst serious depletions of hemoglobin below 8 mg% could be corrected immediately. Temperatures above 40 degrees C were not noticed. There was no indication for renal damage. The electrolytes did not show serious imbalances in comparison with the extreme fluid fluctuations. The blood gas analysis spoke for a bias to partially compensated respiratory alkalosis during the operation and acidosis postoperatively. The vital capacity was improved significantly by preoperative training. Depressed values of the vital capacity were still measured one week after spondylodesis. In conclusion, the results showed that moderate tachycardia was the most frequent complication of the Harrington operation. The Harrington procedure was a safe therapeutical option.

Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding

The purpose of this study was: 1) to define coagulation abnormalities in patients who receive red cell concentrates rather than whole blood for large volume blood loss (greater than 0.5 blood volume); and 2) to determine when coagulation abnormalities lead to increased bleeding in the massively transfused surgical patient. We studied 32 ASA physical status I or II patients (mean age 15.6 +/- 2.3 yr) who lost more than 50% of their blood volume during elective posterior spinal stabilization. Crystalloid solutions and packed red cell concentrates were used to replace blood and fluid losses. Invasive hemodynamic measures, urinary output, and serial hematocrit determinations were used to help maintain a constant intravascular volume and confirm the estimates of blood loss. The quality of hemostasis was assessed during operation. In 15 of the 32 patients, surgical hemostasis remained effective throughout posterior spinal fusion. A coagulation profile (prothrombin time [PT] and activated partial thromboplastin time [aPTT], platelet count, and fibrinogen) was measured at the conclusion of operation in these patients. In 17 patients, increased surgical bleeding as a result of decreased clot formation and increased bleeding from the wound was present. In these 17 patients at the time increased bleeding was diagnosed, hemostatic tests (PT, aPTT, fibrinogen, platelet count, and coagulation factor assays V, VIII, and IX) were obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen consumption and cardiovascular function in children during profound intraoperative normovolemic hemodilution

The clinically acceptable limit of acute normovolemic, normothermic hemodilution, a standard procedure in scoliosis surgery, is not yet well defined. Eight ASA class I patients undergoing idiopathic scoliosis correction were administered a standard anesthetic with 100% oxygen and controlled ventilation. Hemodilution was accomplished by exchanging whole blood for 5% albumin in 0.9% saline. Blood gases, acid-base status, and circulatory variables were recorded prior to and after hemodilution, and every 30 min throughout surgery. The impact of hemodilution was judged by mixed venous oxygen saturation which was maintained at > or = 60%, while intravascular volume was maintained with the 5% albumin solution. Reinfusion of the autologous blood was completed by the end of surgery. In the eight controlled cases in which normovolemic hemodilution was studied, hemoglobin levels decreased from 10.0 +/- 1.6 g/dL to 3.0 +/- 0.8 g/dL. Mixed venous oxygen saturation decreased from 90.8% +/- 5.4% to 72.3% +/- 7.8%. Oxygen extraction ratio increased from 17.3% +/- 6.2% to 44.4% +/- 5.9%. Oxygen delivery decreased from 532.1 +/- 138.1 mL.min-1.m-2 to 260.2 +/- 57.1 mL.min-1.m-2, while global oxygen consumption did not decrease and plasma lactate did not appreciably increase. Central venous pressure increased and peripheral resistance decreased during hemodilution. Cardiac index increased, heart rate remained essentially constant, and left ventricular stroke work index did not decrease significantly. No patients suffered clinically adverse outcomes. Global oxygen transport and myocardial work can be maintained at extreme normovolemic anemia. Our evidence suggests that stages of normovolemic hemodilution more severe than previously reported may be clinically acceptable for young, healthy patients during normocarbic anesthesia.

Treatment of respiratory failure due to kyphoscoliosis with nasal intermittent positive pressure ventilation (NIPPV)

Nasal intermittent positive pressure ventilation (NIPPV) represents a major advance in the management of respiratory failure. While its role in chronic respiratory failure is well documented, its use in acute respiratory failure is less well defined. We studied four patients with respiratory failure due to kyphoscoliosis, two of whom presented with acute respiratory acidosis. All four patients were on conventional maximum medical therapy prior to treatment with NIPPV. All patients survived to be discharged from hospital on home ventilation and significant improvements were noted in pO2, pCO2 and pulmonary function. We conclude that NIPPV is useful in the management of both acute and chronic ventilatory failure due to kyphoscoliosis.