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Background Conventional unilateral biportal endoscopic discectomy for subarticular herniations frequently necessitates extensive hemilaminectomy, increasing the risks of iatrogenic instability and epidural scarring. Method The K-point approach is a precision docking technique utilizing the medial junction between the inferior and superior articular processes. By creating a strategic lateral corridor, it minimizes bone removal and exposes the lateral margin of the ligamentum flavum, allowing direct access to the traversing nerve root. Conclusion By reducing bone resection and preserving the ligamentum flavum, the K-point approach enhances surgical efficiency and provides a refined minimally invasive alternative for subarticular disc herniations.

Tuberculous spondylitis often develops catastrophic bone destruction with uncontrolled inflammation. Because anti-tuberculous drugs do not have a role in bone formation, a combination drug therapy with a bone anabolic agent could help in fracture prevention and promote bone reconstruction. This study aimed to investigate the influence of teriparatide on the effect of anti-tuberculous drugs in tuberculous spondylitis treatment. We used the virulent Mycobacterium tuberculosis (Mtb) H37Rv strain. First, we investigated the interaction between teriparatide and anti-tuberculosis drugs (isoniazid and rifampin) by measuring the minimal inhibitory concentration (MIC) against H37Rv. Second, we evaluated the therapeutic effect of anti-tuberculosis drugs and teriparatide on our previously developed in vitro tuberculous spondylitis model of an Mtb-infected MG-63 osteoblastic cell line using acid-fast bacilli staining and colony-forming unit counts. Selected chemokines (interleukin [IL]-8, interferon γ-induced protein 10 kDa [IP-10], monocyte chemoattractant protein [MCP]-1, and regulated upon activation, normal T cell expressed and presumably secreted [RANTES]) and osteoblast proliferation (alkaline phosphatase [ALP] and alizarin red S [ARS] staining) were measured. Teriparatide did not affect the MIC of isoniazid and rifampin. In the Mtb-infected MG-63 spondylitis model, isoniazid and rifampin treatment significantly reduced Mtb growth, and cotreatment with teriparatide did not change the anti-tuberculosis effect of isoniazid (INH) and rifampin (RFP). IP-10 and RANTES levels were significantly increased by Mtb infection, whereas teriparatide did not affect all chemokine levels as inflammatory markers. ALP and ARS staining indicated that teriparatide promoted osteoblastic function even with Mtb infection. Cotreatment with teriparatide and the anti-tuberculosis drugs activated bone formation (ALP-positive area increased by 705%, P  = 0.0031). Teriparatide was effective against Mtb-infected MG63 cells without the anti-tuberculosis drugs (ARS-positive area increased by 326%, P  = 0.0037). Teriparatide had no effect on the efficacy of anti-tuberculosis drugs and no adverse effect on the activity of Mtb infection in osteoblasts. Furthermore, regulation of representative osteoblastic inflammatory chemokines was not changed by teriparatide treatment. In the in vitro Mtb-infected MG-63 cell model of tuberculous spondylitis, cotreatment with the anti-tuberculosis drugs and teriparatide increased osteoblastic function.

Long bone strength is determined by its outer shell (cortical bone), which forms by coalescence of thin trabeculae at the metaphysis (corticalization), but the factors that control this process are unknown. Here we show that SOCS3-dependent cytokine expression regulates bone corticalization. Young male and female Dmp1Cre.Socs3 f/f mice, in which SOCS3 has been ablated in osteocytes, have high trabecular bone volume and poorly defined metaphyseal cortices. After puberty, male mice recover, but female corticalization is still impaired, leading to a lasting defect in bone strength. The phenotype depends on sex-steroid hormones: dihydrotestosterone treatment of gonadectomized female Dmp1Cre.Socs3 f/f mice restores normal cortical morphology, whereas in males, estradiol treatment, or IL-6 deletion, recapitulates the female phenotype. This suggests that androgen action promotes metaphyseal corticalization, at least in part, via IL-6 signaling. The strength of long bones is determined by coalescence of trabeculae during corticalization. Here the authors show that this process is regulated by SOCS3 via a mechanism dependent on IL-6 and expression of sex hormones.

Background: Bone remodeling depends on the dynamic balance between osteoclast-mediated bone resorption and osteoblast-mediated bone formation. Follistatin-like 1 (FSTL1) has been reported as an osteoclast-secreted protein that inhibits osteoclast differentiation, but its direct effects on osteoblast differentiation remain unclear. This study aimed to determine whether FSTL1 regulates osteoblast differentiation and mesenchymal stem cell migration and characterizes its role in osteoclast-osteoblast cellular cross-talk under in vitro conditions. Methods: Bone marrow-derived macrophages (BMMs) and stromal cells (BMSCs) from mice were used to induce osteoclast and osteoblast differentiation, respectively. Chemotaxis was assessed by Transwell migration, and osteoblast differentiation was evaluated in BMSC and MC3T3-E1 cells using staining, qRT-PCR, Western blotting, and proliferation assays. Results: FSTL1 significantly suppressed osteoclast differentiation and resorptive activity, confirmed by TRAP staining and pit assay, respectively. Expression of osteoclast markers such as NFATc1, TRAP, and DC-STAMP was reduced under FSTL1 treatment. In BMSCs, FSTL1 did not affect proliferation but significantly enhanced chemotaxis. Moreover, FSTL1 promoted osteogenic differentiation and mineralization, as demonstrated by increased ALP activity and Alizarin Red S staining. In MC3T3-E1 pre-osteoblasts, FSTL1 increased cell proliferation and mineralization by MTS and Alizarin Red staining. Key osteogenic markers, including Runx2 and osteocalcin, were also upregulated. Conclusions: Osteoclast-derived FSTL1 significantly suppresses osteoclastogenesis and promotes mesenchymal cell chemotaxis and osteogenic differentiation, indicating a role in regulating osteoclast–osteoblast cellular interactions in vitro. Targeting FSTL1 signaling may represent a promising therapeutic strategy for osteoporosis and other disorders of impaired bone remodeling.

Traumatic spinal cord injury (SCI) can cause permanent disabilities that seriously reduce quality of life. We evaluated the effects of chronic hyperglycemia before SCI on inflammatory markers and functional recovery after SCI in human patients and a rat model. In the human study, multivariate logistical regression analysis revealed that hemoglobin A1c (HbA1c) values, reflecting average plasma glucose concentration over a 3 month period, at admission were a significant risk factor for poor functional recovery. Moreover, patients with chronic hyperglycemia (HbA1c ≥ 6.5%) had high concentrations of inflammatory biomarkers (interleukin [IL]-6 and IL-8) of cerebrospinal fluid after SCI. Consistent with patient findings, chronic hyperglycemia before SCI in rats was associated with increased inflammatory responses and oxygen-free radicals in the spinal cord and blood, thus resulting in poor functional recovery and histological outcomes. Tight glucose control before SCI decreased the harmful effects of hyperglycemia after SCI in both human and rat studies. Our findings suggest that chronic hyperglycemia before SCI may be a significant prognostic factor with a negative impact on functional and histological outcomes, highlighting the importance of tight glucose control before SCI.

PurposeDelayed esophageal perforation after anterior cervical discectomy and fusion (ACDF) is an extremely rare cause of infection such as spondylodiscitis. We present a rare case in which a patient had two delayed esophageal perforations occurring 20 and 25 years after ACDF. By sharing our experience of this rare case, we hope to provide new information related to delayed esophageal perforation.MethodsWe present the case of a 72-year-old patient who underwent ACDF due to cervical spondylosis 25 years ago. Delayed esophageal perforation occurred 20 years postoperatively and healed spontaneously with conservative treatment.ResultsFive years later, a second esophageal perforation occurred, which required surgical intervention and involved recurrent infection.ConclusionsWe suggest that it is important to consider follow-up in patients with spontaneously healed esophageal perforations. Furthermore, any patient with symptoms subsequent to a spontaneously healed esophageal perforation, even after an interval of several years, should receive a thorough evaluation for possible recurrent esophageal perforation.

PurposeThe presence of prominent OALL (ossification of anterior longitudinal ligament) in the anterior cervical spine has been implicated as a cause of dysphagia. Surgical resection of the OALL is considered effective for the management of diffuse idiopathic skeletal hyperostosis (DISH)-related dysphagia. Although many reports have been published on DISH-related dysphagia, no cases of postoperative cervical instability have been reported thus far. We present a case in which the patient developed myelopathy associated with instability consequent to resection of OALL in DISH.MethodsA 62-year-old man presented with progressive dysphagia that persisted for a year. The patient’s symptoms were successfully resolved by resection of OALL. Five years after the surgery, the dysphagia resurfaced and was found to be caused by the regrowth of the OALL. A repeat surgery was performed, and the dysphagia disappeared. Eleven months after the second surgery, he visited the hospital with progressive quadriparesis and pain in the cervical region.ResultsNine-month follow-up radiologic study revealed cervical instability at the level of C5–6 resulting in myelopathy. The patient underwent decompressive laminectomy and posterior fusion surgery.ConclusionSurgical resection of DISH-related dysphagia typically yields excellent outcomes, but our experience in this case highlights the possibility of OALL regrowth and subsequent cervical instability after resection of OALL.

The global pandemic of coronavirus disease 2019 (COVID-19) has resulted in an increased demand for testing, diagnosis, and treatment. Reverse transcription polymerase chain reaction (RT-PCR) is the definitive test for the diagnosis of COVID-19; however, chest X-ray radiography (CXR) is a fast, effective, and affordable test that identifies the possible COVID-19-related pneumonia. This study investigates the feasibility of using a deep learning-based decision-tree classifier for detecting COVID-19 from CXR images. The proposed classifier comprises three binary decision trees, each trained by a deep learning model with convolution neural network based on the PyTorch frame. The first decision tree classifies the CXR images as normal or abnormal. The second tree identifies the abnormal images that contain signs of tuberculosis, whereas the third does the same for COVID-19. The accuracies of the first and second decision trees are 98 and 80%, respectively, whereas the average accuracy of the third decision tree is 95%. The proposed deep learning-based decision-tree classifier may be used in pre-screening patients to conduct triage and fast-track decision making before RT-PCR results are available.

Background By now it has been well established that vertebral artery injury (VAI) is associated with unstable cervical spine injuries resulting from blunt trauma. A more complete understanding of predisposing factors and the mechanism of injury in VAI should result in improved outcomes and reduced risk for patients with VAI associated with unstable cervical spine injury following blunt trauma. The authors report statistical outcome and hypothesis to more thoroughly examine the predisposing factors for VAI, of which management is controversial, in destabilized midcervical spine trauma. Methods Ninety-one of 131 consecutive patients who underwent surgery for a traumatically destabilized subaxial cervical spine were included, and results were analyzed statistically by logistic regression. Results Eighteen patients (19.8 % of 91 patients) had a VAI associated with midcervical spine trauma (C2-C6). In univariate statistical analysis, transverse foramen fracture ( P  = 0.002), facet dislocation ( P  = 0.014), and facet fracture ( P  = 0.001) were significant risk factors. However, only facet fracture was determined to be significant risk factor after multivariate analysis ( P  = 0.006, odds ratio 20.98). It is hypothesized that a VAI occurs in a midcervical spine injury when a facet fracture allows the bony compartment to impinge on the relatively narrow free space of the intervertebral foramen, which is also occupied by the cervical root. Conclusion A facet fracture is the most important risk factor for VAI in patients with a destabilized midcervical spine injury. Patients with a C2–C6 facet fracture may require a definitive evaluation with vertebral artery imaging.

Background The purpose of this study was to evaluate the therapeutic effects of combination therapy with curcumin and alendronate on bone remodeling after ovariectomy in rats. Methods Eighty female Sprague-Dawley rats underwent either a sham operation (the sham group) or bilateral ovariectomy (OVX). The ovariectomized animals were randomly distributed amongst four groups: untreated OVX group, curcumin-administered group, alendronate-administered group, and the combination therapy group. At 8 and 12 weeks after surgery, rats from each of the groups were euthanized. Serum biochemical markers of bone turnover, including osteocalcin and alkaline phosphatase (ALP), and the telopeptide fragment of type I collagen C-terminus (CTX) were analyzed. Bone histomorphometric parameters of the 4th lumbar vertebrae were determined by micro-computed tomography (CT). In addition, mechanical strength was determined by a three-point bending test. Results Serum biochemical markers of bone turnover in the experiment groups (curcumin administered group, alendronate administered group, and the combination therapy group) were significantly lower than in the untreated OVX group ( p  < 0.05). The combination therapy group had lower ALP and CTX-1 concentrations at 12 weeks, which were statistically significant compared with the curcumin only and the alendronate only group ( p  < 0.05). The combination therapy group had a significant increase in BMD at 8 weeks and Cr.BMD at 12 weeks compared with the curcumin-only group ( p  = 0.005 and p  = 0.013, respectively). The three point bending test showed that the 4th lumbar vertebrae of the combination therapy group had a significantly greater maximal load value compared to that of the curcumin only and the alendronate only group ( p  < 0.05). Conclusions The present study demonstrated that combination therapy with a high dose of curcumin and a standard dose of alendronate has therapeutic advantages over curcumin or alendronate monotherapy, in terms of the synergistic antiresorptive effect on bone remodeling, and improving bone mechanical strength.