The effect of epidural methylprednisolone acetate injection on the hypothalamic-pituitary-adrenal axis

Study ObjectiveTo evaluate the effect of an epidural corticosteroid injection of 80 mg and 40 mg of methylprednisolone acetate on the hypothalamic-pituitary-adrenal axis and on back pain.DesignRandomized, single-blinded prospective study.SettingOperating room of a university-affiliated hospital.Patients42 patients with low back pain due to radiculopathy.InterventionsGroup 1 received an epidural corticosteroid injection of 80 mg of methylprednisolone acetate, and Group 2 received an epidural corticosteroid injection of 40 mg of methylprednisolone acetate. All study patients underwent a stimulation test of one μg of adrenocorticotropin hormone (ACTH), and their pain levels were graded just prior to and following the epidural corticosteroid injection on weeks one, 3, and 4.MeasurementsSerum cortisol of the ACTH stimulation tests and back pain levels were rated using a visual analog scale (VAS). Serum cortisol levels lower than 18 ng/mL 30 minutes following the ACTH stimulation test were considered to be secondary adrenal insufficiency.Main Results21 patients were enrolled in each group. The rate of secondary adrenal insufficiency in Group 1 was ~ 86%, ~ 22%, and ~ 17% of patients versus ~ 53% (P = 0.024), 15% (P = 0.874), and ~ 12% (P = 0.715) of Group 2 patients at weeks one, 3, and 4, respectively. About 62%, 56%, and 39% of Group 1 patients had a favorable clinical response as opposed to ~ 47% (P = 0362), 35% (P = 0.21), and ~ 6% (P = 0.049) of Group 2 patients at weeks one, 3, and 4, respectively.ConclusionsEpidural corticosteroid injection of methylprednisolone acetate in both groups was associated with very high rates of secondary adrenal insufficiency, but significantly more so in Group 1 at week one. This suppression was transient, with recovery of the gland in most patients noted over the ensuing weeks. An epidural corticosteroid injection of 80 mg had higher rates of favorable clinical response than a 40 mg injection, but significantly more so at week 4 only. This favorable response waned over a few weeks in both groups.     

Elastic intramedullary nailing combined with methylprednisolone acetate injection for treatment of unicameral bone cysts in children: a retrospective study

PurposeThe aetiology of unicameral bone cysts (UBCs) is unclear. This study aims to evaluate the feasibility of elastic intramedullary nailing (EIN) combined with injections of methylprednisolone acetate (MPA) for the treatment of UBCs in children.MethodsWe retrospectively analyzed 53 children with UBCs in our hospital between January 2010 and April 2016. A total of 24 patients (Group A) were treated by EIN and MPA, whilst 29 patients (Group B) were treated by curettage, bone grafts and EIN fixation. The radiographs of the UBCs were evaluated following the Capanna criteria. All patients were followed-up on the third, sixth, 12th, 24th and 36th months. Fixation time, hospitalization time and complications were evaluated.ResultsIn Group A, the mean number of MPA injections was 1.8 (1 to 3). Based on radiographic evaluation, eight patients were healed (Capanna grade I), 14 were healed with residual cysts (Capanna grade II), one showed recurrence (Capanna grade III) and one showed no response to the treatment (Capanna grade IV). In Group B, 11 patients were evaluated as Capanna grade I, 12 as Capanna grade II, three as Capanna grade III and three as Capanna grade IV. There was significant difference in the early postoperative function activity (p < 0.001), hospitalization time (p = 0.028), blood loss during surgery (p < 0.001) and surgery time (p < 0.001).ConclusionThe combination of EIN and MPA for the treatment of UBCs in children is feasible, has little operative trauma, short surgery time, short hospitalization time, less blood loss and a low risk of incision infection.Level of evidence:III     

Effects of cortisone acetate, methylprednisolone and medroxyprogesterone on wound contracture and epithelization in rabbits.

Standardized flank wounds were made on 20 rabbits divided into the following five groups: Group 1 served as controls, Group 2 were given cortisone acetate 6.25 mg/kg/day (I.M.), Group 3--methylprednisolone (Solu-Medrol) 1 mg/kg/day, Group 4--medroxyprogesterone (Depo-Provera) 35 mg/kg/day, Group 5--methylprednisolone 1 mg/kg/day and medroxyprogresterone 35 mg/kg/day. Wound contracture and epithelization was measured by planimetry of photographs taken twice weekly; weekly weights were recorded, and the maturation phase of wound healing followed in the control and methylprednisolone groups. All three steroids prolonged the latent phase of wound healing, slowed the rate and decreased the total amount of contracture. Cortisone showed the most inhibition of wound contracture and was the only steroid to inhibit epithelization suggesting it may have a slightly different or more potent mode of action. When the methylprednisolone group was followed for seven weeks on daily injections, the maturation phase of wound healing was inhibited, and this inhibition persisted during the next nine weeks after the drug was withdrawn. Only the control and the medroxyprogesterone group gained weight. Combining medroxyprogesterona and methylprednisolone resulted in the severest weight loss of 20% with a 60% mortality.     

Use of methylprednisolone acetate in vasectomy

A double blind study was conducted to determine if the discomfort and complications associated with vasectomy don under local anesthesi could be ameliorated by use of concomitant local steroids (as suggested by Gould).     

The effects of subluxation of the femoral head with avascular necrosis in growing rabbits

To validate the adverse effects of subluxation of the femoral head in Legg-Calve-Perthes disease, the authors made an experimental model of Perthes disease with subluxation in growing rabbits by interrupting the epiphyseal artery (devascularization) and immobilizing the knee in extension (immobilization). Seventy-two rabbits, 4 to 5 weeks old, were divided into three groups: group A with both devascularization and immobilization (25 rabbits), group B with devascularization only (25 rabbits), and group C with immobilization only (22 rabbits). In each experimental group, four to six rabbits each were killed at 1, 2, 4, 8, and 12 weeks. After reviewing the serial radiographs and gross specimens, the authors found six radiologic and six macroscopic abnormalities. The incidence and the severity of deformity in group A rabbits were higher than that of groups B or C in terms of the overall incidence of deformities (P <0.001), head deformity scores (P <0.001), and the incidence of a total collapse of the capital femoral epiphysis. In conclusion, subluxation of the immature femoral head with avascular necrosis in rabbits increased femoral head deformities.     

Scoliosis in growing rabbits induced with an extension splint

An external splint was applied to 49, 6-week-old rabbits to induce lordosis in the thoracolumbar junction. The splint was retained for 8 weeks, and the animals were killed after 6 months. Scoliosis developed in 23 rabbits during the splinting period. The deformity occurred about the thoracolumbar junction, and was more frequent in rabbits whose lordosis was sustained when the splint was removed after 8 weeks. The results support the view that sagittal changes are primarily or secondarily involved in the pathomechanics of scoliosis.     

Scoliosis in growing rabbits induced with an extension splint

An external splint was applied to 49, 6-week-old rabbits to induce lordosis in the thoracolumbar junction. The splint was retained for 8 weeks, and the animals were killed after 6 months. Scoliosis developed in 23 rabbits during the splinting period. The deformity occurred above the thoracolumbar junction, and was more frequent in rabbits whose lordosis was sustained when the splint was removed after 8 weeks. The results support the view that sagittal changes are primarily or secondarily involved in the pathomechanics of scoliosis.     

The effects of methylprednisolone acetate in the treatment of bone cysts. Results of three years follow-up.

The treatment of bone cysts by topical injection of methylprednisolone acetate was initiated at the end of 1973, and the late results are reported in this paper. In seventy-two cases followed up for one to three years favourable results have been obtained in about 90 per cent. The technique of local injection and the surgical equipment employed, in the case of focal recurrences, are considered. With this method, surgical treatment of bone cysts in youth is seldom necessary.     

Lymphocyte traffic effects of systemic and local lidocaine in sheep

The traffic of lymphocytes through lymphoid tissues is of importance in both the initiation and development of the immune response. The effects of lidocaine on lymphocyte traffic through primary peripheral lymph nodes of sheep (popliteal and pre-femoral) was investigated by three routes of lidocaine administration. Infiltration of lidocaine above the study node and as the sole anesthetic agent for study node efferent lymphatic cannulation produced mild depressions in lymphocyte outputs into study node efferent lymph. This depression was comparable to that encountered with regional epidural anesthesia for similar operations, but was significantly less than that associated with general anesthesia (P less than 0.000015). In animals with established chronic cannulation of study node efferent lymphatics, both study node drainage area injection of lidocaine and systemic administration of lidocaine (intravenously by bolus injection at a distant site) produced prompt and sharp depressions in lymphocyte traffic as mirrored in the output of lymphocytes into study node efferent lymph. The output of both small recirculating lymphocytes and of blast lymphocytes was affected.     

Study of local and systemic effects of intravesical BCG

Defects in cell-mediated immunity have been implicated as one of the underlying causes for the appearance and progression of neoplasms. One approach toward correcting these defects employs immune potentiators for the purpose of stimulating cell-mediated immunity. BCG is the immune potentiator which has been used most frequently in the experimental and clinical situation. A preliminary study directed toward ascertaining the local histologic changes and systemic serum response to BCG injection in the dog bladder was undertaken in anticipation of its possible application in the treatment of bladder neoplasm. Local response was predictable and was associated with low morbidity. The appearance of serum precipitin bands to culture filtrates of Mycobacteria tuberculosis strains strongly suggests systemic absorption and reaction to BCG administered intravesically.     

硬膜内局部灌注甲强龙对兔急性脊髓损伤后血清SOD、MDA的影响

目的探讨硬膜内局部灌注甲强龙(MP)对兔脊髓损伤(SCI)后血清超氧化物歧化酶(SOD)、丙二醛(MDA)的浓度的影响。方法将54只白兔随机分为3组,每组18只,Ⅰ组为不完全SCI+局部灌注MP,Ⅱ组为不完全SCI+局部灌注生理盐水(NS),Ⅲ组为对照组。用改良Allen法造成Ⅰ、Ⅱ组不完全SCI模型,硬膜内置管,检测血清中SOD、MDA的变化情况,同时进行改良Tarlov评分测评及病理组织学观察。结果Ⅱ组血清中的MDA升高,SOD浓度下降,与Ⅲ组比较差异有统计学意义(P<0.05)。与Ⅱ组比较,Ⅰ组能明显降低SCI后血清中MDA含量,提高SOD浓度,差异有统计学意义(P<0.05)。结论 SCI后硬膜内局部灌注MP能够降低血清MDA含量,提高SOD浓度,在一定程度上阻止继发性损伤的发展。     

The thermal effects of intramedullary reaming

OBJECTIVE: To study the effect of tourniquet control on intramedullary reaming. DESIGN: An experimental prospective nonsurvival animal study was performed using 5 mongrel dogs. A pneumatic tourniquet was randomized to either the right or left hind limb. Tibial intramedullary reaming was performed with progressively larger reamers. Cortical temperatures were measured using thermocouples inserted into the tibial diaphyseal cortex. Thermocouples were connected to an analog to digital converter that output continuous data that was collected on a computer. Upon completion of the procedure, the animals were killed. RESULTS: The peak and low temperatures for each thermocouple with each reamer passage were recorded. Reamer sizes larger than the internal diameter of the intramedullary canal produced higher peak temperatures. The mean delta t (peak temperature minus low temperature) was calculated for each reamer passage. This measurement represents the overall amount of heat generated during each reamer passage. There were no significant differences between the 2 conditions (P = 0.8, paired t test). Temperatures decreased in between reamer exchange but did not return to baseline levels. CONCLUSIONS: Because similar temperatures were measured both with and without a tourniquet, the risk of thermal necrosis appears to be related more to the process of intramedullary reaming than to the tourniquet. Higher temperatures were measured with reamer sizes larger than the internal diameter of the intramedullary canal. Increasing the time interval between the passage of successive reamers may allow heat to dissipate and decrease the risk of thermal necrosis. The clinical practice of limited reaming ("ream-to-fit") should minimize the occurrence of this complication.     

Remodelling of bone around intramedullary stems in growing patients

The remodelling of bone around intramedullary cemented stems, used for the fixation of massive distal femoral replacements in young patients, has been studied. Several types of remodelling have been identified, and this is common to all of the retrieved specimens that have been in situ for periods of 6 to 18 months. Transection of cortical bone and the insertion of a massive prosthesis leads to (a) the formation of a pedicle of bone or bony bridge that grows from the transection site over the shaft of the prosthesis, (b) bone resorption at the transection site, (c) the development of an inner porotic cortex surrounding the intramedullary stem and subperiosteal bone formation, and (d) a shell of bone around the acrylic cement. The tibial component that allows continued growth of the proximal tibial physis consists of a press fit metallic plateau with a stem that slides into an ultra-high-molecular-weight polyethylene sleeve inserted below the growth plate. A sclerotic layer of bone forms adjacent to a soft-tissue interface around both the sleeve and the metallic component. Remodelling of bone around intramedullary stems is attributed either to a redeveloping blood supply or to load adaptive changes.     

Comparison of the local and systemic effects of sepsis in predicting survival

Progress in the study of sepsis has been hampered by the lack of a suitable system for grading its severity. Systems suggested for scoring sepsis have been based either on its systemic effects (APACHE II) or on a mixture of local and systemic variables (sepsis score). The APACHE II and sepsis scores were applied to patients with intra-abdominal sepsis of more than 3 days' duration, to determine if local or systemic factors were more important in predicting survival. Of 45 patients studied, 14 died. The sepsis score for non-survivors (median 21.5, range 11-32) was significantly higher than for survivors (median 14, range 10-26, P less than 0.05). There was overlap between the two groups, such that an individual score had no predictive value. The local component of the sepsis score was not significantly increased in non-survivors (P less than 0.05), but the systemic component was (P less than 0.05). The APACHE II score for non-survivors (median 24, range 15-38) was significantly higher than for survivors (median 12, range 3-21), and correctly identified 13 of the 14 fatalities. Both the systemic and non-systemic components (age and chronic disease) were significantly higher among the latter. The APACHE II was more effective than the sepsis score in predicting survival. We conclude that any system used for scoring sepsis should be based on systemic rather than local effects. At present the APACHE II score is preferred.