Posterior-Only Approach for En Bloc Sacrectomy

BACKGROUND:

En bloc resection of primary sacral tumors has a demonstrated survival benefit. Total and high sacral amputations are traditionally performed by using a staged anterior and subsequent posterior approach. However, we have found that en bloc resection and biomechanical reconstruction of the spinal column is possible from a posterior-only approach in many cases.

OBJECTIVE:

To assess our series of posterior-only sacrectomies, emphasizing postoperative complications and overall surgical and oncologic outcome.

METHODS:

Sixty-nine consecutive patients underwent sacral resections for tumor at our institution between 2004 and 2009. Medical records of all patients were reviewed, and patients were excluded if they had an intentional intralesional resection, hemipelvectomy, or a previous operation. The records of the resulting 36 consecutive patients who underwent primary posterior-only en bloc sacral resections were retrospectively reviewed.

RESULTS:

Of the posterior-only patients, all underwent midline posterior approaches for en bloc sacral resection. Sacral amputation was defined by the by sacral root preservation: total (2 cases), high (8 cases), middle (9 cases), low (12 cases), and distal (5 cases). Chordoma was the most common tumor type (30 cases), and surgical margins were marginal in 34 cases and contaminated in 2. Overall, there were 13 complications, including 9 wound infections/revisions. The extent of sacrectomy, and thus the extent of roots sacrificed, correlated with functional outcome.

CONCLUSION:

It may be possible to perform a posterior-only approach to en bloc sacral resections/reconstructions in patients with tumors that do not extend beyond the lumbosacral junction or invade the bowel requiring bowel resection and diversion.

Diffusion tensor imaging correlates with the clinical assessment of disease severity in cervical spondylotic myelopathy and predicts outcome following surgery

BACKGROUND AND PURPOSE

CSM is a common neurologic disease that results in progressive disability and eventual paralysis without appropriate treatment. Imaging plays a significant role in the evaluation of CSM and has evolved with recent technical advances. We sought to systematically explore the relationship between clinical disease severity and DTI in CSM, and to investigate the potential use of DTI in surgical decision-making models.

MATERIALS AND METHODS

MR imaging studies and clinical assessments were prospectively collected on 30 patients with CSM. Spearman correlations were used to investigate associations between clinical disease severity and FA at the time of diagnosis. Clinical assessment was performed using mJOA, Nurick, Short Form-36, and NDI scores. Fifteen patients with CSM subsequently underwent decompressive surgery; Spearman correlation and logistic regression were applied to this cohort to study the relationship between baseline DTI measurements and postoperative outcome. Conventional imaging (spinal cord T2 signal intensity and degree of stenosis) was evaluated for comparison with DTI.

RESULTS

At diagnosis, FA demonstrated a strong correlation with baseline mJOA (r = 0.62, P < .01) and Nurick (r = -0.46, P = .01) scores. After surgery, recovery of function demonstrated by improvement in NDI score was associated with higher FA values on preoperative DTI (r = -0.61, P = .04). Severely affected patients with CSM with disproportionately high FA tended to achieve greater mJOA scores after surgery compared with subjects with lower FA (P = .08). T2 signal intensity was associated with functional status at baseline but did not predict postoperative outcome; degree of stenosis lacked any significant correlation with clinical parameters.

CONCLUSIONS

DTI may be a useful diagnostic tool for assessing disease severity in CSM. The predictive value of DTI regarding postoperative outcome may improve surgical decision-making and facilitate health care outcomes research.

Minimally invasive lumbar intradural extramedullary tumor resection

Intradural, extramedullary schwannomas have long been treated with open midline incision, laminectomy, and dural opening to expose and resect the lesion. While this technique is well established, today new surgical techniques can be utilized to perform the same procedure while minimizing pain, size of incision, and trauma to adjacent tissues. In cases of intradural surgery, minimally invasive surgery limits the degree of soft tissue disruption. As a result, there is significant decreased dead space within the surgical cavity that may decrease the rate of CSF leak complications. Minimally invasive techniques have continuously improved over the years and have reached a point where they can be used for intradural surgeries. In this case presentation, we demonstrate a minimally invasive approach to the lumbar spine with resection of an intradural schwannoma. Surgical techniques and the nuances of the minimally invasive approach to intradural tumors compared to the standard open procedure will be discussed. The video can be found here: http://youtu.be/XXrvAIq_H48 .

Ossification of the posterior longitudinal ligament: genetics and pathophysiology

Ossification of the posterior longitudinal ligament (OPLL) is a disease of progressive ectopic calcification of the PLL of the spine. It occurs most frequently in the cervical spine, followed by the thoracic spine. The disease was first described in the Japanese population, and the prevalence of OPLL is highest in Japan at a rate of 1.9%-4.3%. Note, however, that OPLL is also seen and is a known cause of cervical myelopathy in other Asian countries and in the white population. Research into the underlying cause of OPLL over the past few decades has shown that it is a multifactorial disease with significant genetic involvement. Genetic studies of OPLL have revealed several gene loci that may be involved in the pathogenesis of this disease. Genes encoding for proteins that process extracellular inorganic phosphate, collagen fibrils, and transcription factors involved in osteoblast and chondrocyte development and differentiation have all been implicated in the pathophysiology of OPLL. In this paper, the authors review current understanding of the genetics and pathophysiology of OPLL.

Diffusion tensor imaging in the assessment of ossification of the posterior longitudinal ligament: a report on preliminary results in 3 cases and review of the literature

Cervical spondylotic myelopathy due to ossification of the posterior longitudinal ligament (OPLL) is a common neurosurgical disease that carries high morbidity. OPLL and other degenerative processes cause narrowing of the central canal, with subsequent spinal cord injury. Repeated minor trauma and vascular aberrations have been purported to underlie cervical spondylotic myelopathy, although the exact pathophysiological mechanism is unclear. Regardless, detection of early axonal damage may allow more timely surgical intervention and prediction of functional outcome. Diffusion tensor (DT) imaging of the cervical spine is a novel technique with improved sensitivity compared with conventional anatomical MR imaging that is currently available on most clinical scanners. This review describes the theoretical basis, application, and analysis of DT imaging as it pertains to neurosurgery. Particular emphasis is placed on OPLL.

Conservative management of ossification of the posterior longitudinal ligament. A review

OBJECT

Ossification of the posterior longitudinal ligament (OPLL) can result in significant myelopathy. Surgical treatment for OPLL has been extensively documented in the literature, but less data exist on conservative management of this condition.

METHODS

The authors conducted a systematic review to identify all reported cases of OPLL that were conservatively managed without surgery.

RESULTS

The review yielded 11 published studies reporting on a total of 480 patients (range per study 1-359 patients) over a mean follow-up period of 14.6 years (range 0.4-26 years). Of these 480 patients, 348 (72.5%) were without myelopathy on initial presentation, whereas 76 patients (15.8%) had signs of myelopathy; in 56 cases (15.8%), the presence of myelopathy was not specified. The mean aggregate Japanese Orthopaedic Association score on presentation for 111 patients was 15.3. Data available for 330 patients who initially presented without myelopathy showed progression to myelopathy in 55 (16.7%), whereas the other 275 (83.3%) remained progression free. In the 76 patients presenting with myelopathy, 37 (48.7%) showed clinical progression, whereas 39 (51.5%) remained clinically unchanged or improved.

CONCLUSIONS

Patients who present without myelopathy have a high chance of remaining progression free. Those who already have signs of myelopathy at presentation may benefit from surgery due to a higher rate of progression over continued follow-up.

Posterior vertebral column subtraction osteotomy for the treatment of tethered cord syndrome: review of the literature and clinical outcomes of all cases reported to date

Tethered cord syndrome (TCS) is a debilitating condition of progressive neurological decline caused by pathological, longitudinal traction on the spinal cord. Surgical detethering of the involved neural structures is the classic method of treatment for lumbosacral TCS, although symptomatic retethering has been reported in 5%–50% of patients following initial release. Subsequent operations in patients with complex lumbosacral dysraphic lesions are fraught with difficulty, and improvements in neurological function are modest while the risk of complications is high. In 1995, Kokubun described an alternative spine-shortening procedure for the management of TCS. Conducted via a single posterior approach, the operation relies on spinal column shortening to relieve indirectly the tension placed on the tethered neural elements. In a cadaveric model of TCS, Grande and colleagues further demonstrated that a 15–25-mm thoracolumbar subtraction osteotomy effectively reduces spinal cord, lumbosacral nerve root, and filum terminale tension. Despite its theoretical appeal, only 18 reports of the use of posterior vertebral column subtraction osteotomy for TCS treatment have been published since its original description. In this review, the authors analyze the relevant clinical characteristics, operative data, and postoperative outcomes of all 18 reported cases and review the role of posterior vertebral column subtraction osteotomy in the surgical management of primary and recurrent TCS.

Minimally invasive circumferential spinal decompression and stabilization for symptomatic metastatic spine tumor: technical case report

OBJECTIVE

Metastatic epidural spinal cord compression is a potentially devastating complication of cancer and is estimated to occur in 5% to 14% of all cancer patients. It is best treated surgically. Minimally invasive spine surgery has the potential benefits of decreased surgical approach-related morbidity, blood loss, hospital stay, and time to mobilization.

CLINICAL PRESENTATION

A 36-year-old man presented with worsening back pain and lower extremity weakness. Workup revealed metastatic adenocarcinoma of the lung with spinal cord compression at T4 and T5.

INTERVENTION AND TECHNIQUE

T4 and T5 vertebrectomy with expandable cage placement and T1-T8 pedicle screw fixation and fusion were performed using minimally invasive surgical techniques.

RESULT

The patient improved neurologically and was ambulatory on postoperative day 1. At the 9-month follow-up point, he remained neurologically intact and pain free, and there was no evidence of hardware failure.

CONCLUSION

Minimally invasive surgical circumferential decompression may be a viable option for the treatment of metastatic epidural spinal cord compression.

En bloc spondylectomy for treatment of tumor-induced osteomalacia

En bloc spondylectomy represents a radical resection of a spinal segment most often reserved for patients presenting with a primary extradural spine tumor or a solitary metastasis in the setting of an indolent, well-controlled systemic malignancy. The authors report a case in which en bloc spondylectomy was conducted to control a metabolically active spine tumor. A 56-year-old woman, who suffered from severe tumor-induced osteomalacia, was found to have a fibroblast growth factor-23-secreting phosphaturic mesenchymal tumor in the T-8 vertebral body. En bloc resection was conducted, leading to resolution of her tumor-induced osteomalacia. This case suggests that radical spondylectomy may be beneficial in the management of metabolically or endocrinologically active tumors of the spine.

Posterior-Only Approach For Total En Bloc Spondylectomy For Malignant Primary Spinal Neoplasms: Anatomic Considerations and Operative Nuances

MALIGNANT PRIMARY SPINAL tumors are rare tumors that are locally invasive and can metastasize. The majority of these tumors have a poor response rate to chemotherapy and conventional radiotherapy. Studies have shown that long-term survival and the potential for cure is best achieved with en bloc surgical excision of these tumors with negative surgical margins. Total en bloc spondylectomy involves removal of vertebral segment(s) in whole to achieve wide tumor excision. Total en bloc spondylectomy can be performed through staged or combined anterior and posterior approaches, or from a posterior-only approach. The posterior-only approach offers the advantage of achieving complete tumor excision and circumferential spinal reconstruction in a single setting. In this report, we discuss the operative management of malignant primary vertebral tumors using the posterior-only approach for total en bloc spondylectomy. The oncological considerations and surgical nuances that allow for safe but aggressive surgical excision of primary spinal tumors to achieve favorable oncological and neurological outcomes are highlighted.

Intraoperative neurophysiological monitoring during spine surgery: a review

Spinal surgery involves a wide spectrum of procedures during which the spinal cord, nerve roots, and key blood vessels are frequently placed at risk for injury. Neuromonitoring provides an opportunity to assess the functional integrity of susceptible neural elements during surgery. The methodology of obtaining and interpreting data from various neuromonitoring modalities-such as somatosensory evoked potentials, motor evoked potentials, spontaneous electromyography, and triggered electromyography-is reviewed in this report. Also discussed are the major benefits and limitations of each modality, as well as the strength of each alone and in combination with other modalities, with regard to its sensitivity, specificity, and overall value as a diagnostic tool. Finally, key clinical recommendations for the interpretation and step-wise decision-making process for intervention are discussed. Multimodality neuromonitoring relies on the strengths of different types of neurophysiological modalities to maximize the diagnostic efficacy in regard to sensitivity and specificity in the detection of impending neural injury. Thorough knowledge of the benefits and limitations of each modality helps in optimizing the diagnostic value of intraoperative monitoring during spinal procedures. As many spinal surgeries continue to evolve along a pathway of minimal invasiveness, it is quite likely that the value of neuromonitoring will only continue to become more prominent.

Posterior vertebral column subtraction osteotomy: a novel surgical approach for the treatment of multiple recurrences of tethered cord syndrome

Recurrent tethered cord syndrome (TCS) has been reported to develop in 5–50% of patients following initial spinal cord detethering operations. Surgery for multiple recurrences of TCS can be difficult and is associated with significant complications. Using a cadaveric tethered spinal cord model, Grande and colleagues demonstrated that shortening of the vertebral column by performing a 15–25-mm thoracolumbar osteotomy significantly reduced spinal cord, lumbosacral nerve root, and terminal filum tension. Based on this cadaveric study, spinal column shortening by a thoracolumbar subtraction osteotomy may be a viable alternative treatment to traditional surgical detethering for multiple recurrences of TCS.

In this article, the authors describe the use of posterior vertebral column subtraction osteotomy (PVCSO) for the treatment of 2 patients with multiple recurrences of TCS. Vertebral column resection osteotomy has been widely used in the surgical correction of fixed spinal deformity. The PVCSO is a novel surgical treatment for multiple recurrences of TCS. In such cases, PVCSO may allow surgeons to avoid neural injury by obviating the need for dissection through previously operated sites and may reduce complications related to CSF leakage. The novel use of PVCSO for recurrent TCS is discussed in this report, including surgical considerations and techniques in performing PVCSO.

Acute symptomatic cerebellar tonsillar herniation following intraoperative lumbar drainage

Complications of tonsillar herniation associated with lumbar drainage have been reported in the literature. However, acutely symptomatic tonsillar herniation after intraoperative lumbar drainage is rare. The following case illustrates the risk associated with cerebrospinal fluid (CSF) drainage in the setting of tonsillar herniation. The use of lumbar drainage during cranial surgery is a common practice for reducing intracranial pressure and enhancing exposure, but is not without complications. In addition to the complications of the insertion procedure itself, the change in pressure gradient between the intracranial and the suboccipital compartments is of key importance.

The authors present the case of a patient who underwent a subtemporal craniotomy for resection of mesial temporal cavernous malformation with intraoperative lumbar drainage. The patient had a preexisting, asymptomatic 4-mm Chiari malformation and progressive neurological deficits resulting from further cerebellar tonsillar herniation in the early postoperative period developed, which required a lumbar blood patch, decompressive suboccipital craniectomy, and C-1 laminectomy with duroplasty. After placement of the lumbar drain and subsequent CSF drainage, the change in CSF pressure gradient above and below the foramen magnum probably led to the herniation. Unfortunately, the patient has lasting neuropathic pain and cervical cord signal changes on MR images.

Maximizing the potential of minimally invasive spine surgery in complex spinal disorders

Minimally invasive surgery (MIS) in the spine was primarily developed to reduce approach-related morbidity and to improve clinical outcomes compared with those following conventional open spine surgery. Over the past several years, minimally invasive spinal procedures have gained recognition and their utilization has increased. In particular, MIS is now routinely used in the treatment of degenerative spine disorders and has been shown to be as effective as conventional open spine surgeries. Although the procedures are not yet widely recognized in the context of complex spine surgery, the true potential in minimizing approach-related morbidity is far greater in the treatment of complex spinal diseases such as spinal trauma, spinal deformities, and spinal oncology. Conventional open spine surgeries for complex spinal disorders are often associated with significant soft tissue disruption, blood loss, prolonged recovery time, and postsurgical pain. In this article the authors review numerous cases of complex spine disorders managed with MIS techniques and discuss the current and future implications of these approaches for complex spinal pathologies.

Surgical treatment of fixed cervical kyphosis with myelopathy

STUDY DESIGN

A retrospective clinical study.

OBJECTIVE

To investigate clinical and radiographic outcomes following the surgical treatment of fixed cervical kyphosis with myelopathy.

SUMMARY OF BACKGROUND DATA

To our knowledge, a study specifically addressing the surgical treatment of fixed cervical sagittal deformity has never before been published.

METHODS

Sixteen patients treated surgically for fixed cervical kyphosis and myelopathy were followed for a mean of 4.5 years (range, 25-112 months). The study group consisted of 9 males and 7 females, with an average age of 52 years (range, 31-78 years). The principal etiologies of cervical deformity were prior laminectomy (63%), advanced spondylosis (19%), infection (6%), neuromuscular disease (6%), and metabolic disease (renal osteodystrophy) (6%). All patients were clinically evaluated by the Nurick classification and Odom criteria both before surgery and at the time of most recent follow-up. Radiographic analysis was performed using thin-cut CT scans, dynamic radiographs, and 14 x 36-inch scoliosis films.

RESULTS

The mean preoperative cervical Cobb angle as measured from the C2-C7 was +38 degrees and improved to -10 degrees at final follow-up, yielding an average correction of 48 degrees . The mean number of anterior and posterior segments fused was 4.8 (range, 2-6) and 7.2 (range, 3-14), respectively. The mean Nurick score improved from 2.4 before surgery to 1.5 at the time of follow-up. According to Odom criteria, outcomes were as follows: excellent (38%), good (50%), fair (6%), and poor (6%). At the time of most recent follow-up, solid bony arthrodesis and maintenance of correction occurred in all patients; however, revision was required in one patient.

CONCLUSION

The treatment of fixed cervical kyphosis with myelopathy using circumferential spinal osteotomies and instrumented reconstruction is technically demanding; however, restoration and maintenance of a neutral or lordotic cervical profile and excellent clinical outcomes are achievable.

Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance

OBJECT

A primary consideration of all spinal fusion procedures is restoration of normal anatomy, including disc height, lumbar lordosis, foraminal decompression, and sagittal balance. To the authors' knowledge, there has been no direct comparison of anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) concerning their capacity to alter those parameters. The authors conducted a retrospective radiographic analysis directly comparing ALIF with TLIF in their capacity to alter foraminal height, local disc angle, and lumbar lordosis.

METHODS

The medical records and radiographs of 32 patients undergoing ALIF and 25 patients undergoing TLIF from between 2000 and 2004 were retrospectively reviewed. Clinical data and radiographic measurements, including preoperative and postoperative foraminal height, local disc angle, and lumbar lordosis, were obtained. Statistical analyses included mean values, 95% confidence intervals, and intraobserver/interobserver reliability for the measurements that were performed.

RESULTS

Our results indicate that ALIF is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The ALIF procedure increased foraminal height by 18.5%, whereas TLIF decreased it by 0.4%. In addition, ALIF increased the local disc angle by 8.3 degrees and lumbar lordosis by 6.2 degrees, whereas TLIF decreased the local disc angle by 0.1 degree and lumbar lordosis by 2.1 degrees.

CONCLUSIONS

The ALIF procedure is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The improved radiographic outcomes may be an indication of improved sagittal balance correction, which may lead to better long-term outcomes as shown by other studies. Our data, however, demonstrated no difference in clinical outcome between the two groups at the 2-year follow-up.

A novel approach to sagittal balance restoration following iatrogenic sacral fracture and resulting sacral kyphotic deformity

✓The authors describe the use of sacral pedicle subtraction osteotomy (PSO) with multiple sacral alar osteotomies for the correction of sacral kyphosis and pelvic incidence and for achieving sagittal balance correction in cases of fixed sagittal deformity after a sacral fracture.

In this paper, the authors report on a novel technique using a series of sacral osteotomies and a sacral PSO to correct a fixed sagittal deformity in a patient with a sacral fracture that had healed in a kyphotic position. The patient sustained this fracture after a previous surgery for multilevel instrumented fusion. Preoperative and postoperative radiographic studies are reviewed and the clinical course and outcome are presented.

Experts agree that the pelvic incidence is a fixed parameter that dictates the morphological characteristics of the pelvis and affects spinopelvic orientation and sagittal spinal alignment. An increased pelvic incidence is associated with a higher degree of spondylolisthesis in the lumbosacral junction, and increased shear forces across this junction. The authors demonstrate that the pelvic incidence can be altered and corrected with a series of sacral osteotomies to improve sacral kyphosis, compensatory lumbar hyperlordosis, and sagittal balance.

Current Updates in Perioperative Management of Intracerebral Hemorrhage

Spontaneous ICH remains a formidable disease that continues to disable and kill the majority of its victims. Treatment of the disease continues to be controversial and without any proved success, such as improvement in the disease mortality or the resulting disability in survivors. Primary prevention is the most effective medical intervention. Nevertheless, as the population continues to age and patients remain undertreated for hypertension, the incidence of ICH likely will increase, resulting in significant socioeconomic impact on society in the coming years. It is imperative that more research be conducted to improve treatment and outcomes of patients who have ICH. Unlike ischemic stokes or other causes of hemorrhagic stroke, such as SAH, where major advancement of treatment has led to improved outcomes, the increased incidence of ICH has not been matched with any considerable improvement in treatment. This burden to improve therapeutic interventions for patients who have ICH should be shared by all neurosurgeons, stroke neurologists, and critical care physicians who care for these patients on a regular basis. It is hoped that early diagnosis and resuscitation, prevention of hematoma growth, selective surgery or minimally invasive clot evacuation, and judicious critical care and rehabilitation will combine to lessen the burden of this disease.

Adjuvant gamma knife stereotactic radiosurgery at the time of tumor progression potentially improves survival for patients with glioblastoma multiforme

OBJECTIVE

Gamma knife stereotactic radiosurgery (GK-SRS) is a safe and noninvasive treatment used as adjuvant therapy for patients with glioblastoma multiforme (GBM). Several studies have yielded conflicting results in the effectiveness of radiosurgery in GBM. This study is a retrospective review of our institutional experience with GK-SRS adjuvant therapy in the treatment of GBM.

METHODS

From October 1998 to January 2003, 51 consecutive patients were treated with GK-SRS as an "upfront" adjuvant therapy after surgery or at the time of tumor progression at Northwestern Memorial Hospital. Survival analysis was performed using the Kaplan-Meier actuarial method. Univariate and multivariate analyses of patient characteristics and treatment variables were performed.

RESULTS

Treatment with adjuvant GK-SRS yielded a median overall survival of 14.3 months for our cohort. Survival rate of the cohort was 68% at 12 months, 30% at 24 months, and 24% at 36 months. Karnofsky performance score greater than 90 and adjuvant chemotherapy were associated with increased survival on multivariate analysis. Adjuvant GK-SRS performed at tumor progression seems to increase median survival to 16.7 months compared with 10 months when performed after the time of initial tumor resection. Median survival rates by recursive partitioning analysis class breakdown in our cohort are greater than those predicted by other studies.

CONCLUSION

GK-SRS is a relatively safe and noninvasive procedure that conferred an improvement in overall survival of GBM patients in our retrospective study. Particularly, GK-SRS may improve overall survival when performed at the time of tumor progression.

Adjuvant gamma knife stereotactic radiosurgery at the time of tumor progression potentially improves survival for patients with glioblastoma multiforme

OBJECTIVE

Gamma knife stereotactic radiosurgery (GK-SRS) is a safe and noninvasive treatment used as adjuvant therapy for patients with glioblastoma multiforme (GBM). Several studies have yielded conflicting results in the effectiveness of radiosurgery in GBM. This study is a retrospective review of our institutional experience with GK-SRS adjuvant therapy in the treatment of GBM.

METHODS

From October 1998 to January 2003, 51 consecutive patients were treated with GK-SRS as an "upfront" adjuvant therapy after surgery or at the time of tumor progression at Northwestern Memorial Hospital. Survival analysis was performed using the Kaplan-Meier actuarial method. Univariate and multivariate analyses of patient characteristics and treatment variables were performed.

RESULTS

Treatment with adjuvant GK-SRS yielded a median overall survival of 14.3 months for our cohort. Survival rate of the cohort was 68% at 12 months, 30% at 24 months, and 24% at 36 months. Karnofsky performance score greater than 90 and adjuvant chemotherapy were associated with increased survival on multivariate analysis. Adjuvant GK-SRS performed at tumor progression seems to increase median survival to 16.7 months compared with 10 months when performed after the time of initial tumor resection. Median survival rates by recursive partitioning analysis class breakdown in our cohort are greater than those predicted by other studies.

CONCLUSION

GK-SRS is a relatively safe and noninvasive procedure that conferred an improvement in overall survival of GBM patients in our retrospective study. Particularly, GK-SRS may improve overall survival when performed at the time of tumor progression.

Surgical strategies for vertebral osteomyelitis and epidural abscess

Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.

Successful resuscitation of acute massive pulmonary embolism with extracorporeal membrane oxygenation and open embolectomy

Acute massive pulmonary embolism is usually fatal if not treated aggressively, but the management is not standardized. Open pulmonary embolectomy retains a role in the treatment of this disastrous disease. Extracorporeal membrane oxygenation has been used for cardiopulmonary support in some patients with life-threatening pulmonary embolism. This article details our experience of a 58-year-old woman suffering from acute cardiopulmonary collapse caused by massive pulmonary embolism. Under extracorporeal membrane oxygenation support, the patient received pulmonary angiography and underwent open embolectomy for a definitive treatment.

A series of enediynes as novel inhibitors of topoisomerase I

A series of acyclic enediynes, 2-((6-substituted)-3-hexen-1,5-diynyl)benzonitriles (8--11), display potent inhibition against topoisomerase I without the formation of active biradical intermediates and show inhibitory activity against topoisomerase I at 10 microM, which is five times that of camptothecin from the results of agarose gel electrophoresis.

Cloning, expression, and purification of a thermostable nonhomodimeric restriction enzyme, BslI

BslI is a thermostable type II restriction endonuclease with interrupted recognition sequence CCNNNNN/NNGG (/, cleavage position). The BslI restriction-modification system from Bacillus species was cloned and expressed in Escherichia coli. The system is encoded by three genes: the 2,739-bp BslI methylase gene (bslIM), the bslIRalpha gene, and the bslIRbeta gene. The alpha and beta subunits of BslI can be expressed independently in E. coli in the absence of BslI methylase (M.BslI) protection. BslI endonuclease activity can be reconstituted in vitro by mixing the two subunits together. Gel filtration chromatography and native polyacrylamide gel electrophoresis indicated that BslI forms heterodimers (alphabeta), heterotetramers (alpha(2)beta(2)), and possibly oligomers in solution. Two beta subunits can be cross-linked by a chemical cross-linking agent, indicating formation of heterotetramer BslI complex (alpha(2)beta(2)). In DNA mobility shift assays, neither subunit alone can bind DNA. DNA mobility shift activity was detected after mixing the two subunits together. Because of the symmetric recognition sequence of the BslI endonuclease, we propose that its active form is alpha(2)beta(2). M.BslI contains nine conserved motifs of N-4 cytosine DNA methylases within the beta group of aminomethyltransferase. Synthetic duplex deoxyoligonucleotides containing cytosine hemimethylated or fully methylated at N-4 in BslI sites in the first or second cytosine are resistant to BslI digestion. C-5 methylation of the second cytosine on both strands within the recognition sequence also renders the site refractory to BslI digestion. Two putative zinc fingers are found in the alpha subunit of BslI endonuclease.

Computerized tomography-guided stereotactic aspiration of brain abscesses: experience with 28 cases

BACKGROUND

Computerized tomography (CT)-guided stereotactic techniques allow accurate identification of brain abscesses and provide promising results for the management of brain abscesses.

METHODS

We reviewed the results of stereotactic aspiration of brain abscesses in 28 consecutive patients from 1984 to 1995. In all patients, the diagnosis of brain abscess was made by computerized tomography (CT). All patients underwent stereotactic aspiration of abscesses as the primary surgical therapy. Intravenous antibiotics were administered preoperatively and adjusted according to organism type and sensitivity to antibiotics. In patients with multiple lesions, aspirations were performed on abscesses larger than 2 cm in diameter or on those causing significant mass effects. CT was performed weekly to monitor abscess growth or failure to resolve. Patients were followed on an outpatient basis. This report is a retrospective review of clinical features, diagnostic methods, treatment and postoperative results.

RESULTS

A total of 19 patients had good recoveries and six patients had mild neurologic sequelae. One patient had persistent conscious impairment. Intracranial hemorrhage occurred in one patient. Two deaths occurred during hospitalization. One patient with a fungal infection underwent additional surgical excision of the abscess. Most patients had resolution of abscesses after stereotactic treatment within two months. The cure rate was 92% in patients with bacterial brain abscesses treated with stereotactic aspiration and intravenous antibiotics for six weeks.

CONCLUSIONS

Stereotactic surgery is a procedure with minimal morbidity and mortality, and can be the treatment of choice for brain abscesses when combined with appropriate antibiotic therapy.

Resource allocation and resident outcomes in nursing homes: comparisons between the best and worst

The purpose of this study was to identify patterns of resource allocation that relate to resident outcomes in nursing homes. Data on structure, staffing levels, salaries, cost, case mix, and resident outcomes were obtained from state-level, administrative databases on 494 nursing homes. We identified two sets of comparison groups and showed that the group of homes with the greatest percentage of improvement in resident outcomes had higher levels of registered nurse (RN) staffing and higher costs. However, comparison groups based on best-worst average outcomes did not differ in resource allocation patterns. Additional analysis demonstrated that when controlling for RN staffing, resident outcomes in high- and low-cost homes did not differ. The results suggest that, although RN staffing is more expensive, it is key to improving resident outcomes.

Bacteria lacking a multidrug pump: a sensitive tool for drug discovery

Microorganisms express multidrug resistance pumps (MDRs) that can confound antibiotic discovery. We propose the use of mutants deficient in MDRs to overcome this problem. Sensitivity to quinolones and to amphipathic cations (norfloxacin, benzalkonium chloride, cetrimide, pentamidine, etc.) was increased 5- to 30-fold in a Staphylococcus aureus mutant with a disrupted chromosomal copy of the NorA MDR. NorA was required both for increased sensitivity to drugs in the presence of an MDR inhibitor and for increased rate of cation efflux. This requirement suggests that NorA is the major MDR protecting S. aureus from the antimicrobials studied. A 15- to 60-fold increase in sensitivity to antimicrobials also was observed in wild-type cells at an alkaline pH that favors accumulation of cations and weak bases. This effect was synergistic with a norA mutation, resulting in an increase up to 1,000-fold in sensitivity to antimicrobials. The usefulness of applying MDR mutants for natural product screening was demonstrated further by increased sensitivity of the norA- strain to plant alkaloid antimicrobials, which might be natural MDR substrates.

Kinetic mechanisms of polyphosphate glucokinase from Mycobacterium tuberculosis

Polyphosphate glucokinase from Mycobacterium tuberculosis catalyzes the phosphorylation of glucose using inorganic polyphosphates [poly(P)] or ATP. The steady-state kinetic mechanisms of the poly(P)- and ATP-dependent glucokinase reactions were investigated using initial velocity, product inhibition, and dead-end inhibition analyses. In the poly(P)-dependent reaction, the enzyme follows an Ordered Bi Bi sequential mechanism with poly(P) binding to the enzyme first and glucose 6-phosphate dissociating last. Polyphosphate is utilized nonprocessively with a preference for longer chains due to higher kcat/K(m) values. The lack of inhibition at high poly(P) concentrations suggests that binding of poly(P) as a product is not favorable. In the ATP-dependent glucokinase reaction, the data are also consistent with an Ordered Bi Bi sequential mechanism, with ATP binding to the enzyme first and glucose 6-phosphate leaving last. At high concentrations, ATP displays competitive substrate inhibition with respect to glucose, which is consistent with the formation of an enzyme.ATP.ATP nonproductive complex. The overall catalytic efficiencies (kcat/KiaK(b)) of the poly(P)- and ATP-dependent reactions are approximately 10(11) M-2 s-1 and approximately 10(8) M-2 s-1, respectively. The higher catalytic efficiency, high value of the substrate specificity constant (kcat/K(a)) approaching a diffusion-controlled limit, and the absence of substrate inhibition in the poly(P)-dependent reaction suggest that poly(P), rather than ATP, is the major phosphate donor for poly(P)-glucokinase in M. tuberculosis.

Cloning, expression, and characterization of polyphosphate glucokinase from Mycobacterium tuberculosis

Polyphosphate glucokinase from Mycobacterium tuberculosis catalyzes the phosphorylation of glucose using polyphosphate or ATP as the phosphoryl donor. The M. tuberculosis H37Rv gene encoding this enzyme has been cloned, sequenced, and expressed in Escherichia coli. The gene contains an open reading frame for 265 amino acids with a calculated mass of 27,400 daltons. The recombinant polyphosphate glucokinase was purified 189-fold to homogeneity and shown to contain dual enzymatic activities, similar to the native enzyme from H37Ra strain. The high G+C content in the codon usage (64.5%) of the gene and the absence of an E. coli-like promoter consensus sequence are consistent with other mycobacterial genes. Two phosphate binding domains conserved in the eukaryotic hexokinase family were identified in the polyphosphate glucokinase sequence, however, "adenosine" and "glucose" binding motifs were not apparent. In addition, a putative polyphosphate binding region is also proposed for the polyphosphate glucokinase enzyme.

Multicentric plasma cell granuloma of spinal cord meninges

A 37-year-old man had multicentric meningeal plasma cell granuloma of the spinal cord. The presenting symptoms were back pain and progressive numbness and weakness of both legs for 6 months. Through physical examination, hypoesthesia below the inguinal region and decreased muscle power of both legs with bilateral ankle clonus was seen. Computed tomographic myelogram and magnetic resonance imaging showed 2 extramedullary intradural masses at the T5 and T12-L1 levels. The latter produced all the neurologic deficits. The patient underwent 2 consecutive operations: laminectomy with removal of the tumor at the T12-L1 level, and thoracotomy with partial corpectomy and removal of the tumor at T5 level. Findings from both operations showed that the tumors arose from the dura and grew inward compressing the spinal cord. Microscopically, these 2 tumors showed identical pictures of plasma cell granuloma and were characterized by numerous granulomas formed by mature plasma cells with Russell bodies and histiocytes set in a fibrotic background. The patient was discharged with complete recovery of sensory and motor functions of both legs.

Involvement of tryptophan(s) at the active site of polyphosphate/ATP glucokinase from Mycobacterium tuberculosis

The glucokinase (EC 2.7.1.63) from Mycobacterium tuberculosis catalyzes the phosphorylation of glucose using inorganic polyphosphate (poly(P)) or ATP as the phosphoryl donor. The nature of the poly(P) and ATP sites was investigated by using N-bromosuccinimide (NBS) as a probe for the involvement of tryptophan in substrate binding and/or catalysis. NBS oxidation of the tryptophan(s) resulted in fluorescence quenching with concomitant loss of both the poly(P)- and ATP-dependent glucokinase activities. The inactivation by NBS was not due to extensive structural changes, as evidenced by similar circular dichroism spectra and fluorescence emission maxima for the native and NBS-inactivated enzyme. Both phosphoryl donor substrates in the presence of xylose afforded approximately 65% protection against inactivation by NBS. The Km values of poly(P) and ATP were not altered due to the modification by NBS, while the catalytic efficiency of the enzyme was decreased, suggesting that the essential tryptophan(s) are involved in the catalysis of the substrates. Acrylamide quenching studies indicated that the tryptophan residue(s) were partially shielded by the substrates against quenching. The Stern-Volmer quenching constant (KSV) of the tryptophans in unliganded glucokinase was 3.55 M-1, while KSV values of 2.48 and 2.57 M-1 were obtained in the presence of xylose+poly(P)5 and xylose+ATP, respectively. When the tryptophan-containing peptides were analyzed by peptide mapping, the same peptide was found to be protected by xylose+poly(P)5 and xylose+ATP against oxidation by NBS. The two protected peptides were determined to be identical by N-terminal sequence analysis and amino acid composition.(ABSTRACT TRUNCATED AT 250 WORDS)

Purification of polyphosphate and ATP glucose phosphotransferase from Mycobacterium tuberculosis H37Ra: evidence that poly(P) and ATP glucokinase activities are catalyzed by the same enzyme

Polyphosphate [poly(P)n]:D-(+)-glucose-6-phosphotransferase (EC 2.7.1.63) from Mycobacterium tuberculosis H37Ra was purified to homogeneity using an improved method which yielded a 634-fold purification with higher recovery. The purified enzyme migrated as a single band with M(r) 33 kDa on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). The native enzyme was shown to be a dimer by gel filtration using high-performance liquid chromatography (HPLC). The purified enzyme fractionated as a single peak on a C8 reverse-phase HPLC column and was found to display both polyphosphate- and ATP-dependent glucokinase activities. Further evidence that a single protein was responsible for both activities was shown by nondenaturing PAGE, in which the two activities (as determined by an activity stain in dual experiments) were found to comigrate. The C-terminal analysis yielded a single sequence while the N-terminus which was blocked also yielded a single sequence after deblocking. The two activities were found to have the same temperature optimum of 50 degrees C. The pH optima were 9.5 and 8.6-9.5 with poly(P)32 and ATP as the phosphoryl donors, respectively. The apparent Km for poly(P)32 was 18.4 microM while the Km for ATP was 1.46 mM. In addition, the nucleotide analogue, Reactive Blue 4, was found to be a competitive inhibitor with ATP in the ATP-dependent glucokinase reaction, while it displayed noncompetitive inhibition patterns with poly(P) in the poly(P)-dependent glucokinase reaction. It is concluded that the poly(P) and ATP glucokinase activities are catalyzed by the same enzyme but that the two substrates may have different binding sites.