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Chen JA, Mooney MA, Rachlin JR. Landmine Injury Resulting in Comminuted Lumbar Facet Fracture as a Cause of Lumbar Stenosis and Spondylolisthesis. Mil Med 2024; 189:e902-e906. [PMID: 37675860 DOI: 10.1093/milmed/usad358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
Lumbar facet fractures are rarely reported and have been linked to sports and spine surgery. We describe the case of a 77-year-old patient who sustained an injury from multiple landmine blasts during the Vietnam War. He had low back pain since that time, which was initially managed conservatively. However, the pain progressed over decades to severe neurogenic claudication that greatly restricted his quality of life. Neuroimaging revealed the presence of bone fragments impinging on the spinal canal at the L5/6 level (transitional anatomy) that resulted from a comminuted fracture of the lumbar facet at the inferior articular process. We performed an L5/6 decompressive laminectomy, with removal of these fragments, and posterior instrumented fusion, with substantial improvement in symptoms. This case illustrates a unique mechanism of lumbar facet fracture and the biomechanic origination, natural history, and optimal treatment of this entity. We expand on the spectrum of lumbosacral injuries associated with the combat blast injury that have only increased in prevalence in recent conflicts.
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Affiliation(s)
- Jason A Chen
- Department of Neurosurgery, Veterans Affairs Boston Healthcare System, West Roxbury, MA 02132, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Michael A Mooney
- Department of Neurosurgery, Veterans Affairs Boston Healthcare System, West Roxbury, MA 02132, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jacob R Rachlin
- Department of Neurosurgery, Veterans Affairs Boston Healthcare System, West Roxbury, MA 02132, USA
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Yearley AG, Patel RV, Rachlin JR, Gupta S, King JT, Cosgrove GR, Mooney MA. Integration of Veterans Affairs Medical Centers Into Neurosurgical Residency Programs. Neurosurgery 2023; 92:e120-e125. [PMID: 36728276 DOI: 10.1227/neu.0000000000002362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023] Open
Abstract
Veterans Affairs (VA) medical centers serve as a unique training environment for US residency programs. In this study, we aim to explore the scope and details of VA integration into neurosurgery resident training. We used data from the Accreditation Council for Graduate Medical Education database to provide an overview of neurosurgery training programs with an active VA affiliation and developed a multi-institutional survey to gather information related to rotation design, operative volume, expectations, and core training values. Of the 116 neurosurgery residency programs, 40 have an active affiliation with a VA medical center (34%). Residents most frequently rotated at the VA during their third postgraduate year, with an average rotation length of 7.5 months (range 2-21). Nearly all programs reported a weekly mix of clinic and operative days (96%), with residents longitudinally following patients throughout their rotations. Attending neurosurgeons from VA-affiliated programs reported operative experience (100%), independent decision-making (89%), and continuity of care (81%) as core values of VA neurosurgery rotations. Surgical volume varied between programs with an average of 13.4 ± 6.4 (SD) cases per month per rotating resident. A significant portion of neurosurgery residency programs in the United States incorporate VA rotations into resident training. Although rotation details vary from program-to-program, shared values include a strong operative experience, independent decision-making, and continuity of care. This analysis provides a comprehensive assessment of VA rotation structure across the country, which is valuable for programs considering implementing a VA rotation into their training program or modifying an existing rotation.
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Affiliation(s)
- Alexander G Yearley
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruchit V Patel
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob R Rachlin
- Department of Neurosurgery, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph T King
- Department of Neurosurgery, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael A Mooney
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, VA Boston Healthcare System, Boston, Massachusetts, USA
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Yang K, Stein TD, Huber BR, Sartor EA, Rachlin JR, Mahalingam M. Glioblastoma and malignant melanoma: Serendipitous or anticipated association? Neuropathology 2020; 41:65-71. [PMID: 33103282 DOI: 10.1111/neup.12702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/18/2022]
Abstract
We describe a patient who had primary glioblastoma (GB) and malignant melanoma (MM). A 78-year-old man presented with several weeks to months of history of gait disturbance, confusion, memory disturbance, and worsening speech. Imaging studies performed on admission revealed a large frontotemporal lobe mass associated with the surrounding zone of vasogenic edema. Given the patient's medical history of incomplete biopsy of a midback tumor performed three weeks before, the presumptive clinical diagnosis was metastatic MM. Pathological examination of frozen sections of fragmented specimens obtained at stereotactic biopsy performed on admission revealed a high-grade malignant neoplasm characterized by discohesive cells in a blue myxoid background and abundant foci of tumor necrosis. Given these features, in conjunction with the abovementioned pathological report, the frozen section diagnosis by the neuropathologist was "neoplasm identified, favor melanoma." Due to the paucity of lesional tissue, a limited immunohistochemistry performed on the permanent sections revealed positive staining of lesional cells for Sox10 alone using a multiplex MART1/Sox10 immunostain and S-100 protein, an immunohistochemical profile supporting the presumptive frozen section diagnosis. A tumor debulk procedure, performed two weeks later, revealed histopathologic features most compatible with GB, IDH wild-type. Thus, additional immunohistochemistry on the permanent sections revealed positive staining of glial fibrillary acidic protein (GFAP), Sox10, and S-100 protein as well as negative staining of gp100, a complex carbohydrate matrix protein in embryonic melanosomes, using a specific antibody HMB45. The concomitant occurrence of MM and GB in our patient underscores the association between these two entities. Our literature review suggests that the sporadic co-occurrence of these two conditions is likely not serendipitous.
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Affiliation(s)
- Kevin Yang
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Thor D Stein
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Jamaica Plain, Massachusetts, USA
| | - Bertrand R Huber
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,VA Boston Healthcare System, Jamaica Plain, Massachusetts, USA
| | - Emmett A Sartor
- VA Boston Healthcare System, Jamaica Plain, Massachusetts, USA
| | - Jacob R Rachlin
- VA Boston Healthcare System, Jamaica Plain, Massachusetts, USA
| | - Meera Mahalingam
- Tufts University School of Medicine, Boston, Massachusetts, USA.,Dermatopathology Section, Department of Pathology and Laboratory Medicine, VA Consolidated Laboratories, West Roxbury, Massachusetts, USA
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Abstract
BACKGROUND CONTEXT Diastematomyelia is uncommon and rarely presents in adulthood. This report draws attention to the fact that patients who underwent spinal fusion for deformity before the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) may have unrecognized spinal cord abnormalities. This should be considered if revision surgery is contemplated. PURPOSE This case report focuses on the late presentation of lower-extremity weakness in a 44-year-old woman with a split cord malformation (diplomyelia), diastematomyelia and tethered cord syndrome. METHODS The patient underwent instrumented posterior spinal fusion with a Harrington rod as a child for progressive thoracolumbar scoliosis. As an adult, she developed paraparesis after a traumatic event. The patient underwent decompressive laminectomy, subtotal resection of the old fusion mass and resection of the osseous septum. Postoperatively, an anterior spinal fluid leak in the lower thoracic region required repeated fascial grafting, resection of a pseudomeningocele and reverse left latissimus dorsi flap transfer. The leak was controlled, and the patient had near complete resolution of her paraparesis 1 year after her surgery. RESULTS The case described herein is unusual in that patients with diplomyelia and diastematomyelia rarely are symptomatic in adulthood. However, trauma may precipitate the onset of neurologic symptoms. This patient underwent spinal surgeries to address deformity, pain and progressive lower-extremity weakness. Preoperative CT and MRI studies showed a split cord malformation and diastematomyelia at L1-L2 with spinal stenosis and tethering of both hemicords. CONCLUSIONS Progressive weakness without any previous neurologic deficit or neurocutaneous stigmas of an underlying spinal cord abnormality may develop in the adult with unrecognized diastemotomyelia. This case demonstrates that a thorough preoperative workup of patients with complex spinal deformities is imperative.
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Affiliation(s)
- Kai Uwe Lewandrowski
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, USA
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Hirsch JA, Reddy AS, Linfante I, Rachlin JR. Pseudo-Kümmel's disease: a unique application for vertebroplasty. Pain Physician 2003; 6:207-11. [PMID: 16883382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Compression fractures of the vertebrae are a major public health concern. There are approximately 700,000 compression fractures of the vertebrae diagnosed on an annual basis in the thoracolumbar spine. The etiology of senile osteoporosis is multifactorial with the most significant reason being age-related bone loss. Multiple effects of compression fractures include acute and chronic pain syndromes, inability to perform activities of daily living, insomnia and depression. Conventional treatment concepts relate to immobilization of the spine, medical pain control, bracing of the back and physical therapy. Vertebroplasty was developed in the 1980s as a treatment for painful cervical hemangiomas in France. Vertebroplasty has been utilized since 1993 to treat painful, osteoporotic compression fractures. In 1891, Kümmell described the disease with a posttraumatic osteitis in which patients developed a painful kyphosis after a period of being symptom free. Inferential evidence includes that vertebrae in this disease are being subjected to a form of avascular necrosis with intraosseous vacuum phenomenon. Patients with Kümmell's disease, treated with vertebroplasty, have been reported to do very well. In a patient with an advanced case of vertebrae plana, without so intending, authors placed air into the vertebral body and created so-called pseudo-Kümmell's disease. This case report describes with high risk or extreme vertebroplasty to alleviate symptomatology. It is concluded that as the clinical experience with percutaneous vertebroplasty continues to expand, the approaches to treatment can become more focused on the specific disease state and specific treatment paradigms.
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Affiliation(s)
- Joshua A Hirsch
- Chief of Interventional Neuroradiology, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA.
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Affiliation(s)
- Kai Mithöfer
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Baumgartner JE, Rachlin JR, Beckstead JH, Meeker TC, Levy RM, Wara WM, Rosenblum ML. Primary central nervous system lymphomas: natural history and response to radiation therapy in 55 patients with acquired immunodeficiency syndrome. J Neurosurg 1990; 73:206-11. [PMID: 2366078 DOI: 10.3171/jns.1990.73.2.0206] [Citation(s) in RCA: 191] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The incidence of primary central nervous system (CNS) lymphoma has increased rapidly in patients with acquired immunodeficiency syndrome (AIDS) and is predicted to exceed 1800 cases annually by 1991. To characterize the natural history and response to radiation therapy (RT) of these lesions, the authors have reviewed the clinical histories of 55 AIDS patients with biopsy-proven primary CNS lymphomas. The tumors responded both clinically and radiologically to whole-brain RT consisting of 4000 rad in 267-rad fractions over 3 weeks or an equivalent neuroret dose. The mean duration of survival from the appearance of symptoms consistent with the mass lesion was significantly greater in patients who received RT than in those who did not (42 vs. 134 days, p less than 0.5; median 27 vs. 119 days). Autopsy findings showed that patients who did not receive RT died from tumor progression, whereas those who completed RT died of opportunistic infections. Patients with AIDS who are suspected of having primary CNS lymphoma should therefore immediately undergo biopsy and, if the diagnosis is confirmed, whole-brain RT. With early diagnosis and treatment, these tumors respond to, and patients benefit from, RT. Survival of such patients may in future be prolonged by more effective treatments for systemic opportunistic infections.
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Affiliation(s)
- J E Baumgartner
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco
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Smith LJ, Schaible KL, Fessler RG, Rachlin JR, Brown FD. Examination of the utility of the rat as an animal model for human anticoagulation. Haemostasis 1987; 17:206-10. [PMID: 3623264 DOI: 10.1159/000215745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The feasibility of employing the rat as an experimental model for investigation of full-dose heparin anticoagulation was assessed. Striking similarities were found to exist between rats and humans regarding baseline-activated partial thromboplastin time (APTT) values, and dosage per kilogram of heparin required to produce an APTT value of 1 1/2-3 times normal, the clinical definition of full-dose heparinization. Based upon these similarities, it appears that the rat can effectively serve as an experimental model for investigating the effects of heparin in humans.
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Schaible KL, Smith LJ, Fessler RG, Rachlin JR, Brown FD, Mullan S. Evaluation of the risks of anticoagulation therapy following experimental craniotomy in the rat. J Neurosurg 1985; 63:959-62. [PMID: 4056909 DOI: 10.3171/jns.1985.63.6.0959] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The risk of hemorrhagic complications with anticoagulation therapy in patients following intracranial surgery has prevented investigation of the potential use of heparin in the early postoperative period. The authors have evaluated the safety of anticoagulation therapy following experimental craniotomy in male Holtzman rats. The dose and schedule of heparin administration, which elevated and maintained the activated partial thromboplastin time (APTT) within the therapeutic range of 1 1/2 to 3 X control APTT, was alternating doses of 400 and 500 IU/kg injected subcutaneously every 6 hours. This schedule was initiated 2, 4, 7, 10, and 14 days after craniotomy and was continued for 72 hours thereafter. The results demonstrated that the incidence of intracerebral hemorrhage declined as the postoperative interval prior to initiation of anticoagulation increased. If anticoagulation therapy was initiated during the first 7 postoperative days, the risk of intracerebral hemorrhage was high (mean 14.7%): however, if an additional 3 to 7 days elapsed prior to initiation of anticoagulation, the incidence of intracerebral hemorrhage dropped significantly (mean 0%) (p less than 0.05). These results suggest that anticoagulation therapy can be safely initiated 10 to 14 days after craniotomy.
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Abstract
Intraoperative ultrasound can aid the biopsy of deep intracranial lesions. It is, perhaps, less clear whether ultrasound could be useful in functional neurosurgery, where the target is not abnormal in echogenicity. As an example, we chose to investigate in a dog model the periventricular gray target, which is frequently the choice for the placement of electrodes to control intractable pain. Autopsies showed the placement of our electrodes with less than 1 mm of error in four of five brains and a 1.5-mm error in the fifth brain. The largest error was seen to occur on the video screen and was due to our failure to tighten the guide properly. The potential advantages of this technique over conventional stereotaxis include the avoidance of: ventricular catheterization, the injection of contrast agent into the ventricles, the necessity for a stereotactic frame, and multiple x-ray exposures. Also, with real time scanning the surgeon has instant visual confirmation of electrode placement and can observe quickly any significant hematoma formation.
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Fessler RG, Brown FD, Rachlin JR, Mullan S, Fang VS. Elevated beta-endorphin in cerebrospinal fluid after electrical brain stimulation: artifact of contrast infusion? Science 1984; 224:1017-9. [PMID: 6326266 DOI: 10.1126/science.6326266] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Beta-Endorphin-like immunoreactivity in cerebrospinal fluid was assayed in 11 patients receiving electrical stimulation of the brain for chronic pain. Immunoreactivity increased dramatically after contrast ventriculography prior to stimulation. No further elevations were observed after stimulation. The magnitude and time course of elevations were identical after placement of electrodes either in the thalamus or in the periventricular gray matter. These results suggest that previous findings of stimulation-induced elevation of beta-endorphin-like immunoreactivity in cerebrospinal fluid are attributable to an artifact of contrast ventriculography.
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Abstract
Six adult dogs were implanted stereotaxically with chronic indwelling Medtronic platinum-tipped electrodes in the left ventromedial hypothalamic area (VMH); two dogs with electrodes placed in the subcortical white matter served as controls. Following 24 hours of food deprivation, VMH-stimulated dogs delayed their next meal for a period ranging from 1 to 18 hours. When not stimulated, however, each dog ate immediately upon receiving its food and consumed greater than average daily intake (p less than 0.005). The two control dogs ate immediately upon receiving food regardless of whether they were stimulated or not. Dogs that received 1 hour of VMH stimulation every 12 hours for 3 consecutive days maintained an average daily food intake of 35% of normal baseline levels (range 13% to 51%), and water consumption averaged 50% of baseline intake (range 29% to 67%). Both of these results were statistically significant (p less than 0.01). After cessation of stimulation, food and water intake returned to normal within 6 to 9 days, with no observable "rebound hyperphagia." The two animals that received subcortical electrodes showed no change in food or water intake with stimulation. Blood pressure, pulse, respiration, temperature, and gross behavior were not altered during or after stimulation. These results suggest that the use of electrical stimulation of the VMH may be a useful modality for regulating food intake, and deserves further examination as a potential alternative therapy for human morbid obesity.
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Rachlin JR, Fessler RG, Duda EE, Brown FD, Fang V, Mullan S. beta-Endorphin-like immunoreactivity increases in human lumbar cerebrospinal fluid following routine metrizamide myelography. J Neurosurg 1984; 60:800-2. [PMID: 6323647 DOI: 10.3171/jns.1984.60.4.0800] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Much interest has recently been focused on the possible role of the endogenous opiates in the perception of pain in humans. Several investigators have examined the levels of these substances in human cerebrospinal fluid (CSF) in attempts to identify the mechanisms by which electrical stimulation of the brain might induce analgesia. Most of these CSF samples were collected at the time of ventriculography or myelography. In the present study, the levels of beta-endorphin in the CSF of 22 patients undergoing myelography were examined before and after the injection of a contrast agent. beta-Endorphin increased an average of 356% (p less than 0.0005) 15 to 20 minutes following the injection of contrast material into the lumbar subarachnoid space. Thus, routine myelography may have a profound effect on the levels of beta-endorphin measured by radioimmunoassay in human CSF, and great care must be taken in interpreting the significance of changes seen in beta-endorphin levels in CSF collected from patients at the time of myelography or ventriculography. The effect of the injection of contrast material on beta-endorphin immunoreactivity must be distinguished from the postulated effects of any analgesia-inducing therapy.
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Fang VS, Fessler RG, Rachlin JR, Brown FD. Effect of contrast media on radioimmunoassay of beta-endorphin in cerebrospinal fluid. Clin Chem 1984; 30:311-4. [PMID: 6319047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
An effect of metrizamide, a contrast medium, on results of beta-endorphin radioimmunoassay was examined. We found that 1, 5, and 10 microL of the medium added to 100 microL of standard containing 0 to 500 pg of beta-endorphin shifted the standard curve to the left in proportion to the metrizamide concentration. Three other contrast media showed a similar effect at low concentrations of beta-endorphin. This effect of contrast media artificially increased results in radioimmunoassay of beta-endorphin in cerebrospinal fluid, the mean overestimate being 121.9% (range, 0 to 435%). For plasma samples, this effect of contrast media resulted in an average 11.7% overestimate of beta-endorphin (range, -16% to 41%). These observations bring into question the validity of a previous suggestion that an increase in beta-endorphin in cerebrospinal fluid after intracerebral electrical stimulation is the mechanism for stimulation-produced analgesia.
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Abstract
Abstract
An effect of metrizamide, a contrast medium, on results of beta-endorphin radioimmunoassay was examined. We found that 1, 5, and 10 microL of the medium added to 100 microL of standard containing 0 to 500 pg of beta-endorphin shifted the standard curve to the left in proportion to the metrizamide concentration. Three other contrast media showed a similar effect at low concentrations of beta-endorphin. This effect of contrast media artificially increased results in radioimmunoassay of beta-endorphin in cerebrospinal fluid, the mean overestimate being 121.9% (range, 0 to 435%). For plasma samples, this effect of contrast media resulted in an average 11.7% overestimate of beta-endorphin (range, -16% to 41%). These observations bring into question the validity of a previous suggestion that an increase in beta-endorphin in cerebrospinal fluid after intracerebral electrical stimulation is the mechanism for stimulation-produced analgesia.
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