Paravertebral Nerve Block for Procedural Pain in Percutaneous Vertebroplasty

OBJECTIVES

This study aimed to unidimensionally measure procedural pain at each percutaneous vertebroplasty (PVP) stage and evaluate the effectiveness of paravertebral nerve block (PVNB) in reducing procedural pain.

METHODS

A retrospective study of prospectively collected data was conducted on 66 patients who underwent PVP for osteoporotic vertebral compression fractures. The patients were divided into 2 groups: group A (fluoroscopic-guided PVNB; 5 cm 3 of 0.75% ropivacaine on each side) and group B (local anesthesia). To investigate procedural pain associated with PVP, the visual analog scale score was assessed at each surgical stage: before the incision (stage 1), transpedicular approach (stage 2), and polymethylmethacrylate cement injection (stage 3). After the procedure, patients were asked about their surgical experience and satisfaction using the Iowa Satisfaction with Anesthesia Scale. Periprocedural complications were also recorded.

RESULTS

A total of 63 patients (78.65 y of age) were finally enrolled: 30 from group A and 33 from group B. In both groups, a significant ≥2-point increase in procedural pain was observed during PVP compared with that during stage 1 ( P < 0.001). In stages 2 and 3, the pain intensity was significantly lower in group A ( P < 0.001). Upon discharge, the visual analog scale score improved in all groups; however, the Iowa Satisfaction with Anesthesia Scale score was significantly higher in group A ( P < 0.001). There was no difference in periprocedural complications between the two groups ( P = 0.743).

CONCLUSION

PVP causes significant procedural pain, and PVNB is a potentially effective modality for enhancing patient satisfaction and reducing procedural pain.

Comparison of Primary Versus Revision Lumbar Discectomy Using a Biportal Endoscopic Technique

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare the clinical outcomes of the biportal endoscopic technique for primary lumbar discectomy (BE-LD) and revision lumbar discectomy (BE-RLD).

METHODS

Eighty-one consecutive patients who underwent BE-LD or BE-RLD, and could be followed up for at least 12 months were divided into two groups: Group A (BE-LD; n = 59) and Group B (BE-RLD; n = 22). Clinical outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab's criteria. Perioperative results included operation time (OT), length of hospital stay (LOS), amount of surgical drain, and kinetics of serum creatine phosphokinase (CPK) and C-reactive protein (CRP). Clinical and perioperative outcomes were assessed preoperatively and postoperatively at 2 days and at 3, 6, and 12 months. Postoperative complications were noted.

RESULTS

Both groups showed significant improvement in pain (VAS) and disability (ODI) compared to baseline values at postoperative day 2, which lasted until the final follow-up. There were no significant differences in the improvement of the VAS and ODI scores between the groups. According to the modified MacNab's criteria, 88.1 and 90.9% of the patients were excellent or good in groups A and B, respectively. OT, LOS, amount of surgical drain, and kinetics in serum CRP and CPK levels were comparable. Complications in Group A included incidental durotomy (n = 2), epidural hematoma (n = 1), and local recurrence (n = 1) and in Group B incidental durotomy (n = 1) and epidural hematoma (n = 1).

CONCLUSION

BE-RLD showed favorable clinical outcomes, less postoperative pain, and early laboratory recovery equivalent to BE-LD.

Biportal endoscopic discectomy versus tubular microscopic discectomy for treating single-level lumbar disc herniation in obese patients: a multicenter, retrospective analysis

PURPOSE

In microscopic lumbar discectomy in obese patients, a correlation is found between the operation time and increase in estimated blood loss according to the increase in body mass index; however, no studies have investigated the outcomes of biportal endoscopic lumbar discectomy in obese patients. Therefore, this study aimed to compare the clinical and radiographic outcomes of microscopic and endoscopic discectomy in obese patients with lumbar herniated discs.

METHODS

In this multicenter, retrospective study, clinical and radiological data were compared and analyzed in 73 obese patients with a body mass index of > 30 kg/m2 who underwent microscopic or biportal endoscopic lumbar discectomy. Clinical data on the visual analog scale (VAS), Oswestry disability index (ODI), and EuroQol-5D (EQ-5D) scores were measured, and radiological data were obtained using magnetic resonance imaging (MRI).

RESULTS

This study enrolled 43 patients who underwent microscopic discectomy and 30 who underwent biportal endoscopic discectomy. The VAS, ODI, and EQ-5D scores in both groups improved after surgery compared with those before surgery, although there was no difference between the two groups. Although there was a difference in the incidence of recurrent disc herniation confirmed by MRI after surgery, no difference was found in the number of patients requiring surgery between the two groups.

CONCLUSION

In obese patients with lumbar disc herniation that was not improved with conservative treatment, no significant clinical or radiological differences in outcomes were noted between microscopic and biportal endoscopic surgery methods. In contrast, minor complications were less common in the biportal group.

In vivo Comparison of Positive Microbial Culture by Wound Irrigation Methods: Biportal Endoscopic versus Open Microscopic Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

OBJECTIVE

This study aimed to evaluate the risk factors and prevalence of intraoperative contamination (IoC) through the microbial culture of superficial and deep samples obtained during surgery.

SUMMARY OF BACKGROUND DATA

Surgical site infection (SSI) in spinal surgery is a serious complication. The prevalence of IoC may differ based on surgical approach and technique, even in the setting of the same procedure.

METHODS

In this in-vivo study, microbial cultivation was performed with superficial (ligamentum flavum, LF) and deep (nucleus pulposus, NP) surgical specimens to evaluate IoC in 132 patients undergoing single-level transforaminal lumbar interbody fusion (TLIF). Biportal endoscopic (BE) TLIF was performed under continuous wound irrigation (group A, n=66), whereas open microscopic (OM) TLIF was performed under intermittent wound irrigation (group B, n=66). LF and NP specimens were homogenized, gram-stained, and cultured in aerobic and anaerobic media for 14 days. Microbial culture results and occurrence of SSI in the two groups were assessed. The Chi-square test and Fisher's exact test were used to determine significant differences among categorical variables. Logistic regression analysis was used to assess the influence of patient characteristics on the prevalence of positive microbial cultures.

RESULTS

Of the 132 patients, 34 (25.8%) had positive microbial cultures, and positive culture required an incubation period of 72 h to 2 weeks in all these patients except for three. Overall positive culture was significantly higher in group B than in group A (P=0.029). The subgroups of LF- and NP-positive cultures were 18.18% (n=24) and 12.88% (n=17), respectively; the SSI was 0.76% (n=1). Group A had a significantly lower subgroup of NP-positive culture than group B (P=0.035). OM technique was an independent risk factor associatd with overall positive culture (P<0.05). The most common microorganism was Cutibacterium acnes (C. acnes).

CONCLUSION

BE-TLIF with continuous wound irrigation showed significantly lower overall, and NP-positive cultures, than OM-TLIF with intermittent irrigation. The most common strain of positive culture was C. acnes.

LEVEL OF EVIDENCE

II.

Biportal endoscopic paraspinal decompressive foraminotomy for lumbar foraminal stenosis: clinical outcomes and factors influencing unsatisfactory outcomes

BACKGROUND

Lumbar foraminal stenosis (LFS) is an important pathologic entity that causes lumbar radiculopathies. Unrecognized LFS may be associated with surgical failure, and LFS remains challenging to treat surgically. This retrospective cohort study aimed to evaluate the clinical outcomes and prognostic factors of decompressive foraminotomy performed using the biportal endoscopic paraspinal approach for LFS.

METHODS

A total of 102 consecutive patients with single-level unilateral LFS who underwent biportal endoscopic paraspinal decompressive foraminotomy were included. We evaluated the Visual Analogue Scale (VAS) score and the Oswestry Disability Index (ODI) before and after surgery. Demographic, preoperative data, and radiologic parameters, including the coronal root angle (CRA), were investigated. The patients were divided into Group A (satisfaction group) and Group B (unsatisfaction group). Parameters were compared between these two groups to identify the factors influencing unsatisfactory outcomes.

RESULTS

In Group A (78.8% of patients), VAS and ODI scores significantly improved after biportal endoscopic paraspinal decompressive foraminotomy (p < 0.001). However, Group B (21.2% of patients) showed higher incidences of stenosis at the lower lumbar level (p = 0.009), wide segmental lordosis (p = 0.021), and narrow ipsilateral CRA (p = 0.009). In the logistic regression analysis, lower lumbar level (OR = 13.82, 95% CI: 1.33-143.48, p = 0.028) and narrow ipsilateral CRA (OR = 0.92, 95% CI: 0.86-1.00, p = 0.047) were associated with unsatisfactory outcomes.

CONCLUSIONS

Significant improvement in clinical outcomes was observed for a year after biportal endoscopic paraspinal decompressive foraminotomy. However, clinical outcomes were unsatisfactory in 21.2% of patients, and lower lumbar level and narrow ipsilateral CRA were independent risk factors for unsatisfactory outcomes.

Effect of Muscularity and Fatty Infiltration of Paraspinal Muscles on Outcome of Lumbar Interbody Fusion

BACKGROUND

Lumbar paraspinal muscles play an important role in maintaining global spinal alignment and are associated with lower back pain; however, only a few studies on the effect of the paraspinal muscles on the surgical outcome exist. Therefore, this study aimed to analyze the association of preoperative muscularity and fatty infiltration (FI) of paraspinal muscles with the outcome of lumbar interbody fusion.

METHODS

Postoperative clinical and radiographic outcomes were analyzed in 206 patients who underwent surgery for a degenerative lumbar disease. The preoperative diagnosis was spinal stenosis or low-grade spondylolisthesis, and the surgery performed was posterior lumbar interbody fusion or minimally invasive transforaminal lumbar interbody fusion. Indications for surgery were a complaint of severe radiating pain that did not improve with conservative treatment and neurological symptoms accompanied by lower extremity motor weakness. Patients with fractures, infections, tumors, or a history of lumbar surgery were excluded from this study. Clinical outcome measures included functional status, measured using the Oswestry disability index (ODI) and visual analog scale (VAS) score for lower back and leg pain. Other radiographic parameters included measures of spinal alignment, including lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence, C7 sagittal vertical axis, and pelvic incidence-lumbar lordosis mismatch. Lumbar muscularity (LM) and FI were measured preoperatively using a lumbar magnetic resonance image (MRI).

RESULTS

The high LM group showed more significant improvement in VAS score for lower back pain than the low LM group. In contrast, the VAS score for leg pain demonstrated no statistical significance. The high LM group showed more significant improvement in ODI postoperatively than the medium group. The severe FI group showed more significant improvement in ODI postoperatively, whereas the less severe FI group showed more significant improvement in the sagittal balance postoperatively.

CONCLUSION

Patients with high LM and mild FI ratio observed on preoperative MRI demonstrated more favorable clinical and radiographic outcomes after lumbar interbody fusion. Therefore, preoperative paraspinal muscle condition should be considered when planning lumbar interbody fusion.

Biportal endoscopic extraforaminal lumbar interbody fusion using a 3D-printed porous titanium cage with large footprints: technical note and preliminary results

PURPOSE

The aim of this study was to introduce biportal endoscopic extraforaminal lumbar interbody fusion (BE-EFLIF), which involves insertion of a cage through a more lateral side as compared to the conventional corridor of transforaminal lumbar interbody fusion. We described the advantages and surgical steps of 3D-printed porous titanium cage with large footprints insertion through multi-portal approach, and preliminary results of this technique.

METHODS

This retrospective study included 12 consecutive patients who underwent BE-EFLIF for symptomatic single-level lumbar degenerative disease. Clinical outcomes, including a visual analog scale (VAS) for back and leg pain and the Oswestry disability index (ODI), were collected at preoperative months 1 and 3, and 6 months postoperatively. In addition, perioperative data and radiographic parameters were analyzed.

RESULTS

The mean patient age, follow-up period, operation time, and volume of surgical drainage were 68.3 ± 8.4 years, 7.6 ± 2.8 months, 188.3 ± 42.4 min, 92.5 ± 49.6 mL, respectively. There were no transfusion cases. All patients showed significant improvement in VAS and ODI postoperatively, and these were maintained for 6 months after surgery (P < 0.001). The anterior and posterior disc heights significantly increased after surgery (P < 0.001), and the cage was ideally positioned in all patients. There were no incidences of early cage subsidence or other complications.

CONCLUSIONS

BE-EFLIF using a 3D-printed porous titanium cage with large footprints is a feasible option for minimally invasive lumbar interbody fusion. This technique is expected to reduce the risk of cage subsidence and improve the fusion rate.

Learning curve for biportal endoscopic posterior cervical foraminotomy determined using the cumulative summation test

BACKGROUND

Learning curves describe the rate of performance improvements corresponding to the surgeon's caseload, followed by a plateau where limited further improvements are observed. This study aimed to determine the learning curve for biportal full-endoscopic posterior cervical foraminotomy (BE-PCF) for the unilateral cervical foraminal disc.

METHODS

The learning curve was evaluated using a learning curve cumulative summation test (LC-CUSUM). The goal for the operation time was set to 78 min, which is the mean operation time (mOT) of percutaneous full-endoscopic posterior cervical foraminotomy (PE-PCF) performed by a senior surgeon. Moreover, clinical outcomes and post-operative complications were compared between the early and late learning periods 1 year post-operatively.

RESULTS

This study enrolled the first 50 patients who underwent single-level BE-PCF, performed by a single surgeon. The LC-CUSUM signalled competency for surgery at the 20th operation, indicating that sufficient evidence was obtained to prove that the surgeon was competent. The mOT was 71.29 ± 11.69 min in BE-PCF, 71.84 ± 12.61 min in the early learning period, and 67.83 ± 10.31 min in the late learning period (p = 0.254). There was no statistical difference in clinical outcomes, visual analogue scale scores, and neck disability index between both periods (p > 0.05). Four complications were recorded throughout the whole period, with three in the early period and one in the late period (p = 0.285).

CONCLUSION

Our study shows that BE-PCF has a learning curve of 20 caseloads to achieve 90% proficiency, and it significantly reduces the operation time based on the performance of a senior surgeon proficient in PE-PCF.

Oblique Lumbar Interbody Fusion with Selective Biportal Endoscopic Posterior Decompression for Multilevel Lumbar Degenerative Diseases

Oblique lumbar interbody fusion is a minimally invasive procedure for treating degenerative lumbar disease. Its advantages include correcting coronal and sagittal spinal alignment and indirect neural decompression. However, achieving a successful outcome is limited in some patients who need direct decompression for central canal lesions including hard stenotic lesions (endplate or facet articular osteophytes and ossification of posterior longitudinal ligaments) and sequestration of the disk. Biportal endoscopic spinal surgery is a minimally invasive technique, which directly decompresses the lesion. By taking advantage of two procedures, in a longlevel lumbar lesion, alignment correction and direct decompression can be both achieved. Herein, the authors introduce multilevel lumbar fusion through oblique lumbar interbody fusion and selective direct decompression through biportal endoscopic spinal surgery and discuss the surgical indications, surgical pitfalls, and recommendations for application. Consequently, it is regarded as a minimally invasive interbody fusion method for patients with multilevel lumbar degenerative degeneration.

Mid-term efficacy and safety of Escherichia coli-derived rhBMP-2/hydroxyapatite carrier in lumbar posterolateral fusion: a randomized, multicenter study

PURPOSE

This study aimed to evaluate the mid-term efficacy and safety of Escherichia coli-derived bone morphogenetic protein-2 (E.BMP-2)/hydroxyapatite (HA) in lumbar posterolateral fusion (PLF).

METHODS

This multicenter, evaluator-blinded, observational study utilized prospectively collected clinical data. We enrolled 74 patients who underwent lumbar PLF and had previously participated in the BA06-CP01 clinical study, which compared the short-term outcomes of E.BMP-2 with an auto-iliac bone graft (AIBG). Radiographs and CT scans were analyzed to evaluate fusion grade at 12, 24, and 36 months. Visual analog scale (VAS), Oswestry disability index (ODI), and Short Form-36 (SF-36) scores were measured preoperatively and at 36 months after surgery. All adverse events in this study were assessed for its relationship with E.BMP-2.

RESULTS

The fusion grade of the E.BMP-2 group (4.91 ± 0.41) was superior to that of the AIBG group (4.25 ± 1.26) in CT scans at 36 months after surgery (p = 0.007). Non-union cases were 4.3% in the E.BMP-2 and 16.7% in the AIBG. Both groups showed improvement in pain VAS, ODI, and SF-36 scores when compared to the baseline values, and there were no statistically significant differences between the two groups. No treatment-related serious adverse reactions were observed in either group. No neoplasm-related adverse events occurred in the E.BMP-2 group.

CONCLUSIONS

The fusion quality of E.BMP-2/HA was superior to that of AIBG. E.BMP-2/HA showed comparable mid-term outcomes to that of AIBG in terms of efficacy and safety in one-level lumbar PLF surgery.

Can 3-Dimensional Printing for Calcaneal Fracture Surgery Decrease Operation Time and Improve Quality of Fracture Reduction?

We investigated whether 3-dimensional (3D) printed models can decrease operation time and improve the quality of reduction for calcaneal fractures. The study involved 48 patients with unilateral intra-articular calcaneal fractures, who were retrospectively case-matched according to Sander's classification, age, and sex. Group A (24 patients) was operated using 3D printed models as a preoperative and intraoperative tool, and group B (24 patients) was operated using standard techniques without 3D printed model. Operation time was significantly shorter for group A, compared to group B (82.3 ± 13.2 vs 91.4 ± 16.0, p = .036). The differences between the radiological parameters of operated calcaneus, compared to the normal side was similar between the 2 groups (Böhler angle, 5.3° ± 3.9° vs 4.2° ± 4.7°, p = .45, Gissane angle, 5.9° ± 12.5° vs 8.4° ± 11.0°, p = .54). The number of screws projecting more than 5 mm from the cortex was lower in group A than in group B (7/187, 4% vs 16/208, 8%, p = .11). The number of screw holes of the plate cut intraoperatively was significantly lower for group A compared to group B (1 vs 138). Although group A started weightbearing 3 to 4 weeks earlier than group B, the radiological parameters were similar between groups that early weightbearing was possible for group A using the 3D printed models (Böhler angle, - 1.5° ± 0.8° vs - 1.8° ± 1.2°, p = .28, Gissane angle, 2.5° ± 2.6° vs 3.5° ± 4.3°, p = .39). The operation time was shorter while using the 3D printed models, compared to that of the standard technique without using the 3D printed model. The radiological parameters were not statistically different, and the quality of fracture reduction seemed similar. However, with the use of 3D printed models, early weightbearing was possible without significant subsidence of reduced fragments or failure of fracture reduction, comparable to non-weightbearing cases.

Clinical and radiologic outcomes of biportal endoscopic lumbar discectomy in obese patients: a retrospective case-control study

BACKGROUND

Obese patients have a higher risk of complications during spinal surgery than non-obese patients. To the best of our knowledge, no studies have examined the differences in clinical and radiological outcomes after biportal endoscopic lumbar discectomy (BELD) between obese and non-obese patients. The study evaluated the association between obesity and outcomes after BELD in patients with lumbar disc herniation.

METHODS

This was a retrospective case-control study conducted from March 2017 to March 2021 at two hospitals with 360 patients who underwent BELD after showing no improvement with conservative treatment. Clinical and radiologic outcomes were retrospectively analyzed after BELD in the non-obese (body mass index [BMI] < 30 kg/m²) and obese (BMI ≥ 30 kg/m²) groups. Demographic data and surgery-related factors were compared between the two groups. Clinical outcomes were followed up for 12 months after surgery and analyzed for differences.

RESULTS

A total of 211 patients were enrolled in this study, and through case-control matching, the data of 115 patients (29, obese group; 86, non-obese group) were analyzed. The two groups showed no significant differences in Oswestry Disability Index, European Quality of Life-5 Dimensions (EQ-5D), and visual analog scale scores measured immediately after BELD and 12 months after surgery. After surgery, back pain, radiating leg pain, and EQ-5D scores improved. However, there was no significant difference in improvement, residual herniated disc, hematoma, or recurrence between the groups.

CONCLUSIONS

Obese patients who underwent BELD for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients.

Percutaneous transpedicular intracorporeal cage grafting for Kümmell disease

BACKGROUND

Osteonecrosis with progressive collapse and segmental kyphosis can lead to intersegmental instability in some osteoporotic vertebral compression fractures (OVCFs). These conditions are known as Kümmell's disease and often require anterior column reconstruction in elderly patients.

METHODS

We attempted anterior column reconstruction by percutaneous transpedicular intracorporeal cage grafting (PTICG) with short-segment pedicle screw fixation and described the steps, with discussions on the surgical indications and pros and cons.

CONCLUSION

PTICG is expected to be an alternative to vertebral anterior column reconstruction, which can preserve the thoracolumbar posterior arch and paravertebral musculature.

Comparing the efficacy and safety of minimally invasive biportal endoscopic spine surgery versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-BH Trial): a multicenter, prospective, randomized controlled equivalence trial study protocol

Background

Biportal endoscopic surgery has recently been performed in lumbar discectomy, with advantages over conventional surgery, such as less skin scarring and muscle damage. However, the clinical results have not been established. Although previous studies reported no difference between the biportal endoscopic and microscopic discectomy clinical results, the evidence was weak. Therefore, this study aims to evaluate the efficacy and safety of the biportal endoscopic discectomy versus the microscopic discectomy.

Methods

This prospective multicenter randomized controlled equivalence trial is designed to compare the efficacy and safety outcomes of patients who underwent lumbar discectomy using biportal endoscopy or microscopy. We will include 100 participants (50 per group) with a lumbar herniated disc. The primary outcome will be the Oswestry Disability Index (ODI) score 12 months after surgery based on a modified intention-to-treat strategy. The secondary outcomes will include the visual analog scale score for low back and lower extremity radiating pain, the ODI score, the Euro-Qol-5-Dimensions score, surgery satisfaction, walking time, postoperative return to daily life period, postoperative surgical scar, and surgery-related variables, such as postoperative drainage, operation time, admission duration, postoperative creatine kinase, and implementation status of conversion to open surgery. Radiographic outcomes will also be analyzed using magnetic resonance imaging (MRI) or computed tomography (CT) and simple radiographs. Safety will be assessed by evaluating all adverse and severe adverse events and surgery-related effects. The participants will be assessed by a blinded assessor before surgery (baseline) and 2 weeks and 3, 6, and 12 months after surgery.

Discussion

This trial will be the first prospective, multicenter, randomized controlled trial to analyze the efficacy and safety of biportal endoscopic discectomy in lumbar herniated disc.

This trial is designed for evaluating the equivalence of the results between biportal endoscopic and microscopic discectomy including adequate sample size, blinded analyses, and prospective registration to reduce bias. This trial will provide enough data on the effectiveness and safety of biportal endoscopic surgery and will be an important study that allows clear conclusions.

Trial registration

Clinical Research Information Service (cris.nih.go.kr.) (KCT0006191). Registered on 27 March 2021

Evaluation of the efficacy and safety of conventional and biportal endoscopic decompressive laminectomy in patients with lumbar spinal stenosis (ENDO-B trial): a protocol for a prospective, randomized, assessor-blind, multicenter trial

BACKGROUND

Recent studies on biportal endoscopic spine surgery in patients with lumbar spinal stenosis have reported good clinical results. However, these studies have been limited by the small sample sizes and use of a retrospective study design. Therefore, we aim to compare the efficacy and safety of biportal endoscopic decompressive laminectomy with those of conventional decompressive laminectomy in a multicenter, prospective, randomized controlled trial.

METHODS

This study will include 120 patients (60 per group, aged 20-80 years) with 1- or 2-level lumbar spinal stenosis, who will be recruited from six hospitals. The study will be conducted from July 2021 to December 2024. The primary outcome (Oswestry Disability Index at 12 months after surgery) will be evaluated through a modified intention-to-treat method. The secondary outcomes will include the following: visual analog scale score for low back and lower extremity radiating pain, EuroQol 5-dimensions score, surgery satisfaction, walking time, postoperative return to daily life period, postoperative surgical scars, and some surgery-related variables. Radiographic outcomes will be analyzed using magnetic resonance imaging or computed tomography. All outcomes will be evaluated before the surgery and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines for reporting of clinical trial protocols.

DISCUSSION

It is hypothesized that the efficacy and safety of biportal endoscopic and conventional decompressive laminectomy will be comparable in patients with lumbar spinal stenosis. The results of this trial will provide a high level of evidence for the efficacy and safety of the biportal endoscopic technique in patients with lumbar spinal stenosis and facilitate the development of clinical practice guidelines. Furthermore, the results of this study may indicate the feasibility of the biportal endoscopic technique for other types of spinal surgery.

TRIAL REGISTRATION

The ENDO-B trial is registered at Clinical Research Information Service (CRIS, cris.nih.go.kr ) (KCT0006057; April 52,021).

Minimally invasive transforaminal lumbar interbody fusion using the biportal endoscopic techniques versus microscopic tubular technique

BACKGROUND CONTEXT

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with microscopic tubular technique is an established surgical procedure with several potential advantages, including decreased surgical-related morbidity, reduced length of hospital stay, and accelerated early rehabilitation. A recently introduced biportal endoscopic technique for spine surgery presents familiar surgical anatomy and can be conducted using a conventional approach with a minimal footprint; it is also applicable to TLIF.

PURPOSE

To compare the clinical and radiological outcomes of biportal endoscopic technique transforaminal lumbar interbody fusion (BE-TLIF) and microscopic tubular technique transforaminal lumbar interbody (MT-TLIF) in patients with single- or two-segment lumbar spinal stenosis with or without spondylolisthesis.

STUDY DESIGN

A retrospective cohort study.

PATIENT SAMPLE

One hundred two participants with neurogenic intermittent claudication or lumbar radiculopathy with single- or two-level lumbar spinal stenosis with or without spondylolisthesis.

OUTCOME MEASURES

Clinical outcomes were assessed using the visual analog scale (VAS) score for the back and leg pain, Oswestry Disability Index (ODI), and the Short Form-36 health survey Questionnaire (SF-36). Demographic data, operative data (total operation time, estimated blood loss, amount of surgical drain, postoperative transfusion, and length of hospital stay), and laboratory results (plasma hemoglobin, serum creatine phosphokinase, and C-reactive protein) were also evaluated. The fusion rate was assessed using the Bridwell interbody fusion grading system. Postoperative complications were also noted.

METHODS

Patients were divided into two groups: group A (BE-TLIF) and group B (MT-TLIF). The clinical outcomes, including VAS-Back and VAS-Leg, ODI, and SF-36 scores, were evaluated at 1 month, 6 months, and 1 year after surgery. Differences in demographics, operative data, and the laboratory and radiological results were assessed between the two groups. The fusion rate was assessed using standard standing lumbar radiographs and computed tomography scans conducted 1 year after surgery.

RESULTS

Seventy-nine patients were analyzed in this study, 47 from group A and 32 from group B. Demographic and operative data were comparable for both the groups. The VAS-Back and SF-36 scores were more significantly improved in group A than in group B at 1 month after surgery. However, there were no significant differences between groups for the mean VAS-Back, VAS-Leg, ODI, and SF-36 scores at 1year after the surgery. Although the total operation time was significantly longer in group A, the estimated blood loss and the amount of surgical drainage was significantly higher in group B (p < .001). There were no between-group differences for the fusion rate and postoperative complications.

CONCLUSION

Both BE-TLIF and MT-TLIF provided equivalent and favorable clinical outcomes and fusion rates. Further large-scale, randomized, controlled trials with long-term follow-ups are warranted.

Contralateral retrodiscal transforaminal approach for percutaneous epidural adhesiolysis: A technical description and retrospective comparative study

OBJECTIVES

Retrodiscal transforaminal (RdTF) epidural steroid injection (ESI) is clinically comparable to conventional transforaminal ESI and can avoid catastrophic complications. However, it poses a risk of inadvertent intradiscal, intravascular, and intrathecal injections. Therefore, we aimed to evaluate the feasibility of percutaneous epidural adhesiolysis (PEA) using the contralateral (Contra)-RdTF approach.

METHODS

The electronic medical records of 332 patients with unilateral lumbar radiculopathy due to foraminal disk pathology were reviewed. Patients were categorized into two groups: Group A (ESI using the RdTF approach) and Group B (PEA using the Contra-RdTF approach). Effective pain relief (EPR; ≥50% pain relief from baseline) in patients was evaluated using the visual analog scale (VAS) at 4 and 12 weeks after the procedure. The presence of unintended fluoroscopic findings and complications was recorded.

RESULTS

A total of 119 patients were enrolled in the final analysis: 81 in Group A and 38 in Group B. Both groups showed lesser VAS scores after 4 and 12 weeks than at baseline (p < 0.05). However, the proportion of patients with EPR was significantly greater in Group B after 12 weeks (p = 0.015). No complications, including intrathecal injection, infectious discitis, and neurologic deterioration, were reported. However, inadvertent intradiscal and intravascular injections were reported to be significantly higher in Group A than in Group B (14.8% and 0%, respectively; p = 0.009).

CONCLUSIONS

Although applications of this study are limited by its retrospective design, the results suggest that PEA using the Contra-RdTF approach is feasible because it can achieve EPR and avoid unintended fluoroscopic findings.

Biportal endoscopic posterior lumbar decompression and vertebroplasty for extremely elderly patients affected by lower lumbar delayed vertebral collapse with lumbosacral radiculopathy

Background

Lower lumbar osteoporotic vertebral compression fracture in extremely elderly patients can often lead to lumbosacral radiculopathy (LSR) due to delayed vertebral collapse (DVC). Surgical intervention requires posterior instrumented lumbar fusion as well as vertebral augmentation or anterior column reconstruction depending on the cleft formation and intravertebral instability. However, it is necessary to decide on surgery in consideration of the patient’s frail status, surgical invasiveness, and rehabilitation. In the lower lumbar DVC without intravertebral instability, biportal endoscopic posterior lumbar decompression and vertebroplasty (BEPLD + VP) can be simultaneously attempted. This study aimed to assess the clinical outcomes of BEPLD + VP for the treatment of DVC-related LSR.

Methods

This retrospective case series enrolled 18 consecutive extremely elderly (aged ≥ 75-year-old) patients (6 men and 12 women) who had lower lumbar (at or below L3) DVC-related LSR. Patients who require anterior column reconstruction, such as cleft formation accompanied by intravertebral instability and patients who have not been followed for more than 6 months, were excluded from this study. All patients underwent BEPLD + VP under epidural anesthesia. Clinical results were evaluated by the visual analog scale (VAS) score and the modified Japanese Orthopedic Association (mJOA) scores.

Results

Most of the patients had DVC affecting level L4, with the deformation being a flat type or concave type rather than a wedge type. The VAS score (back and leg) significantly decreased from 7.78 ± 1.17 and 6.89 ± 1.13 preoperatively to 2.94 ± 0.64 and 2.67 ± 1.08 within 2 postoperative days (p < 0.001). The mJOA score significantly improved from 4.72 ± 1.27 preoperatively to 8.17 ± 1.15 in the final follow-up (p < 0.001). The mean recovery rate (RR) in the last follow-up was 56.07% ± 9.98. Incidental durotomy was reported in two patients and epidural hematomas in another two patients; however, all patients improved with conservative treatment, and no re-operation was required.

Conclusions

BELPD + VP was a type of salvage therapy that reduces surgical morbidity, requires major spine surgery under general anesthesia and provides good clinical outcomes in extremely elderly patients with DVC-related LSR.

The impact of coronal alignment of device on radiographic degeneration in the case of total disc replacement

BACKGROUND CONTEXT

Numerous studies have been conducted on the importance of radiographic parameters after a total disc replacement (TDR). Most of them have focused on sagittal alignment. There has been no research on what influence the coronal alignment or tilting of device has on radiographic parameters.

PURPOSE

The aim was to investigate the influences of coronal tilting of device on radiographic parameters and degeneration.

STUDY DESIGN/SETTING

This was a prospective comparative study.

PATIENT SAMPLE

A total of 180 patients with single-level cervical disc disease who underwent TDR were included.

OUTCOME MEASURES

Overall and functional spinal unit (FSU) sagittal range of motion (ROM), coronal alignment (or tilting) of device, and postoperative radiographic degeneration (RD) were analyzed.

METHODS

Static anteroposterior, lateral X-rays, and dynamic lateral radiographs were assessed preoperatively, postoperatively, at 1.5, 3, 6, 9, 12, 18, 24 months, and every 6 months thereafter until final follow-up. A correlation with various parameters that could result in RD was investigated, For this, the patients were divided into two groups (Group I, RD; Group II, no RD) and subdivided into Group I-A (<5°; low coronal tilt) and Group I-B (≥5°; high coronal tilt) to analyze whether coronal tilting of device was correlated with RD.

RESULTS

No statistical differences were found in preoperative overall and FSU ROM, postoperative overall and FSU ROM between Groups I and II. However, there was significant difference in coronal tilting of device between Groups I (4.50±2.83°) and II (2.04±1.15°; p=.001). There were no significant differences in preoperative overall and FSU ROM, postoperative overall and FSU ROM between Group I-A and I-B. But, RD incidence rate at surgical segment in Group I-A was 23.1%, whereas that in Group I-B was 75.0% (p=.001). The influence level of a difference in the incidence rate was found to be 10.0 of the odds ratio. Radiographic degeneration incidence rate at adjacent levels in Group I-A was 8.33%, whereas that in Group I-B was 25.0% (p=.013). The influence level of a difference in the incidence rate was found to be 3.67 of the odds ratio.

CONCLUSIONS

It is considered that maintaining appropriate coronal alignment of device is important in long-term success after a cervical TDR.

Specific detection of cell surface-displayed human melanocortin 4 receptors with antibodies generated in mice

The melanocortin-4 receptor (MC-4R) is a 7-transmembrane protein, which is involved in the central regulation of appetite and obesity. Despite the great interest in this protein, tools for detecting this molecule (as expressed on the cell surface in its native state) have been unavailable. Radioactive- or otherwise labeled ligands showed low receptor specificity to this particular melanocortin receptor isotype. Also, the antibodies were only available for epitopes that were displayed in the cytoplasm. To produce antibodies that enable the detection of this receptor (as expressed on the cell surface without disruption of the target cells), a candidate epitope was selected from the extracellular domains by a computer-aided analysis of the IC-4R secondary structure. This particular region was then recombinantly expressed in E. coli. Immunization of BALB/c mice with the recombinant proteins induced a specific immune reaction, which resulted in the production of MC-4R-specific antibodies. Enzyme-linked immunosorbent assays confirmed the specificity of these antibodies. To examine whether this tool also reacts with native cell surface-displayed MC-4R, HEK-293 cells were transfected with the human MC-4R cDNA. They were analyzed with these antibodies using Western blot and flow cytometry. Specificity and exclusion of cross-reactivity of these antibodies to other MC receptors were further confirmed by an immunofluorescence analysis of the HEK-293 cells that were transfected with other MC receptor isotypes. It is evident that with the availability of this tool, studies on the cell- and tissue-specificity, as well as the regulation mechanism of the MC-4 receptor, will be largely facilitated.

Determination of rat leptin activity in vitro using a novel luciferase reporter assay

Leptin is small cytokine-like protein that is involved in appetite and body weight regulation. Due to increased interest in using leptin as an anti-obesity reagent, recombinant forms of leptin have been produced for several species, including humans, mice, rats, pigs, dogs, sheep etc. The biological activities of such recombinant proteins were determined using various in vitro or in vivo systems; however so far, no specific assay system for rat leptin is available. Since rats are representative animal models in obesity research, the establishment of a biological assay system for determining rat leptin activity has been eagerly awaited. This study describes the generation of such a system using chinese hamster ovary (CHO)-cells that were transfected with the long form of the rat leptin receptor isoform, OB-Rb, whereby a signal transduces and activators of transcription-sensitive luciferase reporter system is further employed to quantify the leptin-mediated signals. This system is the first rat-specific leptin bioassay system that has been reported. It is expected that this assay will be used to further quantify and determine leptin activity from various biological fluids and sources.

Regulation of phosphatidylinositol-phosphate kinase IIgamma gene transcription by thyroid-stimulating hormone in thyroid cells

This study was performed to evaluate the effects of thyroid-stimulating hormone (TSH) on phosphatidylinositol-4-phosphate 5-kinase type IIgamma (PIPKIIgamma) gene expression in the thyrocytes of FRTL-5 cells. Although PIPKIIgamma mRNA was expressed constantly in the absence of added TSH, its expression increased remarkably in the presence of 10(-9) M TSH. This increase started within 6 h of the addition of TSH, and reached a maximum at 8 h. The mRNA expression properties of PIPKIIgamma in the cells were identified using inhibitors. Actinomycin D blocked PIPKIIgamma transcription strongly, while cycloheximide did not. In an experiment using 5,6-dichlo-1-beta-d -ribofuranosylbenzimidaxole, the half-life of PIPKIIgamma mRNA was approximately 6 h in the presence or absence of TSH, and it was not affected by the stability of the PIPKIIgamma mRNA. The effects of TSH on PIPKIIgamma gene expression were specific, and other growth factors examined (transferrin, insulin and hydrocortisone) did not alter its expression. It is possible that the mechanism of PIPKIIgamma gene expression is involved in the permissive effect of the TSH-cAMP cascade proper. Our results indicate, for the first time, that the expression of PIPKIIgamma is regulated transcriptionally by TSH in thyrocytes.

Production and characterization of monoclonal antibodies directed to the kringle V and protease domains of human apolipoprotein(a)

Production and use of anti-apolipoprotein(a) monoclonal antibodies (MAbs) specific to single copy regions in the polymorphic lipoprotein(a) (Lp(a)) has been emphasized to be important for the standardization of measurements of the coronary heart disease risk factor, Lp(a). Here, mouse MAbs were prepared against the kringle V (V) and protease (P) domains of human apolipoprotein(a) (apo(a)), which domains are present in single copy in the apo(a) molecule. The cDNA for apo(a)VP was cloned from human liver cDNA library, and the V-P recombinant protein overexpressed in Escherichia coli was used as an antigen for the antibody production. Two antibodies named as MAb(a)20 and MAb(a)23 were finally produced, and they were characterized for their binding specificity and epitopes. The specificity of the antibodies was confirmed by an immunoblotting procedure and an enzyme-linked immunoassay (ELISA). It was shown that the antibodies had little, if any, cross-reactivity with human plasminogen, which is relatively abundant in human serum and is highly homologous (85%) with apo(a) in amino acid (aa) sequence. For epitope analysis, 3'-deletional series of apo(a)VP cDNA were constructed, and expression products of them were analyzed for the binding MAb(a)20 and MAb(a)23 do. It has been revealed that distinct epitopes were recognized by the two MAbs: MAb(a)23 (gamma2b, kappa) bound to the V region about 60 aa downstream from the N-terminal, and MAb(a)20 (gamma1, kappa) bound to the P region close to the C-terminal. A one step-sandwich ELISA system for Lp(a) was developed using MAb(a)20 as a capturing antibody and horseradish peroxidase (HRP)-coupled MAb(a)23 as a detecting antibody. The assay was found to be sensitive and useful for detecting Lp(a) in the range of 4-150 microg/dL (80 pM-3 nM).

TSH regulates a gene expression encoding ERp29, an endoplasmic reticulum stress protein, in the thyrocytes of FRTL-5 cells

This experiment was performed to evaluate the effect of thyroid-stimulating hormone (TSH) on the endoplasmic reticulum resident 29 kDa protein (ERp29) gene expression in the thyrocytes of FRTL-5 cells. Although ERp29 mRNA was constantly expressed, its expression began to increase remarkably from 10(-9) M TSH. On the other hand, the effect of TSH on the abundance of ERp29 mRNA started within 6 h and peaked at 8 h. Actinomycin D strongly blocked this effect while cycloheximide did not. The half-life of ERp29 mRNA was about 4-4.5 h in the presence or absence of TSH that was not affected by the stability of ERp29 mRNA. The effect of TSH on the ERp29 gene expression was specific, while other growth factors (transferrin, insulin and hydrocortisone) did not alter its expression. Our data indicate for the first time that the expression of ERp29 is regulated transcriptionally by TSH in thyrocytes.

Effects of red ginseng saponins and nootropic drugs on impaired acquisition of ethanol-treated rats in passive avoidance performance

Effects of single and repeated administration of red ginseng total saponins (ROTS) and nootropic drugs were examined on impairment of acquisition induced by single oral administration of 3 g/kg ethanol (EtOH) in a step through test. The inhibitory effect of EtOH on acquisition was significantly reduced following single or repeated RGTS administration. The nootropic drugs, piracetam and N-methyl-D-glucamine, given orally significantly reduced impairment of acquisition induced by EtOH. On the other hand, the inhibitory effect of repeated RGTS on the EtOH-induced amnesia was blocked by the pretreatment of alpha-methyl-p-tyrosine (alpha-MT), an inhibitor of catecholamine synthesis, in a dose-dependent manner but not p-chlorophenylalanine (PCPA), an inhibitor of serotonin synthesis, whereas the inhibitory effect of repeated N-methyl-D-glucamine on the EtOH-induced amnesia was blocked neither by alpha-MT nor PCPA. These results suggest that repeated RGTS and N-methyl-D-glucamine ameliorate the impairing effect of EtOH on acquisition, and the effect of RGTS on EtOH-induced amnesia is dependent on the catecholaminergic but not serotonergic neuronal activity, while RGTS and N-methyl-D-glucamine seem to have a different mechanism on EtOH-induced amnesia.

Generation of self-antigen reactive, anti-urocortin specific antibodies by immunization of recombinantly expressed urocortin fusion proteins

Urocortin is a recently described 40-meric neuropeptide, which was originally detected in the rat mid-brain and is believed to play a key role in response to stress situations. While its function in the central nervous system is rather well established, the biological role in the periphery is still to be determined. To investigate its distribution and effect on peripheral cells and tissues, in the present study, urocortin was recombinantly expressed and specific antibodies were generated. So far, the immunological detection of urocortin in the rat was largely dependent on antisera generated in rabbits. However, the polyclonal nature of the serum and the remote species origin tend to show cross-reactivities and higher backgrounds. On the other hand, generation of mouse antibodies to rat urocortin was hampered since mouse and rat urocortin sequences are identical, and such antibodies would represent auto-reactive antibodies. Despite such restrictions, the immunization with a combination of various recombinantly expressed urocortin fusion proteins resulted in the successful generation of mouse antiurocortin antisera, whose specificities were confirmed by ELISA and Western blot analysis. To produce the recombinant proteins for immunization, a cDNA encoding the mature urocortin sequence was cloned and expressed in fusion either with the glutathione-S-transferase, the maltose-binding protein, thioredoxin, or a 6X His tag. Depending on the expression system, the solubility and yield of the recombinant proteins greatly varied. Together with the newly generated antibodies, these recombinantly expressed urocortin proteins will serve as valuable tools in further investigations of the biological function of urocortin.

Identification of cytochrome P450 2E1 in rat brain

We have isolated cDNA fragments that were originated from P450 2E1 in rat brain by PCR analysis. Their size matched up to what we expected based on the reported sequence of rat liver P450 2E1 mRNA. Internal structure of the longest first-round PCR products were investigated by Southern blot analysis and "nested" PCR. Their results confirmed that PCR products actually originated from P450 2E1 mRNA in rat brain. RT-PCR was also carried out using P450 2E1 specific primers and the size of the product was exactly as we expected for P450 2E1. These experimental evidences should clarify the presence of P450 2E1 in rat brain.

Molecular cloning and sequencing of sulfated glycoprotein-2 cDNA from testis of mouse: implications of two different mRNAs of SGP-2

We cloned a mouse homolog of sulfated glycoprotein-2 (SGP-2) cDNA by screening a mouse testicular cDNA library and its nucleotide sequence was determined. The predicted amino acid sequence of the cDNA shares 93% identity with that of rat SGP-2. The nucleotide sequences of both cDNAs show extensive homology throughout the open reading frames and 3' untranslated regions. The 5' untranslated regions, however, share homology only up to 28 bp upstream from the start codons; the rest of sequences are quite different. DNA sequence homology search to mouse SGP-2 cDNA through the EMBL/GenBank database and a recent study on the genomic organization of rat TRPM-2 gene suggest a possibility that there are at least two different SGP-2 mRNAs as a result of alternative splicing and/or different promoter usage in mouse.

DNA sequence, genomic organization, and chromosomal localization of the mouse peripheral myelin protein zero gene: identification of polymorphic alleles

We have cloned and characterized the mouse gene, P0, that encodes the predominant protein of peripheral myelin. Similar to the rat gene, the mouse P0 gene is encoded by six exons that span about 7 kb of DNA. The DNA sequence of the mouse gene is highly homologous with the rat gene, including the regions believed to be important in transcriptional control. Furthermore, the P0 protein appears well conserved throughout evolution. The gene was mapped to mouse chromosome 1 by Southern analysis of a Chinese hamster x mouse somatic cell hybrid panel. Several polymorphic restriction enzyme sites were identified within the P0 locus. Recombinant inbred strain mapping has linked the P0 gene to Ly-9/Ly/Sap in a region corresponding to band 1H3.

Presence of a bi-directional S phase-specific transcription regulatory element in the promoter shared by testis-specific TH2A and TH2B histone genes

During mammalian spermatogenesis, somatic histones are replaced by testis-specific variants. The synthesis of the variants occurs primarily in the germ cells undergoing meiosis in the absence of DNA replication. We have cloned the genes encoding rat somatic and testis-specific H2A (TH2A) histones. The two genes share 300 bp of 5' upstream region with respective H2B genes: somatic H2A with somatic H2B and testis-specific TH2A with testis-specific TH2B gene. The deduced amino acid sequences show that H2A and TH2A histones have eight amino acid differences in the first half of the molecules and three consecutive changes in the C-terminal region. TH2A gene is expressed only in testis. Although synthesis of TH2A and TH2B histones is independent of DNA replication and insensitive to inhibitors of DNA synthesis in testis, the regulatory region shared by the two genes contain a bi-directional S phase-specific transcription regulatory element. In addition, TH2A gene, like TH2B gene, contains the consensus sequence element in the 3' non-coding region which is involved in the S phase-specific stabilization of histone mRNA.

Selenocysteine tRNA[Ser]Sec gene is ubiquitous within the animal kingdom

Recently, a mammalian tRNA which was previously designated as an opal suppressor seryl-tRNA and phosphoseryl-tRNA was shown to be a selenocysteyl-tRNA (B. J. Lee, P. J. Worland, J. N. Davis, T. C. Stadtman, and D. Hatfield, J. Biol. Chem. 264:9724-9727, 1989). Hence, this tRNA is now designated as selenocysteyl-tRNA[Ser]Sec, and its function is twofold, to serve as (i) a carrier molecule upon which selenocysteine is biosynthesized and (ii) as a donor of selenocysteine, which is the 21st naturally occurring amino acid of protein, to the nascent polypeptide chain in response to specific UGA codons. In the present study, the selenocysteine tRNA gene was sequenced from Xenopus laevis, Drosophila melanogaster, and Caenorhabditis elegans. The tRNA product of this gene was also identified within the seryl-tRNA population of a number of higher and lower animals, and the human tRNA[Ser]Sec gene was used as a probe to identify homologous sequences within genomic DNAs of organisms throughout the animal kingdom. The studies showed that the tRNA[Ser]Sec gene has undergone evolutionary change and that it is ubiquitous in the animal kingdom. Further, we conclude that selenocysteine-containing proteins, as well as the use of UGA as a codon for selenocysteine, are far more widespread in nature than previously thought.

Primary choriocarcinoma of the lung

Choriocarcinoma was found in the lung of a 33-year-old woman. It was detected by percutaneous needle lung biopsy in the right lung and severe elevation of B-HCG in serum (200,000 IU/L). Primary choriocarcinoma of the lung is an extremely rare disease. Thus the patient was fully examined, especially the genital tract in order to find the choriocarcinoma foci, but this failed to disclose foci of the choriocarcinoma. After chemotherapy (MTX, actinomycin-D, Cyclophosphamide) the level of B-HCG in serum decreased. Thus we conclued that the choriocarcinoma of the lung was the primary tumor.

Conserved sequences in both coding and 5' flanking regions of mammalian opal suppressor tRNA genes

The rabbit genome encodes an opal suppressor tRNA gene. The coding region is strictly conserved between the rabbit gene and the corresponding gene in the human genome. The rabbit opal suppressor gene contains the consensus sequence in the 3' internal control region but like the human and chicken genes, the rabbit 5' internal control region contains two additional nucleotides. The 5' flanking sequences of the rabbit and the human opal suppressor genes contain extensive regions of homology. A subset of these homologies is also present 5' to the chicken opal suppressor gene. Both the rabbit and the human genomes also encode a pseudogene. That of the rabbit lacks the 3' half of the coding region. Neither pseudogene has homologous regions to the 5' flanking regions of the genes. The presence of 5' homologies flanking only the transcribed genes and not the pseudogenes suggests that these regions may be regulatory control elements specifically involved in the expression of the eukaryotic opal suppressor gene. Moreover the strict conservation of coding sequences indicates functional importance for the opal suppressor tRNA genes.