Surgical strategy for spinal metastases

STUDY DESIGN

A new surgical strategy for treatment of patients with spinal metastases was designed, and 61 patients were treated based on this strategy.

OBJECTIVES

To propose a new surgical strategy for the treatment of patients with spinal metastases.

SUMMARY OF BACKGROUND DATA

A preoperative score composed of six parameters has been proposed by Tokuhashi et al for the prognostic assessment of patients with metastases to the spine. Their scoring system was designed for deciding between excisional or palliative procedures. Recently, aggressive surgery, such as total en bloc spondylectomy for spinal metastases, has been advocated for selected patients. Surgical strategies should include various treatments ranging from wide or marginal excision to palliative treatment with hospice care.

METHODS

Sixty-seven patients with spinal metastases who had been treated from 1987-1991 were reviewed, and prognostic factors were evaluated retrospectively (phase 1). A new scoring system for spinal metastases that was designed based on these data consists of three prognostic factors: 1) grade of malignancy (slow growth, 1 point; moderate growth, 2 points; rapid growth, 4 points), 2) visceral metastases (no metastasis, 0 points; treatable, 2 points: untreatable, 4 points), and 3) bone metastases (solitary or isolated, 1 point; multiple, 2 points). These three factors were added together to give a prognostic score between 2-10. The treatment goal for each patient was set according to this prognostic score. The strategy for each patient was decided along with the treatment goal: a prognostic score of 2-3 points suggested a wide or marginal excision for long-term local control; 4-5 points indicated marginal or intralesional excision for middle-term local control; 6-7 points justified palliative surgery for short-term palliation; and 8-10 points indicated nonoperative supportive care. Sixty-one patients were treated prospectively according to this surgical strategy between 1993-1996 (phase 2). The extent of the spinal metastases was stratified using the surgical classification of spinal tumors, and technically appropriate and feasible surgery was performed, such as en bloc spondylectomy, piecemeal thorough excision, curettage, or palliative surgery.

RESULTS

The mean survival time of the 28 patients treated with wide or marginal excision was 38.2 months (26 had successful local control). The mean survival time of the 13 patients treated with intralesional excision was 21.5 months (nine had successful local control). The mean survival time of the 11 patients treated with palliative surgery and stabilization was 10.1 months (eight had successful local control). The mean survival time of the patients with terminal care was 5.3 months.

CONCLUSIONS

A new surgical strategy for spinal metastases based on the prognostic scoring system is proposed. This strategy provides appropriate guidelines for treatment in all patients with spinal metastases.

Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors

STUDY DESIGN

The study of seven patients with primary malignant or benign aggressive tumors who underwent a new aggressive surgical technique termed "total en bloc spondylectomy" is reported.

OBJECTIVES

To report a new surgical technique of total en bloc spondylectomy for complete, resection of primary spinal malignancy and for oncologic curability.

SUMMARY OF BACKGROUND DATA

The conventional approach for primary spinal malignancy is via intralesional piecemeal resection, and very few reports have described en bloc extralesional resectioning with histopathologically wide or marginal surgical margins.

METHODS

Total en bloc spondylectomy, consisting of en bloc laminectomy and en bloc corpectomy followed by anterior instrumentation with spacer grafting and posterior spinal instrumentation, was performed in five patients with primary malignant tumors and two patients with giant cell tumors. Patients were observed for 2 years to 6.5 years, except for one patient who died 7 months after surgery because of a mediastinal metastasis.

RESULTS

All patients, except one, attained significant clinical improvement after surgery with no major complications. Histologically, the margins were wide or marginal except for the pedicles, and occasionally the spinal canal and the posterior, where they were accepted to be intralesional. One patient died of metastasis that was not directly related to surgery itself. There was no local recurrence.

CONCLUSIONS

The advantages of total en bloc spondylectomy include resection of the involved vertebra(e) in two major blocs, rather than in a piecemeal pattern, and completion of the procedure during one surgical session posteriorly. The "total en bloc spondylectomy" offers one of the most aggressive modes of therapy for primary spinal malignancy.

Late radiographic findings after anterior cervical fusion for spondylotic myeloradiculopathy

A retrospective study was performed to evaluate the radiographic changes that occurred at spinal levels adjacent to fused vertebrae after anterior cervical fusion. One hundred six patients with cervical spondylotic myeloradiculopathy (88 men, 18 women) were followed for an average of 8.5 years. The average age at follow-up was 64 years. Forty-two patients underwent a single-level fusion, 52 had a two-level fusion, and 12 had three levels fused. Seventeen patients who underwent additional surgery after anterior fusion also were reviewed, with an average follow-up period of 2.9 years. Postoperatively, cervical flexion-extension resulted in significantly increased movement about the vertebral interspace at the upper adjacent level. An increment of posterior slip of the vertebra immediately above the fusion level, with associated spinal canal compromise of less than 12 mm, significantly affected neurologic results. Patients with multilevel fusions notably exhibited these radiographic abnormalities at adjacent levels. Spinal canal stenosis, when associated with dynamic spinal canal stenosis in the vertebra above the fusion level, affected late neurologic results. Results of salvage laminoplasty were not satisfactory. Unnecessarily extended longer fusion must be avoided.

Total en bloc spondylectomy for solitary spinal metastases

We have developed a technique for total en bloc spondylectomy through a posterior approach and now report our experience of 20 patients with a solitary or localised metastasis in the thoracic or lumbar vertebrae. There are two steps: an en bloc laminectomy, followed by en bloc resection of the vertebral body with an oncological wide margin and the insertion of a vertebral prosthesis. Pain was relieved in the 17 patients who could be assessed; 11 of the 15 patients with a neurological deficit were much improved, impending paralysis being prevented in 5 patients. There have been no local recurrences. Nine patients are at present alive with a mean follow up of 17.4 months.

Homozygous c.14576G>A variant of RNF213 predicts early-onset and severe form of moyamoya disease

OBJECTIVE

RNF213 was recently reported as a susceptibility gene for moyamoya disease (MMD). Our aim was to clarify the correlation between the RNF213 genotype and MMD phenotype.

METHODS

The entire coding region of the RNF213 gene was sequenced in 204 patients with MMD, and corresponding variants were checked in 62 pairs of parents, 13 mothers and 4 fathers of the patients, and 283 normal controls. Clinical information was collected. Genotype-phenotype correlations were statistically analyzed.

RESULTS

The c.14576G>A variant was identified in 95.1% of patients with familial MMD, 79.2% of patients with sporadic MMD, and 1.8% of controls, thus confirming its association with MMD, with an odds ratio of 259 and p < 0.001 for either heterozygotes or homozygotes. Homozygous c.14576G>A was observed in 15 patients but not in the controls and unaffected parents. The incidence rate for homozygotes was calculated to be >78%. Homozygotes had a significantly earlier age at onset compared with heterozygotes or wild types (median age at onset 3, 7, and 8 years, respectively). Of homozygotes, 60% were diagnosed with MMD before age 4, and all had infarctions as the first symptom. Infarctions at initial presentation and involvement of posterior cerebral arteries, both known as poor prognostic factors for MMD, were of significantly higher frequency in homozygotes than in heterozygotes and wild types. Variants other than c.14576G>A were not associated with clinical phenotypes.

CONCLUSIONS

The homozygous c.14576G>A variant in RNF213 could be a good DNA biomarker for predicting the severe type of MMD, for which early medical/surgical intervention is recommended, and may provide a better monitoring and prevention strategy.

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group

Choosing the right operation for metastatic spinal tumours is often difficult, and depends on many factors, including life expectancy and the balance of the risk of surgery against the likelihood of improving quality of life. Several prognostic scores have been devised to help the clinician decide the most appropriate course of action, but there still remains controversy over how to choose the best option; more often the decision is influenced by habit, belief and subjective experience. The purpose of this article is to review the present systems available for classifying spinal metastases, how these classifications can be used to help surgical planning, discuss surgical outcomes, and make suggestions for future research. It is important for spinal surgeons to reach a consensus regarding the classification of spinal metastases and surgical strategies. The authors of this article constitute the Global Spine Tumour Study Group: an international group of spinal surgeons who are dedicated to studying the techniques and outcomes of surgery for spinal tumours, to build on the existing evidence base for the surgical treatment of spinal tumours.

Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach

STUDY DESIGN

Seven patients with angular kyphotic deformity of the thoracic or thoracolumbar spine were treated by closing-opening wedge osteotomy using a single posterior approach.

OBJECTIVES

To examine the safety and efficacy of closing-opening wedge osteotomy for angular kyphosis.

SUMMARY OF BACKGROUND DATA

Correction osteotomy of severe kyphosis is a challenging operation. A two-stage operation has been commonly used: anterior release and decompression followed by posterior correction and fusion.

METHODS

Seven patients with angular kyphosis were treated. The apex level of kyphosis was T5 in one patient, T11 in one, and T12 in five. There was old fracture in five patients, congenital deformity in one, and neurofibromatosis in one. The first 30-35 degrees of kyphosis are corrected using the closing wedge technique with the hinge of the anterior longitudinal ligament after veretebrectomy and circumspinal decompression of the spinal cord. Then the hinge is moved posteriorly to the spinal cord and the remainder of the requisit angle of osteotomy is corrected using the opening-wedge technique (closing-opening wedge osteotomy). Spinal curvature is stabilized using posterior instrumentation and graft.

RESULTS

Localized kyphosis was reduced from an average of 67 degrees to 18 degrees at 2.2 to 7.5 years' follow-up. Sagittal alignment from T1 to the sacrum became more physiologic than before. There were no neurologic complications. Bony fusion was achieved in all patients, and there was no correction loss.

CONCLUSIONS

Satisfactory correction is safely performed by closing-opening wedge osteotomy with a direct visualization of the circumferentially decompressed spinal cord. Although the performance is technically laborious, it offers good correction without jeopardizing the integrity of the spinal cord.

Expansive midline T-saw laminoplasty (modified spinous process-splitting) for the management of cervical myelopathy

STUDY DESIGN

The authors developed a method of spinous process-splitting laminoplasty using a threadwire saw in a prospective study of 25 patients with cervical myelopathy. This report describes the surgical technique and the results of the expansive midline laminoplasty performed with an threadwire saw.

OBJECTIVES

To compare the efficacy of midline, threadwire-saw laminoplasty with that of the original spinous process-splitting laminoplasty.

SUMMARY OF BACKGROUND DATA

The spinous process-splitting laminoplasty was described by Kurokawa in 1982. Although the procedure has a number of theoretical and practical advantages, it has not been widely used because of technical difficulties.

METHODS

Twenty-five patients who underwent expansive, midline, threadwire-saw laminoplasty from C3 to C7 for cervical myelopathy were studied. The threadwire saw was used to split the spinous processes. The mean follow-up period was 34 months. Neurologic results were evaluated with pre- and postoperative scores, and recovery rates were evaluated by methods described in previous reports using the Japanese Orthopaedic Association scoring system. Radiographic data analyzed included plain radiographs and computed tomography scans. The duration of surgery and the amount of blood lost during this procedure using the threadwire saw were compared with the duration and blood loss that occurred during the original Kurokawa's procedure using a burr.

RESULTS

In all cases, good enlargement of the cervical canal was achieved. The mean increase in cervical cross-sectional area was 36.1%, according to computed tomography scans. No dural tears occurred, and no patients experienced any decrease in neurologic function. The neurologic recovery rate was 72%, which was almost same as the neurologic recovery rate in the original procedure. Using the threadwire saw, the mean duration of surgery was 63 minutes shorter and the mean blood loss was 70 cc less than in procedures using burrs.

CONCLUSIONS

The application of the threadwire saw to split the spinous processes made Kurokawa's procedure simpler, faster, and safer.

Results of 280 liver resections for hepatocellular carcinoma

OBJECTIVE

To evaluate the recent results of liver resection in patients with hepatocellular carcinoma.

DESIGN

Retrospective study.

SETTING

A university hospital in Japan.

PATIENTS

Two hundred eighty patients who underwent liver resection with complete extirpation of hepatocellular carcinoma from 1985 to 1993.

MAIN OUTCOME MEASURES

Morbidity and survival after operation and the pathologic features of hepatocellular carcinoma according to the TNM classification of the International Union Against Cancer.

RESULTS

More than 40% of the patients with stages I and II disease underwent a partial resection of the liver, whereas 50% of those with stages III and IVA were operated on with more than a bisegmentectomy. Fifty percent of all patients had no postoperative complications. The morbidities included intra-abdominal abscess (7%), bile leakage (5%), and hepatic failure (4%, of whom half died; mortality rate, 2%). Histopathologically, 32% of the stage I tumors were well differentiated (grade 1), while, in stage III, 56% had portal invasion and 61% had daughter lesions in the liver. The cumulative survival rates of patients with stages I, II, and III disease and all patients at 5 years were 69%, 52%, 32%, and 50%, respectively, while the disease-free survival rates at 5 years were 38%, 34%, 17%, and 29%, respectively.

CONCLUSION

The recent results of liver resection for hepatocellular carcinoma are generally satisfactory; however, the recurrence rate is still high.

Recurrent mutations of CD79B and MYD88 are the hallmark of primary central nervous system lymphomas

AIMS

Primary central nervous system lymphoma (PCNSL) manifest aggressive clinical behaviour and have poor prognosis. Although constitutive activation of the nuclear factor-κB (NF-κB) pathway has been documented, knowledge about the genetic alterations leading to the impairment of the NF-κB pathway in PCNSLs is still limited. This study was aimed to unravel the underlying genetic profiles of PCNSL.

METHODS

We conducted the systematic sequencing of 21 genes relevant to the NF-κB signalling network for 71 PCNSLs as well as the pyrosequencing of CD79B and MYD88 mutation hotspots in a further 35 PCNSLs and 46 glioblastomas (GBMs) for validation.

RESULTS

The results showed that 68 out of 71 PCNSLs had mutations in the NF-κB gene network, most commonly affecting CD79B (83%), MYD88 (76%), TBL1XR1 (23%), PRDM1 (20%) and CREBBP1 (20%). These mutations, particularly CD79B and MYD88, frequently coincided within each tumour in various combinations, simultaneously affecting diverse pathways within the network. No GBMs had hotspot mutation of CD79B Y196 and MYD88 L265.

CONCLUSIONS

The prevalence of CD79B and MYD88 mutations in PCNSLs was considerably higher than reported in systemic diffuse large B-cell lymphomas. This observation could reflect the paucity of antigen stimuli from the immune system in the central nervous system (CNS) and the necessity to substitute them by the constitutive activation of CD79B and MYD88 that would initiate the signalling cascades. These hotspot mutations may serve as a genetic hallmark for PCNSL serving as a genetic marker for diagnose and potential targets for molecular therapy.

Analysis of treatment outcome after stereotactic radiosurgery for cavernous sinus meningiomas

OBJECT

The long-term outcome of stereotactic radiosurgery for cavernous sinus (CS) meningiomas is not fully understood. The authors retrospectively reviewed their experience with 40 CS meningiomas treated with gamma knife radiosurgery.

METHODS

Follow-up periods for the 40 patients ranged from 12 to 123 months (median 42 months), and the overall tumor control rates were 86.4% at 3 years and 82.3% at 10 years. Factors associated with tumor recurrence in univariate analysis were histological malignancy (p < 0.0001), partial treatment (p < 0.0001), suprasellar tumor extension (p = 0.0201), or extension in more than three directions outside the CS (p = 0.0345). When the tumor was completely covered with a dose to the margin that was higher than 14 Gy (Group A, 22 patients), no patient showed recurrence within the median follow-up period of 37 months. On the other hand, when a part of the tumor was treated with 10 to 12 Gy (Group B, 15 patients) or did not receive radiation therapy (Group C, three patients), the recurrence rates were 20% and 100%, respectively. Neurological deterioration was seen in nine patients, but all symptoms were transient or very mild.

CONCLUSIONS

The data indicate that stereotactic radiosurgery can control tumor growth if the whole mass can be irradiated by dosages of more than 14 Gy. When optimal radiosurgical planning is not feasible because of a tumor's large size, irregular shape, or proximity to visual pathways, use of limited surgical resection before radiosurgery is the best option and should provide sufficient long-term tumor control with minimal complications.

Circumspinal decompression for thoracic myelopathy due to combined ossification of the posterior longitudinal ligament and ligamentum flavum

Ossification of the posterior longitudinal ligament (OPLL) combined with ossification of the ligamentum flavum (OLF) in the thoracic spine can result in serious myelopathy, leading to circumferential compression of the spinal cord in advanced stages of the disease. The authors performed circumspinal decompression (circumferential decompression of the spinal cord) on these patients. This operation consists of two steps: posterior and lateral decompression of the spinal cord by removal of the OLF (first step) and anterior removal of the OPLL for anterior decompression (second step), followed by interbody fusion. In the first step, two deep parallel gutters, covering the extent of the OPLL to be removed anteriorly, are drilled down from the rear into the vertebral body along both sides of the dura to easily and safely remove the OPLL anteriorly at the second step. In the second step, the surgical approach varies according to the affected level; costotransversectomy in the upper thoracic spine and standard thoracotomy in the middle or lower thoracic spine. According to the authors, circumspinal decompression is not an easy procedure, but from their results in 10 patients, they identify it as a radical and promising surgical procedure.

Protective effect of spreading depression against neuronal damage following cardiac arrest cerebral ischaemia

Effect of spreading depression (SD) on survival of CA1 hippocampal neurons was studied in Sprague-Dawley rats subjected to cardiac arrest cerebral ischaemia (CACI). SD was induced either by the topical application of KCI to the cerebral cortex (CSD) or by KCI perfusion of the hippocampus via a microdialysis cannula (HSD). CACI was carried out by intrathoracic compression of major cardiac vessels at 1, 3 and 7 days after CSD induction and 3 days after HSD, following which neuronal loss in the CA1 sector of the hippocampus was determined morphometrically. Our study revealed the significant protective effect of SD on survival of the CA1 pyramidal neurons in rats which were subjected to CACI 3 days later. No significant indication of a protective effect was observed in animals with SD induced 1 or 7 days prior to CACI nor in rats in which KCI was substituted by NaCl of equivalent concentration which did not induce any SD waves. Microdialysis assay during HSD showed a significant elevation of extracellular glutamate. Our studies, demonstrating an induction of a transitory period of neuronal resistance to ischaemia by preceding spreading depression, open an opportunity for elucidation of endogeneous factors responsible for the development of such resistance.

Total en bloc spondylectomy and circumspinal decompression for solitary spinal metastasis

We have developed a new surgical technique, 'total en bloc spondylectomy' (TES), to treat a solitary metastasis in the thoracic or lumbar vertebra. This operation is designed as a local cure for the metastatic site and involves the radical resection of the affected vertebra with a wide margin. The spondylectomy consists of two steps: en bloc laminectomy with posterior spinal instruments for stabilisation (first step) and en bloc corporectomy and replacement using a vertebral prosthesis (second step). TES makes it possible to remove the affected vertebra extracompartmentally with its tumour barrier and accomplishes circumferential decompression of the spinal cord. Before clinical practice, we constructed experimental models using cats to examine spinal cord blood flow (SCBF) after ligation of the nerve roots and circumspinal decompression. The changes of SCBF were negligible, so it was proved that TES on one vertebra has little effect on spinal cord circulation. This method was used in 24 patients. Fourteen of the 18 patients with neurological deficits improved remarkably, and the 23 evaluable cases experienced pain relief. Impending paralysis was prevented in all six patients by this surgical intervention. There has been no recurrence of the local tumour after surgery. After a median follow up period of 14.1 months, 12 patients have survived. These data suggest that TES may have a significant clinical value in the treatment of spinal metastasis.

Cortical spreading depression induces long-term alterations of BDNF levels in cortex and hippocampus distinct from lesion effects: implications for ischemic tolerance

Cortical spreading depression (CSD) protects hippocampal and cortical neurons from an otherwise lethal ischemic insult delivered days later. The present study was undertaken to evaluate changes in the expression of BDNF following CSD, distinct from lesion effects and its possible involvement in delayed ischemic tolerance. CSD was elicited by KCl application and a cortical lesion was made by hyperosmolar NaCl application. BDNF mRNA was examined by in situ hybridization and Northern blot up to 7 days post-CSD. BDNF protein content was measured by ELISA. In the cortex, BDNF protein was mildly elevated despite minimal increases of mRNA in the NaCl lesion group. CSD specifically up-regulated BDNF mRNA at 4 h, followed by a delayed secondary increase at 2-3 days. BDNF protein exhibited smaller biphasic increases at 24 h and 3-7 days post-CSD which were significantly higher than the NaCl lesion group. In the hippocampus, BDNF protein levels showed a delayed decrease in both groups independent of mRNA changes, but CSD specifically delayed this decrease. Thus, CSD can alter BDNF levels independent of lesion effects. The increased BDNF following CSD in the cortex is consistent with the involvement of BDNF in cortical ischemic tolerance. BDNF could not, however, be directly related to ischemic tolerance in the hippocampus.

Enhanced expression of thrombospondin-1 and hypovascularity in human cholangiocarcinoma

Cholangiocarcinoma (CCC) is relatively hypovascular, in contrast to hepatocellular carcinoma (HCC), which is often highly vascular. We investigated if the diminished vascularity of CCC is related to altered expression of thrombospondin-1 (TSP-1), an antiangiogenic factor, and/or vascular endothelial growth factor (VEGF), a potent angiogenic factor, comparing the relationships with those of high- and low-vascular HCC. We also investigated the relationship between the mutation of the p53 gene and TSP-1 expression or VEGF expression. Northern blot analysis and immunohistochemical staining were performed on surgically resected human CCC and HCC. The ratios of TSP-1 mRNA level in cancer cells versus adjacent noncancerous cells (T/N ratios) were significantly higher in CCC (n = 11) than in HCC with high vascularity (n = 15). In contrast, T/N ratios of VEGF mRNA level in CCC (n = 11) were comparable with those in HCC with low vascularity (n = 5). In CCC, the cancer cells and fibroblasts were positively stained with anti-TSP-1 antibody. We observed that T/N ratios of VEGF mRNA level, but not those of the TSP-1 mRNA level, were significantly correlated with vascularity in HCC. The relative increase in TSP-1 and the relative decrease in VEGF in tumors compared with normal tissue may underlie the limited angiogenesis of CCC. The p53 gene did not affect the expression of TSP-1 in CCC or VEGF in HCC.

Radiation-induced apoptosis of oligodendrocytes in the adult rat brain

Although radiation injuries to the brain are well documented, immediate early histological changes in the brain remain to be defined. The present study characterizes glial injury provoked in adult rat white matter within 24 h after a single irradiation of the whole brain (10 or 20 Gray). Irradiated brains were histologically and histochemically analyzed. TUNEL-positive cells exhibiting apoptotic morphology were counted in five representative regions of the white matter. Glial cell death was further evaluated by glial cell density 24 h after irradiation, which induced both dose (p < 0.0001)- and time- (p < 0.0001) dependent apoptosis in these cells. The overall apoptotic rate in the white matter peaked within 8 h after irradiation. Total glial cell density decreased significantly in the white matter 24 h after irradiation. TUNEL-positive cells were immunohistochemically negative for GFAP, a marker for astrocytes, but positive for CNP, a marker for oligodendrocytes. The apoptotic rate was highest in the external capsule (p < 0.0001), followed by the fimbria and genu of the corpus callosum (p < 0.0001). The rates were lowest in the internal capsule and cerebellum. These data indicated that brain irradiation induces rapid apoptotic depletion of the oligodendroglial population, which may participate in the development of radiation-induced pathological conditions.

Chordoma in the cervical spine managed with en bloc excision

STUDY DESIGN

En bloc resection of a chordoma in the midcervical vertebral spine was performed.

OBJECTIVES

To document the surgical technique used for en bloc excision of a chordoma arising in the midcervical spine.

SUMMARY OF BACKGROUND DATA

Malignant tumors arising in long bones are excised en bloc. The authors recently designed a technique for en bloc resection of malignant tumors in the thoracolumbar spine using the T-saw. However, this technique is difficult in tumors of the cervical spine, and there are no previous reports of successful en bloc resection of such tumors.

METHODS

Using an anterior approach, the ipsilateral vertebral artery was ligated. This was followed by sharply cutting the pedicle of the cervical vertebra with a specially designed T-saw.

RESULTS

En bloc excision of chordomas in the cervical spine was achieved using the T-saw.

CONCLUSION

Although the surgical margin was intralesional in a small area, the technique used in this case study indicates that en bloc excision of such tumors can be used with a safety margin even in the cervical spine.

Anti-inflammatory effect of Zingiber cassumunar Roxb. and its active principles

The present study was carried out to elucidate the anti-inflammatory effect of the methanol extract obtained from the rhizomes of Zingiber cassumunar Roxb. and its active principles. The methanol extract was partitioned between ether and water, and then the ether-soluble fraction was extracted with n-hexane. The n-hexane-soluble fraction was chromatographed and part of the fraction was rechromatographed by silica gel column. Three compounds were isolated from the n-hexane-soluble fraction and the chemical structures of these compounds were identified as (E)-1-(3,4-dimethoxyphenyl)but-1-ene, (E)-1-(3,4-dimethoxyphenyl)butadiene and zerumbone. The anti-inflammatory activity of these fractions was investigated on carrageenin-induced edema in rats, as well as on acetic acid-induced vascular permeability and writhing symptoms in mice. The methanol extract (p.o.) showed both anti-inflammatory activity and analgesic activity. These activities shifted successively to ether-soluble and n-hexane-soluble fractions and to (E)-1-(3,4-dimethoxyphenyl)but-1-ene. These results suggest that the anti-inflammatory action and analgesic action of Zingiber cassumunar is the result of the (E)-1-(3,4-dimethoxyphenyl)but-1-ene that it contains.

Application of 62Cu-diacetyl-bis (N4-methylthiosemicarbazone) PET imaging to predict highly malignant tumor grades and hypoxia-inducible factor-1α expression in patients with glioma

BACKGROUND AND PURPOSE

Hypoxic tissue evaluation in glioma is important for predicting treatment response and establishing antihypoxia therapy. In this preliminary study, (62)Cu-ATSM PET was used to determine its validity as a biomarker for distinguishing tumor grade and tissue hypoxia.

MATERIALS AND METHODS

(62)Cu-ATSM PET was performed in 22 patients with glioma, and the (62)Cu-ATSM SUV(max) and T/B ratio were semiquantitatively evaluated. (62)Cu-ATSM uptake distribution was qualitatively evaluated and compared with MR imaging findings. HIF-1α expression, a hypoxia marker, was compared with (62)Cu-ATSM uptake values.

RESULTS

The (62)Cu-ATSM SUV(max) and T/B ratio were significantly higher in grade IV than in grade III gliomas (P = .014 and .018, respectively), whereas no significant differences were found between grade III and grade II gliomas. At a T/B ratio cutoff threshold of 1.8, (62)Cu-ATSM uptake was predictive of HIF-1α expression, with 92.3% sensitivity and 88.9% specificity. The mean T/B ratio was also significantly higher in HIF-1α-positive glioma tissue than in HIF-1α-negative tissue (P = .001). Using this optimal threshold of T/B ratio, (62)Cu-ATSM PET showed regional uptake in 61.9% (13/21) of tumors within the contrast-enhanced region on MR imaging, which was significantly correlated with presence of a necrotic component (P = .002).

CONCLUSIONS

Our results demonstrated that (62)Cu-ATSM uptake is relatively high in grade IV gliomas and correlates with the MR imaging findings of necrosis. Moreover, the (62)Cu-ATSM T/B ratio showed significant correlation with HIF-1α expression. Thus, (62)Cu-ATSM appears to be a suitable biomarker for predicting highly malignant grades and tissue hypoxia in patients with glioma.

Cadaveric vascular anatomy for total en bloc spondylectomy in malignant vertebral tumors

STUDY DESIGN

The authors studied the vascular anatomy of the thoracic and lumbar spine in cadavers related to the clinical use of total en bloc spondylectomy in malignant vertebral tumors.

OBJECTIVE

To enhance anatomic knowledge on major and associated segmental vessels surrounding the anterior vertebral column of the thoracic and lumbar spine.

SUMMARY OF BACKGROUND DATA

No reports have, to the authors' knowledge, referred clinically to the anatomic relationship between the vascular system and the anterior vertebral column in performing posterior total en bloc spondylectomy on the thoracic and lumbar spine.

METHODS

The authors studied the major vessels, segmental arteries and veins, and tendinous portions of the lumbar diaphragm inserting onto the vertebrae in 21 cadavers to view the vascular system surrounding the anterior vertebral column in the thoracic and lumbar spine.

RESULTS

The aorta descended in direct contact with the anterior vertebral column below T4 or T5 and branched into two common iliac arteries at L3 in one cadaver, at L3-L4 in two, at L4 in eight, at L4-L5 in nine, and at L5 in one. The uppermost intercostal artery originated at T4 or T5, and 48 (14%) variations in 348 intercostal arteries did not originate from the thoracic aorta. Two common iliac veins became confluent at L3-L4 in one subject, at L4-L5 in 13, and at L5 in seven. The inferior vena cava ascended in tight contact with the vertebral column and entered into the vena caval foramen of the diaphragm anterior to the right medial crus. The right medial crus of the diaphragm originated from the vertebra at L1-L2 in one subject, at L2 in two, at L2-L3 in 14, and at L3-L4 in four, whereas, on the left, this ligamentous origin located at L1-L2 in six, at L2 in two, at L2-L3 in 11, and at L3-L4 in two. The first two lumbar arteries ran consistently in the space between the medial crus and the vertebral column.

CONCLUSIONS

Total en bloc spondylectomy conducted posteriorly is less likely to damage the thoracic aorta from T1 to T4 but, distal to T5, the aorta must be carefully retracted anteriorly before manipulation of the affected vertebra(e). For a malignant tumor involving L1 or L2, the medial and, occasionally, the intermediate crura of the diaphragm and the first two lumbar arteries must be treated carefully before spondylectomy. Malignant tumors involving the L3 and L4 vertebral bodies can be approached with a total en bloc spondylectomy technique only when the inferior vena cava has been safely retracted anteriorly.

CT classification of small thalamic hemorrhages and their clinical implications

Thirty-seven small thalamic hemorrhages (less than 2 cm) were classified into four types depending on topographic location. Patients with posterolateral lesions had severe sensory and motor disability as well as the worst prognosis. Anterolateral lesions resulted in mild prefrontal signs with milder sensory and motor impairment. Medial hematomas disturbed consciousness in the acute stage, followed by impaired prefrontal signs of long duration. Dorsal hematomas were associated with ipsilateral parieto-occipital signs (aphasia on the left and topographic memory disturbance on the right).

Calcium crystal deposition in the ligamentum flavum of the cervical spine

This article reports eight patients who underwent posterior decompressive surgery for myeloradiculopathy caused by calcium crystal deposition in the ligamentum flavum of the cervical spine. All were women with an average age of 72 years and showed neurologic improvement postoperatively. Four patients had diabetes mellitus, and knee meniscus calcification on radiographs were noted in four patients. The ligamentum flavum of C5-6 and C6-7 were sites frequently involved. Crystallographic examination confirmed resected deposits as calcium pyrophosphate dihydrate crystal in all patients and additional hydroxyapatite crystal in two. Histology confirmed marked degeneration in elastic fibers about the calcium deposits. This pathologic condition is possibly spinal manifestation of systemic calcium crystal deposition disease.

Bacopaside I and II: two pseudojujubogenin glycosides from Bacopa monniera

Two saponins, designated as bacopaside I and II, have been isolated from Bacopa monniera Wettst. and their structures have been elucidated as 3-O-alpha-L-arabinofuranosyl-(1-->2)-[6-O-sulphonyl-beta-D-glucopyranosyl-(1-->3)]-alpha-L-arabinopyranosyl pseudojujubogenin (1) and 3-O-alpha-L-arabinofuranosyl-(1-->2)-[beta-D-glucopyranosyl (1-->3)]-beta-D-glucopyranosyl pseudojujubogenin (2) mainly on the basis of 2D NMR and other spectral analyses.

Recapping T-saw laminoplasty for spinal cord tumors

STUDY DESIGN

A prospective study of patients whose spinal cord tumors were managed surgically with a unique posterior method of removing and replacing the posterior spinal elements using T-saw ("recapping T-saw laminoplasty").

OBJECTIVES

To examine the safety and efficacy of the recapping T-saw laminoplasty technique for spinal canal surgery.

SUMMARY OF BACKGROUND DATA

Laminectomy, laminoplasty, and/or laminotomy typically are used to approach intraspinal lesions. When removal and replacement of the posterior elements have been attempted, the effectiveness of the technique has been limited by the amount of bone sacrificed when using burrs or osteotomes. The authors thought to adapt a unique "threadwire saw" (T-saw) in these cases, because its use results in minimal bone loss.

METHODS

Patients underwent recapping T-saw laminoplasty in the thoracic or lumbar spine for extirpation of spinal cord tumors. The T-saw was used for division of the posterior elements. After resection of the lesion, the excised laminae were replaced exactly in situ to their original anatomic position. The mean follow-up period was 47 months (range, 31-71 months). Patients were observed neurologically and radiologically.

RESULTS

One to eight laminae were excised and replaced in 24 patients. Findings on computed tomography scans confirmed primary bony union in 23 patients by 6 months after surgery, and in one patient by 12 months after surgery. No complications such as postoperative spinal canal stenosis, facet arthrosis, or kyphosis were observed.

CONCLUSIONS

Recapping laminoplasty afforded anatomic reconstruction of the vertebral arch after excision of spinal cord tumors. This procedure appears to warrant further evaluation as an alternative to wide laminectomies for exposure of intraspinal tumors.