Novel use of robotics and navigation for anterior lumbar total disc replacement surgery.

The ability to navigate the anterior lumbar disc space may improve clinical outcomes and implant longevity. However, no robotic navigation systems are presently authorized by the U.S. Food and Drug Administration to assist with anterior retroperitoneal lumbar interbody surgery. Furthermore, no studies to date have investigated such an application of this technology. This study examines the application of robotic navigation to anterior lumbar total disc replacement surgery to improve retroperitoneal exposure and orientation of the anterior lumbar spine, enhance coronal plane centralization of the implant, optimize surgical trajectory, and mitigate radiologic exposure. Postoperative outcomes of a small cohort of patients undergoing anterior lumbar total disc replacement surgery using robotic navigation were analyzed. The results of the study revealed that a modified use of the aforementioned robot-assisted surgical technology enhances coronal plane centralization and trajectory, all while mitigating radiologic exposure, resulting in more accurate placement of the implant within the intervertebral space at each level.

Outpatient Versus Inpatient Anterior Lumbar Spine Surgery: A Multisite, Comparative Analysis of Patient Safety Measures.

BACKGROUND: The frequency and complexity of spinal surgery performed in an ambulatory surgery center (ASC) is increasing. However, safety and efficacy data of most spinal procedures adapted to the ASC are sparse and have focused on anterior cervical surgery. The purpose of this study was to compare the 90-day complication and readmission rates of anterior lumbar spine surgery performed in an ASC or inpatient setting. METHODS: We performed a retrospective comparative analysis of 226 consecutive anterior lumbar surgeries (283 levels treated) completed in an ASC (n = 124) or in an inpatient tertiary care hospital (n = 102) over a 3-year period. These included anterior lumbar interbody fusion (ALIF), artificial disc replacement (ADR), and hybrids. Patients undergoing simultaneous or staged posterior procedures within 3 months were excluded. Patient demographics and surgical parameters between the two surgical settings were compared. Ninety-day medical complications and readmission rates were assessed. One-way analysis of variance and Chi-square analysis were used. A P value of less than .05 was considered statistically significant. RESULTS: The two study groups had similar baseline characteristics. While there was a trend toward fewer complications, reoperations, and readmissions for the ASC cohort, the differences were not statistically significant. There were 7 intraoperative complications (5.6% minor vascular injury) in the inpatient cohort and 0 in the ASC cohort. The overall 90-day postoperative complication rate was 5.6% for the inpatient cohort and 0.9% for the ASC cohort. The 90-day readmission rate was 1.9% in the ASC cohort and 1.6% in the inpatient cohort. The 90-day reoperation rate was 0.8% for the inpatient cohort and 0% in the ASC cohort. The average hospital stay was 2.3 ± 1.5 days for the inpatient cohort. CONCLUSION: The 90-day readmission rates were lower for outpatients than for inpatients, while the complication and reoperation rates were similar. Our results demonstrate that anterior lumbar procedures, including single-level and multilevel ALIF, ADR, and hybrid procedures, can be performed safely in an ASC. This has significant cost savings implications for the ASC setting.

The role of hydroxyurea in decreasing the occurrence of vasso-occulusive crisis in pediatric patients with sickle cell disease at King Saud Medical City in Riyadh, Saudi Arabia.

OBJECTIVES: To measure the incidence of vaso-occlusive crises (VOC) and the role of hydroxyurea (HU) in reducing VOC in sickle cell anemia  patients being treated at a large tertiary care setting in Kingdom of Saudi Arabia (KSA). The secondary objective of this study is to observe the gradual improvement in laboratory data (white blood cell [WBC], platelets, mean corpuscular volume [MCV], hemoglobin [Hgb], HgbF) following regular use of HU. Methods: Clinical effectiveness of HU was evaluated in a large pediatric population using a retrospective cohort, non-interventional, pre-post treatment study designed to control disease severity selection bias. The cohort included children with SCA (sickle cell (SS), sickle-beta thalassemia) at King Saud Medical City, Riyadh, KSA, who initiated HU between January 2012 and June 2017. For each patient healthcare utilization, laboratory values, and clinical outcomes were observed for an equal duration of time pre and post hydroxyurea. Results: Out of 416 SCD patients, 128 children with SCD who initiated HU, of them 82 met the eligibility criteria. After initiation of HU, there was significant reduction in both VOC (80%) and length of stay (LOS) (73%). Significant increase in Hgb (13%), MCV (10%), and HgbF (28%) and significant decrease in WBC (28%) was observed. Only the mean platelet count decreased by 3% with a p greater than 0.05. Conclusion: Hydroxyurea treatment significantly decreased episodes of VOC and LOS, it also led to reductions in hospitalizations and significant improvement in complete blood count indices.

Use of the video telescope operating monitor (VITOM) as an alternative to the operating microscope in spine surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To evaluate the efficacy of video telescope operating monitor (VITOM) as an alternative to operative microscope (OM) in spinal surgery. SUMMARY OF BACKGROUND DATA: The surgical operating microscope can be expensive, cumbersome, and ergonomically disadvantageous. VITOM is a novel telescope-based exoscope system that can be used as an alternative or supplement to OM. METHODS: Patients undergoing spinal surgery were enrolled in a prospective cohort study between December 2008 and March 2011. Age, sex, and operation-matched patients undergoing surgery using the standard OM served as the control group. During surgery, the VITOM system was used in place of the OM in 24 patients. Operative time, length of postoperative hospital stay, and intraoperative complications were assessed. RESULTS.: A total of 48 patients were studied in 2 equal cohorts of 24 patients each. Within each cohort, patients underwent single-level (n = 4) and 2-level (n = 7) posterior decompression as well as single-level (n = 11) and 2-level (n = 2) transforaminal lumbar interbody fusions via VITOM, with an equal number of controls using OM. There were no significant differences in age (P = 0.79) or sex (P = 0.77) between cohorts.There were no statistically significant differences in mean operative room time for single-level decompressions (P = 0.38), 2-level decompressions (P = 0.12), single-level transforaminal lumbar interbody fusions (P = 0.13), or 2-level transforaminal lumbar interbody fusions (P = 0.15). Postoperative hospital length of stay averaged 2.9 days for the VITOM group versus 2.8 days for the traditional OM group (P = 0.75). There were no intraoperative complications in either group. Subjectively, surgeons rated the image quality as very high and equal to the OM. CONCLUSION: The VITOM system for spinal surgery provides outstanding image quality and an ease of manipulation rivaling the OM. There were no statistically significant differences in mean operative room time, intraoperative complications, or total hospital length of stay when using this novel system in several common spinal procedures relative to the OM.

Complications of the spine in ankylosing spondylitis with a focus on deformity correction.

Ankylosing spondylitis (AS) is a systemic inflammatory disorder with frequent spinal axis symptoms. In this paper, the authors explored the spinal manifestations of AS and its characteristic anatomical lesions, radiological findings, and complications. They also offer a comprehensive report of the medical and surgical treatments with a focus on deformity correction.

Expression of antisense uPAR and antisense uPA from a bicistronic adenoviral construct inhibits glioma cell invasion, tumor growth, and angiogenesis.

Urokinase-type plasminogen activator (uPA) and its receptor (uPAR) play an important role in the invasiveness of gliomas and other infiltrative tumors. In glioma cell lines and tumors, high grade correlates with increased expression of uPAR and uPA. We report here the downregulation of uPAR and uPA by delivery of antisense sequences of uPAR and uPA in a single adenoviral vector, Ad-uPAR-uPA (Ad, adenovirus). The bicistronic construct (Ad-uPAR-uPA) infected glioblastoma cell line had significantly reduced levels of uPAR, uPA enzymatic activity and immunoreactivity for these proteins when compared to controls. The Ad-uPAR-uPA infected cells showed a markedly lower level of invasion in the Matrigel invasion assays, and their spheroids failed to invade the fetal rat brain aggregates in the coculture system. Intracranial injection of SNB19 cells with the Ad-uPAR-uPA antisense bicistronic construct showed inhibited invasiveness and tumorigenicity. Subcutaneous injections of bicistronic antisense constructs into established tumors (U87 MG) caused regression of those tumors. Our results support the therapeutic potential of targeting the individual components of the uPAR-uPA system by using a single adenovirus construct for the treatment of glioma and other invasive cancers.

Expression of matrix metalloproteinases, their inhibitors, and urokinase plasminogen activator in human meningiomas.

MMP-2, MMP-9, and uPA have been previously described as important to the invasive and metastatic potential of human tumors, including breast, lung, glioblastoma, and prostate. We examined the activity of these proteases and the levels of their inhibitors (TIMP-1 and TIMP-2) in a series of human meningioma tissue samples. Normal brain tissue did not show elevated levels of uPA, MMP-2 or MMP-9 activity. Meningiomas showed a mild, to moderate to significantly high level of uPA, MMP-2, and MMP-9. However, no increase in TIMP-1 or TIMP-2 levels was detected. Immunohistochemistry confirmed the assay findings and localized these molecules to the cell surface. The findings provide evidence for elevated levels of uPA and MMPs in meningiomas and suggest a therapeutic target for minimizing the malignant propensity of meningiomas using protease inhibitors.

Treatment of aneurysms with wires and electricity: a historical overview.

Endovascular treatment of aneurysms has only recently become an accepted therapeutic modality. Nonetheless, treatment of aneurysms with the aid of various foreign bodies such as needle and wire insertion with or without electrical current has been reported since the first half of the 19th century. In 1832 Phillips induced clot formation in the femoral and carotid arteries of dogs by leaving needles in the arteries for variable lengths of time. Simultaneously, in France, Velpeau had proposed using "l'acupuncture des arteres dans le traitement des anevrismes." Later, Phillips and Pelrequin connected the offending needles to a source of electrical current in an attempt to increase thrombus formation and aneurysm occlusion. Subsequently, Moore introduced the concept of packing the aneurysm with wire inserted through a needle transfixed to the vessel wall. To this method, Corradi added electrical current. Widely known as the Moore-Corradi technique, it was used in ensuing years with variable success. The early phase of endovascular aneurysm treatment culminated when Blakemore and Moore treated a case of symptomatic cavernous sinus aneurysm by passing wire through the patient's orbit. These pioneering cases combined with technological advances in the diagnosis of intracranial aneurysms paved the way for further refinements in coil embolization of aneurysms.

Modulation of cystatin C expression impairs the invasive and tumorigenic potential of human glioblastoma cells.

Increases in the abundance of cathepsin B transcript and protein with increased tumor grade and changes in subcellular localization and activity of this enzyme. We observed progressive reductions in levels of the protease inhibitor cystatin C, an inhibitor of cathepsin B with corresponding increases in the malignancy of glioma cell lines, implying an inverse correlation between cystatin C and tumor grade. To investigate the role of cystatin C in the invasion of brain tumor cells, we stably transfected SNB19 glioblastoma cells with either a 0.4-kb cDNA construct of human cystatin C in the sense orientation or an empty vector. Clones expressing sense-cystatin C cDNA had higher cystatin C mRNA and protein levels than did control cells. Sense-transfected cells were also markedly less invasive than control cells in a Matrigel invasion assay and in a coculture assay of SNB19 spheroids and fetal rat brain aggregates. Finally, the sense-transfected cells did not form tumors in nude mice upon intracerebral injection. These results strongly implicate cystatin C in the invasiveness of human glioblastoma cells and suggest that sense transcripts of cystatin C may prove useful in cancer therapy.

Adenovirus-mediated expression of antisense MMP-9 in glioma cells inhibits tumor growth and invasion.

Matrix metalloproteinase 9 (MMP-9) is known to play a major role in cell migration and invasion in both physiological and pathological processes. Our previous work has shown that increased MMP-9 levels are associated with human glioma tumor progression. In this study, we evaluated the ability of an adenovirus containing a 528 bp cDNA sequence in antisense orientation to the 5' end of the human MMP-9 gene (Ad-MMP-9AS) to inhibit the invasiveness and migratory capacity of the human glioblastoma cell line SBN19 in in vitro and in vivo models. Infection of glioma cells with Ad-MMP-9AS reduced MMP-9 enzyme activity by approximately 90% compared with mock- or Ad-CMV-infected cells. Migration and invasion of glioblastoma cells infected with Ad-MMP-9AS were significantly inhibited relative to Ad-CMV-infected controls in spheroid and Matrigel assays. Intracranial injections of SNB19 cells infected with Ad-MMP-9AS did not produce tumors in nude mice. However, injecting the Ad-MMP-9AS construct into subcutaneous U87MG tumors in nude mice caused regression of tumor growth. These results support the theory that adenoviral-mediated delivery of the MMP-9 gene in the antisense orientation has therapeutic potential for treating gliomas.

Ganglioglioma presenting as a meningioma: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Gangliogliomas are intra-axial, avascular masses located predominantly in the temporal lobe. A ganglioglioma that mimics a meningioma in that it is extra-axial and has a significant extracranial vascular supply has not been reported previously. CLINICAL PRESENTATION: A 12-year-old girl presented with a right temporoparietal mass. A neurological examination revealed nothing abnormal, and the girl's symptoms were limited to headaches. INTERVENTION: Magnetic resonance imaging revealed an extra-axial mass, and cerebral catheter angiography revealed a blood supply mainly from the posterior division of the right middle meningeal artery. Intraoperative findings confirmed the extra-axial location of the tumor, and histological analysis revealed that the tumor was a ganglioglioma. CONCLUSION: This report confirms that gangliogliomas can present as extra-axial, vascular masses that are similar to meningiomas.