Surgical treatment of posttraumatic cystic and tethered spinal cords.

Posttraumatic syringomyelia as a cause of progressive neurologic deterioration has been well described. More recently, the noncystic posttraumatic tethered cord has been associated with identical progressive neurologic deterioration. A retrospective analysis of patients treated surgically with spinal cord untethering and/or cyst shunting to arrest a progressive myelopathy from a posttraumatic tethered and/or cystic cord was performed. Emphasis was on outcome using the American Spinal Injury Association (ASIA) sensory and motor scoring systems. During an 18-month period from May 1993 to December 1994, 70 patients with spinal cord injury were operated upon for tethered and/or cystic spinal cords because of a progressive myelopathy and deteriorating ASIA sensory/motor scores. Fifty-nine patients had follow-up data 1 year postoperatively. At the 1 year follow-up, there was small improvement in light touch sensory scores (0.67 points), pinprick scores (1.3 points), and motor scores (0.41 points) demonstrating that the progression of the myelopathic process was arrested. Thirty-four of these 59 patients had no previous surgery to their spinal cords. At 1 year follow-up, light touch scores improved on average 2.38 points, pinprick scores 3.88 points (p < 0.05), and motor scores 1.47 points, suggesting better outcome with first-time surgery. Of this latter group, 64.3% regained a lost function, 62.5% saw improvement in spasticity, 55.6% had substantial improvement in neurogenic pain, and 95.8% felt that surgery prevented further neurologic deterioration.

Regulation of corneal endothelial barrier function by adenosine, cyclic AMP, and protein kinases.

PURPOSE: To determine which processes or factors that regulate corneal hydration are responsible for the hydration-modulating effects of adenosine. Influx of fluid to the stroma and efflux to the aqueous humor are governed, respectively, by the imbibition pressure of the stromal matrix and the transendothelial ionic gradients determined by the permeability and active transport characteristics of this monolayer. The focus of this study was to assess the effects of adenosine on these endothelial parameters. METHODS: Isolated corneas freshly dissected from rabbit eyes were used throughout. Active ion transport was assessed by measurement of 86Rb+ uptake by the endothelial cells of intact corneas incubated for 30 minutes in 25 mM HCO3(-)-Ringer with agents promoting corneal deturgescence or corneal swelling. Intracellular and extracellular fluid in the scraped endothelial cell mass was estimated from simultaneous counts of 3H-mannitol and 14C-urea, allowing calculation of tissue-to-medium (T-M) ratios of 86Rb+ in cell water. Permeability of the endothelium was determined by measuring the efflux into the superfusate of 5-carboxyfluorescein (CF) applied to the stroma of deepithelialized corneas superfused at the endothelial surface with the same media described for 86Rb+ uptake. Thickness of these corneas and of others fixed for scanning electron microscopy was monitored with a specular microscope. RESULTS: In the control medium, 25 mM HCO3(-)-Ringer, 86Rb+ was accumulated to yield a T-M ratio of 6.21. Neither adenosine nor other agents that increase cyclic adenosine monophosphate (cAMP)--that is, forskolin and dibutyryl cAMP--changed this value to a significant extent. Bumetanide had no effect, but ouabain caused a decrease in T-M to 1.30, a 79% inhibition. Elimination of Na+ or HCO3- also caused marked decreases in uptake. Permeability to CF in control medium was 3.40 x 10(-4) cm/min. A decrease of more than 20% (P < 0.05) was seen in the presence of adenosine and cAMP promoters and also with the protein kinase inhibitor H-8, whereas phorbol myristate acetate caused an increase to 4.50 x 10(-4) cm/min (P < 0.01). Ouabain caused no change, but blocked the effects of adenosine. Reducing the Ca2+ concentration of the superfusing medium caused time-dependent increases in permeability to 4.57 at 15 to 45 minutes and 12.5 at 80 to 110 minutes. At the earlier time, this increase in permeability could be prevented by the addition of adenosine or H-8. Elimination of Na+ or HCO3- ions from the medium caused a small decrease in permeability and, like ouabain, blocked the effect of adenosine. Changes in thickness of corneas were consistent, in most cases, with the observed alterations in 86Rb+ uptake or permeability to CF. Scanning electron microscopy showed contraction and rounding of endothelial cells in low Ca2+ medium, with stretching of intercellular borders, features that were largely eliminated when adenosine was also present. CONCLUSIONS: Adenosine, through increasing cAMP, decreases permeability of the corneal endothelium. This effect, rather than a change in the active transport (fluid pump) mechanism, is responsible for the promotion of deturgescence and maintenance of lower steady state thickness of corneas exposed to adenosine. The mechanism may involve the phosphorylation state of cytoskeletal proteins and seems to be dependent on an undisturbed environment of monovalent ions.

Fluid and ion transport in corneal endothelium: insensitivity to modulators of Na(+)-K(+)-2Cl- cotransport.

The role of Na(+)-K(+)-2Cl- cotransport in ion and fluid transport of the corneal endothelium was examined by measuring changes in corneal hydration and uptake of 86Rb by the endothelial cell layer. Isolated, intact rabbit corneas maintain normal hydration when they are superfused at the endothelial surface with bicarbonate (HCO3-)-Ringer solutions as a result of equilibrium between active ion and fluid transport out of the stromal tissue and leak of fluid into stromal tissue from the aqueous humor. Furosemide and bumetanide did not alter this equilibrium when they were added to the superfusion medium. Uptake of 86Rb by the endothelium of the incubated cornea was increased 25% by bumetanide, but uptake in the presence of ouabain (70% less than that of controls) was not changed by bumetanide. In Na(+)-free medium, uptake of 86Rb was reduced by 58%, but it was unchanged in Cl(-)-free medium. Calyculin A, a protein phosphatase inhibitor and activator of Na(+)-K(+)-Cl- cotransport, was without effect on 86Rb uptake. Hypertonicity (345 mosmol/kg) increased uptake slightly, whereas hypotonicity (226 mosmol/kg) caused a 33% decrease. Neither of these changes was significantly different when bumetanide was present in the media. It is concluded that Na(+)-K(+)-2Cl- cotransporter activity is not exhibited by the in situ corneal endothelium and does not play a role in the ion and fluid transport of this cell layer. Its presence in cultured endothelial cells may reflect the reported importance of this protein in growth, proliferation, and differentiation.

Adenosine promotes regulation of corneal hydration through cyclic adenosine monophosphate.

PURPOSE: To investigate the cellular mechanisms whereby adenosine increases net transendothelial fluid transport by the endothelial cells of the cornea. METHODS: Rabbit corneas were isolated and the endothelial surface was superfused while thickness was measured with the specular microscope. Cyclic adenosine monophosphate (cAMP) was measured in endothelia from fresh and incubated corneas, and adenylyl cyclase and phosphodiesterase activities were measured in homogenates or the particulate fraction of endothelia from bovine or rabbit. Adenosine, adenosine-receptor agonists, dibutyryl cAMP, forskolin, and phosphodiesterase inhibitors were used to modulate physiological and biochemical parameters. RESULTS: Adenosine, N-ethyl(carboxamido)adenosine, dibutyryl cAMP, forskolin, and phosphodiesterase inhibitors all promoted deturgescence of swollen corneas and maintained fresh corneas at lower steady state thicknesses than in controls. These effects were abolished in the presence of ouabain or 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid or after complete removal of HCO3- from the media. Intracellular cAMP was significantly increased by forskolin and phosphodiesterase inhibitors and, to a lesser extent, by agonists. Increases in cAMP concentration declined rapidly with time. Cyclase activity in the bovine tissue was enhanced by agonists and by G-protein activators. Dose-response curves of corneal swelling indicated a greater sensitivity to N-ethyl(carboxamido)adenosine than to the A2 alpha specific agonist CGS 21680. CONCLUSIONS: Adenosine increases net endothelial fluid transport through an increase in cAMP. The effects are mediated by stimulation of adenylyl cyclase through a G-protein coupled to an adenosine receptor, which is most probably of the A2 beta subtype. Results suggest that the regulation of corneal hydration by adenosine is more probably through stimulation of active transport than through a change in permeability, involving either transmembrane fluxes of Na+ or HCO3- or another step tightly coupled to these primary events in fluid movement.