A novel method for predicting the unbound valproic acid concentration.

In this study, we constructed a prediction formula for unbound valproic acid (VPA) concentration that was more accurate and widely applicable than previously reported formulae. A total of 136 datasets from 75 patients were analyzed retrospectively. The median of free fraction of VPA was 0.16 (interquartile range: 0.07; range: 0.07-0.45). The parameter that combined total VPA concentration (CtVPA) and serum albumin (SA), (CtVPA [µM] - 2 × SA [µM]), was significantly related to the free fraction of VPA (r = 0.76, p < 0.001). We constructed a combined parameter-based prediction formula for unbound VPA concentration. Analysis using external datasets from patients without severe renal failure showed that the prediction errors of the unbound VPA concentration were lower than those of previously reported formulae. Although the previous formulae showed large prediction errors, especially in the specific range of CtVPA values, the constructed formula showed a weak trend with CtVPA or SA. The formula based on (CtVPA [µM] - 2 × SA [µM]) had high prediction accuracy and wide applicability in predicting the unbound VPA concentration in patients without severe renal failure.

Three-dimensional phase-contrast magnetic resonance imaging for the detention of a small communicating defect in a patient with a spinal extradural arachnoid cyst: illustrative case.

BACKGROUND: Spinal extradural arachnoid cysts are thought to be pouches that communicate with the intraspinal subarachnoid space through a dural defect. The treatment for these cysts is resection of the cyst wall followed by obliteration of the communicating defect, which is often elusive. OBSERVATIONS: The authors report the case of a 22-year-old man with an extradural arachnoid cyst with claudication and progressive motor weakness. Regular magnetic resonance imaging (MRI) and computed tomography did not reveal the location of the defect in the cyst. However, three-dimensional (3D) phase-contrast MRI clearly indicated the location of the defect and the flow of cerebrospinal fluid into the cyst. These findings allowed the authors to perform the least invasive surgery; the patient recovered motor function and could walk more smoothly. LESSONS: 3D phase-contrast MRI can reveal a subtle dural defect in patients with spinal extradural arachnoid cysts.

[Report on a Psychiatric Clinical Practicum in Which Pharmacy Students Perform a Pharmaceutical Intervention].

Neuropsychiatric disorders are among the most represented disorders in the 2013 revision of the Model Core Curriculum for Pharmaceutical Education in Japan. However, it is reported that many pharmacy students have a negative impression of neuropsychiatric disorders because they do not know how to interact with psychiatric patients. To deepen students' understanding of pharmacotherapy for psychiatric disorders, Chiba University Hospital provides a one-day psychiatric clinical practicum in which pharmacy students perform a pharmaceutical intervention. In this practicum, students first had a group discussion about the case, assessed the pharmaceutical problem, and considered pharmacotherapy solutions to the problem on their own. Then, the students interviewed the patients directly to collect pharmaceutical-related information. Finally, the students participated in a conference and presented their own pharmacotherapy solutions to the problem. In this study, we conducted a questionnaire survey and assessed the students' reports in order to investigate their satisfaction with the practicum, changes in their impression of psychiatric disorders or patients with psychiatric disorders, and the level of knowledge they attained. The results showed that almost all students were satisfied with the practicum. The students' impression of psychiatric disorders or patients with psychiatric disorders changed in a positive direction. It seems that students came to realize the role and responsibility of the pharmacist in medical teams. These findings suggest that the practicum led to a positive change in the students' impression of psychiatric patients through conversations with the patients, assessment of pharmacotherapy from a pharmaceutical point of view, and proposing prescriptions.

Inhibition of Cell-Free Translation and Replication of Tobacco Mosaic Virus RNA by Exogenously Added 5'-Proximal Fragments of the Genomic RNA.

Replication proteins of tobacco mosaic virus (TMV), a positive-sense RNA virus, co-translationally bind to a 5'-proximal ~70-nucleotide (nt) region of the genomic RNA, referred to as the nuclease-resistant (NR) region for replication template selection. Therefore, disruption of the interaction between the viral replication proteins and viral genomic RNA is expected to inhibit the replication of TMV. In this study, we demonstrate that the addition of small RNA fragments (18-33 nts in length) derived from different regions within the NR region inhibit the binding of TMV replication proteins to viral RNA and TMV RNA replication in a cell-free system. Intriguingly, some of the small RNA fragments also inhibited the translation of mRNA in a sequence-nonspecific manner. These results highlight the pleiotropic roles of the 5'-proximal region of the TMV genome.

Tomato brown rugose fruit virus resistance generated by quadruple knockout of homologs of TOBAMOVIRUS MULTIPLICATION1 in tomato.

Tomato brown rugose fruit virus (ToBRFV) is an emerging virus of the genus Tobamovirus. ToBRFV overcomes the tobamovirus resistance gene Tm-22 and is rapidly spreading worldwide. Genetic resources for ToBRFV resistance are urgently needed. Here, we show that clustered regularly interspaced short palindromic repeats/CRISPR associated protein 9 (CRISPR/Cas9)-mediated targeted mutagenesis of four tomato (Solanum lycopersicum) homologs of TOBAMOVIRUS MULTIPLICATION1 (TOM1), an Arabidopsis (Arabidopsis thaliana) gene essential for tobamovirus multiplication, confers resistance to ToBRFV in tomato plants. Quadruple-mutant plants did not show detectable ToBRFV coat protein (CP) accumulation or obvious defects in growth or fruit production. When any three of the four TOM1 homologs were disrupted, ToBRFV CP accumulation was detectable but greatly reduced. In the triple mutant, in which ToBRFV CP accumulation was most strongly suppressed, mutant viruses capable of more efficient multiplication in the mutant plants emerged. However, these mutant viruses did not infect the quadruple-mutant plants, suggesting that the resistance of the quadruple-mutant plants is highly durable. The quadruple-mutant plants also showed resistance to three other tobamovirus species. Therefore, tomato plants with strong resistance to tobamoviruses, including ToBRFV, can be generated by CRISPR/Cas9-mediated multiplexed genome editing. The genome-edited plants could facilitate ToBRFV-resistant tomato breeding.

Influence of Intervertebral Level of Stenosis on Neurological Recovery and Reduction of Neck Pain After Posterior Decompression Surgery for Cervical Spondylotic Myelopathy: A Retrospective Multicenter Study with Propensity Scoring.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: To identify the impact of the intervertebral level of stenosis on surgical outcomes of posterior decompression for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: As the upper affected cervical levels in elderly patients result from degenerative changes in the lower cervical levels with aging, it is usually difficult to determine the influence of the upper affected cervical levels on surgical outcomes after posterior decompression for CSM in older age. METHODS: This study involved 636 patients with CSM who underwent posterior decompression. According to the most stenotic intervertebral level, patients were divided into upper (n = 343, the most stenotic intervertebral level was C2/3, C3/4, or C4/5) and lower (n = 293, the most stenotic intervertebral level was C5/6, C6/7, or C7/T1) cervical stenosis groups. Propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed to compare surgical outcomes, the Japanese Orthopaedic Association (JOA) scores, and visual analog scale (VAS) for neck pain between the upper (n = 135) and lower (n = 135) cervical stenosis groups. RESULTS: Before propensity score matching, age at surgery was older and pre- and postoperative JOA scores were lower in the upper cervical stenosis group (P < 0.001, P < 0.001, and P < 0.001, respectively). Following matching, baseline factors were comparable between the groups. Postoperative JOA scores, preoperative-to-postoperative changes in the JOA scores, and the JOA score recovery rate were not significantly different between the groups (P = 0.866, P = 0.825, and P = 0.753, respectively). No differences existed in postoperative VAS for neck pain and preoperative-to-postoperative changes in VAS for neck pain between the groups (P = 0.092 and P = 0.242, respectively). CONCLUSION: The intervertebral level of stenosis did not affect surgical outcomes after posterior decompression for CSM.Level of Evidence: 3.

Evaluation of association between parameters related to penetration into cerebrospinal fluid and the microbiological efficacy of vancomycin in patients with bacterial meningitis.

Vancomycin (VM) is used as empirical therapy for bacterial meningitis (BM). We investigated the relationship of the microbiological efficacy of VM for BM with VM minimum inhibitory concentration (MICVM), serum VM trough concentration (VMser) and cerebrospinal fluid (CSF) protein (P)/serum albumin (SA) ratio, which may reflect the extent of blood-brain barrier (BBB) disruption. Twelve BM patients were enrolled and VM was microbiologically effective in seven (58.3%). VMser, MICVM, and CSF-P/SA ratio were not associated with the microbiological efficacy of VM. The microbiological efficacy of VM was significantly associated with CSF-P/SA ratio multiplied by VMser relative to the MICVM (η = 0.61, p = 0.04). These results indicate that the parameter combining VMser, MICVM, and the extent of BBB disruption could be associated with the microbiological efficacy of VM in BM patients.

Cooperative recruitment of RDR6 by SGS3 and SDE5 during small interfering RNA amplification in Arabidopsis.

Small interfering RNAs (siRNAs) are often amplified from transcripts cleaved by RNA-induced silencing complexes (RISCs) containing a small RNA (sRNA) and an Argonaute protein. Amplified siRNAs, termed secondary siRNAs, are important for reinforcement of target repression. In plants, target cleavage by RISCs containing 22-nucleotide (nt) sRNA and Argonaute 1 (AGO1) triggers siRNA amplification. In this pathway, the cleavage fragment is converted into double-stranded RNA (dsRNA) by RNA-dependent RNA polymerase 6 (RDR6), and the dsRNA is processed into siRNAs by Dicer-like proteins. Because nonspecific RDR6 recruitment causes nontarget siRNA production, it is critical that RDR6 is specifically recruited to the target RNA that serves as a template for dsRNA formation. Previous studies showed that Suppressor of Gene Silencing 3 (SGS3) binds and stabilizes 22-nt sRNA-containing AGO1 RISCs associated with cleaved target, but how RDR6 is recruited to targets cleaved by 22-nt sRNA-containing AGO1 RISCs remains unknown. Here, using cell-free extracts prepared from suspension-cultured Arabidopsis thaliana cells, we established an in vitro system for secondary siRNA production in which 22-nt siRNA-containing AGO1-RISCs but not 21-nt siRNA-containing AGO1-RISCs induce secondary siRNA production. In this system, addition of recombinant Silencing Defective 5 (SDE5) protein remarkably enhances secondary siRNA production. We show that RDR6 is recruited to a cleavage fragment by 22-nt siRNA-containing AGO1-RISCs in coordination with SGS3 and SDE5. The SGS3-SDE5-RDR6 multicomponent recognition system and the poly(A) tail inhibition may contribute to securing specificity of siRNA amplification.

Lateral mass intra-pedicular screw fixation for subaxial cervical spines - An alternative surgical technique.

BACKGROUND: Lateral mass screw (LMS) and transpedicular screw (TPS) techniques are the two major options for performing posterior cervical fusion of the subaxial cervical spine. Although these two techniques can cover the vast majority of patients who require posterior fixation of the cervical spine, they are not without their limitations. OBJECTIVE: The objective of this study is to introduce a novel technique, lateral mass intrapedicular screw (LMIS) fixation, for posterior subaxial cervical spine (C3-C6) fixation. MATERIALS AND METHODS: The starting point of the screw is defined as the midpoint of the lateral mass. In the axial plane, the screw is angled at 20-25 with respect to the midline of the spinous process. In the sagittal plane, the screw is directed toward the rostral quarter (zone 1) of the vertebral body and placed within the pedicle. A preliminary, proof-of-concept experiment was performed using a bone model created with synthetic bone and computed tomography images before performing the operation on a patient. RESULTS: During the preliminary experiment, insignificant breaching of the inner cortex of the pedicle was observed with one of the screws. However, no other screws breached the inner cortex in the same manner during the preliminary experiment or during the operation, and the intraoperative fixation was strong. CONCLUSION: LMIS is a relatively simple and safe technique that can be performed for the fixation of subaxial cervical spines with screws that are longer than those used in LMS. We believe that this technique may join the two existing techniques to become a common alternative technique, particularly for patients with poor bone quality.

Impact of Tobacco Smoking on Outcomes After Posterior Decompression Surgery in Patients With Cervical Spondylotic Myelopathy: A Retrospective Multicenter Study.

STUDY DESIGN: This was a case-control study. OBJECTIVE: The objective of this study was to clarify the surgical outcomes after cervical posterior decompression in patients who smoked. SUMMARY OF BACKGROUND DATA: Smoking is associated with poor outcomes in the field of spinal surgery. However, the impact of tobacco smoking on the outcomes after posterior decompression surgery has not been fully evaluated in patients with cervical spondylotic myelopathy. MATERIALS AND METHODS: In this retrospective multicenter study, 587 patients with cervical spondylotic myelopathy were enrolled at 17 institutions in Japan. Patients underwent cervical laminoplasty or laminectomy and were followed up for at least 1 year after surgery. Outcome measures were: preoperative smoking status, perioperative complications, the Japanese Orthopedic Association scale, and the Visual Analog Scale for neck pain. After adjusting for age and sex by exact matching, smoking and nonsmoking groups were compared using an unpaired t test for continuous variables or a χ test for categorical variables. RESULTS: There were 182 (31%) current smokers and 405 (69%) nonsmokers including previous smokers. After matching, 158 patients were extracted from each group. Demographic data and surgical information were almost the same between the groups. Regarding postoperative complications, there was no significant difference in the rate of surgical site infection, cerebrospinal fluid leakage, hematoma, segmental motor paralysis, or neurological deficit. However, smokers showed a significantly higher risk for delirium (3.8% vs. 0.0%, P=0.039). Smokers and nonsmokers showed comparable changes in functional recovery according to Japanese Orthopedic Association scores (3.2±2.1 vs. 3.0±2.1, P=0.425) and in neck pain reduction using the Visual Analog Scale (-1.7±3.1 vs. -1.4±2.8, P=0.417) at the final follow-up. CONCLUSIONS: Smokers exhibited functional restoration and neck pain reduction after cervical posterior decompression. Attention is required, however, for the postoperative complication of delirium, which could be caused by the acute cessation of tobacco smoking after admission. LEVEL OF EVIDENCE: Level III.

Soybean antiviral immunity conferred by dsRNase targets the viral replication complex.

Eukaryotic positive-strand RNA viruses replicate their genomes in membranous compartments formed in a host cell, which sequesters the dsRNA replication intermediate from antiviral immune surveillance. Here, we find that soybean has developed a way to overcome this sequestration. We report the positional cloning of the broad-spectrum soybean mosaic virus resistance gene Rsv4, which encodes an RNase H family protein with dsRNA-degrading activity. An active-site mutant of Rsv4 is incapable of inhibiting virus multiplication and is associated with an active viral RNA polymerase complex in infected cells. These results suggest that Rsv4 enters the viral replication compartment and degrades viral dsRNA. Inspired by this model, we design three plant-gene-derived dsRNases that can inhibit the multiplication of the respective target viruses. These findings suggest a method for developing crops resistant to any target positive-strand RNA virus by fusion of endogenous host genes.

Selective Thoracic Fusion for King-Moe Type II/Lenke 1C Curve in Adolescent Idiopathic Scoliosis: A Comprehensive Review of Major Concerns.

INTRODUCTION: Controversies still exist in the surgical indications and outcomes of selective thoracic fusion (STF) for a primary thoracic curve with a compensatory large lumbar curve (King-Moe type II/Lenke 1C curve) in adolescent idiopathic scoliosis (AIS). Issues of the greatest concern regarding this curve type include curve criteria that indicate STF to prevent postoperative coronal decompensation and postoperative radiographic outcomes, including curve correction, coronal balance, and thoracolumbar kyphosis, after STF. METHODS: This review comprehensively documents the issues raised in the literature regarding surgical indications and radiographic outcomes of STF for King-Moe type II/Lenke 1C curve in AIS. RESULTS: Studies suggest that radiographic curve criteria indicating STF for this curve type include the preoperative dominance of the thoracic curve to the lumbar curve in the Cobb angle and the characteristics of the lumbar curve in magnitude and flexibility. Studies warn the need for a careful clinical evaluation of the thoracic and lumbar rotational prominences. Documented radiographic outcomes of importance include the postoperative behavior of the unfused lumbar curve, coronal or sagittal decompensation after STF, and factors associated with these issues. A comprehensive review of the literature suggests that the use of a segmental pedicle screw construct and better instrumented thoracic curve correction achieve better spontaneous lumbar curve correction. Although the causes of postoperative coronal decompensation remain multifactorial, preoperative coronal decompensation to the left and an inappropriate selection of the lowest instrumented vertebra are consistently reported to be the major causative factors. CONCLUSIONS: STF has been validated in general for the treatment of King-Moe type II or Lenke 1C curve in AIS; however, controversies remain regarding the surgical indications and outcomes. Long-term impacts of residual lumbar curve, coronal decompensation, and mild thoracolumbar kyphosis on clinical outcomes after STF, along with optimal indications and strategy for STF, should further be assessed.

Association of Susceptibility Genes for Adolescent Idiopathic Scoliosis and Intervertebral Disc Degeneration With Adult Spinal Deformity.

STUDY DESIGN: Genetic case-control study of single nucleotide polymorphisms (SNPs). OBJECTIVE: To examine the association of previously reported susceptibility genes for adolescent idiopathic scoliosis (AIS) and intervertebral disc (IVD) degeneration with adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: ASD is a spinal deformity that develops and progresses with age. Its etiology is unclear. Several ASD susceptibility genes were recently reported using a candidate gene approach; however, the sample sizes were small and associations with ASD development were not determined. METHODS: ASD was defined as structural scoliosis with a Cobb angle more than 15° on standing radiographs, taken of patients at age 40 to 75 years in this study. Subjects in whom scoliosis was diagnosed before age 20 were excluded. We recruited 356 Japanese ASD subjects and 3341 healthy controls for case-control association studies of previously reported SNPs. We genotyped four known AIS-associated SNPs (rs11190870 in LBX1, rs6570507 in GPR126, rs10738445 in BNC2, and rs6137473 in PAX1) and three IVD degeneration-associated SNPs (rs1245582 in CHST3, rs2073711 in CILP, and rs1676486 in COL11A1) by the Invader assay. RESULTS: Among the AIS-associated SNPs, rs11190870 and rs6137473 showed strong and nominal associations with ASD (P = 1.44 × 10, 1.00 × 10, respectively). Of the IVD degeneration-associated SNPs, rs1245582 and rs2073711 showed no association with ASD, while rs1676486 showed a nominal association (P = 1.10 × 10). In a subgroup analysis, rs11190870 was significantly associated with a Cobb angle more than 20° in the minor thoracic curve (P = 1.44 × 10) and with a left convex lumbar curve (P = 6.70 × 10), and nominally associated with an apical vertebra higher than L1 (P = 1.80 × 10). CONCLUSION: rs11190870 in LBX1, a strong susceptibility SNP for AIS, may also be a susceptibility SNP for ASD. Thus, ASD and AIS may share a common genetic background. LEVEL OF EVIDENCE: 4.

A Cell-Free Replication System for Positive-Strand RNA Viruses for Identification and Characterization of Plant Resistance Gene Products.

Plant cells have lytic vacuoles, which contain ribonucleases and proteinases. The vacuoles are fragile and easily collapsed upon homogenization of plant tissues or cells. Thus, with a few exceptions, plant cell extracts are contaminated by vacuole-derived lytic enzymes and unsuitable for biochemical analyses. Here, we describe a method for removing the vacuoles from intact tobacco BY-2 protoplasts and for cell-free translation and replication of genomic RNA of positive-strand RNA viruses using the extract of evacuolated protoplasts. We also describe a method for the identification and functional characterization of a plant resistance gene product using this system.

Resistance Breeding Through RNA Silencing of Host Factors Involved in Virus Replication.

RNA silencing is a sequence-specific suppression of gene expression conserved in eukaryotes including fungi, plants, and animals. Based on this mechanism, crop improvements have been made to confer pathogen resistance and abiotic stress tolerance. Here we have applied this technique to produce virus resistant tomato plants using host genes involved in viral replication. Tomato homologs of Arabidopsis TOM1 involved in tobamovirus replication has been isolated and used to construct the plasmids that carried inverted repeats of the genes for induction of RNA silencing. Tomato plants were transformed by the plasmids via Agrobacterium, and tested for virus resistance. Actually, the T2 and T3 plants showed resistance to tomato mosaic virus. Here we describe the method to construct RNA silencing-inducing plasmids, to transform tomato plants and to check the introduction of transgenes and virus resistance.

Does Posterior Cervical Decompression Conducted by Junior Surgeons Affect Clinical Outcomes in the Treatment of Cervical Spondylotic Myelopathy? Results From a Multicenter Study.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To evaluate the outcomes of posterior cervical decompression for cervical spondylotic myelopathy (CSM) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS: We reviewed outcomes for 675 patients who underwent surgery for CSM, were followed at least 1 year after surgery, and were assessed preoperatively and at final follow-up by Japanese Orthopaedic Association (JOA) scores and by the visual analog scale (VAS) for the neck. Cervical alignment was assessed on radiographs by C2-C7 angles, and range of motion (ROM) by extension minus flexion C2-C7 angles. We compared outcomes for BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and for NBCS surgeons. RESULTS: BCS surgeons performed 432 of 675 laminoplasties. NBCS surgeons were primary in 243 surgeries, of which 187 were directly supervised by a BCS surgeon. BCS surgeons required significantly less time in surgery (98.0 ± 39.5 vs 108.1 ± 49.7 min; P < .01). BCS and NBCS surgeons had comparable perioperative complications rates, and preoperative-to-postoperative changes in JOA scores (2.9 ± 2.1 vs 3.1 ± 2.3; P = .40) and VAS (-1.5 ± 2.9 vs -1.4 ± 2.5; P = .96). Lordotic cervical alignment and ROM were maintained after operations by both groups. CONCLUSIONS: Surgical outcomes such as functional recovery, complication rates, and cervical dynamics were comparable between the BCS and NBCS groups. Thus, posterior cervical decompression for CSM is safe and effective when performed by junior surgeons who have been trained and supervised by experienced spine surgeons.

Purification and functional characterization of tomato mosaic virus 130K protein expressed in silkworm pupae using a baculovirus vector.

Tomato mosaic virus (ToMV; genus, Tobamovirus) is a member of the alpha-like virus superfamily of positive-strand RNA viruses, which includes many plant and animal viruses of agronomical and clinical importance. The genomes of alpha-like viruses encode replication-associated proteins that contain methyltransferase, helicase and/or polymerase domains. The three-dimensional structure of the helicase domain fragment of ToMV has been determined, but the structures of the other domains of alpha-like virus replication proteins are not available. In this study, we expressed full-length ToMV replication-associated protein 130 K, which contains the methyltransferase and helicase domains, using the baculovirus-silkworm expression system and purified the recombinant protein to near homogeneity. Purified 130 K, which was stable in phosphate buffer containing magnesium ions and ATP, formed a dimer in solution and hydrolyzed nucleoside 5'-triphosphates.

Correlation between vancomycin penetration into cerebrospinal fluid and protein concentration in cerebrospinal fluid/serum albumin ratio.

Bacterial meningitis is a life-threatening condition. Vancomycin (VCM) is one of the antibiotics used as empirical therapy for bacterial meningitis. It is essential to maintain an adequate concentration of VCM in cerebrospinal fluid (CSF) to treat bacterial meningitis effectively. VCM administered intravenously must pass the blood-brain barrier (BBB) to enter the CSF and the extent of VCM penetration into CSF varies widely among patients. Previous report indicated that CSF albumin level is useful for estimation of VCM CSF penetration. However, CSF albumin level is not measured in routine practice. We focused on CSF protein concentration that is generally examined at the beginning of diagnosis and treatment of bacterial meningitis. We examined the relationship between CSF protein concentration/serum albumin ratio and the extent of VCM penetration into CSF. This retrospective study involved 7 patients admitted to our hospital who were treated with VCM for suspected bacterial meningitis. The VCM concentrations in serum and CSF were 17.6 ± 7.2 µg/mL and 3.31 ± 3.14 µg/mL, respectively. The serum VCM concentrations showed no significant correlation with CSF VCM concentrations. On the other hand, the protein concentration in CSF/serum albumin ratio showed a strong positive correlation with the VCM CSF/serum ratio (r = 0.877, p < 0.005). Our study indicates that the ratio of CSF protein concentration/serum albumin is likely useful for estimating the approximate VCM CSF/serum ratio. This could contribute to an improvement in the treatment of bacterial meningitis.

Optimized Screw Trajectory for Lumbar Cortical Bone Trajectory Pedicle Screws Based on Clinical Outcome: Evidence Favoring the Buttress Effect Theory.

BACKGROUND: Cortical bone trajectory (CBT) is a relatively new technique for pedicle screw insertion in the field of spine surgery. Previous studies have demonstrated the significantly better pullout and toggle characteristics the new method offers, and it appears to have certain advantages over the widely used traditional trajectory. The mechanism of the pullout and toggle characteristics still remains unknown. PURPOSE: To report the medium- to long-term follow-up findings of patients who underwent posterior lumbar interbody fusion or posterior lumbar fusion (PLIF/PLF) at our institution and to discuss the ideal screw trajectory when using this technique. STUDY DESIGN: Retrospective radiologic study. METHODS: Fifty-five patients who underwent PLIF/PLF for lumbar spondylosis using the new technique between January 2011 and January 2016 were included. Clinical outcome was assessed using the Japanese Orthopaedic Association scores for low back pain and visual analog scale scores. Screw loosening was evaluated via the presence of a translucent zone surrounding the pedicle screw using plain X-radiography (Xp). The screw trajectory was evaluated by measuring the rostral range (RR) and the lateral range score (LRS). The RR is the angle between the line drawn along the distal end plate of the vertebra and the line drawn along the screw on the lateral view. The LRS is the score given depending on the position of the tip of the screw seen on the Xp taken in the anteroposterior (AP) view. The pedicle ring is equally divided into the medial third (zone A), central third (zone B), and the lateral third (zone C) by four vertical lines. A score of 0 to 3 points is given depending on the position of the tip of the screw: 0, outside the pedicle ring; 1, zone A; 2, zone B; and 3, zone C. RESULTS: Bone fusion was recorded in 49 patients (49/55 patients). The total number of screws with a visible translucent zone on Xp was 26 (26/242 screws). When the screws are inserted at a more acute angle in the lateral view (low RR) or when the screws are directed more medially (low LRS), the risk of developing a translucent zone around the pedicle screw increased. CONCLUSION: With CBT, the pedicle screws are inserted from the pars interarticularis that is rich in cortical bone, strong enough to withstand the substantial forces usually encountered in the region. Our clinical data suggest that the optimal screw trajectory is one where the screw is inserted at an angle > 22.55 degrees (high RR) on the lateral view Xp and where the tip of the screw is directed toward the lateral third of the pedicle on the AP Xp. We believe the naturally occurring buttress effect that exists in the vertebra may give CBT a mechanical and anatomical advantage over the traditional screw trajectory.

[Surgical Technique for Lumbar Spinal Extraforaminal Schwannoma].

INTRODUCTION: Spinal neurinomas are frequently observed in the cauda equina, particularly within the dura mater. However, extraforaminal schwannomas(EFS), which are neither intradural nor dumbbell type, are relatively rare; hence, different surgical procedures have been employed. Here, we report 12 cases of lumbar EFS with total resection that were safely performed. METHODS AND SUBJECTS: This study was comprised of 12 patients with lumbar EFS(excluding those with neurofibromas)who were previously treated at our hospital. Using the Wiltse paraspinal approach, we inserted the microscope until it reached the tumor surface. After confirming the tumor surface, we inserted a scalpel to make an incision in a portion of the outer capsule. Then, we confirmed that the surfaces of the outer capsule and the tumor within the capsule could be dissected. Next, a thread was attached to the outer capsule and pulled upwards so that there was enough space to perform the required procedures within the capsule. Using a CUSA®, we removed the intracapsular tumor. After its removal, the outer capsule was treated carefully to ensure that the origin nerve was not damaged. RESULTS: In all cases, we successfully performed a total removal of the intracapsular tumor;in the mean postoperative observation period of 8 years, no recurrence was observed. Although temporary paralysis was observed in three patients, this improved over time. CONCLUSION: We report our experience with a surgical technique that ensured the safe removal of lumbar EFS. Satisfactory results were achieved, with no recurrences observed during the mean 8-year postoperative observation period.