Development of a Curriculum for Minimally Invasive Spine Surgery (MISS).

The purpose of this review is to describe how a curriculum for minimally invasive spine surgery (MISS) was developed and implemented. The authors discuss the curriculum roadmap, its target audience, and the educational process for teaching general skills and specific procedures in MISS. Initiated by AOSpine, a panel of experts within spinal surgery from multiple centers formed the minimally invasive spine surgery task force. Together, task force members redefined the standards and milestones of the MISS education and training. Therefore, we conclude that the MISS task force created a structured curriculum which will have a positive influence on daily practice for surgeons and patients worldwide.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Meta-analysis of the Fusion Rates. What is the Optimal Graft Material?

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly popular procedure with several potential advantages over traditional open TLIF. OBJECTIVE: The current study aimed to compare fusion rates of different graft materials used in MIS-TLIF, via meta-analysis of the published literature. METHODS: A Medline search was performed and a database was created including patient's type of graft, clinical outcome, fusion rate, fusion assessment modality, and duration of follow-up. Meta-analysis of the fusion rate was performed using StatsDirect software (StatsDirect Ltd, Cheshire, United Kingdom). RESULTS: A total of 1533 patients from 40 series were included. Fusion rates were high, ranging from 91.8% to 99%. The imaging modalities used to assess fusion were computed tomography scans (30%) and X-rays (70%). Comparison of all recombinant human bone morphogenetic protein (rhBMP) series with all non-rhBMP series showed fusion rates of 96.6% and 92.5%, respectively. The lowest fusion rate was seen with isolated use of autologous local bone (91.8%). The highest fusion rate was observed with combination of autologous local bone with bone extender and rhBMP (99.1%). The highest fusion rate without the use of BMP was seen with autologous local bone + bone extender (93.1%). The reported complication rate ranged from 0% to 35.71%. Clinical improvement was observed in all studies. CONCLUSION: Fusion rates are generally high with MIS-TLIF regardless of the graft material used. Given the potential complications of iliac bone harvesting and rhBMP, use of other bone graft options for MIS-TLIF is reasonable. The highest fusion rate without the use of rhBMP was seen with autologous local bone plus bone extender (93.1%).

An approach to personalized cell therapy in chronic complete paraplegia: The Puerta de Hierro phase I/II clinical trial.

BACKGROUND AIMS: Cell transplantation in patients suffering spinal cord injury (SCI) is in its initial stages, but currently there is confusion about the results because of the disparity in the techniques used, the route of administration, and the criteria for selecting patients. METHODS: We conducted a clinical trial involving 12 patients with complete and chronic paraplegia (average time of chronicity, 13.86 years; SD, 9.36). The characteristics of SCI in magnetic resonance imaging (MRI) were evaluated for a personalized local administration of expanded autologous bone marrow mesenchymal stromal cells (MSCs) supported in autologous plasma, with the number of MSCs ranging from 100 × 10(6) to 230 × 10(6). An additional 30 × 10(6) MSCs were administered 3 months later by lumbar puncture into the subarachnoid space. Outcomes were evaluated at 3, 6, 9 and 12 months after surgery through clinical, urodynamic, neurophysiological and neuroimaging studies. RESULTS: Cell transplantation is a safe procedure. All patients experienced improvement, primarily in sensitivity and sphincter control. Infralesional motor activity, according to clinical and neurophysiological studies, was obtained by more than 50% of the patients. Decreases in spasms and spasticity, and improved sexual function were also common findings. Clinical improvement seems to be dose-dependent but was not influenced by the chronicity of the SCI. CONCLUSION: Personalized cell therapy with MSCs is safe and leads to clear improvements in clinical aspects and quality of life for patients with complete and chronically established paraplegia.

Spontaneous resolution of syrinx: report of two cases in adults with Chiari malformation.

Idiopathic syringomyelia is a disease with variable clinical course. We report here two cases of spontaneous resolution of cervical syrinx in adults previously diagnosed of Chiari-syringomyelia complex. They are added to the nine cases previously reported, and documented the need for careful surgical indication in this disease based on the radiological images of spinal cord cavitation.

Cell therapy for spinal cord repair: optimization of biologic scaffolds for survival and neural differentiation of human bone marrow stromal cells.

BACKGROUND AIMS: The suppression of cell apoptosis using a biodegradable scaffold to replace the missing or altered extracellular matrix (ECM) could increase the survival of transplanted cells and thus increase the effectiveness of cell therapy. METHODS: We studied the best conditions for the proliferation and differentiation of human bone marrow stromal cells (hBMSC) when cultured on different biologic scaffolds derived from fibrin and blood plasma, and analyzed the best concentrations of fibrinogen, thrombin and calcium chloride for favoring cell survival. The induction of neural differentiation of hBMSC was done by adding to these scaffolds different growth factors, such as nerve growth factor (NGF), brain-derived-neurotrophic factor (BDNF) and retinoic acid (RA), at concentrations of 100 ng/mL (NGF and BDNF) and 1 micro/mL (RA), over 7 days. RESULTS: Although both types of scaffold allowed survival and neural differentiation of hBMSC, the results showed a clear superiority of platelet-rich plasma (PRP) scaffolds, mainly after BDNF administration, allowing most of the hBMSC to survive and differentiate into a neural phenotype. CONCLUSIONS: Given that clinical trials for spinal cord injury using hBMSC are starting, these findings may have important clinical applications.

Meningel intracranial epithelioid hemangioendothelioma: case report and literature review.

Intracranial epithelioid hemangioendothelioma (EH) is a very rare vascular neoplasm. We describe a case of meningeal intracranial tumor in a 58 year old man, located in the greater wing of the sphenoid bone. The tumor was completely excised via pterional approach and the pahological analysis showed a hemorrhagic lesion with capillary-sized vessels lined by atypical-appearing endothelial cells that expressed CD31, CD34 and Factor VIII antigens. A diagnosis of EH was established, and one year after surgery the patient is symptom-free, without tumor recurrence or residual tumor. A review of the literature disclosed other 34 cases of intracranial EH. In these tumors, total resection is mandatory if possible, otherwise radiotherapy is recommended. Outcome is favorable in the majority of cases.

Malignant prolactinoma with multiple bone and pulmonary metastases. Case report.

Malignant prolactinomas, as with other pituitary carcinomas, are rare tumors. The authors describe a 14-year-old boy who presented with visual loss caused by a pituitary prolactinoma. He underwent transsphenoidal surgery, radiotherapy, and dopamine agonist therapy, but 6 years after the initial diagnosis his pituitary tumor regrew and bone and pulmonary metastases developed. The authors review the literature and discuss the clinical presentation of malignant prolactinomas, their rarity, histological characteristics, distribution of the metastases, different treatment approaches, and their poor prognosis.