BackgroundIntrameningeal cysts are rare lesions without definitive etiologies that can involve the dura or arachnoid mater. Spinal arachnoid cysts have been described, and several different etiologies have been hypothesized. This includes one-way valve mechanisms, traumatic herniation of arachnoid through the dura, and abnormal arachnoid membrane proliferation. To the authors' knowledge, no such descriptions exist regarding purely dural-based cystic lesions; however, the authors hypothesize similar mechanisms may be involved. Most notably, a traumatic injury to the dura leading to a one-way valve mechanism may allow for egress of cerebrospinal fluid between the dural layers, splitting them open. This progressive enlargement can lead to displacement of neural elements and subsequent neurological compromise.MethodsWe describe a 17-year-old girl who presented with progressive neck and back pain, left upper-extremity numbness, bilateral lower-extremity weakness, paresthesias, and numbness without obvious etiology despite an extensive neurologic investigation. She had undergone conservative management options including multiple medications, physical and chiropractic therapy, and epidural steroid injections. Computed tomography myelography revealed a cerebrospinal fluid leak into the lumbar epidural space for which surgical exploration was performed. Despite utilizing fluoroscopy and intrathecal fluorescein, no leak source was identified. Fluid collection was found contained within the dural layers rather than the epidural space.ResultsAn intracystic blood patch was performed with near-complete resolution of the lesion by 6-week follow-up and near-complete return of neurologic function.ConclusionsVentral panspinal cysts are an exceedingly rare cause of radiculopathy and myelopathy that can be resolved by an intracystic blood patch.

BACKGROUND:The Pipeline Flex Embolization Device with Shield technology (PED-Shield [Medtronic, Dublin, Ireland]) is a third-generation flow diverter. Surface modification of the mesh with phosphorylcholine covalently bound to the metal struts aims to reduce thrombogenicity. In the present study, we report the results from the first U.S. series of patients with intracranial aneurysms treated with the PED-Shield and a comprehensive systematic literature review.METHODS:We retrospectively collected the patient demographics, aneurysm characteristics, procedural details, and periprocedural complications from our prospectively maintained endovascular database (April 2021 to July 2021). Our literature review encompassed 3 databases (PubMed, Embase, and MEDLINE).RESULTS:Ten patients with 11 anterior circulation unruptured wide-necked aneurysms (10 saccular, 1 fusiform) were included. The average patient age was 64.7 years (range, 45-86 years), and 9 were women. One device demonstrated insufficient distal opening. No other technical issues or intraprocedural complications had occurred. After the procedure, 1 patient had developed a groin hematoma and 1 had experienced a small intracranial hemorrhage, with no clinical repercussions. All patients were discharged with dual-antiplatelet therapy. In the review, we identified 15 studies. Most had been conducted in Europe and South America and 3 were U.S. case reports of compassionate use of the device.CONCLUSIONS:In our initial periprocedural experience with the PED-Shield for intracranial aneurysm treatment, the device demonstrated an excellent performance and no major complications. Further studies are required to evaluate the long-term follow-up results and the safety of different antiplatelet regimens.

OBJECTIVE:To explore the relationship between spinal cord compression and hypertension through analysis of blood pressure (BP) variations in a cervical spondylotic myelopathy (CSM) cohort after surgical decompression, along with a review of the literature.METHODS:A single-institution retrospective review of patients with CSM who underwent cervical decompression between 2016 and 2017 was conducted. Baseline clinical and imaging characteristics, preoperative and postoperative BP readings, heart rate, functional status, and pain scores were collected. In addition, a PRISMA guidelines-based systematic review was performed.RESULTS:We identified 264 patients with CSM treated surgically; 149 (56.4%) of these had hypertension. The degree of spinal canal compromise and spinal cord compression, preoperative neurologic examination, and the presence of T2-signal hyperintensity on magnetic resonance imaging were associated with hypertension. Overall mean arterial pressure (MAP) decreased significantly at 1 and 12 months after surgery. Patients without T2-signal hyperintensity on imaging showed a MAP reduction at 12 months postoperatively, whereas those with T2-signal hyperintensity showed a transient MAP reduction at 1 month postoperatively before returning to preoperative values. At 12 months after surgery, 24 of 97 patients (24.7%) with initially uncontrolled hypertension had controlled BP values with significant reduction of MAP, systolic BP, and diastolic BP. Including the present study, 5 articles were eligible for systematic review, with all reporting a BP decrease in patients with CSM after decompression.CONCLUSIONS:Analysis of our retrospective cohort and a systematic review suggest that cervical surgical decompression reduces BP in some patients with CSM. However, this improvement is less apparent in patients with preoperative spinal cord T2-signal hyperintensity.

Study Design. Rat posterolateral lumbar fusion model. Objective. The aim of this study was to compare the efficacy of freshly isolated adipose tissue-derived stromal vascular fraction (A-SVF) and bone marrow cells (BMCs) cells in achieving spinal fusion in a rat model. Summary of Background Data. Adipose tissue-derived stromal cells (ASCs) offer advantages as a clinical cell source compared to bone marrow-derived stromal cells (BMSCs), including larger available tissue volumes and reduced donor site morbidity. While pre-clinical studies have shown that ex vivo expanded ASCs can be successfully used in spinal fusion, the use of A-SVF cells better allows for clinical translation. Methods. A-SVF cells were isolated from the inguinal fat pads, whereas BMCs were isolated from the long bones of syngeneic 6- to 8-week-old Lewis rats and combined with Vitoss (Stryker) bone graft substitute for subsequent transplantation. Posterolateral spinal fusion surgery at L4-L5 was performed on 36 female Lewis rats divided into three experimental groups: Vitoss bone graft substitute only (VO group); Vitoss + 2.5 x 10(6) A-SVF cells/side; and, Vitoss + 2.5 x 10(6) BMCs/side. Fusion was assessed 8 weeks post-surgery via manual palpation, micro-computed tomography (mu CT) imaging, and histology. Results. mu CT imaging analyses revealed that fusion volumes and mu CT fusion scores in the A-SVF group were significantly higher than in the VO group; however, they were not significantly different between the A-SVF group and the BMC group. The average manual palpation score was highest in the A-SVF group compared with the BMC and VO groups. Fusion masses arising from cell-seeded implants yielded better bone quality than nonseeded bone graft substitute. Conclusion. In a rat model, A-SVF cells yielded a comparable fusion mass volume and radiographic rate of fusion to BMCs when combined with a clinical-grade bone graft substitute. These results suggest the feasibility of using freshly isolated A-SVF cells in spinal fusion procedures.

Background: Androgen receptor splice variant 7 (AR-V7) has been implicated in resistance to abiraterone and enzalutamide treatment in men with metastatic castration-resistant prostate cancer (mCRPC). Tissue- or cell-based in situ detection of AR-V7, however, has been limited by lack of specificity Objective: To address current limitations in precision measurement of AR-V7 by developing a novel junction-specific AR-V7 RNA in situ hybridization (RISH) assay compatible with automated quantification. Design, setting, and participants: We designed a RISH method to visualize single splice junctions in cells and tissue. Using the validated assay for junction-specific detection of the full-length AR (AR-FL) and AR-V7, we generated quantitative data, blinded to clinical data, for 63 prostate tumor biopsies. Outcome measurements and statistical analysis: We evaluated clinical correlates of A-RFL/AR-V7 measurements, including association with prostate-specific antigen progression-free survival (PSA-PFS) and clinical and radiographic progression-free survival (PFS), in a subset of patients starting treatment with abiraterone or enzalutamide following biopsy. Results and limitations: Quantitative AR-FL/AR-V7 data were generated from 56 of the 63 (88.9%) biopsy specimens examined, of which 44 were mCRPC biopsies. Positive AR-V7 signals were detected in 34.1% (15/44) mCRPC specimens, all of which also co-expressed AR-FL. The median AR-V7/AR-FL ratio was 11.9% (range 2.7-30.3%). Positive detection of AR-V7 was correlated with indicators of high disease burden at baseline. Among the 25 CRPC biopsies collected before treatment with abiraterone or enzalutamide, positive AR-V7 detection, but not higher AR-FL, was significantly associated with shorter PSA-PFS (hazard ratio 2.789, 95% confidence interval 1.12-6.95; p = 0.0081). Conclusions: We report for the first time a RISH method for highly specific and quantifiable detection of splice junctions, allowing further characterization of AR-V7 and its clinical significance. Patient summary: Higher AR-V7 levels detected and quantified using a novel method were associated with poorer response to abiraterone or enzalutamide in prostate cancer. (C) 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

BACKGROUND: Parathyroid hormone (PTH) (1-34) treatment reduces fracture risk in osteoporotic patients. Previously, we demonstrated in a rabbit model that low-dose PTH treatment resulted in increased fusion mass volume. As effects of PTH on bone are dose-dependent, we aimed to evaluate whether increasing dosage of PTH increases both volume and biomechanical stiffness of the resulting fusion masses and/or exhibits synergistic effects with low-dose bone morphogenetic protein 2 (BMP-2). METHODS: Posterolateral lumbar spinal fusion surgery was performed on 60 New Zealand White rabbits divided into 6 experimental groups: iliac crest autograft alone, autograft plus 20 mu g/kg/day PTH, autograft plus 40 mu g/kg/day PTH, BMP-2 alone, BMP-2 plus 20 mu g/kg/day PTH, and BMP-2 plus 40 mu g/kg PTH. Fusion was assessed at postoperative week 6 via manual palpation, volumetric computed tomography analysis, and 4-point bending biomechanical testing. RESULTS: All groups treated with BMP-2 fused. Increasing doses of PTH resulted in increased fusion mass volume compared with autograft alone. Autograft plus 40 mu g/kg/day PTH yielded fusion mass volumes comparable to BMP-2. When the autograft groups were considered alone, increased mechanical stiffness was observed only in the 20 mu g/kg/day group. No significant stiffness differences were observed between BMP-2 groups. CONCLUSIONS: Treatment with the highest dose of PTH resulted in fusion mass volumes similar to those obtained with BMP-2. When the autograft groups were considered alone, significant increases in mechanical stiffness were observed at a dosage of 20 mu g/kg/day, suggesting there may be an optimal dose of PTH in the rabbit model. Effects of BMP-2 on fusion were dominant.

Background/Introduction: Adult spinal deformity (ASD) surgery is a massive undertaking that may involve a significant amount of blood loss, especially when various osteotomy techniques are utilized. Antifibrinolytic agents such as tranexamic acid (TXA) have been used in an attempt to reduce intraoperative blood loss. However, there is no universally accepted dosing protocol for TXA in spine surgery. Moreover, there are very few reports in the literature regarding highdose TXA use in ASD, possibly due to concerns for thromboembolic or seizure risks. This study aims to investigate the safety profile and efficacy of using a high-dose (50mg/kg loading, 5mg/kg/hr infusion) TXA protocol during ASD surgery. Materials/Methods: Consecutive patients undergoing spinal deformity correction over a 14-month period (September 1st 2015 – November 1st 2016) at a single institution were identified. Inclusion criteria were adults (age >= 18 years) who underwent posterior spinal fusion surgery of at least 5 levels. Our standard TXA protocol is 50 mg/kg intravenous loading dose followed by a 5 mg/kg/hr infusion until skin closure. Patient demographics, estimated blood time (EBL), post operative blood transfusion, and other procedure specific information were recorded and analyzed. Results: A total of 100 adult patients were included in the study. Operative procedures were performed by a single surgeon. The mean age was 46.5 years, and 71% of patients were female. Average BMI was 24.7. The average fusion length was 14 levels. 46/100 patients had a primary surgical procedure while the rest were revisions. 61/100 of patients had pelvic fixation. Posterior column osteotomies were performed on 80/100 patients; pedicle subtraction osteotomy (PSO) was performed in 8 patients; and vertebral column resections (VCRs) were performed in 15 patients. Mean intraoperative blood loss among all patients was 1296cc. There was one PE was treated with a heparin drip, and two DVTs which developed in rehab which were treated with oral anticoagulation. There were no MIs, seizures, strokes, or renal complications. Discussion/Conclusion: This study demonstrates that high dose TXA is effective and safe to use in well-selected ASD patients and lays the foundation for further studies on this important topic.