Precise and limited decompression for lumbar spinal stenosis

Summary Fifty-eight consecutive patients with lumbosacral nerve root entrapment due to spinal stenosis were treated with modified microsurgical decompression. Only the clinically relevant sides and levels were decompressed while the spinous processes, the interspinous ligaments, the medial portion of ligamentum flavum and the functionally important parts of the facet joints were preserved. The reviewers rated recovery as good or excellent in 71% of patients while patient self-assessment indicated 76% good or excellent outcome. These data suggest that microsurgical decompression of spondyloarthritic changes can effectively relieve the signs and symptoms of nerve root compression and that with careful evaluation of all available data the number of nerve roots requiring decomperession is often fewer than what is suggested by diagnositic images alone.     

Neuropathology of ALS: Spheroids

I briefly review spheroids observed in the anterior horns of the spinal cord in amyotrophic lateral sclerosis (ALS). Spheroids are argentophilic bodies more than 20 μm in diameter. Recently, some connections between the proximal axonal swellings including spheroids and the perikarya have been reported in some ALS patients with a short clinical course or mild depletion of anterior horn neurons. Most of the cell bodies directly connected with the axonal swellings appear normal, and spheroids are considered to be one of the hallmarks of the early histological changes in this disorder. Spheroids are strongly positive with anti-phosphorylated neurofilament antibody, and are also positive with calcitonin gene-related peptide and anti-peripherin antibody. Some spheroids are immunostained with anti-synaptophysin antibody and anti-ubiquitin antibody. Spheroids are not immunostained with anti-phosphorylated tau antibody, or high molecular weight microtubule associated proteins. Electron microscopically, spheroids are usually composed of densely packed accumulation of 10 nm neurofilaments with a variety of orientations, plus vesicles, dense bodies and mitochondria. When the swellings of the initial segment is relatively pronounced, the undercoating is obscured and the neurofilaments become interwoven in some parts. In the first internode of the myelinated axons, as the swellings become larger, the neurofilaments lose their parallel orientation and become intermingled. Large accumulation of neurofilaments resembling spheroids in the perikarya of large anterior horn cells suggests that spheroids could be derived not only from the axon including the proximal portion, but also from the perikarya. Structures apparently identical to axonal spheroids are observed at the light and electron microscopic levels in the proximal portion of axons of anterior horn cells in animal models intoxicated with β, β'-iminodipropionitrile (IDPN), or with aluminum, in hereditary canine spinal muscular atrophy (HCSMA). The pathogenetic mechanism is probably associated with an impairment in slow axonal transport which particularly affects the neurofilaments in IDPN and aluminum intoxication. Impairment of slow axonal transport of neurofilaments also plays an important role in the pathogenesis of ALS. The average diameter of even normalappearing initial segment is larger in ALS than in the controls. The perikarya connected with the swollen proximal axons and their dendrites almost always appear normal. These findings suggest that the slow axonal transport of neurofilaments is probably impaired in this portion of the axon at an early stage in ALS as well as animal models for human ALS. However, techniques to analyze slow axonal transport in humans still remain tobe developed. Recently, overexpression of neurofilament subunits in transgenic mice produces a condition resembling ALS. The transgenic model may offer an interesting perspective not only for testing therapeutic strategies but also for investigating in a systematic way the various genetic and environment factors controlling the onset and progression of the disease and might yield new insights on the etiology of ALS.     

Ubiquitin and heat shock protein expression in amyotrophic lateral sclerosis

The expression of two heat shock proteins, HSP72 and p57, in addition to ubiquitin, has been studied immunocytochemically in nine amyotrophic lateral sclerosis (ALS) cases and 10 age-matched controls. HSP72 and p57 antibodies did not identify the characteristic ubiquitin-immunoreactive inclusions present in anterior horn cells in ALS spinal cord. Antibodies to HSP72, but not to p57 or ubiquitin, strongly labelled structures corresponding to polyglucosan bodies in spinal grey matter. Such immunoreactive profiles were more abundant in ALS cases, although they were also present in control material. They were sometimes identified by haematoxylin and eosin and periodic acid Schiff reaction, but were not labeled by phosphotungstic acid haematoxylin or by antibodies to glial fibrillary acidic protein. Although ubiquitin, HSP72 and p57 are stress-induced proteins, they are expressed differently and might therefore have different significance in neuronal degeneration.     

Anterior eye focusing of peripheral ultraviolet and visible radiation albedo

Concern about short- and long-term ultraviolet radiation (particularly UVB) damage to the eye has led to increased research in this area. Numerous studies have confirmed the pathogenic enhancing roles of reflected ultraviolet (UV) and visible radiation in our environment. There is concern that conventional sunglasses do not protect the eye adequately from reflected rays (albedo), especially on the lateral aspect, from behind and from below. Using eye models and computer ray tracing methods, the pathways of oblique rays incident at the temporal peripheral cornea have been plotted by Maloof, Ho and Coroneo.¹ These rays are refracted and focused and theoretically can result in up to 20 times the concentration of incident irradiance at the nasal anterior chamber angle and nasal equatorial cortex of the crystalline lens. The purpose of this study was to determine the limits of angular subtense of the incident peripheral light which is refracted in this manner in human subjects and to investigate the relation between corneal shape and certain ocular parameters to the limits. A statistically significant positive correlation was found between temporal entrance angle and anterior chamber depth (r = 0.70, P< 0.0006). The entrance angle ranged from 15 degrees to 30 degrees and was located 10 degrees to 45 degrees posterior to the coronal plane. Our results support Maloof and colleagues' predictions for the implication of focused peripheral UV and high intensity visible radiation in the pathogenesis of pterygium and cortical cataract and emphasise the need for lateral eye protection in conditions of high ultraviolet albedo.     

Segmental fixation with U-shaped rod in the treatment of spondylolisthesis

Summary From 1987 to 1990 the authors treated 20 cases of spondylolisthesis by an improved operative procedure including excision of the medial part of the superior articular processes of the slipped vertebra, excision of the soft tissue between the ununited isthmi, and excision of the ligamentum flavum between the intervertebral space above the slipped segment. In some instances the lower portion of the lamina over the slipped vertebra should be resected. A U-shaped rod was used to hold sublaminar fixation of two segments above and below the slipped vertebra, with the slipped vertebra spared. Utilizing the U-shaped rod as support, bone strips were placed along the lateral and anterior sides of the rod to bridge the gap between the laminae of the displaced vertebra. Other bone grafts were focused on the facet joints. The patients were allowed ambulation early postoperatively. 19 cases could be evaluated at preliminary follow-up. All showed satisfactory results.     

The evolution of a neo-XY1Y2 sex chromosome system by autosome–sex chromosome fusion in Dundocoris nodulicarinus Jacobs (Heteroptera: Aradidae: Carventinae)

Sibling subspecies of Dundocoris nodulicarinus, inhabiting different isolated indigenous evergreen forests in South Africa, have chromosome numbers of 2n(male) = 14XY, 9XY1Y2 and 7XY1Y2. The ancestral chromosome number of Dundocoris is probably 2n(male) = 28XY and several chromosome fusions were involved in the karyotype evolution of these taxa. The XY1Y2 sex chromosome system of the 9XY1Y2 D. nodulicarinus novenus originated by the fusion of a large autosome with the X-chromosome, forming a neo-X with the homologue of the fused autosome forming the neo-Y (=Y1) and the original Y-chromosome, the Y2. While the original X- and Y-chromosomes are heterochromatic and heteropycnotic during prophase I, the autosomal part of the neo-X and the neo-Y stay euchromatic and behave like a normal autosomal pair, forming synapsis and chiasmata. The XY1Y2 sex chromosome system of the 7XY1Y2 D. nodulicarinus septeni probably originated from the 9XY1Y2 karyotype when the homologous chromosomes of a small autosomal pair fused with the original X- and Y-chromosomes, respectively. In both the subspecies with the neo-XY1Y2 systems, the original sex chromosomes still undergo chromatid segregation at anaphase I (= post-reductional). The evolution and behaviour of the karyotypes and sex chromosome systems during the course of meiosis in the subspecies of D. nodulicarinus are described, discussed and illustrated.     

Lateral unicompartimental knee arthroplasty: indications,technique and short-medium term results

Lateral unicompartmental knee arthroplasty (UKA) is a valid alternative treatment in the event of arthritis confined to the lateral compartment. This paper examines its indications, technique and short to medium-term results. A total of 159 Miller–Galante cemented UKA prostheses (Zimmer, Warsaw, Indiana) were implanted consecutively (131 medial and 28 lateral) by the same surgeon. This study investigates 28 lateral UKAs in 27 patients. Twenty-five implants in 24 patients (including a subject operated bilaterally) were followed up for 12–60 months. Three patients were discarded on account of to short a follow-up period. The Hospital for Special Surgery (HSS) knee score was used to compare the pre- and post-operative results of the lateral UKA patients. The HSS score improved from a pre-op mean of 59.92 (range 48–68) to 88.04 (range 71–95) at the last follow-up. There was a positive increase in the pain, function and ROM components of the score. The lateral UKA prosthesis can be regarded as a sound alternative to total knee replacement. Correct patient selection on the basis of optimum surgical indications, however, is essential. No benefits of funds were received in support of the study.     

Three antidepressants (amitriptyline,dothiepin, fluoxetine), with and without alcohol,compared with placebo on tests of psychomotor ability related to car driving

Eight female volunteers received acute doses of amitriptyline 50 mg (AMI), dothiepin 50 mg (DOT), fluoxetine 40 mg (FLU) or placebo both with and without a ‘social’ dose of alcohol (ALC) equivalent to 0·5 g/kg body weight absolute alcohol. Performance on a variety of tests of psychomotor ability and cognitive function (critical flicker fusion, choice reaction time, tracking, Maddox Wing and simulated car steering) were performed at 1·5 and 4 hours following treatment. AMI and DOT both with and without ALC impaired performance on a range of tests at either or both 1·5 and 4 hours, although the effects of AMI and AMI + ALC were more widespread and severe than those found with either DOT or DOT + ALC. FLU and FLU + ALC showed no evidence of impairment on any test at either the 1·5 or the 4 hours assessments. The results suggest that there are differences between the experimental substances, at the doses used, in their intrinsic potential for impairing aspects of psychomotor performance and cognitive function.     

A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results

A newly designed technique for a minimally invasive approach to the laterally herniated disc is presented. Fifteen patients suffering from far lateral disc herniation (extraforaminal) were operated according to this technique. Through a small skin incision (1.5 cm), the paraspinal muscles are spread by dilators, until a working channel of 9 mm inner diameter and 11 mm outer diameter can be placed. The next steps are done through this channel using the surgical microscope. No bone resections are necessary and the facet joints are left untouched. However, partial resection of the intertransverse ligament may be necessary. The mean follow-up period for these 15 patients was 11.5 months, and they were evaluated by using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). The average surgical time was 43 min. The ODI improved from 30.6 (preoperative) to 14.3 (postoperative). The VAS of leg pain improved from 7 (preoperative) to 3.6 (postoperative), which represented a statistically significant improvement at the significance level of (P<0.01). No intra-operative or early postoperative complications occurred. However, one recurrence did occur, which was treated by the same technique. This technique combines the advantages of three-dimensional visual control (operating microscope) with the minimal surgical trauma of endoscopic techniques, while avoiding some of the shortcomings of both the microsurgical and endoscopic techniques.