Cutting Edge Developments in Spine Surgery at the University of Missouri.

The treatment of spinal pathologies has evolved significantly from the times of Hippocrates and Galen to the current era. This evolution has led to the development of cutting-edge technologies to improve surgical techniques and patient outcomes. The University of Missouri Health System is a high-volume, tertiary care academic medical center that serves a large catchment area in central Missouri and beyond. The Department of Neurosurgery has sought to integrate the best available technologies to serve their spine patients. These technological advancements include intra-operative image guidance, robotic spine surgery, minimally invasive techniques, motion preservation surgery, and interdisciplinary care of metastatic disease to the spine. These advances have resulted in safer surgeries with enhanced outcomes at the University of Missouri. This integration of innovation demonstrates our tireless commitment to ensuring excellence in the comprehensive care of a diverse range of patients with complex spinal pathologies.

Impact of post-procedure stenosis on outcomes of patients with severe intracranial stenosis treated with intracranial stent placement.

BACKGROUND: The optimal target post-procedure stenosis after percutaneous angioplasty and stent placement (PTAS) for intracranial stenosis is unknown. We determined the effect of post-procedure stenosis after intracranial PTAS on subsequent clinical events in patients with severe symptomatic intracranial stenosis. METHODS: We categorized the severity of post-procedure stenosis as '<30%', '30-49%', and '≥50%' among 207 patients who underwent PTAS in a multicenter randomized clinical trial. Outcomes included stroke or death within 72 hours and within 30 days, ipsilateral stroke beyond 30 days of treatment, and stroke or death within 30 days or stroke in the qualifying artery beyond 30 days (primary endpoint of the trial). Cox proportional hazards analysis was performed with adjustments for age, initial severity of stenosis, location of stenosis, and qualifying event. Kaplan-Meier curves were generated for the primary endpoint stratified by post-procedure stenosis with log-rank analysis. RESULTS: The severity of post-procedure stenosis was categorized as <30%, 30-49%, and ≥50% in 112, 73, and 22 patients, respectively. Compared with patients with post-procedure stenosis <30%, there was no difference in the risk of primary endpoint among patients with post-procedure stenoses of 30-49% (hazards ratio (HR) 0.85, 95% confidence interval (95% CI) 0.64 to 1.15) or those with ≥50% (HR 0.91, 95% CI 0.57 to 1.43). Log-rank analysis did not demonstrate a difference in rates of primary endpoint between groups stratified by post-procedure stenosis (P=0.70). CONCLUSION: In the absence of any benefit on short- and long-term outcomes, strategies to achieve a low severity of post-procedure stenosis among patients with severe intracranial stenosis may not be warranted.

A bioresorbable peripheral nerve stimulator for electronic pain block.

Local electrical stimulation of peripheral nerves can block the propagation of action potentials, as an attractive alternative to pharmacological agents for the treatment of acute pain. Traditional hardware for such purposes, however, involves interfaces that can damage nerve tissue and, when used for temporary pain relief, that impose costs and risks due to requirements for surgical extraction after a period of need. Here, we introduce a bioresorbable nerve stimulator that enables electrical nerve block and associated pain mitigation without these drawbacks. This platform combines a collection of bioresorbable materials in architectures that support stable blocking with minimal adverse mechanical, electrical, or biochemical effects. Optimized designs ensure that the device disappears harmlessly in the body after a desired period of use. Studies in live animal models illustrate capabilities for complete nerve block and other key features of the technology. In certain clinically relevant scenarios, such approaches may reduce or eliminate the need for use of highly addictive drugs such as opioids.

Evaluation of bone metastases by 18F-choline PET/CT in a patient with castration-resistant prostate cancer treated with radium-223.

BACKGROUND: To date, bone metastases remain the main cause of morbidity and mortality in patients with metastatic castration-resistant prostate cancer (mCRPC). Therefore, the combination of accurate early detection of bony disease and effective treatment of these lesions is crucial in the management of mCRPC patients, but clinical trials specifically designed to test novel approaches are currently lacking. CASE DESCRIPTION: This report describes the case of a 74-year-old male with bone mCRPC and symptomatic and biochemical progression, who underwent radium-223 therapy, following previous treatment failure. 18F-choline positron emission tomography (PET)/computed tomography (CT) was used to assess changes in skeletal tumor activity before and after radium-223. Changes in prostate-specific antigen and alkaline phosphatase were also determined. 18F-choline PET/CT showed that treatment with radium-223 was able to effectively reduce bone metastatic disease, and this was accompanied by an excellent metabolic response. CONCLUSIONS: In clinical practice, metabolic assessment of lesions by 18F-choline PET/CT following radium-223 seems a valid approach to monitor treatment response. Until results from clinical trials become available, reporting of single cases relating to data on the use of this technique remains paramount.

Reliability of myocardial perfusion gated SPECT for the reproducible evaluation of resting left ventricular functional parameters in long-term follow-up.

PURPOSE: Perfusion gated single photon emission computed tomography (SPECT) can assess with good reproducibility left ventricular (LV) volumes and ejection fraction (EF). Whether this reproducibility is maintained in long-term follow-up is unknown. METHODS: We compared LV end-diastolic (ED) and end-systolic (ES) volumes (V) as well as EF calculated using gated SPECT and QGS software in 103 coronary artery disease patients studied twice at > 1-year interval because of standard clinical indications. Patients were divided into two groups: (A) 67 patients without major clinical changes and with stable resting perfusion and (B) 36 with modified clinical status or resting perfusion. RESULTS: The relationship between gated SPECT 2 EF (=y) and gated SPECT 1 EF (=x) was for group A: y=0.91 x + 5.34, r=0.92, p<0.0001, SEE=4 and for group B: y=0.67 x + 13.6, r=0.63, p<0.0001, SEE=10. The 95% limit of agreement was 8 EF units for group A and 20.6 EF units for group B. For EDV, the 95% limit of agreement was 22 ml for group A and 52 ml for group B. For ESV, the 95% limit of agreement was 13 ml for group A and 44 ml for group B. CONCLUSION: In stable patients with an unmodified resting perfusion pattern the functional parameters derived from perfusion gated SPECT have good reproducibility even after a prolonged time interval. This supports the value of gated SPECT for serial evaluations of LV function.

Abnormal response to mental stress in patients with Takotsubo cardiomyopathy detected by gated single photon emission computed tomography.

PURPOSE: Persistent abnormalities are usually not detected in patients with Takotsubo cardiomyopathy (TTC). Since sympathetically mediated myocardial damage has been proposed as a causative mechanism of TTC, we explored whether mental stress could evoke abnormalities in these patients. METHODS: One month after an acute event, 22 patients fulfilling all TTC diagnostic criteria and 11 controls underwent resting and mental stress gated single photon emission computed tomography (SPECT). Perfusion, wall motion, transient ischaemic dilation (TID) and left ventricular (LV) ejection fraction (EF) were evaluated. RESULTS: None of the controls showed stress-induced abnormalities. Mental stress evoked regional changes (perfusion defects and/or wall motion abnormality) in 16 TTC subjects and global abnormalities (LVEF fall >5% and/or TID >1.10) in 13; 3 had a completely negative response. TID, delta LVEF and delta wall motion score were significantly different in TTC vs control patients: 1.08 + or - 0.20 vs 0.95 + or - 0.11 (p < 0.05), -1.7 + or - 6% vs 4 + or - 5% (p < 0.02) and 2.5 (0, 4.25) vs 0 (0, 0) (p < 0.002), respectively. CONCLUSION: Mental stress may evoke regional and/or global abnormalities in most TTC patients. The abnormal response to mental stress supports the role of sympathetic stimulation in TTC. Mental stress could thus be helpful for TTC evaluation.