Cine MRI Is Useful for the Diagnosis of Intradural Arachnoid Cyst with Spinal Arachnoid Web: A Case Report.

CASE: A 28-year-old woman developed gait disturbance due to lower limb weakness 3 years before presentation. Conventional magnetic resonance imaging (MRI) findings were inconclusive; therefore, we performed cine MRI, which confirmed the presence of a pulsatile cyst on the posterior thoracic spinal cord. The cyst compressed the spinal cord, and its pulsations synchronized with the patient's heartbeats. We resected the intradural arachnoid cyst and thickened arachnoid membrane. The gait disturbance improved after surgery. CONCLUSIONS: Cine MRI can be used to identify a pulsating arachnoid cyst that cannot be visualized with a conventional MRI. Cine MRI is useful in patients with unexplained spinal symptoms.

The Relationship between Perivertebral Venous Cement Embolism and Balloon Expansion Pressure in Balloon Kyphoplasty.

INTRODUCTION: Osteoporotic vertebral compression fractures (OVCFs) are common fractures in the elderly suffering osteoporosis. Most patients have bone fusion with deformity of vertebral collapse; however, some patients suffer nonunion and persistent pain at the fracture site. Due to the limitations of conservative treatment, balloon kyphoplasty (BKP) has been recently performed for OVCFs. This study aimed to investigate the relationship between cement embolization and balloon expansion pressure (BEP) in patients who underwent BKP. METHODS: We investigated 62 patients who underwent BKP for cement embolization into the perivertebral veins among the 155 patients admitted to our hospital due to thoracolumbar vertebral compression fractures between April 1, 2019, and March 31, 2020. Surgery was indicated for patients who had severe back or low back pain and whose daily life was severely impaired, and in whom the shape of the vertebral body was clearly changed on functional X-ray. RESULTS: Intraoperative X-ray and postoperative CT revealed cement embolization into the perivertebral veins in three cases (4.83%). The BEP was significantly higher in the group with cement embolism than in the group without cement embolism (P < 0.001). Pulmonary cement embolism (PCE) and infection were not observed. One case of cement leakage into the spinal canal was observed (1.61%). CONCLUSIONS: While the surgical intervention of BKP can contribute to the treatment of OVCFs, careful attention should be paid to the prevention of complications, including cement embolization into the perivertebral veins, and such complications should be appropriately managed.

Technical and Conceptual Review on the L5-S1 Oblique Lateral Interbody Fusion Surgery (OLIF51).

Lumbar lateral interbody fusion (LLIF) has been gaining popularity among the spine surgeons dealing with degenerative spinal diseases while LLIF on L5-S1 is still challenging for its technical and anatomical difficulty. OLIF51 procedure achieves effective anterior interbody fusion based on less invasive anterior interbody fusion via bifurcation of great vessels using specially designed retractors. The technique also achieves seamless anterior interbody fusion when combined with OLIF25. A thorough understanding of the procedures and anatomical features is mandatory to avoid perioperative complications.

Reverse Z-effect phenomenon in a basicervical femoral fracture using cephalomedullary nail with two superior antirotation screws: A case report and procedure evaluation.

We present a case of reverse Z-effect phenomenon in a basicervical femoral fracture using a cephalomedullary nail together with two superior antirotation screws and evaluate the procedure. An 86-year-old woman fell in her home and could not stand due to right hip joint pain. X-ray and CT imaging showed a right basicervical femoral fracture (AO/OTA classification; 31B3), and open reduction and internal fixation (OR/IF) was performed with a cephalomedullary nail and two superior antirotation screws (TES Nail, HOMS, Tokyo, Japan). Two months later, X-ray showed penetration of the femoral head by the inferior lag screw with lateral migration of the two superior antirotation screws; the so-called "reverse Z-effect"; without any trauma. We performed the exchange of a shorter inferior lag screw for the longer one, and replaced the sliding type end cap with one of rocking type. The reverse Z-effect has been reported in cases with two lag screws, i.e. one inferior and one superior, in the past; however, to our knowledge, there has been no case reported in the literature using two superior antirotation screws together with one inferior lag screw.

Salvage Strategy for Failed Spinal Fusion Surgery Using Lumbar Lateral Interbody Fusion technique: A Technical Note.

INTRODUCTION: Failed spinal fusion surgery sometimes requires salvage surgery when symptomatic, especially with postsurgical decrease in intervertebral disc height followed by foraminal stenosis. For such cases, an anterior approach to lumbar lateral interbody fusion (LLIF) provides safe, direct access to the pathological disc space and a potential improvement in the fusion rate. One LLIF approach, oblique lateral interbody fusion (OLIF), targets the oblique lateral window of the intervertebral discs to achieve successful lateral interbody fusion. The current technical note describes spinal revision surgery using the OLIF procedure. TECHNICAL NOTE: The subjects were patients with leg pain and/or lower back pain derived from decreased intervertebral height followed by foraminal stenosis due to failed spinal fusion surgery. These patients underwent additional OLIF surgery and posterior fusion with no additional posterior direct decompression. Their outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scores at baseline and final follow-up. Bony union was also evaluated using computed tomography images at final follow-up. Six subjects were evaluated, with two representative cases described in detail. Four patients had an adjacent segment disorder, and the other two patients had pseudarthrosis due to postoperative infection. The mean JOA score improved from 5.7 ± 5.4 to 21.2 ± 2.3, with a mean recovery rate of 65.0%. All cases showed intervertebral bony union. CONCLUSIONS: We introduced a salvage strategy for failed posterior spine fusion surgery cases using the OLIF procedure. Patients effectively achieved recovered intervertebral and foraminal height with no additional posterior direct decompression.

Ketamine for acute neuropathic pain in patients with spinal cord injury.

Ketamine, an N-methyl-d-aspartic acid (NMDA) receptor antagonist, may be useful for treating neuropathic pain, which is often difficult to control. We report a prospective study of 13 patients with acute neuropathic pain due to spinal cord injury (SCI) treated with ketamine. All underwent a test challenge with 5mg ketamine. Patients with satisfactory responses were then treated intravenously and subsequently perorally with ketamine. Pre- and post-treatment pain was recorded on a visual analogue scale. All 13 patients responded positively to the ketamine test challenge and underwent continued ketamine administration. At the cessation of treatment and alter at final follow up, pain was decreased by 74.7% and 96.8%, respectively. The average administration period was 17.2 days; it was longer (59 days) in one patient treated in the subacute phase. All patients suffered allodynia-type pain and experienced 30% or less of their original pain intensity upon test challenge. Side effects were noted in five patients, although their severity did not require treatment cessation. In patients with SCI, ketamine reduced allodynia. Particularly good results were obtained in patients treated in the acute phase and these patients did not experience post-treatment symptom recurrence. Our results suggest that in patients with SCI, ketamine is useful for treating neuropathic pain in the acute phase.

Effects of temperature gradient reduction in three different carbon dioxide absorbents.

BACKGROUND AND OBJECTIVE: Temperature gradients in CO2 absorbents may locally increase the water content by condensation. We hypothesized that temperature gradient reduction (TGR) would prevent increased water content, thus preserving the reactivity of the CO2 absorbent and thereby increasing its time to exhaustion (longevity). The purpose of this study was to compare the effects of TGR on the longevity of CO2 absorbent with three different types of CO2 absorbents. METHODS: We constructed a novel TGR canister. Experiments were conducted using three different types of CO2 absorbents: Drägersorb 800 Plus (D800), Drägersorb Free and Amsorb Plus. One kilogram of fresh CO2 absorbent of each type was placed into two types of canister: the conventional control canister (n = 6) and the TGR canister (n = 6). RESULTS: In the case of Drägersorb Free, the TGR canister most effectively and specifically prevented local increase in water content of the CO2 absorbent and markedly increased the longevity (30% increase) compared with the control canister. In the case of Amsorb Plus, the TGR canister also prevented local excessive water content, but the increase in longevity was smaller (17% increase). In the case of D800, the TGR canister markedly increased the longevity (27% increase), but its prevention of local excessive water content was smaller. CONCLUSIONS: TGR is a useful method to prevent local increase in water content and improve the longevity of CO2 absorbent. The effectiveness of TGR on longevity and water content changes varied in the different types of CO2 absorbent.

Involvement of the active metabolites in the inhibitory activity of K579 on rat plasma dipeptidyl peptidase IV.

K579 ((S)-1-[4-methyl-1-(2-pyrimidinyl)-4-piperidylamino]acetyl-2-pyrrolidinecarbonitrile), which is a long-acting and a slow binding dipeptidyl peptidase IV inhibitor, preserved the endogenously secreted active forms of glucagon-like peptide-1, augmented the insulin response and ameliorated the glucose excursion during oral glucose tolerance test in rats. In this study, we measured plasma concentrations of K579 after oral administration to rats. However, K579 was eliminated rapidly from plasma after oral administration to rats. Therefore, we postulated that there are active metabolites of K579 in rat plasma. We investigated the effect of K579 on plasma dipeptidyl peptidase IV activity using bile duct-cannulated rats. The duration of inhibitory action of plasma dipeptidyl peptidase IV after the administration of K579 in bile duct-cannulated rats was shorter than that in sham-operated rats. Moreover, we investigated the effect of bile obtained from K579-treated rat on plasma dipeptidyl peptidase IV activity in normal rats. The bile collected from K579-treated rats exhibited tardive and potent inhibitory activity of normal rat plasma. These results suggest that K579 sustained the duration of inhibitory action of plasma dipeptidyl peptidase IV by the character as a slow-binding inhibitor and, as well, by the presence of metabolites of K579, which exhibit the inhibitory activity of dipeptidyl peptidase IV.

Effects of combination treatment with dipeptidyl peptidase IV inhibitor and sulfonylurea on glucose levels in rats.

The effects of orally administered dipeptidyl peptidase IV (DPP-IV) inhibitor on the glucose-lowering effect of glibenclamide are still unknown. We evaluated the effects of combination treatment with a long-lasting DPP-IV inhibitor, K579 ((S)-1-[4-methyl-1-(2-pyrimidinyl)-4-piperidylamino]acetyl-2-pyrrolidinecarbonitrile), and glibenclamide on the glycemic responses to glucose loading in rats. Treatment with K579 inhibited the plasma DPP-IV activity even 8 h after the administration. K579 significantly suppressed the blood glucose elevation in glibenclamide-pretreated rats without excessive hypoglycemia. These profiles of K579 indicate that it could be useful agent to correct the postprandial glucose excursion in type 2 diabetes patients by combination treatment with glibenclamide.

K579, a slow-binding inhibitor of dipeptidyl peptidase IV, is a long-acting hypoglycemic agent.

Dipeptidyl peptidase IV inhibitors are expected to be categorized in a new type of antidiabetic drugs. We had developed a long-acting dipeptidyl peptidase IV inhibitor, K579 [(S)-1-[4-methyl-1-(2-pyrimidinyl)-4-piperidylamino]acetyl-2-pyrrolidinecarbonitrile]. The aim of present study was to characterize the pharmacological profiles of K579. In normal rats, K579 suppressed the blood glucose elevation after an oral glucose tolerance test with the increment of plasma insulin and active forms of glucagon-like peptide-1 (GLP-1). During repetitive glucose loading using Zucker fatty rats, pretreatment with K579 attenuated the glucose excursion after the second glucose loading as well as the first glucose loading without inducing hypoglycemia. The kinetic study using cell extract revealed that K579 was a more potent and slower binding inhibitor than the existing dipeptidyl peptidase IV inhibitor (NVP-DPP728, 1-[[[2-[(5-cyanopyridin-2-yl)amino]ethyl]amino]acetyl]-2-cyano-(S)-pyrrolidine). These profiles of K579 might be advantageous over the existing dipeptidyl peptidase IV inhibitor with respect to less dosing frequency.

Potent and selective inhibitors of platelet-derived growth factor receptor phosphorylation. Part 4: structure-activity relationships for substituents on the quinazoline moiety of 4-[4-(N-substituted(thio)carbamoyl)-1-piperazinyl]-6,7-dimethoxyquinazoline derivatives.

Here, we investigated the structure-activity relationships of the 6,7-dimethoxyquinazoline moiety. With regard to exploration of positions and varieties of substituents on the quinazoline ring, 6,7-dialkoxy substitution was optimal. This study suggests the possibility of further modifications for this moiety.

Potent and selective inhibitors of PDGF receptor phosphorylation. 2. Synthesis, structure activity relationship, improvement of aqueous solubility, and biological effects of 4-[4-(N-substituted (thio)carbamoyl)-1-piperazinyl]-6,7-dimethoxyquinazoline derivatives.

4-[4-(N-Substituted (thio)carbamoyl)-1-piperazinyl]-6,7-dimethoxyquinazoline derivatives such as KN1022 are potent inhibitors of the phosphorylation of platelet derived growth factor receptor (PDGFR). Structure activity relationships in the (thio)urea moiety, the phenyl ring itself, the linker between these two moieties, and the piperazine moiety were investigated. The role of the linker was found to be quite different, where ureas yielded decreasing activity, while thioureas provided increasing activity. Cyanoguanidine as a bioisostere of thiourea and related dicyanovinyl or nitrovinyl groups were not suitable for potent activity. A hydrogen atom on the (thio)urea moiety was essential for activity. Stereochemistry was also important for inhibition of PDGFR phosphorylation. Through the modification of these moieties, benzylthiourea analogues with a small substituent on the 4-position and the 3,4-methylenedioxy group (KN734/CT52923) were found to be optimal for selective and potent activity. Replacement of the phenyl ring by heterocycles improved aqueous solubility without loss of activity and kinase selectivity. Introduction of a methyl group on 5-position of the piperazine ring and replacement by homopiperazine reduced inhibitory activity. An efficient synthetic method was also developed for 2-pyridylurea-containing analogues, via carbonylation of 2-aminopyridine with N,N'-carbonyldiimidazole. A potent analogue, KN734, inhibited smooth muscle cell proliferation and migration induced by platelet derived growth factor-BB (PDGF-BB) and suppressed neointima formation following balloon injury in rat carotid artery by oral administration. Therefore, 4-[4-(N-substituted (thio)carbamoyl)-1-piperazinyl]-6,7-dimethoxyquinazoline derivatives may be expected to have potential as therapeutic agents for the treatment of restenosis.

Potent and selective inhibitors of platelet-derived growth factor receptor phosphorylation. 1. Synthesis, structure-activity relationship, and biological effects of a new class of quinazoline derivatives.

A new series of 4-[4-(N-substituted carbamoyl)-1-piperazinyl]-6,7-dimethoxyquinazoline derivatives were found to show potent and selective inhibition of platelet-dervied growth factor (PDGF) receptor phosphorylation. In this exploration of the structure-activity relationships (SARs) of the prototype inhibitor KN1022, the 4-nitrophenylurea moiety was probed. We found that 4-substitution on the phenyl ring was optimal and the introduction of more than two substituents on the phenyl ring decreased activities. Bulky substituents on the phenyl ring enhanced activities. Thiourea analogues were also prepared, and the SARs were found to be slightly different from those of the urea derivatives. Through this research, we obtained some potent KN1022 derivatives such as 4-(4-methylphenoxy)phenyl (36, IC(50) 0.02 micromol/L), 4-tert-butylphenyl (16, IC(50) 0.03 micromol/L), and 4-phenoxyphenyl (21, IC(50) 0.08 micromol/L) analogues, which had almost a 10-fold increase in activity against KN1022. These potent compounds retained their high selectivity against the PDGF receptor family similar to KN1022. We also observed that these compounds could inhibit the PDGF-BB-induced proliferation of porcine vascular smooth muscle cells without cell toxicity almost at the same IC(50) values observed for PDGF receptor phosphorylation. To evaluate the biological effects in vivo, we selected some analogues on the basis of the measurement of the plasma drug concentration after oral administration to rats. Oral administration of the 4-chlorophenyl (6), 4-bromophenyl (9), or 4-isopropoxyphenyl (20) analogue to Sprague-Dawley rats (30 mg/kg, twice daily) resulted in significant inhibition (24-38%) of neointima formation in the carotid artery of the balloon catheter deendothelialized vessel in the rats. Therefore, 4-[4-(N-substituted carbamoyl)-1-piperazinyl]-6,7-dimethoxyquinazoline derivatives, which are potent inhibitors of PDGFR phosphorylation, may be expected to represent a new therapeutic approach for the treatment of various aspects of atherosclerosis and other cellular proliferative disorders.