Polyetheretherketone (PEEK) Rods in Lumbar Spine Degenerative Disease: A Case Series.

STUDY DESIGN: Retrospective case series. OBJECTIVE: The purpose of our study was to retrospectively review the results of posterior lumbar fusion using polyetheretherketone (PEEK) rods. SUMMARY OF BACKGROUND DATA: Pedicle screw and rod instrumentation has become the preferred technique for performing stabilization and fusion in the lumbar spine for degenerative disease. Rigid fixation with titanium rods leads to high fusion rates, but may also contribute to stress shielding and adjacent segment degeneration (ASD). Thus, some have advocated using semirigid rods made of PEEK. Although the biomechanical properties of PEEK rods have shown improved stress-shielding characteristics and anterior load-sharing properties, there are very few clinical studies evaluating their application in the lumbar spine. METHODS: We evaluated a retrospective cohort of 42 patients who underwent posterior lumbar fusion from 2007 to 2009 for the treatment of lumbar spine degenerative disease using PEEK rods. Reoperation rate was the primary outcome evaluated. Fusion rate was also evaluated. RESULTS: Eight of the 42 patients with PEEK rods required reoperation. Reasons for reoperation mainly included ASD (5/8) and nonunion with cage migration (3/8). Radiographically, documented fusion rate was 86%. Mean follow-up was 31.4 months. No statistical differences were found in fusion rates or reoperation between age above 55 years and younger than 55 years (P=1.00), male and female (P=0.110), single or multilevel fusion (P=0.67), and fusion with and without an interbody graft (P=0.69). Smokers showed a trend towards increased risk of reoperation for ASD or instrumentation failure (P=0.056). CONCLUSIONS: PEEK rods demonstrate a similar fusion and reoperation rate in comparison to other instrumentation modalities in the treatment of degenerative lumbar spine disease.

The impact of arsenic trioxide and all-trans retinoic acid on p53 R273H-codon mutant glioblastoma.

Glioblastoma (GBM) is the most common primary brain tumor in adults and demonstrates a 1-year median survival time. Codon-specific hotspot mutations of p53 result in constitutively active mutant p53, which promotes aberrant proliferation, anti-apoptosis, and cell cycle checkpoint failure in GBM. Recently identified CD133(+) cancer stem cell populations (CSC) within GBM also confer therapeutic resistance. We studied targeted therapy in a codon-specific p53 mutant (R273H) created by site-directed mutagenesis in U87MG. The effects of arsenic trioxide (ATO, 1 µM) and all-trans retinoic acid (ATRA, 10 µM), possible targeted treatments of CSCs, were investigated in U87MG neurospheres. The results showed that U87-p53(R273H) cells generated more rapid neurosphere growth than U87-p53(wt) but inhibition of neurosphere proliferation was seen with both ATO and ATRA. U87-p53(R273H) neurospheres showed resistance to differentiation into glial cells and neuronal cells with ATO and ATRA exposure. ATO was able to generate apoptosis at high doses and proliferation of U87-p53(wt) and U87-p53(R273H) cells was reduced with ATO and ATRA in a dose-dependent manner. Elevated pERK1/2 and p53 expression was seen in U87-p53(R273H) neurospheres, which could be reduced with ATO and ATRA treatment. Additionally, differential responses in pERK1/2 were seen with ATO treatment in neurospheres and non-neurosphere cells. In conclusion, codon-specific mutant p53 conferred a more aggressive phenotype to our CSC model. However, ATO and ATRA could potently suppress CSC properties in vitro and may support further clinical investigation of these agents.

Deconstructing mTOR complexes in regulation of Glioblastoma Multiforme and its stem cells.

Atypical serine-threonine kinase, mTOR (mechanistic target of Rapamycin; originally coined "mammalian TOR"), exists in two distinct multi-protein complexes termed mTOR complex 1 (mTORC1) and 2 (mTORC2), that senses and integrates a variety of environmental signals to control organism growth and homeostasis via non-overlapping signaling pathways. mTOR belongs to the phosphoinositide 3-kinase (PI3-K)-related kinase family, and an aberrant activation of mTORC1 is a potential contributing factor in uncontrolled cell growth, proliferation, and survival of tumor cells via specific effects on cap-dependent translation initiation, as well as in a more sustained manner via advancing ribosome biogenesis. It is thereby shown to be deregulated in numerous pathological conditions including cancer, obesity, type 2 diabetes, and neurodegeneration. Notably, mTOR itself, or through its substrates, regulates stem cell differentiation and maintenance of plueropotency. mTORC2 has been linked to cytoskeletal reorganization and cell survival through Akt, and is crucial to many divergent physiological functions, which may include stem cell regulation.

Deciphering the signaling pathways of cancer stem cells of glioblastoma multiforme: role of Akt/mTOR and MAPK pathways.

These findings emphasize that the mTOR pathway may contribute to maintenance of quiescence of CSCs, and provide a basis for manipulating CSCs in the treatment of GBM. Future research should focus on further defining the PI3K/Akt/mTOR molecular network in the regulation of stem cell quiescence and provide rationale for targeting the cancer-initiating cells of GBM.

Cocaine-induced encephalocele: case report and literature review.

BACKGROUND AND IMPORTANCE: The abuse of cocaine can lead to significant destruction of midline craniofacial structures. This process occurs secondary to myriad mechanisms, including ischemic necrosis, irritation by chemical adulterants, and direct trauma during its administration. Coupled with a prolonged chronic infection of intranasal and anterior skull base regions, an encephalocele can be formed. We report a case of an encephalocele secondary to cocaine use and its associated complications. CLINICAL PRESENTATION: A 56-year-old man presented with altered mental status and cerebritis secondary to the presence of an intranasal encephalocele. On computed tomography, extensive destruction of the anterior cranial fossa was observed. The patient had a 30-year history of intranasal cocaine abuse, and his urine tested positive for the presence of cocaine on admission. The patient was treated with intravenous antibiotics and underwent a repair of his cranial defect and resection of the encephalocele. The patient made a good recovery after treatment. CONCLUSION: Alternative causes of an encephalocele, including trauma, surgery, and congenital malformation, were ruled out in this patient. Histopathological analysis of the necrotic tissue and the absence of renal or pulmonary disease also indicated that the patient did not suffer from Wegener granulomatosis, a known cause of spontaneous intranasal lesions. To the best of our knowledge, this is the first report of an encephalocele likely induced solely by cocaine abuse.

All-trans retinoic acid modulates cancer stem cells of glioblastoma multiforme in an MAPK-dependent manner.

Glioblastoma multiforme (GBM), a grade IV glioma, appears to harbor therapy-resistant cancer stem cells (CSCs) that are the major cause of recurrence. All-trans retinoic acid (ATRA), a derivative of retinoid, is capable of differentiating a variety of stem cells, as well as normal neural progenitor cells, and down-regulates expression of the stem cell marker nestin. This study investigated the effects of ATRA on differentiation, proliferation, self-renewal, and signaling pathways of CSCs in GBM. CSCs differentiated into glial and neuronal lineages at low concentrations of ATRA (10 µM). Proliferation and self renewal of neurospheres were reduced following ATRA, although ATRA induced apopotsis at higher (40 µM) concentrations. Analysis of mitogen-activated protein kinase signaling pathways, specifically extracellular signal-regulated kinases (ERK1/2), showed that ATRA-induced alterations in ERK1/2 were associated with regulation of differentiation, proliferation and apoptosis. These results emphasize that low doses of ATRA may have therapeutic potential by differentiating GBM CSCs and rendering them sensitive to targeted therapy.

Inhibition of mTOR Activates the MAPK Pathway in Glioblastoma Multiforme.

Tumorigenesis of glioblastoma multiforme (GBM), the most aggressive primary intracranial neoplasm, is associated with aberrant PI3K/AKT/mTOR signaling. Inhibitors of mTOR, such as rapamycin (RAPA) or its analogs, have provided limited benefit. Here, we aim to decipher the signaling pathways involved in RAPA resistance. We found that RAPA induced a time-dependent activation of MAPK (pERK1/2) and MEK1/2. Inhibition of upstream kinase MEK1/2 by U0126 partially suppressed RAPA-induced ERK1/2 activation. Small interfering RNA suppression of mTOR resulted in higher pERK1/2 levels and pre-treatment with RAPA potentiated PDGF-induced activation of ERK1/2. Furthermore, nuclear localization of pERK1/2 was evident following RAPA, which was MEK1/2-dependent. Cell proliferation was significantly suppressed by combined MEK1/2 and mTOR inhibition compared to mTOR inhibition alone. These results demonstrate activation of a mitogenic pathway involving a feedback mechanism between mTOR and PI3K/ERK1/2 and support the basis for combined inhibitors in GBM treatment.

Involvement of mTORC1 and mTORC2 in regulation of glioblastoma multiforme growth and motility.

The AKT/mammalian target of rapamycin (mTOR) signaling pathway plays a critical role in glioblastoma multiforme (GBM) oncogenesis due to activation of AKT. We studied two distinct complexes, mTOR complex 1 (mTORC1) and mTOR complex 2 (mTORC2), through which mTOR controls cell survival, growth and motility. Inhibition of mTOR by rapamycin (RAPA) resulted in time-dependent suppression of S6 ribosomal protein (pS6KSer235/236; mTORC1 substrate) and caused transient suppression of pAKTSer473 (mTORC2 substrate) at 1 to 3 h followed by a consistent increase from 6 to 24 h. Inhibition of mTOR or phosphoinositide 3-kinase (PI3K) suppressed platelet-derived growth factor (PDGF)- or fibronectin (FN)-induced activation of p70S6KThr389. Combined inhibition of mTOR and PI3K abolished PDGF- or FN-induced activation of STAT3Ser727. Expression of pAKT was suppressed by siRNA silencing of mTORC2 co-protein rictor, but not by mTORC1 co-protein raptor. GBM cell proliferation and motility paralleled the activation of mTORC2. Combined inhibition of mTOR and PI3K had an additive effect on suppressing cell growth and motility. PDGF-induced nuclear localization of mTOR was blocked by pre-treatment with RAPA. The results demonstrated that an activation of mTORC2 occurs when mTORC1 is inhibited by RAPA. Therefore, simultaneous suppression of mTORC1 and mTORC2 may provide novel therapy for GBM.

Acquired Chiari malformation secondary to hyperostosis of the skull: a case report and literature review.

BACKGROUND: Most cases of generalized hyperostosis of the skull are associated with Camurati-Engelmann disease, craniodiaphyseal dysplasia, Worth-type endosteal hyperostosis, or sclerosteosis. Infrequently, a Chiari malformation may also be described. We present the case of a patient with acquired Chiari malformation secondary to hyperostotic skull formation whose findings did not fit into any of the 4 usual conditions. We review the literature on generalized hyperostosis of the skull and discuss the appropriate treatment based on our analysis of the literature and the patient's imaging results. CASE DESCRIPTION: A 26-year-old woman presented with headaches, vomiting, and visual loss. Imaging revealed hyperostosis of the skull and an acquired Chiari I malformation. Intracranial pressure was markedly increased. She underwent a reduction craniotomy with subtemporal decompression and had good clinical improvement. CONCLUSION: Chiari malformation in association with hyperostosis of the skull is an unusual finding. Our patient could not be classified into any of the 4 main hyperostotic conditions. Careful attention to imaging identified the hyperostosis and deflected treatment from the standard for Chiari I malformation, suboccipital decompression, which could have proved fatal. Instead, a reduction craniotomy with subtemporal decompression relieved the source of the increased ICP and of the downward tonsilar displacement.

A recurrent network in the lateral amygdala: a mechanism for coincidence detection.

Synaptic changes at sensory inputs to the dorsal nucleus of the lateral amygdala (LAd) play a key role in the acquisition and storage of associative fear memory. However, neither the temporal nor spatial architecture of the LAd network response to sensory signals is understood. We developed a method for the elucidation of network behavior. Using this approach, temporally patterned polysynaptic recurrent network responses were found in LAd (intra-LA), both in vitro and in vivo, in response to activation of thalamic sensory afferents. Potentiation of thalamic afferents resulted in a depression of intra-LA synaptic activity, indicating a homeostatic response to changes in synaptic strength within the LAd network. Additionally, the latencies of thalamic afferent triggered recurrent network activity within the LAd overlap with known later occurring cortical afferent latencies. Thus, this recurrent network may facilitate temporal coincidence of sensory afferents within LAd during associative learning.