Journal of Neurosurgery

Michael Jackson’s antigravity tilt — Talent, magic, or a bit of both?

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Three neurosurgeons set out to examine Michael Jackson’s antigravity tilt, introduced in the movie video ‘Smooth Criminal,’ from a neurosurgeon’s point of view.

When was the last time you watched a Michael Jackson music video? If your answer is “never” or “not for quite a while,” you are really missing a treat. According to Rolling Stone, “No single artist … shaped, innovated or defined the medium of ‘music video’ more than Michael Jackson.”

Back in the 1980s and early 1990s, MTV had only one format — music videos — and that genre really took off when Jackson burst on the scene in 1983 with his musical hit “Billie Jean.” Prior to his arrival on MTV, most videos were merely visual promos for artists’ songs, and in some cases the visual side of the promos detracted from the music. Michael Jackson, on the other hand, took his incredible music and added story lines, special effects, cinematography, and amazing choreography. He created high-budget brief movies highlighting both music and dance.

And about that dance. . . . Jackson executed dance moves we thought impossible, at the time and even now. Almost every fan tried to dance like him, but very few could pull it off. Some of Jackson’s dance moves appear to defy the laws of gravity. In one move featured in his 1987 music video “Smooth Criminal,” he pitches forward 45 degrees, with his body straight as a rod and his shoes resting on the stage, and holds the position. That is not how the human body works! How did Michael Jackson do it? Was it talent, magic, or both?

Three neurosurgeons from the Postgraduate Institute of Medical Education and Research in Chandigarh, India — Nishant S. Yagnick, Manjul Tripathi, and Sandeep Mohindra — set out to examine the antigravity tilt introduced in “Smooth Criminal” from a neurosurgeon’s point of view.

First, Yagnick et al. walk us through some basics of spinal biomechanics to show just how impressive is the feat. Even the strongest of dancers can only maintain a 25- to 30-degree forward tilt from the ankle.

Admitted fans of Jackson, the neurosurgeons document how the antigravity tilt was accomplished, taking into account the talent and core strength of the artist, as well as his inventiveness and use of a patented aid, that together seem to move his body past human limits. They also warn other neurosurgeons of new forms of spinal injuries, as dancers follow Jackson’s example and attempt “to jump higher, stretch further, and turn faster than ever before.”

The full story on the antigravity tilt is published today in a new article in the Journal of Neurosurgery entitled “How did Michael Jackson challenge our understanding of spine biomechanics?.”

Read the article soon. This is one of those mysteries where the solution is as fascinating as the performance. After you’ve read the article, you may want to go to YouTube and check out “Smooth Criminal” and other Michael Jackson music videos.

When asked about his article, Dr. Tripathi said, “MJ has inspired generations of dancers to push themselves beyond their limits. Though a visual delight, such moves also lead to new forms of musculoskeletal injuries. “The King of Pop” has not only been an inspiration but a challenge to the medical fraternity.”

Journal Reference:

  1. Nishant S. Yagnick, Manjul Tripathi, Sandeep Mohindra. How did Michael Jackson challenge our understanding of spine biomechanics? Journal of Neurosurgery: Spine, 2018; 1 DOI: 10.3171/2018.2.SPINE171443

Incidence of and risk factors for superior facet violation in minimally invasive versus open pedicle screw placement during transforaminal lumbar interbody fusion: a comparative analysis.

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A reported risk factor for adjacent-segment disease is injury to the superior facet joint from pedicle screw placement. Given that the facet joint is not typically visualized during percutaneous pedicle screw insertion, there is a concern for increased facet violation (FV) in minimally invasive fusion procedures. The purpose of this study was to analyze and compare the incidence of FV among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open transforaminal lumbar interbody fusion (TLIF). The impact of O-arm navigation compared with traditional fluoroscopy on FV in MITLIF is also assessed, as are risk factors for FV.

Methods

The authors identified a consecutive population of patients who underwent MITLIF with percutaneous pedicle screw placement, as well as a matched cohort of patients who underwent open TLIF. Postoperative CT imaging was assessed to determine intraarticular FV due to pedicle screw placement. Patients were stratified into minimally invasive and open TLIF groups. Within the MITLIF group, the authors performed a subanalysis of image guidance methods used in cases of FV. Two-tailed Student t-test, ANOVA, chi-square testing, and logistic regression were used for statistical analysis.

Results

A total of 282 patients were identified, with a total of 564 superior pedicle screw placements. The MITLIF group consisted of 142 patients with 284 screw insertions. The open TLIF group consisted of 140 patients with 280 screw insertions. Overall, 21 (7.4%) of 282 patients experienced FV. A total of 21 screws violated a facet joint for a screw-based FV rate of 3.7% (21 of 564 screws). There were no significant differences between the MITLIF and open TLIF groups in the percentage of patients with FV (6.3% vs 8.6%) and or the percentage of screws with FV (3.2% vs 4.3%) (p = 0.475 and p = 0.484, respectively). Further stratifying the MI group into O-arm navigation and fluoroscopic guidance subgroups, the patient-based rates of FV were 10.8% (4 of 37 patients) and 4.8% (5 of 105 patients), respectively, and the screw-based rates of FV were 5.4% (4 of 74 screws) and 2.4% (5 of 210 screws), respectively. There was no significant difference between the subgroups with respect to patient-based or screw-based FV rates (p = 0.375 and p = 0.442, respectively). The O-arm group had a significantly higher body mass index (BMI) (p = 0.021). BMI greater than 29.9 was independently associated with higher FV (OR 2.36, 95% CI 1.65–8.53, p = 0.039).

Conclusions

The findings suggest that minimally invasive pedicle screw placement is not associated with higher rates of FV. Overall violation rates were similar in MITLIF and open TLIF. Higher BMI, however, was a risk factor for increased FV. The use of O-arm fluoroscopy with computer-assisted guidance did not significantly decrease the rate of FV.

Source: Journal of Neurosurgery

 

 

Overheated and melted intracranial pressure transducer as cause of thermal brain injury during magnetic resonance imaging.

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Case report

Magnetic resonance imaging is used with increasing frequency to provide accurate clinical information in cases of acute brain injury, and it is important to ensure that intracranial pressure (ICP) monitoring devices are both safe and accurate inside the MRI suite. A rare case of thermal brain injury during MRI associated with an overheated ICP transducer is reported.

This 20-year-old man had sustained a severe contusion of the right temporal and parietal lobes during a motor vehicle accident. An MR-compatible ICP transducer was placed in the left frontal lobe. The patient was treated with therapeutic hypothermia, barbiturate therapy, partial right temporal lobectomy, and decompressive craniectomy. Immediately after MRI examination on hospital Day 6, the ICP monitor was found to have stopped working, and the transducer was subsequently removed. The patient developed meningitis after this event, and repeat MRI revealed additional brain injury deep in the white matter on the left side, at the location of the ICP transducer. It is suspected that this new injury was caused by heating due to the radiofrequency radiation used in MRI because it was ascertained that the tip of the transducer had been melted and scorched. Scanning conditions—including configuration of the transducer, MRI parameters such as the type of radiofrequency coil, and the specific absorption rate limit—deviated from the manufacturer’s recommendations. In cooperation with the manufacturer, the authors developed a precautionary tag describing guidelines for safe MR scanning to attach to the display unit of the product.

Strict adherence to the manufacturer’s guidelines is very important for preventing serious complications in patients with ICP monitors undergoing MRI examinations.

Source: Journal of Neurosurgery

 

 

 

 

Response to acute concussive injury in soccer players: is gender a modifying factor?

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Several studies have suggested a gender difference in response to sports-related concussion (SRC). The Concussion in Sport group did not include gender as a modifying factor in SRC, concluding that the evidence at that point was equivocal. In the present study the authors endeavored to assess acute neurocognitive and symptom responses to an SRC in equivalent cohorts of male and female soccer players. The authors hypothesized that female athletes would experience greater levels of acute symptoms and neurocognitive impairment than males.

Methods

Baseline symptom and neurocognitive scores were determined in 40 male and 40 female soccer players by using the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) scale prior to any SRC. After sustaining an SRC, each athlete completed postconcussion ImPACT tests and was carefully matched on a wide array of biopsychosocial variables. Baseline symptom and neurocognitive test scores were compared, and their acute symptoms and neurocognitive responses to concussive injury were assessed.

Results

Specific a priori hypotheses about differences between males and females at baseline and at postconcussion measurements of verbal and visual memory ImPACT scores were evaluated according to simple main effects of the gender variable and according to baseline-to-postconcussion main effect and interaction of 2 × 2 split-plot ANOVA. Neither the interaction nor the main effects nor the simple main effects for either ImPACT variable were found to be statistically significant. Exploratory ANOVAs applied to the remaining ImPACT variables of visualmotor speed, reaction time, impulse control, and symptom total scores revealed only a single statistically significant baseline-to-postconcussion main effect for the symptom total.

Conclusions

The results failed to replicate prior findings of gender-specific baseline neurocognitive differences in verbal and visual memory. The findings also indicated no differential gender-based acute response to concussion (symptoms or neurocognitive scores) among high school soccer players. The implications of these findings for the inclusion of gender as a modifying factor in this tightly matched cohort are addressed. Potential explanations for the null findings are discussed.

Source: Journal of Neurosurgery

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring.

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Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor.

Methods

From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension.

Results

Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality.

Conclusions

In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

Source: Journal of Neurosurgery.

 

 

 

 

Assessment of antiangiogenic effect of imatinib mesylate on vestibular schwannoma tumors using in vivo corneal angiogenesis assay.

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Angiogenesis and the platelet-derived growth factor (PDGF) pathway are active in the pathogenesis of vestibular schwannomas (VSs). The purpose of this study was to test whether imatinib mesylate (Gleevec), a PDGF receptor (PDGFR) blocker, reduces angiogenic capacity in sporadic VS and in VS associated with neurofibromatosis Type 2 (NF2) using a corneal angiogenesis assay.

Methods

From 121 VS tissue samples stored in the tumor bank at the Marmara University Institute of Neurological Sciences, 10 samples (6 from sporadic cases, 4 from NF2-associated cases) were selected at random for use in this study. Expression of PDGF-A and PDGF-B and their receptors was evaluated in sporadic and NF2-associated VS as well as in glioblastoma (GBM) and normal brain tissue by means of immunohistochemistry and Western blot analysis. Corneal angiogenesis assay was then used to evaluate the angiogenic capacity of tissue specimens from sporadic and NF2-associated VS with and without imatinib treatment as well as positive and negative controls (GBM and normal brain tissue).

Results

The angiogenic potential of the sporadic and NF2-associated VS tumor tissue differed significantly from that of the positive and negative control tissues (p <0.05). Furthermore, NF2-associated VS showed significantly lower angiogenic potential than sporadic VS (p <0.05). Imatinib treatment significantly reduced the angiogenic potential in both the sporadic VS and the NF2-associated VS groups. The level of PDGF-A and PDGFR-α as well as PDGF-B and PDGFR-β expression in sporadic VS and NF2-associated VS also differed significantly (p <0.05) from the levels in controls. Additionally the level of PDGFR-β was significantly higher in sporadic VS than in NF2-associated VS (p <0.05).

Conclusions

The findings of this study indicate that NF2-associated VS has significantly more angiogenic potential than sporadic VS and normal brain tissue. Additionally, imatinib reduces the angiogenic activity of both sporadic and NF2-associated VS. The authors conclude that imatinib may be a potential treatment for VS, especially for NF2-associated lesions that cannot be cured with resection or radiosurgery.

Source: Journal of Neurosurgery.

Frontal bur hole through an eyebrow incision for image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage.

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Surgical evacuation of spontaneous intracerebral hemorrhage (sICH) remains a subject of controversy. Minimally invasive techniques for hematoma evacuation have shown a trend toward improved outcomes. The aim of the present study is to describe a minimally invasive alternative for the evacuation of sICH and evaluate its feasibility.

Methods

The authors reviewed records of all patients who underwent endoscopic evacuation of an sICH at the UCLA Medical Center between March 2002 and March 2011. All patients in whom the described technique was used for evacuation of an sICH were included in this series. In this approach an incision is made at the superior margin of the eyebrow, and a bur hole is made in the supraorbital bone lateral to the frontal sinus. Using stereotactic guidance, the surgeon advanced the endoscopic sheath along the long axis of the hematoma and fixed it in place at two specific depths where suction was then applied until 75%–85% of the preoperatively determined hematoma volume was removed. An endoscope’s camera, then introduced through the sheath, was used to assist in hemostasis. Preoperative and postoperative hematoma volumes and reduction in midline shift were calculated and recorded. Admission Glasgow Coma Scale and modified Rankin Scale (mRS) scores were compared with postoperative scores.

Results

Six patients underwent evacuation of an sICH using the eyebrow/bur hole technique. The mean preoperative hematoma volume was 68.9 ml (range 30.2–153.9 ml), whereas the mean postoperative residual hematoma volume was 11.9 ml (range 5.1–24.1 ml) (p = 0.02). The mean percentage of hematoma evacuated was 79.2% (range 49%–92.7%). The mean reduction in midline shift was 57.8% (p < 0.01). The Glasgow Coma Scale score improved in each patient between admission and discharge examination. In 5 of the 6 patients the mRS score improved from admission exam to last follow-up. None of the patients experienced rebleeding.

Conclusions

This minimally invasive technique is a feasible alternative to other means of evacuating sICHs. It is intended for anterior basal ganglia hematomas, which usually have an elongated, ovoid shape. The approach allows for an optimal trajectory to the long axis of the hematoma, making it possible to evacuate the vast majority of the clot with only one pass of the endoscopic sheath, theoretically minimizing the amount of damage to normal brain.

Source: Journal of Neurosurgery.

 

 

 

Endoscopic approaches to the trigeminal nerve and clinical consideration for trigeminal schwannomas: a cadaveric study.

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The course of the trigeminal nerve straddles multiple fossae and is known to be very complex. Comprehensive anatomical knowledge and skull base techniques are required for surgical management of trigeminal schwannomas. The aims of this study were to become familiar with the endoscopic anatomy of the trigeminal nerve and to develop a minimally invasive surgical strategy for the treatment of trigeminal schwannomas.

Methods

Ten fresh cadavers were studied using 5 endoscopic approaches with the aid of 4-mm 0° and 30° endoscopes to identify surgical landmarks associated with the trigeminal nerve. The endoscopic approaches included 3 transcranial keyhole approaches (the extradural supraorbital, extradural subtemporal, and retrosigmoid approaches), and 2 endonasal approaches (the transpterygoid and the transmaxillary transpterygoid approaches).

Results

The trajectories of the extradural supraorbital, transpterygoid, and extradural subtemporal approaches corresponded with the course of the first, second, and third divisions of the trigeminal nerve, respectively. The 3 approaches demonstrated each division in intra- and extracranial spaces, as well as the Meckel cave in the middle cranial fossa. The interdural space at the lateral wall of the cavernous sinus was exposed by the extradural supraorbital and subtemporal approaches. The extradural subtemporal approach with anterior petrosectomy and the retrosigmoid approach visualized the trigeminal sensory root and its neighboring neurovascular structures in the posterior cranial fossa. The transmaxillary transpterygoid approach revealed the course of the third division in the infratemporal fossa.

Conclusions

The 5 endoscopic approaches effectively followed the course of the trigeminal nerve with minimal invasiveness. These approaches could provide alternative options for the management of trigeminal schwannoma.

Source: Journal of Neurosurgery.

 

 

 

The therapeutic potential of ex vivo expanded CD133+ cells derived from human peripheral blood for peripheral nerve injuries.

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CD133+ cells have the potential to enhance histological and functional recovery from peripheral nerve injury. However, the number of CD133+ cells safely obtained from human peripheral blood is extremely limited. To address this issue, the authors expanded CD133+ cells derived from human peripheral blood using the serum-free expansion culture method and transplanted these ex vivo expanded cells into a model of sciatic nerve defect in rats. The purpose of this study was to determine the potential of ex vivo expanded CD133+ cells to induce or enhance the repair of injured peripheral nerves.

Methods

Phosphate-buffered saline (PBS group [Group 1]), 105 fresh CD133+ cells (fresh group [Group 2]), 105 ex vivo expanded CD133+ cells (expansion group [Group 3]), or 104 fresh CD133+ cells (low-dose group [Group 4]) embedded in atelocollagen gel were transplanted into a silicone tube that was then used to bridge a 15-mm defect in the sciatic nerve of athymic rats (10 animals per group). At 8 weeks postsurgery, histological and functional evaluations of the regenerated tissues were performed.

Results

After 1 week of expansion culture, the number of cells increased 9.6 ± 3.3–fold. Based on the fluorescence-activated cell sorting analysis, it was demonstrated that the initial freshly isolated CD133+ cell population contained 93.22% ± 0.30% CD133+ cells and further confirmed that the expanded cells had a purity of 59.02% ± 1.58% CD133+ cells. However, the histologically and functionally regenerated nerves bridging the defects were recognized in all rats in Groups 2 and 3 and in 6 of 10 rats in Group 4. The nerves did not regenerate to bridge the defect in any of the rats in Group 1.

Conclusions

The authors’ results show that ex vivo expanded CD133+ cells derived from human peripheral blood have a therapeutic potential similar to fresh CD133+ cells for peripheral nerve injuries. The ex vivo procedure that can be used to expand CD133+ cells without reducing their function represents a novel method for developing cell therapy for nerve defects in a clinical setting.

Source: Journal of Neurosurgery.