Chad D. Cole

Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches

The authors review and compare posterior lumbar interbody fusion (PLIF) with transforaminal lumbar interbody fusion (TLIF). A review of the literature is performed wherein the history, indications for surgery, surgical procedures with their respective biomechanical advantages, potential complications, and grafting substances are presented. Along with the technical advancements and improvements in grafting substances, the indications and use of PLIF and TLIF have increased. The rate of arthrodesis has been shown to increase given placement of bone graft along the weight-bearing axis. The fusion rate across the disc space is further enhanced with the placement of posterior pedicle screw–rod constructs and the application of an osteoinductive material. The chief advantages of the TLIF procedure compared with the PLIF procedure included a decrease in potential neurological injury, improvement in lordotic alignment given graft placement within the anterior column, and preservation of posterior column integrity through minimizing lamina, facet, and pars dissection.

Vertebroplasty and kyphoplasty: a comparative review of efficacy and adverse events

Vertebroplasty and kyphoplasty have become common surgical techniques for the treatment of vertebral compression fractures. Vertebroplasty involves the percutaneous injection of bone cement into the cancellous bone of a vertebral body with the goals of pain alleviation and preventing further loss of vertebral body height. Kyphoplasty utilizes an inflatable balloon to create a cavity for the cement with the additional potential goals of restoring height and reducing kyphosis. Vertebroplasty and kyphoplasty are effective treatment options for the reduction of pain associated with vertebral body compression fractures. Biomechanical studies demonstrate that kyphoplasty is initially superior for increasing vertebral body height and reducing kyphosis, but these gains are lost with repetitive loading. Complications secondary to extravasation of cement include compression of neural elements and venous embolism. These complications are rare but more common with vertebroplasty. Vertebroplasty and kyphoplasty are both safe and effective procedures for the treatment of vertebral body compression fractures.

TOTAL INTRAVENOUS ANESTHESIA: ADVANTAGES FOR INTRACRANIAL SURGERY

OBJECTIVE Although volatile anesthetics have been widely accepted in anesthetic management for neurosurgery, they reduce vascular resistance, resulting in increased cerebral blood flow and increased intracranial pressure (ICP). In patients with elevated ICP who undergo craniotomy, the increase in ICP during surgery from inhaled anesthetics can make the surgery more difficult, thereby increasing the risk of ischemic cerebral insults. Total intravenous anesthesia (TIVA) using propofol and analgesic drugs (remifentanil or fentanyl) and excluding simultaneous administration of any inhaled drugs is being used in patients undergoing craniotomy because of its potential to reduce ICP and ease access to the operative site. METHODS We reviewed the literature and describe our experience with TIVA, with emphasis on hemodynamic stability, effects on ICP, emergence from anesthesia, extubation times, and return of cognitive function in patients undergoing craniotomy for space-occupying lesions. RESULTS TIVA with propofol is similar to inhaled anesthetics with regard to hemodynamic stability, emergence times, extubation times, early cognitive function, and adverse events. In several prospective, randomized clinical trials, evidence suggests that ICP is decreased and cerebral perfusion pressure is increased in patients receiving TIVA when compared with those receiving volatile anesthetics during elective craniotomy procedures. CONCLUSION The impact of TIVA on ICP, brain swelling, and access to the operative site in patients with severely elevated ICP has yet to be evaluated and is the subject of a future study at our institution.

Downregulation of a pathogenic autoantibody response by IgM autoantibodies directed against the nephritogenic antigen in slowly progressive Heymann nephritis

The purpose of the study was to find out if a new modified vaccination technique would be effective in downregulating immunopathological events during the course of an experimental autoimmune kidney disease (which is morphologically and functionally similar to Heymann nephritis) called ‘slowly progressive Heymann nephritis’ (SPHN). We have shown that the pathogenic IgG autoantibody (aab)‐induced experimental autoimmune kidney disease process can be downregulated early on as well as during the chronic progressive phase, when rats were restimulated. The IgM aab, resulting from stimulation by immune complexes made up of rat kidney fraction 3 (rKF3) antigen and rat anti‐rKF3 IgM antibody in antigen excess (MIC), can greatly diminish pathogenic aab production by removing or blocking nephritogenic antigens. Reduced IgG aab production limits the formation of damaging immune complexes (IC) in the glomeruli and development of proteinuria. At the end of the experiment 60% and 80% of the MIC‐treated groups had no pathogenic IgG aab in their circulation, while all the untreated SPHN rats had high levels of IgG aab associated with disease progression manifesting in increased proteinuria and severe immune complex glomerulonephritis.

The role of autoimmunologists in investigating and treating autoimmune disorders

The role of an autoimmunologist is to investigate and cultivate knowledge of normal and abnormal immune responses against self, which includes developing practical know-how to manipulate autoimmune activity and direct positive autoimmune outcomes. Where a subject develops an abnormal immune response directed against normal self, resulting in an autoimmune disease, the specialist should be able to diagnose the problem and institute an appropriate treatment. Obversely, where a subject lacks an immune response against cells bearing antigens that are abnormal or not quite self, i.e., cancer cells, the specialist should ideally be able to institute a specific cancer cell killing regimen. Essentially there are two beneficial and two harmful aspects of autoimmunity autoimmunologists should be familiar with. The beneficial aspects are the immune responses that assist in the clearance of cellular breakdown products and the elimination of cancer cells. The harmful aspects consist of immune responses, or lack thereof, that manifest in autoimmune disorders, i.e., autoimmune diseases and cancer. Recent medical discoveries, especially the modified vaccination technique developed by the Barabas research group, show great promise in both preventing and curing autoimmune disorders by utilizing the immune systems natural abilities to re-establish normal health.

A Modified Vaccination Technique for the Prevention and Treatment of an Experimental Autoimmune Kidney Disease

Abstract:  The main purpose of this article is to introduce a promising new vaccination technique and to outline its efficacy and safety as demonstrated in an experimental autoimmune kidney disease. We have found that antigen (AG)‐specific downregulation and/or upregulation of immune responses can be achieved by injections of immune complexes (ICs) which contain prepackaged information. This result is attained with the new vaccination method, a method developed in our laboratory which we have called “modified vaccination technique” (MVT). This MVT not only enables the prevention of pathogenic autoimmune events leading to the development of an experimental autoimmune kidney disease; it also allows, with equal effectiveness, therapeutic intervention to terminate the disease. With an injected IC containing predetermined immune response‐inducing components, the process effectuates a specific antibody information transfer conferring advantages that go beyond its prophylactic and therapeutic applicability. Its specificity can induce a precise immune response to correct mishaps, for example, in conditions where the immune system overreacts to an autologous antigen or fails to recognize unwanted self (as in autoimmune disorders, cancer, etc.) Preformed ICs are nontoxic and nonirritant, evoke a predetermined antibody response without the use of adjuvants, cause no disturbance in the overall regulatory function of the immune system, and produce no side effects. We firmly believe that proper implementation of the MVT will be able to induce and maintain specific preventive and/or curative responses in a way that is both natural and more effective in patients with chronic ailments presently treatable only with drugs.

Rathke cleft cyst presenting with hyponatremia: an unusual presentation

The authors report a case of Rathke cleft cyst presenting with severe hyponatremia. A 33-year-old man suffered sudden severe headaches, visual changes, dizziness, nausea, vomiting, and a metallic taste in his mouth. Initial laboratory values demonstrated severe hyponatremia. Magnetic resonance imaging revealed a cystic lesion with questionable intracystic hemorrhage, concerning for pituitary apoplexy. Transsphenoidal decompression and drainage of the cyst confirmed the diagnosis of Rathke cleft cyst and resolved the symptoms. Postoperative follow-up studies at 6 months demonstrated normal endocrine function and no evidence of a cyst.

Correcting autoimmune anomalies in autoimmune disorders by immunological means, employing the modified vaccination technique.

Our research group has developed a new vaccination technique in experimental animals that has the potential of correcting autoimmune anomalies in humans such as autoimmune disorders, cancer, and chronic infections, both prophylactically and therapeutically. The vaccination method is called Modified Vaccination Technique (MVT). The MVT necessitates the introduction of a purified target antigen (ag) and a specific antibody (ab) against the target ag in the form of immune complex (IC) to evoke the desired immune response outcome by ab information transfer in the injected recipient. The injected IC produces the same class of ab in the host, with the same specificity against the target ag, as resides in the inoculum. The MVT promises to provide a means of upregulating beneficial immune events and downregulating undesirable immune responses in individuals, thereby re-establishing normalcy/tolerance to self.

Modified Vaccination Technique for Prophylactic and Therapeutic Applications to Combat Endogenous Antigen–Induced Disorders

Public health can be protected most effectively through vaccination programmes. However, while presently available vaccination techniques protects the individual by provoking immune responses against exogenous antigens (ags), such as those associated with certain bacteria and viruses, they cannot protect against or treat mishaps caused by endogenous ag. Recently, Barabas and colleagues have developed a new vaccination method, called modified vaccination technique (MVT), which allows the presentation of disease causing agents in such a way as to initiate and maintain desired immune response outcomes even in the context of mishaps associated with endogenous ag. For example, in an experimental autoimmune kidney disease, the MVT downregulated/terminated pathogenic immune responses that were causing morphological and functional changes of the kidney. The MVT promises, with appropriate case‐specific modifications, both preventative and curative applications for ailments, such as endogenous ag initiated mishaps (i.e. autoimmune diseases and cancer) and diseases caused by chronic infection, that are presently only treatable with drugs. To achieve specific immune responses, purified components of the vaccine (ag and antibodies) must be produced and assembled into immune complexes having the potential of inducing predetermined corrective immune response outcomes.

Effect of rat kidney fraction 3 (rKF3) antigen and specific IgM antibody against rKF3 on the progression of slowly progressive Heymann nephritis

The aim of the present study was to find out if specific IgM (M) antibody (directed against rat kidney fraction 3 (rKF3)) or rKF3 antigen were able to influence disease progression in an experimental autoimmune kidney disease called slowly progressive Heymann nephritis (SPHN). The level of circulating autoantibodies (aabs) and the morphological and functional changes to the kidney were studied in six groups of rats. All of the treatment components (except post‐treatment with M) used in the SPHN pre‐ and post‐treated rats and post‐treated‐only rats had measurable beneficial effects (even during restimulation with the chemically modified renal antigen, 22 weeks after the induction of the disease) as demonstrated by diminished pathogenic IgG aab production, less severe kidney lesions, and proteinuria reductions. The injected rKF3 minimized progression best in this experiment, especially when administered in a pre‐ and post‐treatment regimen. It is thought that the effect of rKF3 in the reduced progression of SPHN was due to increased production of specific IgM aabs, which in turn limited pathogenic aab production and continuous buildup of immune complexes in the glomeruli by facilitating removal or blockage of nephritogenic autoantigens from the circulation.