Object Opinions vary widely as to the role of surgery (from none to wide margin excision) in the management of spinal metastases. In this study the authors set out to ascertain if surgery improves the quality of remaining life in patients with spinal metastatic and tumor-related systemic disease. Methods The authors included 223 patients in this study who were referred by oncologists and physicians over a 2-year period. All underwent surgery. Surgery was classified according to extent of excision ranging from en bloc excision or debulking to palliative surgery. All patients had a histologically confirmed diagnosis of epithelial spinal metastasis, and an oncology specialist undertook appropriately indicated adjuvant therapy in almost half of the patients. Results The mean patient age was 61 years. Excisional en bloc or debulking surgery was performed in 74%; the rest had (minimal) palliative decompression. All patients considered for surgery were included in the study. Patients presented with pain in 92% of cases, paraparesis in 24%, and abnormal urinary sphincter function in 22% (5% were incontinent). Breast, renal, lung, and prostate accounted for 65% of the cancers, and in 60% of patients there were widespread spinal metastases (Tomita Type 6 or 7). The incidence of perioperative death (within 30 days of surgery) was 5.8%. Postoperatively 71% of the entire group had improved pain control, 53% regained or maintained their independent mobility, and 39% regained urinary sphincter function. The median survival for the cohort was 352 days (11.7 months); those who underwent excision survived significantly longer than those in the palliative group (p = 0.003). As with survival results, functional improvement outcome was better in those who underwent excision. Conclusions Surgical treatment was effective in improving quality of life by providing better pain control, enabling patients to regain or maintain mobility, and offering improved sphincter control. Although not a treatment of the systemic cancer, surgery is feasible, has acceptably low mortality and morbidity rates, and for many will improve the quality of their remaining life.

The incurability of spinal cord injury and subcortical strokes is due to the inability of nerve fibres to regenerate. One of the clearest clinical situations where failure of regeneration leads to a permanent functional deficit is avulsion of the brachial plexus. In current practice, surgical re-implantation of avulsed spinal roots provides a degree of motor recovery, but the patients neither recover sensation nor the use of the hand. In the present rat study, we show that transplantation of cultured adult olfactory ensheathing cells restores the sensory input needed for a complex, goal-directed fore-paw function and re-establishes synaptic transmission to the spinal grey matter and cuneate nucleus by providing a bridge for regeneration of severed dorsal root fibres into the spinal cord. Success in a first application of human olfactory ensheathing cells in clinical brachial plexus injury would open the way to the wider field of brain and spinal cord injuries.

In an ongoing clinical trial, a spinal injured patient who received a transplant of autologous cells cultured from the olfactory bulb is showing greater functional benefit than three previous patients with transplants of mucosal origin. Previous laboratory studies of transplantation into rat spinal cord injuries show that the superior reparative benefits of bulbar over mucosal cultures are associated with regeneration of severed corticospinal tract fibers over a bridge of olfactory ensheathing cells (OECs) formed across the injury site. In a rat rhizotomy paradigm, we reported that transplantation of bulbar cell cultures also enables severed axons of the C6-T1 dorsal roots to regenerate across a bridge of OECs into the spinal cord and restore electrophysiological transmission and forepaw grasping during a climbing test. We now report a repeat of the same rhizotomy procedure in 25 rats receiving cells cultured from olfactory mucosal biopsies. In no case did the transplanted cells form a bridging pathway. No axons crossed from the severed roots to the spinal cord, and there was no restoration of forepaw grasping. This suggests that the superior clinical benefit in the patient receiving bulbar cell transplants is due to regeneration of severed fibers across the injury site, and this correlates with imaging and the pattern of functional recovery. Using present culture protocols, the yield of OECs from bulbar biopsies is around 50%, but that from mucosal biopsies is less than 5%. Improving the yield of OECs from mucosal biopsies might avoid the necessity for the intracranial approach to obtain bulbar cells.

Hyponatremia is common in neurocritical care patients and is associated with significant morbidity and mortality. Despite decades of research into the syndrome of inappropriate antidiuretic hormone (SIADH) and cerebral salt wasting (CSW), their underlying pathophysiological mechanisms are still not fully understood. This paper reviews the history behind our understanding of hyponatremia in patients with neurologic injury, including the first reports of CSW and SIADH, and current and future challenges to diagnosis and management in this setting. Such challenges include distinguishing CSW, SIADH, and hypovolemic hyponatremia due to a normal pressure natriuresis from the administration of large volumes of fluids, and hyponatremia due to certain medications used in the neurocritical care population. Potential treatments for hyponatremia include mineralocorticoids and vasopressin 2 receptor antagonists, but further work is required to validate their usage. Ultimately, a greater understanding of the pathophysiological mechanisms underlining hyponatremia in neurocritical care patients remains our biggest obstacle to optimizing patient outcomes in this challenging population.

Object Basilar impression (BI) secondary to osteogenesis imperfecta (OI) is a rare but debilitating condition that is often progressive unless it is halted. More recently, ventral decompression surgery has been advocated for this condition. This study is a retrospective review of the 21-year experience of ventral decompression surgery and dorsal occipitocervical fixation in patients with BI secondary to OI and is the largest patient series reported to date. Methods Twenty patients treated between 1982 and 2003 by the senior author at the authors' institution were included in this study. All patients underwent ventral decompression surgery followed by dorsal craniocervical stabilization. Patients were followed up for a median of 10 years. Results There were no intraoperative or perioperative deaths. Postoperatively, 16 of 20 (80%) patients showed objective improvement or maintained their good preoperative level of function. After surgery, of the 15 patients admitted with Karnofsky Performance Scale (KPS) scores of 70% or less, 11 improved, two remained unchanged, one patient's condition deteriorated, and one patient died of an unrelated cause. Of five patients admitted with a KPS score of 80% or greater, no patient's condition deteriorated in the short- and midterm period, but one patient had recurrence 15 years after surgery. At the end of follow-up, 25% of the patients had recurrence of brainstem compression symptoms or had died, and 15% showed no improvement after surgery. All of the remaining patients (60%) had sustained a long-term benefit from surgery. Conclusions Aggressive ventral decompression surgery and dorsal stabilization for patients with BI secondary to OI can not only halt disease progression but can also produce a good and sustainable long-term functional outcome, even in those patients who present as severely symptomatic. Patients who presented early with minor symptoms had good long-term outcomes.