The authors present a series of 25 patients who underwent single-stage complete spondylectomy, vertebral body reconstruction, and posterior segmental spinal stabilization for malignant metastatic disease involving multiple columns of the thoracolumbar spine. Patients were selected for this approach primarily because they were poor candidates for a transcavitary or lateral extracavitary approach or because the tumor involved both anterior and posterior columns of the spine. The operative approach used combines radical local resection of tumor via a bilateral transpedicular route, methylmethacrylate vertebral body reconstruction, and Luque rectangle stabilization in a single operation. Following surgery, the majority of patients experienced improvement in their neurological status, reduction in pain, or both. Most patients were functionally improved, or at least no worse, and spinal alignment was maintained in all. There was one local recurrence in a long-term survivor. Complications included cerebrospinal fluid fistulas, migrating graft material, and wound healing problems. The authors conclude that this surgical approach is safe and feasible for the radical resection of vertebral metastasis when combined with reconstruction and stabilization. This technique represents a useful alternative to other commonly used surgical approaches for the treatment of spinal metastases, and it should aid surgeons in selecting the optimum approach for individual patients.

Retrograde transport of the fluorescent tracer True Blue was used in combination with immunohistochemical staining of dopamine-beta-hydroxylase (a marker protein for noradrenergic neurons) to determine the origin of noradrenergic projections to three cranial nerve nuclei: 1) the motor nucleus of the trigeminal nerve, 2) the motor nucleus of the facial nerve, and 3) the spinal trigeminal nucleus pars interpolaris. Noradrenergic cells in the rat brainstem were divided into subgroups and their numbers were determined in serial sections stained with an antiserum to rat dopamine-beta-hydroxylase. Following tracer injections into the three brainstem nuclei, retrogradely labeled noradrenergic neurons were counted and the percentage of True Blue-labeled noradrenergic cells in each subgroup was calculated. Injections of tracer into the three cranial nerve nuclei resulted in distinctly different labeling patterns of noradrenergic cells. Of the total number of norepinephrine neurons projecting to the motor nucleus of the trigeminal nerve, 68% were observed within the A7 cell group; 75% of those innervating the motor nucleus of the facial nerve were found in the A5 cell group, and 65% of those projecting to the spinal trigeminal nucleus pars interpolaris were present in the locus ceruleus and subceruleus. These findings indicate that norepinephrine cells in the rat brainstem do not constitute a homogeneous population of cells but that several discrete systems can be identified that differ not only in topography but also in the terminal distribution of their axons. This combined retrograde transport-immunohistochemical study reveals a much higher degree of topographic order in the projections of norepinephrine neurons than has previously been recognized. The observation of differential projections of noradrenergic subgroups argues against the notion of a global influence of these cells over functionally diverse areas of the brainstem.

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To better understand the spinal transmission of visceral afferent information, we conducted neurophysiological studies of single spinal neurons that receive input from the greater splanchnic nerve (GSN). Extracellular single-neuron recordings were made in the thoracic spinal cord of chloralose-anesthetized, paralyzed, and artificially ventilated rats, some of which had undergone acute spinal transection at C1. Neurons were divided into four classes according to their responses to GSN stimulation: one-burst excitatory, two-burst excitatory, biphasic, and inhibited. We then studied the characteristics of the convergent somatic input to each class of neurons using either natural somatic stimuli or electrical stimulation of the iliohypogastric nerve (IHN). Most splanchnic input was mediated by unmyelinated fibers, whereas somatic input was mediated by both unmyelinated and small myelinated fibers. Most of the neurons exhibited somatic receptive fields, and the majority responded to both innocuous and noxious somatic stimuli. However, a small number could be excited only by GSN stimulation. Although a careful analysis of response characteristics indicated that there was a tendency for neurons to exhibit similar responses to electrical stimulation of the GSN and the IHN, we observed many combinations of somatic and visceral responses. We suggest that visceral afferent activity, in addition to being processed via convergent somatovisceral pathways, may be processed by neurons that convey only visceral information or by neurons in which visceral and somatic information is differentially coded.

The rostral cervical spinal cord is increasingly being considered the source of important propriospinal regulation. To better understand the substrate for this function, we investigated the effects of stimulation of the greater splanchnic nerve (GSN) and both thoracic and cervical somatic afferents on the activity of cervical spinal neurons. Extracellular single-neuron recordings were made in the C2-C5 spinal segments of chloralose-anesthetized, paralyzed, and artificially ventilated rats. Neurons were classified according to their responses to GSN stimulation. Neurons were inhibited by this stimulation as frequently as they were excited. We then studied the characteristics of cervical and thoracic convergent somatic input to each class of neurons. Although all cervical neurons that responded to GSN stimulation responded to electrical stimulation of the iliohypogastric nerve (IHN), only the few neurons that exhibited whole body receptive fields (RF) responded to natural thoracic somatic stimuli. Responses to electrical stimulation of the GSN and IHN were similar for most neurons; most exhibited nociceptive cutaneous RFs in cervical dermatomes. These data indicate that input from cervical somatic afferents and from both thoracic visceral and thoracic somatic afferents converge on individual splanchnic-receptive cervical neurons. Although these neurons exhibited the predicted cervical somatic RFs, responses from thoracic levels did not exhibit discrete RFs, requiring instead more synchronous or more spatially convergent input.

The authors describe a malignant peripheral primitive neuroectodermal tumor (PNET) that originated in the median nerve in an elderly adult. After the diagnosis was made by biopsy, the patient underwent radical local resection with interpositional vein grafting of the brachial artery. The tumor had the typical appearance of a primitive neural tumor with small, round cells forming rosettes. It stained positively for both the Ewing's sarcoma/peripheral PNET antigen (HBA-71) and neuron-specific enolase, confirming its neural origin. Ultrastructural examination revealed dense core granules and suggested neural differentiation of the neoplasm. Cytogenetic analysis suggested a chromosome (11;22) translocation typical of peripheral PNET. Early reports consisted of tumors arising solely in peripheral nerves, but recent series have focused mainly on tumors arising in the soft tissues other than nerves. There are no other cases of true PNET of peripheral nerve in the modern literature that have been fully characterized by immunohistochemical, ultrastructural, and cytogenetic criteria. Although peripheral PNETs occur more commonly in children, this unusual neoplasm should be considered in the differential diagnosis of peripheral nerve neoplasms in adults. Early diagnosis is desirable because of its aggressive nature and poor outcome.

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