The blood-spinal cord barrier (BSCB) is the functional equivalent of the blood-brain barrier (BBB) in the sense of providing a specialized microenvironment for the cellular constituents of the spinal cord. Even if intuitively the BSCB could be considered as the morphological extension of the BBB into the spinal cord, evidence suggests that this is not so. The BSCB shares the same principal building blocks with the BBB; nevertheless, it seems that morphological and functional differences may exist between them. Dysfunction of the BSCB plays a fundamental role in the etiology or progression of several pathological conditions of the spinal cord, such as spinal cord injury, amyotrophic lateral sclerosis, and radiation-induced myelopathy. This review summarizes current knowledge of the morphology of the BSCB, the methodology of studying the BSCB, and the potential role of BSCB dysfunction in selected disorders of the spinal cord, and finally summarizes therapeutic approaches to the BSCB.

The Core Outcome Measures Index (COMI) is a short, multidimensional outcome instrument, with excellent psychometric properties, that has been recommended for use in monitoring the outcome of spinal surgery from the patient's perspective. This study examined the feasibility of implementation of COMI and its performance in clinical practice within a large Spine Centre. Beginning in March 2004, all patients undergoing spine surgery in our Spine Centre (1,000-1,200 patients/year) were asked to complete the COMI before and 3, 12 and 24 months after surgery. The COMI has one question each on back (neck) pain intensity, leg/buttock (arm/shoulder) pain intensity, function, symptom-specific well being, general quality of life, work disability and social disability, scored as a 0-10 index. At follow-up, patients also rated the global effectiveness of surgery, and their satisfaction with their treatment in the hospital, on a five-point Likert scale. After some fine-tuning of the method of administration, completion rates for the pre-op COMI improved from 78% in the first year of operation to 92% in subsequent years (non-response was mainly due to emergencies or language or age issues). Effective completion rates at 3, 12 and 24-month follow-up were 94, 92 and 88%, respectively. The 12-month global outcomes (from N = 3,056 patients) were operation helped a lot, 1,417 (46.4%); helped, 860 (28.1%); helped only little, 454 (14.9%); did not help, 272 (8.9%); made things worse, 53 (1.7%). The mean reductions in COMI score for each of these categories were 5.4 (SD2.5); 3.1 (SD2.2); 1.3 (SD1.7); 0.5 (SD2.2) and -0.7 (SD2.2), respectively, yielding respective standardised response mean values ("effect sizes") for each outcome category of 2.2, 1.4, 0.8, 0.2 and 0.3, respectively. The questionnaire was feasible to implement on a prospective basis in routine practice, and was as responsive as many longer spine outcome questionnaires. The shortness of the COMI and its multidimensional nature make it an attractive option to comprehensively assess all patients within a given Spine Centre and hence avoid selection bias in reporting outcomes.

The Core Outcome Measures Index (COMI) is a reliable and valid instrument for assessing multidimensional outcome in spine surgery. The minimal clinically important score-difference (MCID) for improvement (MCID imp ) was determined in one of the original research studies validating the instrument, but has never been confirmed in routine clinical practice. Further, the MCID for deterioration (MCID det ) has never been investigated; indeed, this needs very large sample sizes to obtain sufficient cases with worsening. This study examined the MCIDs of the COMI in routine clinical practice. All patients undergoing surgery in our Spine Center since February 2004 were asked to complete the COMI before and 12 months after surgery. The COMI has one question each on back (neck) pain intensity, leg/buttock (arm/shoulder) pain intensity, function, symptom-specific well-being, general quality of life, work disability, and social disability, scored as a 0-10 index. At follow-up, patients also rated the global effectiveness of surgery, on a 5-point Likert scale. This was used as the external criterion (''anchor'') in receiver operating characteristics (ROC) analyses to derive cut-off scores for individual improvement and deterioration. Twelve-month follow-up questionnaires were returned by 3,056 (92%) patients. The group mean COMI score change for patients declaring that the ''operation helped'' was a reduction of 3.1 points; the corresponding value for those whom it ''did not help'' was a reduction of 0.5 points. The group MCID imp was hence 2.6 points reduction; the corresponding group MCID det was 1.2 points increase (0.5 minus -0.7). The area under the ROC curve was 0.88 for MCID imp and 0.89 for MCID det (both P \ 0.0001), indicating that the COMI had good discriminative ability. The cut-offs for individual improvement and deterioration, respectively, were C2.2 points decrease (sensitivity 81%, specificity 83%) and C0.3 points increase (sensitivity 83%, specificity 88%). The MCID imp score of 2.2 points was similar to that reported in the original study (2-3 points, depending on external criterion used). The MCID det suggested that the COMI is less responsive to deterioration than to improvement, a phenomenon also reported for other spine outcome instruments. This needs further investigation in even larger patient groups. The MCIDs provide essential information for both the planning (sample size) and interpretation of the results (clinical relevance) of future clinical studies using the COMI.

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The concerted action of CRF and vasopressin (VP) plays a critical role in regulating ACTH release from anterior pituitary cells. In this study, we have explored the expression of these neurohormones in hypophysiotropic paraventricular neurons after repeated exposure of rats to immobilization stress. Cell by cell quantitative in situ hybridization was used to evaluate the steady state level of mRNAs coding for VP and CRF. We found that 16 daily stress exposures resulted in a significant increase in the average cellular level of CRF and VP mRNAs (150% and 200% of control levels, respectively). Moreover, in the repeatedly stressed group, the number of VP-expressing parvicellular neurons was approximately doubled relative to the control value. Using quantitative immunoelectron microscopy, VP- and CRF-immunoreactive sites were assessed in the dense core vesicle compartment of CRF axon terminals in the external zone of the median eminence. We found that after repeated stress, the immunolabeling of VP was augmented, while that of CRF was slightly decreased. Concurrently, we observed a significant increase in the proportion of CRF nerve terminals that were VP positive (from 50% in controls to 90% in stressed animals). We conclude that the observed changes in CRF neurons may represent a physiological response to increased functional demand and may lead to alterations in the composition of the ACTH-releasing signal.