Intrathecal Research Articles

Numerical study of the effects of minor structures and mean velocity fields in the cerebrospinal fluid flow

The importance of optimizing intrathecal drug delivery is highlighted by its potential to improve patient health outcomes. Findings from previous computational studies, based on an individual or a small group, may not be applicable to the wider population due to substantial geometric variability. Our study aims to circumvent this problem by evaluating an individual’s cycle-averaged Lagrangian velocity field based on the geometry of their spinal subarachnoid space. It has been shown by Lawrence et al. (J Fluid Mech 861:679–720, 2019) that dominant physical mechanisms, such as steady streaming and Stokes drift, are key to facilitating mass transport within the spinal canal. In this study, we computationally modeled pulsatile cerebrospinal fluid flow fields and Lagrangian velocity field within the spinal subarachnoid space. Our findings highlight the essential role of minor structures, such as nerve roots, denticulate ligaments, and the wavy arachnoid membrane, in modulating flow and transport dynamics within the spinal subarachnoid space. We found that these structures can enhance fluid transport. We also emphasized the need for particle tracking in computational studies of mass transport within the spinal subarachnoid space. Our research illuminates the relationship between the geometry of the spinal canal and transport dynamics, characterized by a large upward cycle-averaged Lagrangian velocity zone in the wider region of the geometry, as opposed to a downward zone in the narrower region and areas close to the wall. This highlights the potential for optimizing intrathecal injection protocols by harnessing natural flow dynamics within the spinal canal.

Involvement of CXCL12/CXCR4 in CB2 receptor agonist-attenuated morphine tolerance in Walker 256 tumor-bearing rats with cancer pain

While low-dose cannabinoid 2 (CB2) receptor agonists attenuate morphine tolerance in cancer pain models, chemokine ligand 12 (CXCL12)/chemokine receptor 4 (CXCR4) expression induces morphine tolerance. Whether CB2 receptor agonists attenuate morphine tolerance by modulating CXCL12/CXCR4 signaling or whether CXCL12/CXCR4 signaling affects the mu opioid receptor (MOR) in the development of morphine tolerance in cancer pain remains unclear. In this study, we investigated the attenuation of morphine tolerance by a non-analgesic dose of the CB2 receptor agonist AM1241, focusing specifically on the modulation of CXCL12/CXCR4 signaling and its effect on the MOR. Rats received intrathecal Walker 256 tumor cell implantations and were treated with morphine combined with the intrathecal injection of AM1241 or the CB2 receptor antagonists AM630 and AM1241, or a CXCL12-neutralizing antibody, exogenous CXCL12, or the CXCR4 antagonist AMD3100. Our results show that CXCL12 and CXCR4 levels increased significantly in morphine-tolerant rats and were reduced by AM1241 pretreatment, which was reversed by AM630. CXCL12/CXCR4 expression accelerated the development of morphine tolerance and downregulated MOR expression. CXCR4 colocalized with MOR and CB2. Therefore, a non-analgesic dose of AM1241 attenuated morphine tolerance via CXCL12/CXCR4 signaling, whereas CXCL12/CXCR4 signaling participated in the development of morphine tolerance, potentially by modulating MOR expression in Walker 256 tumor-bearing rats.Graphical

Fiducial-marked laminectomy window for intrathecal medication administration after spinal fusion: illustrative case.

Spinal muscular atrophy (SMA) is an inherited disease that leads to weakness, loss of ambulation, and progressive scoliosis in many patients, frequently requiring early spinal fusion. Nusinersen is a disease-modifying agent that improves symptoms and slows the progression of SMA but requires serial lumbar punctures for intrathecal drug delivery. Spinal fusion for scoliosis has historically been a contraindication for nusinersen therapy, as the fused spinal laminae block access to the thecal sac. Here, the authors report a case wherein a patient with SMA and prior scoliosis surgery underwent a one-level lumbar laminectomy with the placement of four titanium microscrews at the corners of the bone window thatfunction as fiducial targets for radiography-guided lumbar punctures. This procedure allowed the patient to receive nusinersen injections easily and successfully on an ongoing basis. Nusinersen is an important novel treatment for children with SMA. Thus, it is imperative to discover new ways to administer intrathecal injections to increase the number of patients able to undergo this therapy. The described one-level laminectomy with microscrew placement for serial lumbar punctures can increase the number of patients able to receive nusinersen and other intrathecal therapies. https://thejns.org/doi/10.3171/CASE24411.

Lipid nanoparticles and transcranial focused ultrasound enhance the delivery of SOD1 antisense oligonucleotides to murine brain

Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease with extremely limited therapeutic options. One key pathological feature of ALS is the abnormal accumulation of misfolded proteins within motor neurons. Hence, reducing the burden of misfolded protein has emerged as a promising therapeutic approach. Antisense oligonucleotides (ASOs) have the potential to effectively silence proteins with gain-of-function mutations, such as superoxide dismutase 1 (SOD1). However, ASO delivery to the central nervous system (CNS) is hindered by poor blood-brain barrier (BBB) penetration and the invasiveness of intrathecal administration. In the current study, we demonstrate effective systemic delivery of a next-generation SOD1 ASO (Tofersen) into the brain of wildtype and G93A-SOD1 transgenic C57BL/6 mice using calcium phosphate lipid nanoparticles (CaP lipid NPs). We show that transcranial focused ultrasound (FUS) with intravenously administered microbubbles can significantly enhance ASO-loaded nanoparticle delivery into the mouse brain. Magnetic resonance imaging (MRI) and immunohistological analysis showed reduced SOD1 expression in the FUS-exposed brain regions and increased motor neuron count in the spinal cord of treated mice suggesting decreased motor neuron degeneration. Importantly, the BBB opening was transient without evidence of structural changes, neuroinflammation or damage to the brain tissue, indicating that the treatment is well tolerated. Overall, our results highlight FUS-assisted nanoparticle delivery of ASOs as a promising non-invasive therapeutic strategy for the treatment of ALS and CNS diseases more broadly.

Comparison of postoperative and outpatient opioid use in adolescent idiopathic scoliosis patients treated with posterior spinal fusion surgery and vertebral body tethering.

Surgical treatments for adolescent idiopathic scoliosis (AIS) include posterior spinal fusion (PSF) and vertebral body tethering (VBT), but there is limited data that compares pain between these groups. We aimed to compare postoperative pain between these patients through inpatient opioid use and opioid prescriptions post-discharge. A retrospective review of patients diagnosed with AIS whounderwent PSF or VBT surgery was reviewed to determine LOS, inpatient opioid use, and opioids prescribed post-discharge. Only PSF patients who received liposomal bupivacaine and intrathecal (IT) hydromorphone, and VBT patients who received a paravertebral catheter of lidocaine and in addition toIT hydromorphone were included. Opioid amounts were reported as oral morphine equivalents (OMEs). Of 198 AIS patients that met inclusion, there were 89 PSF and 109 VBT patients. PSF patients had an increased LOS by 0.6 days compared to VBT patients (p < 0.001). Patients in the PSF group were administered a mean of 30.0 OMEs/day compared with the VBT group who received 12.5 OMEs/day (p < 0.001). At discharge, PSF patients were initially prescribed a mean of 227.7 OMEs while VBT patients' mean prescription was 139.7 (p < 0.001). PSF patients received more refills (Χ2 (1, n = 198) = 26.8, p < .001) and had a higher mean total of outpatient OMEs prescribed when compared to VBT patients (359.4 vs 185.8, p < 0.001). In AIS patients undergoing surgical correction, those who underwent PSF had longer LOS, received more inpatient OMEs, and were prescribed more OMEs both at initial discharge and total as an outpatient, when compared to VBT patients. Level III: (retrospective cohort study).

The dual modulating effects of neuropeptide FF on morphine-induced analgesia at the spinal level.

Increasing evidence indicates that neuropeptide FF (NPFF) produces analgesic effects and augments opioid-induced analgesia at the spinal level. However, our recent research demonstrated that NPFF exerted complex opioid-modulating effects in an inflammatory pain model after intrathecal (i.t.) injection. Consistent with previous findings, we found that i.t. NPFF dose-dependently attenuated complete Freund's adjuvant-induced pain hypersensitivity. Interestingly, pharmacological results illustrated that NPFF exhibited opposite opioid-modulating effects at the spinal level depending on its administration dosage, wherein i.t. NPFF potentiated morphine-induced anti-allodynia at the dose of 10 nmol, while attenuated morphine analgesia at an ultra-low-dose of 10 pmol. Behavioral results obtained from neuropeptide FF receptor 2 (NPFFR2) knockout animals suggested that both pro- and anti-opioid effects of NPFF were mediated by NPFFR2. Moreover, these modulating effects of spinal NPFFR2 were selectively targeting mu-opioid receptor, had no effect on delta- and kappa-opioid receptor agonist-induced analgesia. Finally, the opioid-modulating effects of NPFF were further verified using in vitro calcium imaging assay, demonstrating that pretreated with NPFF in primary-cultured spinal neurons significantly attenuated the inhibitory effects of morphine on high-K+-induced neuronal excitability. Taken together, our results suggested that NPFF exhibited dual modulating effects on morphine-induced analgesia after i.t. administration, which provides a possible mechanism to explain the complex opioid-modulating effects of endogenous NPFF systems.

Spinal AT1R contributes to neuroinflammation and neuropathic pain via NOX2-dependent redox signaling in microglia

Microglia-mediated neuroinflammation demonstrates a crucial act in the progression of neuropathic pain. Oxidative damage induced by reactive oxygen species (ROS) derived from NADPH oxidase (NOX) in microglia drives proinflammatory microglia activation. Recent evidence points to the central renin angiotensin system (RAS) is involved in oxidative stress and neuroinflammation, with the angiotensin converting enzyme/angiotensin II/angiotensin receptor-1 (ACE/Ang II/AT1R) axis promoting inflammation through increased ROS production, counteracted by the ACE2/Ang (1-7)/ Mas receptor (MasR) axis. While interventions targeting spinal AT1R have been shown to alleviate nociceptive hypersensitivity; yet the mechanisms remain elusive. Here, we discovered that spared nerve injury (SNI)-induced mechanical allodynia in rats were associated with M1-like microglia activation, oxidative stress and overactivity of ACE/Ang II/AT1R axis in the spinal cord. Increased AT1R and NOX2 expression were observed in activated dorsal horn microglia following SNI. Blockade of AT1R with losartan potassium (LOP) suppressed NOX2-mediated oxidative stress, and promoted a shift in microglia from the proinflammatory M1 phenotype to the anti-inflammatory M2 phenotype in LPS-treated BV-2 cells. Additionally, NOX2 overexpression triggered the activation of the high-mobility group box 1/ nuclear factor-kappa B (HMGB1/NF-κB) signaling pathway. Intrathecal administration of LOP effectively inhibited SNI-induced NOX2 overactivation in microglia and suppressed the HMGB1/NF-kB pathway, reducing oxidative stress and shifting the microglia polarization from M1 to M2 in the spinal cord, thereby attenuating neuroinflammation and pain hypersensitivity. Collectively, these findings underscore the neuroimmune-modulating effects of spinal AT1R in neuropathic pain, highlighting the regulation of redox homeostasis in microglia via a NOX2 dependent mechanism.

A preclinical and phase I clinical study of ex vivo-expanded amyloid beta-specific human regulatory T cells in Alzheimer’s disease

IntroductionDespite advancements in adoptive regulatory T cell (Treg) therapy, its application in Alzheimer’s disease (AD) remains constrained by challenges in ex vivo Treg selection and expansion with antigen specificity. Our previous findings demonstrated the bystander suppressive immunomodulatory mechanism of ex vivo expanded amyloid β-specific mouse Tregs in AD models, prompting inquiry into the efficacy of ex vivo expanded human Tregs in AD. MethodsWe developed an effective ex vivo expansion method for manufacturing amyloid β-specific human Tregs (Aβ-hTreg) and evaluated their safety and efficacy in 3xTg mouse models of AD and a phase 1 clinical trial with six AD patients. The phenotype of Aβ-hTreg was analyzed using single-cell transcriptomics. The clinical trial involved intravenous administration of Aβ-hTreg, with three patients receiving a low dose and three receiving a high dose. Exploratory assessments of effectiveness, including cognitive tasks and functional evaluations, were conducted ninety days post-treatment. ResultsBehavioral spatial learning and memory impairment, neuroinflammatory and amyloid pathology were dramatically ameliorated by single intrathecal administration of ex vivo expanded Aβ−hTreg to 3xTg AD mice. Single cell transcriptomics analysis revealed alterations in five key genes within a cluster of Tregs under antigen-specific manufacturing conditions. In the clinical trial with six AD patients, dose-limiting toxicity was experienced by none of the participants within five days of receiving GMP-grade Aβ-hTreg (VT301), indicating its good tolerability. Although exploratory assessments of effectiveness did not reach statistically significant values among the groups, these findings offer valuable insights for AD treatment and management, guiding the planning of the next phase of clinical trials. DiscussionThis study suggests that hTregs may modulate Alzheimer's disease pathology by suppressing neuroinflammation, while VT301 shows promise as a safe treatment option. However, further research is necessary to confirm its clinical efficacy and optimize treatment strategies. Trial registrationTitle: A Study of Possibility of Using Regulatory T Cells (VT301) for Treatment of Alzheimer's Disease, ClinicalTrials.gov NCT05016427, Study approval date: Ministry of Food and Drug Safety of the Republic of Korea (MFDS) - August 31st, 2020, Institutional Review Board (IRB) of Seoul National University Hospital, Republic of Korea - September 29th, 2020, The date of first patient enrollment: December 7th, 2020. https://clinicaltrials.gov/study/NCT05016427

Protective role of TRPV1+ nociceptive neurons communication to macrophages against T. cruzi infection in mice

Chagas’ disease is a life-threatening condition caused by Trypanosoma cruzi. Patients with chronic disease may develop gastrointestinal, neurological, or associated neuro-digestive dysfunctions. CNS invasion by T. cruzi can occur in the acute phase, and its presence in the brain and cerebrospinal fluid was reported. T. cruzi induces nociceptor neuron activation and pain. Nociceptive neurons and macrophage interact in diseases, and this neuroimmune communication has a pivotal role in disease outcome. We investigated, the role of TRPV1+ neurons in experimental T. cruzi infection in mice. T. cruzi forms were observed in the DRG and spinal cord in early stages of acute infection, and intrathecal administration of T. cruzi antigens into spinal cord induced pain. Trpv1 mRNA expression was increased in the DRG of infected mice and targeting TRPV1 reduced T. cruzi-induced pain. TRPV1 nociceptor ablation increased blood parasitemia while TRPV1 knockout mice presented 50% mortality upon infection in a normally non-lethal model. TRPV1 knockout also worsened clinical outcomes (hepatomegaly and megacecum), increased plasmatic Th2 cytokines and nitrite in cardiac tissue, and reduced heart leukocyte infiltration. Conditioned media of capsaicin-stimulated DRG neurons decreased macrophage internalization of T. cruzi, and CGRP receptor antagonism in infected mice reduced pain, increased early parasitemia and promoted 18% mortality. This indicates that soluble mediators released upon nociceptor activation such as CGRP increase macrophage ability to control disease outcome. These data unveil TRPV1+ neurons release CGRP to limit macrophage internalization of T. cruzi, triggering protective mechanisms against T. cruzi infection.

Spinal pituitary adenylate cyclase-activating polypeptide and PAC1 receptor signaling system is involved in the oxaliplatin-induced acute cold allodynia in mice

Chemotherapy-induced peripheral neuropathy (CIPN) is a type of peripheral neuropathy that develops in patients treated with certain anticancer drugs. Oxaliplatin (OXA) causes CIPN in approximately 80–90 % of patients; thus, it is necessary to elucidate its underlying mechanism and develop effective treatments and prevention methods. The purpose of this study was to determine whether the pituitary adenylate cyclase-activating polypeptide (PACAP)/PAC1 receptor system in the spinal dorsal horn is involved in OXA-induced acute cold allodynia and examine the effect of a PAC1 receptor antagonist. Administration of OXA induced acute cold allodynia in wild-type mice, but not in PACAP-/- mice. In the dorsal root ganglia, OXA upregulated PACAP expression, particularly in small-sized neurons. OXA-induced cold allodynia was ameliorated by intrathecal (i.t.) injection of PACAP6–38 (peptide antagonist for PACAP receptor) and PA-8 (small-molecule antagonist specific for PAC1 receptor). I.t. PACAP, but not vasoactive intestinal polypeptide, resulted in cold allodynia, which was blocked by PA-8. OXA induced the activation of spinal astrocytes in a PAC1 receptor-dependent manner. The results suggest that spinal PACAP/PAC1 receptor systems are involved in OXA-induced acute cold allodynia through astrocyte activation. Furthermore, we demonstrated that the systemic administration of PA-8 resulted in therapeutic and preventative effects on OXA-induced acute cold allodynia. Because PA-8 did not affect the anticancer effects of OXA, we propose PAC1 receptor inhibition as a new strategy for the treatment and prevention of CIPN. PerspectiveCold allodynia is a hallmark of OXA-induced peripheral neuropathy. This study demonstrated the involvement of spinal PACAP/PAC1 receptors in OXA-induced acute cold allodynia. We propose PAC1 receptor inhibition as a new strategy for the treatment and prevention of OXA-induced acute cold allodynia.

AAV9/SLC6A1 gene therapy rescues abnormal EEG patterns and cognitive behavioral deficiencies in Slc6a1-/- mice.

The SLC6A1 gene encodes the gamma-aminobutyric acid (GABA) transporter GAT-1, the deficiency of which is associated with infantile encephalopathy with intellectual disability. We designed two AAV9 vectors, with either the JeT or MeP promoter, and conducted preclinical gene therapy studies using heterozygous and homozygous Slc6a1 KO mice at different developmental ages and various routes of administration. Neonatal intracerebroventricular administration of either vector resulted in significantly normalized EEG patterns in Slc6a1-/- or Slc6a1+/- mice, as well as improvement in several behavioral phenotypes of Slc6a1-/- mice. However, some mortality and adverse effects were observed in neonatal-treated mice. Intrathecal administration of either vector at postnatal day (PND) 5 normalized EEG patterns in Slc6a1+/- mice, but in Slc6a1-/- mice the treatment only rescued nest building without impact on EEG. Both vectors were well-tolerated in all mice treated at PND5 or later (including WT mice), up to 1 year post-injection. Overall, our data demonstrate compelling efficacy when mice are treated at an early development age. We also identified that outside of the neonatal treatment window, the severe homozygous KO model is more refractory to treatment, whereas our treatments in the heterozygous mice, which genotypically match human patients, have resulted in stronger benefits.

G(1-5)-EM2, a multi-targeted agonist to opioid and growth hormone secretagogue receptors exhibited nontolerance forming antinociceptive effects in a mouse model of burn pain

Burn induced-pain (BIP) is one of the most common pain symptoms, which seriously affects the quality of sufferer life. Researches show that multi-targeted drug therapies offer superior efficacy and fewer side effects compared to single-target drug therapies. Consequently, in this study, we developed G(1-5)-EM2, a multi-targeted peptide designed to target μ-opioid receptor and the growth hormone secretagogue receptor 1α (GHS-R1α), and explored its antinociceptive effects on burn injury pain. Calcium mobilization experiments revealed that G(1-5)-EM2 demonstrated weak multi-agonist activities to μ-opioid receptor and κ-opioid receptor as well as GHS-R1α in vitro. Near-infrared fluorescence imaging experiments demonstrated that G(1-5)-EM2 could penetrate the blood-brain barrier (BBB) and access the brain following intravenous injection. The enzymatic stability of G(1-5)-EM2 was significantly enhanced compared to EM2. Our results indicated that intrathecal administration of G(1-5)-EM2 mitigated mechanical allodynia and thermal hyperalgesia in BIP. These antinociceptive effects of G(1-5)-EM2 were partially mediated through μ-opioid receptor and GHS-R1α. Moreover, intrathecal administration of G(1-5)-EM2 significantly decreased burn-induced up-regulation of phosphorylated p38 MAPK, phosphorylated NF-κBp65 and TRPV1 in the ipsilateral spinal cord, reduced the levels of IL-1β, IL-6 and TNF-α in serum, and enhanced wound healing in burned skin. Repeated intrathecal administration of G(1-5)-EM2 produced a non-tolerance-forming antinociception in BIP. These results suggest that the multi-targeted peptide G(1-5)-EM2 exhibits a novel role in alleviating BIP with fewer side effects and may represent a promising strategy for developing new analgesic drugs.

Lidocaine Induces Neurotoxicity by Activating the CaMKII and p38 MAPK Signaling Pathways through an Increase in Intracellular Calcium Ions

Background: Lidocaine is extensively utilized as an anesthetic in clinical settings; however, it has demonstrated significant neurotoxicity when administered for spinal anesthesia. The specific mechanisms underlying lidocaine-induced neurotoxicity are poorly understood. Objective: This study aimed to investigate the mechanisms through which lidocaine induces neurotoxicity, focusing on its effects on intracellular calcium release and the activation of CaMKⅡ and MAPKs pathways, as well as to evaluate the potential protective effects of cilnidipine. Methods: The investigation has employed both in vitro cell models and in vivo mouse models to conduct the experiments. Neuronal cell viability has been assessed following lidocaine treatment, and neurological function has been evaluated in mice after intrathecal injection of lidocaine. Intracellular calcium levels, CaMKⅡ activation, and the phosphorylation of p38 and p65 have been measured in cultured hippocampal neuronal cells and mouse brain tissues. The effects of the calcium channel blocker cilnidipine on these parameters have also been examined. Results: Lidocaine treatment led to a reduction in cell viability in cultured neuronal cells and induced neurological dysfunction in mice. It increased intracellular Ca2+ levels and activated CaMKⅡ in both cultured neuronal cells and mouse brain tissues. Lidocaine also elevated the phosphorylation levels of p38 and p65 in neuronal cells. These effects have been suppressed by cilnidipine, indicating a calcium-dependent mechanism. Conclusion: This study suggests that lidocaine induces neurotoxicity through a calcium-dependent activation of CaMKⅡ and MAPK pathways, leading to neuronal apoptosis and dysfunction. Cilnidipine has been found to exhibit promise as a protective agent against lidocaine-induced neurotoxicity.

Cosyntropin Prophylaxis With Intrathecal Saline: Impact on Postdural Puncture Headache and Epidural Blood Patch

(Anaesthesia. 2024;79(1):91–92. doi: 10.1111/anae.16139. PMID: 37816309) One of the risks of neuraxial procedures for labor analgesia is accidental dural puncture (ADP), which may lead to further complications including postdural headache (PDPH). The most common treatment for PDPH is an epidural blood patch (EBP); however, this treatment is not infallible. An alternative approach includes the injection of prophylactic intravenous cosyntropin following the dural puncture, which may prevent PDPH or reduce the associated symptoms. Following ADP, anesthetists chose to either select a new site for the epidural or to place an intrathecal (IT) catheter. In this retrospective study, cases where an IT catheter was placed and either administration of intrathecal saline (predelivery) and/or prophylactic intravenous (IV) cosyntropin (postdelivery) occurred were examined to determine the impact on PDPH and EBP.

Activation of MSK-1 exacerbates neuropathic pain through histone H3 phosphorylation in the rats’ dorsal root ganglia and spinal dorsal horn

The exact mechanism underlies the development of neuropathic pain is not yet completely understood. Mitogen and stress-activated kinase 1 (MSK-1) is an important downstream kinase of the mitogen-activated protein kinase (MAPK). It has been extensively studied in the central nervous system, but whether MSK-1 is associated with the neuropathic pain remains elusive. In this experiment, Lumbar 5 spinal nerve ligation (SNL) was used to establish a neuropathic pain condition in the rats. Western blotting, qRT-PCR, immunohistochemistry, intrathecal catheterization and drugs delivery were evaluated to study the physiological responses of the animals. The results showed that SNL resulted in elevated phosphorylated MSK-1 (p-MSK-1) expression in the ipsilateral dorsal root ganglion (DRG) and the spinal dorsal horn in rats, while total MSK-1 (t-MSK-1) did not change significantly. Intrathecal injection of the MSK-1 inhibitor SB747651A partially reversed established neuropathic pain. Additionally, intrathecal administration of MSK-1 siRNA either preoperatively or 7 days postoperatively relieves the development and maintenance of pain, respectively. Meanwhile, the expression levels of p-H3S10, a downstream target of MSK-1, also displayed a significant increase after SNL. And these changes could be reversed by using MSK-1 siRNA. Collectively, the increase of MSK-1 induced by SNL participates in the development and maintenance of neuropathic pain by regulating the expression of p-H3S10 in DRG and spinal dorsal horn. Concentrating on MSK-1 may result in a novel approach to the treatment of neuropathic pain.

Intrathecal Pethidine Plus Dexamethasone Versus Intrathecal Bupivacaine in Lower Extremity Orthopedic Surgeries: A Randomized Clinical Trial

Background: Spinal anesthesia remains the preferred technique for lower abdominal and orthopedic procedures. Objectives: This study compares the effects of an intrathecal injection of pethidine combined with dexamethasone versus intrathecal bupivacaine alone in patients undergoing lower extremity orthopedic surgeries. Methods: In this prospective, randomized, controlled, double-blinded study, 46 participants scheduled for elective lower extremity orthopedic surgeries were randomly allocated into two groups. Group PD (n = 23) received an intrathecal injection of 1 mg/kg preservative-free pethidine combined with 4 mg dexamethasone, diluted with 0.9% sodium chloride saline to a total volume of 3 mL. Group B (n = 23) received an intrathecal injection of 3 mL (15 mg) of 0.5% hyperbaric bupivacaine alone. The primary outcome measured was the time to the first need for rescue analgesia. Secondary outcomes included spinal anesthesia characteristics, intraoperative hemodynamic stability, and incidence of perioperative adverse events. Results: The time to first need for rescue analgesia was significantly longer in Group PD (7.76 ± 0.79 hours) compared to Group B (4.48 ± 0.63 hours). Differences in the onset of sensory and motor blocks between Group PD (6.39 ± 1.12 and 10.09 ± 2.23 minutes, respectively) and Group B (6.43 ± 1.99 and 9.96 ± 2.33 minutes, respectively) were statistically non-significant. However, the regression time for sensory and motor blocks was significantly shorter in Group PD compared to Group B (146.74 ± 15.35 and 119.56 ± 14.13 minutes vs. 188.44 ± 6.84 and 168.04 ± 5.25 minutes, respectively). Incidence of hypotension and shivering was also less frequent in Group PD than in Group B. Conclusions: Intrathecal administration of 1 mg/kg pethidine plus 4 mg dexamethasone provided improved spinal anesthesia, with extended postoperative analgesia, minimal intraoperative hemodynamic disturbances, and reduced incidence of shivering compared to bupivacaine alone in patients undergoing lower extremity orthopedic surgeries. This approach may be particularly beneficial for patients with hypersensitivity to ester or amide local anesthetics, offering a cost-effective alternative to standard local anesthetics.

The potential of long non-coding RNAs for motor function recovery after spinal cord injury in rodents: A systematic review and meta-analysis

ObjectiveLong non-coding RNAs (LncRNAs) have garnered significant attention in preclinical studies for their potential in treating spinal cord injury (SCI). This meta-analysis aimed to assess the overall efficacy of lncRNA treatments in improving motor function in rodent models of SCI. MethodsThe Embase, PubMed, Web of Science, and Scopus databases were searched. Meta-analysis was performed using STATA 14.0. The standardized mean difference (SMD) was employed to combine various motor function scores. ResultsA total of 33 studies were included in this review. Key findings indicated that lncRNA treatments could markedly enhance locomotor function in rodents with SCI compared to control groups (SMD = 4.20, 95% CI: 3.35 to 5.05, I2 = 80.0%, P < 0.0001). Furthermore, in male rats with contusion/compression injuries, targeting specific cytosol-enriched lncRNAs to downregulate their expression may significantly improve motor function recovery. Specifically, intrathecal injection of non-viral vectors for lncRNA delivery proved to be the most effective method in this study. ConclusionsLncRNA treatments have demonstrated the potential to improve motor function in rodent models with SCI. However, the therapeutic efficacy may be overestimated. Future research should rigorously assess the clinical translational efficacy and safety of lncRNA treatments.

Loss of aquaporin-4 impairs cerebrospinal fluid solute clearance through cerebrospinal fluid drainage pathways

The aquaporin-4 (AQP4) water channel is essential in neurofluid dynamics. AQP4 loss impairs solute exchange between the cerebrospinal fluid (CSF) and interstitial fluid (ISF). However, whether AQP4 expression affects solute clearance from the CSF space to the extracranial space remains unclear. This study aimed to investigate this using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) following the intrathecal administration of gadolinium-based contrast agents (GBCAs) to AQP4 knockout (KO) rats. AQP4 KO rats showed reduced efflux of intrathecal GBCAs to the extracranial spaces through CSF drainage pathways and increased retention of intrathecal GBCAs in the CSF space compared with the controls. These results suggest that AQP4 loss impairs solute clearance from the CSF space to the extracranial spaces via the CSF drainage pathways. This study revealed a close relationship between AQP4 expression and CSF solute clearance, contributing to a better understanding of the function of AQP4 in neurofluid dynamics.

Preclinical safety and efficacy evaluation of the intrathecal transplantation of GMP-grade human umbilical cord mesenchymal stem cells for ischemic stroke.

Intrathecal administration of human umbilical cord mesenchymal stem cells may be a promising approach for the treatment of stroke, but its safety, effectiveness, and mechanism remain to be elucidated. In this study, good manufacturing practice-grade human umbilical cord mesenchymal stem cells (5 × 105 and 1 × 106 cells) and saline were administered by cerebellomedullary cistern injection 72 hours after stroke induced by middle cerebral artery occlusion in rats. The results showed (1) no significant difference in mortality or general conditions among the three groups. There was no abnormal differentiation or tumor formation in various organs of rats in any group. (2) Compared with saline-treated animals, those treated with human umbilical cord mesenchymal stem cells showed significant functional recovery and reduced infarct volume, with no significant differences between different human umbilical cord mesenchymal stem cell doses. (3) Human umbilical cord mesenchymal stem cells were found in the ischemic brain after 14 and 28 days of follow-up, and the number of positive cells significantly decreased over time. (4) Neuronal nuclei expression in the human umbilical cord mesenchymal stem cell group was greater than that in the saline group, while glial fibrillary acidic protein and ionized calcium binding adaptor molecule 1 expression levels decreased. (5) Human umbilical cord mesenchymal stem cell treatment increased the number of CD31+ microvessels and doublecortin-positive cells after ischemic stroke. Human umbilical cord mesenchymal stem cells also upregulated the expression of CD31+/Ki67+. (6) At 14 days after intrathecal administration, brain-derived neurotrophic factor expression in the peri-infarct area and the concentrations of brain-derived neurotrophic factor in the cerebrospinal fluid in both human umbilical cord mesenchymal stem cell groups were significantly greater than those in the saline group and persisted until the 28th day. Taken together, these results indicate that the intrathecal administration of human umbilical cord mesenchymal stem cells via cerebellomedullary cistern injection is safe and effective for the treatment of ischemic stroke in rats. The mechanisms may include alleviating the local inflammatory response in the peri-infarct region, promoting neurogenesis and angiogenesis, and enhancing the production of neurotrophic factors.

BIOM-58. RE-INDUCTION OF INTRATHECAL CHEMOTHERAPY IN PRIOR RESPONDERS AND CORRELATION WITH CEREBROSPINAL FLUID CIRCULATING TUMOR CELLS

Abstract INTRODUCTION Leptomeningeal carcinomatosis (LMC) is an aggressive form of metastasis, with a historically poor median overall survival. Newer therapies and treatment strategies are improving outcomes, and more long-term responders exist. However, there are limited options for intrathecal (IT) chemotherapy, and re-induction in prior responders may be a reasonable treatment strategy. In addition, quantitative cerebrospinal fluid circulating tumor cells (CSF CTCs) are a valuable tool in LMC, for both surveillance of recurrence and evaluation of response. METHODS We retrospectively identified 10 patients with LMC who showed a response to IT chemotherapy and were followed with quantitative CSF CTCs on a commercially available platform. At progression, patients underwent re-induction of IT chemotherapy, on a twice a week schedule, and were evaluated for response. RESULTS All 10 patients were treated with re-induction IT chemotherapy. Six patients were re-challenged with topotecan, 3 with topotecan + trastuzumab, and 1 with pemetrexed + trastuzumab. Six patients had a primary diagnosis of breast cancer, three with lung cancer and one with ovarian cancer. The median KPS was 70. Eight were female. Prior to re-induction, all 10 had an increase in quantitative CSF CTCs. Only 1/10 had new symptoms, and 5/10 showed imaging changes on MRI. At the time of re-induction, 3/10 also received stereotactic radiosurgery to brain metastases and 2/10 had a change in systemic chemotherapy. 9/10 had improved CSF CTC counts on the next restaging, typically at 8 weeks. The median overall survival from re-challenge was 12.7 months. CONCLUSION Quantitative CSF CTCs were a more sensitive predictor of recurrence than symptoms or imaging, and were a marker of response to re-induction IT chemotherapy. Re-induction showed a durable survival benefit, and is a reasonable treatment strategy in patients who were prior responders