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Brian Hood, Howard B. Levene and Allan D. Levi

Peripheral nerve injuries are a source of chronic disability. Incomplete recovery from such injuries results in motor and sensory dysfunction and the potential for the development of chronic pain. The repair of human peripheral nerve injuries with traditional surgical techniques has limited success, particularly when a damaged nerve segment needs to be replaced. An injury to a long segment of peripheral nerve is often repaired using autologous grafting of “noncritical” sensory nerve. Although extensive axonal regeneration can be observed extending into these grafts, recovery of function may be absent or incomplete if the axons fail to reach their intended target. The goal of this review was to summarize the progress that has occurred in developing an artificial neural prosthesis consisting of autologous Schwann cells (SCs), and to detail future directions required in translating this promising therapy to the clinic.

In the authors' laboratory, methods are being explored to combine autologous SCs isolated using cell culture techniques with axon guidance channel (AGC) technology to develop the potential to repair critical gap length lesions within the peripheral nervous system. To test the clinical efficacy of such constructs, it is critically important to characterize the fate of the transplanted SCs with regard to cell survival, migration, differentiation, and myelin production. The authors sought to determine whether the use of SC-filled channels is superior or equivalent to strategies that are currently used clinically (for example, autologous nerve grafts). Finally, although many nerve repair paradigms demonstrate evidence of regeneration within the AGC, the authors further sought to determine if the regeneration observed was physiologically relevant by including electrophysiological, behavioral, and pain assessments. If successful, the development of this reparative approach will bring together techniques that are readily available for clinical use and should rapidly accelerate the process of bringing an effective nerve repair strategy to patients with peripheral nerve injury prior to the development of pain and chronic disability.

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Howard B. Levene, Melanie B. Elliott, John P. Gaughan, Christopher M. Loftus, Ronald F. Tuma and Jack I. Jallo


Spinal cord injury (SCI) continues to be a problem without a definitive cure. Research based on improved understanding of the immunological aspects of SCI has revealed targets for treating and ameliorating the extent of secondary injury. Hypertonic saline (HTS), a substance both easy to create and to transport, has been investigated as an immunologically active material that can be used in a clinically relevant interval after injury. In this pilot study, HTS was investigated in a murine model for its abilities to ameliorate secondary injury after a severe spinal cord contusion.


Female C57Bl/6 mice with severe T8–10 contusion injuries were used as the model subjects. A group of 41 mice were studied in a blinded fashion. Mice received treatments with HTS (HTS, 7.5%) or normal saline solution (NSS, 0.9%) at 2 discreet time points (3 and 24 hours after injury.) A separate group of 9 untreated animals were also used as controls. Animals were assessed for autonomic outcome (bladder function). In a group of 33 mice, histological assessment (cellular infiltration) was also measured.


Bladder function was found to be improved significantly in those treated with HTS compared with those who received NSS and also at later treatment times (24 hours) than at earlier treatment times (3 hours). Decreased cellular infiltration in each group correlated with bladder recovery.


The increased effectiveness of later administration time of the more osmotically active and immunomodulatory substance (HTS) suggests that interaction with events occurring around 24 hours after injury is critical. These events may be related to the invasion of leukocytes peaking at 8–24 hours postinjury and/or the peak benefit time of subject rehydration.

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Eli M. Baron, Howard B. Levene, Joshua E. Heller, Jack I. Jallo, Christopher M. Loftus and Devanand A. Dominique

Neuroendoscopy has grown rapidly in the last 20 years as a therapeutic modality for treating a variety of spinal disorders. Spinal endoscopy has been widely used to treat patients with cervical, thoracic, and lumbosacral disorders safely and effectively. Although it is most commonly used with minimally invasive lumbar spine surgery, endoscopy has gained widespread acceptance for the treatment of thoracic disc herniations and for anterior release and rod implantation in the correction of thoracic spinal deformity. The authors review the use of endoscopy in spine surgery and in the treatment of spinal disorders as well as in the treatment of intrathoracic nonspinal lesions. Endoscopy has some significant advantages over open or other minimally invasive techniques in that it can allow for better visualization of the lesion, smaller incision sizes with reduced morbidity and mortality, reduced hospital stays, and ultimately lower cost. In addition, spinal endoscopy allows observers and operating room staff to be more involved in each case and fosters education. Spinal endoscopy, like any novel modality, carries with it additional risks and the surgeon must always be prepared to convert to an open procedure. The learning curve for spinal endoscopy is steep and the procedure should not be attempted alone by a novice surgeon. Nevertheless, with training and experience, the spine surgeon can achieve better outcomes, reduced morbidity, and better cosmesis with spinal endoscopy, and the operating times are comparable to open procedures. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve further roles as a mainstay in spine surgery.

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George M. Ghobrial, Michael Y. Wang, Barth A. Green, Howard B. Levene, Glen Manzano, Steven Vanni, Robert M. Starke, George Jimsheleishvili, Kenneth M. Crandall, Marina Dididze and Allan D. Levi


The aim of this study was to determine the efficacy of 2 common preoperative surgical skin antiseptic agents, ChloraPrep and Betadine, in the reduction of postoperative surgical site infection (SSI) in spinal surgery procedures.


Two preoperative surgical skin antiseptic agents—ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) and Betadine (7.5% povidone-iodine solution)—were prospectively compared across 2 consecutive time periods for all consecutive adult neurosurgical spine patients. The primary end point was the incidence of SSI.


A total of 6959 consecutive spinal surgery patients were identified from July 1, 2011, through August 31, 2015, with 4495 (64.6%) and 2464 (35.4%) patients treated at facilities 1 and 2, respectively. Sixty-nine (0.992%) SSIs were observed. There was no significant difference in the incidence of infection between patients prepared with Betadine (33 [1.036%] of 3185) and those prepared with ChloraPrep (36 [0.954%] of 3774; p = 0.728). Neither was there a significant difference in the incidence of infection in the patients treated at facility 1 (52 [1.157%] of 4495) versus facility 2 (17 [0.690%] of 2464; p = 0.06). Among the patients with SSI, the most common indication was degenerative disease (48 [69.6%] of 69). Fifty-one (74%) patients with SSI had undergone instrumented fusions in the index operation, and 38 (55%) patients with SSI had undergone revision surgeries. The incidence of SSI for minimally invasive and open surgery was 0.226% (2 of 885 cases) and 1.103% (67 of 6074 cases), respectively.


The choice of either ChloraPrep or Betadine for preoperative skin antisepsis in spinal surgery had no significant impact on the incidence of postoperative SSI.