Preoperative Magnetic Resonance Imaging Abnormalities Predictive of Lumbar Herniation Recurrence After Surgical Repair.

OBJECTIVE: There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion. METHODS: Between 2015 and 2018, 188 patients (89 female, 99 male, median age 50) receiving first corrective surgery for lumbar disk herniation were enrolled. Microdiskectomy was performed in 161 of these patients, and endoscopic translaminar diskectomy approach was performed in 27 patients. Clinical status was evaluated before surgery and 4, 12, and 24 months post surgery using a visual analog scale, Oswestry Disability Index, and Short Form 36. RESULTS: Recurrent disk herniation was observed in 21 of 188 patients. Seventeen of the recurrent disk herniations were seen in those who underwent microdiskectomy and 4 in those who underwent endoscopic translaminar diskectomy. There were significant differences in visual analog scale, Oswestry Disability Index, and Short Form 36 scores at 4, 12, and 24 months between patients with recurrence and the 167 no-recurrence patients. The median annular tear length was significantly greater in patients with recurrence than without recurrence. In addition, there were significant differences in recurrence rate according to Modic change type distribution, sacralization or fusion presence, Pfirmann disk; degeneration grade distribution, dichotomized annular tear size, dichotomized Modic change; and type and simplified 3-tier muscle degeneration classification distribution. CONCLUSIONS: Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.

Kyphoplasty with Posterior Dynamic Stabilization in the Surgical Treatment of Unstable Thoracolumbar Osteoporotic Vertebral Compression Fractures.

AIM: To evaluate the role of posterior dynamic stabilization (PDS) with kyphoplasty (KP) in the surgical treatment of unstable osteoporotic compression fractures, which are common in the elderly population. MATERIAL AND METHODS: This study included 25 patients with osteoporotic compression fractures. KP with PDS was performed on all patients. Radiological evaluation was performed with magnetic resonance imaging, computed tomography, and plain radiographs. The vertebral kyphosis angle (VKA), local kyphosis angle (LKA), and percentage of collapse were calculated. Clinical evaluation was performed with the visual analog scale and the Oswestry Disability Index (ODI). The preoperative and postoperative clinical and radiological data were compared. RESULTS: The clinical and radiological parameters showed significant improvement following surgical treatment. The mean preoperative visual analog scale score of 7.78 decreased to 0.94 after 12 months. The mean preoperative ODI score of 70.33 decreased to 15.65 after 12 months. The mean preoperative VKA of 17.89° decreased to 9.22° after 12 months. The mean preoperative LKA of 9.61° decreased to 5.50° after 12 months. The mean preoperative percentage of collapse of 32.56% decreased to 19.00% after 12 months. There were no major complications. CONCLUSION: KP with the PDS method offered satisfactory outcomes in the surgical treatment of unstable osteoporotic compression fractures.

Cardioprotective effects of sevoflurane, isoflurane, and propofol in coronary surgery patients: a randomized controlled study.

BACKGROUND: This study was undertaken to compare the in vivo effects of isoflurane, sevoflurane, and propofol anesthesia on ischemia- and reperfusion-mediated free-radical injury and oxidative stress during coronary artery bypass graft surgery. We also compared the effects of these anesthetic agents on levels of end products of lipid peroxidation and nitric oxide (NO) in human right atrial tissue and blood. METHODS: Sixty patients scheduled to undergo elective coronary surgery with cardiopulmonary bypass (CPB) were enrolled. Patients were randomly allocated to receive 1 of 3 different anesthetic protocols: propofol (group A), isoflurane (group B), or sevoflurane (group C). We recorded global hemodynamic data (mean arterial pressure, mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index, and systemic vascular resistance index) just before the start of surgery, before the start of CPB, 15 minutes after the end of CPB, at the end of the operation, 6 hours after installation in the intensive care unit, and 12 and 24 hours later. Samples of the right atrial appendage were harvested before and after exposure of the heart to blood cardioplegia and short-term reperfusion under conditions of CPB. Biochemical and oxidative stress parameters were analyzed in both blood and tissue. RESULTS: Hemodynamic parameters were kept stable throughout in all groups. Troponin I increased transiently with all used anesthetic regimens, but this increase was significantly lower in groups B and C. After clamp removal, lipid peroxidation in patients who received propofol (group A) was less than in patients who received isoflurane (group B) or sevoflurane (group C) (P= .001, P= .005, respectively). Although the 3 groups showed no statistically significant differences in tissue levels of thiobarbituric acid-reactive substances and superoxide dismutase, propofol significantly lowered NO production in atrial tissue after clamp removal and induced less NO production than sevoflurane (P< .05). CONCLUSION: Inhalation anesthetics such as isoflurane and sevoflurane preserved cardiac function in coronary surgery patients after CPB with less evidence for myocardial damage than propofol. Furthermore, propofol induced lower blood levels of lipid peroxidation than isoflurane and sevoflurane. Propofol also increased glutathione peroxidase activity but induced less NO production compared to sevoflurane. These findings also support the cardioprotective properties that are demonstrated by hemodynamic parameters.

[A new technique for aneurysmal bone cysts of the proximal humerus: cortical collapsing]. / Humerus üst uç yerlesimli anevrizmal kemik kistilerinin tedavisinde yeni bir yöntem: kortikal çöktürme.

OBJECTIVES: We evaluated the results of a new technique developed for aneurysmal bone cysts centrally located in the proximal humeral metaphysis leading to widespread destruction. METHODS: The study included seven patients (5 boys, 2 girls; mean age 12.8 years; range 9 to 15 years) who were treated with cortical collapsing and massive fibular autograft for centrally located aneurysmal bone cysts in the proximal humeral metaphysis leading to widespread destruction. All the patients had type II and active tumors according to the criteria of Capanna et al. and Campanacci et al., respectively. Final evaluations included six patients because one patient was lost to follow-up. The mean follow-up period was 49 months (range 12 to 105 months). RESULTS: No complications were seen in the early postoperative period. Radiographic examination showed partial recurrence in two patients; of whom, one patient underwent curettage and bone grafting in the postoperative second year because of pain and discomfort. No deformity was observed. One patient developed shortening of 0.5 cm. Radiographically, all the patients exhibited metaphyseal remodelling one year after surgery. Function of the shoulder joint was near-normal in all the patients. CONCLUSION: In this technique, cortical collapsing reduces the amount of bone graft used, and massive fibular strut grafting provides structural support to prevent deformities.

Preoperative fibrinogen levels as a predictor of postoperative bleeding after open heart surgery.

BACKGROUND: Open heart surgery still involving major bleeding continues to be a major challenge after cardiac surgery and is also a significant cause of morbidity and mortality. Most hemostatic factors are intercorrelated with postoperative bleeding, and fibrinogen seems the most fundamental hemostatic risk factor for open heart surgery. METHODS: The study included 97 patients who underwent elective coronary artery surgery (78 men and 19 women; mean age, 60.9 +/- 10.3). Preoperative blood samples were obtained and preoprative quantitative determination of plasma fibrinogen levels were measured by the clotting method of Clauss using the fibrinogen kit. Patients were operated on by the same team and the same technique. The total amount of drainage blood from chest tubes was recorded after termination of operation. RESULTS: There were statistical significance between the fibrinogen levels and the drainage (r = -0.897, P < .001). Chest drainage was a mean of 972 mL (range, 240-2445 mL) in the first 48 hours after sternotomy closure. Fibrinogen level and relation to age was statistically significant (P = .015). There was no statistical significance between fibrinogen levels and gender (male gender = 400.7 +/- 123.0 versus female gender = 395.6 +/- 148.1; P = .877) and between drainage and gender (male gender = 968.2 +/- 538.5 versus female gender = 990.0 +/- 554.7; P = .876). Two patients (2%) died early after the surgery. There were no significant differences between the postoperative bleeding and cardiopulmonary bypass time (P = .648) or cross-clamp time (P = .974). CONCLUSION: The results of this study suggested that low preoperative fibrinogen level appears to be a useful diagnostic marker to assess the activity of the coagulation system, and that its preoperative level may serve as a potential risk factor for postoperative bleeding after coronary artery bypass surgery.

Chronic dissecting aneurysm of the ascending aorta developed in a patient who had rejected surgical treatment for type II acute ascending aortic dissection three years earlier.

A 66-year-old male patient was admitted to our clinic because of shortness of breath and chest pain. A grade 4/6 diastolic murmur was heard on auscultation. Physical examination revealed signs of congestive heart failure and poor peripheral perfusion. There was a diagnosis of type II ascending aortic dissection in the history of the patient. He had refused emergency surgical intervention three years earlier. Computed tomography revealed that the ascending aorta was dilated to about 10 cm in diameter, and there was a chronic aortic type II dissection. The patient had second- to third-degree aortic insufficiency and he had a calcified bicuspid aortic valve on echocardiography. Two-vessel disease and a 90-mmHg aortic gradient were detected on angiography. Graft replacement of the ascending aorta, serape aortic valve replacement with a mechanical valve, and coronary arterial bypass grafting were performed successfully under cardiopulmonary bypass with an open aortic technique. The patient was discharged on the 10th postoperative day with no problems.

The medical plant butterbur (Petasites): analytical and physiological (re)view.

Butterbur (Petasites) is an ancient plant which has been used for medical and edible purposes with its spasmolytic agents. However, toxic alkaloid content of the plant limits its direct usage. The paper covers the pyrrolizidine alkaloids (PAs) and butterbur themes in detail in order to display the outline of alkaloid-free plant extract production for medical and edible purposes. The toxic PAs and medicinal constituents of the plant are described with emphasis on analytics, physiological effects and published patent data on alkaloid free extract production. The analytics is based on several commonly used analytical methods including liquid chromatography-mass spectrometry, gas chromatography-mass spectrometry and enzyme linked immunoassay analysis of PAs and N-oxides based on published literature data of butterbur. The analyses of major medicinal constituents of butterbur are given and the physiological effects of these compounds have been discussed to attract attention to the importance of alkaloid-free extract production. The concentration distributions of the medicinal constituents and toxic PAs in different parts of the plant and the outcomes of the published patent data provide comprehensive information for proper plant raw-material selection and production of alkaloid-free butterbur extracts. The review is intended to guide researchers interested in medical plant extracts by providing comprehensive data on the medical plant butterbur and its chemical constituents.

Posterior dynamic stabilization for the treatment of patients with lumbar degenerative disc disease: long-term clinical and radiological results.

AIM: Comparison of long-term preoperative and postoperative clinical and radiological results for patients diagnosed with degenerative disc disease that underwent posterior dynamic stabilization. Lumbar disc degeneration is caused by a variety of factors. Disruptions in the vertebral endplate result in defects in disc nutrition and, thus, disc degeneration. The aims of dynamic stabilization are to unload the disc/facet joints, preserve motion under mechanical load, and restrict abnormal motion in the spinal segment. MATERIAL AND METHODS: Twenty-five patients diagnosed with lumbar degenerative disc disease were enrolled. Totally, 25 vertebral segments were subjected to posterior dynamic stabilization. Patients were clinically evaluated in the preoperative and postoperative periods using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS). Segmental movement was evaluated radiologically in the late postoperative period by measuring the segmental angles during flexion and extension. RESULTS: Significant postoperative improvements were observed in the ODI and VAS measurements (P < 0.01). During the long postoperative period (averaging 5 years and 2 months), lumbar lordosis angles, intervertebral space ratio and segmental ratio were measured and compared statistically. Adjacent segment disease developed in two patients. Both patients received L5-S1 discectomy. CONCLUSION: Good clinical outcomes were observed in the treatment of lumbar degenerative disc disease with a posterior dynamic system.

Unilateral dynamic stabilization for unilateral lumbar spinal pathologies; a new surgical concept.

AIM: Minimally invasive surgical techniques for spine surgery have gained popularity over the last decade. In this study, the authors describe a unilateral dynamic stabilization for unilateral spinal pathologies. MATERIAL AND METHODS: A total of 7 patients with an average age of 46.1 years (range 21-80 years) were included in this study. They are represented various spinal pathologies (degenerative disorders, various tumor pathologies) and having undergone a unilateral facetectomy (or facetectomies) with or without a hemilaminectomy procedure were analyzed in this study. The surgical stabilization was achieved with unilateral dynamic stabilization. RESULTS: The new surgical concept is described here, and the comparative early results of the Oswestry disability index (ODI) and the visual analog scale (VAS) are presented as well. The preoperative average ODI was 73.14 (range 62-94), and the average VAS was 8.14 (range 7-10). Twelve months after the surgery, ODI was 10.6 (range 0-16), and the average VAS was 1 (range 0-2) (p < 0.01). CONCLUSION: Although the limited number of cases analyzed reflects data of only early patient outcome, the procedure is safe, feasible, and cost effective. The unilateral dynamic pedicle screw stabilization without fusion is as a technical option to avoid possible segmental instability after unilateral total facetectomy procedure.

Tarsal tunnel syndrome - the effect of the associated features on outcome of surgery.

Between 1989 and 2000, 16 patients underwent surgery for tarsal tunnel syndrome; 12 patients (13 feet) were available for follow-up at a mean of 83 (12-143) months. The symptoms had resolved in six feet, were improved in four, were unchanged in two and recurred after five years in one. Better results are obtained in patients who have space occupying lesions than in those in whom the aetiology is idiopathic or post-traumatic or those with foot deformities.