Management of Pregnancy-and Lactation-Related Osteoporosis: Case Series.

AIM: To share the experience regarding management and follow-up of patients with Pregnancy- and lactation-related osteoporosis (PLRO) who were effectively treated. MATERIAL AND METHODS: This case series presented 10 patients diagnosed with PLRO and treated from January 2010 to December 2019. Visual analog scale and laboratory findings were evaluated. Spinal and extremity magnetic resonance imaging was obtained for patients with spinal and extremity pains. Dual energy X-ray absorptiometry was used for the measurement of bone mineral density. Values assessed on dual energy X-ray absorptiometry were L1?L4 T score, L2?L4 T score, and femoral neck T score. RESULTS: In the first-month follow-ups, all patients had meaningful pain relief and symptom resolution. The mean duration of pain control during the treatment period was 2.4 months. Two patients who continued breast-feeding were also the patients whose pain control was achieved at the latest. One patient required vertebroplasty. CONCLUSION: Patients with PLRO should be promptly treated and followed up. Discontinuation of breast-feeding will provide rapid advantage and should be the first step of the management. Early diagnosis and treatment of calcium and vitamin D with conservative procedures with spinal braces are very important for the treatment of PLRO patients. Additionally, bisphosphonates or teriparatide can improve the bone mineral density in patients with PLRO.

Lumbar intervertebral disc degeneration, end-plates and paraspinal muscle changes in children and adolescents with low-back pain.

The prevalence of low-back pain (LBP) in adolescents ranges from 7 to 72%. We aimed to define the radiologic characteristics of the lumbar spine in children and adolescents with LBP with/without leg pain. Two hundred and fourteen children and adolescents, who were born between 2001 and 2009 and had lumbar spine MRI for LBP with/without leg pain, were evaluated in terms of intervertebral disc degeneration (IVDD), end-plates and paraspinal muscle changes on lumbar spine MRIs. Severe IVDD was detected at all lumbar levels except for L2-L3. Modic changes were present in 4.2% of the patients. Modic changes were more common in patients with severe IVDD than in those with mild-to-moderate IVDD. Severe IVDD was significantly associated with Modic changes at the corresponding L1-L2 and L3-L4 disc levels. Girls had significantly more fatty infiltration in the paraspinal muscles when compared to boys. The risk of having severe IVDD concomitant with Modic changes was high [odds ratio (OR), 8.6]. The OR was 20.7 for predicting the presence of severe IVDD at any level if Modic changes presented particularly at the L3-L4 level. The ORs of Modic changes presented at any lumbar level at the background of fat-infiltrated multifidus at L3-L4 and L4-L5 levels were 8.3 and 9.1, respectively. Fatty infiltration in the paraspinal muscles and IVDD were closely associated with Modic changes in children and adolescents with LBP. Lumbar IVDD in children and adolescents could be the result of a mechanical pathology.

Could gas-filled pseudocyst mimick extruded disc herniation?

There are case reports and small case series in the literature reporting gas-filled pseudocysts (GFP). However, a systematic review presenting overall view of the disease and its management is still lacking. In the present study, we aimed to make a systematic review of GFP cases, and present an exemplary case of ours. Our second aim was to discuss current theories for pathogenesis of GFP. A systematic review of GFP was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Two large-scaled data search engines were used. A total of 53 articles were retrieved from the literature and presented with an exemplary case of ours. Mean age of the historical cohort was 59.47 years. There were 66 male (54.1%) and 56 female (45.9%) patients. The most prevalent clinical presentation was radicular sign/symptom in lower limbs with (29.1%) or without low back pain (LBP) (67%). Gas-filled pseudocyst has most commonly been diagnosed at the lower lumbar spine (L4-L5, 45.3%; L5-S1, 37.7%). Surgery was the treatment of choice in most of the patients (80%). In the whole cohort, 79.1% of the patients had complete recovery. Gas-filled pseudocysts are rarely observed in daily practice. They present mostly in men at the age of 60s. Precise differential diagnosis determination using appropriate imaging would help clinicians treat the patients properly. Gas-filled pseudocysts should be treated similarly to other spinal pathologies causing nerve root compression.

Is diabetes mellitus a risk factor for modic changes?: A novel model to understand the association between intervertebral disc degeneration and end-plate changes.

OBJECTIVE: Mechanical failure and inflammatory response are two mechanisms proposed for the development of Modic changes, even though they have not been clearly demonstrated, yet. Diabetes mellitus (DM) harbors micro- and macroangiopathy due to the irreversible glycation of proteins, increased oxidative stress, and inflammation. In this study, we aimed to identify whether DM was associated with Modic changes in terms of inflammatory process. METHODS: We conducted a cross-sectional study using our prospectively collected retrospective database of patients with DM who had visited the outpatient clinics at a university hospital. In 3999 patients with DM, 266 had spinal MRI due to cervical, thoracic or low back pain. We included patients, who had lumbar spine MRIs due to low back and/or leg pain and blood draw for HbA1c simultaneously. We analyzed 48 symptomatic patients with DM. We had also symptomatic patients without DM as control group. RESULTS: Severe intervertebral disc degeneration was significantly associated with Modic changes. Severe intervertebral disc degeneration had no significant association with serum HbA1c percentage and DM duration. Patients with Modic changes at any lumbar level had significantly higher HbA1c percentages, and longer duration of DM than those without Modic changes. Symptomatic patients with DM had higher rates of Modic changes compared to symptomatic ones without DM. CONCLUSIONS: Severity and duration of DM were both closely associated with Modic changes, whereas the association of severity and duration of DM with severe intervertebral disc degeneration remained unclear.

Purely extradural spinal nerve root hemangioblastomas.

Spinal nerve root hemangioblastomas present mostly as intradural-extradurally. Purely extradural spinal nerve root hemangioblastoma is a very rare entity. In this study, we aimed to analyze epidemiological perspectives of purely extradural spinal nerve root hemangioblastomas presented in English medical literature in addition to our own exemplary case. PubMed/MEDLINE was searched using the terms "hemangioblastoma," "extradural," "spinal," and "nerve root." Demographical variables of age, gender, concomitant presence of von Hippel-Lindau (VHL) disease; spinal imaging and/or intraoperative findings for tumor location were surveyed from retrieved articles. There are 38 patients with purely extradural spinal nerve root hemangioblastoma. The median age is 45 years (range = 24-72 years). Female:male ratio is 0.6. Spinal levels for purely extradural spinal nerve root hemangioblastomas, in order of decreasing frequency, are thoracic (48.6%), cervical (13.5%), lumbar (13.5%), lumbosacral (10.8%), sacral (8.1%), and thoracolumbar (5.4%). Concomitant presence of VHL disease is 45%. Purely extradural spinal nerve root hemangioblastomas are very rare and can be confused with other more common extradural spinal cord tumors. Concomitant presence of VHL disease is observed in less than half of the patients with purely extradural spinal nerve root hemangioblastomas. Surgery is the first-line treatment in these tumors.

Concomitant Double Tumors of Myxopapillary Ependymoma Presented at Cauda Equina-Filum Terminale in Adult Patient.

A 32-year-old man presented with gradually increasing bilateral buttock pain. He had intermittent claudication. Multiple, homogenously enhanced intradural extramedullary lesions at L2-L3 and L5-S1 levels were observed on magnetic resonance imaging. The tumors were debulked and were removed in piecemeal pattern until they had completely been resected. Histopathological examination of the surgical specimens confirmed that both tumors were myxopapillary ependymomas (MPE). MPE presenting as concomitant double tumor at conus-cauda-filum level are very rare. This kind of presentation could not be directly considered as dissemination, since both tumors were in the site of classical origin of MPE. Ten cases of double spinal MPEs have been reported to date. Including the present case, analysis of the 11 patients revealed some facts. There is a male predominance, which is opposite to the ependymomas that are commonly observed in females. Median age at presentation is 15 years. Most pronounced symptom is low back pain that sometimes radiates to lower extremities. Surgical approach was aimed in all tumors, which could be succeeded in all tumors except one. Adjuvant radiation therapy was applied in 5 patients. No recurrences have been reported after surgery or surgery + radiotherapy regimens.

Association of collagen I, IX and vitamin D receptor gene polymorphisms with radiological severity of intervertebral disc degeneration in Southern European Ancestor.

PURPOSE: Several genomic loci have been previously found to be associated with intervertebral disc degeneration, so far. Data are mostly derived from northern European countries whereas data derived from Southern European Ancestor are limited. This study aimed to evaluate the association between radiological disease severity of lumbar disc degeneration and certain genetic loci in a sample of participants from Southern Europe. METHODS: Seventy-five patients with mild to severe lumbar disc degeneration and 25 healthy controls were enrolled into the study. In each subject, each lumbar intervertebral disc was separately examined to obtain a total radiological score for disease severity. In addition, single-nucleotide polymorphisms of predefined genetic samples were analyzed in all participants: COL1A1 Sp1, COL9a2 Trp2, COL9a3 Trp3, and VDR TaqI. RESULTS: Degeneration scores were significantly worse in cases with COL1A1 Sp1, COL9a3 Trp3, and VDR TaqI mutations; however, COL9a2 Trp2 mutation was not associated with a difference in the severity of disc degeneration. In addition, subjects with mutation in more than one gene sample (n = 20) had significantly worse degeneration scores than the remaining study participants (n = 80) (17.70 ± 2.72 vs. 21.81 ± 1.81, p < 0.001). CONCLUSION: Single-nucleotide polymorphisms occurring in COL1A1, COL9a3 and VDR genes seem to be associated with the development of lumbar disc degeneration in this cohort, possibly with even more pronounced association when multiple mutations are present in the same individual. By further prospective twin studies in associated genes and analyses of their relationship with environmental factors in an internationally sampled large cohort will make a more clear-minded conclusion about their association with disc degeneration, which would yield better appreciation and clinical planning of some predisposed people for these pathologies.

Back pain after labour under epidural analgesia.

In this case report we have discussed a parturient patient who had epidural analgesia during childbirth and then presented with back pain 50 days postpartum as well as the causes of postpartum back pain.

Sporadic spinal hemangioblastomas can be effectively treated by microsurgery alone.

OBJECTIVE: Clinical characteristics and management of hemangioblastomas of the spinal cord associated with von Hippel-Lindau syndrome have been extensively covered in the literature. This report aims to analyze the characteristics and surgical treatment results of sporadic spinal hemangioblastomas (SSHB). METHODS: This is a retrospective analysis of 14 patients with SSHB (8 men and 6 women) operated on during a span of 23 years. The median age was 41.5 years (24-70 years). von Hippel Lindau syndrome was excluded by imaging in all patients. The median follow-up was 4 years (1-23 years). We also conducted a meta-analysis of all 271 SSHB cases reported in the English-speaking language literature from 1967 to 2011. RESULTS: Nine (64.3%) lesions were cervical, 3 (28.5%) were thoracic, and 1 (7.1%) was lumbar. Eight (57.1%) tumors were dorsal intramedullary, 4 (28.6%) were exophytic, 1 (7.1%) was intradural extramedullary, and 1 (7.1%) was completely extradural. Diffuse segmental cord enlargement was present in 7 patients (50%) and a cyst/syrinx was present in 7 (50%). These 14 patients underwent 15 operations, and gross total resection was achieved in all operations. There was no mortality. Symptoms improved after 8 (53.3%) of 15 operations, remained the same after 5 (33.3%), and worsened after 2 (13.3%). The mean Karnofsky performance score improved from 79.3 (± 17.5) to 87.3 (± 12.2) after 6 months of follow-up. There was one recurrence 15 years after magnetic resonance imaging confirmed total resection. CONCLUSIONS: The SSHBs occur most often in the upper spinal cord. Excellent surgical results and long-term outcome can be achieved using microsurgery alone with only rare recurrences.

Perineural cyst presenting like cubital tunnel syndrome.

Perineural cysts are believed to be asymptomatic; however, they rarely cause symptoms related to nerve root compression. Cervical symptomatic perineural cysts are in fact exceedingly rare. There are no reported cervical perineural cysts in the literature that present like cubital tunnel syndrome. A patient with motor weakness of the abductor and adductor muscles of the fingers of the left hand and hypoesthesia in the hypothenar region of the left hand presented at our clinic. A neurological examination, and neuroradiological and electrophysiological evaluations supported the finding that the patient's clinical condition was caused by a perineural cyst located around the C8 neural root. The neurological symptoms of the patient markedly improved after medical treatment. We reported the first cervical perineural cyst as presenting like cubital tunnel syndrome patient in the literature. The visualization of perineural cyst may need extra magnetic resonance imaging (MRI) sections in order to view the nerve root through the neural foramen or extraforaminal area. These lesions are benign, and the appropriate treatment is curative.

Effects of parenteral nutritional support with fish-oil emulsion on spinal cord recovery in rats with traumatic spinal cord injury.

AIM: Aim of this study is to assess effects of parenteral nutritional support with fish-oil emulsion on spinal cord recovery in rats with traumatic spinal cord injury. MATERIAL AND METHODS: For 5 days after SCI rats were received saline in group C and Omegaven in group O. Locomotor strengths (BBB scale)of animals were rated at Day 0,7,14,21,28, and 35. At Day 35 spinal cord sampling was evaluated immunohistochemically. RESULTS: BBB scores were 0 in early period after SCI was inflicted in both groups. BBB scores were progressively increased after Day 7 in both groups (p < .005). BBB scores were significantly higher in group O when compared with control group after Day 7 in all times (p < .005). Neuronal injury (p < .002) and edema was much more in control group when compared with in group O (p < .005). Scores for white mater cavitation, demyelinization and vessel in growth were similar in both groups. VEGF expression in control group was higher (p=.019). CONCLUSION: At the early period of SCI fish-oil emulsion treatment in rats, its anti-inflammatory effects leaded to decrease in edema and had positive effect at the prevention of neuronal injury. We believe that nutritional support with fish-oil emulsion in patients with SCI will result in patient's better clinical outcome and increase in quality of the patient's life.

Tumoral calcinosis and epidural lipomatosis of the lumbar spine.

Lumbar spinal tumoral calcinosis and spinal epidural lipomatosis are rare conditions. We present a 70-year-old female patient with serology negative spondyloarthropathy who developed paresis due to tumoral calcinosis in the left facet joint between L5 and S1 levels and spinal epidural lipomatosis at L5 and S1 levels. Surgery was performed to excise the lesions en bloc. Neural decompression was provided. Neurological symptoms improved after surgery. Here, we report the first serology negative spondyloarthropathy case that had concomitant development of tumoral calcinosis and spinal epidural lipomatosis.

Intraventricular hemorrhage as an unusual presenting form of Sneddon syndrome.

BACKGROUND: Intraventricular hemorrhage, which has a poor prognosis, is an extremely rare presenting symptom of central nervous system vasculitis. Sneddon syndrome, which is a systemic vasculitic disease, generally presents with ischemic stroke and livedo reticularis. Intraventricular hemorrhage is extremely rare in Sneddon syndrome and has not been reported as the presenting complaint. METHODS: We report a 37-year-old woman who presented with acute intraventricular hemorrhage, and on further evaluation her condition was diagnosed as Sneddon syndrome. RESULTS: Patient underwent ventriculoperitoneal shunting operation for hydrocephalus and her condition markedly improved 6 months later; she was independent in her activities of daily living. CONCLUSIONS: In this report, we emphasize the importance of multisystemic evaluation of patients, especially those with obscure angiography findings.

Pigmented villonodular synovitis of the spine: report of a lumbar case.

Pigmented villonodular synovitis is a benign proliferative disease of the synovial structures. This disease is most commonly seen in the extremities, and spinal involvement is extremely rare. In the relevant literature, 53 cases have been reported. We present a 66-year-old female patient with a long history of back pain, which progressed and radiated to the left leg over a period of 2 months. The patient also had a mass in the lumbar region on the grounds of spinal degenerative changes. Following gross total excision, the diagnosis was established by histopathology. In this report, we present our experience and discuss our neuroradiological and clinical findings.

Microvessel density and vascular endothelial growth factor expression as predictors of childrens' survival from cerebellar medulloblastoma.

Cerebellar medulloblastoma is the most common malignant brain tumor of childhood. This neoplasm is highly vascular and has a high growth rate. We aimed to determine whether high microvessel density (MVD) and expression of vascular endothelial growth factor (VEGF) in medulloblastoma tissue is correlated with survival time in children with this tumor. Tissue from 32 cerebellar medulloblastomas in 14 girls and 18 boys was studied. The standard-risk group comprised patients older than 3 years, without metastases of medulloblastoma and a residual post-operative tumor with a surface area less than 1.5 cm(2). The patients assigned to a high-risk group had at least one of the following indicators: younger than 3 years, metastases, or a residual post-operative tumor with a surface area larger than 1.5 cm(2). For each tumor, MVD was determined and the expression of VEGF was assessed using immunohistochemical techniques. The 5-year survival rate for the 32 patients was 56.2%. Five-year survival rates were 70.6% and 40.0% for patients in the standard-risk and high-risk groups, respectively. The mean (+/-standard deviation, SD) MVD for all patients was 22.0+/-9.1 microvessels per 0.7 mm(2). There was no difference in the survival rate between the groups with above-average MVD and below-average MVD (66.7% and 50.0%, respectively). Testing revealed 7 tumors with VEGF expression and 25 without. The 5-year survival rates for these 2 groups were not significantly different (57.1% vs. 56.0%, respectively). The mean (+/-SD) MVD values for the VEGF-positive and VEGF-negative groups were not significantly different (19.1+/-6.5 vs. 22.9+/-9.7 microvessels per 0.7 mm(2), respectively, Mann-Whitney U-test=78.5, Z=-0.41, p=0.68). There were no significant correlations between risk groups and expression of VEGF or MVD. These results indicate that neither high MVD nor the expression of VEGF in tumor tissue predicts poor prognosis in children with cerebellar medulloblastoma.

Outcomes for combined anterior and posterior surgical approaches for patients with multisegmental cervical spondylotic myelopathy.

Corpectomy is widely used to treat cervical spondylotic myelopathy (CSM). However, when this technique alone is performed at 1 or 2 levels for a multisegmental involvement (3 or more vertebrae), the incidence of post-operative complications is high. The optimal treatment for multisegmental CSM is still debatable. The aim of this study was to assess clinical and radiological outcomes for patients with multisegmental CSM who underwent combined anterior and posterior (AP) surgical approaches. Forty adults (17 women and 23 men; age range, 41-76 y) treated at our center between 2004 and 2007 were reviewed retrospectively. Their neurological function was assessed at different times using the Nurick classification (Grades 0 [root symptoms only] to 5 [wheelchair- or bed-bound]). Patients' satisfaction with the surgery was evaluated using Odom's criteria (poor, fair, good, or excellent). Pre-operatively, 20% of patients were assessed as Nurick Grade 0, 60% as Grade 1, and 20% as Grade 2. At the 1-year follow-up, only 10% of patients were assessed as Grade 1. At 1 year after surgery, 85% of patients rated their satisfaction with the operation as "excellent" and 15% rated it as "good". These outcomes suggest that, when surgery is indicated and patients with multisegmental CSM are carefully selected, the combined AP approach yields symptom relief comparable to that of corpectomy alone and a lower incidence of post-operative complications.

Transmandibular approach for upper cervical pathologies: report of 2 cases and review of the literature.

In routine surgical practice, anterior approaches are not often used to treat upper cervical pathologies. Such lesions can be difficult to access surgically. This article describes 2 cases in which the transmandibular approach was used to address anterior upper cervical pathology. One case was a chordoma invading the C2-C3 vertebrae and the other case was atlanto-axial instability. Neurological examination revealed myelopathy in both cases. Each patient had already undergone occipito-cervical fusion at a different center and, thus, had limited neck extension and mouth-opening ability. In the first case, the tumor was totally excised. In the second, the dens was removed. We believe that the transmandibular approach is the best option for patients with limited neck mobility and restricted mouth-opening ability.

The effects of inflammatory response associated with traumatic spinal cord injury in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-beta1) and platelet-derived growth factor (PDGF)-A at the wound site in rats.

At the cellular level, spinal cord injury (SCI) provokes an inflammatory response that generates substantial secondary damage within the cord, but also may contribute to its repair. The aim of this study was to investigate the effects of inflammatory response associated with SCI in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-beta1) and platelet-derived growth factor (PDGF)-A at the wound site in rats. At the 14th day analysis, the mean TGF-beta1 score in trauma group (I) was significantly lower than that in control group (C) (2.60 +/- 0.90 vs. 3.64 +/- 0.37, respectively; p < 0.05). The mean score for PDGF-A expression in group I was similar to the corresponding value in group C (2.42 +/- 0.74 vs. 2.94 +/- 0.72, respectively). Compared to group C, group I had significantly lower mean scores for epidermal and dermal regeneration, but higher mean scores for granulation tissue thickness and similar scores for angiogenesis. The dermal layer contains diffuse deposition of collagen fibers that are not organised as in control rat skin, and intraepidermal and subepidermal vasocongestion is distinct. Based on the results on the parameters evaluated in the study, experimental SCI in rats results in delay in wound healing and low intensity of TGF-beta1 in the dorsal wound-tissue specimens.

Congenital dermal sinus of the cervical spine in an adult.

Congenital dermal sinuses are epithelium-lined tracts that extend from an opening in the skin through deeper tissues. Most dorsal congenital dermal sinuses are located in the lumbosacral area; a cervical location is unusual. This report describes a 24-year-old woman who presented with neck pain of 6 months' duration. A dimple in the skin over her cervical spine and a stunted right foot (0.5 cm shorter than the left) were detected on physical assessment. Neurological examination revealed increased deep tendon reflexes in her lower extremities. Magnetic resonance imaging showed a dermal sinus extending from the dimple site to the spinal cord near the C4-C5 vertebrae. Laminectomies were performed at C3-C4 and the tract was totally excised. The patient's neck pain completely resolved and her deep tendon reflexes were normal at 12 months after surgery. Tethered spinal cord alone does not necessarily demand surgery; however, if a congenital dermal sinus is present then surgery is indicated to prevent spinal infection. Even if there are no neurological symptoms, the tract must be surgically removed and the cord must be fully released to prevent future infectious or neurological complications.