Multi-Level Cervical Disc Degeneration and Vertigo / Degeneração do disco cervical em múltiplos níveis e vertigem

Objective While complaints of pain, loss of strength, and numbness radiating to the neck and arm are common in patients due to cervical disc degeneration, vertigo is a rare symptom. The articles previously published on the subject focus on single-level disk degeneration and its correlation with vertigo. However, in the case of multilevel cervical discopathy, its effect on the severity of vertigo and its response to surgical treatment has not been clarified. Therefore, the objective of the present study is to shed light on the topic. Methods Patients with vertigo complaints in whom all known etiological causes of vertigo had been excluded, but with cervical disc degeneration, were included in the study. The scores on the Visual Analog Scale (VAS) and Cervical Vertigo Evaluation Scale (CVES) were analyzed in terms of numbers of discopathy, spine levels, and differences regarding the preoperative and postoperative status. Results A total of 24 patients (14 with single-level and 10 with multi-level disc degeneration) underwent anterior cervical discectomy. The preoperative CVES score was significantly decreased after surgery. Multi-level disc degeneration causes fewer vertigo symptoms than the single-level kind. No significant correlation between the severity of pain and vertigo was observed. Conclusion Multi-level disc degeneration causes fewer vertigo symptoms. These symptoms decreased after anterior cervical discectomy in cases of single-level disk herniation at upper segments. The surgical intervention could be a favorable choice of treatment. However, the mechanism and treatment approach to cervical vertigo is still a controversial issue.

Objetivo Embora as queixas de dor, perda de força e dormência com irradiação para o pescoço e braço sejam comuns em pacientes devido à degeneração do disco cervical, a vertigem é um sintoma raro. Os artigos publicados anteriormente se concentram na degeneração do disco de nível único e na sua correlação com a vertigem. No entanto, no caso da discopatia cervical em múltiplos níveis, seu efeito sobre a gravidade da vertigem e sua resposta ao tratamento cirúrgico não foi esclarecido. Portanto, o objetivo do presente estudo foi lançar luz sobre essa questão. Métodos Foram incluídos no estudo pacientes com queixa de vertigem nos quais foram excluídas todas as causas etiológicas conhecidas de vertigem, mas que apresentavam degeneração discal cervical. As pontuações na Escala Visual Analógica (EVA) e na Escala de Avaliação da Vertigem Cervical (Cervical Vertigo Evaluation Scale, CVES, em inglês) foram analisadas em termos dos números de discopatia, dos níveis da coluna, e das diferenças entre o estado pré e pós-operatório. Resultados A todo, 24 pacientes (14 com degeneração discal de nível único e 10 com degeneração em múltiplos níveis) foram submetidos a discectomia cervical anterior. A pontuação pré-operatória no CVES sofreu redução significativa após a cirurgia. A degeneração do disco em múltiplos níveis provoca menos sintomas de vertigem do que a de nível único. Não se observou correlação significativa entre a gravidade da dor e a vertigem. Conclusão A degeneração discal em múltiplos níveis provoca menos sintomas de vertigem. Os sintomas de vertigem diminuíram após a de discectomia cervical anterior em hérnia de disco de nível único nos segmentos superiores. A intervenção cirúrgica pode ser uma escolha favorável no tratamento. No entanto, o mecanismo e a abordagem do tratamento da vertigem cervical ainda é uma questão controversa.

Antioxidative effects of alpha-lipoic acid in spinal cord injury An experimental rat model.

BACKGROUND: Traumatic and ischemic injuries of the spinal cord are effective in the development of neurological dysfunction of tissue damage caused by primary and secondary mechanisms. Free radical changes are effective in the development of early ischemia and progressive tissue ischemia is the main cause of secondary damage. Delaying ischemia is the basis of treatment. In this study, we aimed to demonstrate the presence of neuroprotective effects of alpha-lipoic acid in comparison with methylprednisolone. METHODS: 50 Sprague Dawley rats were divided into 5 groups (n = 10) and spinal cord trauma was created by the method, described by Rivlin and Tator. Group 1: Laminectomy group, Group 2: Laminectomy + spinal cord injury (SCI), Group 3: Laminectomy + SCI + alpha-lipoic acid (ALA) (100 mg / kg), Group 4: Laminectomy + SCl + Methyl-prednisolone (30 mg / kg), Group 5: Laminectomy + SCl + ALA + Methyl-prednisolone. RESULTS AND DISCUSSION: Rats with spinal cord injury were found to be paraplegic. There was no significant change in motor function between the groups. When the antioxidant values were compared in the groups, there was a statistically significant difference between Group 2 and Group 3. Oxygen radicals decreased significantly between ALA and Methylprednisolone. The most striking difference was between the monotherapy group and the combined treatment group. CONCLUSION: Our results showed that alpha lipoic acid given after spinal cord trauma in rats decreases anti-oxidant formation. KEY WORDS: Alpha-lipoic acid, Methyl-prednisolone, Oxygen radicals, Spinal cord injury.

Does a Vertebra Fracture Cause a Tumor? A Dorsolumbar Paraspinal Desmoid Tumor: Case Report

Extraabdominal desmoid tumors are uncommon soft-tissue tumors. The etiology of the tumor is still unclear. Injury is one of the etiological factors of soft-tissue tumors. A 41-year-old female patient who had a traumatic vertebral body fracture on the thoracic spine was treated conservatively. Two and a half years later, she presented a painful, palpable swelling on the thoracolumbar region. In the present report, was discuss the patient, who underwent a surgery to remove the desmoid tumor (aggressive fibromatosis), within the context of the current literature. The literature on desmoid tumor caused by a trauma is rare. This is the first case that demonstrates an extraabdominal desmoid tumor following a spinal fracture. The swelling on the region of the trauma must be examined carefully and desmoid tumor must be kept in mind as a possible diagnosis.

The Correlation of Meralgia Paresthetica and Spinal Surgery in Prone Position.

AIM: To investigate the incidence, risk factors, and recovery of patients with meralgia paresthetica (MP) following posterior spine surgery. MATERIAL AND METHODS: Patients who underwent posterior spine surgeries in prone position at the authors’ clinics were included in this study. Patients with preoperative MP were excluded. RESULTS: Among the 560 patients who underwent spine surgery in prone position, 117 (21%) had impaired sensation along the anterolateral aspect of the thigh. One hundred three of them were treated with conservative treatment, whereas 14 underwent surgery for MP. CONCLUSION: Conservative treatment is the first option for MP. Patients who do not recover with conservative treatment may undergo surgical treatment.

Surgical options for meralgia paresthetica: long-term outcomes in 13 cases.

BACKGROUND: Meralgia paresthetica is an entrapment neuropathy of the lateral femoral cutaneous nerve that may cause paresthesias, pain, and sensory loss of the anterior and lateral thigh. Treatment is primarily medical. Surgery is an option for patients who do not respond to medical treatments. METHODS: Patients whose symptoms did not improve after medical and conservative treatment for at least 3 months were included in this study. These patients underwent neurolysis and decompression surgery and had a mean postoperative follow-up of 38 months. Their pain levels were assessed by the VAS scoring system. RESULTS: In 8 (61.5%) patients, the symptoms completely resolved within the first 3 months. In 5 (38.5%) patients, the complaints persisted partially and the recovery was observed after 12 months. In patients having a metabolic etiology, the duration of recovery was up to 12 months. CONCLUSION: The long term results of surgery are good though only partial improvemnts in reported pain were seen in the early postoperative period, especially in patients with a metabolic etiology.

Unusual Clinical Presentation and Association of Cranial Dermoid Tumor and Tethered Cord Syndrome.

Tethered cord syndrome (TCS), a neurological disorder characterized by the lower settlement of the conus medullaris, is a congenital spinal disease which is caused by split cord syndrome, meningomyelocele, and spinal tumors. Cranial dermoid tumor (CDT) is a congenital benign tumor which is generally located on the midline of the cranium. Even though TCS is highly associated with spinal dermoid tumor, the relationship of CDT and TCS is unusual. We pre-sent a case with an unusual symptom of CDT, motion-dependent pain, and an uncommon togetherness with TCS.

Quantitative evaluation of different far lateral approaches to the cranio-vertebral junction using the microscope and the endoscope: a cadaveric study using a tumor model.

BACKGROUND: Several far lateral approaches have been proposed to deal with cranio-vertebral junction (CVJ) tumors including the basic, transcondylar, and supracondylar far lateral approaches (B-FLA, T-FLA, and S-FLA). However, the indications on when to use one versus the other are not well systematized yet. Our purpose is to evaluate in an experimental cadaveric setting which approach is best suited to remove tumors of different sizes. METHODS: We implanted at the CVJ, using a transoral approach, tumor models of different sizes (five 1-cm3 and five 3-cm3 tumors) in ten embalmed cadaveric heads. The artificial tumors were exposed via the three approaches using endoscopic-assisted microneurosurgical technique and neuronavigation. The skull base area exposed and the maneuverability linked to each approach were evaluated using neuronavigation. RESULTS: In 1-cm3 tumors, the T-FLA and the S-FLA exposed a significantly larger skull base area than the B-FLA both using the microscope and the endoscope (P < 0.05); the T-FLA executed with the microscope provided wider vertical and horizontal maneuverability than the B-FLA (P = 0.030 and 0.017, respectively); the S-FLA executed with the endoscope provided wider vertical maneuverability than the T-FLA (P = 0.031). The S-FLA executed using the microscope and the endoscope provided wider vertical maneuverability than the B-FLA both in 1 and 3-cm3 tumors (P < 0.05). CONCLUSIONS: In 1-cm3 tumors, the S-FLA and the T-FLA expose a wider skull base area than the B-FLA. In larger tumors, the exposure is similar for all three approaches. Use of the endoscope in an assistive mode may further increase the surgical exposure and maneuverability.

Is less always better? Keyhole and standard subtemporal approaches: evaluation of temporal lobe retraction and surgical volume with and without zygomatic osteotomy in a cadaveric model.

OBJECTIVE The subtemporal approach is one of the surgical routes used to reach the interpeduncular fossa. Keyhole subtemporal approaches and zygomatic arch osteotomy have been proposed in an effort to decrease the amount of temporal lobe retraction. However, the effects of these modified subtemporal approaches on temporal lobe retraction have never been objectively validated. METHODS A keyhole and a classic subtemporal craniotomy were executed in 4 fresh-frozen silicone-injected cadaver heads. The target was defined as the area bordered by the superior cerebellar artery, the anterior clinoid process, supraclinoid internal carotid artery, and the posterior cerebral artery. Once the target was fully visualized, the authors evaluated the amount of temporal lobe retraction by measuring the distance between the base of the middle fossa and the temporal lobe. In addition, the volume of the surgical and anatomical corridors was assessed as well as the surgical maneuverability using navigation and 3D moldings. The same evaluation was conducted after a zygomatic osteotomy was added to the two approaches. RESULTS Temporal lobe retraction was the same in the two approaches evaluated while the surgical corridor and the maneuverability were all greater in the classic subtemporal approach. CONCLUSIONS The zygomatic arch osteotomy facilitates the maneuverability and the surgical volume in both approaches, but the temporal lobe retraction benefit is confined to the lateral part of the middle fossa skull base and does not result in the retraction necessary to expose the selected target.

Intrapetrous Internal Carotid Artery: Evaluation of Exposure, Mobilization and Surgical Maneuvers Feasibility from a Retrosigmoid Approach in a Cadaveric Model.

OBJECTIVES: To provide a quantification of the exposure of the vertical and horizontal segments of the intrapetrous carotid artery (IPCA) and to evaluate the possibilities of its mobilization and of performing surgical maneuvers on it using the retrosigmoid approach. METHODS: Twelve surgical dissections were performed bilaterally on 6 fresh cadavers. Predissection computed tomography (CT) scans with bone fiducials for intraoperative navigation were acquired. A retrosigmoid craniectomy was performed. The inframeatal space was drilled, the horizontal (HoIPCA) and vertical (VeIPCA) segments of the IPCA were exposed, and their measurements were recorded. The carotid canal was enlarged, the artery was carefully detached from the bone, and a vessel loop was inserted in order to mobilize its horizontal segment. Afterwards we performed different surgical maneuvers: We inflated a 5-French Fogarty balloon to compress the IPCA and repaired a 7-mm arteriotomy with a running suture. Specimens underwent a new CT scan to evaluate the amount of bone removal and the integrity of the inner ear structures. RESULTS: The HoIPCA and VeIPCA were exposed and anatomically preserved in all specimens without injuring the surrounding neurovascular structures. The HoIPCA presented an average length of 24.89 mm (range: 19.41-31.47 mm), and the VeIPCA presented an average length of 10.07 mm (range: 8.92-11.58 mm). The possibility of IPCA mobilization and the feasibility of performing surgical maneuvers were demonstrated. Postdissection CT scan showed the preservation of inner ear structures. CONCLUSION: Exposure and mobilization of the IPCA using a retrosigmoid approach are feasible and could represent a viable option for the possibility of reaching a total resection of selected skull base tumors, even when involvement of the carotid canal is present.

Spondylodiscitis: evaluation of patients in a tertiary hospital.

INTRODUCTION: Spondylodiscitis (SD) is an uncommon but important infection. The aim of this work was to study the risk factors, bacteriological features, clinical, laboratory and radiological findings of SD, and to shed light on the initial treatment. METHODOLOGY: A total of 107 patients who underwent treatment for SD were evaluated. The diagnosis of SD was defined by clinical findings, complete blood count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum tube agglutination (STA) test, Ziehl-Neelsen staining, culture, histopathology, and radiological methods such as magnetic resonance imaging (MRI) and computed tomography (CT) scans. RESULTS: Of the 107 cases, ranging between 17 to 83 years of age, 64 (59.8%) were male. Twenty-seven (25.2%) patients had diabetes mellitus. Laboratory investigations revealed elevated CRP in 70 (65%) patients, elevated ESR in 65 (61%) patients, and elevated white blood cell (WBC) counts in 41 (38.3%) patients. Thirty-six (33.6%) patients were identified as having brucellar SD, and 5 (4.7%) patients were identified as having tuberculous SD. A total of 66 (61.6%) patients were determined to have pyogenic SD. The most frequently isolated microorganism was Staphylococcus aureus. Antibiotic therapy was given intravenously to all pyogenic SD patients. CONCLUSIONS: The incidence of SD has increased as a result of the higher life expectancy of older patients with chronic debilitating diseases and the increase of spinal surgical procedures. In patients with low back pain, SD should be considered as a diagnosis. For effective treatment, it is important to determine the etiology of the disease.