Simple Microsurgical Extirpation as a Method of Choice in Treating Symptomatic Spinal Facet Joint Cysts: A Retrospective Case Series.

BACKGROUND: Facet joint cysts (FJCs) are a cause of radiculopathy, back pain, cauda equina syndrome, and/or claudication. They mostly affect the lumbar spine in the elderly, prevailing in women, and are connected to spinal degeneration and instability. We aimed to evaluate the safety and efficacy of open surgical decompression and cyst excision without a subsequent fusion. METHODS: We evaluated neurologic symptoms and potential signs of spinal instability on preoperative versus postoperative radiological examination. We performed a histological assessment of the extirpated cysts. Statistical analysis was then performed. RESULTS: Of a total of 66 patients, 44 were included in the present study. The average age was 61.2 years. Female patients prevailed (61.4%). The mean follow-up was 5.3 years. The segment most frequently affected by a FJC was L4-L5 (65.9%). Cyst resection led to significant relief from neurologic symptoms for most patients. Thus, 95.5% of our patients reported their postoperative outcome as excellent. Preoperatively, 43.2% and 47.4% of patients had had radiographic signs of instability on magnetic resonance imaging and signs of spondylolisthesis on dynamic radiographs in the operated segment, respectively, with 54.5% manifesting signs of spondylolisthesis in the same segment on a postoperative dynamic radiograph. Despite spondylolisthesis progression, no patient required reoperation. Histologically, pseudocysts without synovium were more frequent than were synovial cysts. CONCLUSIONS: Simple FJC extirpation is a safe and effective method for resolving radicular symptoms, with excellent long-term outcomes. It does not lead to the development of clinically significant spondylolisthesis in the operated segment; thus, no supplementary fusion with instrumented stabilization is required.

Long-Term Outcome After Midline Lumbar Fusion for the Treatment of Lumbar Spine Instability Due to Degenerative Disease.

BACKGROUND: Midline lumbar fusion (MIDLF) is one promising new surgical technique that has been developed to minimize perioperative damage to the paravertebral stabilizing musculotendinous system. The aim of this study was to assess long-term clinical and radiological effects of MIDLF. METHODS: This prospective cohort study evaluated patients who underwent MIDLF for degenerative spinal instability. Clinical and radiological examinations were performed before and after surgery. Perioperative and postoperative complications were recorded. Follow-up was 2 years. P ≤ 0.05 was considered statistically significant. RESULTS: The study included 64 patients (mean age 58.9 ± 10.7 years; 41 women [64.1%]). The most frequent indication for MIDLF was degenerative spondylolisthesis grade I (28 cases [43.8%]); the prevalent spinal segment to be fused was L4-L5 (35 cases [54.7%]). Mean duration of surgery was 148.2 ± 28.9 minutes. Relief of low back pain and leg pain was significant and stable in the postoperative period as assessed by visual analog scale (P < 0.001). Of patients, 86.9% reported fair, good, or excellent outcomes in terms of pain relief based on MacNab score 2 years after surgery. Patients' level of function in activities of daily living improved significantly based on Oswestry Disability Index score: from 66.8 ± 9.8 before surgery to 33.9 ± 16.5 2 years after surgery (P < 0.001). X-rays and computed tomography at 12 months showed interbody fusion in 46 cases (73.4%), inconclusive results in 13 cases (20.3%), and no fusion in 4 cases (6.3%). No damage to neural or vascular structures and no failure of hardware or screw loosening were recorded. CONCLUSIONS: MIDLF is a safe, efficient method for surgical treatment of lumbar spine instability. Its limited invasiveness contributes to better preservation of paravertebral muscles and enhanced postoperative spinal stability.

The role of vascularization on changes in ligamentum flavum mechanical properties and development of hypertrophy in patients with lumbar spinal stenosis.

BACKGROUND CONTEXT: Ligamentum flavum (LF) induced lumbar spinal stenosis (LSS) is conditioned not only by its "gathering" but especially by hypertrophy. Previous studies have examined the pathophysiology and biochemical changes that cause the hypertrophy. Some studies have described a link between chronic LF inflammation and neovascularization but others have reported highly hypovascular LF tissue in LSS patients. Currently, there is no practical application for our knowledge of the pathophysiology of the LF hypertrophy. Considerations for future treatment include influencing this hypertrophy at the level of tissue mediators, which may slow the development of LSS. To our knowledge, there is no study of micromechanical properties of native LF to date. PURPOSE: (1) To clarify the changes in vascularization, chondroid metaplasia, and the presence of inflammatory cell infiltration in LF associated with LSS. (2) To quantify changes in the micromechanical properties associated with LF degenerative processes. STUDY DESIGN/SETTING: Vascular density analysis of degenerated and healthy human LF combined with measurement of micromechanical properties. METHODS: The study involved 35 patients who underwent surgery between November 1, 2015 and October 1, 2016. The LSS group consisted of 20 patients and the control group consisted of 15 patients. LF samples were obtained during the operation and were used for histopathological and nanoindentation examinations. Sample vascularization was examined as microvascular density (Lv), which was morphometrically evaluated using semiautomatic detection in conjunction with NIS-Elements AR image analysis software. Samples were also histologically examined for the presence of chondroid metaplasia and inflammation. Mechanical properties of native LF samples were analyzed using the Hysitron TI 950 TriboIndenter nanomechanical testing system. RESULTS: Vascular density was significantly lower in the LSS group. However, after excluding the effect of age, the difference was not significant. There was high association between Lv and age. With each increasing year of age, Lv decreased by 11.5 mm2. Vascular density decreased up to the age of 50. Over the age of 50, changes were no longer significant and Lv appeared to stabilize. No correlation was observed between Lv and the presence of inflammation or metaplasia; however, LSS patients had a significantly increased incidence of chondroid metaplasia and inflammatory signs. The mechanical properties of control group samples showed significantly higher stiffness than those samples obtained from the LSS group. CONCLUSION: This study showed that Lv changes were not dependent on LSS but were age-dependent. Vascular density was found to decrease up to the age of 50. A significantly higher incidence of chondroid metaplasia and inflammation was observed in LSS patients. The mechanical property values measured by nanoindentation showed high microstructural heterogeneity of the tested ligaments. Our results showed that healthy ligaments were significantly stiffer than LSS ligaments. CLINICAL SIGNIFICANCE: Prevention of the loss of LF vascularization during aging may influence stiffness of LF which in turn may slow down the LF degenerative processes and delay onset of LSS.

Complete diagnostics and clinical approach for a female patient with unusual glioblastoma: A case study.

The present study reports a case of a 44-year-old female patient with a large frontal lobe tumor who underwent surgery using a modern navigation system SonoWand that combines the advantages of a non-frame navigation system with intraoperative real-time ultrasound imaging. The right frontal lobe tumor consisted of two morphologically different sections. A diffuse astrocytoma grade II and a glioblastoma grade IV were identified. These tumors were relatively substantially separated. A 17 p deletion, including TP53, was detected in a diffuse astrocytoma but not in a glioblastoma. EGFR and MDM2 amplifications were detected only in a glioblastoma. Detection of these amplifications is typical for primary glioblastomas. These findings support our assumption of two independent tumors. The KRAS, BRAF and EGFR gene mutations were also detected in a glioblastoma. Such an accumulation of molecular mutations is rare in one tumor. Following oncological treatment the patient was cared for in the oncological center and survived for 15 months after the surgery without any signs of a disease. This is an unusual case, and to the best of our knowledge, is not frequently published in literature.

Comparison of Biochemical Markers of Muscle Damage and Inflammatory Response Between the Open Discectomy, Microsurgical Discectomy, and Microsurgical Discectomy Using Tubular Retractor.

BACKGROUND: One of the methods to compare the invasiveness of different surgical techniques objectively is to measure the levels of biochemical markers of systemic inflammatory response and muscle damage. METHODS: A total of 120 patients undergoing surgery for symptomatic disc herniation at L4-L5 and L5-S1 were enrolled in the study. Patients were operated on using open discectomy (OD), microsurgical discectomy (MD), or microsurgical discectomy with tubular retractor (MD-TUB). Myoglobin (MYO) and creatine kinase (CK) levels were used as indicators of muscle damage, and interleukin-6 (IL-6) and C-reactive protein (CRP) levels were used as indicators of systemic inflammatory response. Sampling and analysis of samples were performed preoperatively and on postoperative days 1, 3, and 7. Levels of postoperative low back pain and radicular pain were recorded on a 10-grade visual analog scale. Statistical evaluation was performed using the analysis of variance test. RESULTS: MYO concentrations in the MD-TUB group on postoperative day 1 were significantly lower than in the MD and OD groups. CK values on postoperative day 1 were significantly lower in microsurgical techniques (MD and MD-TUB) than in the OD group. The lowest IL-6 levels were found in the MD-TUB group, followed by the MD and OD groups. Differences in the IL-6 levels were significant between the groups on postoperative day 1. On all postoperative days that were monitored, values of CRP in the MD-TUB group were significantly lower compared with the MD and OD groups. Lower values in the MD group versus OD group were not statistically significant. CONCLUSION: All studied techniques showed similar efficacy in reducing radicular pain. The microsurgical diskectomy using a retractor in comparison with MD and OD is friendlier toward the paraspinal muscles, but the difference is significant only for the MYO levels. The total stress inflammatory response exhibited by patients undergoing the MD-TUB technique is significantly lower compared with the MD and OD techniques.

Pathomorphology of inflammatory response following traumatic brain injury, serum values of interleukins, and gene polymorphisms.

UNLABELLED: Our present study was aimed to investigate time-profile kinetics of interleukins, vascular endothelial growth factor (VEGF) in acute inflammatory response following traumatic brain injury, and the influence of activated microglial cells in patients who developed severe space occupying lesion (SOL) of secondary traumatic brain injury. Interleukins IL-6, monocyte chemo attractant protein (MCP-1), and VEGF had a significant different time-profile kinetics (p<0.05) in patient with, and without expansive traumatic brain contusions (SOL). The serum VEGF was significantly higher in trauma patients with uncomplicated brain contusions, and lower in patients with SOL. The patients with septic complications developed the sudden increase of TNF alpha and IL-8 within the first 72 hours. Our data suggested PSGL and CD68 immunopositivity of microglial cells in both focal and diffuse TBI, predominantly in perivascular space correlated with telolysosome formation in cytoplasma. Polymorphism of PAI-1, MTHFR, eNOS, VEGF, and Apo E genes in TBI were in patients with SOL were bound to show up leucocyte plugging in capillaries. KEYWORDS: traumatic brain injury - acute inflammatory response - microglial cells - interleukins - vascular endothelial growth factor - monocyte chemoattractant protein - gene polymorphisms.

Application of transcranial color-coded sonography in severe brain injury.

Transcranial color-coded sonography (TCCS) monitoring of severe brain injury patients may reveal various pathological hemodynamic changes. According to changes in flow velocities in basal brain arteries, the presence of brain hyperemia, vasospasms, and oligemia can be detected. The study included a group of 20 patients with severe brain injury. TCCS measured flow velocities and ICP values were monitored on a daily basis in the course of a week after injury. In nearly 50 % of patients significant hemodynamic changes occurred. The most frequent pathological finding was hyperemia (31.8 %), followed by vasospasm (10.9 %) and oligemia (9.1 %). In 42.7 % of patients increased flow velocities were registered and only 9.1 % of records were within the normal range of values. The most substantial elevation in time-averaged mean velocity occurred from the second to the sixth day after injury. In a subgroup of patients with raised intracranial pressure 41.6 % of flow velocity (FV) measuring met the TCCS criteria for hyperemia compared with 26 % in a subgroup of patients without intracranial pressure (ICP) elevation. The study showed that hemodynamic changes after severe brain injury are relatively common findings and that TCCS is a useful bed-side tool for the monitoring of intracranial hemodynamic changes.

Medical consultations and the sharing of medical images involving spinal injury over mobile phone networks.

BACKGROUND: The transmission of medical images and other data over mobile phone networks may facilitate remote medical consultations between neurosurgeons and regional hospitals treating spinal injury patients. The aim of this study was to compare the efficacy of mobile phone consultations with standard hospital workstation consultations in spinal injury patients. METHODS: The images were exported over the Internet from surrounding local hospitals through the Picture Archiving and Communication System, in DICOM III format, to the central hospital server. The xVision browser was used to view the acquired images on a standard workstation. The data were also exported to the secured hospital Web server IIS60 and converted to JPEG format to enable remote physician access and consultation. The remote consulting physician connected to this server by mobile phone using the phone's Internet browser. A second physician, blind to the mobile phone results, evaluated the same images at a workstation in the hospital. The results of the mobile phone consultations were compared with the results from standard workstation consultations. RESULTS: There was no difference in the quality of spinal computed tomographic/magnetic resonance images viewed on the phone screen compared with on the workstation. More importantly, the final diagnoses made by mobile phone did not differ from those made by workstation consultations. A transfer to the department of neurosurgery was required after consultation in 11 patients. CONCLUSION: Mobile phone consultations for patients with spinal injuries was as effective as workstation consultations. Mobile phone consultations can increase the expertise available to regional hospitals, which are often the first responders to medical emergencies.

18 months of experiences with the biotitanium replacement (Implaspin) used in treatment of degenerative lumbar spine diseases.

Between 2007-2008 forty two patients neurosurgery department of the KNTB (Regional Hospital of T. Bat'a) Zlin underwent surgery using the bioactive replacement Implaspin. The group of 21 patient of the total of number of 42 patients was operated first time for diagnosis degenerative instability or spondylolisthesis gr I-II. In this group was the follow-up period of 18 months, the mean baseline Oswestry score was 57%. A value of 37% was achieved after 18 months during the evaluation of the clinical status using the Oswestry questionnaire. This result represented a improvement of the condition. No change of the position of the instruments occurred during the X-ray and CT, MRI controls. Therefore, the Implaspin replacement appeared to be a perfect alternative to other lumbar spine replacements combining the osteoconductive properties of the bioactive material with the rigidity of titanium.

Bioactive titan cage Implaspin in treatment of degenerative disease of the cervcal spine--the results from 2007 till 2008.

The authors present results of surgical treatment of cervical spine degenerative disease via Implaspin biotitanium replacement. Surgery was indicated for a group of 24 patients with symptoms of cervical spondylogenic myelopathy or the irritation decay root syndrome non-reacting to conservative treatment. Pre-surgery X-ray and MRI examinations showed spinal canal stenosis caused by the intervertebral disk osteochondrosis combined with prolapse or dorsal osteophytes. Clinical problems of the group of patients were evaluated through the JOA classification before surgery and during the 2nd, the 6th and month 12th after surgery. The surgery rate of success was evaluated in percentages during post-surgery examinations that took place in the 12th month. Based on the JOA classification, that rate of success falls into the good surgery results zone. The post-surgery X-ray examinations showed two sank replacements by 1/3 of its height into the surrounding vertebral bodies. In these cases we performed the control MRI. No signs of the new spinal compression were found and the spinal canal was free in the operated site. Based on our short-term experiences, the Implaspin bioactive replacement seems to be a suitable alternative to the other types of replacements designed for intervertebral fusion in the lower cervical spine area.

Injuries of the central nervous system - mobile phone consultations.

Transmission of visual documentation between a neurosurgery center and a regional hospital, with a mobile phone, significantly improves consultation on a craniocerebral injury. This is one of the methods of fast consultation on image documentation (CT). We reported on one year of experience (September 2007 to September 2008) of our department with this method of image transmission in 16 patients with craniocerebral injury. The images were exported, via the Internet, from local hospitals through the PACS system [Picture Archiving and Communication System], in DICOM III format, to the server of the Regional Hospital of T. Ba̕a, (KNTB). Browsing of the acquired image documentation at particular stations was possible with the xVision browser. The data were exported to a secure hospital Web server, IIS60, to enable consultation on the images, which were changed to JPEG format. The consulting physician was connected to this server with his/her mobile phone by means of the Internet browser. After establishing the connection, it downloads and gradually displays the images on the screen of the mobile phone. The whole process takes approximately 10 minutes. After comparing the images on the screen of the mobile phone and on the workstation using the xVision browser, we verified that there was no difference in the quality of imaging of the pathological lesions recorded with CT.

Direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy in the treatment of brachial plexus injury.

OBJECT: The authors present the long-term results of nerve grafting and neurotization procedures in their group of patients with brachial plexus injuries and compare the results of "classic" methods of nerve repair with those of end-to-side neurorrhaphy. METHODS: Between 1994 and 2006, direct repair (nerve grafting), neurotization, and end-to-side neurorrhaphy were performed in 168 patients, 95 of whom were followed up for at least 2 years after surgery. Successful results were achieved in 79% of cases after direct repair and in 56% of cases after end-to-end neurotization. The results of neurotization depended on the type of the donor nerve used. In patients who underwent neurotization of the axillary and the musculocutaneous nerves, the use of intraplexal nerves (motor branches of the brachial plexus) as donors of motor fibers was associated with a significantly higher success rate than the use of extraplexal nerves (81% compared with 49%, respectively, p = 0.003). Because of poor functional results of axillary nerve neurotization using extraplexal nerves (success rate 47.4%), the authors used end-to-side neurorrhaphy in 14 cases of incomplete avulsion. The success rate for end-to-side neurorrhaphy using the axillary nerve as a recipient was 64.3%, similar to that for neurotization using intraplexal nerves (68.4%) and better than that achieved using extraplexal nerves (47.4%, p = 0.19). CONCLUSIONS: End-to-side neurorrhaphy offers an advantage over classic neurotization in not requiring sacrifice of any of the surrounding nerves or the fascicles of the ulnar nerve. Typical synkinesis of muscle contraction innervated by the recipient nerve with contraction of muscles innervated by the donor was observed in patients after end-to-side neurorrhaphy.

Blood metallothionein, neuron specific enolase, and protein S100B in patients with traumatic brain injury.

OBJECTIVES: The aim of this study was to evaluate the correlation of neuron specific enolase (NSE), protein S100B and time-profile of Glasgow Coma Score (GCS) development with metallothionein (MT) blood levels in patients with traumatic brain injury (TBI) during 10 days of hospitalization. Patients were divided into 2 groups with respect to NSE and S100B levels - with (group I) and without (group II) GCS improvement. METHODS: Serum NSE and S100B concentrations were measured by immunochemical methods; serum metallothionein concentration by electrochemical technique. Cortical biopsies were investigated immunohistochemically and by electron microscope. A cDNA microarray containing 700 gene probes was used to study the changes in gene expression in the ipsilateral cortex. RESULTS: Values of MT in the blood of group I showed a non-significant decrease compared to group II during 1-3 days after admission. There was an increase of MT during 4-8 days in comparison with values of 1-3 days. The highest value of MT during hospitalization was found in a patient with diffuse axonal injury (group II). The data of cDNA microarray suggested an increase in expression of gene transcripts for oxygen free radical scavenger proteins corresponding with the increase of MT during 4-8 days in both groups. CONCLUSIONS: The experimental data indicate that monitoring the content of MT in patients with trauma brain injury would be a suitable approach to evaluate the degree of injury or duration of prolonging unconsciousness, particularly in diagnosis of diffuse axonal injury.

Quantitative assessment of the ability of collateral sprouting of the motor and primary sensory neurons after the end-to-side neurorrhaphy of the rat musculocutaneous nerve with the ulnar nerve.

In view of the Lack of theoretical information, end-to-side neurorrhaphy is a frequent object of experimental interest. End-to-side neurorrhaphy is based on collateral sprouting of an intact axon. The quantitative assessment of collateral sprouts sent by an intact motor and sensory axon was the goal of the present study. End-to-side neurorrhaphy of the distal stump of transected musculocutaneous nerve (MCN) with intact ulnar nerve (UN) was performed in a rat model. Collateral sprouts were quantitatively evaluated by counting of motoneurons and DRG neurons following their retrograde labeling by Fluoro-Ruby and Fluoro-Emerald applied to the UN and MCN, respectively. The results suggest a comparable capacity of both intact sensory and motor axons to send collateral sprouts into a denervated nerve stump. The ratio of sensory/motor neurons, the axons of which reinnervated distal MCN stumps, was very similar to that of intact UN (6.500 and 6.747, respectively), but different from intact MCN (5.029). This suggests that the pruning process occurred to balance the collateral sprouts at a ratio of sensory/motor neurons for the donor UN, but not according to the number of sensory and motor bands of Bungner available in the distal stump of the MCN. The present experimental study confirms end-to-side neurorrhaphy as a suitable method of nerve reconstruction.