Minimally Invasive Resection of a Foraminal Lumbar Root Schwannoma.

Background and Importance: This video article reports a rare case of a right L5/S1 foraminal root schwannoma that presents the natural course of the disease, imaging findings, treatment protocol, operative procedure, and highlights some of the possible surgical complications. Clinical Presentation: Magnetic resonance imaging (MRI) revealed an intradural, extramedullary, well-enhanced mass at the right L5/S1 level. The operative procedure involved a right minimal L5/S1 laminotomy/foraminotomy posteriorly to open the right L5 root. The facet joints were preserved to prevent spinal instability. The tumor was located along the root after opening the right L5/S1 foramen. Intraoperative electromyography (IOM) was conducted to detect any nerve injury in the patient. After opening the dura, the tumor was carefully separated from the normal root nerve under IOM monitoring. The mass was removed piece-by-piece using mini-forceps. Conclusion: Histopathological examination confirmed the diagnosis of a schwannoma. The patient recovered without incident after surgery with minimal soreness and numbness in the right leg.

Impact of Personal Protective Equipment on Cardiopulmonary Resuscitation and Rescuer Safety.

Background: High-quality cardiopulmonary resuscitation (CPR) is a key element in the rescue of cardiac arrest patients but is difficult to achieve in circumstances involving aerosol transmission, such as the COVID-19 pandemic. Methods: This prospective randomized crossover trial included 30 experienced health care providers to evaluate the impact of personal protective equipment (PPE) on CPR quality and rescuer safety. Participants were asked to perform continuous CPR for 5 minutes on a manikin with three types of PPE: level D-PPE, level C-PPE, and PAPR. The primary outcome was effective chest compression per minute. Secondary outcomes were the fit factor by PortaCount, vital signs and fatigue scores before and after CPR, and perceptions related to wearing PPE. Repeated-measures ANOVA was used, and a two-tailed test value of 0.05 was considered statistically significant. Results: The rates of effective chest compressions for 5 minutes with level D-PPE, level C-PPE, and PAPRs were 82.0 ± 0.2%, 78.4 ± 0.2%, and 78.0 ± 0.2%, respectively (p = 0.584). The fit-factor test values of level C-PPE and PAPRs were 182.9 ± 39.9 vs. 198.9 ± 9.2 (p < 0.001). The differences in vital signs before and after CPR were not significantly different among the groups. In addition, the fatigue and total perception scores of wearing PPE were significantly higher for level C-PPE than PAPRs: 3.8 ± 1.6 vs. 3.0 ± 1.6 (p < 0.001) and 27.9 ± 5.4 vs. 26.0 ± 5.3 (p < 0.001), respectively. Conclusion: PAPRs are recommended when performing CPR in situations where aerosol transmission is suspected. When PAPRs are in short supply, individual fit-tested N95 masks are an alternative. This trial is registered with NCT04802109.

Clinical Outcome and Safety of Lumboperitoneal Shunt in the Treatment of Non-Obstructive Hydrocephalus.

Objective: This study aimed to evaluate the functional outcomes of lumboperitoneal (LP) shunt for the treatment of non-obstructive hydrocephalus. Methods: We retrospectively studied the clinical surgical results of 172 adult patients with hydrocephalus who underwent LP shunt surgery between June 2014 and June 2019. Data regarding the following were collected: pre- and postoperative symptom status, third ventricle width changes, Evans index, and postoperative complications. Additionally, the baseline and follow-up Glasgow Coma Scale (GCS) score, Glasgow Outcome Scale (GOS), and Modified Rankin Scale (mRS) scores were investigated. All patients were followed up for ≥12 months using clinical interview and braining imaging using computed tomography (CT) scan or magnetic resonance imaging (MRI). Results: Majority of patients presented with normal pressure hydrocephalus as the etiology of their disease (48.8%), followed by cardiovascular accident (28.5%), trauma (19.7%), and brain tumor (3%). The mean GCS, GOS, and mRS improved postoperatively. The average period from symptomatic onset to surgery was 402 days. The average width of the third ventricle on CT scan or MRI was 11.43 mm preoperatively and 10.8 mm postoperatively (P<0.001). The Evans index improved from 0.258 to 0.222 after operation. The symptomatic improvement score was 7.0, with a complication rate of 7%. Conclusion: Significant improvement was observed in the functional score and brain image after LP shunt placement. Moreover, the satisfaction with symptomatic improvement after surgery remains high. LP shunt operation is a viable alternative in the treatment of non-obstructive hydrocephalus due to the low complication rate, fast recovery, and high satisfaction.

Tonsillar herniation as a complication of lumboperitoneal shunt: case report and literature review.

Tonsillar herniation is a rare and seldom reported complication after lumboperitoneal (LP) shunting. There have been only few reports that have presented possible options for treatment with varying degrees of success. In this report, we describe a rare case of tonsillar herniation after LP shunting and review related literature.A 17-year-old girl with hydrocephalus related to a traumatic brain injury underwent implantation of an adjustable pressure shunt (valve setting2.5) and a small lumen peritoneal catheter via the L4-L5 interspinal space. One month later, she was admitted to the emergency room with a Glasgow Coma Scale score ofE1M1Vt and dilated pupil. Image studies demonstrated new-onset tonsillar herniation and a mild cervical syrinx. Emergent suboccipital decompressive craniectomy, C1 laminectomy, and duraplasty were performed. This was followed with ligation of the LP shunt and implantation of a ventriculoperitoneal (VP) shunt a few days later. The patient's Glasgow Coma Scale score gradually recovered to 6, which was her previous neurologic status.Tonsillar herniation as a complication after LP shunting is best treated with decompression, ligation or removal of the LP shunt, and a shift to a VP shunt. The tonsillar herniation should be rapidly addressed to avoid persistent symptoms or progression of the neurologic deficits.

Intradural lumbar disc herniation: A case report and literature review.

Study design and objection: Intradural disc herniation is a unusual disease associated with spinal surgery. The definitive diagnosis of intradural herniation depends on intraoperative findings. Summary of background data: We present the case of a 63-year-old woman with backache and left sciatica radiation for more than two months. The L2/3 laminectomy and discectomy were performed after magnetic resonance imaging (MRI) study; however, no disc rupture was noted during surgery. Follow-up lumbar spine MRI revealed one large, ruptured disc. The patient underwent revision surgery with durotomy. The large intradural disc was found and removed piece by piece. Methods Results and Conclusions: Intradural disc herniation, especially large herniation, is hard to diagnose specifically despite the progression of neuroradiologic imaging techniques. A durotomy procedure should be considered if there is a missing ruptured disc or a palpable intradural mass during surgery.

Fabrication of 3D Printed Poly(lactic acid)/Polycaprolactone Scaffolds Using TGF-ß1 for Promoting Bone Regeneration.

Our research was designed to evaluate the effect on bone regeneration with 3-dimensional (3D) printed polylactic acid (PLA) and 3D printed polycaprolactone (PCL) scaffolds, determine the more effective option for enhancing bone regeneration, and offer tentative evidence for further research and clinical application. Employing the 3D printing technique, the PLA and PCL scaffolds showed similar morphologies, as confirmed via scanning electron microscopy (SEM). Mechanical strength was significantly higher in the PLA group (63.4 MPa) than in the PCL group (29.1 MPa) (p < 0.01). Average porosity, swelling ratio, and degeneration rate in the PCL scaffold were higher than those in the PLA scaffold. SEM observation after cell coculture showed improved cell attachment and activity in the PCL scaffolds. A functional study revealed the best outcome in the 3D printed PCL-TGF-ß1 scaffold compared with the 3D printed PCL and the 3D printed PCL-Polydopamine (PDA) scaffold (p < 0.001). As confirmed via SEM, the 3D printed PCL- transforming growth factor beta 1 (TGF-ß1) scaffold also exhibited improved cell adhesion after 6 h of cell coculture. The 3D printed PCL scaffold showed better physical properties and biocompatibility than the 3D printed PLA scaffold. Based on the data of TGF-ß1, this study confirms that the 3D printed PCL scaffold may offer stronger osteogenesis.

Bone Morphogenetic Protein-2-Activated 3D-Printed Polylactic Acid Scaffolds to Promote Bone Regrowth and Repair.

Uneven distribution of pores, lack of connection between holes, low reproducibility, insufficient mechanical strength, and incomplete volatility of organic solvents are some problems associated with traditional tissue engineering methods for bone defect repair. These characteristics reduce the quality and stability of products. This study uses 3D printing (3DP) to fabricate a biocompatible poly(lactic) acid-based scaffold for repairing bone tissue. Hence, three different types of scaffolds are assessed: a freeze-dried polylactic acid (PLA) scaffold constructed using the traditional freeze-extraction method; a 3D-PLA scaffold produced through the 3DP technique; and a 3D-PLA-bone morphogenetic protein-2 (BMP-2) scaffold that is prepared using 3DP technology, with the addition of BMP-2. To enhance biological activity, polydopamine (pDA) is used to graft BMP-2 on the surface of the 3D-PLA-BMP-2 scaffold. Then, the scaffolds are implanted into the bilateral femoral condyles of rabbits, and their ability to repair the bone tissue defects is tested. The results of the experiments reveal that the 3DP scaffolds are more biocompatible than the ones produced through the traditional manufacturing methods because they enhance cell adhesion and differentiation after pDA modification and BMP-2 fixation. In the future, the 3DP products may be applied for the repair of larger bone defects in the clinical setting.

MicroRNA-7 targets T-Box 2 to inhibit epithelial-mesenchymal transition and invasiveness in glioblastoma multiforme.

The dysregulation of microRNA expression in cancer has been associated with the epithelial-mesenchymal transition (EMT) that triggers invasive ability and increases therapeutic resistance. Here, we determined the microRNA expression profile of seven tumor tissues from patients with glioblastoma multiforme (GBM) by use of microRNA array analysis. We discovered that microRNA-7 (miR-7) is consistently downregulated in all tumor samples. Using the microRNA.org algorithm, the T-box 2 gene (TBX2) was identified as a candidate gene targeted by miR-7. In contrast to miR-7, TBX2 had an increased expression in GBM tumors and was linked to poor prognosis. We confirmed that TBX2 mRNA and protein production are significantly repressed by overexpressing miR-7 in GBM cells in vitro. The reporter assay showed that miR-7 significantly represses the signal from luciferase with the 3' UTR of TBX2. Furthermore, TBX2 overexpression decreased E-cadherin expression and increased Vimentin expression, causing an increasing number of invaded cells in the invasion assay, as well as pulmonary metastasis in vivo. Our findings demonstrated that overexpression of TBX2 in GBM tumors via the downregulation of miR-7 leads to EMT induction and increased cell invasion.

Development of mussel-inspired 3D-printed poly (lactic acid) scaffold grafted with bone morphogenetic protein-2 for stimulating osteogenesis.

3D printing is a versatile technique widely applied in tissue engineering due to its ability to manufacture large quantities of scaffolds or constructs with various desired architectures. In this study, we demonstrated that poly (lactic acid) (PLA) scaffolds fabricated via fused deposition not only retained the original interconnected microporous architectures, the scaffolds also exhibited lower lactic acid dissolution as compared to the freeze-PLA scaffold. The 3D-printed scaffolds were then grafted with human bone morphogenetic protein-2 (BMP-2) via the actions of polydopamine (PDA) coatings. The loading and release rate of BMP-2 were monitored for a period of 35 days. Cellular behaviors and osteogenic activities of co-cultured human mesenchymal stem cells (hMSCs) were assessed to determine for efficacies of scaffolds. In addition, we demonstrated that our fabricated scaffolds were homogenously coated with PDA and well grafted with BMP-2 (219.1 ± 20.4 ng) when treated with 250 ng/mL of BMP-2 and 741.4 ± 127.3 ng when treated with 1000 ng/mL of BMP-2. This grafting enables BMP-2 to be released in a sustained profile. From the osteogenic assay, it was shown that the ALP activity and osteocalcin of hMSCs cultured on BMP-2/PDA/PLA were significantly higher when compared with PLA and PDA/PLA scaffolds. The methodology of PDA coating employed in this study can be used as a simple model to immobilize multiple growth factors onto different 3D-printed scaffold substrates. Therefore, there is potential for generation of scaffolds with different unique modifications with different capabilities in regulating physiochemical and biological properties for future applications in bone tissue engineering.

Immobilization of bone morphogenetic protein-2 to gelatin/avidin-modified hydroxyapatite composite scaffolds for bone regeneration.

Bone scaffold surface characterization is important for improving cell adhesion, migration, and differentiation. In this study, bone morphogenetic protein-2 (BMP-2) was immobilized to the surface of the gelatin/hydroxyapatite composite using avidin-biotin binding system to produce a bone-tissue engineering scaffold. Firstly, hydroxyapatite particles reacted with hexamethylene diisocyanate and then the terminal group was converted into a primary amine group. Avidin was then immobilized on the surfaces of hydroxyapatite particles using N-ethyl-N'-(3-(dimethylamino)propyl) carbodiimide and N-hydroxysuccinimide as coupling agents. Gelatin was blended with avidin-modified hydroxyapatite and pure hydroxyapatite to obtain gelain/hydroxyapatite composite. The composite was then cross-linked with glutaraldehyde. Finally, biotin-conjugated BMP-2 was immobilized on the surface of the composite via avidin-biotin binding. In vitro study indicated that BMP-2-immobilized composite film had a higher ALP activity than that composite film without BMP-2. The composite scaffolds were then implanted into rabbit skulls to check bone-tissue regeneration. Ultrasound and micro-CT scans demonstrated that neovascularization and new bone formation in the BMP-2-immobilized composite scaffolds were higher than those in composite scaffolds without BMP-2. Histological evaluation result was similar to that of the micro-CT. Therefore, the surface immobilization of BMP-2 could effectively improve osteogenesis in the gelatin/hydroxyapatite composite scaffold.

Surgical results of cranioplasty using three-dimensional printing technology.

OBJECT: The aim of this research was to evaluate the surgical outcome of a new three-dimensional printing (3DP) technique using prefabrication molds and polymethyl methacrylate (PMMA). PATIENTS AND METHODS: The study included 10 patients with large skull defects (>100 cm2) who underwent cranioplasty. The causes of the skull defects were trauma (6), bone resorption (2), tumor (1), and infection (1). Before the operation, computed tomography (CT) scans were used to create a virtual plan, and these were then converted to 3-dimensional (3-D) images. The field of the skull defect was blueprinted by the technicians and operators, and a prefabricated 3-D model was generated. During the operation, a PMMA implant was created using a prefabricated silicone rubber mold and fitted into the cranial defect. All patients were followed up for at least 2 years, and any complications after the cranioplasty were recorded. RESULTS: Only 1 patient suffered a complication, subdural effusion 2 months after cranioplasty, which was successfully treated with a subdural peritoneal shunt. All patients satisfied the criteria for operative outcome and cosmetic effect. There were no episodes of infection or material rejection. CONCLUSION: The 3DP technology allowed precise, fast, and inexpensive craniofacial reconstruction. This technique may be beneficial for shortening the operation time (and thus reducing exposure time to general anesthesia, and wound exposure time, and blood loss), enhancing preoperative evaluation and simplifying the surgical procedure.

Intramuscular Migration of Venous Catheter as a Rare Complication of Ventriculoatrial Shunt: Case Report and Literature Review.

The most common procedure to manage hydrocephalus is a ventriculoperitoneal shunt. Other alternatives include a ventriculoatrial (VA) shunt, ventriculopleural shunt, lumboperitoneal shunt, or ventriculocisternal shunt. The VA shunt is a relatively rare procedure for hydrocephalus. As reported, several complications of VA shunt include obstructions, malposition, shunt infections, endocarditis, heart failure, tricuspid regurgitation, intra-atrial thrombus, and pulmonary hypertension. In this case report and literature review, we discuss a rare case of intramuscular migration of a venous tube 1 year after VA shunt implantation. We also report all the possible locations of migration after placement of VA shunt.

Cryopreservation versus subcutaneous preservation of autologous bone flaps for cranioplasty: comparison of the surgical site infection and bone resorption rates.

OBJECTIVE: Decompressive craniectomy is performed to treat malignant brain hypertension. Surgical site infection (SSI) and bone resorption are common complications following cranioplasty, and the storage method that minimizes such complication has yet to be identified. METHODS: Over a 10-year period, the details of 290 decompressive craniectomy procedures performed at our trauma and stroke center were recorded. Bone flaps from 110 patients were preserved in subcutaneous pockets (SPs), and 180 were preserved via cryopreservation (CP). RESULTS: SSIs occurred in 20 cases (18.2%) in the SP group and 20 cases (11.1%) in the CP group (P=0.129). After dividing each group according to the traumatic brain injury (TBI) etiologies, we found that in the SP group, the SSI rates in the TBI and non-TBI patients were 17.3% and. 20.7% (P=0.899), respectively, and in the TBI- and non-TBI CP-group patients, the SSI rates were 11.9% and. 9.7% (P=0.864), respectively. The average decrease in bone flap thicknesses were 1.14 mm in the SP group (n=34) and 1.89 mm in the CP group (n=57), and this difference was significant (P=0.039). CONCLUSIONS: In this series, the SSI rates were similar in the SP and CP groups. There was no significant difference when the patients were grouped by TBI etiology. The incidence of bone flap resorption in the CP group was higher than that in the SP group. However, identifying of the method that yields superior results might depend on the individual surgeon's preference and the available equipment.

1.5T versus 3T MRI for targeting subthalamic nucleus for deep brain stimulation.

BACKGROUND: Accurate stereotactic placement of the electrode into the subthalamic nucleus (STN) is imperative to the therapeutic efficacy of deep brain stimulation (DBS). However, it is not always possible to directly visualize the very small STN using 1.5T MR imaging. OBJECTIVE: To evaluate whether 3T MR imaging can provide better identification of the STN and clinical outcome than 1.5T MR imaging. METHODS: Thirty-nine patients with advanced Parkinson's disease underwent 1.5T (n = 16) or 3T (n = 23) fast spin echo T2-weighted (FSE-T2WI) MR imaging for targeting the STN. A semi-quantitative 3-point scoring system was proposed to rank the clearness of STN contour: Score "0" if non-visible; Score "1" if visible but with blurred margin; and "2" if visible with clear margin. The unified Parkinson's disease rating scale (UPDRS) was also compared before operation and post-operation. RESULTS: The STN score was 2 in all the patients of the 3T group, whereas it was relatively blurred (mean score, 1.19) in the 1.5T group (P < 0.001). The number of microelectrode trajectories (1.2 versus 1.5; P < 0.05) was lower in the 3T group; consequently, the operative time was also less (P < 0.05) as compared with that in the 1.5T group. The outcome of UPDRS motor examination showed no significant difference in two groups. CONCLUSION: 3T MR imaging is a reliable and more accurate method for direct targeting of the STN for DBS surgery. However, the technique of high-sequence MR imaging may not influence the clinical outcome significantly.

Single-port endoscopic removal of intraventricular central neurocytoma.

Central neurocytoma is a rare benign intraventricular tumor which occurs in young adults. Craniotomy with tumor removal is associated with relatively high rates of morbidity and mortality. To improve the efficiency of endoscopic surgery for removal of this tumor, we used a polypropylene tube combined with a working channel endoscope. From January 2006 to October 2008, three patients with intraventricular central neurocytoma with acute hydrocephalus were treated by endoscopic surgery in our hospital. The tumor was almost totally removed. At 6-month follow-up no recurrence was found. One patient required a permanent ventriculoperitoneal shunt due to hydrocephalus during follow-up. We report that a working channel endoscope combined with a polypropylene endoscopic sheath facilitates the removal of intraventricular central neurocytoma. Endoscopic neurosurgery is a safe method for removing a central neurocytoma with low risk of permanent neurological deficits.

Rhabdomyolysis accompanied by spontaneous spinal subdural and subarachnoid hematoma related to amphetamine abuse.

STUDY DESIGN: Case report. OBJECTIVE: To describe the rare case of a patient presenting with rhabdomyolysis accompanied by spontaneous spinal subdural hematoma (SDH) and subarachnoid hematoma (SAH), presumably caused by amphetamine abuse. SUMMARY OF BACKGROUND DATA: Spontaneous SDH accompanied by SAH is an extremely rare condition. To date, only one case describing spinal SAH related to amphetamine abuse has been reported. METHODS: A 41-year-old man who had a history of amphetamine abuse presented with severe frank pain and lower limb numbness with incomplete paraplegia. Urinary incontinence was subsequently noted. Thoracic-spine magnetic resonance imaging revealed SDHs in the dorsal aspect of the middle thoracic level and along the anterior part of the thecal sac, as well as SAH in the T11-T12 level. Diffuse paraspinal hyperintensity was detected, indicating rhabdomyolysis (creatine phosphokinase levels were also abnormally elevated). RESULTS: The patient responded well to decompression surgical treatment and has since then exhibited no neurologic deficits. CONCLUSION: We have described a novel case of spinal SDH with SAH. The possible underlying cause of amphetamine abuse is discussed.

Intracavernous sinus arachnoid cyst with optic neuropathy.

An 18-year-old man experienced progressive decreased visual acuity associated with a redness of the right eye for 1 month. An arachnoid cyst was identified within the right cavernous sinus and fenestration to the basal cistern was performed with the aid of a neuroendoscope. Visual acuity improved dramatically after the operation. Intracavernous sinus arachnoid cyst is a rare congenital intracranial lesion and surgical decompression may benefit symptomatic patients.