The role of full-endoscopic lumbar discectomy in patients with neurodegenerative disorders: Technical note and short literature review.

BACKGROUND: Motor neuron disease includes a spectrum of neurodegenerative diseases with progressive courses and unfavorable prognoses. Here, we described a patient with a lumbar disc herniation (LDH) and isolated bulbar palsy (IBP), who successfully underwent a transforaminal full-endoscopic discectomy (TFED) without incurring the added risks of general anesthesia. CASE DESCRIPTION: A 58-year-old male with IBP had an LDH at the L4-L5 level. Avoiding general anesthesia, a TFED was successfully performed under local anesthesia with mild sedation. There were no perioperative complications, and the patient was discharged on the 1st postoperative day. The patient experienced complete relief of radicular symptomatology 1 year postoperatively. CONCLUSION: Here, we present a rare instance of a patient with IBP who successfully underwent a TFED for an LDH performed under local anesthesia utilizing mild sedation, avoiding the risks of general anesthesia.

The Role of Percutaneous Transforaminal Endoscopic Surgery in Lateral Recess Stenosis in Elderly Patients.

Study Design: Prospective clinical study. Purpose: To investigate the effect of percutaneous transforaminal endoscopic surgery (PTES) for lateral recess stenosis (LRS)(LRS) in elderly patients and to assess patients' health-related quality of life (HRQoL). Overview of Literature: PTES is an increasingly used surgical approach, primarily employed for lumbar disc herniation treatment. However, indications for PTES have been increasing in recent years. PTES has been recommended as a beneficial alternative to open decompression surgery in specific LRS cases; PTES is termed as percutaneous endoscopic ventral facetectomy (PEVF) in such cases. Methods: In total, 65 elderly patients with LRS were prospectively studied. Patients presented severe comorbidities (coronary insufficiency, heart failure, diabetes mellitus, and respiratory failure); thus, general anesthesia administration would potentially cause considerable hazards. All the patients underwent successful PEVF in 2015-2016. The patients were assessed preoperatively and at 6 weeks; 3, 6, and 12 months; and 2 years postoperatively. Patients' objective assessment was conducted according to specific clinical scales; the Visual Analog Scale (VAS) was separately used for leg and low-back pain (VAS-LP and VAS-BP, respectively), whereas the Short Form 36 Health Survey Questionnaire was used for the HRQoL evaluation. Results: All studied parameters presented maximal improvement at 6 weeks postoperatively, with less enhancement at 3 and 6 months with subsequent stabilization. Statistical significance was found in all follow-up intervals for all parameters (p <0.05). Parameters with maximal absolute amelioration were VAS-LP, bodily pain, and role limitations due to physical health problems. In contrast, VAS-BP, general health, and mental health were comparatively less enhanced. Conclusions: PEVF was associated with remarkably enhanced HRQoL 2 years postoperatively. PEVF is thus a safe and effective alternative for LRS surgical management in elderly patients with severe comorbidities.

Single anterior cervical discectomy and fusion (ACDF) using self- locking stand-alone polyetheretherketone (PEEK) cage: evaluation of pain and health-related quality of life.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) constitutes the conventional treatment of cervical disc herniation due to degenerative disc disease (DDD). ACDF with plating presents a variety of complications postoperatively and stand-alone cages are thought to be a promising alternative. The aim of this study was firstly, to analyze prospectively collected data from a sample of patients treated with single ACDF using C-Plus self-locking stand-alone PEEK cage system, without the use of plates or screws, in order to evaluate pain levels of patients, utilizing Neck and Arm Pain scale as an expression of visual analogue scale (VAS). Secondly, we aimed to evaluate health-related quality of life, via the short-form 36 (SF-36) and Neck Disability Index (NDI). METHODS: Thirty-six patients (19 male and 17 female) with mean age 49.6±7 years old who underwent successful single ACDF using self-locking stand-alone PEEK cage for symptomatic cervical DDD were selected for the study. Neck and Arm pain, as well as SF-36 and NDI were estimated preoperatively and 1, 3, 6, and 12 months postoperatively. Patients underwent preoperative and postoperative clinical, neurological and radiological evaluation. RESULTS: The clinical and radiological outcomes were satisfactory after a minimum 1-year follow-up. All results were statistically important (P<0.05), excluding improvement in NDI measured between 6 and 12 months. SF-36, Neck Pain, as well as Arm Pain featured gradual and constant improvement during follow-up, with best scores presenting at 12 months after surgery, while NDI reached its best at 6 months postoperatively. CONCLUSIONS: Generally, all scores showed improvement postoperatively during the different phases of the follow-up. Subsequently, ACDF using C-Plus cervical cage constitutes an effective method for cervical disc herniation treatment, in terms of postoperative improvement on pain levels and health-related quality of life and a safe alternative to the conventional method of treatment for cervical DDD.

Health-related quality of life after transforaminal percutaneous endoscopic discectomy: An analysis according to the level of operation.

BACKGROUND: Many patients suffer from radiculopathy and low back pain due to lumbar disc hernia. Transforaminal percutaneous endoscopic discectomy (TPED) is a minimally invasive method that accesses the disc pathology through the intervertebral foramen. Health-related quality of life (HRQoL) has been previously assessed for this method. However, a possible effect of the level of operation on the postoperative progress of HRQoL remains undefined. PURPOSE: The purpose of this study was to evaluate the impact of the level of operation on HRQoL, following TPED. PATIENTS AND METHODS: A total of 76 patients diagnosed with lumbar disc hernia were enrolled in the study. According to the level of operation, they were divided into three groups: Group A (21 patients) for L3-L4, Group B (40 patients) for L4-L5, and Group C (15 patients) for L5-S1 intervertebral level. All patients underwent TPED. Their HRQoL was evaluated by the short-form-36 (SF-36) health survey questionnaire before the operation and at 6 weeks, 3, 6, and 12 months postsurgery. The progress of SF-36 was analyzed in relation to the operated level. RESULTS: All aspects of SF-36 showed statistical significant improvement, at every given time interval (P ≤ 0.05) in the total of patients and in each group separately. Group A had a significantly higher increase in physical functioning (PF) score at 3 and 12 months postsurgery (P = 0.046 and P = 0.056, respectively). On the other hand, Group B had a significant lower increase in mental health (MH) score at 6 months (P = 0.009) postoperatively. CONCLUSION: Our study concludes that the level of operation in patients who undergo TPED for lumbar disc herniation affects the HRQoL 1 year after surgery, with Group A having a significantly greater improvement of PF in comparison with Groups B and C.

Ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty.

PURPOSE: To compare the use of ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty (TKA) in terms of efficacy and safety (lack of toxicity). METHODS: 14 men and 26 women aged 58 to 77 (median, 70) years who had the American Society of Anesthesiologists (ASA) grades I to III physical status were randomised to receive ropivacaine (n=20) or bupivacaine (n=20) of a concentration of 0.5% for 3-in-1 block during TKA. The dosage was 0.5 ml/kg. In addition, a sciatic nerve block (20 ml of prilocaine 1%) was used. The onset of the block, duration of postoperative analgesia, level of motor block, and any side-effects were compared. RESULTS: The median time to onset of block was significantly shorter in those receiving ropivacaine than bupivacaine (13 vs. 17.5 minutes, p<0.001), but the levels of motor blockade were not significantly different (p=0.355). Complete analgesia was achieved throughout the procedure. There was no significant difference between the ropivacaine and bupivacaine groups in terms of the mean duration of analgesia (398 vs. 367 minutes, p=0.62), the mean VAS scores at all time points, and the mean total morphine consumption. One patient in the ropivacaine group developed a joint haematoma and 2 patients in the bupivacaine group had excessive wound drainage. Both conditions resolved after antibiotic use. CONCLUSION: Ropivacaine and bupivacaine showed similar anesthetic and analgesic effects, but the former had a significantly faster onset time.

Evaluation of direct immunofluorescence assay and cytological examination in comparison to polymerase chain reaction of conjunctival swabs in patients with adult inclusion conjunctivitis.

PURPOSE: To evaluate PCR, direct immunofluorescence assay (DIA) and cytological test of conjunctival swabs for the diagnosis of adult follicular conjunctivitis (AFC). METHODS: Eighty-three adult patients with chronic conjunctivitis and sixteen healthy individuals were included. Conjunctival scrapings underwent PCR, DIA and cytological analysis. Exams were repeated two weeks after treatment application. Sensitivity, specificity and agreement rate with PCR of DIA and Cytology were evaluated and correlated with clinical symptoms/signs. RESULTS: Cytology test was more sensitive than DIA and presented an acceptable agreement with PCR (K=0.44) in treatment-naïve patients, concerning especially the combination of both conventional exams (K = 0.77). Inferior diagnostic performance of was detected post-treatment, considering the combination as well (K=0.40). Negative post-treatment PCR correlated well with significant relief of symptoms/signs. CONCLUSION: Combination of Cytology and DIA seems to be a useful diagnostic option for treatment naïve AFC patients. However, PCR remains the most reliable test for post-treatment evaluation.

Terson hemorrhage in patients suffering aneurysmal subarachnoid hemorrhage: predisposing factors and prognostic significance.

OBJECT: The association of vitreous and/or subhyaloid hemorrhage with aneurysmal subarachnoid hemorrhage (SAH) has been frequently identified since the original description by Terson in 1900. In this prospective clinical study the authors examined the actual incidence of Terson hemorrhage in patients suffering aneurysmal SAH, they attempted to identify those parameters that could predispose its development, and they evaluated its prognostic significance in the overall patients' outcome. METHODS: A total of 174 patients suffering aneurysmal SAH were included in this study. The admitting Glasgow Coma Scale scores (GCS), World Federation of Neurological Societies (WFNS) scale scores, Hunt and Hess grades, and Fisher grades were recorded. A careful ophthalmological evaluation was performed in all participants. The exact anatomical locations and the largest diameter of the dome of the ruptured aneurysms were also recorded. Surgical clipping or endovascular coiling was used in 165 patients. Clinical outcome was evaluated at discharge from the hospital by using the Glasgow Outcome Scale and the modified Rankin Scale. Periodic ophthalmological evaluations were performed for 2 years. RESULTS: In this series, the observed incidence of Terson hemorrhage was 12.1%. Statistical analysis of our data demonstrated that patients with low GCS scores and high WFNS scores, Hunt and Hess grades, and Fisher grades had an increased incidence of Terson hemorrhage. The mortality rate for patients with Terson hemorrhage was 28.6%, whereas that for patients without Terson hemorrhage was 2.0%. Moreover, patients with Terson hemorrhage who survived had significantly worse outcomes than those in patients without Terson hemorrhage. CONCLUSIONS: Terson hemorrhage constitutes a common SAH-associated complication. Its incidence is increased in patients with low GCS and high WFNS scores, and high Hunt and Hess and Fisher grades. Its presence is associated with increased mortality and morbidity rates.

Rubeola keratitis: a photographic study of corneal lesions.

PURPOSE: Detailed description of the morphology of rubeola keratitis lesions is missing from textbooks and published reports. We performed a detailed analysis of rubeola keratitis lesions by using a photographic slit lamp and ophthalmic dyes. METHODS: Thirty-four eyes of 17 male young adult patients with rubeola keratitis were examined. Patients were examined at 3.6 days after the development of rash. Ocular symptoms were recorded, and patients underwent complete ocular examination including photography of corneal lesions, with and without instillation of ophthalmic dyes (rose Bengal and fluorescein). RESULTS: Patients complained of foreign-body sensation (88%), photophobia (65%), tearing (65%), and burning sensation (47%). Visual acuity was unaffected (26%) or mildly affected (71%). Conjunctivitis was observed in 74% and keratitis in 100% of eyes. Corneal photographs were studied, and 4 types of corneal lesions were identified: small, punctate epithelial lesions staining only with rose Bengal (100%); small, round, or larger and irregular when they coalesced epithelial defects (100%); large or tiny filaments (39%); and target lesions (100%). Target lesions appeared when both dyes were instilled. The outline of target lesions stained with rose Bengal, and they consisted of a pattern of alternating concentric zones of staining with rose Bengal and fluorescein. Keratitis was strictly confined to the epithelium and resolved gradually in all patients without the appearance of complications. CONCLUSIONS: Rubeola keratitis in healthy young adults runs a benign course. Recognition of the specific to rubeola keratitis corneal target lesions could aid in the differential diagnosis and prevent the transmission of the disease.

A case of successful treatment of neuropathic pain after a scapular fracture using subcutaneous targeted neuromodulation.

Subcutaneous targeted neuromodulation is one part of the wider new peripheral neuromodulation development in the treatment of neuropathic pain. Although it has not received wider acceptance, there are many reports in the literature of successful use of this technique.