Coronavirus Disease 2019: Latest Data on Neuroinvasive Potential.

Coronavirus disease 2019 (COVID-19) is a pandemic infection. Similar to other respiratory viruses, severe acute respiratory syndrome coronavirus (SARS-COV-2) may enter the brain via the hematogenous or neuronal route; however, only a few reports are available on the neurological complications of COVID-19. Encephalopathy is a significant neurological complication of COVID-19. We herein present an update on the virology, neurological pathogenesis, and neuroinvasive potential of coronaviruses and briefly discuss the latest findings on SARS-CoV-2 neuroinfection. The reports thus far indicate that the access of SARS-CoV into host cells is bolstered chiefly by a cellular receptor, angiotensin-converting enzyme 2, and that SARS-CoV-2 may induce some neurological manifestations via direct or indirect mechanisms. Further research is required to shed sufficient light on the impact on the central nervous system and altered mental status in patients with COVID-19. Indeed, a better understanding of the pathways of SARS-CoV-2 neuroinvasion would further clarify the neurological pathogenesis and manifestations of coronaviruses and enhance the management and treatment of this group of patients. In the current epidemic era of COVID-19, health care staff should strongly become aware of SARS-CoV-2 infection as an essential diagnosis to get away misdiagnosis and prevention of transmission.

The Accuracy of the S100B Protein Biomarker in the Prognosis of Patients with Acute Spinal Cord Injury.

Introduction The role of some biomarkers such as S100 beta (S100B) has been somewhat known in determining the severity of primary acute spinal cord injury (SCI), and today, it has been the basis of various relevant studies. Therefore, this study estimates the S100B level in serum and cerebrospinal fluid (CSF) in patients with spinal injuries. Methods This was a descriptive-analytic study. In this study, 31 patients with acute SCI referred to Sari Imam Khomeini Hospital, Iran, were recruited. Patients were divided into two groups of complete and incomplete SCI according to the American Spinal Injury Association (ASIA). The S100B concentrations in serum and CSF levels were compared between the two groups. Result There was only significant positive correlation between S100B CSF concentration and complete SCI based on the ASIA criterion, meaning that in cases of complete SCI the S100B CSF concentration was significantly increased correlation coefficient (CC) (cc = 0.529 and p = 0.002). Based on the results of serum S100B protein concentration, 14.70 ng/dL with a sensitivity of 66.7% and specificity of 55% was determined as cutoff for complete SCI. Also, about the CSF S100B protein level variable, concentration of 342.18 ng/dL with 100% sensitivity and 64% specificity was determined as cutoff for complete injury. Conclusion The results of this unique study have shown that S100B were useful markers for predicting the prognosis of patients with acute SCI and cutoff points determined for serum and especially CSF concentrations can differentiate complete and incomplete SCI.

Quetiapine-induced chest wall edema with the swellings of face and extremities in a young hospitalized patient: A case report.

Key Clinical Message: Quetiapine can lead to the face, extremity and particularly chest wall edema in hospitalized patients in the supine position. Abstract: Quetiapine (QTP) is known as an atypical antipsychotic agent with some adverse effects, such as edema. However, along this line, peripheral edema is not a life-threatening episode, but it is an important side effect affecting medical compliance. Therefore, QTP-induced chest wall edema with the swellings of the face and the extremities is very rare. This report is about a young man who was admitted in the intensive care unit with multiple trauma (MT). On account of his delirious state, QTP was started at 25 mg and then increased to 75 mg, three times a day. The patient developed swelling of the face, the upper and lower limbs, and the chest wall. After stopping the QTP use, his edema went down. Although there is still speculation about the possible mechanisms of antipsychotic-induced edema, some studies have pointed to the relationship between dopaminergic antagonism and peripheral edema. Therefore, it is very important to pay close attention to this side effect.

Placebo-controlled trial of oral amantadine and zolpidem efficacy on the outcome of patients with acute severe traumatic brain injury and diffuse axonal injury.

BACKGROUND: A constituent of diffuse axonal injury (DAI) is supposed to be present in about 1/3 of all severe traumatic brain injury (TBI) as specified by pathologic documents. Diffuse axonal injury is categorized by extensive injury to axons in the brain. A rise in the incidences of TBI, and the limited study to verified effect of drugs like amantadine and zolpidem in improving the consciousness levels of patients with acute traumatic brain injury with axonal injury enthused us to initiate this study in the acute TBI patients. METHODS: In our randomized, controlled trial involving patients with acute severe TBI, we studied 66 patients in 3 groups. Group 1 (n=22) received oral amantadine, Group 2 (n=22) received oral zolpidem, whereas group 3 (n=22) received placebo, the first 8 days after injury respectively. The primary outcome measures included GCS (Glashow coma scale) through the initial admission, a complete medical history was recorded, and each patient had a meticulous physical and neurological investigation. RESULTS: We found that the administration of amantadine in an acute phase after injury improved the rate of patients GCS and GOS (Glasgow Outcome Scale) compared with zolpidem and placebo groups, but without any significant statistical difference. CONCLUSION: Our results has emphasized that because amantadine has intense biochemical effects on several ways, it appears to be beneficial in acute period after DAI-associated TBI.

Association between vitamin D receptor gene polymorphism (rs731236) and aggrecan gene VNTR polymorphism with the risk of lumbar intervertebral disc degeneration.

Background: Low back pain is one of the most common causes of referral to physicians. Lumbar disc degeneration (LDD) is the main cause of back pain in different countries. It seems that genetic factors are more effective than environmental factors in the developing of degenerative phenomena. The aim of this investigation, therefore, was to study the association of the aggrecan gene (ACAN) variable number tandem repeat (VNTR) and the vitamin D receptor (VDR) rs731236 (TaqI) polymorphisms, with lumbar intervertebral disc degeneration in a population in the North of Iran. Methods: In this study, 55 patients with symptomatic intervertebral disk degeneration and 55 control subjects were included. VDR gene polymorphism was genotyped by PCR-based RFLP. The isolated DNA was used to genotype the VNTR of ACAN gene via conventional PCR. Results: For VDR gene polymorphism, the CC genotype (OR=5.337, P=0.019) was significantly higher among the patients compared with the controls, revealing a higher frequency of the C allele in patients compared with controls (OR=2.707, P=0.005). The lower number of frequent repetitions in the VNTR aggrecan gene was associated with a six-time increase of lumbar disc degeneration. Also, high BMI can be considered as an independent factor in the incidence of this disease. Conclusion: Aggrecan gene VNTR polymorphism had an association with degeneration of lumbar intervertebral discs that the shorter VNTR repeats increasing the chance of the disc degeneration in this population in the North of Iran. Moreover, an association between the mutant allele (C) of VDR gene TaqI polymorphism and disc degeneration is found.

Aldolase C Profiling in Serum after Mild Traumatic Brain Injury: A Prospective Cohort Study.

BACKGROUND: After a traumatic brain injury (TBI), in addition to clinical indices, the serum level of neurological biomarkers may provide valuable diagnostic and prognostic information. The present study aimed to investigate the aldolase C (ALDOC) profile in serum for early diagnosis of brain damage in patients with mild TBI (mTBI) presented to the Emergency Department (ED). METHODS: A single-center prospective cohort study was carried out in 2018-2019 at Imam Khomeini Hospital affiliated with Mazandaran University of Medical Sciences, Sari, Iran. A total of 89 patients with mTBI were enrolled in the study. Blood samples were taken within three hours after head trauma to measure ALDOC serum levels. Brain CT scan was used as the gold standard. Statistical analysis was performed using the Kruskal Wallis, Mann-Whitney U, and Chi square tests. The receiver-operating characteristic (ROC) curve plot was used to determine the optimal cutoff point for ALDOC. The sensitivity and specificity of the determined cutoff point were calculated. P values less than 0.05 were considered statistically significant. RESULTS: Of the 89 patients, the CT scan findings showed a positive TBI in 30 (33.7%) of the patients and in 59 (66.3%) a negative TBI. The median ALDOC serum level in the patients with positive CT scan findings (8.35 ng/mL [IQR: 1.65]) was significantly higher than those with negative CT scan findings (5.3 ng/mL [IQR: 6.9]) (P<0.001). The optimal cutoff point for ALDOC serum level was 6.95 ng/mL, and the area under the curve was 99.6% (P<0.001). The sensitivity and specificity of the determined cutoff point were 100% and 98%, respectively. CONCLUSION: The ALDOC serum level in patients with mTBI significantly correlates with the pathologic findings of the brain CT scan. This biomarker, with 100% sensitivity, is a suitable tool to detect brain structural abnormalities in mTBI patients.

Anterior cervical spine surgery opens up concerns about thyroid function.

BACKGROUND AND OBJECTIVES: The anterior approach for cervical discectomy and fixation is a valuable procedure for decompression of the spinal cord in patients with severe canal stenosis and stabilization of cervical vertebral column. Although some studies have investigated the thyroid complications especially in cervical cancer surgery or recently in tracheostomy, little research has been performed on the anterior spine surgery so far. The present study aimed to evaluate possible changes in the thyroid in patients experiencing anterior cervical approaches for degenerative diseases. MATERIALS AND METHODS: Seventy patients who were undergoing anterior cervical spine surgery were selected and their demographic information was recorded, including age, sex, weight, body mass index (BMI), and medical records. Thyroid hormones (TSH, free T4, and free T3) were measured before surgery and three months after surgery. RESULTS: Most patients had cervical disc herniation (60%). The mean duration of surgery was 71.9 ± 8.36 minutes (range: 60-90 minutes). Twenty-one patients (30%) had anterior plating while 49 patients (70%) did not. Spearman's correlation coefficient was used to examine the correlation of the following variables with TSH changes: Number of operated cervical levels, level of operated spine, incision type, duration of surgery, type of surgery (ACDF or ACCF). None of these variables showed a significant correlation. Meanwhile, a significant and direct correlation was observed between TSH changes and age. CONCLUSIONS: Although the results of our study did not show any signs of functional changes due to thyroid tissue injury during surgery, based on rare case reports and age-related laboratory changes, we recommend thyroid function tests for diagnosing subclinical thyroid dysfunction before anterior cervical spine surgery in patients with degenerative diseases and especially in older adults.

Basal Ganglia Involvement and Altered Mental Status: A Unique Neurological Manifestation of Coronavirus Disease 2019.

Like other respiratory viruses, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may enter the central nervous system (CNS) via the hematogenous or neuronal path. However, neurological complications of coronavirus disease 2019 (COVID-19) have not been reported frequently. Encephalopathy has been described as a presenting symptom or complication of COVID-19 in some reports. We report a case of a 54-year-old patient who presented with unique clinical characteristics and imaging with brain basal ganglia involvement likely due to SARS-CoV-2 infection. In our experience, the incidence of spontaneous bilateral basal ganglia hemorrhage is rare. Further study will be needed to investigate this finding of the CNS and altered mental status in patients with this new type of coronavirus infection. Based on the case presented and other cases, understanding the pathways of virus neuroinvasion is necessary to help recognize possible pathologically related consequences of infection and to evaluate new diagnostic and management approaches that will help improve SARS-CoV-2 infection treatment and control.

One-Stage Posterior Only Corpectomy and Fusion in the Treatment of a Unique Acute Low Lumbar L4 Burst Fracture Without Neurologic Deficit: A Case Presentation.

L4 and L5 fractures are different from those at the thoracolumbar area. These differences include anatomy, biomechanics, classification, and treatment possibilities. Given the accessible literature and lack of high-quality information about the management of low lumbar fractures, we describe the case of a young 26-year-old male was referred to our emergency medical center with a severe L4 vertebral body comminuted burst fracture with complete spinal canal compression (AO type 4). Incredible, all neurological functions were intact initially. The patient was cured through a one-stage posterior only vertebrectomy and fusion with preservation of all neurological functions. Clinical and radiologic follow-up was satisfactory after 2 years. In more severe lumbar injuries, decisions contain spinal decompression and stabilization through a posterior or anterior approach based on the surgeon's favorite. In our experience in this patient, a posterior approach only was used both for decompression and stabilization without routine challenging existing in anterior approaches.

Association between Serum Levels of Interleukin-6 on Pain and Disability in Lumbar Disc Herniation Surgery.

CONTEXT: Many inflammatory cytokines are also elevated in degenerated or herniated intervertebral discs. Among biomarkers, interleukin-6 (IL-6) plays an essential role in the inflammatory process of disc herniation. Some studies have suggested that an increase in serum IL-6 levels occurs in sustained radicular pain. AIMS: The aim of this study was to determine the relationship between changes in IL-6 serum level and pain and disability index in patients with radicular pain in acute herniated lumbar disc before and after lumbar disc surgery. SETTINGS AND DESIGN: This is a descriptive-analytic prospective study to examine the association between IL-6 serum levels on pain and disability before and after the surgery in patients admitted with acute herniated lumbar intervertebral discs from 2015 to 2018 in Imam Khomeini Hospital, Sari, Mazandaran, Iran. SUBJECTS AND METHODS: The blood level of IL-6, the severity of pain based on visual analog score, and disability based on the Oswestry disability index were measured before and 3 months after surgery. STATISTICAL ANALYSIS USED: All data were analyzed using SPSS version 24. RESULTS: Thirty-two patients were enrolled in the study. Seventeen patients were male. The mean age was 39.53 ± 8.89 years. IL-6 concentration, 4.36 and 1.16 pg/ml were determined as cutoff before and after the surgery. CONCLUSIONS: The acceptable sensitivity and specificity of IL were obtained in this study. Our findings revealed that IL-6 could be used as a biomarker for predicting postoperative pain relief and disability improvement.

The Effect of Ultra-low-dose Intrathecal Naloxone on Pain Intensity After Lumbar Laminectomy With Spinal Fusion: A Randomized Controlled Trial.

BACKGROUND: Despite advances in pain management, several patients continue to experience severe acute pain after lumbar spine surgery. The aim of this study was to assess the safety and effectiveness of single ultra-low-dose intrathecal (IT) naloxone in combination with IT morphine for reducing pain intensity, pruritus, nausea, and vomiting in patients undergoing lumbar laminectomy with spinal fusion. MATERIALS AND METHODS: In this double-blind trial, patients scheduled for lumbar laminectomy with spinal fusion were randomly assigned to receive single ultra-low-dose IT naloxone (20 µg) and IT morphine (0.2 mg) (group M+N) or IT morphine (0.2 mg) alone (group M). The severity of postoperative pain, pruritus and nausea, and frequency of vomiting were assessed at recovery from anesthesia and, subsequently, at 1, 3, 6, 12, and 24 hours postoperatively using an 11-point (0-10) visual analogue scale. RESULTS: A total of 77 patients completed the study, and there were significant differences in postoperative pain, pruritus, and nausea visual analogue scale between the groups (P<0.05). After adjusting for body mass index and surgery duration, IT naloxone administration reduced the pain score (coefficient=1.84; 95% confidence interval [CI], 1.05-2.63; P<0.001), and the scores of pruritus and nausea (coefficient=0.9; 95% CI, 0.44-1.37; P<0.001 and coefficient=0.71; 95% CI, 0.12-1.31; P=0.02, respectively) compared with IT morphine alone. No serious adverse effects were observed. CONCLUSIONS: The addition of ultra-low-dose IT naloxone to IT morphine provides excellent postoperative pain management and effectively controls pruritus and nausea in patients undergoing laminectomy with spinal fusion.

Complications Associated With Minimally Invasive Anterior to the Psoas (ATP) Fusion of the Lumbosacral Spine.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To analyze complications associated with minimally invasive anterolateral retroperitoneal antepsoas lumbosacral fusion (MIS-ATP). SUMMARY OF BACKGROUND DATA: MIS-ATP provides anterolateral access to the lumbar spine allowing for safe anterior lumbar interbody fusions between T12-S1. Anecdotally, many surgeons believe that ATP approach is not feasible at L5-S1 level, predisposing to catastrophic vascular injuries. This approach may help overcome limitations associated with conventional straight anterior lumbar interbody fusions, MIS lateral lumbar interbody fusion, and oblique lateral interbody fusion. METHODS: A detailed retrospective chart review of patients who had underwent MIS-ATP approach for lumbar fusion between T12-S1 was performed. Available electronic data from surgeries performed between January 2008 and March 2017 was carefully screened for surgical patients treated for spondylolisthesis, spondylosis, stenosis, sagittal, and/or coronal deformity. Detailed review of electronic medical records including operative notes, progress notes, discharge summaries, laboratory results, imaging reports, and clinic visit notes performed by a single independent reviewer not involved in patient care for documented complications. A complication is defined as any adverse event related to the index spine procedure for which patient required specific intervention or treatment. RESULTS: Nine hundred forty patients with a total of 2429 interbody fusion levels performed via MIS-ATP were identified during the study period. Sixty-seven patients (7.2%) sustained one or more complications during the perioperative period, of which 25.5% were surgical and 74.5% were medical. Overall, 78 (8.2%) surgical complications pertaining to the index procedure were noted during a postoperative period of 1 year from the date of surgery. No major vascular or direct visceral injuries were encountered. CONCLUSIONS: MIS-ATP approach provides a safe access to anterolateral interbody fusions between T12-S1. The ATP approach is performed by the spine surgeon, does not require neuromonitoring, and warrants minimal to no psoas muscle retraction resulting in significantly reduced postoperative thigh pain and rare neurologic injuries. Additionally, the direct and clear visualization of the retroperitoneal vasculature provided by the ATP approach minimizes the risk of inadvertent vascular injury. LEVEL OF EVIDENCE: 4.

Effects of Minocycline on Neurological Outcomes In Patients With Acute Traumatic Brain Injury: A Pilot Study.

Traumatic brain injury (TBI) is a public health problem worldwide. Secondary damage of brain injury begins within a few minutes after the trauma and can last a long time. It can be reversible, unlike primary injury. Therefore, therapeutic intervention can be used. The aims of this study were to assess the effects of minocycline on neurological function and serum S100B protein and neuron-specific enolase (NSE) levels in patients with moderate to severe TBI. Patients with acute onset of TBI and surgical evacuation of hematoma were randomized to receive either minocycline 100 mg orally twice daily or placebo for 7 days. The primary outcomes included changes in level of S100B and NSE at different time points during the trial. Additionally, changes in Glasgow coma scale (GCS) score were evaluated. The Glasgow Outcome Scale-Extended (GOS-E) score at 6 months after injury was assessed in discharge patients. Thirty four patients were randomized into the placebo (n = 20) and treatment (n = 14) groups. There was a marginal statistically significant differences in the normalized value of S100B between groups (p < 0.1). The reduction in serum NSE level from baseline to day 5 was statistically significant (p = 0.01) in minocycline group while it was not significantly decrease in placebo group (p = 0.2). Also, GCS improvement over time within the minocycline group was significant (p = 0.04) while was not significant in placebo group (p = 0.11). The GOS-E scores were not significantly different between minocycline and placebo group. Based on this study, it seems that the use of minocycline may be effective in acute TBI.

Cotreatment with Furosemide and Hypertonic Saline Decreases Serum Neutrophil Gelatinase-associated Lipocalin (NGAL) and Serum Creatinine Concentrations in Traumatic Brain Injury: A Randomized, Single-Blind Clinical Trial.

Acute kidney injury (AKI) occurs both after traumatic brain injury (TBI) and after hypertonic saline administration; furosemide may be useful in preventing AKI indirectly. Serum neutrophil gelatinase-associated lipocalin (sNGAL) is superior to serum creatinine (sCr) in diagnosing early AKI. We compared the administration of hypertonic saline plus furosemide (HTS+F) versus hypertonic saline (HTS), using sCr and sNGAL to investigate kidney injury in patients with TBI. This randomized, single-blind clinical trial was conducted from August 2016 to July 2017 in a neurosurgical intensive care unit, and included patients with a Glasgow Coma Score (GCS) 7-13 and brain edema. One group (n = 22) received hypertonic saline 5% (100 mL over 60 min then 20 mL/h) plus furosemide (40 mg over 60 min then 0.05 mg/kg per hour) for 72 h. The other group (n = 21) received only hypertonic saline 5%, in the same dose as noted above. The sCr and sNGAL concentrations, GCS, and length of stay were measured. Mean ± SD differences were -51.15 (47.07) and 9.96 (64.23) ng/mL for sNGAL and -0.12 (0.22) and -0.005 (0.2) mg/dL for sCr in HTS+F group and HTS group respectively (both p < 0.001). The incidence of stage one AKI according to Improving Global Outcomes (KDIGO) criteria was 4.5% in the HTS+F group and 19.0% in the HTS group (p = 0.16). Hypokalemia was common in both groups. HTS+F group, compared with HTS group, was associated with lower concentrations of sCr and sNGAL. Incidence AKI (KDIGO criteria) did not have difference between groups.

A huge ependymoma of the cervical spinal cord with subtle atypical manifestations and hyperhidrosis: Case report.

INTRODUCTION: Ependymomas are the most common neuroepithelial tumors of the spinal cord, accounting for 50-60% of spinal cord gliomas. The nonspecific clinical presentation of a spinal cord tumor frequently results in delay of diagnosis with opposing outcomes. PRESENTATION OF CASE: We report a 34-year-old man presented with abnormally enhanced sweating on the left side of his neck, upper extremity, and chest that had been occurring for 1 year. In the sagittal MRI there were a centrally localized mass lesion extending from medulla and C1 to T2 vertebra level and expanding the cord. Surgical elimination of the tumor was performed with posterior midline approach and near total resection of tumor was achieved. CONCLUSION: Cervical intramedullary ependymal is a rare, slow growing spinal cord tumor. Attention to uncommon characteristics like hyperhidrosis might be an important key to early diagnosis of this rare spinal tumor. Surgical resection is the choice of treatment with infrequent recurrence.

Is transforaminal retrieval of intradiscal deeply seated broken surgical knife blade all time pars sparing? A case report.

BACKGROUND: One risk accompanying with Lumbar discectomy is breaking of the surgical scalpel during discectomy. Greatest of the broken blades can be detached during the first surgery. Conversely, in few cases, surgeon's efforts might be ineffective, causing in engaged foreign body in the disc space. Works regarding this matter is infrequent, and there are no exclusive strategies to discourse this complication. PRESENTATION OF CASE: A 26-year-old female with L5-S1 left disc sequestration and plantar flexion disturbance, underwent a one level hemilaminectomy for lumbar disc herniation. The knife blade was broken in the disc space and could not be found despite 3h consumed on its tried removal by her surgeon. Transforaminal path as an unconventional access strip for its removal is planned, but pars inter articularis was not saving intact and fusion process had done.The patient was discharged a day after blade removal and fusion surgery is doing well now. CONCLUSIONS: The transforaminal route might be a harmless and informal substitute corridor for all intradiscal retained foreign bodies including a broken blade. Sometimes because of better exposure especially in deeply seated material, resection of pars and then fusion surgery avoid inevitable.

Effects of Nasal Calcitonin vs. Oral Gabapentin on Pain and Symptoms of Lumbar Spinal Stenosis: A Clinical Trial Study.

Lumbar spinal stenosis (LSS) is a chronic and prevalent disease that occurs in 10.8% of the general population, mostly in old age. We designed the first clinical trial study to compare the effects of administering the nasal salmon calcitonin spray and gabapentin in patients with LSS. In this clinical trial, 90 patients with symptoms of neurogenic claudication and magnetic resonance imaging-proven LSS were randomly assigned to nasal salmon calcitonin, gabapentin, or placebo treatments for eight weeks (30 participants in each group). This was followed by a washout period of four weeks. After three months of study and after four weeks off the prescription, mean values of Oswestry Disability Index in the calcitonin, gabapentin, and control groups were 23 ± 12.05, 32 ± 16.08, and 38 ± 22.09, respectively (P ≤ 0.05, calcitonin group vs. gabapentin group, and P ≤ 0. 001, calcitonin group vs. control group with respect to pretreatment scores). Thus, three months after the treatment, although most of the patients in the control group had a satisfactory period of improvement, the improvement in the calcitonin group was more than the other two groups with a significant difference (P ≤ 0.05 when compared to gabapentin group and P ≤ 0.01 when compared to placebo group). We revealed that the 200 International Unit (IU) and nasal calcitonin spray daily are more effective compared to 300 mg gabapentin three times per day and the placebo effect for eight weeks of treatment of symptoms of patients with LSS.

Posterior Epidural Migration of a Sequestrated Lumbar Disk Fragment Causing Cauda Equina Syndrome in an Old Patient: A Case Report.

Disk fragment relocation is commonly limited to the anterior epidural space, although posterior epidural movement of a sequestrated disk piece to the posterior epidural space is infrequent. We present an uncommon case of dorsal extradural sequestration of lumbar disk herniation. A 77-year-old man presented with severe leg pain, low back pain, and urinary incontinence. Deep tendon reflexes were inattentive at the knee and ankle, and the motor power in terms of ankle dorsiflexion and great toe dorsiflexion was 2/5 in both lower limbs. There was hypoesthesia in the S1, S2, and S3 dermatomes. Magnetic resonance imaging displayed a large isointensity lesion at the L4-L5 level on the T2 sagittal image, indenting circumferentially the thecal sac from lateral to posterior of the thecal sac. The patient underwent an L4-L5 central laminectomy. A large, solid epidural disk fragment was recognized dorsally, with major compression of the thecal sac. The patient report improved lower extremity motor function at three-month follow-up. A displaced disk fragment should be considered as causative when patients present with cauda equine syndrome and be treated as a surgical emergency.

Outcome after Surgery of Lumbar Spinal Stenosis: A Randomized Comparison of Bilateral Laminotomy, Trumpet Laminectomy, and Conventional Laminectomy.

BACKGROUND: Laminectomy is the traditional operating method for the decompression of spinal canal stenosis. New partial decompression processes have been suggested in the treatment of lumbar stenosis. The benefit of a micro surgical approach is the chance of an extensive bilateral decompression of the spinal canal or foramen at one or numerous levels, through a minimal para-spinal muscular separation. PURPOSE: To match the safety and the clinical consequences after a bilateral laminotomy, laminectomy and trumpet laminectomy in patients with lumbar spinal stenosis who were randomized to one of three treatment groups. STUDY DESIGN: Prospective study. METHODS: One hundred twenty consecutive patients with 227 levels of lumbar stenosis without significant herniated discs or instability were randomized to three treatment groups [bilateral laminotomy (Group 1), laminectomy (Group 2), and trumpet laminectomy (Group 3)]. Perioperative parameters and complications were documented. Symptoms and scores, such as a visual analog scale (VAS), Oswestry Disability Index, and patient satisfaction, were assessed preoperatively at 3, 6, and 12 months after surgery. Adequate decompression was achieved in all patients on the basis of surgeon satisfaction. RESULTS: The global complication rate was lowest in patients who had undertaken bilateral laminotomy (Group 1). The minimum follow-up of 12 months was achieved in 100% of patients. Matched with that experience in Group 1, but, with more remaining back and leg pain was found in Group 2, 3.85 ± 0.28 and 1.60 ± 0.44, respectively and 3.24 ± 0.22 and 2.44 ± 0.26 in Group 3, respectively compared with 1.84 ± 0.28 and 1.25 ± 0.12 (Group 1) at the 1-year follow-up assessment (p < 0.05). It was the same for the ODI scores, which reached 14 ± 8% (Group 1), 28 ± 12% (Group 2), and 26 ± 16 after 12 months of surgery (Group 3) (significant, p < 0.01 compared with preoperative scores). Patient satisfaction was higher in Group 1, with 7.5, 20, and 25% of patients displeased (in Groups 1, 2, and 3, respectively; p < 0.01). CONCLUSION: Bilateral Laminotomy is certified acceptable and harmless in decompression of lumbar stenosis, causing a highly significant decrease of symptoms and disability.

The Relation Between Sacral Angle and Vertical Angle of Sacral Curvature and Lumbar Disc Degeneration: A Case-Control Study.

The purpose of this study is to determine the reliability and validity of a goniometric measurement of the vertical angle of the sacrum and sacral angle (SA), and their relationships to lumbar degeneration.A herniated lumbar disc is one of the most frequent medical issues. Investigators in a number of studies have reported associated risk factors for prevalent disc degeneration. Atypical lumbosacral angles and curvature are thought to contribute to the degradation of the spine by many researchers. This study analyzed 360 patients referred to our clinic from 2013 to 2015 due to low back pain. A cross-sectional case-control study was designed in order to compare the sagittal alignment of the lumbosacral area in 3 groups of patients suffering from LBP. A total 120 patients were in a control group with a normal lumbar magnetic resonance imaging (MRI), 120 patients had lumbar disk herniation (LDH), and 120 patients had spinal stenosis. From the sagittal plan of lumbar MRI, SA and vertical angle of sacral curvature (VASC) were determined and then analyzed.The means of VASC in these groups were: 38.98 (SD: 6.36 ±â€Š0.58), 40.89 (SD: 7.69 ±â€Š0.69), and 40.54 (SD: 7.13 ±â€Š0.92), respectively (P = 0.089). Moreover, studies of SA in 3 groups showed that the means of SA were: 39.30 (SD: 6.69 ±â€Š0.63), 40.52 (SD: 7.47 ±â€Š0.65), and 35.63 (SD: 6.07 ±â€Š0.79), respectively. Relation between SA and spinal stenosis was just statistically significant (P ≤ 0.05).One significant limitation of our study is the lack of standing MRI for increased accuracy of measurement. However, we were reluctant to give patients needless exposure to radiation from conventional X-ray, and instead used MRI scans. We did not find any significant correlation between the VASC and LDH in lumbar MRI. Also, SA is not an independent risk factor for LDH in men and women. We suggested that there are several biomechanical factors involved in LDH.