Technical challenges and surgical outcomes of percutaneous transforaminal endoscopic discectomy in patients with upper lumbar disc herniation: a prospective clinical study.

INTRODUCTION: Upper lumbar disc herniation (ULDH) constitutes a considerably complex and rare anatomic entity. As such, there are only a handful of studies investigating the application of percutaneous transforaminal endoscopic discectomy (PTED) in the management of this cause of low back pain. RESEARCH QUESTION: To elucidate the safety and effectiveness of PTED in patients with ULDH. MATERIALS AND METHODS: Twenty-six (26) individuals with diagnosed ULDH (L1-L2, L2-L3) according to clinical and radiologic criteria were prospectively evaluated in a 2-year follow-up period. All patients were assessed preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively. Clinical evaluation was conducted with visual analogue scale for lower limb (VAS-LP) and low back (VAS-BP) pain in conjunction with Short-Form 36 (SF-36) Medical Health Survey Questionnaire. Potential complications were recorded in each follow-up interval. RESULTS: One patient (3.8%) featured temporary postoperative dysesthesia that was completely resolved at 6 weeks. No other major perioperative complications were observed. Values of all studied indices were found to be statistically significantly ameliorated at the end of follow-up. Improvement was depicted to be quantitatively maximal at 6 weeks postoperatively. CONCLUSIONS: PTED constitutes a safe and effective technique for surgical management of ULDH that merits further assessment in current clinical practice in the framework of multicenter randomized controlled trials. LEVEL OF EVIDENCE: Level III.

Factors governing the assignment of visual consequence to the corresponding action.

To achieve fast feedback control of voluntary movements, the visual consequences of our motor commands need to be quickly identified and analyzed by the motor control processes in the brain. These processes work remarkably well even in complex visual environments and in the face of discrepancies between physical actuator and visually perceived effect, e.g. when moving a computer mouse on a visually crowded screen. Here, we use an ambiguous situation in which a single cursor could be controlled by either the left or the right hand to determine the visual and cognitive factors that determine the assignment of a visual stimulus to the corresponding motor command. Our results demonstrate that the visuomotor system is exquisitely sensitive to the spatio-temporal correlation between cursor and hands, learning the appropriate mapping implicitly within several minutes. In contrast, spatial proximity between end effector and visual consequence has an immediate but only transient effect on the assignment process. Finally, an explicit instruction about which hand controls the cursor only has a minor influence when the instruction is presented first. These findings provide insight into the relative importance of the factors that determine the binding of visual information to the corresponding motor structures to enable fast feedback control.NEW & NOTEWORTHY For efficient visuomotor online control, the brain needs to solve the correspondence problem between an ongoing movement and its visual consequences. Here, we challenge the visuomotor system with an ambiguous reaching task, in which the visual feedback was controlled by either hand or by a combination of both. Our findings characterize the properties of a flexible assignment process that quickly takes into account the spatio-temporal properties of movements and the visual scene.

Pharmacotherapy in SAH: Clinical Trial Lessons.

Subarachnoid Haemorrhage (SAH) is a medical emergency with potentially devastating outcomes. It is without doubt that over the past decades, there has been a radical change in the approach towards patients with SAH, both in terms of the surgical as well as of the pharmacological treatments offered. The present review aims to outline the principal data regarding the best practice in the pharmacotherapy of SAH, as well as to sum up the emerging evidence from the latest clinical trials. To date, nimodipine is the only evidence-based treatment of vasospasm. However, extensive research is currently underway to identify novel substances with magnesium sulphate, cilostazol, clazosentan and fasudil, demonstrating promising results. Antifibrinolytic therapy could help reduce mortality, and anticoagulants, in spite of their associated hazards, could actually reduce the incidence of delayed cerebral ischemia. The effectiveness of triple-H therapy has been challenged, yet evidence on the optimal regimen is still pending. Statins may benefit some patients by reducing the incidence of vasospasm and delayed ischemic events. As several clinical trials are underway, it is expected that in the years to come, more therapeutic options will be added to the attending physician's armamentarium.

Platelet-Rich Plasma for Degenerative Spine Disease: A Brief Overview.

Background: The emergence of novel minimally invasive techniques has opened new horizons for the management of degenerative diseases of the spine. Platelet-rich plasma (PRP) has gained considerable attention through its applications in various pathologies. In the present review, an overview of the science behind the application of PRP is provided, ultimately focusing on the clinical trials that may render it a useful tool in the hands of spine surgeons in the future. Methods: A review of the available literature is conducted, focusing on its existing clinical and experimental applications with a particular interest in the degenerative diseases of the spine. Results: In terms of the degenerative diseases of the spine, initial studies suggest that it is a safe and effective method that could change the practice of spinal cord medicine in the years to come. The available studies demonstrate that besides being minimally invasive, causing less discomfort than that of surgery, it provides longer lasting improvement than standard pharmaceutical interventions. Conclusions: PRP is an emerging and promising biodrug for the treatment of patients with spinal pain. PRP has demonstrated some promising qualities; however, careful consideration of its indications of use and strict protocols of application need to be established before widespread clinical induction.

Assessment of Health-Related Quality of Life in Patients With Traumatic Fractures Following Thoracolumbar Fusion: Short-Term Results.

INTRODUCTION: Thoracolumbar vertebral fractures (TVFs) constitute frequent injuries with specific therapeutic challenges and remarkable implications for affected individuals. The aim of this study is to investigate the alteration of overall health-related quality of life (HRQoL) in patients with traumatic TVFs undergoing thoracolumbar fusion surgery. MATERIALS AND METHODS: A total of 72 patients with single-level traumatic thoracic or lumbar vertebral fractures (AO type A3 or A4) were enrolled in this prospective cohort study. All patients were subjected to thoracolumbar spinal fusion surgery with or without posterior decompression, being followed up for a two-year period. Clinical assessment was conducted via the implementation of the Visual Analog Scale (VAS) and 36-item Short-Form Survey Questionnaire (SF-36) for the evaluation of pain and HRQoL, respectively. Patient assessment was performed in determined postoperative follow-up intervals. RESULTS: Recorded values of assessed outcome measures demonstrated a statistically significant improvement during the entire two-year follow-up period. This improvement was more pronounced throughout the first three to six postoperative months, subsequently demonstrating a plateau. No statistically significant correlation between age, SF-36, and VAS was found, with the exception of the bodily pain index, the improvement of which was observed to be positively correlated with age. Transient causalgia and cerebrospinal fluid leak were recorded in 5% of evaluated individuals. CONCLUSIONS: Thoracolumbar fusion constitutes a safe and efficient option for the surgical management of single-level traumatic vertebral fractures. Nevertheless, rehabilitation is a lasting procedure that may last over six months until final amelioration is observed. Clinical improvement may be more pronounced in older patients, potentially due to different expectations.

Posterolateral Instrumented Fusion in Elderly Patients With a Single Osteoporotic Vertebral Fracture: Evaluation of Health-Related Quality of Life.

Introduction Treatment of osteoporotic vertebral fractures (OVFs) is a factor that affects the quality of life and should be considered during management. In patients with a single OVF and neurologic deficit, surgical procedures aiming at neural decompression with instrumented fusion should be considered in elderly individuals. Posterolateral instrumented fusion (PLF) constitutes a largely performed fusion surgery for patients featuring indications for fusion surgery. The aim of this study was to determine the safety, effectiveness, and impact on health-related quality of life (HRQoL) of PLF surgery in elderly patients diagnosed with a single OVF. Methods This study was conducted at Interbalkan European Medical Center, Thessaloniki, Greece. Eighty (80) consecutive individuals with OVFs were subjected to PLF and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at one, three, six, and 12 months and two years. The assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. Results No major perioperative complications were observed. All parameters of SF-36 presented significant improvement over the entire follow-up period with VAS scores reaching a plateau at six months. Depicted improvement of these parameters proves the beneficial role of PLF in elderly patients who suffered from a single OVF with or without referable neurological deficit. Conclusion OVFs have a significant impact on the quality of life of elderly patients, and surgical treatment with PLF with or without decompression can lead to functional recovery, pain relief, and HRQoL amelioration. Our results demonstrated that the outcomes of PLF in the surgical treatment of these patients are remarkably favorable, demonstrating the safety and efficacy of the technique.

Complications From Subdural Drains in Burr Hole Drainage of Chronic and Subacute Subdural Haematomas: A Single-Centre Experience.

Introduction The use of drains following the burr-hole evacuation of chronic (CSDH) and subacute subdural haematomas (SASDH) is a well-established practice offering a significant reduction in recurrence rates and improvement of survival. The purpose of this work is to investigate the complication rate of subdural drains following the burr-hole evacuation of CSDH and SASDH. Methods A retrospective review of the clinical records of all patients managed surgically for CSDH or SASDH was conducted. Patients over 18 years, that met the criteria for surgical evacuation, were included in this study. Patients admitted for CSDH or SASDH but managed either conservatively or with craniotomy were excluded from further analysis. Results A total of 97 cases, with a mean age at the time of diagnosis of 78.25 years were identified in which 122 drains were used. Three complications, two acute subdural haematomas, and one case of drain-associated seizures were identified, yielding an overall complication rate of 3%. Conclusion The use of intradural drains is associated with a small, yet not negligible, possibility of serious complications.

Use of Focused Ultrasound (Sonication) for the Diagnosis of Infections in Neurosurgical Operations: A Systematic Review and Meta-Analysis.

OBJECTIVE: Postoperative infections are one of the most devastating complications in neurosurgery, and their results are even more disastrous when biocompatible implants are involved. As the application of these implants increases, the need for a sensitive and efficient method to detect pathogens becomes imperative. The application of sonication appears to be a viable option. METHODS: A systematic review and meta-analysis of the available literature was conducted, looking for studies reporting findings from the application of sonication following neurosurgical operations. To be included, an article needed to contain information about the material that was subjected to sonication, indication of other culture methods that were applied, and information about the isolated pathogens. RESULTS: Six studies comprising 437 patients were included in the meta-analysis. Potential superiority of sonication over conventional microbiologic methods was found in the detection of gram-positive bacteria and in particular of coagulase-negative Staphylococcus species. A sensitivity of 0.87 and a specificity of 0.57 were calculated. CONCLUSIONS: Regardless of the potential of sonication, it is still not a panacea. Additional studies are expected to provide significant insight into the indications and limitations of this technique.

Transcorporeal Tunnel Approach for Cervical Radiculopathy and Myelopathy: A Systematic Review and Meta-Analysis.

OBJECTIVE: The transcorporeal tunnel approach is a relatively new alternative of anterior cervical decompression and fusion for the treatment of cervical radiculopathy and myelopathy, with its main presumed advantage being the preservation of the intervertebral space. The aim of the present article is to present the outcomes of the systematic review and meta-analysis regarding the short-term outcomes of this surgical technique. METHODS: A systematic review and a meta-analysis using the random-effects method of the available studies were performed to assess the safety and efficiency of the transcorporeal tunnel approach for cervical radiculopathy and myelopathy. RESULTS: In total, 15 eligible studies were identified, with a cumulative number of 254 patients. Pooled data yielded a complication rate of 0.053 and a failure rate of the technique of 0.081; a patient-reported favorable outcome of 0.94 was documented. The available data did not allow for a definite conclusion on the effects of the technique on the intervertebral space height. CONCLUSIONS: Although technically challenging, like all minimally invasive methods, the transcorporeal tunnel approach seems to be a safe and efficient option for the treatment of cervical radiculopathy and myelopathy, presenting comparable outcome profiles to alternative open or less invasive techniques.

Spinal angiolipoma: Presentation of two cases and review of the literature for the years 2012-2017.

INTRODUCTION AND OBJECTIVES: Angiolipomas of the spinal canal are a rare condition of unknown origin. They are considered histologically benign; however, some have the potential to infiltrate adjacent structures. The aim of this systematic review was to suggest a potential mechanism for the pathogenesis of spinal angiolipomas, along with a useful approach for their preoperative management. MATERIALS AND METHODS: A literature review of cases of spinal angiolipoma was performed. In addition, two of the cases encountered in our practice are presented. The first case refers to a 35-year-old male patient with a history of spinal fusion because of a T9 fracture, while the second concerns a 46-year-old male patient with an epidural mass extending outside the spinal canal, who underwent fine needle biopsy and embolisation of its feeding vessel. RESULTS: From the review of the literature performed, we were unable to identify any correlation between the infiltrative potential and the patients' demographic and tumour characteristics. CONCLUSIONS: Angiolipomas are considered to be sporadic, yet theories concerning their pathogenesis include reaction to harmful stimuli and congenital malformation of the adipose tissue. Fine needle biopsy may be mistakenly considered non-diagnostic, due to the presence of well-differentiated adipocytes.

En Plaque Meningioma Presenting as a Cutaneous Nodule.

Meningiomas are the most common central nervous system tumor and can be found anywhere in the neuraxis. In rare cases, they may extend beyond the cranial vault, while cases without evidence of intracranial mass existence have also been reported. Here, we report the case of a 64-year-old male patient with a history of craniectomy for parasagittal meningioma, who presented at the emergency department with onset of focal seizures. The patient underwent nonenhanced brain computed tomography scan which was indicative of recurrence of the mass. The patient was scheduled for craniotomy and excision of the mass. He also expressed his desire to have a scalp nodule removed concomitantly. Thickening of the meninges underlying the nodule was observed but without indication of a space-occupying lesion. Both histological examinations were suggestive of Grade II, atypical meningiomas. A case of a subcutaneous meningioma in a patient with a history of surgically excised parasagittal meningioma is presented. Radiologic evidence of dural proliferation underlying the mass was suggestive of an en plaque meningioma secondary to iatrogenic dissemination of tumor cells.

Cavernoma of the cauda equina.

BACKGROUND: Cavernomas are benign malformations of the vasculature. In the central nervous system, they are mostly located supratentorially. However, in adults, cavernomas also comprise about 3% of all subdural spinal cord tumors. Notably, cavernomas of the cauda equina are extremely rare, with only 23 cases reported in the literature. Here, we report the 24th case involving a 77-year-old male. CASE DESCRIPTION: A 77-year-old male presented with low back pain for 3 years duration. His history included prostate cancer, skin melanoma, and a sick sinus syndrome requiring a pacemaker. An enhanced computed tomography of the lumbar spine showed an inhomogeneously enhanced, intramedullary mass, located at the L3 level. The patient underwent an L3 hemilaminectomy with gross total excision of the lesion. Macroscopically, the tumor was mulberry-shaped and well demarcated. However, it was strongly adherent to a nerve root of the cauda equina which required resection. The histologic examination was consistent with a cavernoma. The patient subsequently fully recovered without a focal neurological deficit. CONCLUSIONS: Cavernomas of the cauda equina are extramedullary, arise on the inner aspect of the dura, and may be tightly adhered to the nerve roots. To attain gross total excision, the involved nerve may have to be sacrificed; in some cases, this may result in a permanent neurological deficit. Of interest, half of the cauda equina lesions were previously found in patients who had prior radiotherapy; this was not the case in this patient.

Impact of multidisciplinary tumor boards on patients with rectal cancer.

Οncological outcomes in patients with primary rectal cancer have markedly improved over the last few years, mainly due to the widespread application of the total mesorectal excision technique. This improvement should also be largely attributed to multiple specialties, other than colorectal surgery, such as radiology, oncology and pathology. Therefore, a multimodal approach is key to efficient and appropriate rectal cancer management. Multidisciplinary tumor (MDT) boards have become an important asset for the management and treatment of patients with rectal cancer, and a number of studies published to date suggest the beneficial effect of the multidisciplinary approach on the management of such patients. The available evidence demonstrates a modification of the treatment plan, attributed to the MDT implementation, in a non-negligible proportion of these patients. However, more studies are required in order to assess the exact impact of MDT boards on disease-free and overall survival of patients with primary rectal cancer.

Iron in neurodegenerative disorders: being in the wrong place at the wrong time?

Brain iron deposits have been reported consistently in imaging and histologic examinations of patients with neurodegenerative disorders. While the origins of this finding have not been clarified yet, it is speculated that impaired iron homeostasis or deficient transport mechanisms result in the accumulation of this highly toxic metal ultimately leading to formation of reactive oxygen species and cell death. On the other hand, there are also those who support that iron is just an incidental finding, a by product of neuronal loss. A literature review has been performed in order to present the key findings in support of the iron hypothesis of neurodegeneration, as well as to identify conditions causing or resulting from iron overload and compare and contrast their features with the most prominent neurodegenerative disorders. There is an abundance of experimental and observational findings in support of the hypothesis in question; however, as neurodegeneration is a rare incident of commonly encountered iron-associated disorders of the nervous system, and this metal is found in non-neurodegenerative disorders as well, it is possible that iron is the result or even an incidental finding in neurodegeneration. Understanding the underlying processes of iron metabolism in the brain and particularly its release during cell damage is expected to provide a deeper understanding of the origins of neurodegeneration in the years to come.

Concurrent intrathyroidal thymus and parathyroid in a patient with papillary thyroid carcinoma: a challenging diagnosis.

During embryogenesis, the thymus and inferior parathyroid glands develop from the third pharyngeal pouch and migrate to their definite position. During this process, several anatomic variations may arise, with the thyroid being one of the most common sites of ectopic implantation for both organs. Here, we report the case of a young female patient, who underwent total thyroidectomy for papillary carcinoma of the thyroid. The patient's history was remarkable for disorders of the genitourinary system. Histologic examination revealed the presence of well-differentiated intrathyroidal thymic tissue, containing an inferior parathyroid gland. While each individual entity has been well documented, this is one of the few reports in which concurrent presentation is reported. Given the fact that both the thymus and the inferior parathyroid are derivatives of the same embryonic structure (i.e. the third pharyngeal pouch), it is speculated that the present condition resulted from a failure in separation and migration during organogenesis. LEARNING POINTS: Intrathyroidal thymus and parathyroid are commonly found individually, but rarely concurrently.It is a benign and asymptomatic condition.Differential diagnosis during routine workup with imaging modalities can be challenging.

Shared and distinct oculomotor function deficits in schizophrenia and obsessive compulsive disorder.

Detailed analysis of oculomotor function phenotypes in antisaccade, smooth eye pursuit, and active fixation tasks was performed in a sample of 44 patients with schizophrenia, 34 patients with obsessive compulsive disorder (OCD), and 45 matched healthy controls. A common pattern of performance deficits in both schizophrenia and OCD emerged including higher antisaccade error rate, increased latency for corrective antisaccades, as well as higher rates of unwanted saccades in smooth eye pursuit compared to healthy controls. This common pattern could be related to the dysfunction of a network of cognitive control that is present in both disorders, including the dorsolateral prefrontal cortex, the posterior parietal cortex, and the anterior cingulate cortex. In contrast, only patients with schizophrenia showed a specific increase for correct antisaccade mean latency and the intrasubject variability of latency for error prosaccades as well as a decrease in the gain for smooth eye pursuit, suggesting a specific deficit in saccadic motor control and the frontal eye field in schizophrenia that is not present in OCD. A specific deficit in fixation stability (increased frequency of unwanted saccades during active fixation) was observed only for OCD patients pointing to a deficit in the frontostriatal network controlling fixation. This deficit was pronounced for OCD patients receiving additional antipsychotic medication. In conclusion, oculomotor function showed shared and distinct patterns of deviance for schizophrenia and OCD pointing toward shared and specific neurobiological substrates for these psychiatric disorders.

A systematic investigation of sclerosing mesenteritis through CT and MRI.

Sclerosing mesenteritis is primarily diagnosed through histologic and radiologic evaluation; however, only a few works provide a systematic description using MRI. This work presents the case of a 68-year-old male, who was admitted for a routine cholecystectomy. Intraoperativly, a large mass was identified dislocating the abdominal viscera. The microscopic examination revealed vascular congestion of the omentum. The contrast-enhanced CT and MRI scans revealed the presence of a heterogenous, lipomatous mass with lesions visible only in T2W and contrast-enhanced T1W MRI. Based on these findings, the diagnosis of sclerosing mesenteritis was made. According to the available literature, depending on the stage of sclerosing mesenteritis, different radiologic features are encountered; however, it is possible that features from more than one form of the condition coexist in the same lesion. We therefore suggest that a combination of MRI sequences should be acquired for a more accurate staging of the condition.