Safety and efficiency of Wharton's Jelly-derived mesenchymal stem cell administration in patients with traumatic brain injury: First results of a phase I study.

BACKGROUND: Traumatic brain injury (TBI) is characterized by a disruption in the normal function of the brain due to an injury following a trauma, which can potentially cause severe physical, cognitive, and emotional impairment. Stem cell transplantation has evolved as a novel treatment modality in the management of TBI, as it has the potential to arrest the degeneration and promote regeneration of new cells in the brain. Wharton's Jelly-derived mesenchymal stem cells (WJ-MSCs) have recently shown beneficial effects in the functional recovery of neurological deficits. AIM: To evaluate the safety and efficiency of MSC therapy in TBI. METHODS: We present 6 patients, 4 male and 2 female aged between 21 and 27 years who suffered a TBI. These 6 patients underwent 6 doses of intrathecal, intramuscular (i.m.) and intravenous transplantation of WJ-MSCs at a target dose of 1 × 106/kg for each application route. Spasticity was assessed using the Modified Ashworth scale (MAS), motor function according to the Medical Research Council Muscle Strength Scale, quality of life was assessed by the Functional Independence Measure (FIM) scale and Karnofsky Performance Status scale. RESULTS: Our patients showed only early, transient complications, such as subfebrile fever, mild headache, and muscle pain due to i.m. injection, which resolved within 24 h. During the one year follow-up, no other safety issues or adverse events were reported. These 6 patients showed improvements in their cognitive abilities, muscle spasticity, muscle strength, performance scores and fine motor skills when compared before and after the intervention. MAS values, which we used to assess spasticity, were observed to statistically significantly decrease for both left and right sides (P < 0.001). The FIM scale includes both motor scores (P < 0.05) and cognitive scores (P < 0.001) and showed a significant increase in pretest posttest analyses. The difference observed in the participants' Karnofsky Performance Scale values pre and post the intervention was statistically significant (P < 0.001). CONCLUSION: This study showed that cell transplantation has a safe, effective and promising future in the management of TBI.

A Morphometric Study of Cadavers for the Anterior Approach to the Lower Lumbar Spine.

AIM: To explore the relationship between the retroperitoneal vasculature and anterior surface of the lower spine, and to establish values for aiding in prediction of the pertinence of anterior approach at the L4-L5 and L5-S1 intervertebral discs. MATERIAL AND METHODS: The study included 13 fresh human cadavers. After exploration of the abdominal cavity and removal of the visceral organs, the vasculature, and anterior spinal surface were revealed beneath the lower extension of the perirenal fascia. Morphometric measurements of the great vessels and the intervertebral discs were obtained. All measurements were analyzed and presented as mean and standard deviation. Differences in the values between sexes were assessed. RESULTS: The anterior height of the L4-L5 and L5-S1 intervertebral disc was 6.8 ± 0.81 mm and 6.7 ± 0.99 mm, respectively. The widths of the aorta, inferior vena cava, right and left common iliac arteries, and right, and left common iliac veins were 16.4 ± 3.58, 20.6 ± 3.36, 11.5 ± 2.32, 11.5 ± 2.43, 14.7 ± 3.13, and 15.5 ± 3.27 mm, respectively. The mean aortic bifurcation angle was 45.5°. The aortic bifurcation was located above the lower endplate of the L4 vertebrae in 53.8% of the cadavers. The area of the interarterial and interiliac trigones was 14.6 ± 5.33 cm < sup > 2 < /sup > and 7.1 ± 4.35 cm2, respectively. No statistically significant differences were noted between the sexes. CONCLUSION: An elaborate radiological examination of the vasculature should be performed prior to surgery to avoid unwanted vascular complications during the anterior approach. Knowing the area of the interarterial and interiliac triangles and the aortic bifurcation location could be aid in assessing the safe working zone.

Allogeneic mesenchymal stem cells may be a viable treatment modality in cerebral palsy.

BACKGROUND: Cerebral palsy (CP) describes a group of disorders affecting movement, balance, and posture. Disturbances in motor functions constitute the main body of CP symptoms. These symptoms surface in early childhood and patients are affected for the rest of their lives. Currently, treatment involves various pharmacotherapies for different types of CP, including antiepileptics for epilepsy and Botox A for focal spasticity. However, none of these methods can provide full symptom relief. This has prompted researchers to look for new treatment modalities, one of which is mesenchymal stem cell therapy (MSCT). Despite being a promising tool and offering a wide array of possibilities, mesenchymal stem cells (MSCs) still need to be investigated for their efficacy and safety. AIM: To analyze the efficacy and safety of MSCT in CP patients. METHODS: Our sample consists of four CP patients who cannot stand or walk without external support. All of these cases received allogeneic MSCT six times as 1 × 106/kg intrathecally, intravenously, and intramuscularly using umbilical cord-derived MSCs (UC-MSC). We monitored and assessed the patients pre- and post-treatment using the Wee Functional Independence Measure (WeeFIM), Gross Motor Function Classification System (GMFCS), and Manual Ability Classification Scale (MACS) instruments. We utilized the Modified Ashworth Scale (MAS) to measure spasticity. RESULTS: We found significant improvements in MAS scores after the intervention on both sides. Two months: Right χ2 = 4000, P = 0.046, left χ2 = 4000, P = 0.046; four months: Right χ2 = 4000, P = 0.046, left χ2 = 4000, P = 0.046; 12 months: Right χ2 = 4000, P = 0.046, left χ2 = 4000, P = 0.046. However, there was no significant difference in motor functions based on WeeFIM results (P > 0.05). GMFCS and MACS scores differed significantly at 12 months after the intervention (P = 0.046, P = 0.046). Finally, there was no significant change in cognitive functions (P > 0.05). CONCLUSION: In light of our findings, we believe that UC-MSC therapy has a positive effect on spasticity, and it partially improves motor functions.

Effects of exosomes from mesenchymal stem cells on functional recovery of a patient with total radial nerve injury: A pilot study.

BACKGROUND: Peripheral nerve injury can result in significant clinical complications that have uncertain prognoses. Currently, there is a lack of effective pharmacological interventions for nerve damage, despite the existence of several small compounds, peptides, hormones, and growth factors that have been suggested as potential enhancers of neuron regeneration. Despite the objective of achieving full functional restoration by surgical intervention, the persistent challenge of inadequate functional recovery remains a significant concern in the context of peripheral nerve injuries. AIM: To examine the impact of exosomes on the process of functional recovery following a complete radial nerve damage. METHODS: A male individual, aged 24, who is right-hand dominant and an immigrant, arrived with an injury caused by a knife assault. The cut is located on the left arm, specifically below the elbow. The neurological examination and electrodiagnostic testing reveal evidence of left radial nerve damage. The sural autograft was utilized for repair, followed by the application of 1 mL of mesenchymal stem cell-derived exosome, comprising 5 billion microvesicles. This exosome was split into four equal volumes of 0.25 mL each and delivered microsurgically to both the proximal and distal stumps using the subepineural pathway. The patient was subjected to a period of 180 d during which they had neurological examination and electrodiagnostic testing. RESULTS: The duration of the patient's follow-up period was 180 d. An increasing Tinel's sign and sensory-motor recovery were detected even at the 10th wk following nerve grafting. Upon the conclusion of the 6-mo post-treatment period, an evaluation was conducted to measure the extent of improvement in motor and sensory functions of the nerve. This assessment was based on the British Medical Research Council scale and the Mackinnon-Dellon scale. The results indicated that the level of improvement in motor function was classified as M5, denoting an excellent outcome. Additionally, the level of improvement in sensory function was classified as S3+, indicating a good outcome. It is noteworthy that these assessments were conducted in the absence of physical therapy. At the 10th wk post-injury, despite the persistence of substantial axonal damage, the nerve exhibited indications of nerve re-innervation as evidenced by control electromyography (EMG). In contrast to the preceding. EMG analysis revealed a significant electrophysiological enhancement in the EMG conducted at the 6th-mo follow-up, indicating ongoing regeneration. CONCLUSION: Enhanced comprehension of the neurobiological ramifications associated with peripheral nerve damage, as well as the experimental and therapy approaches delineated in this investigation, holds the potential to catalyze future clinical progress.

Percutaneous Pain Procedures in Patients Who Underwent Lumbar Disc Herniation Surgery: Is It an Important Tool in the Management of Post-Surgical Ongoing Pain?

AIM: To evaluate the efficacy of percutaneous pain interventions in patients who previously underwent lumbar disc herniation surgery. MATERIAL AND METHODS: We retrospectively analyzed 48 patients with persistent / recurring complaints who underwent lumbar disc surgery (LDS) and were treated with percutaneous interventions. They were grouped into recurrent disc herniations (RDHs) and other discovertebral pathologies (ODVP). Moreover, patients were evaluated as those who received transforaminal injection (TFI) with facet blockage (FB) and who received both caudal injection (CI) and TFI in addition to FB. Patients were evaluated using Oswestry Disability Index (ODI) and visual analog scale (VAS). RESULTS: Between the recurrent and ODVP groups, preoperative, at 1-hour postoperative, and at 6-month postoperative ODI (p=0.867, p=0.055, p=0.892) and VAS (p=0.902, p=0.136, p=0.462) scores did not show a statistically significant difference, respectively. Additionally, in the comparison of patients who underwent FB+TFI+CI and only FB+TFI, there was no statistically significant correlation between preoperative and 6-month postoperative ODI (p = 0.284) and VAS (p=0.248) scores in both recurrent and ODVP groups, respectively. The success rates at the 3rd and 6th months of patients with RDH and ODVP were 47.61% (10/21) and 42.85% (9/21) and 70.37% (19/27) and 63.96% (17/27), respectively. CONCLUSION: There was no statistically significant difference in ODI and VAS scores between recurrent and ODVP groups. The clinical success rate was numerically better in the ODVP group. Thus, we suggest that co-administration of TFI and CI did not significantly contribute to our clinical outcome.

The Effects of Using Hearing Aids and Hearing Assistive Technologies on Programmable Ventriculoperitoneal Shunt.

BACKGROUND: To investigate interaction between behind-the-ear (BTE) hearing aids, hearing assistive technologies, and programmable shunt valve to understand how use of BTE hearing aids in patients who underwent ventriculoperitoneal shunt (VPS) surgery affects the settings of a programmable shunt valve. METHODS: In this study, we investigated the magnetic field (MF) generation of 3 BTE hearing aids made by different companies, 1 frequency modulated system using telecoil technology, and 1 wireless microphone technology and their interactions with 2 programmable shunt valves. All measurements were made in a silent booth using 2 different models. The influence of MF strength in the distance modeling was investigated based on the distance from source auditory prostheses. The measurements were recorded using a Gauss meter. In the anatomical modeling, the change in the settings and interaction of the valve in a bust mannequin were investigated. RESULTS: No MF created by BTE hearing aids was detected in the distance modeling. The highest value measured was 32.67 µT (<90 dB noise) when BTE hearing aids and frequency modulated systems were used, and this value decreased as the distance increased. No MF generation was observed at measurements done for distances >10 mm. In the anatomical modeling, the settings of both programmable valves did not change under all acoustic conditions. CONCLUSIONS: This is the first study to our knowledge examining the MF created by hearing aids and hearing assistive technologies and its impact on programmable valves and variations in their settings. Our findings showed that it is safe to use BTE hearing aids, frequency modulated systems, and wireless microphone technologies in patients with a programmable VPS.

Metric Evaluation of Reliability and Transparency of the Videos About Carpal Tunnel Syndrome Surgery in the Online Platforms: Assessment of YouTube Videos' Content.

OBJECTIVE: To evaluate the quality and reliability of carpal tunnel syndrome surgery videos on YouTube. METHODS: A keyword set of "carpal tunnel syndrome surgery" was searched on YouTube. The DISCERN scoring system, Journal of the American Medical Association (JAMA) scoring system, and Health on the Net (HON) ranking systems were used to evaluate the quality and reliability of the first 50 videos appeared in the search results. The characteristics of each video, such as the number of likes, dislikes and views, upload days, video length, and the uploader, were collected retrospectively. The relationships between the video quality and these factors were investigated statistically. RESULTS: All of the featured videos sorted were found to be of poor content (mean DISCERN score [n = 1.71 of 5], mean JAMA score [n = 1.76 of 4], mean HON score [n = 5.65 of 16]). Yet, DISCERN scores of the videos uploaded by medical centers were higher than that of the others (p = 0.022). No relationship was detected between the other variables and video quality. CONCLUSION: Healthcare professionals and organizations should be more cautious when recording and uploading a video to the online platforms. As those videos could reach a wide audience, their content should provide more information about possible complications of a treatment and other treatment modalities.

Feasibility of allogeneic mesenchymal stem cells in pediatric hypoxic-ischemic encephalopathy: Phase I study.

BACKGROUND: Hypoxic-ischemic encephalopathy (HIE) is one of the leading causes of death and long-term neurological impairment in the pediatric population. Despite a limited number of treatments to cure HIE, stem cell therapies appear to be a potential treatment option for brain injury resulting from HIE. AIM: To investigate the efficacy and safety of stem cell-based therapies in pediatric patients with HIE. METHODS: The study inclusion criteria were determined as the presence of substantial deficit and disability caused by HIE. Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) were intrathecally (IT), intramuscularly (IM), and intravenously administered to participants at a dose of 1 × 106/kg for each administration route twice monthly for 2 mo. In different follow-up durations, the effect of WJ-MSCs administration on HIE, the quality of life, prognosis of patients, and side effects were investigated, and patients were evaluated for neurological, cognitive functions, and spasticity using the Wee Functional Independence Measure (Wee FIM) Scale and Modified Ashworth (MA) Scale. RESULTS: For all participants (n = 6), the mean duration of exposure to hypoxia was 39.17 + 18.82 min, the mean time interval after HIE was 21.83 ± 26.60 mo, the mean baseline Wee FIM scale score was 13.5 ± 0.55, and the mean baseline MA scale score was 35 ± 9.08. Three patients developed only early complications such as low-grade fever, mild headache associated with IT injection, and muscle pain associated with IM injection, all of which were transient and disappeared within 24 h. The treatment was evaluated to be safe and effective as demonstrated by magnetic resonance imaging examinations, electroencephalographies, laboratory tests, and neurological and functional scores of patients. Patients exhibited significant improvements in all neurological functions through a 12-mo follow-up. The mean Wee FIM scale score of participants increased from 13.5 ± 0.55 to 15.17 ± 1.6 points (mean ± SD) at 1 mo (z = - 1.826, P = 0.068) and to 23.5 ± 3.39 points at 12 mo (z = -2.207, P = 0.027) post-treatment. The percentage of patients who achieved an excellent functional improvement (Wee FIM scale total score = 126) increased from 10.71% (at baseline) to 12.03% at 1 mo and to 18.65% at 12 mo post-treatment. CONCLUSION: Both the triple-route and multiple WJ-MSC implantations were safe and effective in pediatric patients with HIE with significant neurological and functional improvements. The results of this study support conducting further randomized, placebo-controlled studies on this treatment in the pediatric population.

Phase I study on the safety and preliminary efficacy of allogeneic mesenchymal stem cells in hypoxic-ischemic encephalopathy.

BACKGROUND: Hypoxic-ischemic encephalopathy (HIE) is a leading cause of morbidity and mortality in the adult as well as in the neonate, with limited options for treatment and significant dysfunctionality. AIM: To investigate the safety and preliminary efficacy of allogeneic mesenchymal stem cells (MSCs) in HIE patients. METHODS: Patients who had HIE for at least 6 mo along with significant dysfunction and disability were included. All patients were given Wharton's jelly-derived MSCs at 1 × 106/kg intrathecally, intravenously, and intramuscularly twice a month for two months. The therapeutic effects and prognostic implications of MSCs were evaluated by multiple follow-ups. Functional independence measure (FIM), modified Ashworth, and Karnofsky scales were used to assess any side effects, neurological and cognitive functions, and overall outcomes. RESULTS: The 8 subjects included in the study had a mean age of 33.25 ± 10.18 years. Mean HIE exposure and mean post-HIE durations were 45.63 ± 10.18 and 19.67 ± 29.04 mo, respectively. Mean FIM score was 18.38 ± 1.06, mean modified Ashworth score was 43.5 ± 4.63, and mean Karnofsky score was 20. For the first 24 h, 5 of the patients experienced a subfebrile state, accompanied by mild headaches due to intrathecally administration and muscle pain because of intramuscularly administration. Neurological and functional examinations, laboratory tests, electroencephalography, and magnetic resonance imaging were performed to assess safety of treatment. Mean FIM score increased by 20.88 ± 3.31 in the first month (P = 0.027) and by 31.38 ± 14.69 in 12 mo (P = 0.012). The rate of patients with an FIM score of 126 increased from 14.58% to 16.57% in the first month and 24.90% in 12 mo. CONCLUSION: Multiple triple-route Wharton's jelly-derived MSC administrations were found to be safe for HIE patients, indicating neurological and functional improvement. Based on the findings obtained here, further randomized and placebo research could be performed.

Functional Recovery After Wharton's Jelly-Derived Mesenchymal Stem Cell Administration in a Patient with Traumatic Brain Injury: A Pilot Study.

AIM: To introduce a traumatic brain injury (TBI) patient who underwent stem cell transplantation (SCT) in order to minimize the remaining injury deficiencies. MATERIAL AND METHODS: This study included a 29 years old male who had TBI resulting from a vehicle accident which took place one and a half years ago. The participant received six doses of intrathecal, intramuscular, and intravenous transplantation of Wharton?s jellv-derived mesenchymal stem cells (WJ-MSCs) at a goal dose of 1xl0 < sup > 6 < /sup > / kg respectively for each route of administration for six months. RESULTS: No important negative effects were reported. The patients? speech, cognitive, memory and fine motor skills were improved. The efficacy of treatment with SCT was assessed with cranial magnetic resonance imaging (MRI), computed tomography (CT) screening, and electroencephalography (EEG). CONCLUSION: SCT can have a promising future as a medical approach in recurrent TBI.

Morphometric Analysis of Lumbar Arteries and Relationship with Intervertebral Discs: A study of Surgical Anatomy on Human Fresh Cadavers.

AIM: To examine the morphological structure of anterior lumbar spinal region. MATERIAL AND METHODS: Fifteen fresh human cadavers were studied in our forensic medicine institution. Within the first 24 hours after death, cadavers were subject to a routine autopsy, by which the intestines were removed and the structures adjacent to the lumbar arteries (LAs) were examined. The following characteristics of the LA were examined and recorded: diameter, number of LA, intervertebral disc, and vertebral corpus relationship, and LA anatomical variations. RESULTS: In 14 of the 15 cadavers (93.3%), the first four LAs originated from the abdominal aorta. In one (6.7%) cadaver, the fourth LA originated from the right aortic trunk together with the median sacral artery (MSA), and this was observed only in the right side. In one cadaver, the first LAs emerged as a common trunk. Twelve cadavers did not have a fifth LA. In one cadaver (6.7%), the fifth LAs emerged as in a pair, distally from the origin of the MSA. Two cadavers (13.3%) had fifth LAs that emerged from the common trunk with the MSA and this occurred only on the right side. LAs which emerged from the right side of the abdominal aorta passed under the inferior vena cava. Of the first four LA, the third LA had the largest vessel diameter, and the first LA had the narrowest vessel diameter. Fifth LAs had one of the narrowest vessel diameters of all LAs. CONCLUSION: We consider that anatomical study of LAs using fresh cadavers can be useful to ensure safer anterior lumbar spinal surgeries.

Kyphoplasty in the Early Oncologic Diagnosis and Treatment of Vertebral Fractures: A Clinical Study.

AIM: To elucidate the characteristics of kyphoplasty in correlation with spinal metastasis. MATERIAL AND METHODS: Data of patients treated by kyphoplasty between January 2017 and December 2019 were reviewed retrospectively. Preoperative prophylactic antibiotics and low-molecular-weight heparin injections were performed. Postoperative follow-up was conducted at least 24 hours after the procedure. All patients were treated under sedoanalgesia. Bone biopsies were collected from all patients. RESULTS: One hundred ninety-nine vertebra fractures were treated in 130 patients. The mean age of the patients was 65.27 ± 8.79 years (18?90 years) and 66 patients were male (50.7%). Forty-five patients had osteoporosis, six patients showed malignancy, and osteomyelitis was found in three patients, while the others? presentations were secondary to trauma. Most commonly, the L1 (n=59), Th12 (n=45), and L2 (n=34) levels were found to develop vertebral fractures. Forty patients had multiple levels of vertebral fracture, with a higher rate of osteoporosis (n=24; 60%). Three patients showed undiagnosed oncologic disease with an initial diagnosis of acute fracture following minor trauma, while the primary oncologic diagnosis was established by bone biopsy taken during the routine procedure in each procedure (e.g., plasmacytoma, lymphoma, adenocarcinoma of the lung). None of the patients developed an infection due to kyphoplasty, permanent neuromotor deficit, or mortality. The mean postoperative hospital length of stay was 1.6 days. CONCLUSION: Bone biopsy should be performed to diagnose early spinal metastases. Although an accurate bone biopsy may not be obtained from some patients, particularly from those with osteoporosis, performing bone biopsy during the procedure does not cause time loss or any other complications, and protects the surgeon from possible medicolegal problems.

Challenges in the Clinical and Radiological Differential Diagnosis of Cerebrovascular Events and Malignant Primary Brain Tumors: Reports from a Retrospective Case Series.

AIM: To reveal difficulties in differential diagnosis of some cases of cerebrovascular events (CVEs) and malignant primary brain tumors (MBTs) even a multidiciplinary evaluation in grand rounds. MATERIAL AND METHODS: This study retrospectively analyzed the patient archives from January 2017?December 2019. The records of 572 patients discussed in these meetings were examined. A total of 8 patients having a challenge in differential diagnosis were detected. RESULTS: This study has included 8 cases in which neurology-neurosurgery-neuroradiology clinicians have difficulty in differentiating CVE and MBT. In the present study, three patients were evaluated with a preliminary diagnosis of hemorrhagic CVE in the emergency room. Since degradation products of hemoglobin have prevented advanced imaging methods to diagnose in two patients, these patients have been followed closely. The correct diagnosis could be made through the scan performed during control follow-ups The preliminary diagnosis of seven patients was CVE, but they received the MBT diagnosis during the follow-up. One patient was thought to have MBT initially; however, he/she was diagnosed with CVE after an advanced examination and close follow-up. CONCLUSION: Despite developing medical imaging methods and diagnostic studies, there are still some difficulties in making differential diagnosis of CVEs and MBTs. In some patients, further examination and imaging methods may be needed such as magnetic resonance imaging-spectroscopy (MRI-S), perfusion magnetic resonance imaging (Per-MRI), digital substratioangiography (DSA). Despite all these neuroradiological examinations and multidiciplinary evaluation, distinction between CVE and MBT may be difficult, and medicolegal problems may be encountered.

Comprehensive Anatomic and Morphometric Analyses of Triangular Working Zone for Transforaminal Endoscopic Approach in Lumbar Spine: A Fresh Cadaveric Study.

OBJECTIVE: The aim of this study is to provide essential information for endoscopic transforaminal approach by performing morphometric analysis of the triangular working zone (TWZ) in fresh cadavers. METHODS: Fifteen fresh human cadavers (9 women and 6 men) with no history of spinal surgery were used in this study. Anatomic dissection of 150 foraminal levels were performed. Significant surgical landmarks constructing TWZ were measured bilaterally from L1-2 to L5-S1 on 15 fresh cadavers. The relationship between traversing roots and intervertebral discs was defined. RESULTS: Base, height, and hypotenuse measurements of TWZ were longer as the level lowered. Mean base height and hypotenuse of TWZ were 12.15 mm, 11.29 mm, and 16.69 mm (L1-2); 17.94 mm, 17.18 mm, and 28.03 mm (L5-S1), respectively. TWZ was triangular shaped at the upper lumbar levels (L1-2, L2-3, and L3-4), and trapezoid at the lower lumbar levels (L4-5 and L5-S1). Going down the levels, the exiting root angle was narrower, the mean exiting angle of the L5 root being 28.23°. All L2 and L3 traversing roots and nearly all L4 traversing roots (86.7%) originated from below the disc level. Forty percent of L5 traversing roots originated above the disc level, and 53.3% originated at the disc level. Most S1 traversing roots originated at the proximal margin of the disc level (80%). CONCLUSIONS: Our study reveals a detailed morphometric analysis of TWZ. Understanding the foraminal anatomy is crucial for safely performing transforaminal endoscopic surgery. The learning curve of transforaminal surgery can be reduced by garnering knowledge of TWZ anatomy.

Anatomical Features of Neural Foramen at T12â€"L1 Level for Endoscopic Transforaminal Approach of Paramedian and Foraminal Disc Herniations: An Anatomical Study on Fresh Human Cadavers.

AIM: To explore the anatomic features of the neural foramen in particularly at the T12-L1 level in order to assess reveal the safety and efficiency of the endoscopic transforaminal approach for paramedian and foraminal disc herniations at this level. MATERIAL AND METHODS: The study included 15 fresh human cadavers. The soft tissues were removed at the T12-L1 level and bony tissues, were exposed including the transverse processes. The bilateral facets and pars interarticulares at this level were resected revealing the foraminal anatomy and exiting roots. The anatomical structures constituting the triangular safe working zone (TSWZ) were explored. The nerve root length, nerve root width, nerve root angle, TSWZ height, and base of TSWZ base, nerve root width, nerve root angle and disc height were recorded. RESULTS: The root length is the hypotenuse of the TSWZ between the axilla of the exiting root and the lateral margin of the pedicle, and the mean root length was 14.94 ± 2.45 mm. The dural height is the interval between the axilla of the exiting nerve root axilla and the superior end plate of the caudal vertebra, and the mean of the dural height was 10.95 ± 1.74 mm. The base of TSWZ is the distance between the lateral margin of the dural sac and the medial margin of the exiting root, and the mean measurement for the base measurement was 11.83 ± 2.26 mm. CONCLUSION: According to the results data from our cadaveric study, we believe that Kambin’s triangular working zone is a safe area to consider for the endoscopic transforaminal approach at the T12-L1 level, especially for paramedian and foraminal disc herniations.

Radiofrequency Thermocoagulation of the Ganglion Impar for Coccydynia Management: Long-Term Effects.

OBJECTIVE: To investigate the short- and long-term effects of ganglion impar radiofrequency thermocoagulation (RFT) treatment in patients with chronic coccydynia. METHODS: We retrospectively analyzed the medical records of patients who underwent RFT of the ganglion impar between 2009 and 2011. Pain intensity visual numeric scale (VNS) scores and Euroqol 5D (EQ-5D) index scores were recorded pre-intervention and post-intervention at the first, sixth, and twelfth months. The differences between pre-procedural VNS scores and post-procedural VNS scores at the first, sixth, and twelfth months were evaluated. The success of the intervention was recorded as the percentage difference between the pre-intervention VNS scores and post-intervention VNS scores at the first, sixth, and twelfth months. RESULTS: The mean age of the patients, including 11 females (55%) and 8 males (45%), was 48.7 ± 14.3 years. The average follow-up duration was 17.3 ± 2.9 months. Statistically significant differences were observed between the pre- and post-procedure VNS scores (P < 0.0001). Improvements in VNS scores were correlated with improvements in EQ-5D index scores. Mid-term (sixth month) and long-term (twelfth month) evaluations after the intervention revealed that 67.4% and 61.1% of the patients had successful outcomes, respectively. CONCLUSION: Our data suggested that RFT of the ganglion impar in patients with chronic coccydynia resulted in effective outcomes, and patients who responded to RFT had significantly lower post-RFT pain scores.

Wharton's Jelly-Derived Mesenchymal Stem Cell Transplantation in a Patient with Hypoxic-Ischemic Encephalopathy: A Pilot Study.

Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) have been introduced as a possible therapy in hypoxic-ischemic encephalopathy (HIE). We report a 16-year-old boy who was treated with WJ-MSCs in the course of HIE due to post-cardiopulmonary resuscitation. He received a long period of mechanical ventilation and tracheostomy with spastic quadriparesis. He underwent the intrathecal (1×106/kg in 3 mL), intramuscular (1×106/kg in 20 mL) and intravenous (1×106/kg in 30 mL) administrations of WJ-MSCs for each application route (twice a month for 2 months). After stem cell infusions, progressive improvements were shown in his neurological examination, neuroradiological, and neurophysiological findings. To our best knowledge, this is a pioneer project to clinically study the neural repair effect of WJ-MSCs in a patient with HIE.

The clinical factors associated with benefit finding of complementary medicine use in patients with back pain: A cross-sectional study with cluster analysis.

BACKGROUND: Complementary and alternative medicine (CAM) use has been increasing. OBJECTIVE: To identify the factors associated with perceived benefit from CAM methods in back problems. METHODS: The study was conducted on patients who practiced any CAM methods due to complaints of back pain. Social-demographic properties, details of CAM methods employed were questioned. Severity of pain was measured by visual analog scale (VAS); benefits were evaluated by the Likert scale. Hierarchical cluster analysis was used to discover relationships among variables. RESULTS: In total, 500 patients (265 female, 235 male) were included in the study. Mostly used methods were herbal therapy (32%), balneotherapy (31%), cupping (19.4%) and massage-manipulation (19.2%). Of patients, 355 (71%) were satisfied. The variables associated with benefit finding were female gender, age, chronicity and severity of pain, high educational level, upper middle income status, use as a result of recommendation, dissatisfaction with conventional methods, residence in an urban area, non-herbal method use, being married, and social insurance (p < 0.005). CONCLUSION: The majority of patients using CAM perceived benefits; in particular, women living in urban areas, highly educated, aged more than 40, who suffer from severe chronic back pain, may be more inclined to go to CAM therapists.

Lumbosacral Conjoined Root Anomaly: Anatomical Considerations of Exiting Angles and Root Thickness.

AIM: Conjoined nerve roots (CNR) can be damaged during lumbar disc surgery and lead to neuropathic pain due to excessive retraction. The purpose of this study was to investigate the factors that facilitate the identification of CNRs that can lead to the loss of fragments in the secondary axilla, nerve root injury or unpleasant surprises during lumbar disc surgery. Accordingly, we aimed to measure the thicknesses and exit angles of the nerve roots close to the pedicle to obtain scientific data regarding rare double roots. MATERIAL AND METHODS: The data of 612 patients who were operated for lumbar disc disease in our hospital between 2012 and 2014 were reviewed retrospectively. Twenty one cases of CNR were detected in this series. RESULTS: The mean nerve root thickness was 1.92 ± 0.45 mm for medially located roots and 3.33 ± 0.95 mm for laterally located roots. The comparison of medially located roots versus laterally located roots revealed a significant difference in mean values (p < 0.0001). The mean exit angle was 12.290± 4.890 for medially located roots, and 22.110 ± 5.420 for laterally located roots (p < 0.0001). In addition, the exit angles of the medially and laterally located roots increased as going down to caudal levels, (p=0.005, p=0.042). CONCLUSION: CNRs are congenital anomalies that are usually diagnosed during the surgical procedure and affect the success of discectomy. The presence of a more medially located or thinner root during surgical exploration and the absence of the fragment in the axilla in extruded or sequestered discs usually indicate a conjoined nerve root closer to the pedicle.

The Relationship of the Vertebral Artery with Anatomical Landmarks in the Posterior Craniovertebral Junction of Fresh Human Cadavers in the Turkish Population.

AIM: Surgical anatomy concerning the posterior craniovertebral region in fresh human cadavers was studied to provide most accurate information for the surgical approach. MATERIAL AND METHODS: In thirty-two fresh human cadavers, the distance from the posterior tubercle to the sulcus of vertebral artery (VA), the thickness and length of the third segment of VA (V3), the distance of C1/C2 facet to V3, the length, height and shape of the C2 ganglion to the neighboring structures, the distance from medial border of C1 lateral mass to dura mater, the distance of the transverse process of atlas to mastoid tip, the thickness of C1 posterior arcus were measured. RESULTS: There were variations of sulcus of VA in 14 of 32 cadavers (43.7%), the right VA was larger in 23 cadavers (71.8%). The ganglion was found over the C1 lateral mass screw entry point in 45 of 64 ganglions (70.31%) and below the screw entry point in 19 of 64 ganglions (29.69%). The distance of the medial border of the C1 lateral mass to dural tube was 3.81±0.55 mm at the right side and 3.91±0.59 mm at the left. The thickness of C1 posterior arch was 3.73±0.75 mm at the right side and 3.75±0.77 mm at the left. The mean distance from the transverse process of C1 to the mastoid tip was 15.82±4.49 mm at the right side and 15.46±4.38 mm at the left. CONCLUSION: This is the most comprehensive and only fresh cadaver study about this region in the literature.