[The outcomes of treatment of cauda equina ependymomas in adults].

UNLABELLED: Ependymoma is a rare tumor that accounts for about 4% of all central nervous system tumors. Ependymomas typically have intramedullary localization; however, sometimes the tumor is located outside of the spinal cord and affects the cauda equina nerve roots. OBJECTIVE: To study the outcomes of treatment in patients diagnosed with extramedullary ependymoma. MATERIAL AND METHODS: Fifty patients (23 males and 27 females) aged 38.7 years (range: 18-76 years) with ependymoma of the cauda equina region were operated on at the 10th Department of the N.N. Burdenko Neurosurgical Institute between January 2009 and December 2013. Thirty-six patients were newly diagnosed with tumors. Fourteen patients were admitted to the N.N. Burdenko Neurosurgical Institute with recurrent or continued tumor growth. The patients were subdivided into two groups according to this criterion. The outcomes of treatment were evaluated using the Frankel, the Karnofsky, and the VAS scales. The criteria proposed by Kawabata et al. were used to assess the long-term outcomes of surgical treatment. Tumor growth was monitored by contrast-enhanced MRI. RESULTS: Tumors were divided into two subtypes: the encapsulated vs. infiltrative forms. Ependymomas were resected subtotally in 5 patients; continued growth of ependymoma was observed in 3 patients. Positive results were obtained for both groups according to the evaluation performed using the scales. According to the criteria of Kawabata et al., the patients were distributed in a following way: in group 1 patients, the good outcome (class 1) was observed in 26 (72%); the fair outcome (class 2), in 8 (22.5%) patients; while the results were equivocal in 2 (5.5%) patients. A number of patients received radiotherapy as a component of combination treatment. Tumor growth stabilization was achieved. CONCLUSIONS: Microsurgical intervention is obligatory, since it has a positive effect on the outcomes of surgical treatment of extramedullary intradural tumors, including ependymomas of the cauda equina region. Treatment effectiveness decreases for the infiltrative subtype of tumor growth. Radiation therapy should be used if continued tumor growth is detected or degree of tumor resection was subtotal.

[Experience of using an intraoperative cone beam computed tomography scanner and the modern navigation system in surgical treatment of spine and spinal cord disorders].

UNLABELLED: Spine disorders are a highly relevant problem in neurosurgical pathology. The development of diagnostic imaging methods makes it possible to perform intraoperative computed tomography. A special intraoperative cone beam computed tomography scanner "O-arm" has been designed; it combines a function of a C-arm machine and computer tomography scanner. The O-arm system can be used along with navigation system and robotic assistance device. Availability of these devices in an operating room allowed us to study the effectiveness and features of intraoperative CT imaging. OBJECTIVE: To evaluate the intraoperative use a cone beam computed tomography scanner "O-arm" and the navigation system in surgical treatment of spine disorders. MATERIAL AND METHODS: In August-November 2013, 43 patients with degenerative spine disorders, spine and spinal canal tumors underwent surgeries at the N.N. Burdenko Neurosurgical Institute using an intraoperative computed tomography scanner "O-arm" and the navigation system. RESULTS: It is reasonable to use intraoperative CT "O-arm" device with the navigation system when surgical treatment is performed under complex anatomical conditions (a thin root of the vertebral arch, scoliotic or post-traumatic spinal deformity) and the surgery zone cannot be visualized using 2D imaging methods. Intraoperative CT control and navigation system can be employed by neurosurgeons in clinics where the standard stabilizing surgeries and percutaneous methods either are employed rarely or have just started to be used. CONCLUSIONS: The use of an intraoperative CT device "O-arm" with the modern navigation system for surgical treatment of spine and spinal cord disorders allows one to perform surgical interventions under complex anatomical conditions, reduces the absorbed radiation dose, and is safe for patients.

[Effectiveness of one-stage microdiscectomy and radiofrequency denervation of intervertebral joints compared to microdiscectomy in patients with spinal disc herniation].

The article analyzes of the early and long-term outcomes in 113 patients who underwent surgical treatment for lumbosacral disc herniations. The first group of patients (n=32) underwent microdiscectomy in a combination with radiofrequency destruction (RFD) of the facet nerves. The control group patients (n=81) underwent microdiscectomy. This study demonstrates the advantage of combining RFD with open surgery. In this case, regression of both nerve root and back pain is achieved, which greatly accelerates rehabilitation of patients, restoration of their work ability, and therefore their return to normal life.

[The use of minimally invasive approaches to resect intradural extramedullary spinal cord tumors].

AIM: To conduct a comparative analysis of outcomes in patients with extramedullary tumors operated on using a minimally invasive approach and traditional laminectomy. MATERIAL AND METHODS: The study included 40 patients (13 males and 27 females) who underwent surgical treatment at the Department of Spinal Neurosurgery of the Burdenko Neurosurgical Institute. The mean age of patients was 47 years (range: 41-60 years). Tumors were located in the cervical, thoracic and lumbar spine. All patients were divided into two groups. In the control group, 20 patients underwent traditional laminectomy using a yard retractor or an Egorov-Freidin retractor. In the study group, 20 patients underwent hemilaminectomy using a retractor for minimally invasive surgery (Caspar and MAST Qudrant). The outcomes were evaluated 3, 6, and 12 months after surgery. The McCormik and VAS scales were used for the evaluation. MRI data were also evaluated. RESULTS: Total tumor resection was reached in all cases. The mean surgery duration was 247 min (range: 180-320 min) for the first group and 105.25 min (range: 60-190 min) for the second one. The volume of blood loss was 297 mL (range: 100-600 mL) for the first group and 210 mL (50 to 400 mL) for the second group. The histological nature of the tumors was as follows: neurinoma, meningioma, and ependymomas of the cauda equina. The evaluation of the pain syndrome in the early postoperative period revealed that the pain syndrome intensity according to VAS was reduced in patients of the second group compared to that in patients of the first group. The evaluation using the McCormik scale revealed no obvious difference in the results between the study and control groups. MRI studies performed in the postoperative period showed no tumor recurrence. CONCLUSION: Surgical treatment of patients with intradural extramedullary tumors can be safely and effectively performed using minimally invasive approaches. A potential reduction in surgery duration, intraoperative blood loss, the amount of anesthetic drugs and reduction in the pain syndrome in the early postoperative period allow us to conclude that, when performed by an experienced surgeon, the method of minimally invasive surgery may be an alternative to the traditional removal of an extramedullary tumor.

[Virtual clinical diagnosis support system of degenerative stenosis of the lumbar spinal canal].

UNLABELLED: The aim of the study was to develop a virtual clinical diagnostic support system of degenerative lumbar spinal stenosis on database of spine registry. MATERIALS AND METHODS: Choice of criteria's for diagnostic system was made on symptom analysis of 298 patients with lumbar spinal stenosis. Also was analysed a group of patient with disc herniation's for sensitivity and specify assessment of developed diagnostic support system. Represented clinical diagnostic support system allows identifying patients with degenerative lumbar spinal stenosis on stage of patient's primary visit. System sensitivity and specify are 90 and 71% respectively. RESULTS: "Online" mode of diagnostic system in structure of spine registry provides maximal availability for specialists, regardless of their locations. Development of tools "medicine 2.0" is the actual direction for carrying out further researches with which carrying out the centralized baea collection by means of specialized registers helps.

[Working results of the electronic "on-line" version of the Spine Registry for Degenerative Lumbar Spine Diseases and study of its synchronization capacity with the electronic case history]. / Itogi raboty portal'noi versii poiasnichnogo vertebrologicheskogo registra i izuchenie voprosa ego sinkhronizatsii s élektronnoi istoriei bolezni.

AIM: To assess the results of use of lumbar spine on-line registry in 2012 (IV quarter). MATERIAL AND METHODS: The Burdenko Neurosurgery Institute of the Russian Academy of Medical Sciences (RAMS) and the System Analysis Institute of the Russian Academy of Sciences (RAS) have developed an electronic "on-line" portal of the Spine Registry for Degenerative Lumbar Spine Diseases. The data on 1295 retrospective and 145 prospective patients who underwent treatment in Burdenko Neurosurgery Institute, the "AXIS" clinic, Medical Centre of the Bank of Russia, "Marina Spine Clinic" LA, USA and in the Neurosurgery department of Research Institute of Traumatology and Orthopedics, Nizhny Novgorod were analyzed. Since May 2012 to the present time outcomes of 1295 (retrospective group) and 145 (prospective group) patients with Degenerative Lumbar Spine Diseases, which underwent treatment from 2002 to 2012 were entered into online registry and subsequently analyzed. The current study has revealed two problems that need to be discussed. First problem is that the archived information is not sufficient for data base update. The second problem is low activity of many physicians in inputting data into the register. We believe that the solution of these problems lies in the plane of synchronization of on-line registry with electronic medical records. This synchronization between registry and online records will allow studying their joint work. If found to be successful after the development of the other sections of the register they will be added to an already running version as provided by the principles of its work - scalability and extesibility. The results of this work will be profile of vertebrological version of electronic medical records. In the future it could be used in clinics dealing with spine disorders. RESULTS: Since May 2012 the outcomes of 1295 (retrospective group) and 145 (prospective group) patients with Degenerative Lumbar Spine Diseases, who were operated on in Burdenko Neurosurgery Institute (Moscow, Russia), minimally invasive spinal surgery clinic "AXIS" (Moscow, Russia), Medical Centre of The Bank of Russia (Moscow, Russia), "Marina Spine Clinic" (LA, USA) and Neurosurgery department of Research Institute of Traumatology and Orthopedics (Nizhny Novgorod, Russia) from 2002 to 2012 were analyzed. The perspective of this work is development of other parts of spine registry (for cervical and thoracic spine) and improving the outcome assessment process in Russian spinal surgery clinics.

[Evidence-based medicine methods and critical reading of the paper devoted to degenerative lumbar and sacral spinal stenosis (comment to the article)].

The paper provides critical analysis of the article "Correlated analysis of radiologic criteria's referred to central degenerative spinal canal stenosis and intensity of clinical implications". Critical analysis was carried out by the 5-step evidence cycle. First step is supposed to formulate primary goal of the research and identify its type. This investigation belongs to prognostic studying of certain patient's characteristics and their impact on the state of disease and the treatment outcome. According to Oxford evidence based center of medicine gradation, this study is attributed to level IV (clinical series). Analysis performed allowed to state that investigation sampling might be considered as representative, but nonhomogeneous. Absence of blind evaluation of the treatment results could alter treatment outcomes when compared by two different scales. Multifactor analysis was not held in the present study. Analyzed investigation has low methodological level, however, it has no major disadvantages. Statistical significance between various factors and clinical effect can be achieved when study is based upon database analysis of many patients, which however cannot be managed by efforts of a single medical institution. Organizing investigations by registration treatment outcomes with follow up evaluation nationwide could be a problem solution. In particular, vertebrological register might be a very useful tool for development prognostic risk scales and predictive models in degenerative spine disease surgery.

[Analysis of radiological criteria correlation and clinical manifestation of central lumbosacral spinal stenosis].

OBJECTIVE: to assess the correlation analysis of radiologic criteria referred to central degenerative spinal stenosis and intensity of clinical manifestation. MATERIALS AND METHODS: a retrospective cohort data were collected from 2010 till 2011, 27 patients who underwent surgical treatment of central spinal stenosis in Burdenko Neurosurgical Institute. 16 male and 11 female patients were included in the present study. Mean age of the patients at the time of surgery was 57.9 years. All patients had spinal canal decompression and transpedicular or oblique transcorporal fusion. Stabilization included different types of pedicle screws, including transcutaneous stabilization systems. Interbody fusion was achieved by posterolateral transforaminal approach (TLIF --transforaminal lumbar interbody fusion). 13 cases included combination of interbody fusion and guided oblique lumbar interbody fusion "GO-LIF", which could not be managed without robotic assistance. All patients underwent full preoperative examination. MR image evaluation included: antero-posterior diameter of the spinal canal (mm), interfacet interval (mm), and cross-section area of the spinal canal (mm2). Patients were evaluated by outcome analysis scales: Degenerative Disease Intensity Level (DDIL) and Swiss Spinal Stenosis Score (Zurich Claudication Questionnaire, Brigham spinal stenosis questionnaire). Surgical outcomes were evaluated according to modified classes of Kawabata et al. RESULTS AND DISCUSSION: analysis of our patients group demonstrated absence of correlation between intensity level of degenerative central spinal stenosis based on neurovisualization methods and intensity of its clinical manifestation. Pearson's coefficient of correlation and Spearmen rank correlation for variable which evaluates clinical signs (DDIL in %) and neurovisualization data (antero-posterior diameter of the spinal canal (mm), interfacet interval (mm), and cross-section area of the spinal canal (mm2)) are not significant to zero (p > 0.2).

[CyberKnife stereotactic radiotherapy for mass lesions of the spinal cord and spine].

Introduction of a novel technology of stereotactic radiation treatment using linear accelerators, refining of systems for visualization and guidance provided rapid development of extracranial radiosurgery. Nowadays there is a possibility of precise stereotactic irradiation of lesions with different size and localization. One of the most actual and promising indications for radiosurgery are different primary and metastatic lesions and arteriovenous malformations of spinal cord and spine. Radiosurgery and hypofractionated radiotherapy with precise dose delivery during one or several sessions allow effective and safe treatment of neoplasms with any degree of radioresistance. This paper contains analysis of the first Russian experience of stereotactic radiation treatment of lesions of spinal cord and spine using robotized system CyberKnife (Accuray Inc., USA).

[Necessity of development of Russian vertebrologic registry].

Development of national and international registers for the most socially significant diseases is an important problem of contemporary medicine. Importance and priority of vertebrological register is explained by relatively young age of spinal neurosurgery as specialty, in which many questions concerning indications and optimal methods of treatment remain unsolved, and accumulated experience is quite limited. Nevertheless, vertebrology is on the way from opinions of certain experts to evidence-based scientific proofs. This transition needs generally accepted and convenient instruments for assessment of outcomes of treatment and procedures which should be presented by national vertebrological register. Aims of its development include accumulation of clinically valuable resources and knowledge in vertebrology by means of organization of society of interested professionals and patients. The paper discusses architecture, contents and importance of development of Russian vertebrological register targeted on neurosurgeons, orthopaedic surgeons, vertebrologists and other specialists dealing with this problem. Foreign vertebrological registers are analyzed, their advantages and disadvantages are summarized, requirements for inclusion of criteria in the register are investigated.

Cell technology employing femtosecond laser pulses.

Practical advantages of using femtosecond laser pulses for manipulations in cell surgery were demonstrated. The use of femtosecond laser pulses enables precision punching of the zona pellucida of the embryo without damaging its cells. With the help of femtosecond laser tweezers/scalpel, auxillary laser hatching was performed and a technique of optical biopsy of mammalian embryo was developed, which enabled non-contact sampling of embryonic material for preimplantation diagnostics. Our findings suggest that about 90% embryos retained the ability to develop at least to the blastula stage after this manipulation.

[Melanotic schwannoma of C(III) spinal root].

We present a case report of the very rare tumor--melanotic schwannoma. Since its first description on 1932 only approximately 100 cases were reported in literature. Due to intensive pigmentation and many features that common for metastatic melanoma and melanotic schwannoma differentiation between these tumors is a challenging and important problem. 61-year-old male patient underwent surgical removal of pigmented extramedullary mass lesion at C2-C3 level. Melanotic schwannoma was diagnosed on the basis of morphological and immunohistochemical signs. Despite positive expression of so-called 'melanoma markers', (HMB-45, S-100, Melana A) cells of melanotic schwannoma also express type IV collagen and laminin which are not characteristic for melanoma. In addition, Ki-67 is very low in melanotic schwannoma, thus it confirms benign character of this tumor. Mentioned immunohistochemical profile allowed to diagnose melanotic schwannoma. It is distinctly clear that prognosis in melanotic schwannoma is incomparably better than in melanoma. Surgical removal is the best treatment option, and postoperative radiation therapy is not necessary as in melanoma.

[Application of robotic assistance in surgical treatment of degenerative disease of lumbosacral spine].

Robotic assistance has gained increasing popularity in spinal surgery recently. Robotic assistance provides higher effectiveness and safety especially in conditions of complicated anatomy. It also enables the novel, previously unavailable surgical techniques, such as GO-Lif for lumbar spine fusion. The aim of the study is to assess the applicability and effectiveness of the robotic assistance in surgical treatment of degenerative lesion of lumbar spine. 16 patients were operated with robotic assistance device (SpineAssist; MAZOR Surgical Technologies, Caesarea, Israel) between August 2009 and February 2010 in Spinal Department of Burdenko Neurosurgical Institute (Moscow, Russia) with degenerative disc disease. Preoperative assessment included MRI, X-rays and high-resolution CT (slice < 1 mm). The CT is essential for preoperative planning using computed work station SpineAssist. The robot was utilized for automated intraoperative positioning of the instruments according to preoperatively planned trajectories. Basic parameters of surgeries were thoroughly recorded: overall surgery time, radiation dose (all manipulations were performed under fluoroscopic control), accuracy of screw placement relative to preoperative planning, which was assessed using postoperative high-resolution CT with 3D reconstruction. Particular interest of the study was focused on the novel fusion technique for lumbar spine: Go-Lif (Guided Oblique Lumbar Interbody Fusion). This fusion modality enables segment fixation with two screws only, it is comparable with pedicular screws in terms of stability, being far less invasive. It may be used standalone or together with TLIF techniques. Robotic assistance enabled optimal screw placement even in complex anatomical cases (thin pedicles and rotational deformity). No implant-related complications were recorded. Surgery time was much longer in first 2 cases, though in further it decreased nearly to conventional (without robot) surgery time. For radiation dose same tendency was observed--in first 2 cases all surgical steps were fluoroscopically controlled, in further cases--only for primary anatomy registration. Based on control CT, accuracy of implant placement with robotic assistance is 1 mm.

[Replacement of lumbosacral intervertebral disks using artificial prostheses: surgical tactics and technique].

The mail goal of the study is to present surgical technique of intervertebral disk replacement using artificial disks and to completely evaluate effectiveness of this modality of treatment of degenerative spine disease using a set of original scales, clinical data and neuroradiological examination. Since 2002 to 2007 14 patients underwent intervertebral disk replacement by artificial prostheses in the Department of Spinal Neurosurgery in Burdenko Neurosurgical Institute (Moscow, Russia). Analysis of results of treatment was performed using multidimensional assessment scales. Potential complications of intervertebral disk replacement by artificial disks are evaluated.

Injection form of tissue-engineering construct on the basis of autogenous chondroblasts for regeneration of the cartilaginous tissue.

We present an injection form of tissue-engineering construct on the basis of autogenous human chondroblasts for regeneration of the cartilaginous tissue. A material meeting the requirements for the creation of the injection form of an ITC construct (injectable chondrocyte transplantation) was used as the matrix carrier. The developed construct on the basis of autogenous human chondroblasts and homogenized hemostatic gelatin sponge is now at the stage of complex experimental testing.

[Experience with endoscopic interventions in diseases of the vertebral column].

The paper analyzes the results of treatment for various diseases of the vertebral column, by applying endoscopic technologies. Group 1 included 5 patients with cervical hernias appeared as cervical radiculopathy. Group 2 comprised patients with diseases of the thoracic vertebral column, including 8 patients with discal hernias, 6 with primary or metastatic lesions of the thoracic vertebrae, 2 with sympathalgia, and 5 with uncomplicated thoracic vertebral body fractures. Group 3 consisted of 86 patients with lumbosacral hernias, of whom 33 patients were endoscopically operated on and the remaining 53 patients made up a control group and were microsurgically operated on. The clinical findings were analyzed by using the current scales and questionnaires to make an objective assessment of subjective index, such as pain syndrome. A preliminary comparison of endoscopic and microscopic surgical treatments for diseases and lesions of the vertebral column demonstrate the noticeable advantages of endoscopic technology. Further development of neuroendoscopy in spinal neurosurgical care is expected to substantially enhance the efficiency of treatment due to the lower traumaticity rates of surgical interventions. Furthermore, mastering endoscopictechniques in surgery of bone tumors, but also spinal cord extra- and intramedullary neoplasms is promising, as considered by the authors.

[Clinical diagnostic rating (score) of the degree of lumbosacral degenerative lesion].

The study was undertaken to work out an objective rating scale in a patient with lumbosacral degenerative lesion to define its degree. From 2002 to 2007, the Spinal Surgery Department, Research Institute of Neurosurgery, Russian Academy of Medical Sciences, operated on 292 patients with degenerative lesions of the lumbosacral spine. The developed scale was used to analyze patients with umbosacral disk herniation (n = 194), vertebral canal stenosis (n = 57), spondylolisthesis (n = 23), and degenerative comorbidity (n = 18). A classification scheme of the degrees of lumbosacral degenerative lesion has been proposed on the basis of the developed multiobjective rating scale.

Compression asymmetric static experimental model of degenerative disk diseases.

We propose an experimental model of degenerative-dystrophic changes in intervertebral disks of rat tail. The results of X-ray examination and histological studies showed that degenerative changes in the disk tissues caused by experimental compression of intervertebral disks in rat tails are identical to those in humans.

[Preoperative study of the good condition of nerve neurotizers].

In traumatic injury of the brachial plexus, neurotization of peripheral nerves of the hand with different nerve donors is indicated at the preganglionary level in order to restore motor function. This communication describes a procedure for preoperatively determining the state of the nerves to be neurotized. This procedure evaluates the, state of the estimated nerve donors and presents a means of planning in advance the way of performing an operation aimed at recovering the lost motor functions, by considerably reducing the time of the operation.

[Vertebroplasty in the treatment of spinal diseases]. / Vertebroplastika pri lechenii zabolevanii pozvonochnika.

The results of surgical treatment by vertebroplasty are analyzed in 28 patients with different spinal diseases. A procedure for percutaneous vertebroplasty with polymethyl methacarylate is presented. This miniinvasive method has been shown to be highly effective in treating vertebral hemangiomas, osteoporotic compression fractures, and vertebral metastases and in strengthening the anterior vertebral column as compared with anterior spondylosis in open surgical operations.