Demographical Aspects of Central Large Lumbar Disc Herniation.

AIM: The purpose of this study was to investigate the risk factors for the development of the central large disc herniations and to compare the demographic data between central mass prolapse and broad-based central disc herniation. MATERIAL AND METHODS: Between 2002 and 2007, 1630 patients underwent surgery and a large disc herniation was the main problem in 59 patients (3.6%). We performed a retrospective analysis of the demographic data of these patients. Magnetic resonance (MR) images were evaluated according to the disc type and level. Variables were evaluated both at baseline and follow-up, with special emphasis on physical job characteristics, sports activities, and MR - based morphologic findings. RESULTS: Central large disc herniation was diagnosed in 59 patients consisting of 41 males and 18 females. The average age was 34.7 years. 36 patients had a central mass prolapse that occupied more than 50% of the spinal canal. Intraoperative observations confirmed that 29 out of 36 central disc prolapse patients (80.5%) had intact posterior longitudinal ligaments. Interestingly, the condition in these 29 patients was found to have a direct relation with age and occupation or other body training sports activities. CONCLUSION: The size of the large central disc herniation, physical activity, age and gender are major factors in the development of disc herniation.

Comparison of deferoxamine and methylprednisolone: protective effect of pharmacological agents on lipid peroxidation in spinal cord injury in rats.

STUDY DESIGN: Experimental study. OBJECTIVE: To investigate the protective effect of deferoxamine (DFO) administration in comparison with methylprednisolone (MP) on lipid peroxidation and antioxidants after spinal cord injury (SCI) in rats. SUMMARY OF BACKGROUND DATA: DFO is used for treating an iron-chelating agent, which is also used in the treatment of iron poisoning and thalassaemia. The neuroprotective effect of DFO was evaulated as a therapeutic agent for SCI. METHODS: Forty Wistar rats were randomly divided into 5 groups as sham laminectomy (n = 8), laminectomy with SCI (n = 8), laminectomy with SCI and 0.9% saline intraperitoneal (i.p.) (n = 8), laminectomy with SCI and 30 mg/kg MP i.p. (n = 8), and laminectomy with SCI and 30 mg/kg DFO i.p. (n = 8). Neurological deficits were examined 24 hours after trauma, and all rats were killed. Spinal cord segments were harvested for both biochemical and histopathological evaluation. RESULTS: At 24 hours post-SCI, whereas malondialdehyde levels were increased, superoxide dismutase, catalase, and glutathione peroxidase levels were decreased in groups I, II, and III. MP and DFO treatment decreased MDA levels and increased superoxide dismutase CAT, and glutathione peroxidase levels in control and study groups. There was no statistically significant difference between treatment with MP and DFO (P> 0.05). All rats were paraplegic after SCI, except in the sham group. Histopathological improvement was observed in control and study groups. CONCLUSION: This study indicates that beneficial effects may be provided and further studies need to investigate the dose-dependent beneficial and side effects of DFO in SCI. LEVEL OF EVIDENCE: N/A.

Existence of two separate facet joints on the same side: case of a congenital anomaly.

We present a case that had two separate facet joints on the same side causing an intervertebral instability. The embryological pathogenesis of the congenital existence of two separate facet joints on the same side of the vertebra is not conclusively known. A 68-year-old woman presented with lower back pain and severe left leg pain. Neuroradiological evaluation including dynamic plain radiography, computed tomography, and magnetic resonance imaging of the lumbar spine revealed the existence of two separate facet joints on the same side of the first sacral vertebra, severe degenerative changes of both right and left L5-S1 facet joints, and Grade II L5-S1 spondylolisthesis. Subsequently, she underwent surgery. Intraoperatively, two separate facet joints on the same side of the first sacral vertebra were confirmed. The patient's symptoms were resolved after decompression and fusion surgery. This is a unique case of the congenital existence of two separate facet joints on the same side of the first sacral vertebra.

Anterior tarsal tunnel syndrome secondary to missed talus fracture: a case report.

The anterior tarsal tunnel syndrome (ATTS) has first been described by Kopell and Thompson in 1963. The anterior tarsal tunnel is formed by the fascia lining the inferior extensor retinaculum and talus as well as the navicular bone. Many ATTS cases with various etiologies have been reported since the first description. We report here an ATSS case resulting from a fibro-osseous structure that occurred after a missed talus fracture. The ATTS diagnosis can be made with a comprehensive clinical neurological examination and electrophysiological study. The treatment is based on the underlying etiology, while surgery is the most common treatment providing successful outcomes in the long term.

Early surgical treatment protocol for sciatic nerve injury due to injection--a retrospective study.

BACKGROUND AND PURPOSE: We retrospectively researched 119 patients with buttock level traumatic injury to sciatic nerves and 42 cases of sciatic nerve injuries due to intramuscular injections were observed among them. Our aim was finding out the post-operative outcomes of early intervention and describing a timing schedule for surgical intervention. METHODS: Between 1984 and 2004 a total of 73 patients were operated on to explore the nerve lesion. These injuries consisted of post-injection injury, hip fracture/dislocation, contusion, compression, gunshot wound, hip arthroplasty and laceration. Our study took into account 29 cases operated because of injection injury. The most common presenting symptom was pain, which often masked underlying loss of function. Findings at operation were analysed according to the type of sciatic nerve damaged following intramuscular injection, the nature of this injury and the referring speciality. Some of the more common causal operations and procedures are discussed. Preventive measures are listed, and early diagnosis and treatment are recommended. The aim of the operation was to establish the diagnosis, to resolve pain and to improve function by epineural or interfasciculary neurolysis. RESULTS: We analysed the findings at operation according to the nature of the injury and the procedures which the patients underwent. Seven patients (24.1%) had an excellent outcome, 14 patients (48.2%) had good outcome and 4 patients (13.8%) had fair outcome. The other four patients (13.8%) had poor outcome. No patients suffered from additional post-operative neurological deficits or from worsening of pre-operative deficits. CONCLUSIONS: Based on our experiences, we recommend measures by which the morbidity rate of these injuries may be reduced. We stress, however, that if the clinical evidence points to transection of a nerve, that nerve may be explored without waiting for electrophysiological confirmation. Delay in recognition and therefore treatment was a cause of litigation, and contributed to the poor outcome in many cases.

Capillary hemangioma of the cervical intervertebral disc.

An anterior cervical decompression and fusion operation was complicated by extensive bleeding from the disc space. Histopathological evaluation of the resected specimen revealed the diagnosis as the very first reported case of capillary hemangioma in intervertebral disc space. Retrospective review of the preoperative MRI demonstrated supporting findings of a capillary hemangioma within the cervical intervertebral disc.

Combined hyperbaric oxygen and hypothermia treatment on oxidative stress parameters after spinal cord injury: an experimental study.

BACKGROUND AND AIMS: We undertook this study to investigate the possible beneficial effects of combined hypothermia and hyperbaric oxygen (HBO) treatment in comparison with methylprednisolone in experimental spinal cord injury (SCI). METHODS: Forty eight male Wistar albino rats (200-250 g) were randomized into six groups; A (normothermic control group; only laminectomy), B (normothermic trauma group; laminectomy + spinal trauma), C (normothermic methylprednisolone group; laminectomy + spinal trauma + methylprednisolone treated), D (hypothermia group; laminectomy + spinal trauma + hypothermia treated); E (HBO group; laminectomy + spinal trauma + HBO therapy), F (hypothermia and HBO group; laminectomy + spinal trauma + hypothermia and HBO treated) each containing eight rats. Neurological assessments were performed 24 h after trauma and spinal cord tissue samples had been harvested for both biochemical and histopathological evaluation. RESULTS: After SCI, tissue malondialdehyde (MDA) level of the control group was measured increased, and superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) enzyme activities were measured decreased. In group F, it was also shown that MDA level elevation had been prevented, and group F has increased the antioxidant enzyme activities than the other experimental groups C, D, E (p <0.05). CONCLUSIONS: We concluded that the use of combined hypothermia and HBO treatment might have potential benefits in spinal cord tissue on secondary damage.

Curcumin improves early functional results after experimental spinal cord injury.

BACKGROUND: Curcumin is a polyphenol extracted from the rhizome of Curcuma longa and well known as a multifunctional drug with anti-oxidative, anticancerous, and anti-inflammatory activities. The aim of the study was to evaluate and compare the effects of the use of the curcumin and the methylprednisolone sodium succinate (MPSS) functionally, biochemically, and pathologically after experimental spinal cord injury (SCI). METHOD: Forty rats were randomly allocated into five groups. Group 1 was performed only laminectomy. Group 2 was introduced 70-g closing force aneurysm clip injury. Group 3 was given 30 mg/kg MPSS intraperitoneally immediately after the trauma. Group 4 was given 200 mg/kg of curcumin immediately after the trauma. Group 5 was the vehicle, and immediately after trauma, 1 mL of rice bran oil was injected. The animals were examined by inclined plane score and Basso-Beattie-Bresnahan scale 24 h after the trauma. At the end of the experiment, spinal cord tissue samples were harvested to analyze tissue concentrations of malondialdehyde (MDA) levels, glutathione peroxidase (GSH-Px), superoxide dismutase (SOD) activity, and catalase (CAT) activity and pathological evaluation. FINDINGS: Curcumin treatment improved neurologic outcome, which was supported by decreased level of tissue MDA and increased levels of tissue GSH-Px, SOD, and CAT activity. Light microscopy results also showed preservation of tissue structure in the treatment group. CONCLUSIONS: This study showed the neuroprotective effects of curcumin on experimental SCI model. By increasing tissue levels of GSH-Px, SOD, and CAT, curcumin seems to reduce the effects of injury to the spinal cord, which may be beneficial for neuronal survival.

The effects of meloxicam on neural tube development in the early stage of chick embryos.

AIM: The aim of this study is to demonstrate the effect of meloxicam in early stage chick embryos on neural tube development. MATERIAL AND METHODS: One hundred specific pathogen-free (SPF) chicken eggs were used to investigate the neurulation. SPF eggs were invastigated in four groups (n:25). All of the groups were incubated at 37.2 +/- 0.1 degrees C and 60 +/- 5 % relative humidity for 30 hours, and an embryological development in the ninth stage as classified by Hamburger and Hamilton was obtained. In the end of the 30th hour, group A(control group) was administered 0.1 ml of saline (0.9% NaCl) in ovo and the other groups were administered meloxicam in increasing doses. At the end of 72 hours, all of the embryos were extracted from eggs and they underwent pathological examination with hematoxylin eosine and immunohistopathological examinations with CD138 and tubulin beta II. RESULTS: While the groups Aand B showed no neural tube defects, totally eight defective embryos were detected in the groups C and D (three in group C and five in group D. CONCLUSION: Our results suggested that meloxicam, a nonselective COX inhibitor, caused neural tube closure defects when injected at supratherapeutic doses. However, further studies with larger numbers of subjects are needed for its use in lower doses.

Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach.

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36-96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.

Effect of hyperbaric oxygen therapy on the duration of treatment of spinal tuberculosis.

The aim of this retrospective study was to investigate the effect of adjuvant hyperbaric oxygen (HBO) therapy on the duration of antibiotic treatment and rate of radiological improvement in the management of spinal tuberculosis. We reviewed a total of 51 patients with tuberculous spondylitis of the spine who were treated by percutaneous abscess drainage or radical surgical debridement with chemotherapy, and of whom 16 randomly selected patients also received adjuvant HBO therapy and 35 did not. Serological markers were monitored in the course of treatment. Percutaneous needle biopsy was performed on each patient before treatment. Spine and chest radiographs, CT scans and MRI were performed. Infection control was achieved in all patients and no recurrence occured. To our knowledge this is the first reported series of patients with spinal tuberculosis treated with HBO therapy as an adjunct to antituberculous chemotherapy. This combination provided earlier clinical and radiologic improvement than chemotherapy alone.

Two-level contiguous cervical disc disease treated with peek cages packed with demineralized bone matrix: results of 3-year follow-up.

Interbody cages are widely used instruments for cervical fusion operations. Long-term follow-up studies are needed to clarify if these devices are dependable. In this prospective study, 79 patients (42 women and 37 men) with a mean age of 51 years operated between January 2000 and December 2005 for treatment of degenerative cervical disc disease and spondylosis associated with radiculopathy or myelopathy were evaluated. Patients underwent two-level contiguous anterior cervical discectomy and fusion operations with standard anterior Smith-Robinson approach. To achieve fusion PEEK cages packed with demineralized bone matrix mixed with autologous blood were used. Clinical outcome was evaluated with Odom's criteria and results were evaluated as 'excellent', 'good', 'fair' and 'poor'. Spinal curves, mobility and fusion status were assessed with anterior-posterior and lateral (neutral, flexion and extension) radiographs obtained before surgery and at 3, 12, 24 and 36 months postoperatively. The Ishihara curvature index (ICI) was used for spinal curve evaluation. Lateral dynamic (flexion and extension) radiographs at postoperative 12th month revealed the fusion status classified as 1A, 1B, 2A and 2B. The radiological outcomes were classified as 'non-fusion' when 2B healing was observed, and as 'fusion' when 1A, 1B or 2A healing was observed at the levels subjected to surgery. According to Odom's criteria, clinical outcomes were classified as 'excellent' or 'good' in 69 patients (success rate: 87.3%). Eight patients were graded as 'fair' and two as 'poor'. Preoperative mean ICI was 10.4+/-3.72 and postoperative mean ICI was 10.1+/-3.14. The difference was statistically insignificant (P>0.05); therefore, preoperative lordosis was said to be preserved at final follow-up. Final fusion rate (Types 1A, 1B, and 2A) was 91.7% (145/158 levels). Radiological imaging showed no cage failure or dislodgement and reoperation due to non-fusion was not needed.

Use of ultrasonography in ulnar nerve entrapment surgery--a prospective study.

The purpose of our study is to assess the usefulness of high-resolution ultrasonography in observing the morphology and dynamics of the ulnar nerve in the cubital tunnel and also the efficacy of ultrasonography in a more accurate diagnosis and appropriate surgical treatment decision. Cross-sectional area of the ulnar nerves of 40 healthy volunteers in the control group were measured bilaterally at the level of the epicondyle, 2 cm proximal to and 2 cm distal to the epicondyle. Measurements were obtained for elbows both in extension and flexion. Then, we prospectively obtained the cross-sectional area values of 18 patients at the same levels, elbows in extension and flexion position, and compared the data obtained from the patient group and the control group. The differences between the cross-sectional areas of the ulnar nerves in extension and flexion were statistically significant in the patient population (p < 0.001). Mean cross-sectional area of the ulnar nerve in the patient population was calculated as 0.16 cm(2), and we accepted the cut-off point as 0.1 cm(2). This value for cross-sectional area yielded a sensitivity of 90% and a specificity of 100% in diagnosis of ulnar nerve entrapment. Results substantiated conspicuous morphological changes in ulnar nerve during flexion and extension of the elbow. We also observed that as the degree of the nerve displacement by virtue of elbow flexion that is discerned by ultrasonography increased, a more aggressive decompressive surgery was needed for an appropriate treatment.

A less invasive surgical approach in the lumbar lateral recess stenosis: direct approach to the medial wall of the pedicle.

The lateral recess is one of the main compression sites in lumbar spinal canal stenosis. Lumbar nerve root is mainly entrapped by bony tissue in compression syndrome. The patient has a long history of back pain in conjunction with claudication symptoms. Besides laminotomy and facetectomy techniques, several specific surgical approaches to treat the lateral recess stenosis have been described. The surgical technique of bilateral lateral recess decompression via subarticular fenestrations used in this study is a less invasive technique, which enables to decompress the neural structures while preserving as much of the bony structures and ligamentum flavum as preferred. In 16 patients, we measured lateral recess heights with computerized tomography. The number of involved lumbar segments was one in 11 patients and two in 5 patients. The visual analogue scale (VAS) results were maintained before, 3 and 12 months after the operation. All patients benefited from the operations. Mean VAS scores were 7.0, 5.5, and 4.0, respectively. There were not any surgery-related complications. Mean follow-up period is 22.6 months. The surgical technique described and used in this study provides easy access to every zone of lateral recess and is safe and effective in treating the lumbar lateral recess stenosis syndrome.