Protectin D1 ameliorates non-compressive lumbar disc herniation through SIRT1-mediated CGRP signaling.

Background. Neuro-inflammatory response promotes the initiation and sustenance of lumbar disc herniation (LDH). Protectin D1 (PD1), as a new type of specialized pro-resolving mediator (SPM), can improve the prognosis of various inflammatory diseases. Recent studies have shown that over representation of calcitonin gene-related peptides (CGRP) may activate nociceptive signaling following nerve injury. Silent information regulator 1 (SIRT1) is ubiquitously expressed in the dorsal horn of the spinal cord and plays a role in the pathogenesis of LDH. In this study, we investigated the analgesic effects of PD1 and elucidated the impact of neurogenic inflammation in the pathogenesis of neuropathic pain induced by non-compressive lumbar disc herniation (NCLDH) in a rat model. Methods. NCLDH models were established by applying protruding autologous nucleus pulposus to the L5 Dorsal root ganglion (DRG). PD1, SIRT1 antagonist or agonist, CGRP or antagonist were administered as daily intrathecal injections for three consecutive days postoperatively. Behavioral tests were conducted to assess mechanical and thermal hyperalgesia. The ipsilateral lumbar (L4-6) segment of the spinal dorsal horn was isolated for further analysis. Alterations in the release of SIRT1 and CGRP were explored using western blot and immunofluorescence. Results. Application of protruded nucleus (NP) materials to the DRG induced mechanical and thermal allodynia symptoms, and deregulated the expression of pro-inflammatory and anti-inflammatory cytokines in rats. Intrathecal delivery of PD1 significantly reversed the NCLDH-induced imbalance in neuro-inflammatory response and alleviated the symptoms of mechanical and thermal hyperalgesia. In addition, NP application to the DGRs resulted the spinal upregulation of CGRP and SIRT1 expression, which was almost restored by intrathecal injection of PD1 in a dose-dependent manner. SIRT1 antagonist or agonist and CGRP or antagonist treatment further confirmed the result. Conclusion. Our findings indicate PD1 has a potent analgesic effect, and can modulate neuro-inflammation by regulating SIRT1-mediated CGRP signaling in NCLDH.

The paravertebral lymphatic system is involved in the resorption of the herniated nucleus pulposus and the regression of inflammation associated with disc herniation.

OBJECTIVE: To investigate the role of the paravertebral lymphatic system in the nucleus pulposus herniation (NPH) resorption and the inflammation regression. DESIGN: Clinical specimens (n = 10) from patients with lumbar disc herniation (LDH) were collected, C57BL/6 (n = 84) and conditional Vegfr3 knockout mice (n = 14) were used. Immunofluorescence staining detected lymphatic vessels (LVs) and NP cells. Near-infrared imaging assessed lymphatic drainage function, and Alcian Blue/Orange determined inflammation. RESULTS: Lymphangiogenesis was observed in the herniated NP of patients with LDH, and the proportion of capillary LVs was higher than that of collecting LVs (mean 68.2% [95% confidence interval: 59.4, 77.1]). In NPH mice, NP cells were detected in paravertebral tissue (38.6 [32.0, 45.2]) and draining lymph nodes (dLN) at 4 h (76.9 [54.9, 98.8]). A significant increase of NP cells in dLNs was observed at 24 h (157.1 [113.7, 200.6]). Most of the herniated NP cells were cleared in paravertebral tissue after 1 week (7.5 [4.4, 10.6]), but disc inflammation peaked at 1 week (19.9% [14.7, 25.1]), along with persistent lymphangiogenesis (9.5 [7.2, 11.8]). However, conditional Vegfr3 knockout mice exhibited impaired lymphangiogenesis (5.7 [4.4, 7.0]) and herniated NP cell clearance (6.1 [1.8, 10.5]) during NPH, leading to exacerbated disc inflammation (23.7% [19.3, 28.2]). CONCLUSION: The paravertebral lymphatic system is involved in the NPH resorption and inflammation regression. Promoting lymphangiogenesis may be a novel strategy for facilitating NPH resorption and inflammation regression in patients with LDH.

CCR2 monocytes as therapeutic targets for acute disc herniation and radiculopathy in mouse models.

OBJECTIVE: Back pain and radiculopathy caused by disc herniation are major health issues worldwide. While macrophages are key players in disc herniation induced inflammation, their roles and origins in disease progression remain unclear. We aim to study the roles of monocytes and derivatives in a mouse model of disc herniation. METHODS: Using a CCR2-CreER; R26R-EGFP (Ai6) transgenic mouse strain, we fate-mapped C-C chemokine receptor type 2 (CCR2) expressing monocytes and derivatives at disc herniation sites, and employed a CCR2RFP/RFP mouse strain and a CCR2-specific antagonist to study the effects of CCR2+ monocytes on local inflammatory responses, pain level, and disc degeneration by immunostaining, flow cytometry, and histology. RESULTS: CCR2+ monocytes (GFP+) increased at the sites of disc hernia over postoperative day 4, 6, and 9 in CCR2-CreER; Ai6 mice. F4/80+ cells increased, and meanwhile, CD11b+ cells trended downward. Co-localization analysis revealed that both GFP+CD11b+ and GFP+F4/80+ constituted the majority of CD11b+ and F4/80+ cells at disc hernia sites. Fluorescence activated cell sorter purified GFP+ cells exhibited higher cytokine expressions than GFP- cells. Inhibition of CCR2 signaling reduced infiltration of monocytes and macrophages, alleviated pain, maintained disc height, and reduced osteoclast activity in adjacent cortical bone for up to 1 month. CONCLUSION: Our findings suggest that circulating CCR2+ monocytes play important roles in initiating and promoting the local inflammatory responses, pain sensitization, and degenerative changes after disc herniation, and thus may serve as therapeutic targets for disc herniation induced back and leg pain.

Deep Learning Model for Grading and Localization of Lumbar Disc Herniation on Magnetic Resonance Imaging.

BACKGROUND: Methods for grading and localization of lumbar disc herniation (LDH) on MRI are complex, time-consuming, and subjective. Utilizing deep learning (DL) models as assistance would mitigate such complexities. PURPOSE: To develop an interpretable DL model capable of grading and localizing LDH. STUDY TYPE: Retrospective. SUBJECTS: 1496 patients (M/F: 783/713) were evaluated, and randomly divided into training (70%), validation (10%), and test (20%) sets. FIELD STRENGTH/SEQUENCE: 1.5T MRI for axial T2-weighted sequences (spin echo). ASSESSMENT: The training set was annotated by three spinal surgeons using the Michigan State University classification to train the DL model. The test set was annotated by a spinal surgery expert (as ground truth labels), and two spinal surgeons (comparison with the trained model). An external test set was employed to evaluate the generalizability of the DL model. STATISTICAL TESTS: Calculated intersection over union (IoU) for detection consistency, utilized Gwet's AC1 to assess interobserver agreement, and evaluated model performance based on sensitivity and specificity, with statistical significance set at P < 0.05. RESULTS: The DL model achieved high detection consistency in both the internal test dataset (grading: mean IoU 0.84, recall 99.6%; localization: IoU 0.82, recall 99.5%) and external test dataset (grading: 0.72, 98.0%; localization: 0.71, 97.6%). For internal testing, the DL model (grading: 0.81; localization: 0.76), Rater 1 (0.88; 0.82), and Rater 2 (0.86; 0.83) demonstrated results highly consistent with the ground truth labels. The overall sensitivity of the DL model was 87.0% for grading and 84.0% for localization, while the specificity was 95.5% and 94.4%. For external testing, the DL model showed an appreciable decrease in consistency (grading: 0.69; localization: 0.66), sensitivity (77.2%; 76.7%), and specificity (92.3%; 91.8%). DATA CONCLUSION: The classification capabilities of the DL model closely resemble those of spinal surgeons. For future improvement, enriching the diversity of cases could enhance the model's generalization. TECHNICAL EFFICACY: Stage 2.

Prediction of transforaminal epidural injection success in sciatica (POTEISS): a protocol for the development of a multivariable prediction model for outcome after transforaminal epidural steroid injection in patients with lumbar radicular pain due to disc herniation or stenosis.

BACKGROUND: Transforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI. METHODS: This study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling. DISCUSSION: Patients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

MRI analysis of neurodevelopmental anatomy in myelomeningocele: prenatal vs postnatal repair.

OBJECTIVE: Compared with postnatal repair, prenatal myelomeningocele (MMC) repair is associated with improved motor function and decreased need for cerebrospinal fluid (CSF) diversion. It is unknown how prenatal surgery alters neuroanatomical structures identifiable on magnetic resonance imaging (MRI). The purpose of this study was to use MRI to compare neurodevelopmental anatomy in patients undergoing fetal MMC repair compared with those undergoing postnatal repair. METHODS: This was a retrospective review of neonates who underwent prenatal or postnatal MMC repair at our institution between 2016 and 2021. Imaging data, including prenatal ultrasound and pre- and postnatal MRI examinations, if available, were retrieved. We analyzed anatomical findings characteristically seen on MRI of the neuroaxis in patients with MMC and compared imaging findings between patients with prenatal vs postnatal MMC repair. RESULTS: The study population included 61 patients who underwent surgical repair for MMC during the 6-year study period, of whom 25 underwent prenatal repair and 36 postnatal repair. CSF diversion was required in 24% of the prenatally repaired cohort vs 67% of the postnatally repaired cohort (P = 0.001). On postnatal MRI, a syrinx was present in 13% of the prenatally repaired cohort vs 42% in the postnatally repaired cohort (P = 0.02). Postnatal corpus callosal (CC) morphology was abnormal in 54% of the prenatally repaired cohort vs 53% of the postnatally repaired cohort (P = 0.92), while falx morphology was normal in 92% of the prenatally repaired cohort vs 34% of the postnatally repaired cohort (P < 0.001). On postnatal MRI, patients in the prenatally repaired cohort had a shorter tentorium-to-foramen-magnum distance compared with those in the postnatally repaired cohort (mean, 18.43 mm vs 22.42 mm; P = 0.01), a larger foramen magnum diameter (mean, 22.87 mm vs 18.94 mm; P < 0.001) and a smaller degree of hindbrain herniation (mean, 1.53 mm vs 8.72 mm; P < 0.001). The cerebral aqueduct was patent in 79% of the prenatally repaired cohort vs 100% of the postnatally repaired cohort on postnatal MRI (P = 0.008). Between the two cohorts, at postnatal MRI there was no significant difference in the presence of gray-matter heterotopia, presence of the septum pellucidum or size of the massa intermedia. CONCLUSIONS: We report variations in developmental neuroanatomy in patients with MMC, including rates of CC dysgenesis, gray-matter heterotopia and additional cranial and spinal MRI findings. Compared to postnatal surgery, prenatal surgery is associated with changes to infratentorial anatomy, with minimal effect on supratentorial brain development. This information will be useful in counseling parents affected by fetal MMC and in understanding how prenatal repair of MMC affects brain development. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Right lower lung midline herniation as a rare complication in an infant with heart-lung transplantation: A case report.

BACKGROUND: Lung herniation is a rare complication of heart-lung transplantation that can be fatal owing to vascular compromise and airway obstruction. To date, only five cases of lung herniation related to heart-lung transplantation have been reported in the literature; however, to the best of our knowledge, this is the first worldwide report of heart-lung transplantation-related lung herniation in an infant. METHODS: We describe the case of lung herniation as a rare heart-lung transplantation-related complication in an infant. A 12-month-old female baby developed severe bronchopulmonary dysplasia with severe pulmonary hypertension, and she underwent extracorporeal membrane oxygenation for cardiac collapse and lung support. Then, we performed heart-lung transplantation to manage the irreversible deterioration of her lung function. After the heart-lung transplantation, we found the radiological abnormalities persisted on follow-up chest radiographs until the 13th postoperative day diagnosed as lung herniation of the right lower lobe on chest computed tomography. RESULTS: After the relocation of the herniated lung, the clinical condition of the patient improved, and the patient is currently growing without any respiratory symptoms. CONCLUSIONS: In this case report, we emphasize that clinical awareness and high suspicion of this rare complication are needed for early diagnosis and proper treatment to prevent post-transplantation morbidity and mortality related to potential ischemic injury.

Late presentation of traumatic tricuspid valve chordal rupture and pericardial rupture with cardiac herniation: a case report.

BACKGROUND: Although chest trauma happens very often, accompanying tricuspid valve injuries occur rarely and may be manifested by scarce symptoms and signs. Pericardial rupture with cardiac herniation is even a bigger rarity. Transthoracic echocardiography plays a key role in the diagnosis of valve injuries but is of limited value in cardiac herniation. CASE PRESENTATION: We present the case of 58-year-old man who experienced severe chest trauma in a car accident. Symptoms of right heart failure occurred 10 years after the injury, due to the loss of tricuspid leaflet support caused by the rupture of tendinous chords with significant tricuspid regurgitation. Intraoperatively, old posttraumatic pericardial rupture into left pleura was also found, with partial cardiac herniation and pressure of the edge of pericardium on all left-sided coronary arteries simultaneously. The patient was successfully operated and is free of symptoms 4 years later. CONCLUSIONS: This case emphasizes the importance of timely diagnosis and underlines a mechanism that leads to delayed rupture of the tricuspid valve apparatus. Repeated echocardiography in all patients who experienced chest trauma could be of great importance. Also, given the limited value of echocardiography in posttraumatic pericardial rupture and cardiac herniation, cardiac computed tomography should be performed.

Congenital diaphragmatic hernia: automatic lung and liver MRI segmentation with nnU-Net, reproducibility of pyradiomics features, and a machine learning application for the classification of liver herniation.

Prenatal assessment of lung size and liver position is essential to stratify congenital diaphragmatic hernia (CDH) fetuses in risk categories, guiding counseling, and patient management. Manual segmentation on fetal MRI provides a quantitative estimation of total lung volume and liver herniation. However, it is time-consuming and operator-dependent. In this study, we utilized a publicly available deep learning (DL) segmentation system (nnU-Net) to automatically contour CDH-affected fetal lungs and liver on MRI sections. Concordance between automatic and manual segmentation was assessed by calculating the Jaccard coefficient. Pyradiomics standard features were then extracted from both manually and automatically segmented regions. The reproducibility of features between the two groups was evaluated through the Wilcoxon rank-sum test and intraclass correlation coefficients (ICCs). We finally tested the reliability of the automatic-segmentation approach by building a ML classifier system for the prediction of liver herniation based on support vector machines (SVM) and trained on shape features computed both in the manual and nnU-Net-segmented organs. We compared the area under the classifier receiver operating characteristic curve (AUC) in the two cases. Pyradiomics features calculated in the manual ROIs were partly reproducible by the same features calculated in nnU-Net segmented ROIs and, when used in the ML procedure, to predict liver herniation (both AUC around 0.85).          Conclusion: Our results suggest that automatic MRI segmentation is feasible, with good reproducibility of pyradiomics features, and that a ML system for liver herniation prediction offers good reliability.          Trial registration: https://clinicaltrials.gov/ct2/show/NCT04609163?term=NCT04609163&draw=2&rank=1 ; Clinical Trial Identification no. NCT04609163. What is Known: • Magnetic resonance imaging (MRI) is crucial for prenatal congenital diaphragmatic hernia (CDH) assessment. It enables the quantification of the total lung volume and the extent of liver herniation, which are essential for stratifying the severity of CDH, guiding counseling, and patient management. • The manual segmentation of MRI scans is a time-consuming process that is heavily reliant upon the skill set of the operator. What is New: • MRI lung and liver automatic segmentation using the deep learning nnU-Net system is feasible, with good Jaccard coefficient values and satisfactory reproducibility of pyradiomics features compared to manual results. • A feasible ML system for predicting liver herniation could improve prenatal assessments and CDH patient management.

C3-C4 cervical disc herniation producing Brown-Séquard syndrome: A case report and review of the literature.

Brown-Séquard Syndrome (BSS) is a rare form of incomplete spinal cord injury and is characterized by ipsilateral motor deficit and contralateral sensory loss. BSS is commonly associated with traumatic etiologies, but non-traumatic causes should be considered as well. A 38-year-old woman presented with a 3-week history of weakness in her right upper extremity, and she has developed numbness and tingling in her left upper and lower extremities over the past week and a half, along with some motor difficulty. Imaging showed a large right paracentral disc protrusion at the C3-C4 level causing severe spinal canal narrowing and resulting in abnormal cord signal. The patient subsequently underwent a C3-4 cervical total disk replacement. Hemovac placed during surgery was removed on post-op day one, and she was re-evaluated by PT/OT and recommended for outpatient therapies on post-op day two. Our case, along with a review of the literature, highlights those non-traumatic causes of BSS should be considered as a cause of BSS. BSS produced by a herniated cervical disc is extremely rare and is often misdiagnosed.

Subdural hemorrhage in middle cranial fossa arachnoid cysts: a report of two cases at two ends of the spectrum.

Arachnoid cysts are usually asymptomatic, benign lesions commonly occurring in the middle cranial fossa. However, the cysts may rupture in rare cases causing intracystic or subdural hemorrhages with significant mass effect. We report two cases of middle cranial fossa arachnoid cyst with subdural hemorrhage with very different clinical course. The first case presented with significant mass effect with cerebral herniation and had significant neurological morbidity post-surgery. The second case had minimal symptoms and was managed conservatively with offer of elective surgery. The report underscores the importance of prompt diagnosis and appropriate surgical intervention in managing arachnoid cysts with hemorrhage, highlighting the potential for diverse clinical presentations and outcomes.

lVentral tethering-is the prognosis worse than in dorsal tethering in the dysraphic spine?

OBJECTIVE: To compare cases of dysraphism with ventral tethering of cord with those with dorsal tethering and to find out any differences in the outcome of surgery in them. METHODS: We collected the data of 188 consecutively operated tethered cord patients at our institute in the past 7 years and divided them into ventral tethering and dorsal tethering groups. Those that we felt had both dorsal and ventral tethering were excluded. Their preoperative clinical, radiological, and baseline neurophysiological parameters as well as postoperative clinical and radiological parameters were analyzed in a retrospective study. RESULTS: Among the 188 tethered cord patients, 52 (28%) had ventral tethering and 136 (72%) had posterior tethering. Preoperative neurodeficit and cord signal changes as well as absent baseline MEP (of any one muscle) were significantly more associated with ventral tethered cord than the dorsal tethered cord. The neurological deterioration after surgery occurred significantly in the ventral tethered cord group than in the dorsal tethered cord group. Also, the postoperative MRI had more incomplete detethering cases in the ventral group than in the dorsal tethered cord group. CONCLUSION: Ventral tethered cord is more likely to present with preoperatively neurological deficits. It should be carefully identified in the preoperative MRI, so that the intraoperative difficulties in complete detethering and postoperative deterioration can be anticipated.

Clinical feasibility of MRI-based synthetic CT imaging in the diagnosis of lumbar disc herniation: a comparative study.

BACKGROUND: Computed tomography (CT) and magnetic resonance imaging (MRI) are indicated for use in preoperative planning and may complicate diagnosis and place a burden on patients with lumbar disc herniation. PURPOSE: To investigate the diagnostic potential of MRI-based synthetic CT with conventional CT in the diagnosis of lumbar disc herniation. MATERIAL AND METHODS: After obtaining prior institutional review board approval, 19 patients who underwent conventional and synthetic CT imaging were enrolled in this prospective study. Synthetic CT images were generated from the MRI data using U-net. The two sets of images were compared and analyzed qualitatively by two musculoskeletal radiologists. The images were rated on a 4-point scale to determine their subjective quality. The agreement between the conventional and synthetic images for a diagnosis of lumbar disc herniation was determined independently using the kappa statistic. The diagnostic performances of conventional and synthetic CT images were evaluated for sensitivity, specificity, and accuracy, and the consensual results based on T2-weighted imaging were employed as the reference standard. RESULTS: The inter-reader and intra-reader agreement were almost moderate for all evaluated modalities (κ = 0.57-0.79 and 0.47-0.75, respectively). The sensitivity, specificity, and accuracy for detecting lumbar disc herniation were similar for synthetic and conventional CT images (synthetic vs. conventional, reader 1: sensitivity = 91% vs. 81%, specificity = 83% vs. 100%, accuracy = 87% vs. 91%; P < 0.001; reader 2: sensitivity = 84% vs. 81%, specificity = 85% vs. 98%, accuracy = 84% vs. 90%; P < 0.001). CONCLUSION: Synthetic CT images can be used in the diagnostics of lumbar disc herniation.

Endoscopic third ventriculostomy (ETV) for Chiari 1 malformation: a systematic review and meta-analysis.

Meta-analysis and systematic review. To understand the role of endoscopic third ventriculostomy (ETV) for the treatment of concurrent Chiari Malformation Type I (CMI) and hydrocephalus in adults. A literature search on PubMed and Medline with MeSH terms relating to ETV and CMI identified 155 articles between 1988 and 2024. After excluding pediatric cases and other CNS pathologies with associated CMI, 11 articles met inclusion criteria. The Newcastle-Ottawa Scale was identified to assess heterogeneity and risk of bias among the 11 studies analyzed in this systematic-review and meta-analyses compared pre- and post-operative outcomes to examine the use of ETV as a treatment modality for CMI with hydrocephalus. From the 11 included studies, 35 cases of concurrent CMI and hydrocephalus treated with ETV were identified. ETV provided a pooled rate of symptom resolution or improvement of 66%. Additionally, meta-analysis discovered the following pooled rates: a reduction of tonsillar descent in 94% of patients, decreased ventriculomegaly in 94%, and ETV patency in 99%. Syringomyelia, nausea, papilledema and cerebellar dysfunction did not have sufficient numbers for meaningful statistical analyses. However, in each of these categories, more than 85% of the symptoms or radiographic findings improved. This review summarizes the safety and efficacy of ETV for the concurrent management of acquired CMI with hydrocephalus. Specifically, ETV improves radiological outcomes of both ventriculomegaly and tonsillar descent as well as the most prevalent neurological symptom, headaches.

Characteristics in patients with very early therapeutic response of condoliase chemonucleolysis for lumbar disc herniation.

INTRODUCTION: Treatment of lumbar disc herniation (LDH) using condoliase chemonucleolysis (CC) requires more time than surgery to demonstrate therapeutic effects. This study aimed to identify patients who show significant improvement in leg pain very early after CC and to determine pretreatment factors that can predict a very early therapeutic response. METHODS: The study included 52 patients who underwent CC for treatment-resistant LDH. Scores for low back and leg pain measured by a numerical rating scale were assessed at four time points (1 day, 1 week, 1 month, and 3 months after CC). Patients who reported subjective pain relief the day after treatment and further exhibited an improved straight leg raising (SLR) angle compared to pretreatment were classified as "very early responders (VER)". RESULTS: Of the 52 patients, 39 (75%) were VER, and 13 (25%) were non-VER. The VER showed earlier improvement in leg pain. The VER had a significantly higher proportion of positive SLR test patients (p = 0.01) and a significantly smaller pretreatment SLR angle compared to the non-VER (VER vs. non-VER: 40.6 ± 19.0 vs. 63.1 ± 16.9, p < 0.001). There were no significant differences in the level, type, and size of LDH and the disc regression rate between the two groups. CONCLUSIONS: Patients with a smaller pretreatment SLR angle are more likely to experience very early or early symptomatic relief, with a significant and sustained reduction in leg pain up to 3 months after CC treatment.

Perioperative management of antithrombotic therapy in elderly patients undergoing lumbar discectomy: a retrospective study on 163 patients.

BACKGROUND CONTEXT: The prevalence of lumbar disc herniation (LDH) has risen alongside the aging population, often necessitating neurosurgical intervention. However, managing antithrombotic medications in elderly patients with a history of major cardiovascular events (MACE) presents challenges, as treatment may require modification or cessation. This study aims to compare surgical outcomes among elderly patients receiving antithrombotic drugs and assess their impact and potential complications. The findings aim to inform the management of elderly patients with cardiovascular and spinal conditions undergoing neurosurgery. METHODS: This retrospective, observational study was conducted at a single center. A total of 163 patients aged 60 or above who underwent lumbar discectomy for LDH were included. Patients were categorized into three groups based on their antithrombotic drug management: Group A (46 patients) replaced antiplatelet agents with low-dose aspirin for secondary prevention, Group B (54 patients) discontinued antiplatelet agents for primary prevention one week preoperatively and replaced them with LMWH, and Group C (63 patients) did not receive antithrombotic medication. Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed across all three groups. Continuous variables were compared between groups using the two-tailed Mann-Whitney test, with significance set at p < 0.05. RESULTS: No significant differences were found in intraoperative blood loss or surgical time among groups A, B, and C. Similarly, no significant differences were observed between groups B and C across all analyzed variables. No early or delayed hemorrhagic complications occurred perioperatively or during the 3-month postoperative follow-up period. CONCLUSIONS: The study suggests that elective discectomy surgery in patients receiving anticoagulant and antiplatelet therapies may proceed without early complications and can be safely continued perioperatively. These findings have implications for the management of elderly patients requiring neurosurgical intervention in the context of cardiovascular comorbidities.

Scalp incision technique for decompressive hemicraniectomy: comparative systematic review and meta-analysis of the reverse question mark versus alternative retroauricular and Kempe incision techniques.

Decompressive hemicraniectomy (DHC) is a critical procedure used to alleviate elevated intracranial pressure (ICP) in emergent situations. It is typically performed to create space for the swelling brain and to prevent dangerous and potentially fatal increases in ICP. DHC is indicated for pathologies ranging from MCA stroke to traumatic subarachnoid hemorrhage-essentially any cause of refractory brain swelling and elevated ICPs. Scalp incisions for opening and closing the soft tissues during DHC are crucial to achieve optimal outcomes by promoting proper wound healing and minimizing surgical site infections (SSIs). Though the reverse question mark (RQM) scalp incision has gained significant traction within neurosurgical practice, alternatives-including the retroauricular (RA) and Kempe incisions-have been proposed. As choice of technique can impact postoperative outcomes and complications, we sought to compare outcomes associated with different scalp incision techniques used during DHC. We queried three databases according to PRISMA guidelines in order to identify studies comparing outcomes between the RQM versus "alternative" scalp incision techniques for DHC. Our primary outcome of interest in the present study was postoperative wound infection rates according to scalp incision type. Secondary outcomes included estimated blood loss (EBL) and operative duration. We identified seven studies eligible for inclusion in the formal meta-analysis. The traditional RQM technique shortened operative times by 36.56 min, on average. Additionally, mean EBL was significantly lower when the RQM scalp incision was used. Postoperatively, there was no significant association between DHC incision type and mean intensive care unit (ICU) length of stay (LOS), nor was there a significant difference in predisposition to developing wound complications or infections between the RQM and retroauricular/Kempe incision cohorts. Superficial temporal artery (STA) preservation and reoperation rates were collected but could not be analyzed due to insufficient number of studies reporting these outcomes. Our meta-analysis suggests that there is no significant difference between scalp incision techniques as they relate to surgical site infection and wound complications. At present, it appears that outcomes following DHC can be improved by ensuring that the bone flap is large enough to enable sufficient cerebral expansion and decompression of the temporal lobe, the latter of which is of particular importance. Although previous studies have suggested that there are several advantages to performing alternative scalp incision techniques during DHC, the present study (which is to our knowledge the first to meta-analyze the literature on outcomes in DHC by scalp incision type) does not support these findings. As such, further investigations in the form of prospective trials with high statistical power are merited.

"Advancements in minimally invasive treatment for lumbar disc herniation: insights into condoliase and chondroitin sulfate ABC endolyase".

This study examines the efficacy and safety of condoliase chemonucleolysis (CC) in treating lumbar disc herniation (LDH) and highlights emerging alternatives like chondroitin sulfate ABC endolyase. Research indicates that condoliase, an enzyme used to degrade glycosaminoglycans in the nucleus pulposus, provides effective and prompt relief of leg pain, with significant reductions observed within a day of treatment. Studies reveal that a lower pretreatment straight leg raising (SLR) angle may predict early symptom relief, and condoliase is generally effective at doses up to 1.25 U, balancing efficacy and safety. Despite promising results, concerns about long-term safety, including disc height reduction and imaging changes, persist. Additionally, chondroitin sulfate ABC endolyase shows potential as a safer and more effective alternative, though further research is needed to optimize treatment protocols and assess long-term outcomes. Future investigations should address current limitations, such as small sample sizes and short follow-up periods, to better understand the long-term benefits and risks of these treatments.

Autophagy in an extruded disc compared to the remaining disc after lumbar disc herniation in the same patient.

PURPOSE: The purpose of this study was to investigate autophagy in an extruded disc and to compare this activity with the activity in the remaining disc after lumbar disc herniation in the same patient. METHODS: In total, 12 patients (females 4, males 8) with the extruded type of lumbar disc herniation (LDH) were surgically treated. Their mean age was 54.3 ± 15.8 years (range: 29 ~ 78 years). The mean interval from the occurrence of symptoms to the operation was 9.8 ± 9.4 weeks (range: 2 ~ 24 weeks). The extruded discs were excised, and the remaining disc material removed, to prevent recurrence of herniation. Immediately after specimen collection, all tissues were stored at -70 °C prior to analysis. Autophagy was assessed immunohistochemically and via Western blotting for Atg5, Atg7, Atg12, Atg12L1, and Beclin-1. And the relationship between autophagy and apoptosis was investigated by correlation analysis of caspase-3 with autophagy proteins. RESULTS: The expression levels of autophagic markers were significantly increased in the extruded discs compared to the remaining discs within the same patients. The mean expression levels of Atg5, Atg7, Atg12, and Beclin-1 in extruded discs were statistically significantly higher than those in the remaining discs (P < 0.01, P < 0.001, P < 0.01, and P < 0.001 respectively). CONCLUSIONS: The autophagic pathway was more active in extruded disc material than in remaining disc material within the same patient. This may explain spontaneous resorption of the extruded disc after LDH.

Evaluation of the effect of cervical and lumbar disc herniations on female sexual function: a comparative prospective study.

PURPOSE: We aimed to evaluate the effect of cervical disc herniation (CDH) and lumbar disc herniation (LDH) on female sexual functioning before and after surgical intervention. METHODS: The current study was conducted from February 2022 to February 2023. A total of 100 sexually active female patients in their reproductive phase who were diagnosed with CDH and LDH based on physical examination and previous magnetic resonance imaging (MRI) results, as well as 50 healthy females, were enrolled. The female subjects were evaluated using the validated Arabic version of the female sexual function index (ArFSFI), a 0 to 10 visual analogue scale (VAS), the Oswestry disability index (ODI) and Beck's depression index (BDI). RESULTS: The baseline ArFSFI domains and total scores were greatest in the controls, followed by the CDH group. The ArFSFI domains and total scores were greatest in the control group, followed by the postoperative ArFSFI domains and total scores in the cervical group. The variations in satisfaction, pain, and overall ArFSFI ratings were significant across research groups. The difference in desire, arousal, lubrication, and orgasm was substantial in the lumbosacral group, but there were no significant changes between the cervical and control groups. Postoperatively, ArFSFI domains and overall scores improved in both of the cervical and lumbar groups. Both research groups' ODI score and grade improved after surgery. Finally, both groups' BDI score and grade improved after surgery. CONCLUSION: Female sexual dysfunctions caused by CDH and LDH improved considerably after surgery.