Radiopaque Gelified Ethanol Application in Lumbar Intervertebral Soft Disc Herniations: Croatian Multicentric Study.

Objective: Minimally invasive percutaneous spinal procedures are popular in trying to reduce spinal pain. The aim of this paper is to evaluate the safety of intervertebral disc chemonucleolysis and to report the effectiveness of a percutaneous, minimally invasive treatment for contained herniated intervertebral discs in the lumbar spine using the recently marketed radiopaque gelified ethanol. Methods: Pain relief before and after the procedure was self-evaluated by each patient using a verbal numeric scale (VNS) ranging from 0 to 10. Patients were also scored prior to procedure and after chemonucleolysis during several follow-up periods using the Roland-Morris low back pain and disability questionnaire (RMQ). Follow-up periods were defined as 0-6, 6-12, 12-18, 18-24, and 24-30 months. Clinically significant functional improvement (CSFI) was defined as a decrease of five or more points on the RMQ scale and a decrease of at least 50% of pain intensity using VNS. Results: Using the RMQ scale, CSFI was achieved in 20/29 patients in the first follow-up period, 20/27 patients in the second follow-up period, 9/12 patients in the third follow-up period, 8/9 patients in the fourth follow-up period, and 4/4 patients in the last follow-up period. Using the VNS rating, CSFI was accomplished in 19/29 patients in the first follow-up period, 19/27 patients in the second follow-up period, 9/12 patients in the third follow-up period, 8/9 patients in the fourth follow-up period, and 4/4 in the last follow-up period. Conclusions: Intradiscal application of gelified ethanol may be effective in pain reduction using the VNS and Roland-Morris low back pain and disability questionnaire. The treatment is safe and easy to handle.

[First guidelines of Croatian interest group in diagnosing and treating pain conditions of cervical and thoracic spine using minimally invasive procedures]. / Prve hrvatske smjernice za dijagnostiku i lijecenje bolnih stanja vratne i prsne kraljeznice minimalno invazivnim postupcima.

Pain syndromes originating from cervical and thoracic spine remain to be a major public health problem. Medical expenses in general and surgical procedures associated with overall care for the neck and thoracic pain are high and growing. Furthermore, these two chronic pain conditions are also leading causes for missed workdays. Chronic pain syndromes originating from cervical spine are most commonly caused by degenerative changes of the facet joints. Cervi- cobrachial syndrome is most commonly caused by herniated discs. Diagnostic controlled blocks, performed in order to identify, the source of pain, often predetermine patient for further therapeutic minimally invasive interventions. If the chronic pain syndromes of the cervical and thoracic spine are caused by degenerative facet joints, patient can be offered neuroablative procedures using radiofrequency. In patients suffering from chronic cervical and thoracic pain caused by painful intervertebral disc minimally invasive intradiscal decompression procedures can be performed. In cases where the neck pain and radicular pain are caused by the central and foraminal spinal stenosis patients are advised epidural steroid injections. The purpose of above advised procedures, using steroids, local anesthetics and RF current, is to relieve patients' pain, allow optimal physical therapy, and improved functional capacity, consequently providing a better quality of life.

[Guidelines for interventional and invasive treatment in patients with mechanical back pain]. / Smjernice za intervencijske i invazivne postupke u bolesnika s mehanickom krizoboljom.

Back pain caused primarily by mechanical disorders is the most common type of back pain and it is usually found in young and middle-aged population, i.e. active population. This is why back pain is one of the most important public health problems. Treatment of pain syndrome affecting spine depends on a variety of factors and generally includes conservative and invasive methods. Relative indication for interventional and surgical procedures is long lasting back pain, the symptoms of which, predominantly pain, cause significant problems for the patient on performing everyday activities. Invasive/surgical treatment is applied after minimally 3 months of unsuccessful conservative treatment. Invasive and surgical procedures comprise a wide spectrum of interventions, from interventional and semi-interventional procedures, minimally invasive procedures to extensive, invasive operations that include instrumentation. The choice of intervention is based on clinical findings, duration and severity of pain and other symptoms, as well as on diagnostic reports. Despite recommendations based on the results of clinical studies, individual approach to each patient is the main principle of successful treatment.

[First guidelines of Croatian interest group in diagnosing and treating lower back and radicular pain using minimally invasive diagnostic and therapeutic procedures]. / Prve hrvatske smjernice za dijagnostiku i lijecenje krizobolje i lumboishialgije minimalno invazivnim procedurama.

Low back and radicular pain recently became a major public health problem. Medical expenses in general, and surgical procedures associated with overall care for the lower back pain are high and growing. Furthermore, these two chronic pain conditions are also leading causes for missed workdays. Degenerative changes of the intervertebral disc, facet joints, sacroiliac joint or disc herniation as described during imaging diagnostics may or may not be the cause of patients' lower back pain. Diagnostic blocks often precede further interventions in order to confirm or dispute a source of the lower back pain. Chronic lower back pain caused by painful intervertebral disc should be treated using biacuplasty. If the pain of the lumbar spine is caused by facet joints or sacroiliac joint, patient can be offered neuroablative procedures using radiofrequency. In cases where the low back and radicular pain are caused by the central and foraminal spinal stenosis patients are advised epidural steroid injections, unless claudications are present. Patients suffering from the chronic radicular pain may be treated with various nucleoplasty procedures or they may be offered percutaneous radiofrequent neuromodulation. The purpose of above advised procedures is to relieve patients' pain, allow optimal physical therapy, and improved functional capacity, consequently providing better quality of life.

Long-term Clinical Outcomes Following Endoscopic Foraminoplasty for Patients With Single-Level Foraminal Stenosis of the Lumbar Spine.

BACKGROUND: The aim of this study is to evaluate the safety and long-term clinical outcomes of transforaminal endoscopic foraminoplasty using local anesthesia and total intravenous analgesia (TIVA) in patients with single-level lumbar foraminal stenosis and unilateral leg pain. METHODS: Postoperative pain relief was self-evaluated by 46 consecutive patients using a visual analog scale (VAS) and Oswestry Disability Index (ODI). Patient scores were obtained before the procedure and at 6, 12, 24, and 60 months after surgery. RESULTS: Pain reduction of at least 50% in the VAS score and a decrease of at least 50% or more in ODI score was achieved in 37 of 46 patients throughout the follow-up period. Median VAS score decreased from 7.5 preoperatively to 2.5 postoperatively. Median ODI score decreased from 62% preoperatively to 15% postoperatively. All patients reached 24-month follow-up and 37 patients reached 60-month follow-up. There were no surgery-related complications. CONCLUSION: Transforaminal endoscopic foraminoplasty performed under local anesthesia and TIVA produces sustained reduction in pain and improves functionality in patients with single-level lumbar foraminal stenosis without complications even in patients with comorbidities. CLINICAL RELEVANCE: Endoscopic foraminoplasty may be a useful adjunct to open micro decompressive surgery for patients with foraminal stenosis of the lumbar spine LEVEL OF EVIDENCE: 4.

Isolated cerebellar intraparenchymal Rosai-Dorfman disease--case report and review of literature.

BACKGROUND: Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy) rarely affects intracranial structures without involvement of other sites. We herein review the tumour characteristics, differential diagnosis and treatment policy of this rare disease. METHOD: We conducted a PUBMED search using a combination of words 'Rosai-Dorfman disease', 'Central nervous system', and identified 42 cases of such a disease infecting exclusively central nervous system. Out of those cases only one case was reported to be purely intracerebellar making our case the second one in the literature. Clinical features, differential diagnosis, treatment details and follow-up were discussed. We also described the case of 41-year-old man presented with vertiginous symptoms and mild cerebellar ataxia who was diagnosed with a solitary lesion localised deep in the right cerebellar hemisphere. Immunohistological findings revealed Rosai-Dorfman disease. FINDINGS: The most common locations of the tumour were frontal and parietal region, but CNS lesions have commonly involved the skull base with a leptomeningeal component too. The median age at presentation was in the third decade, ranging from 3 to 78 years. There is a slight male predominance. The follow-up ranged from 1 month to 11 years. Recurrence was not observed in the cases where total surgical excision was performed. CONCLUSION: Though Rosai-Dorfman disease is a rarity, one should take it into a consideration when treating solitary intracerebellar lesion. Thorough preoperative evaluation is mandatory and biopsy should be done whenever feasible. Surgical treatment of this type of tumour is not always necessary, however, it is essential for postulating the right diagnosis. When total tumour removal is achieved, the outcome is generally better, with minimal risk of recurrence and with no need for further additional therapy.

Interaction of α-melanocortin and its pentapeptide antisense LVKAT: effects on hepatoprotection in male CBA mice.

The genetic code defines nucleotide patterns that code for individual amino acids and their complementary, i.e., antisense, pairs. Peptides specified by the complementary mRNAs often bind to each other with a higher specificity and efficacy. Applications of this genetic code property in biomedicine are related to the modulation of peptide and hormone biological function, selective immunomodulation, modeling of continuous and linear epitopes, modeling of mimotopes, paratopes and antibody mimetics, peptide vaccine development, peptidomimetic and drug design. We have investigated sense-antisense peptide interactions and related modulation of the peptide function by modulating the effects of a-MSH on hepatoprotection with its antisense peptide LVKAT. First, transcription of complementary mRNA sequence of a-MSH in 3'→5' direction was used to design antisense peptide to the central motif that serves as a-MSH pharmacophore for melanocortin receptors. Second, tryptophan spectrofluorometric titration was applied to evaluate the binding of a-MSH and its central pharmacophore motif to the antisense peptide, and it was concluded that this procedure represents a simple and efficient method to evaluate sense-antisense peptide interaction in vitro. Third, we showed that antisense peptide LVKAT abolished potent hepatoprotective effects of a-MSH in vivo.

Osteolytic skull metastasis with dural involvement from a papillary thyroid carcinoma.

Skull metastatic tumors are relatively rare medical entities and originate most often from the lungs, breast or prostate. We report a case of a 76-year-old woman who presented with a bulging, well-circumscribed mass on the right side of the forehead. Neuroimaging of the cranium detected an osteolytic lesion measuring 7 cm in the largest diameter while propagating outwards and intracranially. A thorough medical history revealed that patient had undergone surgery for invasive breast ductal carcinoma and also for a well-differentiated thyroid carcinoma 13 years ago. Considering patients medical history metastatic breast carcinoma was suspected. After a frontal craniotomy the tumour tissue was totally resected. Histological examination revealed metastatic papillary carcinoma characterized by ground-glass nuclei with intranuclear pseudo inclusion and nuclear grooves. We report clinical and neuroradiological features of this uncommon lesion and discussed the differential diagnosis of skull osteolytic lesion together with the treatment management.

Five-Year Outcomes After Transforaminal Endoscopic Foraminotomy and Discectomy for Soft and Calcified Thoracic Disc Herniations.

BACKGROUND: The aim of this study was to evaluate the safety and long-term clinical outcomes of transforaminal full endoscopic discectomy and foraminotomy performed with manual reamers under local anesthesia on soft and calcified herniated discs in the mid and lower thoracic spine. METHODS: Postoperative pain relief was self-evaluated by 16 patients using a visual analog scale (VAS) and Oswestry Disability Index (ODI). Patients were scored at 6, 12, 24, and 60 months after surgery. RESULTS: Significant pain reduction of more than 50% in the VAS score was achieved in 15 out of 16 patients at all review points throughout this study. Similarly, a decrease of more than 50% in ODI scores was achieved in 15 out of 16 patients in all 4 review points. There were no surgical complications. Good postoperative results were achieved in patients regardless of the consistency of the disc herniation. CONCLUSIONS: Transforaminal full endoscopic discectomy and foraminotomy with manual reamers performed under local anesthesia produces sustained reduction in pain and improves functionality in patients with mid and lower thoracic spine soft and calcified disc herniations. The surgery is safe and straightforward to perform with the correct training. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Thoracic transforaminal endoscopic discectomy and foraminotomy, performed in TIVA, may be a useful adjunct for treatment of patients with soft and calcified disc herniations in thoracic spine.

The influence of alpha-, beta-, and gamma-melanocyte stimulating hormone on acetaminophen induced liver lesions in male CBA mice.

Research over the past decade has indicated that melanocortin peptides are potent inhibitors of inflammation and a promising source of new anti-inflammatory and cytoprotective therapies. The purpose of the present paper is to compare protective effects of alpha-, beta-, and gamma-melanocyte stimulating hormone on acetaminophen induced liver lesions in male CBA mice. Acetaminophen was applied intragastrically in a dose of 150 mg/kg, and tested substances were applied intraperitoneally 1 hour before acetaminophen. Mice were sacrificed after 24 hours and intensity of liver injury was estimated by measurement of plasma transaminase activity (AST and ALT) and histopathological grading of lesions. It was found that alpha-, beta-, and gamma-MSH decrease intensity of lesions by both criteria in a dose-dependent manner.

Accidental finding of an anomalous spinal nerve root during lumbar-disc surgery: a case report and a review of literature.

Anomalies of lumbosacral nerve roots, even though are rare, have been well documented so far in the medical literature. The early diagnosis of these anomalies may be difficult and it is crucial to develop specific methods for depicting them. Preoperative diagnosis of anomalous lumbosacral spinal nerve roots using the magnetic resonance imaging is essential to facilitate thorough surgical planning in order to avoid unnecessary complications for the patient during surgery. The operative management of these anomalies depends on the patient's neurological problems and while asymptomatic and accidentally diagnosed cases do not require treatment, patients who suffer low back or sciatic pain need surgical intervention in order to decompress nerve roots. We report a 45-years old woman presented with severe low back pain associated with left lumboischialgia. Intraoperative finding of an aberrant L5/S1 nerve root, optimal surgical therapy and different classifications are discussed together with a review of literature.

Transforaminal Endoscopic Discectomy for Large, Two Level Calcified, Thoracic Disc Herniations With 5-Year Follow-up.

To describe technical details and benefits of transforaminal endoscopic discectomy for treatment of patients with large, dorsomedial, calcified thoracic disc herniations at 2 levels and to report on their clinical outcomes in long follow-up period of 5 years using 4 different outcome tools. We present 2 patients with large, calcified disc herniations at 2 levels in mid and lower thoracic spine treated endoscopically in local anesthesia. Clinical outcomes were analyzed using verbal numeric scale (VNS), Roland-Morris low back pain and disability questionnaire (RMQ), Oswestry Disability Index (ODI), and modified MacNab criteria at 6-, 12-, 24-, 60-month follow-up. After transforaminal endoscopic discectomy, both patients had significant postoperative reduction of back pain using VNS and significant outcome improvement using ODI, RMQ score, and modified MacNab criteria. These results did not change during all 4 follow-up periods. Transforaminal percutaneous full-endoscopic discectomy and hand reamers foraminotomy in local anesthesia is feasible and effective surgical technique for patients with large, calcified thoracic disc herniations at 2 levels even in long follow-up period of 5 years using 4 different outcome measuring tools. All 3 outcome measuring tools correlated well with pain reduction using VNS.

Effects of alpha-melanocortin enantiomers on acetaminophen-induced hepatotoxicity in CBA mice.

Proteins and peptides in mammals are based exclusively on L-amino acids. Recent investigations show that D-amino acids exhibit physiological effects in vivo, despite of their very small quantities. We have investigated the hepatoprotective effects of the Land D-enantiomers of alpha-melanocortin peptide (alpha-MSH). The results showed that peptide-enantiomerism is related to the protective effects of melanocortin peptides in vivo. L-alpha-MSH exhibited potent hepatoprotective effect in the experimental model of acetaminophen induced hepatotoxicity in male CBA mice, while its D-mirror image was inefficient. Furthermore, the antibody to the L-peptide did not recognize the D-structure. The results indicate that the opposite peptide configuration may be used to modulate its function and metabolism in vivo and in vitro.

Giant choroid plexus cyst as an accidental finding in an older man.

Choroid plexus cysts (CPC) are usually found at the end of the second trimester of pregnancy. Sometimes they can be accidentally and found on prenatal ultrasound examinations. Vast majority of CPC resolve spontaneously by 28th weeks gestation. In the older aged group the choroid plexus cysts are extremely rare pathomorphologic medical entity. Since they are almost always asymptomatic, they are therefore accidentally found on brain magnetic resonance (MR) or computed tomography (CT) scans. They are usually located in the lateral ventricles and measure around 2 cm in diameter. We present a case of a 75-year-old male with a giant choroid plexus cyst whose leading symptom was excruciating headache refractory to previous conservative therapy. He underwent surgery when osteoplastic craniotomy was performed with cyst fenestration and ablation. His recovery was uneventful with total regression of headaches. Reviewing the recent literature we did not find such a case considering the patients age and the size of the choroid plexus cyst.

Thoracic intramedullary sarcoidosis mimicking an intramedullary tumor.

Sarcoidosis is a chronic, systemic granulomatous reticulosis of unknown origin, characterized by formation of hard tubercles and noncaseatinggranulomas. Since other infectious diseases such as berylliosis, mycobacterium and fungal infections may present with a noncaseating granulomas, histological diagnosis of sarcoidosis is made using the elimination method. Central nervous system manifestations of sarcoidosis may be present in 5-10% of the cases involving cranial nerves, leptomeninges and third ventricle respectively. Any part of the central nervous system can be affected. Involvement of spinal cord in sarcoidosis is extremely rare and presents with only 0.3-0.4% in patients with systemic sarcoidosis. Intramedullary sarcoidosis is a rare first manifestation of the disease and it can mimic an intramedullary tumor, which is often manifested with symptoms that initiate from spinal cord compression, resulting in paraparesis, sensory disorders and sphincter dysfunction. We present a case of intramedullary sarcoidosis that mimics a tumor of the thoracic spinal cord. Clinical features, neuroradiological, pathohistological findings, laboratory analysis and surgical treatment of such a rare entity are being discussed.

Hypopituitarism caused by pituitary metastasis of supraglottic laryngeal carcinoma: case report.

Intracranial metastases from laryngeal carcinoma are rarely clinically diagnosed. To our knowledge, this is the first report of hypopituitarism due to pituitary metastasis from laryngeal carcinoma. We report on a 70-year-old man who had a supraglottic squamous cell carcinoma, which was resected surgically followed by local full dose radiation therapy. Four months later, he presented with a sudden onset of diplopia, syncope, headache, general malaise and loss of appetite. Magnetic resonance imaging of the brain revealed a tumorous process of the sellar region. Endocrinological tests disclosed the presence of hypopituitarism. The tumor was subtotally resected endoscopically via endonasal transsphenoidal approach. Histopathology of tumor specimens indicated squamous cell carcinoma. Tumors of the sellar and parasellar region as in the case presented may easily be confused with pituitary adenoma. Pituitary metastases should be considered on differential diagnosis of unusual pituitary tumors, especially in patients with as well as in those without a history of malignant disease.

Traumatic leptomeningeal cyst in a 24-year-old man: case report.

OBJECTIVE AND IMPORTANCE: Traumatic leptomeningeal cysts represent a rare complication of a childhood cranial fracture, and occur in only 0.05 to 0.6% of all cranial fractures. In adults, clinical manifestations of a childhood trauma are very rare and usually appear in the form of nontender, nonpulsatile, subcutaneous mass, accompanied by a progressive neurological deficit and seizures, as shown in our case. CLINICAL PRESENTATION: We present the case of a 24-year-old man with seizures caused by a traumatic leptomeningeal cyst resulting from the head injury he suffered at the age of 9 months. INTERVENTION: Right-sided craniotomy was performed with consequent microsurgical removal of the leptomeningeal cyst. The dura was reconstructed in a watertight manner and a cranioplasty was performed with Palacos (Howmedica International, Limerick, Ireland). CONCLUSION: It is important to consider traumatic leptomeningeal cysts when treating adult patients with erosive bone lesions who have a history of head trauma.