The Importance of Spinopelvic Parameters in Recurrent Lumbar Disk Herniation.

STUDY DESIGN: Retrospective clinical study. OBJECTIVES: We aimed to investigate preoperative spinopelvic mismatch as a risk factor for recurrent lumbar disk herniation (RLDH) in patients undergoing lumbar disk herniation (LDH) surgery. SUMMARY OF BACKGROUND DATA: Spinopelvic parameters have been associated with lumbar degenerative diseases, particularly LDH. However, the relationship between these parameters and RLDH has yet to be studied. MATERIALS AND METHODS: Data of 1453 patients aged ≥18 who underwent single-level, unilateral fenestration microdiscectomy for the first time in our hospital between 2013 and 2019 were reviewed. The study group comprised 88 patients who underwent surgery for RLDH. The control group comprised 101 randomly selected patients who underwent surgery for LDH but not RLDH. Age, sex, body mass index, occupational activity level, operative level, Roussouly classification type, and time to recurrence were recorded. Moreover, pelvic incidence, lumbar lordosis (LL), interverteberal disk height (IDH), segmental lordosis, sacral slope (SS), pelvic tilt (PT), and sacral table angle (ST) were measured for each patient. Pelvic mismatch was calculated. RESULTS: Mean age was 46.5±11.4 y (range, 20-70). Both groups were similar concerning age, sex, body mass index, occupational activity level, and level of surgery. The mean time to recurrence was 167.3±36.6 d (range, 62-363). Measurements in the RLDH group were as follows: IDH=7.6±1.5 mm, pelvic incidence =54.4°±10.1°, LL=47.3°±13°, segmental lordosis =9.3°±5°, SS=35.1°±9.9°, and PT=19.3°±7.3°. Mean IDH was significantly lower in the RLDH group ( P =0.02). Less LL and lower PT at L3-4 level and increased SS at L5-S1 level were considered risk factors for RLDH. CONCLUSION: This study showed that preoperative low IDH is at higher risk for RLDH in patients undergoing LDH surgery. LL, PT, and SS may be risk factors for specific levels.

A new posterior stabilization technique in pediatric subaxial cervical vertebrae: Stabilization of spinous processes with the microplate/screw system: A radiological anatomy study.

BACKGROUND: There are limited options for posterior stabilization techniques in cases of cervical subaxial instability in children. We designed this study to investigate whether the spinous process (SP) stabilization, which was previously used in adults, can also be used in children. METHODS: Children aged 4-12 years who were admitted to our hospital between 2012 and 2020 and underwent 3D cervical computed tomography (CT) were retrospectively screened. Children without cervical spine fractures, tumors, deformities, or any ab-normalities and motion artifacts on CT were included in the study. Eight hundred seventy children were identified. Then, 360 children randomly selected from the patient pool were divided into nine different age groups or 3 different age groups (4-6 years, 7-9 years, and 10-12 years). The length, height, thickness, and anomalies of subaxial SPs were studied on CT images of children. The suitability of the SPs for the microplate/screw stabilization system was investigated. RESULTS: The suitability rate for screw insertion was 57.6% and the suitability rate for the stabilization in at least one segmental unit was 74.7%. The eligibility rate for stabilization involving C3, 4, 5, 6, and 7 vertebrae was 16.1%. There were nine different stabilization combinations and C6-7 segmental unit (71.9%) were the most common in those combinations. Bifidity prevented screw insertion in 21% of children. We found that the screw acceptance rate of SP started to increase statistically around 8 years of age and the number of segmental units that could be stabilized was at the age of 10-12 at most. CONCLUSION: According to the results of this study, we believe that the SP stabilization method recommended for children can be used as a salvage method, to support anterior stabilization or alone in a small number of selected cases.

The calcimimetic R-568 attenuates subarachnoid hemorrhage-induced vasospasm through PI3K/Akt/eNOS signaling pathway in the rat model.

Cerebral vasospasm (CVS) causes mortality and morbidity in patients after subarachnoid hemorrhage (SAH). The mechanism and adequate treatment of CVS are still elusive. R-568 is a calcimimetic agent known to exert a vasodilating effect. However, there is no report on its vasodilator effect against SAH-induced vasospasm. In the present study, we investigated the therapeutic effect of R-568 on the SAH-induced CVS model in rats. Seventy-two adult male Sprague-Dawley rats were divided into 8 groups: sham surgery; SAH only; SAH + Vehicle, SAH + R-568; SAH + R-568 + Wortmannin (the PI3K inhibitor); SAH + Wortmannin; SAH + R-568 + Calhex-231 (a calcilytic agent); SAH + Calhex-231. SAH was induced by blood (0.3 mL) given by intracisternal injection. R-568 (20 µM) was administered intracisternal immediately prior to experimental SAH. Basilar arteries (BAs) were obtained to evaluate PI3K/Akt/eNOS pathway (immunoblotting) and morphological changes 48 h after SAH. Perimeters of BAs were decreased by 24.1% in the SAH group compared to the control group and the wall thickness was increased by 75.3%. With R-568 treatment, those percentages were 9.6% and 29.6%, respectively, indicating that vasospasm was considerably improved when compared with the SAH group (P < 0.001 in both). While p-PI3K/PI3K and p-Akt/Akt ratio and eNOS protein expression were markedly decreased in the SAH rats, treatment with R-568 resulted in a significant increase in these levels. The beneficial effects of R-568 were partially blocked in the presence of Calhex-231 and completely blocked in the presence of Wortmannin. Herein, we found that treatment with R-568 would attenuate SAH-induced CVS through the PI3K/Akt/eNOS pathway and demonstrate therapeutic promise in CVS treatment following SAH.

Does the Position of the Polyaxial Screw Head in Patients With L5-S1 Stabilization Lead to an Increased Difficulty in L5 Transforaminal Nerve Injection? A Three-Dimensional Computerized Tomography Study.

Background Challenges may be encountered if transforaminal nerve injection (TFNI) is required in patients who have undergone posterior transpedicular stabilization (PTS) surgery to the L5-S1 level. In this study, we investigated the contributory factors that lead to these challenges. Methods We selected 125 patients who underwent PTS surgery involving the L5-S1 segment, between 18 to 70 years of age to be included in the study. The demographic data of the patients, body mass indexes (BMI), postoperative spondylolisthesis grades, heights of the iliac crest, and the positions of the polyaxial screw head were assessed. The shortest trajectory of L5-TFNI, the distance of the needle entry point (NEP) to the midline, and optimum viewing angles (VA) were measured on the three-dimensional computed tomography (CT) sections. Results Pre-PTS surgery, in males compared to females, NEP was noted to be more medial (p=0.007), the needle trajectory was shorter (p=0.001), and the optimal VA was narrower (p=0.001). Increasing BMI and increasing height of the iliac crest caused the TFNI trajectory to become longer. Post-PTS surgery, angulation of polyaxial screw heads of more than 15 degrees laterally in both genders significantly caused a decrease in VA (p=0.001). Conclusions Using the reconstruction technique in 3D CT, we demonstrated that pedicle screw heads angled laterally, a higher iliac crest height, and an increased BMI make L5-TFNI difficult to be performed. Locking the stabilization system while targeting the most neutral position for polyaxial screw heads during surgery may facilitate the L5-TFNI.

Immediate versus delayed primary repair of the sciatic nerve in a nerve transaction model in rats.

BACKGROUND: The debate continues concerning surgical timing in a peripheral nerve injury. This study aims to evaluate the result of immediate versus delayed primary (after seven days) repair of peripheral nerve injury. METHODS: In this study, Wistar rats were divided into four groups as follows: The nerve was sharply transected in Group 1, 2 and 4. It was immediately sutured in Group 1 and sutured seven days later in Group 2, and it was not sutured in Group 4. In Group 3, the left sciatic nerve was only explored. Eight weeks later, tissue samples were extracted from the injured nerve area. Both gastrocnemius muscles were weighed. The nerve samples were examined for axon degeneration. Myelin vacuolization, axon irregularity, and edema/inflammation parameters were evaluated. RESULTS: There were not any significant differences in the score of axon degeneration and the weight of the gastrocnemius muscle between the immediate and delayed primary repair groups. However, these parameters were significantly better in both repair groups than to be in the control group and significantly worse than to be in the sham-operated group. CONCLUSION: To delay the repair about one week did not affect the histological results and weight of the muscle that was innervated by the sectioned nerve comparing to be in the immediate repair in a sciatic nerve transaction model in rats.

Metastatic Gallbladder Carcinoma in Meningioma: A Case Report.

Metastases from tumors to systemic cancers are rare. The most common intracranial recipient tumor is meningioma. Metastasis from gallbladder cancer has been previously reported from only one patient during autopsy. We present a case of a 72-year-old woman who underwent surgery for right frontal skull base meningioma. The tumor was completely removed. Histological specimens showed gallbladder carcinomatous metastasis with diffuse neuroendocrine differentiation in meningothelial meningioma. The Ki-67 proliferation index of the meningioma was 3%. Further, 60% positive immunoreactivity with the progesterone receptor was observed in meningioma cells. In carcinoma cells, diffuse positive immunoreactivity with chromogranin, CDX2, CEA, panCK, cytokeratin 7, and synaptophysin was observed. A combination of molecular, metabolic, immunological, and/or hormonal factors may contribute to the pathogenesis of this lesion. It cannot be ruled out that it is more common than expected.

Empty Bladed PEEK Cage for Interbody Fusion after Anterior Cervical Discectomy.

AIM: Cervical disc herniation (CDH) can be treated using different anterior and posterior methods. Anterior cervical discectomy and fusion (ACDF) is currently gold standard and provides bony fusion and good clinical outcome. Recently many studies reported good clinical and radiological outcomes in cases who underwent anterior cervical discectomy (ACD) and reconstruction with empty cage. This study aimed to review our results after cervical microdiscectomy reconstructed with empty polyether ether ketone (PEEK) cage. MATERIAL AND METHODS: Twenty-five cases with single level CDH who underwent microdiscectomy were included to this study. Reconstruction was performed using empty bladed cervical PEEK cages. Clinical (Visual analogue scale (VAS) and Odom scores) and radiological results (intervertebral disc and foraminal heights, mean cervical spine lordosis angle, and fusion rate) were reviewed one day and one year after surgery. RESULTS: There were 18 males and 7 females, aged between 25 and 54 years (mean: 40.8). Mean neck and arm VAS scores reduced from 2.9 to 1.4, and from 7.2 to 1.8, respectively. Odom scores were found to be 1.6 and 1.4 at 1st day and one year postoperatively, respectively. Subsidence was seen in three cases (12%). There was no significant change in heights of neural foramina and intervertebral discs, and no change in cervical spine lordosis, when compared postoperative 1st day and one year radiographs. Fusion was detected in 92% of cases in one year. CONCLUSION: Bladed cervical cages are safe with almost no risk of dislocation. Empty cages provide acceptable rates of fusion and subsidence.

The Role of Wrist Magnetic Resonance Imaging in the Differential Diagnosis of the Carpal Tunnel Syndrome.

AIM: The carpal tunnel syndrome (CTS) is the commonest compressive neuropathy. Electromyography (EMG) is accepted as gold standard in diagnosis of CTS. However, pathologies and variations that are associated with a various findings may lead to failure. MATERIAL AND METHODS: Magnetic resonance Imaging (MRI) was applied to 69 wrists of 55 patients, who received a diagnosis of CTS by means of clinical and electrodiagnostic testing (EDT) during the years 2011 and 2013. RESULTS: We detected a total of 71 additional pathologies in MRI analyses: 29 degenerative bone cysts, 28 ganglion cysts, 8 tenosynovitis, and 6 avascular necroses. While the MRI detected 44 (59.5%) additional radiological pathologies in 39 wrists diagnosed with mid-level CTS by means of EMG, the number of detected additional pathologies was 27 (36.5%) in 30 wrists diagnosed with advanced-level CTS. CONCLUSION: Wrist MRI is an effective means to reveal associated pathologies in patients diagnosed with CTS by means of clinical testing and EDT. Additional pathologies may not only change the applicable type of surgery, but also decrease the number of postoperative failures. Wrist MRI is recommended, especially for young cases with unilateral CTS history accompanied by dubious clinical symptoms and lacking any pronounced predisposing factors.

Sudden paraplegia following epidural lipomatosis and thoracal compression fracture after long-term steroid therapy: a case report.

Sudden paraplegia secondary to the posterior spinal epidural compression and vertebral compression fracture as a complication in corticosteroid treatment is extremely rare. The authors presented a case 49-year-old man with chronic relapsing attack of Still's disease. After the identification of pathology, the surgical evacuation of lipid tissue and pedicle-based instrumentation showed therapeutic success. To the authors' knowledge, this is the first case showing both vertebral fracture and paraplegia that required urgent surgery in the follow-up Still's disease.

Bilateral Lhermitte-Duclos disease.

Lhermitte-Duclos disease (LDD) is a pathologic entity with progrediating, diffuse hypertrophy chiefly of the stratum granulosum of the cerebellum. Typically LDD is a unilateral lesion of the cerebellum or in vermis. Here we report a case of LDD with bilateral lesions of cerebellar hemispheres managed surgically. A 28-year-old woman presented with one-year history of progressive headache, nausea, vomiting, and blurred vision. Neurologic examination revealed a bilateral mild papilledema, mild dysmetria, and dysdiadochokinesia. The cerebellar lesions caused moderate mass effect in posterior fossa with hydrocephalus, and Chiari type I malformation. We performed the suboccipital-retrosigmoid approach, and removed completely the left intracerebellar mass. Symptoms related to elevated intracranial pressure disappeared in a short period postoperatively.

A case of McCune-Albright syndrome associated with Gs alpha mutation in the bone tissue.

The syndrome of McCune-Albright syndrome (MAS) is clasically defined as a triad presentation with the findings of polyostotic fibrous dysplasia, café-au-lait spots, and sexual precocity. However, not all patients present with complete symptoms. A 52-year-old man was diagnosed as having a variant of McCune-Albright syndrome with the following findings: polyostotic fibrous dysplasia, acromegaly due to pituitary tumor and subclinical hyperthyroidism due to toxic multinodular goiter. Sexual precocity and café-au-lait spots were not noted. Acromegaly was confirmed by laboratory examination (IGF-1, glucose suppression test and TRH stimulation test). Long acting somatostatin analogue was used as treatment. Although the pituitary tumor could not be removed due to technical problems, mass lesions on the cranium were removed subtotally. Histopathological evaluation demonstrated that the lesion complied with fibrous dysplasia. Genomic DNAs were isolated from the craniofacial bones and peripheral leucocytes of the patient. After amplifying the related regions, Gs alpha (Gs alpha) gene was analysed by automatic DNA sequence analysis. An activating mutation of the Gs alpha gene (Arg 201 Cys) was found in the genomic DNA isolated from the bone tissue of the patient, but not in the genomic DNA isolated from the blood. We described a case of MAS associated with Gs alpha mutation in the bone tissue, presenting with polyostotic fibrous dysplasia, subclinical hyperthyroidism and acromegaly.