Spinal epidural fibrosis following hemostatic agent employment.

OBJECTIVE: Failed Back Surgery Syndrome (FBSS) refers to a subset of patients who have new or persistent pain after spinal surgery for back or leg pain. Epidural fibrosis (EF) is a common cause of FBSS. Many agents aiming to prevent EF have been tested. However, hemostatic agents are readily available at hospitals, easy to reach and frequently used. For these reasons, oxidized regenerated cellulose, polysaccharide hemostat, hemostatic thrombin-gelatin matrix and chitosan linear polymer were evaluated for their effects on epidural fibrosis on rats after laminectomy. METHODS: 40 Sprague-Dawley rats were randomly divided into 5 equal groups including the control group where only the laminectomy was performed. The other 4 groups received hemostatic agents after laminectomy. The rats were euthanized 45 days later and were assessed by a blinded observer to grade the fibrosis level. RESULTS: The study revealed that oxidized regenerated cellulose, polysaccharide hemostat and hemostatic thrombin-gelatin matrix lowered the epidural fibrosis grade which was statistically significant (p < 0.001). Although chitosan linear polymer created fibrosis similar to the control group it was not proven to be statistically significant (p = 0.8999). However, when compared with other hemostatic agents it resulted in a higher fibrosis grade (p < 0.001). CONCLUSION: The results obtained from this experimental study revealed that Pahacel, Sealfoam and Surgiflo, were effective in reducing epidural fibrosis after laminectomy in rats.

Chiari 1 malformation with optic disc drusen.

A 32 year old female patient with CM 1 diagnosis was referred for the management of papilledema. Ophthalmologic examination revealed normal visual acuity (20/20 in both eyes), normal optic nerve function tests and normal slit-lamp biomicroscopic findings. Fundoscopy revealed bilateral irregular optic nerve heads with blurred margins. B scan ultrasonography (USG) and Spectral domain optical coherence tomography were performed and bilateral optic nerve heads were diagnosed as ODD. We concluded that the pseudopapilledema must be taken into account before making papilledema diagnosis in patients with CM 1 to protect the patients from redundant interventional procedures.

Effects of tadalafil-Type-V phosphodiesterase enzyme inhibitor-On rats with spinal trauma.

In this research, the effect of tadalafil, a selective inhibitor of cyclic guanosine monophosphate-specific phosphodiesterase type 5, on rats with spinal trauma was evaluated. The evaluation consisted of neurological examination and biochemical parameters. Twenty healthy male Wistar albino rats were used in this study. They were separated into three groups: tadalafil-receiving (TD) group (n=7), laminectomy and trauma (LT) group (n=7), and just laminectomy group (n=6). The TD group received daily dose of tadalafil (10 mg/kg) for a week along with bait and water. Each rat's spinal cord was dissected with utter caution. The spinal cord was traumatized by Allen's weight-drop method. Using a standard apparatus, 5 g of weight was dropped from a height of 10 cm on the spinal cords of the TD and LT (laminectomy+trauma) group. No extra maneuvers were conducted on the laminectomy group. A day later, the rat's functional neurological status was examined followed by re-exploration of the spinal cord for sampling 1 cm of tissue. The Tarlov scale was used to evaluate the functional neurological status. The modified Tarlov scale was rated to be significantly higher in the TD group than that in the LT group. For the biochemical parameters, malondialdehyde (MDA) and cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) involved in the inflammatory process were examined. MDA--an indicator of lipid peroxidation--was found to be significantly lower in the TD group compared with that in the LT group. TNF-α and IL-6 levels were also found to be lower in the TD group compared with those in the LT group. Shortly, this research showed that the use of TD group in spinal trauma resulted in better neurological outcome and significant improvement in biochemical parameters.

Six-level isolated spinous process fracture of the thoracic vertebrae (clay-shoveler's fracture) and a review of the literature.

Clay-shoveler's fractures are isolated, avulsion-type spinous process fractures of the lower cervical and upper thoracic vertebrae. Multi-level fractures of the spinous processes are extremely rare. We report the case of a 60-year-old female patient with a six-level isolated spinous process fracture of the thoracic spine. Our case is the fourth reported case in literature, of an isolated spinous process fracture involving five or more levels in the thoracic vertebrae.

Study the effects of zonisamide on fine structure of rabbit basilar artery and hippocampus in rabbit subarachnoid hemorrhage model.

BACKGROUND: In this study, we investigated the effect of a novel antiepileptic drug, zonisamide (ZNS), on the basilar artery and hippocampus in a rabbit subarachnoid hemorrhage (SAH) model. METHODS: Three groups of New Zealand white rabbits were used: a sham (non-SAH) group, an SAH + saline group, and SAH + drug treatment group that received ZNS. In the treatment group, the subjects were given ZNS for 3 days after the SAH. Hippocampal sections were evaluated for neural tissue degeneration. Basilar artery lumen areas and arterial wall thickness were also measured in all groups. RESULTS: The mean luminal area of the SAH + ZNS was significantly greater than the SAH + saline group. In addition, the arterial wall thickness of SAH + ZNS group was significantly thinner than the SAH + saline group. The neuronal degeneration scores of the hippocampal CA1 regions in the SAH + ZNS group were significantly lower than the SAH + saline treatment animals. CONCLUSIONS: These results indicate that ZNS has a vasodilatatory effect on the basilar artery and a neuronal protective effect in the CA1 region of the hippocampus in a rabbit SAH model.

The effects of fetal allogeneic umbilical cord tissue transplant following experimental spinal cord injury on urinary bladder morphology.

BACKGROUND AND PURPOSE: In continuation of our previous experimental study on spinal cord injury (SCI) using fetal stem cells, we investigated here the effects of fetal allogeneic umbilical cord tissue transplant on the urinary bladder morphology in a rat SCI model. MATERIAL AND METHODS: Five pregnant albino Wistar rats at 12 days of gestation were used to obtain the umbilical cord cell graft. In Group 1 (n = 5), Th8-Th9 laminectomy was performed. Group 2 (n = 5) received spinal cord injury. In Group 3 (n = 5), the cultured fetal umbilical cord cells coated with alginate gel were placed into the lesion cavity. In Group 4 (n = 5), only alginate sponges without umbilical cord cells were placed into the injury cavity. The bladders of animals were analyzed pathologically at 21 days after surgery. RESULTS: The thickness of the epithelium and the lamina propria did not differ among studied groups (p > 0.05). The lamina muscularis thickness was significantly higher in Group 2 and Group 4 than the others (p < 0.05). The bladder weight was similar among Groups 1, 2, and 3 (p > 0.05). Fibrosis was significantly increased in Group 2 (p < 0.05); it was greater in Group 2 than in Group 3 (p < 0.05) but did not differ between Groups 1 and 3 (p > 0.05). CONCLUSIONS: This study suggests that allogeneic umbilical cord tissue transplantation after SCI may prevent bladder wall hypertrophy and fibrosis in the rat SCI model.

Effects of intramuscular parecoxib administration on vasospasm in an experimental subarachnoid hemorrhage model.

AIM: We examined whether intramuscular parecoxib administration has a preventive or therapeutic effect on vasospasm following experimental subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: Twenty New Zealand White Rabbits were assigned randomly to one of four groups. Animals in Group I were not subjected to SAH (control group). Animals in all other groups were subjected to SAH. Animals in Group II received no treatment after SAH induction (SAH group). Animals in Group III received intramuscular parecoxib (diluted with saline) injection at 6 and at 30 hours after SAH (treatment group). Animals in Group IV received only intramuscular saline injection at 6 and at 30 hours after SAH (vehicle group). Animals were euthanized by perfusion and fixation 48 hours after SAH induction. Basilar artery cross-sectional areas and wall thicknesses were measured. Statistical comparisons were performed using Kruskal-Wallis and Mann-Whitney U tests. RESULTS: Basilar artery cross-sectional areas in the treatment group were significantly higher than in the SAH or vehicle group (p<.05). Basilar artery wall thickness in the treatment group was significantly smaller than in the SAH or vehicle group (p<.05). CONCLUSION: Our study revealed that intramuscular administration of parecoxib significantly attenuates vasospasm following experimental SAH.

Azathioprine as a Neuroprotective Agent in Experimental Traumatic Spinal Cord Injury.

AIM: To evaluate the protective effects of azathioprine, a macrophage-inhibiting agent, on secondary injury in spinal cord trauma. MATERIAL AND METHODS: A total of 40 Wistar rats were randomly divided into 4 groups. All the animals had undergone T8-10 laminectomy. Except in group I (control), all the animals were exposed to spinal cord trauma at the T9 level. Animals in group II (trauma) received no treatment following trauma. Animals in group 3 (treatment) and group IV (vehicle) were given intraperitoneal azathioprine 4 mg/kg and saline 2 ml, respectively, 30 minutes after the trauma. Half of the animals in each group were sacrificed 24 hours after injury and specimens were used for biochemical and immunohistochemical evaluations. The rest of the animals were followed-up for 4 weeks in terms of neurological functions and were also sacrificed to perform the histopathological analysis. RESULTS: Significant decrease in apoptotic cells and improved neurological function were observed in the animals treated with azathioprine. Biological and immunohistochemical analysis also showed less oxidative stress in this group compared to those without treatment. CONCLUSION: Azathioprine, a potent macrophage-inhibiting agent, has been shown to decrease the extent of secondary injury following spinal cord trauma.

Fetal allogeneic umbilical cord cell transplantation improves motor function in spinal cord-injured rats.

AIM: The objective of this study was to investigate whether the transplantation of fetal umbilical cord tissue cells as a source of stem cells into the acutely injured spinal cord would produce some regenerations and/or functional recovery in a rat model of spinal cord injury. MATERIAL AND METHODS: Five pregnant albino Wistar rats of 12 days gestation were used for obtaining an umbilical cord cell graft. At the second stage of the experiment only Th8-Th9 laminectomy was performed in Group A animals while Group B animals underwent spinal cord hemitransection. The cultured fetal umbilical cord cells coated with Alginate Gel were placed into the lesion cavity immediately after surgery in Group C animals. Group D animals received only Alginate gel sponges into the injured area. All experiment groups were analyzed histologically and immunohistochemically (GFAP, Ki-67, and Pan cadherin) and for motor function after surgery. RESULTS: The umbilical cord cell transplanted animals showed a significant motor recovery compared to non-transplanted animals at 8 and 21 days after spinal cord injury (p=0.008). Significant GFAP and Ki-67 expressions were noted in transplanted animals (p=0.048) suggesting astroglial proliferation. CONCLUSION: Our findings support the possibility of some functional recovery after umbilical cord cell transplantation following spinal cord injury.

Comparison of the effect of mexiletine and methylprednisolone on neural function and histopathological damage after transient spinal cord ischemia in rabbits.

AIM: The purpose of this study was to investigate the effect of mexiletine on the neural function and histopathological changes after ischemic spinal cord injury in rabbits. We also compared the effect of mexiletine to that of methylprednisolone. MATERIAL AND METHODS: Twenty six male New Zealand white rabbits were randomly divided into six groups. Group 1; sham operated group (n=3) underwent only the surgical exposure of infrarenal aorta. Group 2 (n=4) received neither intravenous (iv) nor intraperitoneal medication but the infrarenal aorta was cross-clamped. Group 3 (n=5) received intravenous infusion of 20 ml/kg/h normal saline. Group 4 (n=5) received 30 mg/kg intravenous methylprednisolone. Group 5 (n=3) received intraperitoneal 20mg/kg/h normal saline. Group 6 (n=6) received 50mg/kg mexiletine intraperitoneally. Temporary spinal cord ishemia was induced by infrarenal aortic occlusion for 25 minutes and followed by reperfusion. The neural status was scored using the Tarlov criteria at 24 hours after reperfusion. Immediately after the neurological scoring, the spinal cords of all animals were removed for histopathological study. RESULTS: Histopathological examination scores were significantly higher in group 6 compared to group 2 (p < 0.05). CONCLUSION: Mexiletine can significantly ameloriate the neural function and prevent histopathological damage after transient spinal cord ischemia in rabbits. This is the first research that investigates the neuron=protective effect of mexiletine in a spinal cord ischemia model.

Topiramate attenuates hippocampal injury after experimental subarachnoid hemorrhage in rabbits.

OBJECTIVE: The aim of this study was to investigate the ability of topiramate (TPM) to prevent neural injury in a rabbit model of subarachnoid hemorrhage (SAH). The effect of TPM on cerebral vasospasm was also evaluated. METHODS: Fifty-three New Zealand white rabbits were allocated into three groups randomly. SAH was induced by injecting autologous blood into the cisterna magna. The treatment groups were as follows: (1) sham operated (no SAH (n=18); (2) SAH only (n=17); (3) SAH + TPM (n=18). Hippocampal sections were evaluated for neural tissue degeneration, using the previously described neural degeneration scoring system. The ApopTag peroxidase in situ apoptosis detection kit (Serologicals Corp., former Intergen) was used to assess apoptosis in the hippocampal sections and the effect of TPM on the apoptotic response. Basilar artery lumen areas and arterial wall thickness were also measured in all groups. RESULTS: There was a statistically significant difference between the mean degeneration scores of the control and SAH only groups (p<0.05). The level of neural degeneration in TPM treated group was significantly lower compared with SAH only group (p<0.05), but not significantly higher than the control group (p>0.05). There were no statistically significant differences between arterial cross-sectional area and arterial wall thickness measurements of the SAH group and SAH + TPM group. CONCLUSION: These findings demonstrate that TPM has marked neuroprotective effect in an experimental model of SAH in rabbits. This observation may have clinical implications suggesting that this antiepileptic drug could be used as a possible neuroprotective agent in patients without major adverse effects.

Functional and clinical evaluation for the surgical treatment of degenerative stenosis of the lumbar spinal canal.

OBJECT: This study was designed to evaluate the efficacy of decompressive surgery for degenerative lumbar spinal stenosis (LSS) on a functional and clinical basis. METHODS: A prospective analysis and follow-up of 125 consecutive patients with degenerative LSS between 2000 and 2006 were performed. All patients underwent surgery for lumbar stenosis. Functional evaluations of the patients were performed using a treadmill, the visual analog scale, and the Oswestry Disability Questionnaire (ODQ). These parameters were recorded before surgery and the 3rd month and 1st and 2nd years after treatment. The first symptom time (FST), maximal walking duration (MWD), and thecal sac cross-sectional area (CSA) before and after surgery were also recorded. Statistical relations between variables were calculated. RESULTS: As patient ages increased, the CSA of the thecal sac decreased. Decompressive surgery reached the target according to the difference between the preoperative and postoperative thecal sac CSA. A correlation between the CSA of the thecal sac and FST, and between the CSA of the thecal sac and MWD could not be established. There was a significant correlation between the FST and MWD, and a negative correlation could be established between the MWD and the ODQ score. Surgery led to significant decreases in the ODQ score. Maximal improvement was observed in the 3rd month after decompressive surgery. CONCLUSIONS: The treatment for LSS should be decided using functional criteria; radiological criteria may not correlate with the severity of the disease. Improvements following lumbar decompression surgery continued within 1 year of treatment according to the ODQ and did not change significantly thereafter.

Crossed Wernicke's aphasia after aneurysmal subarachnoid hemorrhage: a case report.

Crossed aphasia (CA) refers to aphasia occurring after right brain damage in right handers. In the literature, numerous CA cases following cerebral ischemia have been reported, but few met the criteria for a prompt diagnosis. The authors present the case of a 52-year-old woman with SAH caused by a right middle cerebral artery (MCA) saccular aneurysm who developed non-fluent aphasia characterized by reduced verbal output, word-finding disturbances and phonemic paraphasias in both oral and written language. 99mTc-HMPAO SPECT was also consistent with right parieto-temporal and frontoparietal ischemia with crossed cerebellar diaschisis on the right cerebellum. A diagnosis of CA was made. One year follow-up showed improvement in communication skills but persistent right fronto-temporo-parietal ischemia. Cerebral vasospasm after aneurysmal SAH symptomatology may vary from motor and sensory disturbances to cognitive disabilities. Aphasia developing after cerebral ischemia of the right hemisphere in a right-hand dominant patient following vasospasm may be a misleading symptom for the localization of the insult. Keeping a high index of suspicion may help in making the correct diagnosis. The changes in the perfusion patterns of cerebellum as assessed by SPECT study during the acute and recovery phases suggests the involvement of cerebellum in language functions.

Circumferential total resection of cervical tumors: report of two consecutive cases and technical note.

To date, few studies have addressed the subaxial vertebrectomy technique and related anatomical landmarks in this method. Total spondylectomy is performed via piecemeal resection or en bloc removal in a one-stage procedure associated with stabilizing the spine and preserving neurological status. In this presentation, a circumferential total cervical tumor resection for subaxial cervical spine lesions was described. Two cases of subaxial cervical malignancy, one with primary C3 chondrosarcoma and the other with C4 lung adenosarcoma metastasis, were both treated by the anterior-posterior approach. The lesions could be removed macroscopically totally in both cases. The patients did well after surgery with preserved neurological status and they survived a considerable period without tumor recurrence. Subaxial total tumor resection can be performed safely while preserving vertebral arteries with adequate anatomical knowledge and careful surgical planning, and circumferential vertebrectomy (even intralesional) can provide a long recurrence-free survival period for patients suffering from subaxial spine tumors.

A simple, safe and effective surface marking and targeting method combined with intraoperative ultrasonography for small subcortical intracranial lesions.

BACKGROUND: Accurately locating small subcortical brain lesions is very important for maximal surgical resection with minimal neurological damage. Intraoperative MRI has proved to be more precise than ultrasound, it is relatively expensive and is not available in all centers. Herein we describe a new, simple, safe and effective method for determining a small skin incision and craniotomy via skin staples combined with intraoperative ultrasonography to determine the margins, vascularity and residue of the lesion. METHODS: Thirty-three patients with small subcortical lesions were admitted into the study. The maximum diameter of the lesions ranged between 18 and 30 mm. The depth of the lesion was described as the distance between the cortical surface and most outer point of the lesion. The mean of the depth of the lesions was 10.56 mm ranging between 3.3 and 18.7 mm. Multiple skin staples were used as irremovable skin markers. Before and after dural incision, ultrasound was used to assess the lesion size and location, its relationship with the surrounding tissue and the Doppler function to reveal the blood supply to the lesion. RESULTS: In this study mean craniotomy diameter was 44 mm ranging between 32-55 mm. The location, extent, characteristics and adjacent tissue of the lesion were observed by high frequency ultrasonography during the operation. CONCLUSIONS: We describe a simple, safe and effective method for determining a small skin incision and craniotomy combined with intraoperative ultrasound for small subcortical intracranial lesions for health center that does not have intraoperative MRI and navigation systems.

Medullomyoblastoma: teratoid nature of a quite rare neoplasm.

BACKGROUND: Medullomyoblastoma is a quite-rarely reported biphasic histologic variant of medulloblastoma since the first published description of a tumor consisting of medulloblastic and myogenic elements. Controversy over its origin still goes on. Here, an additional case of medullomyoblastoma variant is reported, and discussed are the clinicopathologic features and pathophysiologic mechanisms of and treatment options for this neoplasm. CASE REPORT: A 7-year-old girl was admitted to our clinic with headache, vomiting, and gait disturbances. An MRI scan on admission showed a solid tumor with a 2.5-cm axial diameter located in cerebellar vermis. The tumor was removed totally. Histologic examination revealed loose mesenchymal structures of the tumor and small muscle strands and isolated cells having large eosinophilic cytoplasm with striations. The muscular strands also demonstrated striations under light microscope. Glial fibrillary acidic protein, synaptophysin, and myogenin positivity are observed. CONCLUSION: There are some strong evidences that the medullomyoblastoma may be a teratoma. Survival time with the tumor is very short, outcome is poor, and the tumor can spread along cerebrospinal fluid pathways. Total resection, chemotherapy, and craniospinal irradiation are mainstays of the treatment of medullomyoblastomas.

Lamotrigine attenuates cerebral vasospasm after experimental subarachnoid hemorrhage in rabbits.

BACKGROUND: Increasing evidence implicates voltage-dependent sodium and potassium channels, in addition to calcium channels of various types, in the pathophysiological development of cerebral vasospasm. This study investigated the ability of LTG, an antiepileptic drug with multi-ion channel inhibition properties, to prevent cerebral vasospasm and subsequent neural ischemia in a rabbit model of SAH. METHODS: Thirty-five New Zealand white rabbits were assigned to 1 of 3 groups: (1) control (no SAH, saline injection); (2) SAH alone; (3) SAH + LTG, 20 mg/kg daily. Animals were killed 72 hours after SAH, then basilar artery lumen areas and arterial wall thickness were measured in all groups. The histological sections of the CA1 and CA3 regions and dentate gyri of the hippocampi were evaluated semiquantitatively for neural tissue degeneration. RESULTS: In the SAH group, the mean luminal cross-sectional area of the basilar artery was reduced by 62% after SAH as compared with the non-SAH controls (P < .0001). After SAH, the vasospastic response was attenuated by 36% in animals treated with 20 mg/kg of LTG compared with the SAH group (P < .005). The mean luminal cross-sectional areas of the basilar artery were 279000 +/- 27000 microm(2) in the control group, 173000 +/- 17600 microm(2) in the SAH group, and 236000 +/- 10000 microm(2) in the SAH + LTG group. The differences between the SAH group and the LTG-treated group were statistically significant (P < .0001). Histological examination was done in 12 control, 12 SAH, and 9 SAH + LTG-treated animals. The mean degeneration score for the control group and SAH + LTG group was statistically significant (P = .012). The difference between the SAH group and SAH+ LTG group was also statistically significant (P = .006). CONCLUSIONS: These findings demonstrate that oral administration of LTG has marked neuroprotective effect and significantly attenuates cerebral vasospasm after SAH, thus providing additional support for the role of non-L-type calcium channels and voltage-dependent sodium channels in vasospasm.

Multifocal Ewing's sarcoma of the brain, calvarium, leptomeninges, spine and other bones in a child.

Ewing's sarcoma (ES) is a malignant osseous neoplasm that mostly affects children and young male adults, and usually presents as a solitary bony lesion. Multifocal ES of the central nervous system is extremely rare, with an incidence ranging from 1.1% to 4.3%. Clinically, ES may mimic osteomyelitis. In this report, we describe the case of an 11-year-old boy who had multiple calvarial, leptomeningeal, spinal and various other bony lesions of ES, which were diagnosed radiologically and histopathologically. To the best of our knowledge, this is the first time that multiple brain, calvarial and spinal lesions of ES in a single patient have been reported in the English-language literature. We discuss possible mechanisms and differential diagnoses for this rare pathology.

Spinal subdural abscess: a rare cause of low back pain.

Spinal subdural abscess (SSA) is a rare but well-described entity. It may occur secondary to a systemic infectious focus or following a surgical procedure. There are only two SSA cases in the literature that are unrelated to such conditions and without any well-documented etiology. SSA is a neurosurgical emergency and diagnosis may be difficult. Progressive neurological deficits and severe pain with fever suggest the diagnosis. Surgical drainage and subsequent prompt antimicrobial therapy should be performed without delay. We report a patient with SSA unrelated to any predisposing condition and discuss underlying mechanisms of this disease.