Morphometric Analysis of Lumbar Arteries and Relationship with Intervertebral Discs: A study of Surgical Anatomy on Human Fresh Cadavers.

AIM: To examine the morphological structure of anterior lumbar spinal region. MATERIAL AND METHODS: Fifteen fresh human cadavers were studied in our forensic medicine institution. Within the first 24 hours after death, cadavers were subject to a routine autopsy, by which the intestines were removed and the structures adjacent to the lumbar arteries (LAs) were examined. The following characteristics of the LA were examined and recorded: diameter, number of LA, intervertebral disc, and vertebral corpus relationship, and LA anatomical variations. RESULTS: In 14 of the 15 cadavers (93.3%), the first four LAs originated from the abdominal aorta. In one (6.7%) cadaver, the fourth LA originated from the right aortic trunk together with the median sacral artery (MSA), and this was observed only in the right side. In one cadaver, the first LAs emerged as a common trunk. Twelve cadavers did not have a fifth LA. In one cadaver (6.7%), the fifth LAs emerged as in a pair, distally from the origin of the MSA. Two cadavers (13.3%) had fifth LAs that emerged from the common trunk with the MSA and this occurred only on the right side. LAs which emerged from the right side of the abdominal aorta passed under the inferior vena cava. Of the first four LA, the third LA had the largest vessel diameter, and the first LA had the narrowest vessel diameter. Fifth LAs had one of the narrowest vessel diameters of all LAs. CONCLUSION: We consider that anatomical study of LAs using fresh cadavers can be useful to ensure safer anterior lumbar spinal surgeries.

Comprehensive Anatomic and Morphometric Analyses of Triangular Working Zone for Transforaminal Endoscopic Approach in Lumbar Spine: A Fresh Cadaveric Study.

OBJECTIVE: The aim of this study is to provide essential information for endoscopic transforaminal approach by performing morphometric analysis of the triangular working zone (TWZ) in fresh cadavers. METHODS: Fifteen fresh human cadavers (9 women and 6 men) with no history of spinal surgery were used in this study. Anatomic dissection of 150 foraminal levels were performed. Significant surgical landmarks constructing TWZ were measured bilaterally from L1-2 to L5-S1 on 15 fresh cadavers. The relationship between traversing roots and intervertebral discs was defined. RESULTS: Base, height, and hypotenuse measurements of TWZ were longer as the level lowered. Mean base height and hypotenuse of TWZ were 12.15 mm, 11.29 mm, and 16.69 mm (L1-2); 17.94 mm, 17.18 mm, and 28.03 mm (L5-S1), respectively. TWZ was triangular shaped at the upper lumbar levels (L1-2, L2-3, and L3-4), and trapezoid at the lower lumbar levels (L4-5 and L5-S1). Going down the levels, the exiting root angle was narrower, the mean exiting angle of the L5 root being 28.23°. All L2 and L3 traversing roots and nearly all L4 traversing roots (86.7%) originated from below the disc level. Forty percent of L5 traversing roots originated above the disc level, and 53.3% originated at the disc level. Most S1 traversing roots originated at the proximal margin of the disc level (80%). CONCLUSIONS: Our study reveals a detailed morphometric analysis of TWZ. Understanding the foraminal anatomy is crucial for safely performing transforaminal endoscopic surgery. The learning curve of transforaminal surgery can be reduced by garnering knowledge of TWZ anatomy.

A new lumbar fixation device alternative to pedicle-based stabilization for lumbar spine: In vitro cadaver investigation.

Context: To evaluate the stability provided by a new bilateral fixation technique using an in vitro investigation for posterior lumbar segmental instrumentation.Design: Experimental cadaver study. In this study, we propose an alternative technique for a posterior lumbar fixation technique called "inferior-oblique transdiscal fixation" (IOTF).Setting: Study performed at Engineering Center for Orthopedic Research Exellence (ECORE) in Toledo University-Ohio.Participants: Six human lumbar cadaveric specimen used in this study.Interventions: In this study, we propose an alternative technique for a posterior lumbar fixation technique called "inferior-oblique transdiscal fixation" (IOTF). As a novel contribution to the classical technique, the entry point of the screw is the supero-lateral point of the intersecting line drawn between the corpus and the pedicle of the upper vertebra. This approach enables the fixation of two adjacent vertebrae using a single screw on each side without utilizing connecting rods.Outcome Measures: Flexion (Flex), extension (Ext), right and left lateral bending (LB & RB), and right and left axial rotation (LR & RR), and the position data were captured at each load step using the Optotrak motion measurement system and compared for IOTF and posterior transpedicular stabilization.Results: The Posterior stabilization system (PSS) and IOTF significantly reduced the ROM of L4-L5 segment compared to intact segment's ROM. During axial rotation (AR) IOTF fused index segment more than PSS. Besides this, addition of transforaminal lumbar interbody fusion (TLIF) cage improved the stabilization of IOTF system during flexion, extension and lateral bending. Whereas, PSS yielded better fusion results during extension compared to IOTF with and without interbody fusion cages.Conclusions: We hypothesized that the new posterior bilateral system would significantly decrease motion compared to the intact spine. This cadaver study showed that the proposed new posterior fusion technique IOTF fused the index segment in a similar fashion to the classical pedicle screw fusion technique.

Anatomical Features of Neural Foramen at T12â€"L1 Level for Endoscopic Transforaminal Approach of Paramedian and Foraminal Disc Herniations: An Anatomical Study on Fresh Human Cadavers.

AIM: To explore the anatomic features of the neural foramen in particularly at the T12-L1 level in order to assess reveal the safety and efficiency of the endoscopic transforaminal approach for paramedian and foraminal disc herniations at this level. MATERIAL AND METHODS: The study included 15 fresh human cadavers. The soft tissues were removed at the T12-L1 level and bony tissues, were exposed including the transverse processes. The bilateral facets and pars interarticulares at this level were resected revealing the foraminal anatomy and exiting roots. The anatomical structures constituting the triangular safe working zone (TSWZ) were explored. The nerve root length, nerve root width, nerve root angle, TSWZ height, and base of TSWZ base, nerve root width, nerve root angle and disc height were recorded. RESULTS: The root length is the hypotenuse of the TSWZ between the axilla of the exiting root and the lateral margin of the pedicle, and the mean root length was 14.94 ± 2.45 mm. The dural height is the interval between the axilla of the exiting nerve root axilla and the superior end plate of the caudal vertebra, and the mean of the dural height was 10.95 ± 1.74 mm. The base of TSWZ is the distance between the lateral margin of the dural sac and the medial margin of the exiting root, and the mean measurement for the base measurement was 11.83 ± 2.26 mm. CONCLUSION: According to the results data from our cadaveric study, we believe that Kambin’s triangular working zone is a safe area to consider for the endoscopic transforaminal approach at the T12-L1 level, especially for paramedian and foraminal disc herniations.

Combined and individual use of pancaspase inhibitor Q-VD-OPh and NMDA receptor antagonist riluzole in experimental spinal cord injury.

BACKGROUND: We investigated the effects of an N-methyl-D-aspartate receptor antagonist, riluzole, and a pancaspase inhibitor and basic apoptosis mediator, Q-VD-OPh, in combination or alone in posttraumatic spinal cord injury. METHODS: In our study, 45 healthy male Sprague Dawley rats were used. Spinal trauma was induced by the clip compression technique via thoracal 7, 8, 9 laminectomies. After inducing the trauma, the drug was continuously administered intraperitoneally for 5 days. After inducing the trauma, the subjects were assessed using Tarlov's motor grading scale and inclined plane test. Five days after the trauma, the spinal cord specimens were harvested, and a histopathological examination was performed. RESULTS: Compared with the other groups, a statistically significant difference with regard to better results for necrosis, inflammation, and apoptosis was observed in the riluzole only and combination groups. Statistically better motor function scores were observed in the Q-VD-OPh only group than in the other groups. CONCLUSION: With regard to limiting secondary damage after trauma, statistically significant results were observed in the Q-VDOPh only and Q-VD-OPh-riluzole combination groups. More extensive laboratory studies are required to limit and control the effects of secondary damage after spinal cord trauma.

The Axon Protective Effects of Syringic Acid on Ischemia/Reperfusion Injury in a Rat Sciatic Nerve Model.

AIM: In the relevant literature, there is no experimental study that investigated the axon protective effects of syringic acid- a polyphenol compound- with an anti-oxidant capacity on ischemia/reperfusion injury. MATERIAL AND METHODS: The rats were randomly divided into four groups: Control group (no medication or surgical procedure), Sham group, Syringic acid group, and Methyprednisolone (MP) Group. Ischemia was achieved by abdominal aorta clamping and all animals were sacrificed 24 hours after ischemia. Harvested sciatic nerve segments were investigated histopathologically and for tissue biochemistry. RESULTS: Ischemic fiber degeneration scores were found significantly lower in syringic acid and MP groups than sham group. Additionally, apoptosis-related cysteine peptidase caspase-3 immunostaining scores were lower in syringic acid and MP groups. Biochemically, superoxide dismutase and nuclear respiratory factor 1 values were significantly higher in syringic acid group compared to those of control and sham groups while malondialdehyde levels were significantly lower in the syringic acid group. CONCLUSION: Syringic acid reduces oxidative stress and axonal degeneration in rat sciatic nerve after ischemia/reperfusion injury. Therefore, syringic acid may play a role in the treatment of peripheral nerve injuries due to ischemia/reperfusion.

LUNG CANCER METASTASIS TO THE SPINE.

BACKGROUND: In patients affected by malignant tumors, spinal column metastases are frequent. Incidence varies between 30% -70%. Lung cancer is the second most frequent cancer invading spine in women, following breast cancer. In men, the first. All patients are under risk of symptomatic spinal cord compression. Prognosis is poor. Indications for surgery are progressive neurologic deficit, intractable pain, and impending vertebral fracture. Treatment is to preserve neurologic function, promote pain relief and provide functional improvement. STUDY DESIGN: Report of five patients with symptomatic thoracic vertebral invasion secondary to lung cancer who underwent nine surgical procedures. In all patients, invasion to spinal column was from neighbouring lung tissue by direct extension or through segmental arteries. METHODS: Five patients with symptomatic metastatic spinal cord compression at thoracal level, secondary to lung cancer were operated. They were evaluated regarding neurologic status, pain and disability scores, tumor type, level, surgical procedure. CONCLUSION: Lung cancer is an aggressive tumor. Patients with symptomatic spinal cord compression must be treated aggressively. With current spinal surgical techniques and with the coordinated effort, the life expectancy and quality of these patients are extended.

Clinical results of anterior odontoid screw fixation for Type II odontoid fractures.

AIM: In this study, 31 patients with a diagnosis of Type II odontoid fractures were reported. All patients were treated with anterior transodontoid screw fixation and clinical outcomes were reported. MATERIAL AND METHODS: In this study, the retrospective clinical analysis of 31 patients with traumatic type II odontoid fractures who were treated through anterior transodontoid fixation in Neurosurgery Department at VKV American Hospital between 1998 and 2012 was performed. The age, sex, cause of injury, diagnosis time, neurological examination before and after surgery, follow-up period were evaluated. The neurological status of patients was classified according to the Frankel scale. RESULTS: In 4 patients, 2 transodontoid screws were inserted. The mean hospital stay was 3.35 days. Posterior occipito-cervical fusion was done in 1 patient due to the lack of fusion in the first operation. No vascular injury, screw malposition, infection, neurologic deterioration, or complications were observed during the peroperative and postoperative stage. The mean postoperative follow-up period was 36 months after surgery. Radiological imaging of patients were performed at the early and late postoperative stage. CONCLUSION: We found satisfying fusion rates and better patient comfort during the postoperative period. We think that stabilization and fusion through a transodontoid screw is a minimal invasive method.

Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients.

OBJECTIVE: To evaluate the clinical outcomes of patients with lumbar disc disease undergoing fully endoscopic surgery at a single clinic. METHODS: Between August 2009 and January 2012, 163 patients (74 men and 89 women) underwent fully endoscopic lumbar discectomy. All patients were followed for 1 year after surgery. The Oswestry Disability Index and a visual analog scale were used to analyze outcomes. RESULTS: During the follow-up period, 114 (70%) patients had no complaints, 30 (18%) patients had occasional pain, and 19 (12%) patients had no improvement. During postoperative follow-up, 8 patients required repeat surgery for recurrence or residual fragments. Postoperatively, 4 patients experienced dysesthesia, which completely resolved in time. Neurologic deterioration occurred in 5 patients, 4 of whom recovered completely without any intervention. Dural tears occurred in 6 patients. CONCLUSIONS: Fully endoscopic interlaminar or transforaminal surgeries are safe and effective treatment modalities for lumbar disc herniations. Despite the difficulties of acquiring this new technique, good results can be achieved with sufficient experience.

Delayed diagnosis of cleidocranial dysplasia in an adult: a case report.

OBJECTIVE: To describe a rare case of cleidocranial dysplasia, an autosomal dominant inherited disease involving the skeleton and teeth, with delayed diagnosis. CASE REPORT: We report a 24-year-old man with cleidocranial dysplasia admitted with hearing loss, rhinolalia, dyspnea and fatigue. Partial absence of clavicles, a bell-shaped ribcage, an open frontal fontanel, unerupted permanent teeth and broad sutures were identified at radiographic examination. CONCLUSION: Cleidocranial dysplasia is very rare, and is commonly missed or diagnosed late. Radiographic findings are essential for diagnosis. An open frontal fontanel is a particularly important finding for neurosurgeons in diagnosis. We describe this rare case and discuss the clinical features of CCD.

Unusual pain due to unilateral facet degeneration at the C1-2 level.

AIM: Neck pain is a common problem that may result from abnormalities in the soft tissues, bones and joints of the spine. However, upper neck and occipital pain syndrome due to unilateral idiopathic arthrosis of a C1-2 lateral articulation is a very rare condition. MATERIAL AND METHODS: We describe two patients with unilateral arthrosis of a C1-2 lateral articulation who were successfully treated with C1-2 fusion. RESULTS: The patients presented with severe headache and/or neck pain. The diagnosis was made with a careful history and imaging studies, including X-ray films, CT scans, and MRI studies. Posterior atlanto-axial transfacet screw fixation was performed in both patients. There were no surgical complications. CONCLUSION: C1-2 fusion is necessary to relieve intractable pain after failure of conservative treatment and/or invasive pain procedures in unilateral C1-2 arthrosis.

Effects of combined and individual use of N-methyl-D aspartate receptor antagonist magnesium sulphate and caspase-9 inhibitor z-LEDH-fmk in experimental spinal cord injury.

BACKGROUND: We investigated the individual and combined effects of magnesium sulphate, which is an N-Methyl-D aspartate receptor antagonist (NMDA), and z-LEHD-FMK, which is a caspase 9 inhibitor, on the genesis of secondary injury in a rat spinal cord injury model. We aimed to minimize the effects of secondary injury in spinal cord trauma by choosing these two agents which served to block the two major mechanisms of cell loss, apoptosis and necrosis. METHODS: The drugs were given to the subjects according to their groups, either in singular or combined fashion. For motor examination, the subjects were kept under close clinical evaluation for five days. Histopathological examination and the emerging spinal cord samples were prepared with haematoxylene-eosin and Tunel techniques. RESULTS: A statistically significant difference in favor of the treatment groups has been found between the treatment and control groups in terms of histological data. However, there was no difference in the evaluation of motor examination between trauma and treatment groups. CONCLUSION: We have found no difference between the individual and combined uses of MgSO4 and z-LEHD-FMK in the prevention of secondary injury; however, there were better histological results in the treatment groups compared to trauma and control groups which gives us hope for future investigations.

Dynamic stabilisation in the treatment of degenerative disc disease with modic changes.

Objective. Posterior dynamic stabilization is an effective alternative to fusion in the treatment of chronic instability and degenerative disc disease (DDD) of the lumbar spine. This study was undertaken to investigate the efficacy of dynamic stabilization in chronic degenerative disc disease with Modic types 1 and 2. Modic types 1 and 2 degeneration can be painful. Classic approach in such cases is spine fusion. We operated 88 DDD patients with Modic types 1 and 2 via posterior dynamic stabilization. Good results were obtained after 2 years of followup. Methods. A total of 88 DDD patients with Modic types 1 and 2 were selected for this study. The patients were included in the study between 2004 and 2010. All of them were examined with lumbar anteroposterior (AP) and lateral X-rays. Lordosis of the lumbar spine, segmental lordosis, and ratio of the height of the intervertebral disc spaces (IVSs) were measured preoperatively and at 3, 12, and 24 months after surgery. Magnetic resonance imaging (MRI) analysis was carried out, and according to the data obtained, the grade of disc degeneration was classified. The quality of life and pain scores were evaluated by visual analog scale (VAS) score and Oswestry Disability Index (ODI) preoperatively and at 3, 12, and 24 months after surgery. Appropriate statistical method was chosen. Results. The mean 3- and 12-month postoperative IVS ratio was significantly greater than that of the preoperative group (P < 0.001). However, the mean 1 and 2 postoperative IVS ratio was not significantly different (P > 0.05). Furthermore, the mean preoperative and 1 and 2 postoperative angles of lumbar lordosis and segmental lordosis were not significantly different (P > 0.05). The mean VAS score and ODI, 3, 12, and 24 months after surgery, decreased significantly, when compared with the preoperative scores in the groups (P = 0.000). Conclusion. Dynamic stabilization in chronic degenerative disc disease with Modic types 1 and 2 was effective.

Posterior Transpedicular Dynamic Stabilization versus Total Disc Replacement in the Treatment of Lumbar Painful Degenerative Disc Disease: A Comparison of Clinical Results.

Study Design. Prospective clinical study. Objective. This study compares the clinical results of anterior lumbar total disc replacement and posterior transpedicular dynamic stabilization in the treatment of degenerative disc disease. Summary and Background Data. Over the last two decades, both techniques have emerged as alternative treatment options to fusion surgery. Methods. This study was conducted between 2004 and 2010 with a total of 50 patients (25 in each group). The mean age of the patients in total disc prosthesis group was 37,32 years. The mean age of the patients in posterior dynamic transpedicular stabilization was 43,08. Clinical (VAS and Oswestry) and radiological evaluations (lumbar lordosis and segmental lordosis angles) of the patients were carried out prior to the operation and 3, 12, and 24 months after the operation. We compared the average duration of surgery, blood loss during the surgery and the length of hospital stay of both groups. Results. Both techniques offered significant improvements in clinical parameters. There was no significant change in radiologic evaluations after the surgery for both techniques. Conclusion. Both dynamic systems provided spine stability. However, the posterior dynamic system had a slight advantage over anterior disc prosthesis because of its convenient application and fewer possible complications.

Skipping posterior dynamic transpedicular stabilization for distant segment degenerative disease.

Objective. To date, there is still no consensus on the treatment of spinal degenerative disease. Current surgical techniques to manage painful spinal disorders are imperfect. In this paper, we aimed to evaluate the prospective results of posterior transpedicular dynamic stabilization, a novel surgical approach that skips the segments that do not produce pain. This technique has been proven biomechanically and radiologically in spinal degenerative diseases. Methods. A prospective study of 18 patients averaging 54.94 years of age with distant spinal segment degenerative disease. Indications consisted of degenerative disc disease (57%), herniated nucleus pulposus (50%), spinal stenosis (14.28%), degenerative spondylolisthesis (14.28%), and foraminal stenosis (7.1%). The Oswestry Low-Back Pain Disability Questionnaire and visual analog scale (VAS) for pain were recorded preoperatively and at the third and twelfth postoperative months. Results. Both the Oswestry and VAS scores showed significant improvement postoperatively (P < 0.05). We observed complications in one patient who had spinal epidural hematoma. Conclusion. We recommend skipping posterior transpedicular dynamic stabilization for surgical treatment of distant segment spinal degenerative disease.

A short history of posterior dynamic stabilization.

Interspinous spacers were developed to treat local deformities such as degenerative spondylolisthesis. To treat patients with chronic instability, posterior pedicle fixation and rod-based dynamic stabilization systems were developed as alternatives to fusion surgeries. Dynamic stabilization is the future of spinal surgery, and in the near future, we will be able to see the development of new devices and surgical techniques to stabilize the spine. It is important to follow the development of these technologies and to gain experience using them. In this paper, we review the literature and discuss the dynamic systems, both past and present, used in the market to treat lumbar degeneration.