Optimal Timing and Outcome of Transforaminal Epidural Steroid Injection for the Management of Radicular Pain due to Extruded Lumbar Disc Herniation.

AIM: To evaluate the optimal timing and outcome of fluoroscopically guided transforaminal epidural steroid injections (TFESI) for the management of radicular pain due to extruded lumbar disc herniation (LDH). MATERIAL AND METHODS: In this clinical study, 305 individuals received fluoroscopically guided TFESI for the management of radicular pain due to extruded LDH. Preprocedural and 12-week postprocedural Visual Analog Scale (VAS) scores measuring radicular pain were statistically compared. The neurological conditions of the patients and the complications of the procedure were also recorded. RESULTS: The intensity of radicular pain evaluated by the mean preprocedural and 12-week postprocedural VASs were 8.765 ± 0.559 and 2.281 ± 0.401, respectively (p=0.001, and t=119.01). A correlation was noted between the short duration of symptoms before the procedure and the effectiveness of the procedure. After 12 weeks of the procedure, 32 of the 58 patients showed improvement in terms of neurological deficit. There was no major complication. Nine patients required lumbar disc surgery after the procedure. CONCLUSION: This clinical research demonstrated that TFESI for the management of extruded LDH may alleviate radicular pain and may decrease the neurological deficit and that it is more effective when performed at the earliest possible time point.

AGR2 Gene Expression in Glioblastoma: A Novel Molecular Potential Target for Diagnosis and Treatment.

AIM: To assess anterior gradient protein 2 (AGR2) gene expression in patients with human glioblastoma (GBM) in comparison to levels in healthy brain tissues. MATERIAL AND METHODS: We evaluated the expression levels of AGR2 gene in 34 tissue samples: 29 of them were derived from patients with glioblastoma (GBM group) and 5 were derived from patients with mesial temporal lobe epilepsy (control group). Moreover, in order to demonstrate the AGR2 gene expression, we performed RNA isolation from tissue samples, cDNA acquisition from RNA via reverse transcription and the demonstration of gene expression via real-time polymerase chain reaction. We therefore confirmed findings of both groups. RESULTS: The mean age of the GBM and control groups were 53.1 ± 12.82 years and 40.4 ± 10.92 years respectively. AGR2 gene expression levels of the GBM group were significantly higher than those of the control group (p < 0.01). There were no significant differences of AGR2 gene expression levels across age groups, levels of glucose, urea, creatinine, white blood cell count (WBC), neutrophil, lymphocyte, hemoglobin, platelet, thyroid-stimulating hormone (TSH), T3 and T4 in GBM group (p > 0.05). CONCLUSION: AGR2 gene expression was significantly higher in patients with GBM. Thus, AGR2 gene can be considered as a potential therapeutic target.

The Evaluation of Survivin and Bcl-2 Expression on the Medical Radiation Doses for Neural Tube Defect Development.

AIM: To investigate the effects of different radiation doses on the development of the neural tube defect in chick embryos using computed tomography (CT), and assess its correlation with survivin and Bcl-2 expressions. MATERIAL AND METHODS: A total of 150 chicken eggs were used and grouped into five categories. In Group 1 (n=30), the embryos were not exposed to radiation. In Group 2 (n=30), the embryos were irradiated using lung cancer screening chest CT protocol. In Groups 3 and 4 (n=30 each), the abdominopelvic and adult routine head CT protocols, respectively, were used to irradiate the embryos. In Group 5 (n=30), the embryos were irradiated using adult brain perfusion CT protocol. Subsequently, the embryos were examined under a stereomicroscope to assess the presence of neural tube developmental abnormalities. Moreover, immunohistochemical staining was performed to determine the survivin and Bcl-2 expression levels. RESULTS: The risk of developing neural tube defect increased with the amount of exposed radiation. Moreover, no significant correlation was observed between the survivin and Bcl-2 expression levels and the radiation dose. CONCLUSION: Overall, the results of this study indicate that the radiation from CT may cause neural tube defect in chicken embryos.

Exome sequencing implicates genetic disruption of prenatal neuro-gliogenesis in sporadic congenital hydrocephalus.

Congenital hydrocephalus (CH), characterized by enlarged brain ventricles, is considered a disease of excessive cerebrospinal fluid (CSF) accumulation and thereby treated with neurosurgical CSF diversion with high morbidity and failure rates. The poor neurodevelopmental outcomes and persistence of ventriculomegaly in some post-surgical patients highlight our limited knowledge of disease mechanisms. Through whole-exome sequencing of 381 patients (232 trios) with sporadic, neurosurgically treated CH, we found that damaging de novo mutations account for >17% of cases, with five different genes exhibiting a significant de novo mutation burden. In all, rare, damaging mutations with large effect contributed to ~22% of sporadic CH cases. Multiple CH genes are key regulators of neural stem cell biology and converge in human transcriptional networks and cell types pertinent for fetal neuro-gliogenesis. These data implicate genetic disruption of early brain development, not impaired CSF dynamics, as the primary pathomechanism of a significant number of patients with sporadic CH.

Transforaminal Epidural Steroid Injection in the Treatment of Pain in Foraminal and Paramedian Lumbar Disc Herniations.

AIM: To compare the effect of fluoroscopically guided transforaminal epidural steroid injections on radicular pain in foraminal and paramedian lumbar disc herniations. MATERIAL AND METHODS: This study included patients who did not benefit from previous medical treatments or are not suitable for surgery. Transforaminal epidural steroid injections for the treatment of foraminal and paramedian lumbar disc herniation were performed in 370 and 1262 patients, respectively. Every group’s preprocedural visual analogue scale (VAS) and 12-week postprocedural VAS scores were recorded, and statistical analysis was performed. The complications noted were also recorded. RESULTS: The preprocedural and postprocedural mean VAS scores for radicular pain in foraminal disc herniation were 67.11 ± 4.28 and 34.78 ± 3.64, respectively. However, the preprocedural and postprocedural mean VAS scores in paramedian disc herniation were 62.16 ± 6.65 and 19.07 ± 4.50, respectively. Statistical analysis of the varying preprocedural and postprocedural VAS scores showed that transforaminal epidural steroid injections were more effective for paramedian disc herniation than for foraminal disc herniation (p < 0.05). CONCLUSION: Transforaminal epidural steroid injections were more effective for paramedian lumbar disc herniation than for foraminal disc herniation, 12 weeks after the procedure.

Effects of Different Therapeutic Radiation Doses on the Development of Neural Tube Defects in Chick Embryos and the Correlation with Bone Morphogenetic Protein 4 and 7 Expression Levels.

AIM: To investigate the effects of different therapeutic radiation doses on the prevalence of neural tube defects (NTDs) in chick embryos and bone morphogenetic protein (BMP) 4 and BMP7 expression levels. MATERIAL AND METHODS: The chick embryos (n=143) were derived from fertile, specific pathogen-free eggs of domestic fowl. The presence of NTDs was analyzed using a stereomicroscope, and BMP4 and BMP7 expression levels were assessed by immunohistochemical staining. The chick embryos were divided into five groups: control (no radiation exposure) (n=23), exposure to thorax computerized tomography (CT) (n=30); exposure to abdominopelvic CT (n=30), exposure to cranium CT (n=30), and exposure to brain perfusion CT (n=30). RESULTS: The prevalence of NTDs and BMP4 and BMP7 expression levels in the different groups were compared. In the cranium CT dose group, both the NTD prevalence (20%, p=0.002) and BMP7 (p=0.031) expression levels were significantly higher than those in the other groups. However, none of the medical doses of irradiation altered BMP4 expression levels (p=0.242). No NTDs were detected in the thorax CT and abdominopelvic CT groups. CONCLUSION: Exposure to irradiation at cranium CT doses may induce the development of NTDs and increase BMP7 expression. Dose radiation exposure using thorax CT and abdominopelvic CT protocols does not appear to induce NTDs.

Successful Application of the Ventriculo-Gallbladder Shunt: A Salvage Procedure.

Ventriculo-gallblader shunt is very rarely used in the treatment of hydrocephalus. A 44-year-old male with ventriculoatrial shunt dysfunction was evaluated. His ventriculoatrial shunt was not working. His medical history revealed that his hydrocephalus was treated five times by venrtriculoperitoneal shunt, and four times by ventriculoatrial shunt. Another trial for ventriculoperitoneal or ventriculoatrial shunting was not considered feasible. A ventriculo-gallbladder shunt was placed to the patient as a potential salvage procedure. Remarkably, the patient benefited from the ventriculo-gallbladder shunt and was discharged from the hospital. We think that ventriculo-gallbladder shunting is a safe and effective treatment for hydrocephalus as the last resort in complicated cases of shunt dysfunction.

Comparison of the Effect of Single Lumbar Transforaminal Epidural Steroid Injections for the Treatment of L4-5 and L5-S1 Paramedian Disc Herniation.

AIM: To compare the outcomes of fluoroscopically guided transforaminal epidural steroid injections between L4-L5 paramedian disc herniation and L5-S1 paramedian disc herniation for the treatment of radicular pain. MATERIAL AND METHODS: A total of 593 patients treated by transforaminal epidural steroid injections for the treatment of L4-5 paramedian disc herniation and 504 patients treated by transforaminal epidural steroid injections for the treatment of L5-S1 paramedian disc herniation were included in the study. All the patients were regularly followed up for 12 weeks. Preprocedural Visual Analogue Scale (VAS) scores, 12-week post-procedural VAS scores and complications were recorded. RESULTS: The mean preprocedural and postprocedural VAS scores for L4-5 paramedian disc herniation were 63.09 ± 5.37 and 15.81 ± 3.58, respectively, and the mean preprocedural and postprocedural VAS scores for L5-S1paramedian disc herniation were 61.15 ± 5.45 and 27.06 ± 3.62, respectively, for radicular pain. There was a statistically significant difference between preprocedural and postprocedural VAS scores for L4-5 and L5-S1 paramedian disc herniation (p < 0.05). Transforaminal epidural steroid injections for L4-5 paramedian disc herniation were more effective than transforaminal epidural steroid injections for L5-S1 paramedian disc herniation. CONCLUSION: This study showed that transforaminal epidural steroid injections for L4-5 paramedian disc herniation were more effective than transforaminal epidural steroid injections for L5-S1 paramedian disc herniation in the 12-week follow-up period.

De Novo Mutation in Genes Regulating Neural Stem Cell Fate in Human Congenital Hydrocephalus.

Congenital hydrocephalus (CH), featuring markedly enlarged brain ventricles, is thought to arise from failed cerebrospinal fluid (CSF) homeostasis and is treated with lifelong surgical CSF shunting with substantial morbidity. CH pathogenesis is poorly understood. Exome sequencing of 125 CH trios and 52 additional probands identified three genes with significant burden of rare damaging de novo or transmitted mutations: TRIM71 (p = 2.15 × 10-7), SMARCC1 (p = 8.15 × 10-10), and PTCH1 (p = 1.06 × 10-6). Additionally, two de novo duplications were identified at the SHH locus, encoding the PTCH1 ligand (p = 1.2 × 10-4). Together, these probands account for ∼10% of studied cases. Strikingly, all four genes are required for neural tube development and regulate ventricular zone neural stem cell fate. These results implicate impaired neurogenesis (rather than active CSF accumulation) in the pathogenesis of a subset of CH patients, with potential diagnostic, prognostic, and therapeutic ramifications.

The Correlation of SCL-90-R Anxiety, Depression, Somatization Subscale Scores with Chronic Low Back Pain.

AIM: To investigate the correlation of the Symptom Checklist-90-R (SCL-90-R) anxiety, depression, and somatization subscale scores with chronic low back pain (LBP). MATERIAL AND METHODS: Seventy-five patients who were admitted with the complaint of chronic LBP (patient group) and 75 healthy persons (control group) were evaluated. SCL-90-R anxiety, depression, and somatization subscale scores of patients having chronic LBP and healthy persons were measured. The mean values were paired and using two tailed t test they were statistically evaluated. RESULTS: The difference between SCL-90-R anxiety subscale subscores of patients having chronic LBP and healthy persons was not statistically significant (p > 0.05). The difference between SCL-90-R depression subscale subscores of patients having chronic LBP and healthy persons was not statistically significant (p > 0.05). The difference between SCL-90-R somatization subscale subscores of patients having chronic LBP and healthy persons was statistically significant (p < 0.05). CONCLUSION: SCL-90-R somatization subscale subscores are higher in patients with low back pain. The treatment of low back pain can be more successful when combined with the treatment of somatization.

Comparison of Single-Level and Multilevel Decompressive Laminectomy for Multilevel Lumbar Spinal Stenosis.

OBJECTIVE: This study aimed to clarify whether multiple compressions of nerve roots resulted in poorer surgical outcome when patients were treated with single-level decompressive laminectomy or multilevel decompressive laminectomy. To reach this we compared preoperative and postoperative Oswestry Disability Index (ODI) scores, Visual Analogue Scale (VAS) scores, and walking duration of multilevel lumbar spinal stenosis (LSS) patients treated with single-level and multilevel decompressive laminectomy. METHODS: This retrospective study included 112 consecutive patients undergoing lumbar decompressive surgery without arthrodesis for LSS between March 2010 and September 2013. Forty-eight patients were treated with single-level laminectomy and 64 patients were treated with multilevel laminectomy. ODI scores, VAS scores, and walking duration were measured for all patients preoperatively and 30 months after decompressive surgery. RESULTS: The mean age of the patients was 64.41 ± 13.4 years. The ODI scores, VAS scores, and walking duration difference between patients treated with single-level laminectomy and multilevel laminectomy were statistically significant and higher for the first group (P < 0.05). There were more operative complications in patients treated with multilevel decompressive laminectomy; however, there was no statistically significant difference between single-level and multilevel decompressed patients regarding complications (P = 0.119). Four of the patients treated with multilevel decompressive laminectomy experienced postoperative spondylolisthesis needing posterior instrumented fusion. CONCLUSION: Recovery in terms of ODI scores, VAS scores, and walking duration was better in LSS patients undergoing single-level laminectomy than in those undergoing multilevel laminectomy. Also, the rates of operative complications and postoperative follow-up spondylolisthesis were higher in patients treated with multilevel laminectomy.

Spontaneous Resolution of a Sylvian Arachnoid Cyst in a Child: A Case Report.

We report the case of a 7-year-old boy with an incidentally diagnosed left sylvian arachnoid cyst. At a clinical follow-up of 2 years, cranial computed tomography scans found the cyst to be totally resolved. The mechanism of this rare spontaneous resolution of an arachnoid cyst is discussed.

The Effect of Ankaferd Blood Stopper? on Epidural Fibrosis After Laminectomy in Rats: An Experimental Study.

AIM: Lumbar epidural fibrosis is increasingly recognized as a cause of persistent back pain. The aim of this study was to examine the effect Ankaferd Blood Stopper on epidural fibrosis following laminectomy in rat models. MATERIAL AND METHODS: Twenty Sprague-Dawley male rats were randomly allocated to 2 groups of 10 each. The dura mater and nerve root were exposed after L1 unilateral laminectomy. Close attention was paid not to traumatize the dura, the nerve roots, or the dissected muscles. Immediate muscle and skin closure was made in sham group. In the Ankaferd Blood Stopper group, cotton wool soaked with 1 mL Ankaferd Blood Stopper was applied to the exposure site for 5 minutes, and muscle and skin closure was then made. Histological analysis was performed at four weeks postoperatively. RESULTS: Epidural fibrosis formation evaluation and fibroblastic activity evaluation revealed that there was a significant difference between the sham and the Ankaferd Blood Stopper treated groups (p = 0.011, p = 0.009). Severe epidural adhesions were observed in the Ankaferd Blood Stopper group. Dissection of these epidural adhesions was difficult and accompanied by bleeding and disruption of the dura mater. CONCLUSION: The results of this study showed that there was no positive effect of Ankaferd Blood Stopper on the prevention of epidural fibrosis, which is one of the most significant problems following spinal surgery, and the epidural fibrosis actually increased.

Thalamic abscess caused by a rare pathogen: streptococcus constellatus.

Streptococcus constellatus is a microorganism that lives commensally in the oropharyngeal region, urogenital region, and intestinal tract. However, it can cause infection in patients with certain predisposing factors. Rarely, this microorganism can cause a brain abscess. Thalamic localization of brain abscesses is much rarer than abscesses in other locations of the brain. Brain abscess caused by streptococcus constellatus are very rarely been reported in the literature. We present a rare case of a left-sided thalamic abscess caused by streptococcus constellatus in a 25-year-old male patient who was injured by shrapnel pieces in the head and who was malnourished. The patient was successfully treated by stereotactic aspiration and antibiotherapy.

Ten-year follow-up results of posterior instrumentation without fusion for traumatic thoracic and lumbar spine fractures.

BACKGROUND: This retrospective study aims to present and evaluate the long follow-up results of posterior instrumentation without fusion in patients with traumatic thoracic and lumbar fractures. METHODS: 45 patients were operated. The mean follow-up period was 147.6 months. Sagittal plane kyphosis (SPK) and anterior wedge angle (AWA) were evaluated in preoperative and follow-up. RESULTS: SPK and AWA improved significantly in the early postoperative. However, the correction was lost in the 10-year follow-up. The loss of correction was statistically significant in SPK and AWA. CONCLUSION: Posterior instrumentation without fusion is still among the most useful in treatment of traumatic thoracolumbar fractures.

Comparison of pedicle screw fixation and hybrid instrumentation in adolescent idiopathic scoliosis.

OBJECTIVE: The purpose of this study was to compare pedicle screw fixation (PSF) with hybrid instrumentation (HI) in cases of adolescent idiopathic scoliosis (AIS). METHODS: Thirty-eight patients with AIS who underwent PSF (n=19) or HI (n=19) between 2001 and 2011 were retrospectively reviewed. Patients had similar age at surgery and similar number of fused vertebrae. Operative time, intraoperative blood loss, and postoperative complications were compared between the 2 groups. Spinal radiographs for apical vertebral translation, global coronal balance, major curve Cobb angle, global sagittal balance, thoracic kyphosis, and lumbar lordosis were measured in all patients preoperatively and at 2-year follow-up; the results were then compared between the 2 groups. Postoperative correction was calculated for all patients and compared between the 2 groups. RESULTS: The average time of surgery ofthe PSF group was significantly longer than that of the HI group (p<0.05). The amount of bleeding of the PSF group was significantly higher than the HI group (p<0.01). No statistically significant difference was found between the groups in respect to the development of complications (p>0.05). Both the major curve Cobb angle and the global sagittal balance showed greater improvement in the PSF group compared to the HI group (p<0.01). Postoperative correction was better in the PSF group than the HI group. CONCLUSION: The PSF system provided better improvement than the HI system in major curve Cobb angle and global sagittal balance, and postoperative correction was better in the PSF group than the HI group.

Computerized tomography imaging in adolescent idiopathic scoliosis: prone versus supine.

BACKGROUND: The aim of the present study was to assess the degree of apical vertebral rotation values in Adolescent Idiopathic Scoliosis (AIS) that were obtained on CT scans, and to analyze the influence of patient position (supine versus prone) on the degree of rotation. METHODS: The study included 50 apical vertebra rotation measurements of 34 patients with Type 1A and Type 3C curvature according to the Lenke classification. CT imaging was applied to the patients in supine and prone positions to measure the apical vertebral rotation (AVR). The average AVR angles were measured using the Aaro-Dahlborn method and the results were compared. RESULTS: No significant differences were found between the vertebral rotation measured in the prone and supine positions for the Lenke 1A subgroup and the Lenke 3C thoracic group (p = 0.848; p = 0.659, respectively). In the Lenke 3C lumbar group, however, the vertebral rotation in the supine position was found to be significantly lesser than that in the prone position (difference -1.40° ± 1.79°, p = 0.007). CONCLUSION: The assessment of the apical vertebra rotation is crucial in AIS. Even though the vertebral rotation in the supine position was found to be significantly lesser than that in the prone position, CT imaging in a prone position could not be considered clinically more relevant than the CT images in a supine position as there was less than 3° difference.

Cavernous sinus meningiomas: imaging and surgical strategy.

Cavernous sinus (CS) meningiomas which are by definition those meningiomas which originate from the parasellar region are difficult skull base tumors to deal with. For deciding the most appropriate surgical strategy, surgeons need detailed preoperative neuroimaging. The vicinity of the tumor with the vital and highly functional neurovascular structures, tumor extensions into the basal cisterns and skull base structures, and the arterial vascularization and venous drainage pathways, as they shape operative strategy, are important preoperative data to take into account. Thin section CT scan with bone windows, 3D spiral CT reconstruction, MRI, MR angiography, and DSA performed with selective arteriography including late venous phases give those required detailed informations about the tumor and its relation with neurovascular and bony structures. The type of craniotomy and complementary osteotomy and the usefulness of an extradural anterior clinoidectomy with unroofing the optic canal can be decided from preoperative neuroimaging. Data collected also help in determining whether extensive exposure of the middle cranial fossa is necessary to ensure substantial devascularization of the tumor and whether proximal control of the internal carotid artery (ICA) at its intrapetrosal portion might be useful. Study of the capacity of blood supply of the Willis circle is wise for deciding the need and way of performing an extra-intracranial bypass together with tumor removal. Currently the concept of operating only the tumors with extracavernous extensions and to limit resection to only their extracavernous portions is the most accepted way of treating these tumors. It was that strategy that was adopted in the senior author's 220-patient series.Radiosurgery or stereotactic fractionated radiotherapy may complement surgery or can be only reserved for growing remnants.

Brain malformations associated with Knobloch syndrome--review of literature, expanding clinical spectrum, and identification of novel mutations.

BACKGROUND: Knobloch syndrome is a rare, autosomal recessive, developmental disorder characterized by stereotyped ocular abnormalities with or without occipital skull deformities (encephalocele, bone defects, and cutis aplasia). Although there is clear heterogeneity in clinical presentation, central nervous system malformations, aside from the characteristic encephalocele, have not typically been considered a component of the disease phenotype. METHODS: Four patients originally presented for genetic evaluation of symptomatic structural brain malformations. Whole-genome genotyping, whole-exome sequencing, and confirmatory Sanger sequencing were performed. Using immunohistochemical analysis, we investigated the protein expression pattern of COL18A1 in the mid-fetal and adult human cerebral cortex and then analyzed the spatial and temporal changes in the expression pattern of COL18A1 during human cortical development using the Human Brain Transcriptome database. RESULTS: We identified two novel homozygous deleterious frame-shift mutations in the COL18A1 gene. On further investigation of these patients and their families, we found that many exhibited certain characteristics of Knobloch syndrome, including pronounced ocular defects. Our data strongly support an important role for COL18A1 in brain development, and this report contributes to an enhanced characterization of the brain malformations that can result from deficiencies of collagen XVIII. CONCLUSIONS: This case series highlights the diagnostic power and clinical utility of whole-exome sequencing technology-allowing clinicians and physician scientists to better understand the pathophysiology and presentations of rare diseases. We suggest that patients who are clinically diagnosed with Knobloch syndrome and/or found to have COL18A1 mutations via genetic screening should be investigated for potential structural brain abnormalities even in the absence of an encephalocele.

Anatomy of the spinal dorsal root entry zone: its clinical significance.

BACKGROUND: The posterolateral sulcus (PLS) is an important surgical landmark, especially for DREZ (dorsal root entry zone) operations. METHODS: The present study aimed to show the variations of the PLS using human spinal cord histological sections and report the variability in the number of dorsal rootlets of the spinal nerves in each the spinal cord segment. Further, measure the height and width of the dorsal horn on histological sections for cervical, thoracic, and lumbar levels. RESULTS: The results of the present study showed various patterns of PLS 1.clearly present PLS, 2. short PLS, 3. absent PLS or 4. irregular PLS. Height and width measurements of the dorsal horn showed that the average width was greatest at lower cervical (0.48 ± 0.04 mm) and least at lower thoracic levels (0.41 ± 0.04 mm), whereas the average height was greatest at upper cervical (3.0 ± 0.06 mm) and smallest at lower lumbar levels (1.8 ± 0.08 mm). The average number of rootlets varied considerably, at cervical level it was 7.6 ± 1.4 mm, at thoracic 6.6 ± 0.8 mm and at lumbar 6.1 ± 0.4 mm. CONCLUSIONS: The detailed anatomy of the variations of the PLS and the average number of rootlets at each spinal level can increase the success of regional surgery. Further, fine measurements on histological sections can give detailed knowledge on the size necessary for lesioning in DREZ operations.