Limited versus Aggressive Open Discectomy for a Single Level Lumbar Intervertebral Disc Prolapse.

Open lumbar discectomy is the gold standard surgical procedure for intervertebral disc herniation but still controversy exit whether limited or aggressive open discectomy provides better outcomes. Retrospectively we evaluate 2380 patients to compare the clinical outcomes, complications and recurrence rate between limited (LD) and aggressive open discectomy (AD). Records of 745 men and 255 women aged 19 to 55 (mean, 38.03±9.1) years for LD and 995 men and 385 women aged 21 to 60 (mean, 43.7±9.3) years for AD were reviewed. Demographic data, surgical data, complications and re-herniation rate were collected and assessment done by Visual analogue score (VAS), Oswestry Disability Index (ODI) and modified Mcnab criteria. The mean follow-up period was 24.5 and 28.8 months respectively. In compare to aggressive discectomy, limited discectomy required significantly less operative time (95 vs. 55 minutes, p<0.001, unpaired 't' test), less used of post-operative analgesic (p<0.05) and better patients' satisfaction (p<0.05). But low back pain, leg pain, recurrence rate, infection, per-operative blood loss and periods of hospitalization were without significant difference. Both groups achieved satisfactory clinical outcomes 85%, 78.62 % respectively. Complications were foot drop (n=2, 5), dural tear (n=7, 14), superficial wound infection (n=7, 17) and discitis (n=19, 37) and reherniation (55, 64) respectively. Limited discectomy is an alternative to the aggressive discectomy. Both groups showed satisfactory outcome but in limited discectomy group shown better satisfaction in relation to aggressive discectomy.

Management of Spinal Injuries in Polytrauma Patients: An Experience of Tertiary Care Hospital.

Spine injuries, a common component in Polytrauma are usually affects the young people and is a major cause of morbidity and poses a significant health care expenditure and considerable threats to survival and quality of life. We retrospectively assess the demographics, incidence, mode of trauma, associated spine injuries, complications, neurological improvement and mortality. Records of total 1695 admitted patients, spinal injuries were 262 patients. Among them 30(11.45%) patients were associated with Polytrauma victims. Eleven patients (36.67%) were admitted through Ortho emergency dept, 14(46.67%) patients through Intensive care unit (ICU), 5(16.66%) patients through other department (CVS, Urology). Most (56%) of the patients were young in the age range of 16 to 40 years. Cervical spines were most commonly (44%) affected followed by lumbar (31%), thoracic (13%), thoraco-lumbar (9%) and Cervico-thoracic (3%) spines. Road traffic accident was the common cause (80%). Twelve patients (40%) had problems at various steps of management and maximum problems occur in step III. Nineteen patients (63.33%) management needs co-ordination between various specialties. Significant number of patients (76.67%) required operative treatment (p<0.05) and 13.33% were managed conservatively. Mortality rate (10%) was insignificant (p>0.05%). Of these patients, 73.33% had shown neurological improvement of at least one ASIA grade. The treatment of spinal injury in polytrauma patient should follow the principle of Advanced Trauma Life Support (ATLS). Once life and limb-threatening injuries have been identified and addressed, suspected spinal cord injury patients should be immobilized as early as possible to reduced the secondary injury, improve motor and sensory function as well as reduced the extend of permanent paralysis.

Short-segment versus Long-segment Stabilization for Unstable Thoracolumbar Junction Burst Fractures.

The treatment of unstable thoracolumbar junction burst fractures remains a controversial issue. We evaluate the efficacy of short segment (SS) compared with that of long-segment (LS) stabilization in terms of clinical and the radiological outcomes. Records of 88 patients with thoracolumbar burst fracture underwent posterior pedicle screw fixation from January 2004 to December 2015, studied retrospectively. These patients were divided into two groups: SS and the LS-group. Clinical parameters: back pain, disability, neurological deficit and radiologic parameters: Cobb angle, sagittal index, the kyphotic deformation of vertebral body, vertebral height and canal compromise were measured before surgery and immediately after surgery and at 3, 6 and 12 months postoperatively. Overall outcomes were evaluated using the modified Mcnab criteria at the last follow-up. Chi-squared test and paired-t test were used for statistical analysis using SPSS. There were 36 and 52 patients in the SS and LS- group, respectively. The mean age of the patients was 30.6±8.4 and 33.4±8.4 years and the mean follow-up period was 24.5 and 16.8 months in SS and LS-group respectively. In the SS-group, the fractured vertebral body level was L1, T12, L2, T11 and T10 in 15, 10, 6, 3 and 2 cases and LS- group, the fractured vertebral body level was L1, T12, L2, T11 and T10 in 22, 17, 5, 5 and 3 cases, respectively. Both groups achieved satisfactory clinical outcomes according to the modified Mcnab criteria. In the SS-group, 8(22.22%), 21(58.33%) and 7(19.44%) cases were considered to have excellent, good and fair outcome and LS-group, 18(34.61%), 25(48.08%), 6(11.54%) and 3(5.77%) cases were considered to have excellent, good, fair, and poor outcome, respectively. Short-segment pedicle screw fixation including the fractured vertebral body might be as effective as long-segment pedicle screw fixation for the treatment of unstable thoracolumbar junction burst fracture.

Open-door Laminoplasty for Multilevel Cervical Spondylotic Myelopathy and Ossification of the Posterior Longitudinal Ligament (OPLL) using Titanium Reconstruction Miniplate and Screws.

To review outcome of 25 patients who underwent open-door cervical laminoplasty for multilevel cervical spondylotic myelopathy (MCSM) and ossification of the posterior longitudinal ligament (OPLL) using titanium reconstruction miniplate and screws. Records of 18 men and 7 women aged 35 to 78 (mean, 62.6) years were reviewed retrospectively from October 2009 and October 2014 at Bangabandhu Sheikh Mujib Medical University (BSMMU) and in our private settings, Dhaka, Bangladesh. Four patients had 5 levels (C3-C7), 21 patients had 4 levels (C3-C6) decompression and 3 patients (12%) performed foraminotomies. A total of 104 laminae were opened, all of them were fixed with a titanium reconstruction miniplates. In 21 patients, a 20-hole titanium miniplate bent to the contour of a lamina was used and fixed into 4 laminae and 4 patients fixed in 5 laminae levels. In most patients, screw fixation was unicortical and no spacer or bone graft was used. Demographic and surgical data were collected and clinical outcomes were assessed with neck pain score, neck disability index and Nurick's grading. Outcome analysis was done using Odom's criteria. The mean follow-up duration was 1.8 (range, 1-5) years. Diagnoses were MCSM (n=20), OPLL (n=5). Mean estimated blood loss (EBL) was 120ml (range: 50-200), mean surgery time was 153 min (range: 75-240). Following Nurick's grading, 23 patients (92%) improved, 2 (08%) had the same Nurick grade. No intraoperative complications were noted and average hospital stay was 6.12 days (range: 5 to 9). Significance improvements in overall NDI scores occurred at 1 year follow up (p<0.002). Radiographic evaluation showed an increase in the mean sagittal diameter from 13.3mm at pretreatment to 19.4mm post surgery. Two patients developed transient C5 palsy. Open-door Laminoplasty technique is safe, easy and achieves a good canal expansion and neurological recovery and can be used as an alternative treatment for cases of MCSM and OPLL patients without instability.

Surgical Outcome of Intradural Spinal Tumors.

Results of 63 surgically treated intradural spinal tumors between the period of October 2003 and December 2014 at Bangabandhu Sheikh Mujib Medical University (BSMMU) and in our private settings, Dhaka, were analyzed retrospectively. There were 33 males, 30 females with an average age of 52.4 years (13-70 years) and followed up for at least a year. The preoperative symptom with duration, tumors location and intradural space occupancy and the histopathological diagnosis were analyzed. Pain was evaluated by the visual analogue scale (VAS) and the neurologic function was assessed by Nurick's grade. The tumors were located as, thoracic (n=32, 50.79%), lumbar (n=16, 25.39%), cervical (n=05, 07.93%), and junctional (n=10, 15.87%, CervicoThoracic-01, Thoracolumbar-09). The histopathological diagnosis included schwannoma (n=30, 47.7%), meningiomas (n=14, 22.3%), neurofibroma, arachnoid cyst and myxopapillary ependymoma (n=03, 04.76%) each and paraganglioma (n=01, 01.59%). Among the intramedullary tumors, ependymoma (n=03, 04.76%), astrocytoma and epidermoid cyst (n=02, 03.17%), haemangioblastoma, paraganglioma and cavernous haemangioma (n=01, 01.59%) each. The VAS score was reduced in all cases from 8.0±1.2 to 1.2±0.8 (p<0.003) and the Nurick's grade was improved in all cases from 3.0±1.3 to 1.0±0.0 (p<0.005). The preoperative neurological deficit improved within 8 postoperative weeks in most cases and within 1 postoperative year in all cases. Complications included cerebrospinal fluid leakage, parasthesia and further neurological deterioration (Astrocytoma) (n=02, 03.17%) and dependant bedsore and recurrence (Ependymoma) (n=01, 01.59%). Aggressive surgical excision potentially minimizes neurologic morbidity and improved outcome except intramedullary tumors where initial treatment consists of maximum safe surgical resection or biopsy.

Early Outcome of Repair of Symptomatic Pars Defect by Intra-Laminar Screws and Bone Graft.

Out of wide range of surgical techniques direct repair techniques are emphasized to avoid fusion related complications in pars defects. To assess the clinical, functional and radiological outcome of direct operative repair of pars defects by intra-laminar screws and bone graft, this retrospective study was done in Bangabandhu Sheikh Mujib Medical University and in our private settings, within the period of July 2005 to December 2012. Records of 12 patients (age range, 21-35 years) with symptomatic pars defect, 07 men and 05 women (mean 28 years) who underwent direct pars repair with intralaminar screws and bone graft were reviewed. The surgical time, intra-operative blood loss, post operative hospital stay and time to achieve union was recorded. Self evaluated back pain [using Visual Analogue Score (VAS)] and disability [using Oswestry disability (ODI) questionnaire] was analyzed. Clinical outcome was assessed [using Modified Prolo Scale], Radiological fusion (using Shin criteria), restoration of total lumbar lordosis (TLL) and overall functional outcome [using Odom's Criteria] was calculated. Chi-squared test and paired-t test were used for statistical analysis using SPSS. The VAS, ODI and clinical outcome had significant (p<0.05) improvement as had the radiological fusion and TLL. Overall satisfactory outcome was achieved in 91.67% cases. Despite of no intra-operative or post-operative complications, pseudarthrosis developed in 01 case which could be managed conservatively. Direct repair of spondylitic defect with intra-laminar screws and bonegraft is satisfactory in properly selected cases.

Role of USG-guided fine needle aspiration cytology in the diagnosis of abdominal mass.

The present study was carried out with the aims to diagnose abdominal masses by FNAC with the help of ultrasonography guidance and to determine the diagnostic accuracy of FNAC. One hundred consecutive patients were studied during the period from January 2005 to December 2005. Histopathological examination was done to correlate with the cytologic diagnosis. The results of comparative study of USG-guided FNAC and histopathology were significant (P value was <0.001). In USG-guided FNAC, it was found that 64 were malignant tumors, 5 were benign tumors, 28 were inflammatory and 3 were inadequate material. Histopathology of 3 inadequate materials showed 1 was adenoma and 2 were leiomyoma. As a whole test results of USG-guided FNAC were sensitivity 95.52%, specificity 100%, positive predictive value 100%, negative predictive value 91.67% and accuracy 97%. USG-guided FNAC has been proved to be a rapid, reliable and cost-effective diagnostic method.

Outcome of symptomatic upper lumbar disc herniation.

"Upper" lumbar disc herniations (LDH) are different from the "lower" and possess increased chance of neural compromise and cauda equina syndrome that necessitates operative management despite of contradictory surgical outcome. We underwent the study to assess the clinical and functional outcome of symptomatic upper LDH surgery from July 2003 to June 2012 in BSMMU, Dhaka, Bangladesh. The records of 123 patients (age range, 30-69 years), 56 men and 67 women (mean 52 years) having upper lumbar discectomy were reviewed. The surgical time, intra-operative blood loss, self evaluated back pain and thigh and/or groin pain status [using Visual Analogue Score (VAS)] and the disability status [using Oswestry disability (ODI) questionnaire] was analyzed. Radiological stability (using Posner's criteria), functional outcome [using Japanese Orthopaedic Association (JOA) Score] and overall outcome (using MacNab`s criteria), was calculated. Chi-squared test and z-test using SPSS revealed mean operative time and mean blood loss had no significant (p>0.05) difference. Pain, sensory, motor and reflex status as well as VAS, ODI and all the components of JOA questionnaire had significant (p<0.05) improvement. In spite of intra-operative complications in 20.32% cases, overall satisfactory outcome was achieved in 83.74% cases. The postoperative complications (08.13%) could be managed conservatively. However, carefully decided surgical alternatives resulted in satisfactory clinical and functional outcome in upper LDH surgery.

Transforaminal lumbar interbody fusion in symptomatic low-grade isthmic spondylolisthesis.

Isthmic spondylolisthesis (IS) is the most common spondylolytic disorders and one of the most common causes of low back pain and sciatica in adolescents and adults. Although the initial management is conservative, surgery is often the ultimate solution. Interbody fusion has been found superior and replaced the gold standard postero-lateral fusion. Transforaminal Lumbar Interbody Fusion (TLIF) has been associated with fewer complications and has become the choice of surgery. This study was done to evaluate the clinical, radiological and functional outcome of TLIF in Low Grade Isthmic Spondylolisthesis (LGIS). The clinical records of 46 consecutive patients within the age range of 31 to 60 years, who had symptomatic unstable Low Grade Isthmic Spondylolisthesis (LGIS) with or without unilateral radiculopathy in Bangabandhu Sheik Mujib Medical University (BSMMU) and private settings, from April 2007 to March 2012 were reviewed with 2 year completed follow-up. Patients were evaluated for pain by Visual Analogue Score (VAS), Disability by Oswestry Disability Index (ODI), radiological fusion by Brantigan and Steffee criteria, reduction of listhesis by Taillard's method and the overall functional outcome by the Macnab's criteria. Pain (Low back and leg), disability, neurological status had highly significant (p<0.001, paired t test) improvement. Forty two (91.30%) cases achieved satisfactory radiological fusion with overall 30% reduction of slip. Satisfactory outcome was reached in 45(97.83%) cases. Transforaminal Lumbar Interbody Fusion results in significant improvement of clinical, radiological and functional debility of symptomatic LGIS in adults.

Instrumented posterior lumbar interbody fusion (PLIF) with interbody fusion device (Cage) in degenerative disc disease (DDD): 3 years outcome.

This prospective interventional study carried out at Bangabandhu Sheikh Mujib Medical University and a private hospital in Dhaka, Bangladesh during the period from October 2003 to September 2011. Surgical treatment of degenerative disc disease (DDD) should aim to re-expand the interbody space and stabilize until fusion is complete. The present study conducted to find out the efficacy of using interbody fusion device (Cage) to achieve interbody space re-expansion and fusion in surgical management of DDD. We have performed the interventional study on 53 patients, 42 female and 11 male, with age between 40 to 67 years. All the patients were followed up for 36 to 60 months (average 48 months). Forty seven patients were with spondylolisthesis and 06 with desiccated disc. All subjects were evaluated with regard to immediate and long term complications, radiological fusion and interbody space re-expansion and maintenance. The clinical outcome (pain and disability) was scored by standard pre and postoperative questionnaires. Intrusion, extrusion and migration of the interbody fusion cage were also assessed. Forty seven patients were considered to have satisfactory outcome in at least 36 months follow up. Pseudoarthrosis developed in 04 cases and 06 patients developed complications. In this series posterior lumbar interbody fusion (PLIF) with interbody cage and instrumentation in DDD showed significant fusion rate and maintenance of interbody space. Satisfactory outcome observed in 88.68% cases.

Relationship between physical work load and lumbar disc herniation.

Lumbar disc herniation (LDH) is a disabling problem. This retrospective case control study was done to evaluate the possible relevance of physical work load with Lumbar Disc Herniation. We have performed this study in the Spinal Surgery Unit of Department of Orthopaedic Surgery at BSMMU, Dhaka from July 2007 to June 2010 where 200 cases with Lumbar Disc Herniation and 200 control subjects matched by age, gender and area of residence were taken and analyzed. Chi-square test was computed for sex, area of residence, type of physical work and effort at work, whereas Odds ratio was computed for physical work load, stress at work and daily working period. The highest odds ratio (OR) was with the physical work load (OR: 03.48, CI: 01.84-06.59), hard work (OR: 03.14, CI: 01.74-05.65) and working period of >8 hours (OR: 01.34, CI: 0.75-02.38). Odds ratio for heavy load carrying at work was 03.48 and less job satisfaction or stress at work was 02.45. There was a statistically significant positive association between cumulative exposure of physical work load and lumbar disc herniation indicating an increased occurrence of herniation in heavy physical work load and occupation requiring harder efforts.

Loss of interleukin-2-dependency in HTLV-I-infected T cells on gene silencing of thioredoxin-binding protein-2.

The transition from interleukin-2 (IL-2)-dependent to IL-2-independent growth is considered one of the key steps in the transformation of human T-cell leukemia virus type-I (HTLV-I)-infected T cells. The expression of thioredoxin-binding protein-2 (TBP-2) is lost during the transition of HTLV-I-infected T-cell lines. Here, we analysed the mechanism of loss of TBP-2 expression and the role of TBP-2 in IL-2-dependent growth in the in vitro model to investigate multistep transformation of HTLV-I. CpGs in the TBP-2 gene are methylated in IL-2-independent but not in IL-2-dependent cells. Sequential treatment with 5-aza-2'-deoxycytidine and a histone deacetylase inhibitor augmented histone acetylation and TBP-2 expression, suggesting that loss of TBP-2 expression is due to DNA methylation and histone deacetylation. In IL-2-dependent cells, a basal level of TBP-2 expression was maintained by IL-2 associated with cellular growth, whereas TBP-2 expression was upregulated on deprivation of IL-2 associated with growth suppression. Overexpression of TBP-2 in IL-2-independent cells suppressed the growth and partially restored responsiveness to IL-2. Knockdown of TBP-2 caused the IL-2-dependent cells to show partial growth without IL-2. These results suggested that epigenetic silencing of the TBP-2 gene results in a loss of responsiveness to IL-2, contributing to uncontrolled IL-2-independent growth in HTLV-I-infected T-cell lines.

Immunohistochemical localization of thyroid hormone nuclear receptors in human hair follicles and in vitro effect of L-triiodothyronine on cultured cells of hair follicles and skin.

To investigate the cellular basis of the action of thyroid hormone on hair follicles, we studied the immunohistochemical localization of thyroid hormone receptors (TRs) in human scalp skin using a mouse monoclonal antibody, TR alpha 1 (C4) against TRs. Immunoreactive TRs were detected in the nuclei of the outer root sheath cells (ORSCs), dermal papilla cells (DPCs), fibrous sheath cells of hair follicles, hair arrector pili muscle cells and sebaceous gland cells. However, nuclei of hair matrix cells were not clearly stained with TR alpha 1 (C4). The epidermis showed positive nuclear staining by the antibody. Ductal and secretory portions of eccrine sweat glands were also stained with the antibody as we had expected. In the dermis, almost all the cell components including fibroblasts, vascular endothelial and smooth muscle cells, and Schwann cells were positively stained. Immunofluorescence also showed TRs expression in cultured ORSCs, DPCs, epidermal keratinocytes and dermal fibroblasts. L-triiodothyronine stimulated the proliferation and/or metabolism of all these four types of cells significantly, although there was variation at the rate of stimulation. Whereas, structurally similar, but metabolically inactive analog, reverse T3 had no effect. These results demonstrate the presence of thyroid hormone nuclear receptors in human hair follicles. Furthermore, the presence of TRs in different cell types in the skin suggests numerous direct effects of thyroid hormone on this target tissue.