Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury.

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.

Novel Therapeutic Effects in Rat Spinal Cord Injuries: Recovery of the Definitive and Early Spinal Cord Injury by the Administration of Pentadecapeptide BPC 157 Therapy.

Recently, marked therapeutic effects pertaining to the recovery of injured rat spinal cords (1 min compression injury of the sacrocaudal spinal cord (S2-Co1) resulting in tail paralysis) appeared after a single intraperitoneal administration of the stable gastric pentadecapeptide BPC 157 at 10 min post-injury. Besides the demonstrated rapid and sustained recovery (1 year), we showed the particular points of the immediate effect of the BPC 157 therapy that began rapidly after its administration, (i) soon after injury (10 min), or (ii) later (4 days), in the rats with a definitive spinal cord injury. Specifically, in counteracting spinal cord hematoma and swelling, (i) in rats that had undergone acute spinal cord injury, followed by intraperitoneal BPC 157 application at 10 min, we focused on the first 10-30 min post-injury period (assessment of gross, microscopic, and gene expression changes). Taking day 4 post-injury as the definitive injury, (ii) we focused on the immediate effects after the BPC 157 intragastric application over 20 min of the post-therapy period. Comparable long-time recovery was noted in treated rats which had definitive tail paralysis: (iii) the therapy was continuously given per orally in drinking water, beginning at day 4 after injury and lasting one month after injury. BPC 157 rats presented only discrete edema and minimal hemorrhage and increased Nos1, Nos2, and Nos3 values (30 min post-injury, (i)) or only mild hemorrhage, and only discrete vacuolation of tissue (day 4, (ii)). In the day 4-30 post-injury study (iii), BPC 157 rats rapidly presented tail function recovery, and no demyelination process (Luxol fast blue staining).

Stable gastric pentadecapeptide BPC 157 can improve the healing course of spinal cord injury and lead to functional recovery in rats.

BACKGROUND: We focused on the therapeutic effects of the stable gastric pentadecapeptide BPC 157 in spinal cord injury using a rat model. BPC 157, of which the LD1 has not been achieved, has been implemented as an anti-ulcer peptide in inflammatory bowel disease trials and recently in a multiple sclerosis trial. In animals, BPC 157 has an anti-inflammatory effect and therapeutic effects in functional recovery and the rescue of somatosensory neurons in the sciatic nerve after transection, upon brain injury after concussive trauma, and in severe encephalopathies. Additionally, BPC 157 affects various molecular pathways. METHODS: Therefore, BPC 157 therapy was administered by a one-time intraperitoneal injection (BPC 157 (200 or 2 µg/kg) or 0.9% NaCl (5 ml/kg)) 10 min after injury. The injury procedure involved laminectomy (level L2-L3) and a 60-s compression (neurosurgical piston (60-66 g) of the exposed dural sac of the sacrocaudal spinal cord). Assessments were performed at 1, 4, 7, 15, 30, 90, 180, and 360 days after injury. RESULTS: All of the injured rats that received BPC 157 exhibited consistent clinical improvement, increasingly better motor function of the tail, no autotomy, and resolved spasticity by day 15. BPC 157 application largely counteracted changes at the microscopic level, including the formation of vacuoles and the loss of axons in the white matter, the formation of edema and the loss of motoneurons in the gray matter, and a decreased number of large myelinated axons in the rat caudal nerve from day 7. EMG recordings showed a markedly lower motor unit potential in the tail muscle. CONCLUSION: Axonal and neuronal necrosis, demyelination, and cyst formation were counteracted. The functional rescue provided by BPC 157 after spinal cord injury implies that BPC 157 therapy can impact all stages of the secondary injury phase.

Surgical Treatment of Metastatic Disease of the Vertebral Column

Spinal metastatic disease is a rather common occurrence and definitely warrants attention and treatment due to the high likelihood of leaving cancer patients severely disabled in their final months of life. Recent developments in the understanding of the behavior of different tumor types, as well as advances in surgical treatment, are allowing for the evolution of treatment algorithms, especially when surgical treatment is to be considered. This paper gives an overview of the decision-making process and the array of surgical options currently available.

Vertebral artery injury in a patient with fractured C4 vertebra.

Vertebral artery injuries due to cervical spine trauma, although rarely described in the literature, are relatively common. While most of them will remain asymptomatic, a small percentage of patients may suffer life threatening complications. We report a case of the right vertebral artery injury in a patient with fracture of C4 vertebra, successfully treated with endovascular approach. A 78-year-old male patient was hospitalized for cervical spine injury caused by falling off the tractor. Radiological assessment revealed fracture of C4 vertebra with proximal two-thirds of C4 body dislocated five millimeters dorsally. Significant swelling of soft prevertebral tissues distally of C2 segment was also present. During emergency surgery using standard anterior approach for cervical spine, excessive bleeding started from the injured right vertebral artery. Bleeding was stopped by tamponade with oxidized regenerated cellulose sheet and C4-C5 anterior fixation; then partial reduction of displacement was done. Fifteen days later, after angiography, endovascular repair of the right vertebral artery was performed using percutaneous stent graft. Follow up computed tomography scan angiography showed valid stent patency without contrast extravasation. In cases of cervical spine trauma, surgeon should always be prepared to manage injury of vertebral artery. Bleeding can primarily be stopped by hemostatic packing, and definitive repair can be successfully achieved by endovascular approach using percutaneous stent graft.

Precise nail tip positioning after tibial intramedullary nailing prevents anterior knee pain.

PURPOSE: Anterior knee pain (AKP) is a common complication following intramedullary nailing of tibial shaft fractures. Our aim was, by analysing the postoperative lateral knee X-rays and clinical status (VAS score), to find the best intramedullary tip position of a non protruded nail that will provide the best postoperative outcome avoiding AKP. METHODS: We evaluated the postoperative outcome of 221 patients, from the last four years, with healed fractures initially treated with intramedullary reamed nails with two or three interlocking screws proximally and distally through a medial paratendinous incision for nail entry portal. Our aim was to analyse a possible relationship between AKP according to the VAS scale, and nail position marked as a distance from tip of nail to tibial plateau (NP) and to tibial tuberosity (NT), measured postoperatively on lateral knee X-rays. RESULTS: Two groups of patients were formed on the basis of presence of pain related to AKP (the level of pain was neglected): group A were patients with pain and group B without pain. The difference between the two groups concerning NP and NT measurements appeared to be statistically significant concerning NT measurement (p < 0.05), with high accuracy according to the classification tree. CONCLUSIONS: We presume that the position of the proximal tip of the nail and its negative influence on the innervation pattern of the area dorsal to patellar tendon could be the key factor of AKP. We conclude that the symptoms of AKP will not appear if the tip of the nail position is more than 5.5 mm from the tibial plateau (NP) and more than 2.5 mm from the tibial tuberosity (NT).

Course and rate of post-fracture bone healing in correlation with bone-specific alkaline phosphatase and bone callus formation.

Alkaline phosphatase (ALP) and bone-specific alkaline phosphatase (S-bone ALP) activities may serve as markers of the course and rate of bone healing after sustained fractures. The aim of this study was to examine whether the assessment of S-bone ALP as a biochemical parameter in the early posttraumatic phase may indicate the course of fracture healing. To date, the methods used to monitor the bone healing process have been based on the patients' assessment and the radiographic findings. In view of the fact that patient opinion is highly subjective, that the radiographic findings depend on the radiologist's experience and that the monitoring of bone healing is a long-lasting process, measurements of biochemical parameters appear to be the only objective evidence of the changes occurring during bone regeneration. In this study, the activity of bone-specific alkaline phosphatase was measured in the serum of 41 patients who had sustained long bone fractures. The participants included 26 males and 15 females, aged 15 to 80 years. All patients were treated surgically. The activity of S-bone ALP was assessed every seven days over a period of 4 weeks. The study patients were followed up radiologically for several months. Our research showed that the increase of alkaline phosphatase correlated with an increase of S-bone ALP levels. In addition, changes in ALP levels on days 7 and 14 as compared to those on day 1 post injury were associated with changes in S-bone ALP levels on the same day. Likewise, the callus volume correlated with the decrease, no change or increase in the levels of ALP and S-bone ALP in the same way. Based on these results, it may be concluded that monitoring changes in the biochemical parameters alkaline phosphatase and bone-specific alkaline phosphatase allows early detection of fracture healing rates. A minor increase in the activity or no change in the level of the biochemical parameters ALP and S-bone ALP in the period of the first two weeks indicates successful fracture fixation, rapid bone healing and the formation of a minimal or insignificant callus. A major increase in the activity of the biochemical parameters ALP and S-bone ALP in the period of the first two weeks indicates inadequate fracture fixation, delayed bone healing and the formation of a visible and significant callus.

All-inside arthroscopic suturing technique for meniscal ruptures.

The most frequent indication for surgical treatment of the knee is lesion of the meniscus. The "all inside" arthroscopic technique with bioresorptive material for meniscus lesion is becoming the most popular treatment. This prospective study included 10 patients with posterior meniscal horn lesion operatively treated at Sports Traumatology Department. The "all inside" technique was performed by intra-articular application of bioresorptive pins-Darts sticks or Meniscus Viper and bioresorptive string. Patients were followed up for 2-6 months postoperatively and graded according to the IKDC 2000 scale. All surgical treatments showed satisfactory results. Young patients with acute longitudinal peripheral lesion-posterior horn lesions, in the red-red or red-white meniscal zone, 1-2 centimeters long are most appropriate for this type of treatment. In these patients, this technique proved to be superior and free from the risk of neurovascular damage. For better authentication of this conclusion, additional prospective randomized studies should be performed.

[Spontaneous rupture of the spleen in infectious mononucleosis: case report and review of the literature]. / Spontana ruptura slezene u infekcioznoj mononukleozi: prikaz bolesnika uz pregled literature.

OBJECTIVE: Spontaneous splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Abdominal pain is uncommon in infectious mononucleosis, and splenic rupture should be strongly considered whenever abdominal pain occurs. The onset of pain may be insidious or abrupt. The pain is usually in the left upper quadrant. AIM: To indicate that infectious mononucleosis is not always the innocent kissing disease, but could be complicated with splenic rupture as a life-threathenig condition. CASE-REPORT: Our first case is described and a short literature review is provided. We report on the case of a 27-year-old man with infectious mononucleosis who had spontaneous splenic rupture that was successfully managed by splenectomy. On admission, he was febrile (38.5 degrees C) with hepatosplenomegaly, and had a blood pressure of 100/70 mm Hg. Six hours later, the patient complained of increasing abdominal pain. Abdominal ultrasound and computed tomography showed a 16.5 cm heterogeneous splenomegaly with subcapsular hematoma as well as free ascites. Laparotomy confirmed spontaneous rupture of the splenic capsule with active abdominal bleeding. Splenectomy was performed with a good clinical response. Examination of the spleen revealed a ruptured capsule with a subcapsular hematoma. DISCUSSION: Infectious mononucleosis is the most common infectious disease to result in spontaneous spleen rupture. The prognosis is favorable when diagnosis is made on time and correct treatment is started immediately. Although splenectomy was advocated as definitive therapy in the past, numerous recent reports have documented good outcomes with non-operative management. Based on the literature review, an approach to the management of a spontaneously ruptured spleen secondary to infectious mononucleosis is suggested. Non-operative management can be successful in hemodynamically stable patients, i.e. in patients with subcapsular hematoma without overt rupture of the capsule to avoid complications of splenectomy (e.g. post-splenectomy sepsis). CONCLUSION: We report on a 27-year-old man with infectious mononucleosis who had spontaneous splenic rupture that was successfully managed by splenectomy.