Adopting and adapting clinical practice guidelines for timing of decompressive surgery in acute spinal cord injury from a developed world context to a developing region.

PURPOSE: The proper application of high-quality clinical practice guidelines improves trauma patients' care and outcomes. This study aimed to adopt and adapt guidelines on the timing of decompressive surgery in acute spinal cord injury (SCI) in Iranian clinical settings. METHODS: This study followed a systematic search and review of the literature to enter them into the selection process. The source guidelines' clinical suggestions were converted into clinical scenarios for clinical questions on the timing of decompressive surgery. After summarizing the scenarios, we prepared an initial list of recommendations based on the status of the Iranian patients and the health system. The ultimate conclusion was reached with the help of a national interdisciplinary expert panel comprising 20 experts throughout the country. RESULTS: A total of 408 records were identified. After title and abstract screening, 401 records were excluded, and the full texts of the remaining seven records were reviewed. Based on our screening process, only one guideline included recommendations on the topic of interest. All of the recommendations were accepted by the expert panel with slight changes due to resource availability in Iran. The final two recommendations were the consideration of early surgery (≤24 h) as a treatment option in adult patients with traumatic central cord syndrome and in adult patients with acute SCI regardless of the level of injury. CONCLUSION: Considering early surgery for adult patients with acute traumatic SCI regardless of the level of injury was the final recommendation for Iran. Although most of the recommendations are adoptable in developing countries, issues with infrastructure and availability of resources are the limitations.

Adopting Clinical Practice Guidelines for Pharmacologic Management of Acute Spinal Cord Injury from a Developed World Context to a Developing Global Region.

BACKGROUND: Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients' outcomes on the ability and knowledge of "individual" health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods. METHODS: This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each suggestion and the triad of feasibility, acceptance and adoptability for the Iranian health-care context. RESULTS: Two guidelines were included in the adaptation process. Based on high-quality of these guidelines and the feasibility and adoptability evaluation of the organizing committee, we decided to adopt the suggestion of both guidelines. Overall, seven suggestions were extracted from the source guidelines. CONCLUSION: This work provides a framework to apply guidelines for acute SCI to the developing regions of the world. Attempts should be made to implement these suggestions in order to improve the health outcomes of Iranian SCI patients.

Role of Percutaneous Laser Disc Decompression in Patients with Lumbar Disc Herniation on Pain Relief: A Quasi-Experimental Pilot Study:.

Background: Disc herniation is broadly defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space. The disc material may be the nucleus, cartilage, fragmented apophyseal bone, annular tissue, or any combination thereof. Laser surgery is one of the treatment modalities for treating patients with lumbar disc herniation. This study aims to examine the effect of Percutaneous Laser Disc Decompression (PLDD) in patients with lumbar disc herniation. Materials and Methods: This study was conducted on 58 patients who underwent PLDD (optical fiber inserted through an 18G needle, 8 joules, and 8 watts). Individuals were monitored before and after treatment using the comparing visual analog scale (VAS) pain score (from 0 [no pain] to 10 [severe pain]). Results: The mean age of participants was 63.19±13.48 years. Regarding gender, 24 patients (41.4%) were female. The mean VAS score before surgery was 8.73±1.29, and VAS score after surgery was 55.2±2.71, which means pain was significantly reduced (P0.001). Conclusion: The patients' post-PLDD pain may decrease; hence, PLDD can use as an appropriate method for treating lumbar disc herniation.

Systemic Inflammatory Index Is a Novel Predictor of Intubation Requirement and Mortality after SARS-CoV-2 Infection.

Coronavirus disease 2019 (COVID-19), with an increasing number of deaths worldwide, has created a tragic global health and economic emergency. The disease, caused by severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-19), is a multi-system inflammatory disease with many of COVID-19-positive patients requiring intensive medical care due to multi-organ failures. Biomarkers to reliably predict the patient's clinical cause of the virus infection, ideally, to be applied in point of care testing or through routine diagnostic approaches, are highly needed. We aimed to probe if routinely assessed clinical lab values can predict the severity of the COVID-19 course. Therefore, we have retrospectively analyzed on admission laboratory findings in 224 consecutive patients from four hospitals and show that systemic immune inflammation index (SII) is a potent marker for predicting the requirement for invasive ventilator support and for worse clinical outcome of the infected patient. Patients' survival and severity of SARS-CoV-2 infection could reliably be predicted at admission by calculating the systemic inflammatory index of individual blood values. We advocate this approach to be a feasible and easy-to-implement assay that may be particularly useful to improve patient management during high influx crisis. We believe with this work to contribute to improving infrastructure availability and case management associated with COVID-19 pandemic hurdles.

Surgical management of a thoracic extradural arachnoid cyst with communication to subarachnoid space through nerve root: a case report.

Spinal extradural cysts are uncommon and may cause cord and nerve root compression. The cysts usually appear in thoracic spine. We report a 29-year-old man with an extradural arachnoid cyst from T4 to T6. The cyst was communicated to the subarachnoid space through a fistula at the left T6 nerve root. To access the fistula, we had to unroof the foramen of left T6 nerve root which could lead to spinal instability. We decided to save the bony and soft tissue elements of the foramen at the mentioned thoracic spine level. Therefore, the cyst walls were excised and then the ostia of the cyst at the cystic side of the fistula was tightly closed.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients.

BACKGROUND: Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran. METHODS: The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2). RESULTS: A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation. CONCLUSION: Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Mature Cystic Teratoma of Spinal Cord in a 16-Year-Old Male: A Case Report.

Teratoma is a type of multipotential cell tumor, which includes a mixture of two or three germinal layers of ectodermis, endodermis, and mesodermis. Although neonatal sacrococcygeal teratoma has been frequently reported, its occurrence in older age is not common. In this study, we report a rare case of spinal intradural mature cystic teratoma in a 16-year-old male, emphasizing on considering this unusual condition in differential diagnosis of spinal cord cystic tumors.

Solitary neurofibroma of the orbit with intracerebral extension associated with ocular surface melanocytoma: a case report.

Solitary or isolated neurofibroma is uncommonly observed in the orbit. Neurofibromas typically involve peripheral nerves and occasionally the cranial nerves. A 29-year-old man presented with recent onset left eye proptosis and exotropia. Physical examination was positive for hyperpigmented lesions of the ipsilateral ocular surface and hard palate. Imaging revealed an infiltrative orbital mass with extension through superior orbital fissure into the brain. There was also bone defect of greater sphenoid wing. Medial orbitotomy was performed to obtain biopsies of the orbital mass and the pigmented ocular surface lesions. Histopathologic diagnosis of neurofibroma was confirmed for the former and melanocytoma for the latter. His symptoms and examinations remained stable during the follow up. This case is unique due to several features, including extensive intracerebral spread of orbital neurofibroma in a patient without definite diagnosis of neurofibromatosis type 1 and association with ipsilateral ocular surface melanocytoma and palatal pigmented lesions. ABBREVIATIONS: CT: computed tomography; GFAP: glial fibrillary acid protein; MRI: magnetic resonance imaging; NF-1: neurofibromatosis type 1.

Diversity in tumor territory of meningioma: Protein expression in vascular endothelial growth factor and epidermal growth factor.

Background: Vascular endothelial growth factor (VEGF) and epidermal growth factor (EGF) are involved in tumor development and progression. But, the classified-based data of protein expression (PE) in meningiomas is unavailable. Therefore, we aimed to explore the PE of VEGF and EGF in meningiomas by considering evolutionary strategy and the regional tumor-based assay. Methods: PE was assayed using immunofluorescence (IF) within the peripheral, central, and basal sections of four meningioma tumors, and a lung metastatic brain tumor as a positive control. Results: Diverse characteristics and harmonic cross-talk in the individual sections and between different tumor sections were traced. The mode of PE was puzzling and personalized issue. Co-expression had a key impact on tumor evolution and diverse PE profiles led to draw the heterogenic classification, as the personalized/complementary insight in the functional behavior of VEGF and EGF. D1853N polymorphism of ATM gene was mosaics in two patients with meningiomas. Conclusion: The classified heterogeneity, harmonic co-expression, and diverse functional information in different regions of tumors may lead to predict the aggressiveness mode of tumors as a translational insight to the clinical managements including therapy in brain tumors.

Comparison of Surgical Outcome Between Diabetic Versus Nondiabetic Patients After Lumbar Fusion.

BACKGROUND: The prevalence of diabetes mellitus (DM) is increasing worldwide. Thereby, an increasing rate of patients with DM are subjecting to spine surgery. Reviewing the literature, a higher rate of surgery-related complications is reported in DM patients. There is no prospective study comparing the outcomes of lumbar fusion surgery in patients with and without DM. We aimed to investigate whether DM is associated with worse patient-reported outcomes, lower fusion rate, and higher complication rate in subjects undergoing spinal lumbar fusion surgery. METHODS: Forty-eight subjects with DM (DM group) and 48 controls (control group) were recruited. Data regarding age, duration of diabetes, comorbidities, fasting blood sugar, HbA1c, insulin dependence, duration of operation and the volume of bleeding, and the number of infused packed cell were recorded for all patients. Pain and functional status of the patients using the visual analogue scale (VAS) and Oswestry Disability Index (ODI) were measured before operation and 2 weeks, 6 months, and 1 year after lumbar spinal fusion surgery. Using lumbar computed tomography scan and anteroposterior and lateral x-ray 1 year after the surgery, fusion was assessed. RESULTS: Fusion rate after 1 year was 78% in the control group and 53% in the DM group (P = .02). Patients with DM had higher VAS scores comparing to controls 1 year after the operation, but the difference was not significant (P = .07). However, comparing the functional status of the subjects, significantly higher ODI scores were found among DM patients comparing to controls (P = .002). CONCLUSION: Rate of fusion among diabetic patients who undergo lumbar spinal fusion surgery is lower than healthy controls. Spine surgeons should consider this to provide the best possible facilities during the surgery to increase the fusion rate in these patients.

Prevalence of low back pain among athletes: A systematic review.

BACKGROUND: The prevalence of low back pain (LBP) in athletes across a variety of time frames and sports is not known. OBJECTIVES: To systematically collate and appraise studies on the prevalence of LBP in athletes and stratify by point, one year and life-time prevalence. METHODS: A comprehensive search was conducted in February 2016. The following sources were individually searched: PubMed (1950 to present), Ovid SP Medline (1950 to present), ISI (1982 to present) and Google Scholar; Surveys were included if they aimed to report the prevalence of LBP amongst the athletes. Two reviewers independently evaluated the methodological quality of the studies. RESULTS: The literature search generated 4379 records. Title and/or abstracts were reviewed by two investigators and full-texts of 201 relevant articles were selected for further evaluation. Studies were included if they reported the prevalence of LBP in an athletic population (any level of participation in sports and any age range) and were written in English. Furthermore, to adequately assess the prevalence rate, studies had to report the number of athletes with LBP as a percentage of the total number of athletes. Studies that did not contain necessary data to calculate prevalence rate including case reports and non-original studies were excluded and 41 studies entered the bias assessment step. A bias assessment was applied to the methodology of 41 studies, and 36 with low to moderate risk for bias were included in this review. LBP in athletes was shown to have a point prevalence ranging from 10% to 67%, a one-year prevalence ranging from 17% to 94%, and a life-time prevalence ranging from 33% to 84%. The highest prevalence of LBP was found among skiers, floorball players and rowers and the lowest were found in shooters, golfers and triathletes. CONCLUSION: Like general population, LBP is quite prevalent among athletes. There is a lack of sound data on the prevalence and mechanism of LBP in some popular sports such as volleyball, swimming and track and field. The lack of standardization of research methods and outcome measurement tools are significant problems in literature. Researchers need to use standard and internationally acceptable definitions for LBP and related functional disability. Investigators are encouraged to conduct epidemiologic studies, along with search for possible mechanism of LBP, by recruitment of large sample population of the athletes who are selected through randomization of the national population and adopt recent recommendations for a standard definition of LBP.

Adaptation of Traumatic Brain Injury Guidelines in Iran.

CONTEXT: The National institute for health and care excellence (NICE) and scottish intercollegiate guidelines network (SIGN) are two well-known sources of clinical guideline development. In the past years, they have developed clinical guidelines for the management of head injury. In this report, we will highlight our modifications to these guidelines according to the domestic situation in a developing country. EVIDENCE ACQUISITION: The guidelines were appraised using the appraisal of guidelines for research and evaluation (AGREE) instrument. All key recommendations were reviewed by 14 prominent Iranian neurosurgeons; levels of evidence were evaluated and items with limited evidence were determined. Available evidence for selected items were reviewed and discussed. RESULTS: The following items were the most challenging when accounting for the domestic situation in Iran: age as a risk factor for referral, computed tomography scan, the impact of medical comorbidities, pregnancy, consultation, referral to a neurosurgical unit, and teleconsulting and observation before discharge. CONCLUSIONS: The evidence in the discussed topics was limited and controversial. This report is important because it exposes the current knowledge gap in head trauma studies in Iran.

Anatomical considerations for insertion of pedicular screw in cervicothoracic junction.

Background: This study aimed to investigate the pedicle dimension and angulation in cervicothoracic junction (CTJ) using the findings of computed tomographic (CT) to help accurate insertion of pedicular screw. Methods: Forty three patients with high quality CT images of CTJ were evaluated. Pedicle width (PW), pedicle height (PH), pedicle axis length (PAL), transverse angle (TA) and sagittal angle (SA) were measured bilaterally from C6 to T2. Results: Mean PW was 5.3 mm at C6, 6.2 mm at C7, 8.1 mm at T1 and 6.5 mm at T2. Males had larger pedicles than females. PH was greater than PW in all vertebrae. SA was relatively constant and around 15 degrees to horizontal plane. There was high variability of vertebral characteristics especially in PAL and TA. Conclusion: Small diameter screws must be used for pedicular fixation in CTJ. Because of high variability of pedicle morphometry, CT scan is recommended in all patients before instrumentation.

Frequency of Vertebral Endplate Modic Changes in Patients with Unstable Lumbar Spine and Its Effect on Surgical Outcome.

STUDY DESIGN: Prospective cohort study. PURPOSE: In this study, we investigated the frequency of vertebral endplate Modic changes (MCs) and their effects on surgical outcomes in patients with unstable lumbar spines. OVERVIEW OF LITERATURE: Signal changes in endplates have been classified into three types by Modic. The prognostic role of MCs has been investigated in various spinal disorders. METHODS: A series of 70 patients with clinical and radiographic unstable lumbar spine were included in the study. Endplate signal intensity was determined according to Modic classification. All patients underwent instrumented posterolateral fusion. Functional evaluation was made using the visual analog scale (VAS) and Oswestry disability index (ODI). RESULTS: Eighteen patients (26%) had normal endplate intensity, 31 patients (44%) had MC type I, 20 patients (28%) had MC type II, and one patient (1.4%) had MC type III. Pain level VAS and ODI decreased significantly from the preoperative evaluation to the six-month and one-year postoperative evaluations. The surgical outcome (VAS and ODI) was not significantly different between the various types of MC. CONCLUSIONS: Posterolateral fusion is an effective treatment in patients with unstable lumbar spines. MC do not have a significant effect on the surgical outcome of these patients.

Accuracy of magnetic resonance spectroscopy in distinction between radiation necrosis and recurrence of brain tumors.

BACKGROUND: Distinction between radiation necrosis and recurrence of intraparenchymal tumors is necessary to select the appropriate treatment, but it is often difficult based on imaging features alone. We developed an algorithm for analyzing magnetic resonance spectroscopy (MRS) findings and studied its accuracy in differentiation between radiation necrosis and tumor recurrence. METHODS: Thirty-three patients with a history of intraparenchymal brain tumor resection and radiotherapy, which had developed new enhancing lesion were evaluated by MRS and subsequently underwent reoperation. Lesions with Choline (Cho)/N-acetyl aspartate (NAA) > 1.8 or Cho/Lipid > 1 were considered as tumor recurrence and the remaining as radiation necrosis. Finally, pre-perative MRS diagnoses were compared with histopathological report. RESULTS: The histological diagnosis was recurrence in 25 patients and necrosis in 8 patients. Mean Cho/NAA in recurrent tumors was 2.72, but it was 1.46 in radiation necrosis (P < 0.01). Furthermore, Cho/Lipid was significantly higher in recurrent tumors (P < 0.01) with the mean of 2.78 in recurrent tumors and 0.6 in radiation necrosis. Sensitivity, specificity, and diagnostic accuracy of the algorithm for detecting tumor recurrence were 84%, 75% and 81%, respectively. CONCLUSION: MRS is a safe and informative tool for differentiating between tumor recurrence and radiation necrosis.

Complementary effect of H MRS in diagnosis of suprasellar tumors.

OBJECTIVE: Suprasellar tumors are considered exceptionally important in neurosurgical practice due to their proximity to vital portions of the brain. Predicting histology of these tumors is of prime importance in determining the surgical approach, prognosis, and probable postoperative complications. There are numerous cases where computed tomography and magnetic resonance imaging (MRI) fail to predict histology. We have studied the role of magnetic resonance spectroscopy (MRS) in the diagnosis of suprasellar tumors. METHODS: Twenty-three patients with primary nonfunctional suprasellar tumors and high-quality magnetic resonance spectra were studied. The most probable diagnosis (adenoma, meningioma, craniopharyngioma, or astrocytoma) was made by a neuroradiologist based on the MRI findings and then based on MRI plus MRS findings. Finally, the results were compared with the pathology report. RESULTS: The information provided by MRS led the radiologist to alter his prior diagnosis that was based on the MRI in four patients, and the final diagnoses were in accordance with the histopathology. Wrong diagnosis was made by MRI plus MRS in three patients. Test efficiency of MRI was 69.6%, and it was 87% for MRI plus MRS. However, the difference was not statistically significant (P value=.152). CONCLUSION: MRS may be useful in providing a more improved preoperative diagnosis of suprasellar tumors.

Huge hydrocephalus: definition, management, and complications.

OBJECTIVE: Lack of comprehensive knowledge and numerous socioeconomic problems may make the parents leave hydrocephalic children untreated, leading to progressive hydrocephalus and eventual unordinary big head. Management of huge hydrocephalus (HH) differs from common hydrocephalus. We present our experience in the management of these children. METHODS: HH is defined as head circumference larger than the height of the infant. Nine infants with HH have been shunted in Children's Hospital Medical Center and followed up for 0.5 to 7 years. RESULTS: The most common cause of hydrocephalus was aqueductal stenosis. The mean age of patients during shunting was 3 months. The head circumference ranged from 56 to 94 cm with the average of 67 cm. Cognitive statuses were appropriate based on their age in five patients. Motor development was normal only in one patient. Complications were found in most cases which included subdural effusion (six patients), shunt infection (four patients), skin injury (three patients), proximal catheter coming out of ventricle to the subdural space (two patients), and shunt exposure (one patient). Three patients died due to shunt infection and sepsis. CONCLUSION: Numerous complications may occur in patients with HH after shunt operation such as subdural effusion, ventricular collapse, electrolyte disturbance, skull deformity, scalp injury, and shunt infection. Mental and motor disabilities are very common in patients with HH. Many of these complications can be related to overdrainage; therefore, drainage control using programmable shunts is advisable.

Iniencephaly: clinical, radiological and surgical findings.

The authors report a case of iniencephaly in a 6-year-old boy with a huge occipital bone defect and encephalocele, extensive spina bifida of the cervical vertebrae and fixed retroflexion of the head due to Sprengel's deformity. He presented with some cerebellar and cranial nerve symptoms and new episodes of neck pain and drop attacks. Brain imaging confirmed progressive deformity of the brain stem, cerebellar herniation into the encephalocele sac and ventriculomegaly. Surgical repair of the encephalocele was performed with preservation of all herniated cerebellar tissue and the release of thick arachnoid adhesions to make more space to return the herniated neural tissue from the sac to the cranium. The patient was found to have progressive facial palsy and intracranial hypertension 3 days after surgery, which improved with ventriculoperitoneal shunting. Iniencephaly is generally a fatal anomaly, and only 7 such patients have been reported to have survived. Because of the fatality of this anomaly, prenatal diagnosis of iniencephly and pregnancy termination are important. The patient presented herein is only the second patient with iniencephaly and encephalocele to be operated on. The severity of associated systemic and cranial abnormalities is fundamental with regard to survival. Essential points for surgery are preparing enough space to save herniated functional neural tissues, management of associated hydrocephalus and brain stem rotation/compression due to decreased postoperative space. In the surviving child, early correction of Sprengel's deformity would provide a better aesthetic position of the neck with preservation of brachial plexus integrity.