Spinal epidural fibrosis following hemostatic agent employment.

OBJECTIVE: Failed Back Surgery Syndrome (FBSS) refers to a subset of patients who have new or persistent pain after spinal surgery for back or leg pain. Epidural fibrosis (EF) is a common cause of FBSS. Many agents aiming to prevent EF have been tested. However, hemostatic agents are readily available at hospitals, easy to reach and frequently used. For these reasons, oxidized regenerated cellulose, polysaccharide hemostat, hemostatic thrombin-gelatin matrix and chitosan linear polymer were evaluated for their effects on epidural fibrosis on rats after laminectomy. METHODS: 40 Sprague-Dawley rats were randomly divided into 5 equal groups including the control group where only the laminectomy was performed. The other 4 groups received hemostatic agents after laminectomy. The rats were euthanized 45 days later and were assessed by a blinded observer to grade the fibrosis level. RESULTS: The study revealed that oxidized regenerated cellulose, polysaccharide hemostat and hemostatic thrombin-gelatin matrix lowered the epidural fibrosis grade which was statistically significant (p < 0.001). Although chitosan linear polymer created fibrosis similar to the control group it was not proven to be statistically significant (p = 0.8999). However, when compared with other hemostatic agents it resulted in a higher fibrosis grade (p < 0.001). CONCLUSION: The results obtained from this experimental study revealed that Pahacel, Sealfoam and Surgiflo, were effective in reducing epidural fibrosis after laminectomy in rats.

Six-level isolated spinous process fracture of the thoracic vertebrae (clay-shoveler's fracture) and a review of the literature.

Clay-shoveler's fractures are isolated, avulsion-type spinous process fractures of the lower cervical and upper thoracic vertebrae. Multi-level fractures of the spinous processes are extremely rare. We report the case of a 60-year-old female patient with a six-level isolated spinous process fracture of the thoracic spine. Our case is the fourth reported case in literature, of an isolated spinous process fracture involving five or more levels in the thoracic vertebrae.

Histopathological Study of the Effects of Dura Adhesive Agents Used in Spinal Surgery Practice on Spinal Epidural Fibrosis in Experimental Animal Model.

Objective: Histopathological examination of the effects of Tisseel, Cova, Glubran and Coseal, which are used for sealing purposes in spinal surgery practice, on epidural fibrosis is aimed. Methods: Forty Sprague Dawley rats were randomly divided into five groups in our study as Group 1 (n=8) control group (Laminectomy); Group 2 (n=8) Cova group (Laminectomy + Cova); Group 3 (n=8) Tissel group (Laminectomy + Tisseel); Group 4 (n=8) Coseal group (Laminectomy + Coseal); and Group 5 Glubrane group (Laminectomy + Glubrane). Control group was only applied laminectomy. After laminectomy to other groups, Cova was applied to the 2nd group, Tissel to the 3rd group, Coseal to the 4th group and Glubran to the 5th group in surgical fields. After the rats were monitored in separate cages for 6 weeks after the operation, the relevant spinal level was extracted and the samples were examined histopathologically and the results were evaluated statistically. Results: It was found that there was a statistically significant difference in Tisseel and Glubran groups in terms of fibrosis grading compared to the control group, and this had a positive effect on fibrosis. Compared to the control group, there was no statistically significant difference on fibrosis in Cova and Coseal groups. Conclusion: As dura adhesive agents used in spinal surgery practice did not increase spinal epidural fibrosis statistically significantly, we concluded that these products can be used safely during spinal surgery if necessary.

Solitary thoracic osteochondroma causing spinal compression: Case report.

Spinal osteochondromas are very rare, and they present with nonspecific localized pain owing to bone involvement. Diagnosis is made based on direct X-ray and computed tomography (CT) imaging of the exophytic bone lesion with pedunculated or sessile structure. Although asymptomatic patients can be observed, surgical excision is the main treatment modality. We present the case of a 34-year-old man with solitary thoracic osteochondroma. The patient presented with complaints of pain in the legs, numbness, and inability to walk. The diagnosis was confirmed with CT imaging showing calcified heterogeneous bone lesion originating from the left side of T1-2 facet joint. After total excision, histopathological examination revealed the diagnosis of osteochondroma. No new clinical or radiological findings were detected in the 10-month follow-up.

Comparison of the effect of mexiletine and methylprednisolone on neural function and histopathological damage after transient spinal cord ischemia in rabbits.

AIM: The purpose of this study was to investigate the effect of mexiletine on the neural function and histopathological changes after ischemic spinal cord injury in rabbits. We also compared the effect of mexiletine to that of methylprednisolone. MATERIAL AND METHODS: Twenty six male New Zealand white rabbits were randomly divided into six groups. Group 1; sham operated group (n=3) underwent only the surgical exposure of infrarenal aorta. Group 2 (n=4) received neither intravenous (iv) nor intraperitoneal medication but the infrarenal aorta was cross-clamped. Group 3 (n=5) received intravenous infusion of 20 ml/kg/h normal saline. Group 4 (n=5) received 30 mg/kg intravenous methylprednisolone. Group 5 (n=3) received intraperitoneal 20mg/kg/h normal saline. Group 6 (n=6) received 50mg/kg mexiletine intraperitoneally. Temporary spinal cord ishemia was induced by infrarenal aortic occlusion for 25 minutes and followed by reperfusion. The neural status was scored using the Tarlov criteria at 24 hours after reperfusion. Immediately after the neurological scoring, the spinal cords of all animals were removed for histopathological study. RESULTS: Histopathological examination scores were significantly higher in group 6 compared to group 2 (p < 0.05). CONCLUSION: Mexiletine can significantly ameloriate the neural function and prevent histopathological damage after transient spinal cord ischemia in rabbits. This is the first research that investigates the neuron=protective effect of mexiletine in a spinal cord ischemia model.

Composite nanofibers incorporating alpha lipoic acid and atorvastatin provide neuroprotection after peripheral nerve injury in rats.

Despite the new treatment strategies within the last 30 years, peripheral nerve injury (PNI) is still a worldwide clinical problem. The incidence rate of PNIs is 1 in 1000 individuals per year. In this study, we designed a composite nanoplatform for dual therapy in peripheral nerve injury and investigated the in-vivo efficacy in rat sciatic nerve crush injury model. Alpha-lipoic acid (ALA) was loaded into poly lactic-co-glycolic acid (PLGA) electrospun nanofibers which would release the drug in a faster manner and atorvastatin (ATR) loaded chitosan (CH) nanoparticles were embedded into PLGA nanofibers to provide sustained release. Sciatic nerve crush was generated via Yasargil aneurism clip with a holding force of 50 g/cm2. Nanofiber formulations were administered to the injured nerve immediately after trauma. Functional recovery of operated rat hind limb was evaluated using the sciatic functional index (SFI), extensor postural thrust (EPT), withdrawal reflex latency (WRL) and Basso, Beattie, and Bresnahan (BBB) test up to one month in the post-operative period at different time intervals. In addition to functional recovery assessments, ultrastructural and biochemical analyses were carried out on regenerated nerve fibers. L-929 mouse fibroblast cell line and B35 neuroblastoma cell line were used to investigate the cytotoxicity of nanofibers before in-vivo experiments. The neuroprotection potential of these novel nanocomposite fiber formulations has been demonstrated after local implantation of composite nanofiber sheets incorporating ALA and ATR, which contributed to the recovery of the motor and sensory function and nerve regeneration in a rat sciatic nerve crush injury model.

A simple, safe and effective surface marking and targeting method combined with intraoperative ultrasonography for small subcortical intracranial lesions.

BACKGROUND: Accurately locating small subcortical brain lesions is very important for maximal surgical resection with minimal neurological damage. Intraoperative MRI has proved to be more precise than ultrasound, it is relatively expensive and is not available in all centers. Herein we describe a new, simple, safe and effective method for determining a small skin incision and craniotomy via skin staples combined with intraoperative ultrasonography to determine the margins, vascularity and residue of the lesion. METHODS: Thirty-three patients with small subcortical lesions were admitted into the study. The maximum diameter of the lesions ranged between 18 and 30 mm. The depth of the lesion was described as the distance between the cortical surface and most outer point of the lesion. The mean of the depth of the lesions was 10.56 mm ranging between 3.3 and 18.7 mm. Multiple skin staples were used as irremovable skin markers. Before and after dural incision, ultrasound was used to assess the lesion size and location, its relationship with the surrounding tissue and the Doppler function to reveal the blood supply to the lesion. RESULTS: In this study mean craniotomy diameter was 44 mm ranging between 32-55 mm. The location, extent, characteristics and adjacent tissue of the lesion were observed by high frequency ultrasonography during the operation. CONCLUSIONS: We describe a simple, safe and effective method for determining a small skin incision and craniotomy combined with intraoperative ultrasound for small subcortical intracranial lesions for health center that does not have intraoperative MRI and navigation systems.

Diagnosis, Treatment, and Management Strategy of Meningioma during Pregnancy.

The most common benign tumor of the brain is meningiomas. Usually diagnosed between the ages of 40-60, they are more common in women. Studies have shown a strong relationship between hormones and malignancies. Although meningiomas are slow-growing tumors of the brain, pregnancy seems to induce its growth speed. Studies concerning meningiomas and hormone relationship may explain the reason why symptoms during pregnancy flare. More specifically, the estrogen and progesterone receptor may take an active role through signal transduction in inducing the growth of the tumor. Thus, the dilemma of pregnancy + meningioma arises. In this case, a 21-year-old pregnant with a giant meningioma diagnosed on the symptom of loss of sight is reported. Her pregnancy was terminated, and the tumor was excised. Her vision improved and the histopathological examination showed a progesterone receptor positive meningioma. It is a challenging decision to be made by the physician, the patient and the family when deciding if and when pregnancy should be terminated once an intracranial meningioma is diagnosed.

Chronic Subdural Hematoma Associated with Fahr Syndrome: A Clinical Association or Just a Simple Coincidence?

The Fahr syndrome (FS) is a rare degenerative neurological disorder (its prevalence is <0.5%). FS is distinguished by the presence of abnormal bilateral intracranial calcifications with a predilection for the basal ganglia, also presented by movement disorders such as parkinsonism, paresis, and speech disorders. Chronic subdural hematoma (CSH), which is typically the result of mild head trauma, is a regularly encountered condition in elderly. A 63-year-old man has referred to our clinic from another hospital with a history of mild head trauma approximately a month ago. At the time of admission, the patient's Glasgow Coma Scale point was 15 points. In the history, there was only mild ataxia and right-sided hemiparesis. The laboratory examination revealed no electrolytes level abnormalities and normal endocrinal test examinations. Computed tomography revealed bilateral calcifications of basal ganglia, dentate nuclei which were misinterpreted as intracerebral contusion; with CSH of left temporal and parietal region. The hematoma was evacuated by burr-hole drainage. The patient was discharged 5 days after the surgery. The pathophysiology of FS is still unrevealed. There are some suggestions such as secondary to local disturbance of blood-brain barrier or a calcium neuronal metabolism disorder. However, on the other hand, local blood-brain barrier disturbance would also take part in CSH pathology. We hypostasized that patients with the history of FS, who had mild head traumas, might prone to subdural collections. On the other hand, FS and CSH coexistence is very unusual. Neurosurgeons might keep in mind FS when bilateral calcifications are seen in a patient.

Medically treated paravertebral Brucella abscess presenting with acute torticollis: case report.

BACKGROUND: Atlantoaxial subluxation secondary to a paravertebral (retropharyngeal) abscess is a well known but rare event in children. CASE DESCRIPTION: The authors describe the clinical and radiologic findings of a case of 6-year-old child who presented with acute torticollis (duration, 4 days). Type 2 atlantoaxial rotatory fixation and upper cervical paravertebral (retropharyngeal) abscess were diagnosed on radiologic examination. Laboratory test results showed positive agglutination titer for Brucella melitensis, in the rate of 1/640 dilution. This is the first reported case of Brucella-related atlantoaxial subluxation in a child in the pediatric literature. The patient was treated successfully with anti-inflammatory drugs, Brucella-specific antibiotic regimen, and Philadelphia collar application. Possibly, effusion of the atlantoaxial joint, due to Brucella infection, led to the laxity of the ligaments and contributed to subluxation. CONCLUSIONS: Brucella abscess should be kept in mind for the differential diagnosis of retropharyngeal mass, and the torticollis may be the only presenting sign. The authors recommend a trial of medical treatment with adequate dosages for a reasonable length of time and immobilization before considering surgical intervention for the spinal paravertebral Brucella abscess and related atlantoaxial subluxation.

Melanotic schwannoma.

BACKGROUND: Melanotic schwannomas are tumors of Schwann cell origin, characterized by cytoplasmic deposition of melanin. Melanotic schwannomas are rare. Description of the course of these tumors differs somewhat, but it is generally considered a benign lesion. CLINICAL PRESENTATION: A 54-year-old man presented with hypoesthesia, pain and weakness of the right arm and leg for 4 months. An MRI scan revealed an intradural extramedullary lesion at the level of the foramen magnum and C1. OPERATION: Total resection of the mass was performed. A diagnosis of melanotic schwannoma was made based on histologic morphology and the immunohistochemical profile. Over a 2-year follow-up period there has been no local recurrence. CONCLUSION: Melanotic schwannoma is a rare variant of schwannoma composed of melanin-producing cells with ultrastructural features of Schwann cells. Distinguishing between this tumor and malignant melanoma is important in planning management. Total resection should be performed. Appropriate long-term follow-up is needed for all melanotic schwannomas.

Is the use of hemostatic matrix (Floseal) and alkylene oxide copolymer (Ostene) safe in spinal laminectomies? Peridural fibrosis assessment.

OBJECTIVE: Failed Back Syndrome (FBS) is unacceptable relief of pain or recurrence of symptoms in patients after spinal surgery, such as laminectomy. One possible cause of FBS is peridural fibrosis (PF). PF is the overproduction of scar tissue adjacent to the dura mater. Bleeding can cause PF after laminectomy. Ostene is an alkylene oxide copolymer material used to stop bleeding from bony surfaces. Floseal is a gelatin thrombin matrix sealant used to assist fibrin formation and to promote coagulation. METHODS: Total of 32 female Sprague-Dawley rats were evenly allotted to 4 experimental groups: laminectomy only, laminectomy + Ostene (Baxter International, Inc., Deerfield, IL, USA), laminectomy + Floseal (Baxter International, Inc., Deerfield, IL, USA), and laminectomy + Adcon-L (aap Implantate AG, Berlin, Germany). After performing total laminectomy, agents were placed over dura mater. Spinal column of test subjects was harvested 6 weeks after laminectomy. Histopathological examination of samples was based on Masson's trichrome and hematoxylin and eosin staining. PF observed in the groups was graded using system previously described by He et al. Statistically significant p value was defined as p < 0.005. RESULTS: Present study revealed that Adcon-L, Ostene, and Floseal groups had reduced PF compared with laminectomy only group (p = 0.001). Comparison of Ostene and Floseal groups with Adcon-L group yielded no significant difference. CONCLUSION: Reoperation as result of FBS has greater risk and often has poor outcome; surgeons must take precautions to avoid FBS, such as careful selection of appropriate patient and operation technique. Ostene and Floseal may be applied and left in the operation field safely during laminectomy to reduce occurrence of PF after procedure.

Effects of Topical Cova™, Tisseel® and Adcon® Gel Application on the Development of Spinal Peridural Fibrosis: An Experimental Study in Rats.

AIM: Leptomeningeal adhesions and fibrosis in the spinal peridural space are the most common causes of post-laminectomy syndrome. Fibrin sealant agents and membrane barriers are commonly used for hemostasis and sealing purposes in spinal surgery. Peridural fibrosis may be a risk of the usage of these topical agents. In this study, we aimed to compare the effects of Cova ™, Tisseel® and Adcon ® Gel on the development of spinal peridural fibrosis in the experimental rat model. MATERIAL AND METHODS: Thirty-two Sprague Dawley female rats were randomly divided into 4 groups. Groups were constituted as group 1; Cova™ group (laminectomy+Cova™), group 2; Tisseel® group (laminectomy+Tisseel®), group 3; Adcon®Gel group (laminectomy + Adcon®Gel), group 4; control group (laminectomy only). Six weeks after laminectomy, spinal columns were removed en bloc between L1 and L4 vertebrae. Peridural fibrosis was evaluated histologically and the results were compared statistically. RESULTS: Statistically significant reduction of peridural fibrosis was achieved in groups 1, 2, and 3 when compared with the control group (p < 0.05). Our data revealed a statistically significant difference between group 1 and group 3 (p < 0.05). When we compared with group 2 and 3, the fibrosis grades were not different between these two groups (p > 0.05). CONCLUSION: Fibrin sealant agent Tisseel® and membrane barrier Cova™ do not enhance peridural fibrosis following laminectomy. Cova™ and Tisseel® may be appropriate for hemostasis and leakage prevention during the spinal surgery and it is safe to leave these materials on the operation surface.

Comparison of Short-Term Clinical and Electrophysiological Outcomes of Local Steroid Injection and Surgical Decompression in the Treatment of Carpal Tunnel Syndrome.

AIM: To investigate the effectiveness of local steroid injection and surgical decompression in the treatment of patients with severe carpal tunnel syndrome (CTS) and also to compare short-term outcomes using clinical and electrophysiological criteria. MATERIAL AND METHODS: The patients diagnosed as severe CTS were divided into two groups. Group 1 received local steroid injection and Group 2 underwent surgical decompression. The Boston Questionnaire that consists of two sections as the Boston Symptom Severity Scale (BSS) and the Functional Status Scale (FSS) was completed by the patients. RESULTS: A total of 33 patients completed the study. Since two patients had bilateral severe CTS, a total of 35 hands were evaluated in the study. In Group 1, a significant difference was recorded between some pre- and post-treatment clinical parameters (BSS and FSS scores) and all electrophysiological parameters excluding motor conduction velocities. In Group 2, a statistically significant difference was found between pre- and post-treatment BSS scores and all electrophysiological parameters excluding motor conduction velocity and distal latency. However intergroup differences were not statistically significant as for all clinical and electrophysiological parameters (BSS, FSS, sensory amplitude, sensory conduction velocity, distal latency, motor amplitude, motor conduction velocity). CONCLUSION: In the treatment of severe CTS, steroid injection and surgical decompression achieved favourable improvements in clinical and electrophysiological parameters within a short-term without superiority of one treatment over other. Therefore, in patients in whom surgical decompression can not be applied, local steroid injection can be recommended as a less invasive and a promising treatment alternative.

Effect of Asiatic Acid on the Treatment of Spinal Cord Injury: An Experimental Study in Rats.

AIM: Spinal cord injury (SCI) is a devastating condition of the central nervous system. There is no proven therapeutic agent for the treatment of this complex disorder. Asiatic acid (AA) has been used as an anti-inflammatory and anti-oxidant agent in Eastern countries for many years. The aim of this study was to investigate the effectiveness of AA on the treatment of traumatic SCI in rats. MATERIAL AND METHODS: Thirty-two adult male Sprague-Dawley rats were divided into 4 groups as laminectomy, laminectomy+trauma, vehicle, and AA treatment groups. SCI was created by the modified Allen"s weight-drop technique. After the injury, the levels of pro-inflammatory cytokines (IL-6, IL1-Β, TNF-α) and lipid peroxidation products (MDA) were measured. Tarlov functional recovery scores were also determined for each rat. The One-way ANOVA test was used for the analysis of difference between 4 experimental groups and the groups were compared individually by Tukey-LSD post hoc analysis test (p=0.001). RESULTS: AA administration just after SCI attenuated the levels of lipid peroxidation products (MDA) and pro-inflammatory cytokines (TNF-α, IL1Β). It also increased the Tarlov functional recovery scores of the rats. CONCLUSION: AA administration could attenuate a number of deleterious reactions after traumatic SCI. Further studies are needed to elucidate the pathways of neuroprotective effects of AA after spinal trauma.

Chronic subdural hematoma in patients with idiopathic thrombocytopenic purpura: A case report and review of the literature.

BACKGROUND: cSDH is a rare form of bleeding in patients with ITP. Intracerebral hematoma or subarachnoid hemorrhage is more frequently reported in these patients. Spontaneous resolution of cSDH in patients with idiopathic subdural hematoma is uncommon. CASE DESCRIPTION: We report a case of spontaneous cSDH in a patient with ITP, and we review the related cases in the literature. In our patient, the hematoma resolved spontaneously despite very low platelet levels. There also was an incidental left parietal convexity meningioma. A review of the literature is presented, and the management of the patients is discussed. CONCLUSION: In patients with ITP, cSDHs may resolve spontaneously or with medical treatment, and surgery might be deferred except in emergency conditions or in patients with normal neurological findings. Close neurological and radiological observation along with the medical treatment may be appropriate in the management of patients with normal neurological findings.

Primary lumbar epidermoid tumor mimicking schwannoma.

A case of a primary lumbar epidermoid tumor is described. Intraspinal epidermoid tumors are rare. The differential diagnosis on this case was a nerve sheath tumor, such as aschwannoma, as the tumor entered the dural sac and caused dural ectasia. The diagnostic pitfalls of this feature of the tumor are discussed.

Comparative Biochemical and Motor Function Analysis of Alpha Lipoic Acid and N-Acetyl Cysteine Treatment on Rats with Experimental Spinal Cord Injury.

AIM: Spinal Cord Injury (SCI) is a devastating health problem both for the patient and the clinician. Numerous treatment modalities have been studied to reverse the effects of spinal cord injury. Herein is reported the effects and the comparison of Alpha Lipoic Acid and N-Acetyl Cysteine on rats with SCI. MATERIAL AND METHODS: 38 adult male Sprague-Dawley rats were randomly divided into 5 groups: only laminectomy, laminectomy and trauma, laminectomy trauma and Alpha Lipoic Acid 100 mg/kg IP administration, laminectomy trauma and N-Acetyl Cysteine 300 mg/kg IP administration, and vehicle group (PEG). The trauma model was the Modified Allen Weight drop method. After the procedure, the rats' motor function was evaluated using the modified Tarlov Scale and consequently they were sacrificed and the spinal cord tissue was analyzed biochemically for inflammation markers. RESULTS: Both Alpha Lipoic Acid and N-Acetyl Cysteine administration after the injury significantly improved the results. There was no statistically significant difference in between the agents. CONCLUSION: Although these agents both proven to be effective in ameliorating the effects of SCI, there was not enough evidence in this research to conclude the benefit of one agent over the other.