Functional electrical stimulation cycling in patients with chronic spinal cord injury: a pilot study.

OBJECTIVE: To examine the therapeutic value of lower extremity functional electrical stimulation (FES) - evoked cycling on functional independence, health status, gait parameters, pulmonary functions, and biochemical values in patients with chronic complete/incomplete spinal cord injury (SCI). MATERIALS AND METHODS: Fifteen patients with SCI (duration of more than 6 months) who were able to stand up and walk with long leg braces or assistive devices and had stable neurological status and trunk balance undertook FES cycling for 6 weeks (three times per week). The main outcomes were: Functional Independence Measure (FIM), Nottingham Health Profile (NHP), 6-minute walk test (6MWT), and 20-meter walk test (20MWT). Secondary outcomes include measurements of pulmonary function tests and biochemical values. All parameters were evaluated at the beginning and end of the program. RESULTS: Improvements were seen in motor and total scores of FIM (p = 0.007), physical mobility subscale of NHP (p = 0.011), 6MWT (p = 0.001), and 20MWT (p = 0.011). In pulmonary functions, only forced vital capacity (FVC) levels demonstrated a significant increase compared with baseline (p = 0.011). Biochemical values reached no significant level. CONCLUSION: The results of this study showed that the FES cycling exercise program improves motor and total FIM scores, gait parameters, and FVC values of pulmonary functions in patients with chronic SCI experience. The FES cycle might be a valuable and well-tolerated intervention in clinical rehabilitation.

Localized delivery of methylprednisolone sodium succinate with polymeric nanoparticles in experimental injured spinal cord model.

With important social and economic consequences, spinal cord injuries (SCIs) still exist among major health problems. Although many therapeutic agents and methods investigated for the treatment of acute SCI, only high dose methylprednisolone (MP) is being used currently in practice. Due to the serious side effects, high dose systemic MP administration after SCI is a critical issue that is mostly considered controversial. In our study, it is aimed to develop a nanoparticle-gel combined drug delivery system for localization of MP on trauma site and eliminating dose-dependent side effects by lowering the administered dose. For this purpose, methyl prednisolone sodium succinate (MPSS) loaded polycaprolactone based nanoparticles were developed and embedded in an implantable fibrin gel. The effects of MPSS delivery system are evaluated on an acute SCI rat model, by quantification the levels of three inflammatory cytokines (interleukin-1ß, interleukin-6 and caspase-3) and assessment of the damage on ultrastructural level by transmission electron microscopy. Developed NP-gel system showed very similar results with systemic high dose of MPSS. It is believed that developed system may be used as a tool for the safe and effective localized delivery of several other therapeutic molecules on injured spinal cord cases.

Effects of tadalafil-Type-V phosphodiesterase enzyme inhibitor-On rats with spinal trauma.

In this research, the effect of tadalafil, a selective inhibitor of cyclic guanosine monophosphate-specific phosphodiesterase type 5, on rats with spinal trauma was evaluated. The evaluation consisted of neurological examination and biochemical parameters. Twenty healthy male Wistar albino rats were used in this study. They were separated into three groups: tadalafil-receiving (TD) group (n=7), laminectomy and trauma (LT) group (n=7), and just laminectomy group (n=6). The TD group received daily dose of tadalafil (10 mg/kg) for a week along with bait and water. Each rat's spinal cord was dissected with utter caution. The spinal cord was traumatized by Allen's weight-drop method. Using a standard apparatus, 5 g of weight was dropped from a height of 10 cm on the spinal cords of the TD and LT (laminectomy+trauma) group. No extra maneuvers were conducted on the laminectomy group. A day later, the rat's functional neurological status was examined followed by re-exploration of the spinal cord for sampling 1 cm of tissue. The Tarlov scale was used to evaluate the functional neurological status. The modified Tarlov scale was rated to be significantly higher in the TD group than that in the LT group. For the biochemical parameters, malondialdehyde (MDA) and cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) involved in the inflammatory process were examined. MDA--an indicator of lipid peroxidation--was found to be significantly lower in the TD group compared with that in the LT group. TNF-α and IL-6 levels were also found to be lower in the TD group compared with those in the LT group. Shortly, this research showed that the use of TD group in spinal trauma resulted in better neurological outcome and significant improvement in biochemical parameters.

Endoscopic endonasal optic nerve decompression in a patient with pseudotumor cerebri.

Pseudotumor cerebri (idiopathic intracranial hypertension) is a syndrome characterized by intracranial pressure elevation and associated signs and symptoms in the absence of a space-occupying intracranial lesion. The most common symptoms are visual loss and headache. Sometimes, surgical therapy is needed in patients who have no apparent response to medical therapy and exhibit a progressive course. Optic nerve decompression is an effective and recommended treatment approach for patients with pseudotumor cerebri in whom visual loss predominates. With the growing experience with endoscopic skull base approaches, this method has begun to be used as an alternative and effective treatment modality. In this study, we aimed to present the outcome of endoscopic endonasal optic nerve decompression and to review the literature on this treatment modality in 2 patients diagnosed with pseudotumor cerebri that was unresponsive to medical therapy and associated with progressive visual loss.

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.

Heterotopic ossification as rare complication of hemiplegia following stroke: two cases.

BACKGROUND: Heterotopic ossification (HO), characterized by new bone formation in the periarticular regions of large joints, is frequently seen after spinal cord injury, traumatic brain injury, burn and trauma. It is a rare complication of hemiplegia following stroke, with a reported incidence of 1% or less. CASE REPORTS: This study reports two unusual presentations of HO: (1) A 56-year-old male with a history of atrial fibrillation on warfarin developed sudden-onset left hemiplegia. Eight months after the event, he was diagnosed with HO of the hip joint including both the affected and unaffected sides. (2) A 55-year-old female with left hemiplegia due to subarachnoid bleeding developed HO on the left hip joint 7 months later. In both cases, spasticity around the hip muscle groups, especially hip flexors, adductors and knee extensors, and limited range of motion accompanied by pain were present. X-ray and pelvic computed tomography revealed HO around the hip joints. After 4 weeks of inpatient rehabilitation, the ranges of hip joint motion improved, without exceeding 10° in the direction of flexion and rotations, and ambulation levels were wheelchair-bound for the first case and dependent on a cane for the second case. CONCLUSIONS: Considering the presented cases, it is suggested that HO should be kept in mind in the differential diagnosis in stroke patients presenting with spontaneous joint pain or limitation. The clinical importance of HO development on both the affected and unaffected sides in post-stroke hemiplegia is emphasized, since it may worsen the patient's functional status.

Assessment of phonophoresis and iontophoresis in the treatment of carpal tunnel syndrome: a randomized controlled trial.

To define the role of phonophoresis and iontophoresis of corticosteroids in conjunction with wrist splint use in the treatment of carpal tunnel syndrome (CTS) compared to wrist splint use alone, 52 CTS subjects were analyzed based on clinical and electrophysiological criteria. A prospective, randomized controlled trial was carried out to assess symptom severity, motor skills, and hand function according to the Boston Symptom Severity Scale (BSSS), grip strength, and nine-hole peg test (NHPT), respectively, on the initial visit and in the 3rd month after treatment. The patients underwent conservative interventions randomly as follows: (1) 3 weeks of phonophoresis with betamethasone in conjunction with wrist splint use (group I, n: 18) or (2) 3 weeks of iontophoresis with betamethasone in conjunction with wrist splint use (group II, n: 16) or (3) wrist splint use alone (control, group III, n: 18). The mean age of the patients was 43.7 ± 8.4 (range 24-57) years. Groups I, II, and III showed a significant and further improvement in BSSS at the 3rd month evaluations compared with baseline (P < 0.001, P = 0.001, P < 0.001, respectively), but no significant change was observed in grip strength or NHPT (P > 0.05). There was a statistically significant difference between the phonophoresis and control groups after treatment only regarding BSSS, in favor of phonophoresis (P = 0.012). We recommend the use of wrist splints especially with phonophoresis for relief of symptoms in patients with CTS. Our results demonstrated no superiority among the treatment groups. Further, transdermal steroid treatments are not key determinants of efficacy with respect to motor skills and hand dexterity.

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.

Relationship Between Vasospasm and Serum Chromogranin A Levels in an Experimental Subarachnoid Hemorrhage Model.

AIM: To analyze Chromogranin A levels on vasospasm in an experimental subarachnoid heamorrhage (SAH) model. MATERIAL AND METHODS: Sixteen Wistar Albino male rats were used in study. Two groups are formed; first was consisting of 8 rats that experimental SAH was performed on them, second group was control group that nothing was done. Animals were sacrified fourtyeight hours later subarachnoid heamorrhage was occured. Peripheral venous blood samples were taken from the experimental group before SAH formation, 15 minutes, 75 minutes after experimental SAH formation and 48 hours as peak of vasospasm. Simultaneous peripheral venous blood samples were also collected from the control group. Blood samples were biochemically evaluated after centrifugation and serum Chromogranin A levels were studied. RESULTS: Serum chromogranin A levels increased statistically significant (p < 0.05) at the 15th minute after SAH, as the samples obtained from the experimental and control groups were anticipated as a result of the statistical analysis of the data after the biochemical examinations. CONCLUSION: In all these findings, we concluded that Chromogranin A could be used as a marker for the investigation of endocrine stress in the early period of post-SAH vasospasm and it could be proved by more studies.

Huge intradiploic epidermoid cyst.

A 60-year-old man presented with an occipital mass under the scalp and complained of headache, nausea, and dizziness. Magnetic resonance imaging showed a well-defined mass in the occipital scalp extending from the scalp through the cranium and several centimetres into the posterior fossa. There were well-defined margins in the deep portion and the mass was totally removed. Histological examination showed that the cystic structure was lined by squamous epithelium containing laminated keratin material. The pathological findings were consistent with the diagnosis of an epidermoid cyst. The patient was discharged free of symptoms.

Acute low back pain: clinical course and prognostic factors.

PURPOSE: The aim of this study was to assess the clinical course of patients with acute low back pain (LBP) throughout 12 weeks and to identify the prognostic factors for non-recovery in the short term. METHOD: A total of 91 patients with acute LBP (<3 weeks) were included in this study. Baseline assessments including demographic variables, clinical characteristics of pain, lost work time and results of clinical examination were noted. Pain intensity, disability, general health perception and depression were assessed according to visual analogue scale, Roland Morris Disability Questionnaire (RMDQ), Nottingham Health Profile (NHP) and Beck Depression Inventory, respectively. Patients were assessed for pain intensity and disability at baseline, and at 1, 2, 4, 8 and 12 weeks of follow-up. Recovery was considered if patients scored <4 on the RMDQ and pain had resolved. At the 2nd week of follow-up, patients were divided into two groups according to recovery (Group 1) or non-recovery (Group 2) to identify the prognostic factors, which were analysed by multiple logistic regression. RESULTS: At 2 weeks, 52 (57.1%) of the patients had recovered and only eight (8.7%) developed chronic LBP. Mean pain intensity and mean disability scores dropped 96.7 and 96.4%, respectively, of initial levels during the 12 weeks. Sixty per cent of 63 employed patients reported lost time from work. A comparison between groups revealed that finger-floor distance, RMDQ and NHP (pain, physical mobility, emotional reactions, sleep, energy level, and distress subgroups) were statistically significantly lower in Group 1, and NHP-pain was strongly associated with non-recovery in the short term. CONCLUSIONS: Acute LBP patients with disability generally recover in the first weeks. General health perception (NHP) - pain subgroup score was identified in particular as the best prognostic factor for non-recovery in the short term. Hence, pain should be given particular consideration in baseline assessments of acute LBP patients.

The effect of mitomycin C as fibrosis preventive agent during craniectomies.

OBJECT: The authors conducted a study to determine the effectiveness of mitomycin C (MMC) in preventing epidural fibrosis in rats which underwent craniectomy. METHODS: Craniectomies were performed in the right frontoparietal region; after the procedure the animals had been divided in 2 groups of 10 each. Cotton pads soaked with 0.1 mg/ml MMC or saline (control) were applied to the operative sites. Four weeks after craniectomy the rats were sacrificed, and epidural fibrosis was evaluated histologically. The dura mater thickness, the density of epidural fibrosis, arachnoidal involvement, and bone regeneration were determined. RESULTS: No obvious adhesion formed in the rats in the MMC group, but severe epidural adhesions were found in control group. The duramater thickness, the density of epidural fibrosis, and arachnoidal involved rat number in the MMC group were significantly lower than in control groups. CONCLUSIONS: Epidural fibrosis can be a devastating condition that forms after craniectomy. Topical application of mitomycin C may be a successful method of preventing epidural fibrosis following craniectomy.

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.

Classification of Radiological Changes in Burst Fractures.

AIM: Burst fractures can occur with different radiological images after high energy. We aimed to simplify radiological staging of burst fractures. METHODS: Eighty patients whom exposed spinal trauma and had burst fracture were evaluated concerning age, sex, fracture segment, neurological deficit, secondary organ injury and radiological changes that occurred. RESULTS: We performed a new classification in burst fractures at radiological images. CONCLUSIONS: According to this classification system, secondary organ injury and neurological deficit can be an indicator of energy exposure. If energy is high, the clinical status will be worse. Thus, we can get an idea about the likelihood of neurological deficit and secondary organ injuries. This classification has simplified the radiological staging of burst fractures and is a classification that gives a very accurate idea about the neurological condition.

Idiopathic bilateral trigeminal neuralgia treated by bilateral microvascular decompression.

Idiopathic trigeminal neuralgia is the most common type of cranial neuralgia. Trigeminal neuralgia is a form of facial pain characterized by proximal lancinating pain confined to the somatosensory distribution of the trigeminal nerve. Bilateral trigeminal neuralgia is a rare situation with an incidence of 1% to 6% in large trigeminal neuralgia series. There is no single or standard method for the treatment of bilateral trigeminal neuralgia. Microvascular decompression for treatment trigeminal neuralgia is an effective and relatively safe method in older patients. We report a rare case of bilateral trigeminal neuralgia treated by bilateral microvascular decompression.

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.

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.

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.