Technical challenges and surgical outcomes of percutaneous transforaminal endoscopic discectomy in patients with upper lumbar disc herniation: a prospective clinical study.

INTRODUCTION: Upper lumbar disc herniation (ULDH) constitutes a considerably complex and rare anatomic entity. As such, there are only a handful of studies investigating the application of percutaneous transforaminal endoscopic discectomy (PTED) in the management of this cause of low back pain. RESEARCH QUESTION: To elucidate the safety and effectiveness of PTED in patients with ULDH. MATERIALS AND METHODS: Twenty-six (26) individuals with diagnosed ULDH (L1-L2, L2-L3) according to clinical and radiologic criteria were prospectively evaluated in a 2-year follow-up period. All patients were assessed preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively. Clinical evaluation was conducted with visual analogue scale for lower limb (VAS-LP) and low back (VAS-BP) pain in conjunction with Short-Form 36 (SF-36) Medical Health Survey Questionnaire. Potential complications were recorded in each follow-up interval. RESULTS: One patient (3.8%) featured temporary postoperative dysesthesia that was completely resolved at 6 weeks. No other major perioperative complications were observed. Values of all studied indices were found to be statistically significantly ameliorated at the end of follow-up. Improvement was depicted to be quantitatively maximal at 6 weeks postoperatively. CONCLUSIONS: PTED constitutes a safe and effective technique for surgical management of ULDH that merits further assessment in current clinical practice in the framework of multicenter randomized controlled trials. LEVEL OF EVIDENCE: Level III.

Extreme cases in percutaneous transforaminal endoscopic surgery: case series and brief review of the literature.

PURPOSE: Percutaneous transforaminal endoscopic decompression (PTED) is a minimally invasive method of surgical treatment of miscellaneous spinal conditions. We describe our experience with PTED in extreme cases of foraminal stenosis (FS) in adult degenerative scoliosis (ADS), recurrent foraminal stenosis (RFS) after previous open decompression surgery and adjacent segment disease (ASD) after previous lumbar fusion. METHODS: Twenty-one (21) patients with FS encountered in the clinical framework of ADS (n = 6), previous open decompression surgery (n = 8) and ASD (n = 7) were prospectively reviewed. Patients were preoperatively assessed via clinical and radiologic evaluation. All patients underwent PTED in 2018-2019. Postoperative evaluation was conducted with clinical examination and evaluation of Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria in predetermined chronic intervals in a 1-2 years follow-up. RESULTS: All patients were successfully managed with PTED. Operated levels were L3-L4 (19.0%), L4-L5 (52.4%) and L5-S1 (28.6%). No major perioperative complications were recorded. VAS and ODI scores were demonstrated to exhibit a clinically and statistically significant (p < 0.05) amelioration in all patients' categories directly postoperatively, which was preserved until the end of follow-up. Overall outcomes according to modified MacNab criteria were excellent in 12 patients (57.1%), good in 6 (28.6%) and fair in 3 (14.3%) patients. CONCLUSIONS: PTED is safe and effective in extreme cases of FS encountered in patients with ADS, previous posterior open decompression surgery and ASD after previous spinal fusion.

Perioperative Blood Management in Posterior Instrumented Fusion for Adolescent Idiopathic Scoliosis: Original Study and Short Review of the Literature.

BACKGROUND: The potential hazards of allogeneic blood transfusion are well established in literature. Few things are known, however, about the results of combining different blood saving techniques and their results in avoiding allogeneic blood transfusion (ABT) in scoliosis surgery. AIM: To report specific results about utilization of preoperative autologous blood donation (PABD) and intraoperative blood-saver (BLDS) in conjunction, aiming to minimize the need for ABT. MATERIALS AND METHODS: Between 1989 and 2012, 107 patients underwent posterior instrumented fusion (PIF) for adolescent idiopathic scoliosis (AIS) correction. Retrospective evaluation was conducted. Patients were classified into two groups, according to the method utilized: group A with only allogeneic blood transfusion (ABT) and group B where PABD with BLDS intraoperatively was applied. Hematocrit and hemoglobin values were evaluated preoperatively, postoperatively, and at discharge. The variables we examined included also gender, age, levels fused and number of predeposited blood units, required transfused blood units (TBU), as well as ABT rates between the two groups. RESULTS: More than 70% of the transfusions in both groups were needed intraoperatively. In group A, an average of 2.4 units per patient was transfused and ABT reached 76%. In contrast, in group B an average of 4.5 units per patient was transfused but ABT rate was only 7.3%, while the rest 92.7% was autologous blood. However, the wasted autologous blood reached 24.9%. CONCLUSIONS: Our results demonstrated that PABD with intraoperative cell salvage (CS) is associated with statistically significant ABT rates decrement but the combination of these methods cannot assure ABT avoidance.

Death due to fracture of thin calvarial bones after a fall: A forensic approach.

A 45-year-old male was autopsied. He had fallen backwards from a two-stairs height to the ground and passed away. A skull fracture was detected in the left occipital area, extending up to the left side of the skull base. The patient's death occurred due to the very low thickness of the calvarial bones, which led to the aforementioned fracture, and in turn resulted in subarachnoid hemorrhage and death. The cortical thickness was measured and compared with average values at standardized points. Uniform bone thinning was confirmed rather than localized. Calvarial thinning may result from various conditions. In the present case study, however, the exact mechanism which led to the low thickness of the calvarial bones of the patient is undetermined. Death due to the susceptible structure and fracture of calvarial bones has rarely been reported throughout relevant literature.

Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature.

Cauda equina syndrome (CES) is a rare neurologic condition that is caused by compression of the cauda equina. Cauda equina consists of spinal nerves L2-L5, S1-S5 and the coccygeal nerve. The compression of these nerve roots can be caused mainly by lumbar disc herniation (45% of all causes). The diagnosis consists of two critical points: a) detailed history and physical examination and b) MRI or CT. The gold standard of the treatment of this syndrome is the surgical approach in combination with the timing of onset of symptoms. The surgery as an emergency situation is recommended in the fi rst 48 hours of onset of symptoms. Any delay in diagnosis and treatment leads to a poor prognosis of CES.

Can Severe Kyphoscoliosis Lead to Aorta Rupture?

Neurofibromatosis type 1 is a polysystemic disease presenting with a multifaceted clinical picture. Clinical manifestations may present in the skin, as well as in the skeletal and cardiovascular system. The present study aims to describe and examine the case of a 46-year-old woman, who suffered from neurofibromatosis type 1 and died abruptly in the emergency room. The forensic examination attributed her death to traumatic rupture of the thoracic aorta resulting from an acute angulation that her vertebral column formed in the thoracic region (severe kyphosis). Outspread cutaneous neurofibromas, severe scoliosis, and osteoporosis (brittle bones) were observed during the autopsy. No atherosclerotic lesions were detected in the aortic lumen. To the authors' knowledge, no similar case has been reported throughout relevant literature.

Platelet-Rich Plasma for Degenerative Spine Disease: A Brief Overview.

Background: The emergence of novel minimally invasive techniques has opened new horizons for the management of degenerative diseases of the spine. Platelet-rich plasma (PRP) has gained considerable attention through its applications in various pathologies. In the present review, an overview of the science behind the application of PRP is provided, ultimately focusing on the clinical trials that may render it a useful tool in the hands of spine surgeons in the future. Methods: A review of the available literature is conducted, focusing on its existing clinical and experimental applications with a particular interest in the degenerative diseases of the spine. Results: In terms of the degenerative diseases of the spine, initial studies suggest that it is a safe and effective method that could change the practice of spinal cord medicine in the years to come. The available studies demonstrate that besides being minimally invasive, causing less discomfort than that of surgery, it provides longer lasting improvement than standard pharmaceutical interventions. Conclusions: PRP is an emerging and promising biodrug for the treatment of patients with spinal pain. PRP has demonstrated some promising qualities; however, careful consideration of its indications of use and strict protocols of application need to be established before widespread clinical induction.

Surgical management of complex lumbosacral anomaly with minimally invasive spinal fusion: A clinical image.

Key Clinical Message: Lumbosacral junction anomalies represent a rather frequent finding in patients with low back pain. Involved healthcare professionals should be familiar with these dysplasias, in order to achieve proper diagnosis and optimize clinical outcomes. Abstract: Dysplastic alterations in lumbosacral junction represent a frequent finding in patients with low back pain. Lumbosacral transitional vertebra (LSTV), spina bifida occulta (SBO) and isthmic spondylolisthesis (IS) present recognized etiologies of low back pain. Herein, we present a rare case of concurrent presence of LSTV, SBO and IS in a middle-aged male individual who was presented with low back pain in our department. Considering the resistant to conservative treatment symptomatology in conjunction with clinical-radiologic presence of segmental instability, patient was subjected to uneventful minimally invasive lumbosacral fusion featuring complete recession of symptomatology directly postoperatively with no signs of recurrence until 6 months follow-up. To our best knowledge, coexistence of LSTV, IS and SBO in lumbosacral junction has never been described in contemporary literature. Whenever surgery is indicated, minimally invasive spinal fusion may be considered as a safe and effective alternative in these cases.

Assessment of Health-Related Quality of Life in Patients With Traumatic Fractures Following Thoracolumbar Fusion: Short-Term Results.

INTRODUCTION: Thoracolumbar vertebral fractures (TVFs) constitute frequent injuries with specific therapeutic challenges and remarkable implications for affected individuals. The aim of this study is to investigate the alteration of overall health-related quality of life (HRQoL) in patients with traumatic TVFs undergoing thoracolumbar fusion surgery. MATERIALS AND METHODS: A total of 72 patients with single-level traumatic thoracic or lumbar vertebral fractures (AO type A3 or A4) were enrolled in this prospective cohort study. All patients were subjected to thoracolumbar spinal fusion surgery with or without posterior decompression, being followed up for a two-year period. Clinical assessment was conducted via the implementation of the Visual Analog Scale (VAS) and 36-item Short-Form Survey Questionnaire (SF-36) for the evaluation of pain and HRQoL, respectively. Patient assessment was performed in determined postoperative follow-up intervals. RESULTS: Recorded values of assessed outcome measures demonstrated a statistically significant improvement during the entire two-year follow-up period. This improvement was more pronounced throughout the first three to six postoperative months, subsequently demonstrating a plateau. No statistically significant correlation between age, SF-36, and VAS was found, with the exception of the bodily pain index, the improvement of which was observed to be positively correlated with age. Transient causalgia and cerebrospinal fluid leak were recorded in 5% of evaluated individuals. CONCLUSIONS: Thoracolumbar fusion constitutes a safe and efficient option for the surgical management of single-level traumatic vertebral fractures. Nevertheless, rehabilitation is a lasting procedure that may last over six months until final amelioration is observed. Clinical improvement may be more pronounced in older patients, potentially due to different expectations.

Posterolateral Instrumented Fusion in Elderly Patients With a Single Osteoporotic Vertebral Fracture: Evaluation of Health-Related Quality of Life.

Introduction Treatment of osteoporotic vertebral fractures (OVFs) is a factor that affects the quality of life and should be considered during management. In patients with a single OVF and neurologic deficit, surgical procedures aiming at neural decompression with instrumented fusion should be considered in elderly individuals. Posterolateral instrumented fusion (PLF) constitutes a largely performed fusion surgery for patients featuring indications for fusion surgery. The aim of this study was to determine the safety, effectiveness, and impact on health-related quality of life (HRQoL) of PLF surgery in elderly patients diagnosed with a single OVF. Methods This study was conducted at Interbalkan European Medical Center, Thessaloniki, Greece. Eighty (80) consecutive individuals with OVFs were subjected to PLF and recruited in this prospectively designed non-randomized study. Clinical evaluation was performed preoperatively and postoperatively at particular chronic intervals at one, three, six, and 12 months and two years. The assessment was conducted via the standardized Visual Analogue Scale (VAS) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire for pain and HRQoL, respectively. Results No major perioperative complications were observed. All parameters of SF-36 presented significant improvement over the entire follow-up period with VAS scores reaching a plateau at six months. Depicted improvement of these parameters proves the beneficial role of PLF in elderly patients who suffered from a single OVF with or without referable neurological deficit. Conclusion OVFs have a significant impact on the quality of life of elderly patients, and surgical treatment with PLF with or without decompression can lead to functional recovery, pain relief, and HRQoL amelioration. Our results demonstrated that the outcomes of PLF in the surgical treatment of these patients are remarkably favorable, demonstrating the safety and efficacy of the technique.

External auditory canal mass as the first manifestation of a bronchogenic carcinoma: report of a rare case.

OBJECTIVES: Metastatic tumors in the external auditory canal (EAC) are exceptionally rare. These metastases almost always occur in the latter stages of the disease process. Ten cases of metastatic tumors of the EAC have been reported in the literature. We report the first case of a metastatic bronchogenic adenocarcinoma that presented initially as an EAC mass. METHODS: We present a case report and a literature review. RESULTS: Although bronchogenic adenocarcinoma not uncommonly metastasizes to the temporal bone, metastasis to the EAC is extremely rare. We report the case of a 62-year-old woman who presented with a 6-week history of swelling in her right EAC and sudden onset of hearing loss. Physical examination revealed a small, polypoid, friable mass originating from the superior-posterior wall of the right EAC. Incision biopsy was performed, and the histopathologic examination of specimens revealed a moderately to poorly differentiated adenocarcinoma compatible with a bronchogenic origin. CONCLUSIONS: A patient with an aural mass presents a diagnostic dilemma. Metastatic tumors in the EAC are extremely rare, but they should be included in the differential diagnosis of a mass in this location.

Papillary thyroid microcarcinoma: clinicopathological characteristics and implications for treatment in 276 patients.

BACKGROUND: There is debate concerning the clinical significance of papillary thyroid microcarcinoma (PTMC), and therefore, the rise in the incidence of PTMC creates management dilemmas. The purpose of this study was to analyse the clinicopathological characteristics of PTMC in an island region that has a high prevalence of goitre and to determine risk factors for the worst prognosis. MATERIALS AND METHODS: Data from 1874 patients who underwent a total thyroidectomy between January 2002 and December 2008 were reviewed retrospectively. A total of 276 patients who were diagnosed with PTMC in a final pathology report were included in the study. A PTMC was defined as a papillary thyroid carcinoma with a diameter ≤ 10 mm. Clinicopathological features were evaluated by both univariate and multivariate analyses. RESULTS: Of the 276 patients with PTMC, 219 patients (79·3%) were incidentally diagnosed. Two hundred and two patients had carcinomas of ≤ 5 mm, and 74 patients presented with carcinomas that ranged in size from 0·6 to 1·0 cm. Lymph node metastasis was diagnosed in 3·5% of patients with tumours ≤ 5 mm, and 21·6% of patients presented tumours > 5 mm. Upon multivariate analysis, clinically suspected diagnosis, a tumour size > 5 mm and an age over 45 years at diagnosis were independent risk factors for capsule invasion, while tumour multifocality, bilaterality, size of tumour > 5 mm and thyroid capsule invasion were independent risk factors for lymph node metastasis at diagnosis. CONCLUSIONS: Patients presenting multifocal, bilateral PTMC with a maximum diameter > 5 mm and thyroid capsule invasion may have an increased risk of lymph node metastasis. These factors should be considered in the follow-up for these patients.

Plexiform (multinodular) schwannoma of soft palate. Report of a case.

Plexiform schwannoma is a rare benign neoplasm of the neural sheath characterized by a multinodular plexiform growth pattern. Only 5% of schwannomas have a plexiform or multinodular growth pattern. Schwannoma apparently derives from the Schwann cells. Extracranially, 25% of all schwannomas are located in the head and neck region, but only 1% show an intraoral origin. The intraoral lesions show a predilection for the tongue, followed by the palate, buccal mucosa, lip and gingival. Microscopic examination is necessary to confirm the diagnosis. Characteristic histological signs are the palisading of the spindle-shaped Schwann cells around the central acellular area, so called Verocay bodies. We report a case of a 21-year-old woman with a smooth mass of the soft palate that was gradually increasing. Surgical excision of the mass was done and the histopathology and immunohistochemistry study of the excised lesion revealed a multinodular plexiform schwannoma of the soft palate. The patient is under regular clinical control, with no signs of recurrence after 17 months. Plexiform schwannomas of the soft palate are mentioned very rarely in the English literature. This rare benign tumor is worthy of recognition because it can be misdiagnosed as plexiform neurofibroma.

Full-Endoscopic Ventral Facetectomy vs Open Laminectomy for Lumbar Lateral Recess Stenosis: A Comparative Study and Brief Literature Review.

BACKGROUND: Lateral recess stenosis (LRS) represents a major etiology of pain and disability in recent years. The aim of the present study was to compare the clinical outcomes of full-endoscopic ventral facetectomy (FEVF) vs conventional open laminectomy (OL) for surgical treatment of lumbar LRS. METHODS: Ninety individuals with diagnosed LRS according to clinical and radiological criteria were included in this study. Patients were appropriately classified into 2 distinct groups according to received treatment. Group A was constituted from 48 patients subjected to FEVF. Contrariwise, the 42 patients of Group B underwent OL. All patients were consecutively evaluated with particular clinical scores preoperatively and at 6 weeks, 3, months, 6 months, 12 months, and 2 years postoperatively. Clinical assessment was conducted with the visual analog scale for leg pain (VAS-LP) and back pain (VAS-BP) and with the Short-Form 36 (SF-36) medical questionnaire. RESULTS: Values of all studied indices in both groups featured a major clinical improvement in 6 weeks with subsequent quantitatively minor albeit still statistically significant amelioration until the end of follow-up at 2 years. Comparative evaluation of recorded parameters between the 2 groups disclosed that VAS-BP, bodily pain, and role emotional indices of SF-36 were quantitatively and statistically differentiated in favor of Group A in 6 weeks, featuring an amelioration that persisted until the end of follow-up. Registered values of the other parameters were not found to demonstrate a quantitatively and clinically noteworthy differentiation between the 2 groups. CONCLUSIONS: FEVF represents a feasible, safe, and beneficial alternative for surgical therapy of patients with LRS, featuring comparable outcomes with conventional OL. CLINICAL RELEVANCE: Lumbar LRS represents a frequent entity with remarkable clinical sequelae. FEVF represents a novel, groundbreaking and minimally invasive technique that should be considered as a safe and efficacious alternative over conventional open surgery in specific patients with LRS.

Tissue Engineering of Human Intervertebral Disc: A Concise Review.

Intervertebral disc (IVD) represents a structure of crucial structural and functional importance for human spine. Pathology of IVD institutes a frequently encountered condition in current clinical practice. Degenerative disc disease (DDD), the principal clinical representative of IVD pathology, constitutes an increasingly diagnosed spinal disorder associated with substantial morbidity and mortality in recent years. Despite the considerable incidence and socioeconomic burden of DDD, existing treatment modalities including conservative and surgical methods have been demonstrated to provide a limited therapeutic effect, being not capable of interrupting or reversing natural progress of underlying disease. These limitations underline the requirement for development of novel, innovative, and more effective therapeutic strategies for DDD management. Within this literature framework, compromised IVD replacement with a viable IVD construct manufactured with tissue-engineering (TE) methods has been recommended as a promising therapeutic strategy for DDD. Existing preliminary preclinical data demonstrate that proper combination of cells from various sources, different scaffold materials, and appropriate signaling molecules renders manufacturing of whole-IVD tissue-engineered constructs a technically feasible process. The aim of this narrative review was to critically summarize current published evidence regarding particular aspects of IVD-TE, primarily emphasizing in providing researchers in this field with practicable knowledge to enhance clinical translatability of their research and informing clinical practitioners about the features and capabilities of innovative TE science in the field of IVD-TE. Impact Statement Human intervertebral disc (IVD) pathology represents an extremely frequent condition in current clinical practice. Given the considerable limitations of available treatment options, deployment of novel and groundbreaking therapeutic modalities constitutes a rather urgent need. Tissue engineering of entire human IVD, a technically feasible process within laboratory framework, is theoretically capable of overcoming limitations that characterize currently applied therapeutic measures. Optimization of laboratory manufacturing techniques in conjunction with more diligent in vivo evaluation of tissue-engineered constructs are expected to lay the foundations for clinical trials initiation.

Application of susceptibility weighted imaging (SWI) in diagnostic imaging of brain pathologies - a practical approach.

Susceptibility weighted imaging (SWI) has been broadly incorporated to MR protocols as it provides unique additional diagnostic information in a wide variety of neurological conditions. SWI exploits local field inhomogeneities created by various paramagnetics (deoxyhaemoglobin, blood breakdown products), diamagnetics (calcium) or oxygenated blood, hereby provides contrast based on magnetic susceptibility. In this review we present various examples from everyday clinical practice including, among others, acute stroke, neurodegenerative disorders, haemorrhagic lesions, vascular malformations, mycotic intracranial aneurysm, primary central nervous system vasculitis, neoplasms in which SWI was essential for diagnosis. The strongest indications for SWI applications are the neurodegenerative and neuro-vascular diseases, therefore this review is aimed at a wide range of clinicians, mainly neurologists, neurosurgeons and radiologists.

Implementation of Percutaneous Transforaminal Endoscopic Discectomy in Competitive Elite Athletes With Lumbar Disc Herniation: Original Study and Review of the Literature.

BACKGROUND: Lumbar disc herniation (LDH) represents a frequent clinical entity in athletes. Surgical treatment of LDH with endoscopic spine surgical techniques has been proposed as a feasible alternative in these patients. PURPOSE: To study the particular outcomes of percutaneous transforaminal endoscopic discectomy (PTED) in competitive elite athletes with surgically treatable LDH. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 55 competitive elite athletes with diagnosed LDH based on clinical and radiologic criteria were enrolled in this prospectively designed study. All patients underwent successful PTED. Clinical evaluation was conducted with the well-established visual analog scale for lower limb and low back pain separately. The 36-Item Short Form Health Survey (SF-36) was implemented for health-related quality of life analysis. Patients were assessed preoperatively and at regular postoperative intervals: 6 weeks and 3, 6, and 12 months, as well as 2 years. RESULTS: Operated levels were L3-L4 (5.5%), L4-L5 (69.1%), and L5-S1 (25.4%). No major perioperative complications were observed. All patients successfully reached the end of follow-up at 2 years. Both visual analog scale scores (lower limb and low back pain) showed clinically and statistically significant improvement at 6 weeks postoperatively, with subsequent minor improvement and stabilization. All recorded SF-36 parameters demonstrated major clinical amelioration at 6 weeks, with subsequent minor but constant statistically significant improvement until the end of follow-up. Comparative evaluation of the SF-36 revealed that the physical function, bodily pain, role-emotional, and mental health parameters showed quantitatively greater improvement in comparison with rest indices. CONCLUSION: PTED constitutes a feasible and effective technique for surgical management of LDH in athletes, providing favorable outcomes in terms of postoperative pain and health-related quality of life. Proper performance of technique for specific cases of L5-S1 LDH may be more challenging, and these cases should be evaluated selectively for suitability for this procedure.

Unusual intramuscular lipoma of deltoid muscle.

Lipomas are common soft tissue tumors usually located under the skin. Nevertheless, intramuscular lipomas of deltoid muscle are unusual tumors. We present a case of 74-year-old woman with an intramuscular like clepsydra lipoma of deltoid muscle. The lesion was a palpable soft mass at the lateral side of the humerus. The patient had no previous history of trauma. The main symptom was pain only in abduction and extension. Imaging, pathological findings and surgical excision are discussed.

A 20-year-old man with large gastric lipoma--imaging, clinical symptoms, pathological findings and surgical treatment.

A broad search of the available literature yielded no other report of gastric lipoma of that size (13.5 x 6.5 x 4.5 cm) at this early age. The patient (a 20-year-old man with giant lipoma in the anterior gastric wall) presented with haematemesis and melena after excessive alcohol consumption. Gastric resection was performed. At 5-year follow up the patient is healthy and doing well. Epidemiology of gastric lipoma, the differential diagnosis, means of diagnosis and treatment are discussed.

The endoscopic aspect of foraminal anatomy and dorsal root ganglion in percutaneous transforaminal endoscopic discectomy.

Percutaneous Transforaminal Endoscopic Discectomy (PTED) offers an exceptional visualization of foraminal anatomy. Dorsal root ganglion and adjacent foraminal structures are satisfactorily visualized, thereby minimizing the risk of their intraoperative injury.