Spontaneous resolution of large non-traumatic bilateral acute-on-chronic subdural hematoma

Background and importance: Chronic subdural hematomas are a frequently encountered neurosurgical pathology, especially in the elderly. They often require surgical evacuation, but recent studies have shown good results with conservative treatment in selected cases.

Clinical presentation: We report the case of a 72-year old patient that developed large, non-traumatic, bilateral, acute-on-chronic subdural hematoma after repeated abdominal surgery for appendicular carcinoma. He presented an abdominal wound infection and good neurological status (GCS score of 14 points), factors that indicated the delay of surgical intervention. Subsequent clinical and radiological improvement forestalled the operation altogether and he presented complete spontaneous resolution of subdural hematomas at only 5 months after diagnosis.

Conclusion: Although surgical treatment is performed in the majority of chronic subdural hematomas, in clinically and radiologically selected cases, the operation can be avoided. The hematoma can present resolution, either spontaneously or with the help of conservative treatment.

Diagnostic challenge in a patient with primary bilateral Dumbbell-shaped lumbar non-Hodgkin’s lymphoma

Objective: Primary bilateral dumbbell-shaped lumbar non-Hodgkin lymphomas with epidural and extraspinal involvement, are rare occurrences. Patients presenting at advanced stages and rapid evolution towards neurological impairment lead to diagnostic dilemmas for which only immunohistochemistry can provide a correct, although delayed solution.

Case report: We report the first case of a bilateral, dumbbell-shaped, lumbar lymphoma in a 65-year-old man with a medical history of chronic viral hepatitis type B and D under interferon treatment. The patient presented with back pain radiating down the right leg, with rapid progression to paraplegia and sphincter dysfunction. CT and MRI revealed a large dumbbell mass (approx. 5/5/10 cm) in the right paraspinal musculature, at the L4-L5 level, with intraspinal epidural extension. A similar mass of smaller size was described on the left side, almost mirroring the first lesion, the imagistic aspect suggesting a neural sheath tumor. Intraoperatively, in the right lumbar paraspinal musculature, a soft, yellowish region was discovered, the macroscopic appearance being rather suggestive for a diffuse infection. Clinical, imagistic and surgical findings were not conclusive, nor was the histological examination in light microscopy of the surgical specimen or of the bone marrow biopsy. Immunohistochemistry identified the presence of large B cells, leading to the diagnosis of B cell lymphoma. Although the patient was treated with systemic chemotherapy, his condition rapidly deteriorated and he died within 3 months.

Conclusions: In the case of a lumbosacral, dumbbell shaped mass, developed both epidural and extraspinal, the differential diagnosis must include lymphoma. The histological examination, especially immunohistochemistry provided the final diagnosis. Delays in establishing a diagnosis, associated with a malignant evolution of lymphoma, diminish the chances of determining and applying a treatment strategy that could prolong survival.

A retrospective comparison of laminectomy and unilateral fenestration with foraminotomy on outcome of patients with lumbar spinal stenosis

Background: Neural decompression for lumbar spinal stenosis (LSS) can be performed, besides conventional lumbar laminectomy, by many other surgical techniques.

Objective: The goal of this study is to analyze the results of laminectomy versus unilateral fenestration and foraminotomy with bilateral neural decompression in LSS patients.

Methods: A number of 58 patients with lumbar spinal stenosis were divided into two groups: group A (no.=22) consists of patients that underwent a laminectomy procedure and group B (no.=36) of cases where unilateral fenestration with foraminotomy was used. Outcome was assessed at 1, 6 and 12 months postoperatively. Two parameters were evaluated: level of pain with the VAS (Visual Analogue Scale) score and the ODI (Oswestry Disability Index) scale for functional improvement.

Results: The level of pain was reduced in both patient groups. Cases in group A maintained higher levels of back pain in the first postoperative month versus group B. Improvement was faster for those operated by unilateral approach. At 6 months and 1 year follow-ups, VAS values were very similar. All patients presented functional recovery evaluated with the ODI scale, that showed continuous improvement at 6 months and 1 year.

Conclusions: Bilateral decompression by unilateral approach is an efficient method that represents the first option of treatment for patients with lateral lumbar spinal stenosis with unilateral or predominantly unilateral symptoms. For patients with severe central stenosis, classic laminectomy remains the first surgical choice.

Quantitative contrast-enhanced ultrasound of intraplaque neovascularization in patients with carotid atherosclerosis

PURPOSE

Intraplaque neovascularization (IPN) is an increasingly studied marker of the vulnerable atherosclerotic plaque, and contrast-enhanced ultrasound (CEUS) is an in vivo imaging technique for the assessment of IPN. The purpose of this study was to test novel quantification methods for the detection of carotid IPN using CEUS.

MATERIALS AND METHODS

25 patients with established carotid atherosclerosis underwent bilateral carotid CEUS using a Philips iU-22 ultrasound system with an L9 - 3 transducer. Visual scoring of IPN was performed using a 3-point score. Quantification of IPN was performed using novel custom developed software. In short, regions of interest were drawn over the atherosclerotic plaques. After motion compensation, several IPN features were calculated. Statistical analysis was performed using Spearman's rho. Reproducibility of the quantification features was calculated using intra-class correlation coefficients and mean differences between calculations.

RESULTS

45 carotid arteries were available for the quantification of IPN. The quantification of IPN was feasible in all 45 carotid plaques. The IPN area, IPN area ratio and neovessel count had a good correlation with the visual IPN score (respectively ρ = 0.719, ρ = 0.538, ρ = 0.474 all p < 0.01). The intra-observer and inter-observer agreement was good to excellent (p < 0.01). The intra-observer and inter-observer variability was low.

CONCLUSION

The quantification of carotid IPN on CEUS is feasible and provides multiple features on carotid IPN. Accurate quantitative assessment of IPN may be important to recognize and to monitor changes during therapy in vulnerable atherosclerotic plaques.

Incidental durotomy in lumbar spine surgery - incidence, risk factors and management

Incidental durotomy is a common complication of lumbar spine operations for degenerative disorders. Its incidence varies depending on several risk factors and regarding the intra and postoperative management, there is no consensus. Our objective was to report our experience with incidental durotomy in patients who were operated on for lumbar disc herniation, lumbar spinal stenosis and revision surgeries. Between 2009 and 2012, 1259 patients were operated on for degenerative lumbar disorders. For primary operations, the surgical approach was mino-open, interlamar, uni- or bilateral, as for recurrences, the removal of the compressive element was intended: the epidural scar and the disc fragment. 863 patients (67,7%) were operated on for lumbar disc herniation, 344 patients (27,3%) were operated on for lumbar spinal stenosis and 52 patients (5%) were operated for recurrences. The operations were performed by neurosurgeons with the same professional degree but with different operative volume. Unintentional durotomy occurred in 20 (2,3%) of the patients with herniated disc, in 14 (4,07%) of the patients with lumbar spinal stenosis and in 12 (23%) of the patients who were operated on for recurrences. The most frequent risk factors were: obesity, revised surgery and the physician’s low operative volume. Intraoperative dural fissures were repaired through suture (8 cases), by applying muscle, fat graft or by applying curaspon, tachosil. There existed 4 CSF fistulas which were repaired at reoperation. Incidental dural fissures during operations for degenerative lumbar disorders must be recognized and immediately repaired to prevent complications such as CSF fistula, osteodiscitis and increased medical costs. Preventing, identifying and treating unintentional durotomies can be best achieved by respecting a neat surgical technique and a standardized treatment protocol.

Essential versus accessory aspects of cell death: recommendations of the NCCD 2015

Cells exposed to extreme physicochemical or mechanical stimuli die in an uncontrollable manner, as a result of their immediate structural breakdown. Such an unavoidable variant of cellular demise is generally referred to as ‘accidental cell death' (ACD). In most settings, however, cell death is initiated by a genetically encoded apparatus, correlating with the fact that its course can be altered by pharmacologic or genetic interventions. ‘Regulated cell death' (RCD) can occur as part of physiologic programs or can be activated once adaptive responses to perturbations of the extracellular or intracellular microenvironment fail. The biochemical phenomena that accompany RCD may be harnessed to classify it into a few subtypes, which often (but not always) exhibit stereotyped morphologic features. Nonetheless, efficiently inhibiting the processes that are commonly thought to cause RCD, such as the activation of executioner caspases in the course of apoptosis, does not exert true cytoprotective effects in the mammalian system, but simply alters the kinetics of cellular demise as it shifts its morphologic and biochemical correlates. Conversely, bona fide cytoprotection can be achieved by inhibiting the transduction of lethal signals in the early phases of the process, when adaptive responses are still operational. Thus, the mechanisms that truly execute RCD may be less understood, less inhibitable and perhaps more homogeneous than previously thought. Here, the Nomenclature Committee on Cell Death formulates a set of recommendations to help scientists and researchers to discriminate between essential and accessory aspects of cell death.

Postoperative spondylodiscitis. A review of 24 consecutive patients

BACKGROUND

Postoperative discitis is a rare complication of spine surgery that creates a significant patient suffering and requires long-term treatment. The aim of this study was to compare the empirical antibiotic treatment with the treatment according antibiotics to susceptibility of isolates germs in curing this complication.

MATERIAL AND METHOD

In the period January 2002 - December 2012, 4698 patients were operated for lumbar spine disorders:lumbar disc herniation, spinal canal stenosis. Of these patients, 47 (1%) were diagnosed with postoperative discitis. In December 2012 there were 24 cases of spondylodiscitis after lumbar disc herniation operated by inter-lamar approach and foraminotomy. The A group of 13 patients received antistaphylococcalempirical antibiotic treatment. The B group consisting of 11 patients received antibiotic therapy after germ isolation by open biopsy from discal intervertebral space (n=8)and from surgical wound secretion (n=3) and antibiotic susceptibility testing.

RESULTS

After 4 to 6 months of antibiotic treatment associated with immobilization in Boston corset the symptoms gradually improved in parallel with normalization of biological constants, ESR, CRP. Five patients of Group A did not respond to the given antibiotic treatment and required further debridement and germ isolation.

CONCLUSIONS

Spondylodiscitis is a complication of spine surgery that is treated with antibiotics given for a long time of 4-6 months. Germ isolation by needle biopsy or open biopsy allows proper antibiotic treatment and faster healing.

[Regeneration of airway epithelium]

INTRODUCTION

Epithelial regeneration is a complex process. It can lead to the remodeling of the airway epithelium as in asthma, COPD or cystic fibrosis.

BACKGROUND

The development of in vivo and in vitro models has allowed the analysis of remodeling mechanisms and showed the role of components of extracellular matrix, proteases, cytokines and growth factors. Airway epithelial progenitors and stems cells have been studied in these models. However, their identification remains difficult.

CONCLUSION

Identification and characterization of airway epithelial progenitor/stem-cells, and a better knowledge of the regeneration process may allow the development of new therapeutic strategies for airway epithelial reconstitution.

Comparison of percutaneous nucleoplasty and open discectomy in patients with lumbar disc protrusions

INTRODUCTION

Coblation nucleoplasty is a minimally invasive method, at middle way between conservative and open surgical treatment of patients with degenerative disc disease and lumbar disc protrusion. Authors compare the outcome of patients treated through the two methods.

MATERIAL AND RESULTS

Two groups of 80 patients each were treated through open discectomy and nucleoplasty. Patients with radicular symptoms caused by disc protrusions, having antero-posterior diameter of herniated disc less 6 mm, resistant to conservative treatment, were operated using nucleoplasty. When antero-posterior diameter of the disc herniation was > 6 mm, classical discectomy method was applied. Classical surgeries (discectomies) were performed by the senior author (D.A.), while the nucleoplasty procedures all three authors equally participated. In the first group improvement of radicular pain was immediate. At 1 year after the procedure only one third of the patients returned to work. In the group treated through nucleoplasty improvement of pain was slow but gradual. After 1 postoperative year the VAS score of patients treated through the two methods were very close. At 3 days post nucleoplasty all patients returned to work. In this group there were not intraoperative or post-operative complications. One patient was afterwards operated through open discectomy.

CONCLUSION

Coblation nucleoplasty is a safe and efficient method to treat patients with lumbar disc protrusion.