Evaluation of the Effect of Repetitive Transcranial Magnetic Stimulation of Motor Cortex on Failed Back Surgery Syndrome Pain Control in the Short Term

BACKGROUND

 This study aimed to evaluate the short-term efficacy of repetitive transcranial magnetic stimulation (rTMS) on the treatment of failed back surgery syndrome (FBSS).

METHODS

 In this prospective clinical trial study, 13 patients with FBSS were selected to undergo rTMS, including 5 sessions of stimulation of the primary motor cortex of 90 trains with a frequency of 10 Hz for 2 seconds and an intertrain interval of 20 seconds with a total pulse rate of 1800 per session. The time of each session was 30 minutes with an intensity of 80% of the motor threshold. The severity of pain before and after the intervention was measured by the short-form McGill Pain Questionnaire and visual analog scale (VAS).

RESULTS

 The mean of pain severity was 26.54 ± 6.78 and 14.92 ± 10.1 before and after rTMS, respectively. The severity of pain was significantly decreased after the intervention (p = 0.001). According to the McGill Pain Questionnaire, the severity of pain in the patients was decreased by 44.09 ± 27.32. The mean of the severity of pain according to VAS was 77.31 ± 16.66 before rTMS and 53.46 ± 22.49 after rTMS, which showed that pain intensity was significantly decreased after the intervention (p = 0.006).

CONCLUSIONS

 The use of rTMS of the primary motor cortex in patients who have undergone lumbosacral spine surgery and suffer from pain related to FBSS is associated with a significant reduction in the severity of pain. Because rTMS is a noninvasive treatment method, it can be used as a suitable treatment in these patients.

Harnessing the therapeutic potential of mesenchymal stem/stromal cell-derived extracellular vesicles as a novel cell-free therapy for animal models of multiple sclerosis

Multiple sclerosis (MS) is a chronic, neuroinflammatory, and demyelinating disease of the central nervous system (CNS). Current treatments offer only limited relief from symptoms, and there is no cure. Mesenchymal stem/stromal cells (MSCs) have demonstrated therapeutic potential for MS. However, their clinical application faces challenges, including immune rejection and the potential for tumor formation. Recent studies suggest that MSCs exert their effects through extracellular vesicles (EVs) released from the cells, rather than direct cellular engraftment or differentiation. This discovery has sparked interest in the potential of MSC-derived EVs as a cell-free therapy for MS. This review explores the existing literature on the effects of MSC-EVs in animal models of MS. Administration of MSC-EVs from various tissue sources, such as bone marrow, adipose tissue, and umbilical cord, was found to reduce clinical scores and slow down disease progression in experimental autoimmune encephalomyelitis (EAE), the primary mouse model of MS. The mechanisms involved immunomodulation through effects on T cells, cytokines, CNS inflammation, and demyelination. Although the impact on CNS repair markers remained unclear, MSC-EVs exhibited the potential to modulate neuroinflammation and suppress harmful immune responses in EAE. Further studies are still required, but MSC-EVs demonstrate promising therapeutic effects for MS and warrant further exploration as a novel treatment approach.

Lesson learned from assessing teachers' and students' perspectives regarding the quality of e-learning in medical education during the pandemic: a mixed-methods study

BACKGROUND

The evaluation of e-learning systems ensures the provision of quality training. The goal was to identify the perspectives of teachers and students on e-learning in medical education during the COVID-19 pandemic at Shiraz University of Medical Sciences (SUMS), Iran.

METHODS

This study utilized a convergent mixed methods research design with a two-phase approach to collect and analyze data between June and August 2022. In the first stage, a cross-sectional descriptive study was conducted to evaluate the quality of e-learning systems from the perspective of 400 students. In the second stage, semi-structured interviews were conducted with 10 virtual education professors and 10 student representatives to identify the strengths, weaknesses, opportunities, and threats of virtual education. A validated questionnaire was administered to assess the quality of the e-learning system, and data were analyzed using SPSS-21. Qualitative data were subjected to content analysis.

RESULTS

Our findings revealed that the student support system, the course structure, and the infrastructure and technology subscales' mean scores were significantly higher than the average level (P < 0.001). However, the professors' methods of teaching and learning strategies were unsatisfactory. The results of the present study showed that the evaluation mean score was significantly higher among, younger, female, and undergraduate students. Virtual education has strengths and weaknesses, and innovative approaches are needed to enhance student engagement. The lack of appropriate infrastructure and virtual teaching tools for teachers and students is a significant challenge that needs to be addressed. Blended learning is effective in medical education, and the shift from teacher-centered to learner-centered teaching approaches is an opportunity to explore innovative teaching approaches.

CONCLUSION

From the perspective of students, the quality of eLearning systems at the universities was moderate. Virtual education offers both benefits and drawbacks, and there is a requirement for innovative solutions to enhance student engagement and lessen boredom.

The effect of SARS-CoV-2 on the development of Parkinson's disease: the role of α-synuclein

The current coronavirus disease 2019 (COVID-19) can lead to various neurological complications in infected people. These neurological effects include problems in both central nervous system (CNS) and peripheral nervous system (PNS). Hyposmia, a PNS symptom of COVID-19, frequently manifests in the early stages of Parkinson's disease (PD) and serves as an early warning sign of the condition. In addition, the olfactory system is recognized as an early site for the onset of α-synuclein pathology, the pathological hallmark of PD. PD is characterized by accumulation and aggregation of misfolded α-synuclein (α-Syn) into Lewy bodies and Lewy neurites, resulting in the degeneration of dopaminergic neurons in substantia nigra pars compacta (SNpc). Previous research has also shown the involvement of α-Syn in the innate immune response following viral infections. Consequently, the potential link between viral infections and development of PD has gained attention in recent years. However, it's still too early to definitively conclude whether COVID-19 can cause Parkinsonism. Nevertheless, we can explore the likelihood of this connection by examining past studies and possible mechanisms to better understand how COVID-19 might potentially lead to PD following the infection. Based on the various pieces of evidence discussed in this review, we can infer that SARS-CoV-2 promotes the aggregation of α-Syn and, ultimately, leads to PD through at least two mechanisms: the stable binding of the S1 protein to proteins prone to aggregation like α-Syn, and the upregulation of α-Syn as part of the immune response to the infection.

Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature

INTRODUCTION AND IMPORTANCE

Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention.

CASE PRESENTATION

We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up.

CLINICAL DISCUSSION

The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion).

CONCLUSION

Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.

The combination treatment of methylprednisolone and growth factor-rich serum ameliorates the structural and functional changes after spinal cord injury in rat

STUDY DESIGN

Preclinical pharmacology.

OBJECTIVES

Our study aims to evaluate the combined effect of Methylprednisolone (MP) and growth factor-rich serum (GFRS) on structural and functional recovery in rats following spinal cord injury (SCI).

SETTING

Shiraz University of Medical Sciences, Shiraz, Iran METHODS: Male Sprague-Dawley rats were randomly assigned to five groups: sham group (laminectomy); SCI group (the spinal cord clip compression model); SCI-MP group (30 mg/kg MP was administrated intraperitoneally (IP) immediately after SCI); SCI-GFRS group (GFRS (200 µl, IP) was administrated for six consecutive days); and SCI-MP + GFRS group (the rats received MP (30 mg/kg, IP) immediately after SCI, and GFRS (200 µl, IP) for six consecutive days). Motor function was assessed weekly using the Basso, Beattie, and Bresnahan (BBB) scale. After 4 weeks, we conducted the rotarod test, then removed and prepared the spinal cords (including the epicenter of injury) for stereological and histological estimation, and biochemical assays.

RESULTS

The results showed that MP and GFRS combining treatment enhanced functional recovery, which was associated with a decrement in lesion volume, increased spared white and gray matter volume, reduced neuronal loss, as well as decreased necrosis and hemorrhage after SCI. Moreover, administration of MP and GFRS inhibited lipid peroxidation (malondialdehyde (MDA) content), and increased antioxidant enzymes including glutathione (GSH), superoxide dismutase (SOD), and catalase (CAT) after rat SCI.

CONCLUSIONS

We suggests that the combination treatment of MP and GFRS may ameliorate the structure and functional changes following SCI by reducing oxidative stress, and increasing the level of antioxidants enzymes.

Reconstruction of C1 lateral mass with an expandable cage in addition to vertebral artery preservation: presenting two cases

PURPOSE

C1 lateral mass reconstruction is recommended, in cases of instability caused by tumor involvement or extensive C1 lateral mass resection. However, because of the anatomical complexity of the area and, most importantly, the proximity to vertebral arteries, few cases of reconstruction have been reported to date. The purpose of this report is to present technical details of C1 lateral mass reconstruction in conjunction with vertebral artery preservation from a posterior approach.

METHODS

Two cases of one stage craniovertebral junction instrumentation and C1 lateral mass reconstruction in conjunction with vertebral artery preservation from a posterior approach are presented.

RESULTS

In both cases of extensive resection of lateral mass due to tumor involvement, an expandable cage was used for C1 lateral mass reconstruction, which has been used only in one patient in literature. Complementary pathological examinations of the two cases indicated two rare tumors that had been reported in the upper cervical region so far. The first case became an unknown origin metastatic cancer and the second was reported to be a primary non- Hodgkin lymphoma.

CONCLUSIONS

C1 lateral mass reconstruction with an expandable cage together with VA preservation is recommended in cases of extensive C1 lateral mass resection to increase the total strength and to shorten the length of the posterior device and probably better fusion. The expandable cage is preferred because of safer placement under compression instead of the lateral mass.

Spinal Ganglioneuroma: A Systematic Review of the Literature

OBJECTIVE

Spinal ganglioneuromas (GNs) are rare benign tumors that often manifest as symptoms related to the compression of neural elements. The preferred treatment for affected patients is surgical resection, which typically improves symptoms and accompanies a low likelihood of tumor recurrence. We conducted a systematic review of reports of GNs involving the spinal cord and nerve roots, examining their clinical presentation, surgical management, and outcomes.

METHODS

Using the keywords "ganglioneuroma" and "spinal," we conducted a systematic database review of MEDLINE (PubMed), Scopus, and Embase, querying studies reporting cases of spinal GNs. Patients' demographics, location of the tumors, clinical features, and surgical outcomes were extracted from eligible articles.

RESULTS

A total of 93 spinal GN cases in 52 case reports/series met our criteria. Data analysis revealed a general male predominance, though thoracic spinal GNs were seen more in females. The mean age of patients with cervical, thoracic, thoracolumbar, and lumbar spinal GNs were 41.28, 27.65, 15.61, and 38.73 years, respectively. Multiple-level GNs were mostly seen in male patients or individuals with neurofibromatosis type 1. In all but 1 case, recurrence and reoperation were not reported in the short-term (months) and long-term (2-10 years) follow-up.

CONCLUSIONS

We found unique epidemiologic characteristics for patients with GNs of different spinal regions. The treatment of choice is achieving gross total resection, but given the eloquency of the lesions, achieving decompression via subtotal resection can also be associated with improved outcomes. To date, no global postoperative surveillance protocol exists, considering the low recurrence rate and relevant cost-benefit ratios.

Sacrectomy with Posterior-Only Approach in Sacral Tumors: An Analysis of 26 Cases and Review of Literature

BACKGROUND

Sacral masses can be removed using anterior, posterior, or combined approaches. Achieving total sacrectomy through a posterior-only approach results in a shorter procedure time, minimal tissue damage, and a reduced risk of complications. In this study, we aimed to share our experience with performing total sacrectomy using a posterior-only approach in 26 patients and to assess their clinical outcomes at our center.

MATERIALS AND METHODS

This retrospective study examines the clinical progression, surgical response, and outcomes of 26 patients with various sacral mass pathologies. We accessed patient information from our hospital records.

RESULTS

The study included 14 men (54%) and 12 women (46%), with an average age of 49.8 years. Most cases had a normal body mass index, while 6 were overweight. Sacrectomy was performed at a high level in 12 patients and at a middle level in 14 patients. In addition to pain, motor deficits were observed in 9 patients, and sphincter dysfunction was found in 5. Preoperative embolization was conducted for 11 patients. The most prevalent lesions were chordoma (8 patients), malignant peripheral nerve sheath tumor (4 patients), giant cell tumor (3 patients), and solitary plasmacytoma (3 patients). Only 1 patient experienced a temporary partial motor deficit after surgery. There were no instances of cerebrospinal fluid leakage. Five patients experienced local recurrence, and 1 had distant metastasis.

CONCLUSIONS

Performing sacrectomy for large or giant sacral tumors through a posterior approach is both feasible and safe, resulting in reduced morbidity and no significant change in overall survival.

Atypical Scheuermann's disease with severe kyphosis and negative sagittal balance in the thoracolumbar region: A case report and literature review

INTRODUCTION AND IMPORTANCE

Scheuermann's kyphosis is a structural deformity of the thoracolumbar spine that is classified in typical (thoracic) and atypical (lumbar and thoracolumbar) Scheuermann's disease. Surgical intervention is reserved for those with progressive kyphosis, intractable pain and neurological impairment. Although, previous literature focuses on the correction of the thoracic kyphosis (TK), recent lines of evidence recommend considering all the sagittal balance parameters when performing a surgery. We herein, report a posterior-only approach in a patient with Scheuermann's kyphosis, considering all the sagittal balance parameters.

CASE PRESENTATION

The patient was a 17-year-old boy with a kyphotic deformity in the lumbar region, with urinary retention and upper back intractable pain. The preoperative physical examination was normal except for a kyphotic gait. The patient was first treated with thoracic lumbosacral orthoses (TLSO) brace that was not effective; consequently, the patient underwent posterior only approach (pedicular screw fixation along with Smith-Peterson osteotomy) with correction of the sagittal balance and kyphosis. The patient's sign and symptoms improved significantly. The surgery was uneventful and no complication was recorded. The 1-year follow-up revealed normal neurological examination and normal sagittal balance parameters.

CLINICAL DISCUSSION

Atypical Scheuermann's kyphosis with neurological impairment and progressive kyphosis should be treated with surgical intervention.

CONCLUSION

Considering the sagittal parameters of the spine, the surgical intervention should be designed to correct the kyphosis and the other indices of the sagittal balance. Posterior-only approach is safe and effective method for correction of the TK and improving the signs and symptoms of the patients.

Effect of Disease-Modifying Therapies on COVID-19 Vaccination Efficacy in Multiple Sclerosis Patients: A Comprehensive Review

According to current knowledge, the etiopathogenesis of multiple sclerosis (MS) is complex, involving genetic background as well as several environmental factors that result in dysimmunity in the central nervous system (CNS). MS is an immune-mediated, inflammatory neurological disease affecting the CNS. As part of its attack on the axons of the CNS, MS witnesses varying degrees of myelin and axonal loss. A total of about 20 disease-modifying therapies (DMTs) are available today that, both in clinical trials and in real-world studies, reduce disease activity, such as relapses, magnetic resonance imaging lesions, and disability accumulation. Currently, the world is facing an outbreak of the new coronavirus disease 2019 (COVID-19), which originated in Wuhan, Hubei Province, China, in December 2019 and spread rapidly around the globe. Viral infections play an important role in triggering and maintaining neuroinflammation through direct and indirect mechanisms. There is an old association between MS and viral infections. In the context of MS-related chronic inflammatory damage within the CNS, there has been concern regarding COVID-19 worsening neurological damage. A high rate of disability and increased susceptibility to infection have made MS patients particularly vulnerable. In addition, DMTs have been a concern during the pandemic since many DMTs have immunosuppressive properties. In this article, we discuss the impact of DMTs on COVID-19 risks and the effect of DMTs on COVID-19 vaccination efficacy and outcome in MS patients.

A case report: Bilateral reconstruction of C2 lateral masses with expandable titanium cages following axis (C2) solitary plasmacytoma resection with 2-year follow-up

Background

Solitary plasmacytoma (SP) caused the collapse/destruction of the C2 vertebral body in a 78-year-old male. To provide sufficient posterior stabilization, the patient warranted lateral mass fusion to supplement the bilateral pedicle/screw rod instrumentation.

Case Description

A 78-year-old male presented with neck pain alone. X-rays, computed tomography, and magnetic resonance studies documented C2 vertebral collapse with the complete destruction of both lateral masses. The surgery required a laminectomy (i.e., bilateral lateral mass resection), plus placement of bilateral expandable titanium cages from C1 to C3 to supplement the screw/rod occipitocervical (O-C4) fixation. Adjuvant chemotherapy and radiotherapy were also administered. Two years later, the patient remained neurologically intact and radiographically had no evidence of tumor recurrence.

Conclusion

In patients with vertebral plasmacytomas and bilateral lateral mass destruction, posterior occipital-cervical C4 rod/screw fusions may warrant the additional bilateral placement of titanium expandable lateral mass cages from C1 to C3.

Acute supratentorial subdural hematoma after craniocervical junction arachnolysis in a patient with posttraumatic syringomyelia; case report and literature review

In patients with SAA rapid CSF drainage while performing durotomy must be avoided by utilizing cotton pads and lowering the head level to avoid catastrophic complications.

Development of Acute Transverse Myelitis following COVID-19 Infection: A Review on the Potential Pathways

BACKGROUND

Acute transverse myelitis (ATM) is a rare neurological disorder in adults characterized by localized inflammation of gray and white matter in one or more contiguous spinal cord segments in the absence of a compressive injury. Several reports have connected the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to the pathophysiology of ATM.

SUMMARY

Direct invasion of the spinal cord, cytokine storm, or an autoimmune response are the possible pathways by which the SARS-CoV-2 virus can affect the spinal cord and lead to ATM. Direct invasion is facilitated by the presence of angiotensin-converting enzyme 2 (ACE2) receptors on the membranes of the spinal cord neurons. Cytokine storm syndrome could be derived from elevated levels of several immunological factors following severe involvement with Coronavirus disease 2019 (COVID-19). Finally, autoimmune responses can cause post-infectious ATM through several hypothesized processes, including molecular mimicry, epitope spreading, bystander activation, and polyclonal B-cell activation.

KEY MESSAGES

COVID-19-induced ATM is mostly a longitudinally-extensive ATM (LEATM) in which more spinal cord segments are damaged, which results in a worse sequel compared to short-segment ATM. Therefore, it is suggested that COVID-19 patients, particularly severe cases, be followed up for a probable incidence of ATM, even long after recovery from the disease and elimination of the virus from the host, because an early diagnosis and effective therapy may stop the spread of inflammation to adjacent segments.

Surgical Decompression of Thoracic Ossification of the Posterior Longitudinal Ligament through Posterior Approach: A Case Report

Thoracic ossification of the posterior longitudinal ligament (OPLL) is a rare condition that is mainly accompanied by cervical OPLL or ossification of thoracic ligamentum flavum. In case of causing neurological manifestations, it is preferred to treat the condition surgically. Several surgical procedures were introduced, including anterior, posterior, or combined approaches. Laminectomy with instrumented fusion is the most popular procedure utilized via the posterior approach. A 32-year-old obese woman, who suffered from back pain and weakness in both lower extremities for one month, was referred to our spine outpatient clinic. Imaging revealed lower thoracic OPLL (T7/T8 & T8/T9 & T9/T10). The posterior longitudinal ligament had a mixed ossification pattern (beaked and continuing cylindrical). To maintain thoracic spine stability and prevent future kyphosis, we performed laminectomy and long segment fixation (T7 to T12). The post-operative neurological examination revealed a considerable increase in muscle strength and significant pain relief.

Metastatic thoracic and lumbar intramedullary and extramedullary Ewing's sarcoma: a rare case report and literature review

Ewing sarcoma (ES) is a highly aggressive bone and soft tissue tumor that occurs mainly in young children and adolescents and is associated with primary and metastatic disease. Intramedullary ES (either primary or secondary) is rare, and the ideal management remains inconclusive. We herein report intramedullary and extramedullary metastatic ES in a single patient. A 46-year-old woman was referred to our outpatient clinic from the oncology clinic with progressive paraparesis and paresthesia for 1 week prior to presentation. She had developed left clavicular ES 2 years earlier for which surgery and chemoradiotherapy had been performed. At the present evaluation, she was diagnosed with intramedullary thoracic and lumbar extradural masses. Thoracic surgery was performed, and a biopsy of the lesion was obtained. The diagnosis of ES was confirmed histopathologically, and she underwent adjuvant chemotherapy. Her neurological status did not improve after surgery, and she underwent rehabilitation and physical therapy. The lumbar lesion resolved with chemotherapy. Metastasis of ES to the spinal cord, especially intramedullary lesions, is extremely rare, and there is no standard management guideline. However, surgical decompression and adjuvant chemotherapy are the main treatments in these cases.

Hypoxia-inducible factor 1 alpha (HIF-1α) stimulated and P2X7 receptor activated by COVID-19, as a potential therapeutic target and risk factor for epilepsy

Based on available evidence, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a neuroinvasive virus. According to the centers for disease control and prevention (CDC), coronavirus disease 2019 (COVID-19) may cause epilepsy. In this line, COVID-19 can stimulate hypoxia-inducible factor-1 alpha (HIF-1α) and activate P2X7 receptor. Both HIF-1α and P2X7 receptors are linked to epileptogenesis and seizures. Therefore, in the current study, we suggested that COVID-19 may have a role in epileptogenesis and seizure through HIF-1α stimulation and P2X7 receptor activation. Consequently, pharmacological targeting of these factors could be a promising therapeutic approach for such patients.

Evaluating the effect of finely ground, dry-rolled, and crumbled corn grain on performance, feeding behavior, and starch digestion in Holstein dairy heifers

Corn processing methods including finely ground (FGC), dry rolled (DRC), and crumbled corn (CRC) were evaluated to determine their effects on average daily gain (ADG), structural growth, starch digestibility, feeding behavior, and blood metabolites of young dairy heifers. In this study, 36 Holstein heifers [91 ± 4 d of age, 105 ± 6.5 kg of body weight (BW); mean ± standard deviation] housed in 9 pens (4 heifers per pen) were fed diets (dry matter basis) containing 20% forage (wheat straw) and 80% corn-based concentrate for 60 d. Pens were randomly assigned to 1 of 3 dietary treatments based on the type of corn grain used for the diets: (1) ground corn (FGC; fine: 1.11 ± 0.52 mm); (2) dry-rolled corn (DRC; 2.30 ± 0.68 mm); and (3) crumbled corn (CRC; 2.54 ± 0.70 mm). Heifers had ad libitum access to diets and water throughout the experiment and the feed intake was measured daily. Animals were weighed at the beginning (91 d of age) and end (151 d of age) of the study. The ADG (kg of BW/d) was calculated at the end of experiment at an individual level. Feeding behavior was recorded based on direct observation by monitoring each heifer every 5 min during a 22-h period at 150 d of age. The CRC and DRC tended to increase feed intake compared with FGC, whereas heifers fed CRC tended to have a greater withers height compared with other treatments. Feed efficiency was not affected; however, ADG and final BW increased in heifers fed the CRC diet compared with other diets. Feeding CRC increased total-tract starch digestibility compared with FGC and DRC diets (97.8 vs. 93.1 and 89.5%, respectively). Compared with FGC diet, feeding DRC and CRC tended to increase rumination time. The molar proportion of propionate was greater, and the molar proportion of acetate and acetate-to-propionate ratio were lower in heifers fed CRC than in those fed DRC. The blood glucose and insulin-like growth factor concentrations increased in heifers fed CRC compared with feeding DRC; however, blood urea concentrations decreased by CRC feeding. In conclusion, thermal processing (CRC diet) improved total-tract starch digestibility, ADG, feed intake, and skeletal growth, but had no effect on feed efficiency during the experimental period. Our results indicated that the thermal processing of corn grain improved growth performance of weaned heifers; however, the performance of heifers over a 60-d period did not differ between mechanical processing methods (grinding and dry rolling).

The Effect of Spironolactone on β-amyloid-Induced Memory Impairment in Male Rats: The Role of Microglial Inhibition

Purpose: Neuroinflammation was indicated in the pathophysiology of Alzheimer’s disease (AD). Previous reports have also signified that spironolactone has anti-inflammatory effects. Therefore, the aim of this study was to assess the modulatory effects of spironolactone on neuroinflammation and memory loss in a rat model of AD.

Methods: The β-amyloid protein fragment 25-35 (Aβ) was injected in the dorsal hippocampus (5 μg/2.5 μL each side) of male Sprague-Dawley rats for four consecutive days to induce memory impairment. Animals have intraperitoneally received spironolactone (10, 25, or 50 mg/kg, N = 6/ group) or vehicle for 14 days. The passive inhibitory avoidance and the novel recognition tests were used for memory evaluation. Neuroinflammation was assessed by measuring the level of Iba1 protein, a marker of microglial activation, using western immunoblotting.

Results: Different doses of spironolactone showed no significant changes in latency times and discriminations ratios in passive inhibitory avoidance and novel recognition tests, respectively, as compared to vehicle. However, spironolactone-treated groups showed significantly lower Iba1 protein levels in comparison to the vehicle-treated group (P < 0.01).

Conclusion: Spironolactone had a modulatory effect on neuroinflammation through a repressive effect on microglial activation with no valuable effect on memory improvement in a rat model of AD. The findings of this study suggest that Aβ-induced memory loss may not be directly linked to microglial activation. Spironolactone may be a potential candidate to be examined in other neuroinflammatory disorders.

Medical education and COVID-19 pandemic: a crisis management model towards an evolutionary pathway

The COVID-19 crisis has had a profound effect on higher education, especially medical education due to its sensitive nature, dealing with people's life and wellbeing. This study presented a crisis management model of how to direct medical education during crises. A qualitative design was used via a focus group among 83 medical education administrators at Shiraz University of Medical Sciences. Four major challenges emerged regarding medical education during the COVID-19 pandemic including "The health and wellbeing of faculty members and students"; "Spatial constraints"; "Time constraints", and "Access to resources". A total of 13 strategies were suggested to tackle the challenges, including virtualization, technological support, empowerment, participation, sharing, helping, integration, compression, omission, flexibility and diversity, severance, protection; and monitoring. For a sustainable educational pathway in medical education, personalized approach to education via the incorporation of technology is essential. This provides opportunities to tackle the issues caused by the crisis, by provision of any time and anywhere approach to education via flexible technologies/platforms adjusted based on the audiences. The scope of crisis management expands not only on individual and academic levels but also on social and global relations.

Comparative Study between Transforaminal Lumbar Interbody Fusion and Posterolateral Fusion for Treatment of Spondylolisthesis: Clinical Outcomes and Spino-Pelvic Sagittal Balance Parameters

Objective This retrospective study aims to compare the clinical and radiological outcomes of posterolateral fusion (PLF) with transforaminal lumbar interbody fusion (TLIF + PLF) for the treatment of patients with low-grade spondylolisthesis.

Methodology A total of 77 adult patients ≥18 years with low-grade spondylolisthesis, Meyerding grades I and II, were assigned into two groups: 36 patients treated with PLF and 41 patients treated with TLIF + PLF. The PLF group is composed of the patients that were operated with pedicle screw and the TLIF + PLF group is composed of the ones that were operated with fixation and TILF by autografting. Clinical evaluation was performed using the spino-pelvic sagittal balance, Numeric Rating Scale, Oswestry Disability Index, blood loss, operation times, and postoperative hospital stay of the PLF vs TLIF groups. The incidences of postoperative low back pain and radicular pain in the two groups were also recorded. Radiography was performed preoperatively and postoperatively to assess spino-pelvic parameters.

Results Significant restoration of spino-pelvic sagittal balance was observed in the TLIF group after surgery, and all spino-pelvic sagittal balance parameters showed significant improvement in the TLIF group after surgery, while in the PLF group, all spino-pelvic sagittal parameters had improved except the segmental angle lordosis (p = 0.316), which showed no significant difference after surgery in the PLF group. Postoperative pelvic incidence and pelvic tilt significantly improved in the TLIF group in comparison to PLF groups. Hence, TLIF can achieve better postoperative spino-pelvic sagittal balance parameters than PLF. There was no difference in the complication rates for each group. Both groups achieved significant improvement in postoperative clinical outcomes, and there was no significant difference in the incidence of postoperative low back pain or radicular pain between the two groups.

Conclusion Both surgical procedures PLF and TLIF were effective. PLF and TLIF can result in improved clinical and radiological outcomes for patients treated for low-grade spondylolisthesis. TLIF can achieve better restoration of spino-pelvic sagittal balance parameters than PLF alone.

A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients

Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1–L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24–72 h) decompressive surgery after T1–L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1–L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24–72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment.

Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39, p = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38, p = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1–L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months.

MicroRNA-199a Upregulation Mediates Lumbar Intervertebral Disc Degeneration and is Associated with Clinical Grades of Degeneration

AIM

To determine the expression profile of miRNA-199a-5p in intervertebral disc degeneration (IDD) and its correlation to the grade of IDD.

MATERIAL AND METHODS

This case-controlled study was conducted during a 6-month period from 2017 to 2018 in two university hospitals in Shiraz, Iran. We included 15 patients with grade 3 and 4 of Pfirrmann and 5 patients with traumatic lumbosacral fractures with grade I. Total discectomy was performed in all the individuals and the samples were sent to the laboratory. The nucleus pulposus (NP) cells were isolated and the RNA was extracted. cDNA was synthesized by reverse transcriptase and the expression was measured using real-time polymerase chain reaction (RT-PCT).

RESULTS

We overall included 20 patients in two study groups. Both study groups were comparable regarding the baseline and clinical characteristics except for age (p=0.026). The fold change (p=0.007), and relative expression (p=0.012) of the miRNA-199a- 5p was found to be significantly higher in patients compared to controls. The fold change (p=0.001), and relative expression (p < 0.001) were also associated with the Pfirrmann grading. We found that the area under curve (AUC) was 0.880 (95%CI: 0.721- 0.938) indicative of moderate accuracy.

CONCLUSION

Expression of the miRNA-199a-5p is increased in the IDD. The expression of the miRNA-199a-5p was also associated with the grade of the degeneration based on the Pfirrmann grading.

Contribution of Lysosome and Sigma Receptors to Neuroprotective Effects of Memantine Against Beta-Amyloid in the SH-SY5Y Cells

Purpose: Memantine is an approved drug for the treatment of Alzheimer’s disease (AD). Autophagy, lysosome dysfunction, and sigma receptors have possible roles in the pathophysiology of AD. Therefore, we aimed to investigate the contribution of sigma receptors and lysosome inhibition to the neuroprotective effects of memantine against amyloid-beta (Aβ)-induced neurotoxicity in SH-SY5Y cells.

Methods: We determined the neuroprotective effects of memantine (2.5 µM), dizocilpine (MK801, as a selective N-methyl-D-aspartate (NMDA) receptor antagonist) (5 μM) against Aβ25– 35 (2 μg/μL)-induced neurotoxicity. We used chloroquine (10, 20, and 40 μM) as a lysosome inhibitor and BD-1063 (1, 10, and 30 μM) as a selective sigma receptor antagonist. The MTT assay was used to measure the neurotoxicity in the SH-SY5Y cells. Data were analyzed using the one-way ANOVA.

Results: Memantine (2.5 µM), dizocilpine (5 µM), chloroquine (10 and 20 µM) and BD-1063 (1, 10 and 30 µM) decreased the neurotoxic effects of Aβ on the SH-SY5Y cells. However, chloroquine (40 µM) increased the neurotoxic effects of Aβ. Cell viability in the cells treated with memantine + Aβ + chloroquine (10, 20, and 40 μM) was significantly lower than the memantine + Aβ-treated group. Moreover, cell viability in the memantine + Aβ group was higher than the memantine + Aβ + BD-1063 (10 and 30 μM) groups.

Conclusion: The lysosomal and sigma receptors may contribute to the neuroprotective mechanism of memantine and other NMDA receptor antagonists. Moreover, the restoration of lysosomes function and the modulation of sigma receptors are potential targets in the treatment of AD.

Spinal brucellosis with large circumscribed paraspinal and epidural abscess formation: a case report

Human Brucellosis is a bacterial infection caused by species of Brucella, which can involve multiple organs and tissues. Spinal epidural abscesses are rare and may be complicated by potentially life threatening neurological or vascular compromise. We report a 21-year-old female with spinal brucellosis complicated by lumbar spondylodiscitis, epidural abscess and a large right-sided paraspinal abscess extended from L4 to sacrum. The diagnosis was based on laboratory and magnetic resonance imaging results, symptoms and her occupation. Ultrasound guided needle aspiration and percutaneous abscess drainage was performed, followed by 8 weeks of combination antibiotic therapy. Our therapeutic strategy in this rare case can cause us to reach a greater clearance rate of the infection.

Clinical Outcomes of Posterolateral Fusion Versus Posterior Lumbar Interbody Fusion in Patients with Lumbar Spinal Stenosis and Degenerative Instability

Background: Degenerative lumbar spine disease can lead to lumbar spine instability. Lumbar spine instability is defined as an abnormal response to applied loads characterized kinematically by abnormal movement in the motion segment beyond normal constraints. Patients with lumbar spinal stenosis (LSS) typically present with low back pain (LBP), cramping, cauda equine syndrome, and signs of nerve root compression associated by weakness, numbness and tingling in their legs that are worsened with standing and walking. This degenerative condition severely restricts function, walking ability, and quality of life (QOL). Objectives: This study aims to compare clinical and radiological outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation in the treatment of LSS and degenerative instability. Study Design: A randomized, prospective, controlled clinical study. Methods: In this prospective study, 88 patients with LSS and degenerative instability were randomly allocated to one of 2 groups: PLF (Group I) or PLIF (Group II). Primary outcomes were the control of LBP and radicular pain, evaluated with visual analog scale (VAS), the improvement of QOL assessed by the Oswestry disability index (ODI) scale, and measurement of fusion rate, Cobb angle, spinal sagittal balance, and modic changes in the 2 groups. Results: At 24 months postoperatively, the mean reduction in VAS scores in Group I was more than in Group II (5.67 vs. 5.48, respectively) and the patients in Group I had more improvement in the ODI score than the patients in Group II (42.75 vs. 40.94, respectively). There was a statistically significant difference between the preoperative and postoperative sagittal balance in the 2 groups. The mean Cobb angle changed significantly in the 2 groups. Limitations: There are few prospective studies of PLIF or PLF in patients with LSS and degenerative lumbar spine instability, and a limited number of studies which exists have examined the safety and outcome of each procedure without comparing it with other fusion techniques. Because most of the studies in the literature have been conducted in the patients with IS, we could not compare and contrast our findings with studies in patients with LSS and degenerative lumbar spine instability. In addition, although in our study the findings at a 24-month follow-up period showed that PLF was better than PLIF in these patients, there were some studies in which the authors reported that PLIF showed better clinical results than PLF at a 48-month followup period. So we suggest that rigorous controlled trials at longer follow-up periods should be undertaken in groups of patients with LSS and degenerative lumbar spine instability who undergo posterior decompression and instrumented fusion to help to determine the ultimate best fusion technique for these patients. Conclusion: PLF with posterior instrumentation provides better clinical outcomes and improvement in the LBP, radicular pain, and functional QOL, more correction of the Cobb angle, more restoration of sagittal alignment, more decrease in Modic type 1, and more increase in Modic type 0, despite the low fusion rate compared to PLIF. Key words: Lumbar spinal stenosis, degenerative instability, posterolateral fusion, posterior lumbar interbody fusion, low back pain, quality of life, cobb angle, fusion rate, mobic changes, sagittal balance

Clinical Outcomes of Posterolateral Fusion vs. Posterior Lumbar Interbody Fusion in Patients with Lumbar Spinal Stenosis and Degenerative Instability

BACKGROUND

Degenerative lumbar spine disease can lead to lumbar spine instability. Lumbar spine instability is defined as an abnormal response to applied loads characterized kinematically by abnormal movement in the motion segment beyond normal constraints. Patients with lumbar spinal stenosis (LSS) typically present with low back pain (LBP), cramping, cauda equine syndrome, and signs of nerve root compression associated by weakness, numbness and tingling in their legs that are worsened with standing and walking. This degenerative condition severely restricts function, walking ability, and quality of life (QOL).

OBJECTIVES

This study aims to compare clinical and radiological outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation in the treatment of LSS and degenerative instability.

STUDY DESIGN

A randomized prospective controlled clinical study.

METHODS

In this prospective study, 88 patients with LSS and degenerative instability were randomly allocated to one of 2 groups: PLF (Group I) or PLIF (Group II). Primary outcomes were the control of LBP and radicular pain, evaluated with visual analog scale (VAS), the improvement of QOL assessed by the Oswestry disability index (ODI) scale, and measurement of fusion rate, Cobb angle, spinal sagittal balance, and modic changes in the 2 groups.

RESULTS

At 24 months postoperatively, the mean reduction in VAS scores in Group I was more than in Group II (5.67 vs. 5.48, respectively) and the patients in Group I had more improvement in the ODI score than the patients in Group II (42.75 vs. 40.94, respectively). There was a statistically significant difference between the preoperative and postoperative sagittal balance in the 2 groups. The mean Cobb angle changed significantly in the 2 groups.

LIMITATIONS

There are few prospective studies of PLIF or PLF in patients with LSS and degenerative lumbar spine instability, and a limited number of studies which exists have examined the safety and outcome of each procedure without comparing it with other fusion techniques. Because most of the studies in the literature have been conducted in the patients with IS, we could not compare and contrast our findings with studies in patients with LSS and degenerative lumbar spine instability. In addition, although in our study the findings at a 24-month follow-up period showed that PLF was better than PLIF in these patients, there were some studies in which the authors reported that PLIF showed better clinical results than PLF at a 48-month follow-up period. So we suggest that rigorous controlled trials at longer follow-up periods should be undertaken in groups of patients with LSS and degenerative lumbar spine instability who undergo posterior decompression and instrumented fusion to help to determine the ultimate best fusion technique for these patients.

CONCLUSION

PLF with posterior instrumentation provides better clinical outcomes and improvement in the LBP, radicular pain, and functional QOL, more correction of the Cobb angle, more restoration of sagittal alignment, more decrease in Modic type 1, and more increase in Modic type 0, despite the low fusion rate compared to PLIF.

KEY WORDS

Lumbar spinal stenosis, degenerative instability, posterolateral fusion, posterior lumbar interbody fusion, low back pain, quality of life, cobb angle, fusion rate, modic changes, sagittal balance.

Unilateral lag screw fixation of isolated non-union atlas lateral mass fracture: a new technical note

We describe a novel and new technique of posterior unilateral lag screw fixation of non-union atlas lateral mass fracture. A 46-year-old man presented with cervical pain and tenderness after a vehicle turn over accident and he was diagnosed to have left atlas lateral mass fracture. He was initially treated by immobilization using Minerva orthosis. About 2 months later, he developed severe neck pain and limitation of motion and thus he was scheduled for operation due to non-union atlas lateral mass fracture. A 28 mm lag screw was inserted under anterior-posterior and lateral fluoroscopic views. The entrance point was at the dorsal aspect of left atlas posterior arc at its junction to the lateral mass, and by using the trajectory of 10 degrees medial and 22 degrees cephalad fracture reduction was achieved. Unilateral lag screw fixation of atlas fractures is an appropriate, safe and effective surgical technique for the management of unilateral atlas fractures.

Caffeine Neuroprotective Mechanism Against β-Amyloid Neurotoxicity in SHSY5Y Cell Line: Involvement of Adenosine, Ryanodine, and N-Methyl-D-Aspartate Receptors

Purpose: Some reports have shown neuroprotective effects of caffeine in several neurodegenerative disorders. However, its mechanism of action is not completely clear. Therefore, the aim of this study was to explore the interference of ryanodine, N-methyl-D-aspartate (NMDA) and adenosine modulators with the neuroprotective effects of caffeine against β-amyloid (Aβ) neurotoxicity in the SHSY5Y cells.

Methods: The SHSY5Y cells were treated with Aβ23-35 (20µM) and/or caffeine (0.6 and 1mM), or both for 24 hours. Adenosine (20, 40, 60, 80, 100µM), NMDA (20, 50, 70, 90µM), dantrolene (2, 4, 6, 8, 10µM) were also added to the medium and incubated for 24 hours. The cell viability was measured via the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide) method. The data were analyzed using one-way ANOVA followed by Bonferroni test.

Results: Caffeine at all the used concentrations (0.6, 0.8, 0.9, 1, and 3mM) significantly protected neuronal cells against Aβ neurotoxicity. Adenosine at the concentrations of 20, 40, 80 and 100μM diminished the neuroprotective effects of caffeine (0.6 and 1mM) against Aβ neurotoxicity. NMDA at the concentrations of 20, 50, 70 and 90μM blocked caffeine (0.6 and 1mM) neuroprotective effects. Dantrolene at the concentration of 2, 4, 6, 8 and 10μM diminished the neuroprotective effects of caffeine (0.6mM) and at the concentrations of 2 and 10μM impede caffeine (1mM) neuroprotection against Aβ neurotoxicity.

Conclusion: Caffeine produced neuroprotective effect against Aβ neurotoxicity. Blockade of adenosine and NMDA receptors, as well as the activation of ryanodine receptors, may contribute to the neuroprotective effects of caffeine.

Clinical and radiological outcomes after decompression and posterior fusion in patients with degenerative scoliosis

OBJECTIVE

The prevalence of degenerative scoliosis (DS) increases with age and an overall increase is seen due to the aging population. This study aims to evaluate the clinical and radiological outcomes after decompression and posterior fusion in patients with DS.

METHODS

In this is prospective study, 43 patients with DS, aged 37 to 70 years, were eligible to undergo decompression and posterior fusion. Primary outcomes were low back pain (LBP) with or without radicular pain, which was evaluated preoperatively and at 12 and 24 months after surgery with the use of a visual analog scale (VAS), and the quality of life (QOL), which was assessed at the same time periods by the Oswestry Disability Index (ODI) questionnaire. The Cobb's method was used to measure the degree of scoliosis in each patient preoperatively and at 24 hours, 12 and 24 months after the surgery.

RESULTS

VAS scores improved significantly from a mean of 8.18 preoperatively to 4.48 at 12 months and 3.07 at 24 months postoperatively (P < .001). The mean radicular pain scores also decreased significantly (P < .001). At postoperative 12 months, the mean ODI score was significantly lower than the mean preoperative ODI score (47.81 ± 16.06 vs. 72.18 ± 12.28; P = .001). ODI score at 24 months postoperatively was significantly better than the preoperative ODI (15.53 ± 7.21 vs. 72.18 ± 12.28; P = .016). The mean Cobb angle changed significantly from 31.4° ± 4.88 preoperatively to 3.28° ± 2.10 at 24 months postoperatively (P < .001).

CONCLUSIONS

Our findings suggest that decompression and posterior fusion in the patients with DS is an effective surgical method which is associated with satisfying clinical results in terms of improvement of postoperative LBP, radicular pain, and QOL, and correction of Cobb angle at 12 and 24 months after the surgery and restoration of sagittal alignment at 2 months postoperatively.

Effects of methylene blue on postoperative low-back pain and functional outcomes after lumbar open discectomy: a triple-blind, randomized placebo-controlled trial

OBJECT

Despite advances in surgical and anesthesiology techniques, many patients continue to experience postoperative pain after lumbar disc operations. This study aims to investigate the effects of methylene blue (MB) on preventing postoperative low-back pain (LBP) with or without radicular pain and improving the quality of life (QOL) in patients undergoing lumbar open discectomy.

METHODS

This is a prospective, randomized, triple-blind, placebo-controlled clinical trial, which was conducted at Shiraz University of Medical Sciences between July 2011 to January 2012. Of a total of 130 patients, 115 were eligible for participation; 56 received 1 ml of MB solution at a concentration of 0.5% (MB group) and 59 received an equivalent volume of normal saline (control group). Primary outcomes were the control of LBP with or without radicular pain, which was evaluated preoperatively and at 24 hours and 3 months after surgery with the use of a visual analog scale (VAS), and the improvement of QOL, which was assessed preoperatively and 3 months postoperatively by means of the Persian translation of the Oswestry Disability Index questionnaire.

RESULTS

The mean VAS scores for LBP were significantly lower in the MB group compared with the control group at 24 hours (1.25 ± 0.97 vs 2.80 ± 0.69, p < 0.001) and 3 months (1.02 ± 1.29 vs 2.07 ± 1.10, p = 0.019) after treatment. The mean radicular pain scores decreased significantly in the 2 groups at 24 hours after surgery, but the mean radicular pain score was significantly lower in the MB-treated patients than the control group. However, the difference between radicular pain scores in the MB group (1 ± 1.1) and the control group (1.2 ± 1) was not statistically significant (p = 0.64). The reduction in LBP was greater in the MB group than the control group (8.11 ± 1.74 vs 6.07 ± 1.52, p = 0.023, CI 95% −1.37 to −0.10). The functional QOL improved significantly 3 months after the operation in both groups (p < 0.001). Moderate disability occurred more frequently in the control group than in the MB group (14.5% vs 7.7%, p = 0.004). No toxicity, adverse effects, or complications were found in the group of patients treated with MB injection.

CONCLUSIONS

A single dose of MB (1 ml 0.5%) for coating the dura and surrounding tissues (facet and muscle) shows promising results in terms of safety, reduction of postoperative pain, and functional outcome compared with placebo.

Effects of Human Erythropoietin on Functional Outcome of Patients with Traumatic Cervical Cord Injury; A Pilot Randomized Clinical Trial

OBJECTIVE

To determine the effects of recombinant human erythropoietin (rhEPO) on functional outcome and disability of patients with traumatic cervical spinal cord injury (SCI).

METHODS

This was a randomized, double blind, placebo controlled clinical trial being performed in Nemazee and Shahid Rajaei hospitals of Shiraz during a 3-year period from 2011 to 2014. A total number of 20 patients with acute traumatic cervical SCI less than 8 hours after injury were included. We excluded those with anatomic cord dissection, penetrating cord injury and significant concomitant injury. Patients were randomly assigned to receive rhEPO in 500IU/mL dosage immediately and 24-hour later (n=11) or placebo (n=9). All the patient received standard regimen of methylprednisolone. Neurological function was assessed on admission, 1, 6 and 12 months after the injury according to the American Spinal Cord Injury Association (ASIA).

RESULTS

Overall we include a total number of 20 patients. The mean age of the patients was found to be 40.1±9.5 (ranging from 19 to 59) years. There were 18 (90.0%) men and 2 (10.0%) women among the patients. There was no significant difference between two study groups regarding the baseline characteristics. The baseline ASIA score was comparable between two study groups. The motor and sensory ASIA scores were comparable between two study groups after 1, 6 and 12 months follow-ups. We also found that there was no significant difference between two study groups regarding the motor and sensory outcome in complete cord injury and incomplete cord injury subgroups.

CONCLUSION

Administration of rhEPO does not improve the functional outcome of patients with traumatic cervical SCI.

Resection of large sacral tumors: a report of 4 cases

Tumors of the sacrum and related neurological and pelvic structures are rare pathologic conditions.

Sacral tumors are a diagnostic challenge because patients often present with nonspecific complaints such as low back pain, sacrococcygeal joint pain, referred lag and buttock pain. Because of diagnostic and radiographic challenges, the detection of sacral mass can be delayed which complicates any prospect surgical intervention as tumors can be quite large at the time of treatment. Furthermore, the complex local anatomy of the sacrum and presence of numerous other structures make the resection procedure even more sophisticated and necessitate adoption of a multidisciplinary approach towards the treatment. The present study discuses the diagnosis, treatment and complication of 4 cases with large sacral mass.

Evaluation of operation outcomes in patients with degenerative lumbar scoliosis

Background:

Due to the increase of life expectancy, the prevalence of degenerative spine diseases such as adult degenerative lumbar scoliosis (ADLS) has been increasingly more than before which is required appropriate control and management. Therefore, the present study was aimed to survey the result of surgery in ADLS patients in Shiraz (Iran).

Methods:

This is a preliminary report of 30 patients with ADLS who underwent pedicular screw fixation, posterolateral fusion, posterior decompression and correction of coronal plane deformity operation according to surgical indications in the Chamran and Kowsar hospitals during 2009-2011. The patients were followed up at 1, 6 and 12 months post operation. Radiologic changes were evaluated and the Oswestry low back pain disability (OLBP) scale and visual analogue scale (VAS) were used to evaluate functional and pain improvement, respectively. Data were analyzed using SPSS software version 15. We used Wilcoxon signed-rank test to compare the parameters of pain and LBP scale.

Results:

Primary analysis showed that 42.9% of operated patients were in 50-60 years age group. 71% of the patients were female and 29% were male. Prevalence of LBP from radicular pain among the patients was 95.2%. There was a significant difference between pre-operation and post-operation VAS and Oswestry LBP scale (P less than 0.001).

Conclusions:

Our findings showed that posterior decompression combined with pedicular fixation, posterolateral fusion and correction of coronal plane deformity seems to be a suitable method for the relief of pain and improvement of function in ADLS patients. Only decompression can relieve low back pain but for the relief of radicular pain and correction of deformity, fixation and fusion are recommended.

Keywords:

Scoliosis, Degenerative, Low back pain, Adult lumbar, Radicular pain

Randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures

OBJECT

Osteoporotic vertebral compression fractures (VCFs) are a major cause of increased morbidity in older patients. This randomized controlled trial compared the efficacy of percutaneous vertebroplasty (PV) versus optimal medical therapy (OMT) in controlling pain and improving the quality of life (QOL) in patients with VCFs. Efficacy was measured as the incidence of new vertebral fractures after PV, restoration of vertebral body height (VBH), and correction of deformity.

METHODS

Of 105 patients with acute osteoporotic VCFs, 82 were eligible for participation: 40 patients underwent PV and 42 received OMT. Primary outcomes were control of pain and improvement in QOL before treatment, and these were measured at 1 week and at 2, 6, 12, 24, and 36 months after the beginning of the treatment. Radiological evaluation to measure VBH and sagittal index was performed before and after treatment in both groups and after 36 months of follow-up.

RESULTS

The authors found a statistically significant improvement in pain in the PV group compared with the OMT group at 1 week (difference -3.1, 95% CI -3.72 to -2.28; p < 0.001). The QOL improved significantly in the PV group (difference -14, 95% CI -15 to -12.82; p < 0.028). One week after PV, the average VBH restoration was 8 mm and the correction of deformity was 8°. The incidence of new fractures in the OMT group (13.3%) was higher than in the PV group (2.2%; p < 0.01).

CONCLUSIONS

The PV group had statistically significant improvements in visual analog scale and QOL scores maintained over 24 months, improved VBH maintained over 36 months, and fewer adjacent-level fractures compared with the OMT group.

The effect of methylene blue on peridural fibrosis formation after laminectomy in rats: an experimental novel study

BACKGROUND CONTEXT

Despite progress in surgical techniques, some patients still face postoperative recurrence of pain, although the rate of successful outcomes is estimated to be approximately 70% and 86% after primary decompression spinal surgery. Recently, attention has been focused on peridural fibrosis (PF), which may be responsible for recurrent pain after laminectomy or discectomy. Methylene blue (MB) has been shown to prevent fibrosis formation in various tissues.

PURPOSE

The aims of this study were to investigate the effects of MB and assess the effects of different doses on the prevention of postlaminectomy fibrosis formation in a rat model. This preclinical model is a potential platform for future clinical trials to identify an effective agent for the prevention of clinically important epidural scar formation.

STUDY DESIGN

An established bilateral L5-L6 rat laminectomy model was used to evaluate postlaminectomy PF with macroscopic and microscopic analyses.

PATIENT SAMPLE

Seventy-five male adult white Sprague-Dawley rats that underwent laminectomy at the L5-L6 levels were divided into five groups of 15 rats each.

OUTCOME MEASURES

Dissected specimens were evaluated macroscopically and microscopically by examiners who were unaware of the group assignment to record the presence or absence of PF formation.

METHODS

Groups A and B served as controls and Groups C, D, and E received treatment. Group A (sham) underwent laminectomy, and Group B was treated with normal saline at the laminectomy site. Rats in Groups C, D, and E received 0.1 mL MB at concentrations of 0.5%, 1%, and 2%, respectively, at the laminectomy site. All rats were killed 4 weeks after laminectomy. The results were compared statistically with the nonparametric Kruskal-Wallis test and Poisson regression.

RESULTS

Peridural fibrosis was found in five rats (33%) in control Groups A and B and in two rats (10%) in MB-treated laminectomy Groups C and D. The difference between control and MB groups was not statistically significant (p = .27). The preventive effect of MB on PF was not seen at the highest dose of MB (2%) in Group E. Severity of fibrosis was lower in Groups C (MB 0.5%) and D (MB 1%) than in Group E (MB 2%) (p < .01). Wound healing was not affected, and there was no cerebrospinal fluid leakage. No neurological deficits were seen.

CONCLUSION

Low doses of MB may be an effective agent in preventing PF formation after lumbar laminectomy in rats. Clinical significance and safety in human use are currently undetermined.

Slipped vertebral epiphysis (report of 2 cases)

Avulsion or fracture of posterior ring apophysis of lumbar vertebra is an uncommon cause of radicular low back pain in pediatric age group, adolescents and athletes. This lesion is one of differential diagnosis of disc herniation. We reported two teenage boys with sever low back pain and sciatica during soccer play that ultimately treated with diagnosis of slipped vertebral apophysis.