Correlation of matrix metalloproteinase (MMP)-1, -2, -3, and -9 expressions with demographic and radiological features in primary lumbar intervertebral disc disease

Degeneration of IVD is a progressive and irreversible process and can be evaluated with immunohistochemical examination or radiological grading. MMPs are a family of proteolytic enzymes and involved in the degradation of the matrix components of the IVD. We aimed to compare MMP-1, -2, -3, and -9 expressions with demographic features, visual analogue scale (VAS), Oswestry Disability Index (ODI) and radiological (MRI) grades. The study involved 60 participants. We recorded data about age, complaint, radiological imaging, expression levels of MMP-1, -2, -3, and -9, ODI and VAS for back pain retrospectively. Intervertebral disc degeneration was graded on a 0-5 scale according to the Pfirrmann classification. As a result of the study, the median age was 52.09±12.74years. There were statistical significances between age and MMP-1, and MMP-2. There was a close correlation between grade and MMP-9. We found correlation between the VAS and the MMP-9 expression. In addition, there was relationship between expression of MMP-2 and MMP-1, MMP-3, MMP-9. In conclusion, the expressions of MMP-1 and -2 are increased with aging. There was no relationship between radiological evaluation of IVDD and aging. Increased expression of MMPs affected IVDD positively. The relationship with MMPs is not explained. This study adds to our understanding of the interaction between MMPs and IVDD.

The relation of matrix metalloproteinase 1, 2, 3 expressions with clinical and radiological findings in primary and recurrent lumbar disc herniations

AIM

In this study, our aim was to examine if matrix metalloproteinase expressions (MMP-1, MMP-2, MMP-3) in patients operated with a lumbar disc hernia diagnosis are different in terms of clinical and neuroradiological findings.

MATERIAL AND METHODS

The study included 80 patients treated with micro discectomy for lumbar disc hernia. Degeneration was scored via magnetic resonance (MR) images. MMP-1, MMP-2, and MMP-3 antibodies were used for immunohistochemical evaluation of degenerated disc materials. MMP expressions were compared between primary and recurrent cases, and correlation analysis was conducted.

RESULTS

Discectomy material showed higher expression of MMP-1 and MMP-3 in cases of recurrent lumbar disc herniation than in primary herniation. There was no significant relationship between MMP expression and MR degeneration score.

CONCLUSION

MMP-1 and MMP-3 expressions were significantly higher in recurrent cases in terms of magnetic resonance degeneration score. We assume that the higher co-expression of MMP-1 and MMP-3 might be used in targeted treatment regiemens in patients with recurrent LDH.

Does Glp-2 have a protective effect on cerebral ischemia/reperfusion model?

BACKGROUND/AIM

To investigate the neuroprotective effects of glucagon-like peptide 2 (Glp-2), which increases cerebral blood flow, on the hippocampal complex after cerebral ischemia/reperfusion (I/R) injury in rats.

MATERIALS AND METHODS

Animals were randomized into 4 groups: sham, I/R + 0.9% NaCl, I/R + pre-Glp-2, and I/R + post-Glp-2. Cerebral ischemia was performed via the occlusion of the bilateral internal carotid artery for 40 min and continued with a reperfusion process. At the end of 6 h of reperfusion, animals were decapitated in all groups and brain tissues were removed. Malondialdehyde (MDA) and natural intracellular antioxidant glutathione (GSH) levels and myeloperoxidase (MPO) activities were measured in the left hippocampal tissue. The right hippocampal tissues of all group members were taken for histopathologic study.

RESULTS

MDA levels and MPO activities increased from Group I to Group II and decreased from Group II to Groups III and IV. On the other hand, GSH levels were not significantly different among the groups. The number of apoptotic hippocampal tissue cells increased from Group I to Group II and decreased from Group II to Groups III and IV.

CONCLUSION

Our preliminary study revealed that Glp-2 treatment may decrease oxidative damage from I/R in cerebral tissue.

The effect of bone morphogenetic protein-2 injection at different time points on intervertebral disk degeneration in a rat tail model

STUDY DESIGN

Prospective in vivo rat tail model of disk degeneration comparing the effects of recombinant human bone morphogenetic protein-2 (rhBMP-2) injection over various time points and grades of degeneration.

OBJECTIVE

To evaluate the effect of timing and disk grade on rhBMP-2 injection in a rat tail model of disk degeneration.

SUMMARY OF BACKGROUND DATA

rhBMP-2 stimulates the proliferation of intervertebral disk cells and the secretion of extracellular matrix. However, few in vivo studies have demonstrated whether rhBMP-2 also improves disk degeneration and the severity of disk degeneration beyond which disks cannot be recovered by rhBMP-2 treatment.

METHODS

Two coccygeal disks of each rodent subject were punctured percutaneously using an 18 G needle. At 4 weeks after the puncture, disks demonstrating induced degeneration were divided into 3 groups. Groups 1, 2, and 3 were treated with 7.5 μg rhBMP-2 or phosphate buffered saline by injection into the disk at 4, 6, and 8 weeks postpuncture, respectively. Plain radiographs and magnetic resonance images (MRIs) were obtained on the day of puncture and every 2 weeks thereafter until sacrifice. At 6 weeks after injection, each group was killed and examined with histologic and immunohistochemical analysis.

RESULTS

According to MRI disk grade evaluation of the degenerative disk, rhBMP-2 significantly improved degeneration grade in group 1 at 2 weeks after injection. According to radiographic disk height index, groups 1 and 2 showed a trend toward improvement at 2 weeks after rhBMP-2 injection. Chondrogenic differentiation was noted on immunohistochemical staining of many disks treated with rhBMP-2.

CONCLUSIONS

rhBMP-2 injection of degenerated disks at 4 weeks postpuncture induced a transient improvement in disk grade on MRI and stimulated chondrogenic differentiation. These data suggest rhBMP-2 as a potential therapy for degenerative disk disease.

Comparison of disc and body volumes in degenerated and nondegenerated lumbar discs: a stereological study

AIM

To carry out comparison and correlation analyses of the intervertebral disc (IVD) and vertebral body (VB) volumes in magnetic resonance (MR) images of patients with degenerated and nondegenerated lumbar discs.

MATERIALS AND METHODS

MR images were examined retrospectively in 93 patients. Lumbar VB and IVD volumes in T1-T2 weighted sagittal MR images were calculated via the Cavalieri method, a stereological method. Volumetric changes in degenerated and nondegenerated discs were compared.

RESULTS

The percentages of degenerated IVDs were 12.9%, 12.9%, 28%, 50.5%, and 52% in discs from levels L1 to L5, respectively. There were no differences in VB volumes between the degenerated and nondegenerated groups for all lumbar vertebra levels. However, significant volumetric decreases were observed in degenerated IVDs for all lumbar vertebra levels, as compared to nondegenerated IVDs. Comparisons of VB volume and IVD volume ratios also revealed decreases, but they were significant only for levels L1 and L4.

CONCLUSION

Disc volumes were found to be decreased, although vertebral bodies were not affected in degenerated IVD groups. However, using VB and IVD volume ratios may not always yield reliable results.

The role of a single nucleotide polymorphism of the matrix metalloproteinase-1 gene promoter region in invasion and prognosis of meningiomas

AIM

The matrix metalloproteinase (MMP) enzyme family has been shown to be active in tumorigenesis and tumor progression. In this study, we analyzed the prevalence of a guanine insertion in the MMP-1 gene promoter region in meningiomas and its effect on invasion and prognosis.

MATERIAL AND METHODS

The study was performed with 33 meningioma patients. We also included 33 healthy patients in the study as a control group. The promoter area was amplified by polymerase chain reaction (PCR) following DNA isolation. The polymorphism was detected by restriction fragment length polymorphism (RFLP).

RESULTS

According to the WHO classification of meningiomas, 87.9% of the affected patients were grade 1, and 12.1% were grade 2. In total, 72.7% of the meningioma patients (n=24) had at least one copy of the insertion (2G/1G or 2G/2G genotypes) and 27.3% (n=9) did not (1G/1G). There was no significant difference between the meningioma and control groups according to genotype distribution.

CONCLUSION

In this study, the polymorphism in the matrix metalloproteinase-1 gene promoter region did not have an effect on the initiation, growth and progression of meningioma.

Load sharing in lumbar spinal segment as a function of location of center of rotation

Object

The center (axis) of rotation (COR) in the lumbar spine has been studied well. However, there is limited information on the kinetic and kinematic consequences of imposed shift in the location of the COR, although this type of shift can be seen after surgeries using motion preservation or dynamic stabilization devices. The objective of this study was to assess the kinetic and kinematic changes in the lumbar spinal segment due to various imposed CORs.

Methods

A 3D finite element model of the L4–5 segment was constructed and validated. The segment was loaded under a 7.5-Nm bending moment while constrained to rotate about various imposed CORs in the sagittal and axial motion planes. Range of motion, ligament forces, facet loads, and disc stresses were measured.

Results

The present model showed an agreement with previous in vitro and finite element studies under the same load and boundary conditions. Range of motion, facet forces, disc stresses, and ligament loads showed a strong association with the location of the COR.

Conclusions

Acute alterations in the location of the COR can significantly change the load sharing characteristics within the spine segment. The normal location of the COR is a result of the tendency of the vertebra to move in the path of least cumulative resistance.

Instantaneous center of rotation behavior of the lumbar spine with ligament failure

Object

The goal of this study was to investigate the effect of ligament failure on the instantaneous center of rotation (ICR) in the lower lumbar spine.

Methods

A 3D finite element model of the L4–5 segment was obtained and validated. Ligament failure was simulated by reducing ligaments in a stepwise manner from posterior to anterior. A pure bending moment of 7.5 Nm was applied to the model in 3 anatomical planes for the purpose of validation, and a 6-Nm moment was applied to analyze the effect of ligament failure. For each loading case, ligament reduction step, and load increment, the range of motion of the segment and the ICR of the mobile (L-4) vertebra were calculated and characterized.

Results

The present model showed a consistent increase in the range of motion as the ligaments were removed, which was in agreement with the literature reporting the kinematics of the L4–5 segment. The shift in the location of the ICR was below 5 mm in the sagittal plane and 3 mm in both the axial and coronal planes.

Conclusions

The location of the ICR changed in all planes of motion with the simulation of multiple ligament injury. The removal of the ligaments also changed the load sharing within the motion segment. The change in the center of rotation of the spine together with the change in the range of motion could have a diagnostic value, revealing more detailed information on the type of injury, the state of the ligaments, and load transfer and sharing characteristics of the segment.

Intracranial metallic foreign bodies in a man with a headache

We report the case of a 22-year old man with intracranial metallic foreign bodies who presented complaining of a headache. His history of headaches had begun when he was five years old and continued with increasing severity. Six months before hospital admission, nausea and vomiting began to accompany his headache. Computed tomography scan revealed that 2 metallic foreign bodies were located adjacent to the vertex and another was next to the ambient cistern. The location and position of foreign bodies suggested that they were introduced in infancy through the anterior fontanelle before its closure in an unsuccessful homicide attempt. This case is one of the few reported cases combining headache and intracranial foreign bodies and we discuss the relationship between headache and these metallic materials.

Unilateral surgical approach for lumbar disc herniation with contralateral symptoms

Object

In most cases of lumbar disc herniation, the primary problem is usually limited to radicular pain due to nerve compression on the herniated side, which is generally limited to the side of operation. The aim of this study was to reevaluate the side of the surgical approach in a selected group of patients with leg pain and contralateral lumbar disc herniation.

Methods

Included in this study were a total of 5 patients with lumbar disc herniations who presented with contralateral symptoms and neurological signs. In all cases, patients underwent a microdiscectomy from the side ipsilateral to the herniated lumbar disc, the side contralateral to the motor deficits and leg pain.

Results

The symptoms and signs, to some extent, resolved during the immediate postoperative period. There were no postoperative complications.

Conclusions

The findings confirm that performing a laminotomy via the side of the herniation is sufficient for this group of patients.

Unusual cause of acute low-back pain: sudden annulus fibrosus rupture

Low-back pain is a common problem in neu-rosurgery practice, and an algorithm has been developed for assessing these cases. However, one subgroup of these patients shares several clinical features and these individuals are not easy to categorize and diagnose. We present our observations for 8 of these patients, individuals with low-back pain caused by atypical annulus fibrosus rupture (AAR). The aim of this study is to show the consequences of overlooked annular tears on acute onset of low back pain. Eight patients with acute-onset severe low-back pain were admitted. Physical examinations were normal and each individual was examined neurologically and assessed with neuroradiologic studies [plain x-rays, magnetic resonance imaging (MRI), discography and computed tomography (CT) discography]. AAR was ultimately diagnosed with provocative discography. In all cases, MRI showed a healthy disc or mild degeneration, whereas discography and CT discography demonstrated disc disease. Anterior interbody cage implantation was performed in 3 of the 8 cases and posterior dynamic stabilization was carried out in 3 cases. The other 2 individuals refused surgery, and we were informed that one of them developed disc herniation at the affected level 1 year after our diagnosis. Clinical and radiological outcomes were evaluated. In cases where AAR is suspected, MRI, discography, and CT discography should be performed in addition to routine neuroradiologic studies.

Resection of a large spinal intradural ependymoma using a limited unilateral laminectomy approach in the lumbosacral region

Ependymomas are the most common gliomas of the lower spinal cord, conus medullaris and filum terminale. Although there are several surgical modalities indicated in the removal of spinal tumors, total laminectomy is the conventional method used. However, surgical complications, such as spinal deformities and instability are more common with this approach compared to limited unilateral hemilaminectomy. To present the clinical and radiologic results of patient with a large spinal intradural ependymoma via a limited posterior unilateral laminectomy approach in the lumbosacral region. The aim of this study was to present a modified duramater incisions and surgical positions setup, and discussed the major controversies in treatment in the literature. This article reports the surgical resection of a lumbosacrally localized ependymoma in a 25-year-old male patient using unilateral laminectomy at the L4 to S3 levels. The tumor was removed with any difficulty in reaching to contralateral side. A follow-up lumbar magnetic resonance imaging scan with and without contrast performed 18 months postoperatively showed no residual or recurrent tumor lesions. This procedure may be more difficult than the conventional total laminectomy as suturing of the duramater. However, modified duramater incisions and setup of microscope-operating table provides best facilitates to surgery manipulation. Besides, unilateral limited laminectomy protected the posterior supporting elements. In order to reduce the postoperative complications and minimize the destruction of tissue, unilateral limited hemilaminectomy is recommended for the removal of intradural tumors. This technique facilitates the return of the patient to ordinary life.

L5 vertebrectomy for the surgical treatment of tumoral and traumatic lesions of L5 vertebra

We retrospectively reviewed the clinical characteristics and the surgical results of seven patients treated with L5 vertebrectomy. The pathologies, clinical characteristics, preoperative and postoperative radiological findings, surgical techniques, and instrumentation for seven patients operated on between 1998 and 2009 are presented in this article. Biopsies were performed on all patients except those involving trauma. Patients were followed up at three-month intervals in the first year, at 6-month intervals in the second year, and on a regular basis afterward. One patient had a traumatic L5 burst fracture; the other six had tumoral pathologies in the L5 vertebrae. One tumoral lesion was a chordoma, another was a hemangioma, and the remaining four were metastatic lesions. Radiotherapy and chemotherapy were performed for the metastatic tumor patients during the postoperative period. Patients with renal cancer and chordoma survived for 3 years; patients with lung cancer and bladder cancer survived for 1 year; and patients with breast cancer survived for 16 months. The lumbosacral region presents significant stabilization problems because of the presence of sacral slope. In our opinion, if the lesion involves only the L5 vertebra, anterior cage-filled bone cement or bone graft should be performed, as dictated by the pathology and posterior transpedicular instrumentation. If the lesion involves the L4 vertebra or the sacrum and the L5 vertebra, the instrumentation can be extended to cover other segments with sacral attachments. The present cases involved only L5 vertebra and treatment with short-segment stabilization covering the anterior and posterior columns.

Thoracoscopic surgery for thoracic disc herniation

Technical improvements in endoscopy have had a major effect in the practice of minimally invasive surgery, which is preferable to more invasive surgical procedures for central and hard thoracic disc herniation. Eleven patients underwent surgery between 2002 and 2008. Data was collected from self-reporting questionnaires completed by the patient at each visit before surgery and after surgery at 3,6,12 and 24 months. The questionnaires included in the study were the Oswestry Disability Questionnaire and a visual analog scale(VAS) for the evaluation of pain. In all eleven patients, the thoracoscopic approach was technically performed satisfactorily. There was a significant initial improvement in both the Oswestry score and the VAS pain score at up to nine months(P<0.05). The average relative difference in the Oswestry and VAS score was not significant at 12 and 24 months. The complication rate(pleurisy and lung contusion) in our small study was 18%, which compares favorably with the literature. Video assisted thoracic spine surgery (VATS) clearly provides a minimally invasive and effective alternative to open thoracic surgery. A surgeon must be familiar with the surgical anatomy and the endoscopic techniques to ensure an optimal surgical outcome. Hence, that is one limitation in the practice of thoracoscopic discectomy.

Primary central nervous system lymphoma presenting as a pure third ventricular lesion: a case report

Introduction

Primary central nervous system lymphomas are infrequently occurring lymphomas that account for only 0.3-1.5% of all intra-cranial neoplasms in patients without acquired immune deficiency syndrome. However, a pure third ventricle lymphoma is extremely rare. Here, we discuss the similar radiological appearances of lesions localized in the third ventricle and the importance of accurately diagnosing primary central nervous system lymphomas for favorable treatment outcomes.

Case presentation

A 38-year-old Caucasian man from Turkey presented with a severe headache lasting for three months that failed to respond to any medication. Both severity and duration of the symptoms increased gradually, resulting in vomiting, nausea and gait disturbance that accompanied the headache for three weeks. Neuro-imaging studies showed a lesion located solely in the third ventricle, resulting in partial obstruction of the foramen of Monro. The pre-operative diagnosis was a colloid cyst. Following the surgical procedure, the results of pathological and immunochemical assays revealed that the pre-operative diagnosis was incorrect and that the lesion was a primary central system lymphoma.

Conclusion

Pure third ventricle lymphomas are extremely rare and are exceptionally localized. It is important to be aware of, and to differentiate between, other possible third ventricular lesions that may mimic the same radiological appearance. Accurate diagnosis is necessary for selecting appropriate treatment modalities.

Hypercholesterolemia increases vasospasm resulting from basilar artery subarachnoid hemorrhage in rabbits which is attenuated by Vitamin E

BACKGROUND

Aneurysm rupture results in subarachnoid hemorrhage (SAH) with subsequent vasospasm in the cerebral and cerebellar major arteries. In recent years, there has been increasing evidence that hypercholesterolemia plays a role in the pathology of SAH. It is known that hypercholesterolemia is one of the major risk factors for the development of atherosclerosis. Among the factors that have been found to retard the development of atherosclerosis is the intake of a sufficient amount of Vitamin E. An inverse association between serum Vitamin E and coronary heart disease mortality has been demonstrated in epidemiologic studies. Therefore, we tested, in an established model of enhanced cholesterol feed in rabbits, the effects of hypercholesterolemia on vasospasm after SAH by using computed tomography (CT) angiograms of the rabbit basilar artery; in addition, we tested the effects of Vitamin E on these conditions, which have not been studied up to now.

METHODS

In this study rabbits were divided into 3 major groups: control, cholesterol fed, and cholesterol + Vitamin E fed. Hypercholesterolemia was induced by a 2% cholesterol-containing diet. Three rabbit groups were fed rabbit diet; one group was fed a diet that also contained 2% cholesterol and another group was fed a diet containing 2% cholesterol and they received i.m. injections of 50 mg/kg of Vitamin E. After 8 weeks, SAH was induced by the double-hemorrhage method and distilled water was injected into cisterna magna. Blood was taken to measure serum cholesterol and Vitamin E levels. Basilar artery samples were taken for microscopic examination. CT angiography and measurement of basilar artery diameter were performed at days 0 and 3 after SAH.

RESULTS

Two percent cholesterol diet supplementation for 8 weeks resulted in a significant increase in serum cholesterol levels. Light microscopic analysis of basilar artery of hypercholesterolemic rabbits showed disturbances in the subendothelial and medial layers, degeneration of elastic fibers in the medial layer from endothelial cell desquamation, and a reduction of waves in the endothelial layer. However, the cholesterol + Vitamin E group did not exhibit these changes. The mean diameter of the basilar artery after SAH induction in the cholesterol-treated group was decreased 47% compared with the mean diameter of the control group. This value was less affected in cholesterol + Vitamin E-treated rabbits, which decreased 18% compared with the mean diameter of the control group.

CONCLUSIONS

Hypercholesterolemia-related changes in the basilar artery aggravate vasospasm after SAH. Adding Vitamin E to cholesterol-treated rabbits decreased the degree of vasospasm following SAH in the rabbit basilar artery SAH model. We suggest that Vitamin E supplements and a low cholesterol diet may potentially diminish SAH complicated by vasospasm in high-risk patients.

Osteoid Osteoma and Osteoblastoma of the Cervical Spine: The Cause of Unusual Persistent Neck Pain

Background: The most important symptom in patients with osteoid osteoma and osteoblastoma is a resistant localized neck pain and stiffness in the spine. Objective: To evaluate and analyze 6 cases of osteoid osteoma and osteoblastoma of the cervical spine that were surgically treated over a 7-year period and to emphasize the unusual persistent neck pain associated with osteoid osteoma and osteoblastoma of the cervical spine. Study Design: Retrospective study. Methods: Six patients, 3 male and 3 female, with a mean age of 21 years (range 16-31) diagnosed with osteoid osteoma or osteoblastoma during 2003 to 2009 were analyzed retrospectively. The preoperative neurological and clinical symptoms, neck pain duration, preoperative deformity, location of lesion, radiological findings, surgical technique and clinical follow-up outcomes of each patient were evaluated. Results: The average follow-up duration was 40.5 months (range, 19 to 83 months). Three patients had osteoid osteoma (2 female and one male), and 3 patients had osteoblastoma (one female and 2 male). Two male patients had recurrent osteoblastoma. The locations of the lesions were as follows: C7 (2 patients), C3 (one patient), C2 (one patient), C3-C4 (one patient) and C5-C6 (one patient). The most common symptom was local neck pain in the region of the tumor. Among all patients, only one patient, who had osteoblastoma, had neurological deficits (right C5-C6 root symptoms). The other patients had no neurological deficits. All patients were treated with surgical resection using microsurgery. Two patients underwent only tumor resection, one patient underwent tumor resection and fusion, and the other 3 patients underwent tumor resection, fusion and spinal instrumentation. No perioperative complications developed in any of our patients. There was no tumor recurrence during the follow-up period. Limitations: A retrospective study with 6 analyses of cases. Conclusion: Surgical treatment of osteoid osteoma and osteoblastoma of the spine has been standardized. The most common symptom of osteoid osteoma and osteoblastoma of the cervical spine is local persistent neck pain in the region of the tumor. This symptom can be significant in the diagnosis of these tumors. Key words: neck pain, osteoid osteoma, osteoblastoma, bone tumors, cervical spine

Clinical outcomes of degenerative lumbar spinal stenosis treated with lumbar decompression and the Cosmic "semi-rigid" posterior system

Background

Although some investigators believe that the rate of postoperative instability is low after lumbar spinal stenosis surgery, the majority believe that postoperative instability usually develops. Decompression alone and decompression with fusion have been widely used for years in the surgical treatment of lumbar spinal stenosis. Nevertheless, in recent years several biomechanical studies have shown that posterior dynamic transpedicular stabilization provides stabilization that is like the rigid stabilization systems of the spine. Recently, posterior transpedicular dynamic stabilization has been more commonly used as an alternative treatment option (rather than rigid stabilization with fusion) for the treatment of degenerative spines with chronic instability and for the prevention of possible instability after decompression in lumbar spinal stenosis surgery.

Methods

A total of 30 patients with degenerative lumbar spinal stenosis (19 women and 11 men) were included in the study group. The mean age was 67.3 years (range, 40–85 years). Along with lumbar decompression, a posterior dynamic transpedicular stabilization (dynamic transpedicular screw–rigid rod system) without fusion was performed in all patients. Clinical and radiologic results for patients were evaluated during follow-up visits at 3, 12, and 24 months postoperatively.

Results

The mean follow-up period was 42.93 months (range, 24–66 months). A clinical evaluation of patients showed that, compared with preoperative assessments, statistically significant improvements were observed in the Oswestry and visual analog scale scores in the last follow-up control. Compared with preoperative values, there were no statistically significant differences in radiologic evaluations, such as segmental lordosis angle (α) scores (P = .125) and intervertebral distance scores (P = .249). There were statistically significant differences between follow-up lumbar lordosis scores (P = .048). There were minor complications, including a subcutaneous wound infection in 2 cases, a dural tear in 2 cases, cerebrospinal fluid fistulas in 1 case, a urinary tract infection in 1 case, and urinary retention in 1 case. We observed L5 screw loosening in 1 of the 3-level decompression cases. No screw breakage was observed and no revision surgery was performed in any of these cases.

Conclusions

Posterior dynamic stabilization without fusion applied to lumbar decompression leads to better clinical and radiologic results in degenerative lumbar spinal stenosis. To avoid postoperative instability, especially in elderly patients who undergo degenerative lumbar spinal stenosis surgery with chronic instability, the application of decompression with posterior dynamic transpedicular stabilization is likely an important alternative surgical option to fusion, because it does not have fusion-related side effects, is easier to perform than fusion, requires a shorter operation time, and has low morbidity and complication rates.

Thoracoscopic surgical approaches for treating various thoracic spinal region diseases

AIM

Minimally invasive surgery is currently a goal for surgical intervention in the spine. The effectiveness of endoscopic thoracic spine surgery and technological improvements are two factors that are always under consideration in the practice of spinal surgery.

MATERIAL AND METHODS

We present twenty-five patients whose thoracoscopic spinal surgeries were performed between 2002 and 2008 for the treatment of various spinal diseases. Eleven patients with thoracic disc herniation, five patients with traumatic thoracic spinal compressive fracture, six patients with metastatic thoracic spinal tumors and three patients with tubercular spondylitis underwent thoracoscopic spine surgery. Clinical evaluations were performed at 3, 6,12 and 24 months post-surgery. The Oswestry disability questionnaire and linear visual analog scale (VAS) were used for the evaluation of pain.

RESULTS

Postoperatively, two patients had lung contusions, one patient had pneumonia and one patient had instability. There were significant initial improvements in both the Oswestry score and the VAS pain score up to 6 months (p<0.05). The average relative difference in pain scores in all groups was not significant at 12 and 24 months (p>0.05).

CONCLUSION

The favorable results of thoracoscopic spinal surgery encourage its application to situations in which a conventional thoracic approach is indicated. Thoracoscopic spine surgery is applicable to all patients with various spinal diseases.

Osteoid osteoma and osteoblastoma of the cervical spine: the cause of unusual persistent neck pain

BACKGROUND

The most important symptom in patients with osteoid osteoma and osteoblastoma is a resistant localized neck pain and stiffness in the spine.

OBJECTIVE

To evaluate and analyze 6 cases of osteoid osteoma and osteoblastoma of the cervical spine that were surgically treated over a 7-year period and to emphasize the unusual persistent neck pain associated with osteoid osteoma and osteoblastoma of the cervical spine.

STUDY DESIGN

Retrospective study.

METHODS

Six patients, 3 male and 3 female, with a mean age of 21 years (range 16-31) diagnosed with osteoid osteoma or osteoblastoma during 2003 to 2009 were analyzed retrospectively. The preoperative neurological and clinical symptoms, neck pain duration, preoperative deformity, location of lesion, radiological findings, surgical technique and clinical follow-up outcomes of each patient were evaluated.

RESULTS

The average follow-up duration was 40.5 months (range, 19 to 83 months). Three patients had osteoid osteoma (2 female and one male), and 3 patients had osteoblastoma (one female and 2 male). Two male patients had recurrent osteoblastoma. The locations of the lesions were as follows: C7 (2 patients), C3 (one patient), C2 (one patient), C3-C4 (one patient) and C5-C6 (one patient). The most common symptom was local neck pain in the region of the tumor. Among all patients, only one patient, who had osteoblastoma, had neurological deficits (right C5-C6 root symptoms). The other patients had no neurological deficits. All patients were treated with surgical resection using microsurgery. Two patients underwent only tumor resection, one patient underwent tumor resection and fusion, and the other 3 patients underwent tumor resection, fusion and spinal instrumentation. No perioperative complications developed in any of our patients. There was no tumor recurrence during the follow-up period.

LIMITATIONS

A retrospective study with 6 analyses of cases.

CONCLUSION

Surgical treatment of osteoid osteoma and osteoblastoma of the spine has been standardized. The most common symptom of osteoid osteoma and osteoblastoma of the cervical spine is local persistent neck pain in the region of the tumor. This symptom can be significant in the diagnosis of these tumors.

The effects of human umbilical cord blood transplantation in rats with experimentally induced spinal cord injury

OBJECT

Even though there have been many efforts to recover neuronal dysfunction following spinal cord injuries, there are limitations to the treatment of these injuries. The purpose of this laboratory investigation was to determine the clinical and neurophysiological effects of human umbilical cord blood (HUCB) transplantation in a rat hemisection model of spinal cord injury.

METHODS

In this study, experimental hemisection of the thoracic spinal cord was performed in rats. The rats were divided into 4 groups (6 rats in each group). One group of rats (Group 1) underwent thoracic laminectomy only. Rats in Group 2 underwent laminectomy and right hemisection of the thoracic spinal cord. Rats in Group 3 underwent right hemisection and implantation of freshly obtained HUCB on Day 0 postinjury. Rats in Group 4 underwent hemisection and implantation of freshly obtained HUCB on Day 4 postinjury. Clinical evaluations of rat motor function included the following: neurological examination, Rotarod performance, and inclined plane tests. Rats also underwent reflex evaluation.

RESULTS

The neurological examinations revealed that the frequency of plegic rats was 70.8% at the beginning of the study across all 4 groups; this value decreased to 20.8% by the end of the study. The percentage of rats with a normal examination increased from 25% to 50%. The results of Rotarod performance and 8-week inclined plane performance tests showed statistical significance (p < 0.05) in an overall group comparison across all time points. At the end of the 8 weeks, a statistically significant difference was found in the inclined plane test results between rats in Groups 1 and 2. There were no statistically significant differences between Groups 1, 3, and 4 (p < 0.05). When the reflex responses of the hemisectioned sides were compared, statistically significant differences were detected between groups (p < 0.05). All groups were significantly different with regard to the right-side reflex response score (p < 0.05). Spinal cord preparations of rats in all groups were examined for histopathological changes.

CONCLUSIONS

Human umbilical cord blood is stem cell rich and easily available, and it carries less risk of inducing a graft-versus-host reaction in the recipient. Human umbilical cord blood serum is also noted to contain stem cell–promoting factors, which is why cell isolation was not used in this study. Freshly obtained cord blood was also used because storage of cord blood has been reported to have some negative effects on stem cells. Transplantation of freshly obtained HUCB into the hemisectioned spinal cord experimental model demonstrated clinical and neurophysiological improvement.

Dynamic stabilization of the spine: a new classification system

Fusion surgeries are still the gold standard in the treatment of the degenerative spine. Spinal fusion has some problems, however. Adjacent segment disease, donor place ailment, and the morbidity of the surgery has emerged as important problems over the years. As a consequence of such complications after fusion, the search for an alternative treatment for the degenerative spine widened. While trying to maintain the motion in the joint, dynamic stabilization aims to remove the pain by distributing the weight between anterior and posterior elements of the spine. Various new devices have now been developed for the dynamic stabilization of the spine. In this report, the dynamic stabilization devices of the spine are classified anew and, the authors explain briefly the historical evolution process, specialties, indications and contraindications of these dynamic stabilization devices.

Posterior dynamic stabilization in the treatment of lumbar degenerative disc disease: 2-year follow-up

BACKGROUND

A prospective pilot study was designed to evaluate the role of a posterior dynamic stabilization technique in the surgical treatment of degenerative disc disease. Posterior dynamic stabilization with a hinged screw is a new concept in the surgical treatment of degenerative disc disease of the lumbar spine. The traditional surgical treatment is to apply a fusion procedure. However, numerous reports showed unsatisfactory clinical outcomes even when patients have satisfactory radiological outcomes following fusion procedures.

MATERIAL AND METHODS

The study included patients who were surgically treated with a dynamic stabilization technique due to painful degenerative disc disease. Clinical and radiological findings for the 20 participating patients were analyzed in a 2-year follow-up study. Preoperative and postoperative data at the 3 (rd), 12 (th) and 24 (th) month were collected for both clinical and radiological outcomes. Statistical analyses between preoperative and postoperative data were performed using the Wilcoxon test.

RESULTS

The clinical outcome measurements (VAS, ODI) showed significant improvement in all postoperative measurements compared to preoperative values. The mean preoperative visual analogue score (VAS, 7.9) and Oswestry Disability Index (ODI 59.2) significantly decreased to 0.8 for VAS and 9.2 for ODI, at 2 years post-operation (p<0.05). The radiological studies showed no significant changes between pre- and postoperative values, in all parameters. There was no mortality or morbidity.

CONCLUSIONS

The results of this pilot study are encouraging. Dynamic stabilization may be an effective technique in the surgical treatment of painful degenerative disc disease. A larger series study, with longer follow-up periods and with control groups is needed to determine the success and safety of posterior dynamic stabilization in the surgical treatment of degenerative disc disease.

Comparison of posterior dynamic and posterior rigid transpedicular stabilization with fusion to treat degenerative spondylolisthesis

This article describes the clinical and radiological outcomes of a comparison of posterior dynamic transpedicular stabilization and posterior rigid transpedicular stabilization with fusion after decompression in the treatment of degenerative spondylolisthesis. This prospective clinical and radiologic study was conducted between 2004 and 2007 and included 46 patients, of whom 33 were women (71.7%) and 13 were men (28.3%). Mean patient age was 61.67+/-10.80 years (range, 45-89 years). Twenty-six patients who underwent lumbar decompression and posterior dynamic transpedicular stabilization were followed for a mean of 38 months (range, 24-55 months). In the fusion group, 20 patients who underwent lumbar decompression and rigid stabilization with fusion were followed for a mean of 44 months (range, 26-64 months). The intervertebral space measurements of the dynamic group at the preoperative examination and at 12 and 24 months postoperatively were statistically significantly higher than the intervertebral space measurements of the fusion group (P<.05). In the dynamic group, complications occurred in 2 patients; the first was a screw malposition, which was improved with revision surgery within 1 month of the initial surgery, and the second was a fusion performed in the second year in 1 patient because the patient reported continued pain. In the fusion group, adjacent segment disease was observed in 1 patient, with subsequent reoperation. Lumbar decompression and posterior dynamic transpedicular stabilization yield satisfactory results in the treatment of degenerative lumbar spondylolisthesis and can be considered a valid alternative to fusion.

Dynamic lumbar pedicle screw-rod stabilization: two-year follow-up and comparison with fusion

Background:

A lumbar pedicular dynamic stabilization system (LPDSS) is an alternative to fusion for treatment of degenerative disc disease (DDD). In this study, clinical and radiological results of one LPDSS (Saphinaz, Medikon AS, Turkey) were compared with results of rigid fixation after two-year follow-up.

Methods:

All patients had anteroposterior and lateral standing x-rays of the lumbar spine preoperatively and at 3 months, 12 months and 24 months after surgery. Lordosis of the lumbar spine, segmental lordosis and ratio of the height of the intervertebral disc spaces (IVS) measured preoperatively and at 3 months, 12 months and 24 months after surgery.

All patients underwent MRI and/or CT preoperatively, 3months, 12 months and 24 months postoperatively. The ratio of intervertebral disc space to vertebral body height (IVS) and segmental and lumbar lordosis were evaluated preoperatively and postoperatively. Pain scores were evaluated via Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) preoperatively and postoperatively.

Results:

In both groups, the VAS and ODI scores decreased significantly from preoperatively to postoperatively. There was no difference in the scores between groups except that a lower VAS and ODI scores were observed after 3 months in the LPDSS group. In both groups, the IVS ratio remained unchanged between preoperative and postoperative conditions. The lumbar and segmental lordotic angles decreased insignificantly to preoperative levels in the months following surgery.

Conclusions:

Patients with LPDSS had equivalent relief of pain and maintenance of sagittal balance to patients with standard rigid screw-rod fixation. LPDSS appears to be a good alternative to rigid fixation.

Clinical analysis of 21 cases of spinal cord ependymoma : positive clinical results of gross total resection

OBJECTIVE

To evaluate the clinical results of gross total resection in the surgical approach to spinal ependymoma.

METHODS

Between June 1995 and May 2009, 13 males and 8 females (mean age 34) diagnosed with intramedullary or extramedullary spinal ependymoma were surgically treated at our centre. The neurological and functional state of each patient were evaluated according to the modified McCormick scale.

RESULTS

The average follow-up duration was 54 months (ranging from 12 to 168 months). The locations of the lesions were: thoracic region (4, 19%), lumbar region (7, 34%), cervical region (4, 19%), cervicothoracic region (3, 14%) and conus medullaris (3, 14%). Four patients (19%) had deterioration of neurological function in the early postoperative period. The neurological function of three patients was completely recovered at the 6th postoperative month, while that of another patient was recovered at the 14th month. In the last assessment of neurological function, 20 patients (95%) were assessed as McCormick grade 1. No perioperative complications developed in any of our patients. In one patient's 24-month assessment, tumour recurrence was observed. Re-operation was not performed and the patient was taken under observation.

CONCLUSION

Two determinants of good clinical results after spinal ependymoma surgery are a gross total resection of the tumour and a good neurological condition before the operation. Although neurological deficits in the early postoperative period can develop as a result of gross total tumour resection, significant improvement is observed six months after the operation.

Minimum two-year follow-up of cases with recurrent disc herniation treated with microdiscectomy and posterior dynamic transpedicular stabilisation

The objective of this article is to evaluate two-year clinical and radiological follow-up results for patients who were treated with microdiscectomy and posterior dynamic transpedicular stabilisation (PDTS) due to recurrent disc herniation. This article is a prospective clinical study. We conducted microdiscectomy and PDTS (using a cosmic dynamic screw-rod system) in 40 cases (23 males, 17 females) with a diagnosis of recurrent disc herniation. Mean age of included patients was 48.92 +/- 12.18 years (range: 21-73 years). Patients were clinically and radiologically evaluated for follow-up for at least two years. Patients' postoperative clinical results and radiological outcomes were evaluated during the 3rd, 12th, and 24th months after surgery. Forty patients who underwent microdiscectomy and PDTS were followed for a mean of 41 months (range: 24-63 months). Both the Oswestry and VAS scores showed significant improvements two years postoperatively in comparison to preoperative scores (p<0.01). There were no significant differences between any of the three measured radiological parameters (alpha, LL, IVS) after two years of follow-up (p > 0.05). New recurrent disc herniations were not observed during follow-up in any of the patients. We observed complications in two patients. Performing microdiscectomy and PDTS after recurrent disc herniation can decrease the risk of postoperative segmental instability. This approach reduces the frequency of failed back syndrome with low back pain and sciatica.

The major complications of transpedicular vertebroplasty

OBJECT

Vertebroplasty is a well-known technique used to treat pain associated with vertebral compression fractures. Despite a success rate of up to 90% in different series, the procedure is often associated with major complications such as cord and root compression, epidural and subdural hematomas (SDHs), and pulmonary emboli, as well as other minor complications. In this study, the authors discuss the major complications of transpedicular vertebroplasty and their clinical implications during the postoperative course.

METHODS

Vertebroplasty was performed in 12 vertebrae of 7 patients. Five patients had osteoporotic compression fractures, 1 had tumoral compression fractures, and 1 had a traumatic fracture. Two patients had foraminal leakage, 1 had epidural leakage, 1 had subdural cement leakage, 2 had a spinal SDH, and the last had a split fracture after the procedure.

RESULTS

Three patients had paraparesis (2 had SDHs and 1 had epidural cement leakage), 3 had root symptoms, and 1 had lower back pain. Two of the 3 patients with paraparesis recovered after evacuation of the SDH and subdural cement; however, 1 patient with paraparesis did not recover after epidural cement leakage, despite cement evacuation. Two patients with foraminal leakage and 1 with subdural cement leakage had root symptoms and recovered after evacuation and conservative treatment. The patient with the split fracture had no neurological symptoms and recovered with conservative treatment.

CONCLUSIONS

Transpedicular vertebroplasty may have major complications, such as a spinal SDH and/or cement leakage into the epidural and subdural spaces, even when performed by experienced spinal surgeons. Early diagnosis with CT and intervention may prevent worsening of these complications.

Utilizing dynamic rods with dynamic screws in the surgical treatment of chronic instability: a prospective clinical study

AIM

In this study, we examined the results of utilizing the agile posterior dynamic stabilization system with dynamic transpedicular screws in our patients.

MATERIAL AND METHODS

Posterior dynamic instrumentation with agile rods and dynamic transpedicular screws was employed in 15 (seven male and eight female) patients (mean age = 42, ranging from 30 to 53). The average follow-up duration was 19 months (ranging from 12 to 25). The primary purpose for the surgery was degenerative disc disease. For subjective evaluation, patients underwent a physical examination utilizing the Oswestry disability index (ODI) and visual analogue scale (VAS). Radiographic parameters, including the angle of lumbar lordosis (LL), angle of segmental lordosis (alpha) and intervertebral space (IVS), were also evaluated. Both subjective patient evaluations and radiographic parameters were assessed at the 3rd and 12th postoperative months.

RESULTS

Significant postoperative improvements were observed in the ODI and VAS measurements (P < 0.05). There were no significant differences in the LL, alpha and IVS parameters. One patient experienced a broken screw.

CONCLUSION

We obtained good clinical results by utilizing dynamic rods with dynamic transpedicular screws.

Clinical outcomes following cervical laminoplasty for 19 patients with cervical spondylotic myelopathy

OBJECTIVE

Cervical laminoplasty is an effective procedure. We describe the technique of open-door and french-door cervical laminoplasty and present our clinical results.

METHODS

All patients undergoing laminoplasty at our clinic during the 1997- 2008 period were included in the study. All patients had myeloradiculopathy. Neurological functions and recovery in myelopathy in patients were evaluated using the Nurick score. Pre- and postoperative kyphotic evaluation was measured using the sagittal tangent method. Peri- and postoperative complications were recorded.

RESULTS

Clinical evaluation showed that all patients had reduced postoperative complaints compared to their complaints before the procedure. Average time of surgery was 180 min. Average blood loss in surgeries was 300 cc. According to the Nurick classification, no improvement was observed in seven patients; nine patients showed improvement of one grade; and three patients showed an improvement of two grades. Temporary C5 nerve root paralysis was observed in two patients as a postoperative complication. Complete recovery was observed in both patients within 2 months.

CONCLUSIONS

Laminoplasty is a safe and effective alternative procedure to treat cervical spondylotic myelopathy.

Monoradiculopathy and secondary segmental instability caused by postoperative pars interarticularis fracture: a case report

Instability can develop after lumbar spinal surgery. What is also known as secondary segmental instability is one of the important causes of failed back syndrome. In this paper, we described a 45-year-old female patient who was diagnosed with secondary segmental instability caused by left L3 pars interarticularis fracture after a high lumbar disc surgery and was subsequently treated with re-operation. We evaluated the clinical course, diagnosis, and treatment methods for secondary segmental instability caused by postoperative pars interarticularis fracture. Furthermore, we emphasized the importance of preserving the pars interarticularis during upper lumbar disc surgeries in order to avoid a potential stress fracture.

The combined use of a posterior dynamic transpedicular stabilization system and a prosthetic disc nucleus device in treating lumbar degenerative disc disease with disc herniations

Background

Prosthetic replacement of spinal discs is emerging as a treatment option for degenerative disc disease. Posterior dynamic transpedicular stabilization (PDTS) and prosthetic disc nucleus (PDN) devices have been used sporadically in spinal surgery.

Methods

This was a prospective study of 13 patients averaging 40.9 years of age with degenerative disc disease who underwent posterior placement of a PDN with a PDTS. The Oswestry low-back pain disability questionnaire and visual analog scale (VAS) for pain were used to assess patient outcomes at the 3rd, 6th, and 12th postoperative months.

Lumbar range of motion was evaluated using a bubble inclinometer preoperatively and at 12 months postoperatively. Radiological parameters including lumbar lordosis angle (LL), segmental lordosis angle (α), disc height at the operated level (DHo), and disc height of the adjacent level (DHu) were evaluated. A typical midline posterior approach for complete discectomy was followed by the simultaneous placement of the PDN with PDTS.

Results

Both the Oswestry and VAS scores showed significant improvement postoperatively (P < .05). There were no significant differences in LL, α, DHo, and DHu parameters. We observed complications in 3 patients including 2 patients who had the PDN device embedded into the adjacent corpus; 1 had massive endplate degeneration, and the other experienced interbody space infection. In 1 patient, the PDN device migrated to one side in the vertebral space.

Conclusion

The use of a PDN in combination with posterior dynamic instrumentation can help to restore the physiologic motion of the anterior and posterior column and could help to establish posterior dynamic instrumentation as an important treatment of degenerative disc disease. Theoretically this concept is superior, but practically we need more advanced technology to replace disc material. Because this study examined the combination of the PDN and stabilization instrumention, the results cannot be compared with those reported in the literature for either PDN alone or dynamic screws alone.

Level of Evidence

Prospective cohort study with good follow-up (level 1b).