Anatomical Features of Neural Foramen at T12â€"L1 Level for Endoscopic Transforaminal Approach of Paramedian and Foraminal Disc Herniations: An Anatomical Study on Fresh Human Cadavers

AIM

To explore the anatomic features of the neural foramen in particularly at the T12-L1 level in order to assess reveal the safety and efficiency of the endoscopic transforaminal approach for paramedian and foraminal disc herniations at this level.

MATERIAL AND METHODS

The study included 15 fresh human cadavers. The soft tissues were removed at the T12-L1 level and bony tissues, were exposed including the transverse processes. The bilateral facets and pars interarticulares at this level were resected revealing the foraminal anatomy and exiting roots. The anatomical structures constituting the triangular safe working zone (TSWZ) were explored. The nerve root length, nerve root width, nerve root angle, TSWZ height, and base of TSWZ base, nerve root width, nerve root angle and disc height were recorded.

RESULTS

The root length is the hypotenuse of the TSWZ between the axilla of the exiting root and the lateral margin of the pedicle, and the mean root length was 14.94 ± 2.45 mm. The dural height is the interval between the axilla of the exiting nerve root axilla and the superior end plate of the caudal vertebra, and the mean of the dural height was 10.95 ± 1.74 mm. The base of TSWZ is the distance between the lateral margin of the dural sac and the medial margin of the exiting root, and the mean measurement for the base measurement was 11.83 ± 2.26 mm.

CONCLUSION

According to the results data from our cadaveric study, we believe that Kambin’s triangular working zone is a safe area to consider for the endoscopic transforaminal approach at the T12-L1 level, especially for paramedian and foraminal disc herniations.

The influence of adjunctive caudal epidural steroid injection on the therapeutic effect of transforaminal epidural steroid injection

BACKGROUND

Epidural steroid injection is widely used to treat the short and long-term symptoms of low back and radicular pain. To the best of our knowledge, the influence of transforaminal epidural steroid injection (TFSI) combined with caudal epidural steroid injection (CESI) on pain intensity, patient satisfaction, and quality of life in lumbar radiculopathy has not been examined.

AIM

To evaluate the short and long-term efficacy of TFSI, and TFSI combined with CESI (TFSI + CESI) in patients with lumbar radiculopathy.

MATERIALS AND METHODS

We retrospectively examined the records of 104 patients with lumbar radicular pain and L4/5 and/or L5/S1 intervertebral disc disease who underwent TFSI or TFSI + CESI. We compared the pain intensity using a Visual Numeric Scale (VNS), North American Spine Society (NASS) pain satisfaction index, and EuroQol five dimensions (EQ-5D) quality of life scores before intervention, and after 1, 6 and 12 months.

RESULTS

In the TFSI group, the mean pre-treatment VNS score was 9.2, which improved to 4.9 after 1 month and to 7.2 after 12 months. In the TFSI + CESI group, the mean pre-treatment VNS score was 9.4, which improved to 2.6 and 4.6 after 1 and 12 months, respectively. Improvement in the VNS scores was significantly higher in the TFSI + CESI group (P < 0.0001 for each). Mean EQ-5D quality of life index in the TFSI group improved from 0.59 in the pre-treatment phase to 0.76 after 12 months of intervention, while it improved from 0.62 in the pre-treatment phase to 0.84 at 12 months of intervention in the TFSI + CESI group. The EQ-5D scores were significantly better in the TFSI + CESI group at 1, 6, and 12 months after the procedure (P = 0.004, 0.036, and 0.042, for 1, 6, and 12 months, respectively). The NASS scores were significantly better in the TFSI + CESI group at 6 and 12 months after the intervention (P = 0.025 and 0.001 for 6 months and 12 months, respectively).

CONCLUSION

In patients with lower lumbar radiculopathy, a combined TFSI + CESI technique offers superior short and long-term pain relief, quality of life, and long-term patient satisfaction, than when TFSI is performed alone.

The Effects of Proanthocyanidin on Vasospasm After Experimental Subarachnoidal Hemorrhage in Rats

AIM

Delayed ischemic neurological deficit (DIND) and cerebral vasospasm (CV) remain the most common and debilitating neurological complications following aneurysmal subarachnoidal hemorrhage (SAH). Many reports demonstrate the importance of proanthocyanidins (PR) on the vascular system, including endothelium-dependent relaxation of blood vessels. These effects of PR on the cerebral vascular system were examined in this study. < p < MATERIAL and METHODS: Fifty-two adult Sprague-Dawley male rats were used for the experimental double hemorrhage model. They were divided to control, sham, pre- and post-interventional treatment groups. 100 mg/kg PR was administered for the treatment for respect to groups. Basilar artery diameter (BAD) and arterial wall thickness were measured and the apoptosis ratio of the endothelial cells was calculated. Arterial walls were examined electron microscopically (EM).

RESULTS

There were significant differences between the groups except control and pre-SAH (p=0.37) and post-SAH and pre- SAH groups (p=0.15) with respect to BAD. According to arterial wall thickness, apoptosis ratio, and grading, there were significant differences between the groups except control and pre-SAH (p=0.85, p=0.49 and p=0.18 respectively) and SAH and post-SAH (p=0.08, p=0.21 and p=0.24 respectively) groups. EM findings revealed that pro-apoptotic and pro-necrotic degenerated endothelial cells with seldom vacuolization in post-SAH treatment group which were more serious in SAH group.

CONCLUSION

Pre-SAH administration of PR induces better vasodilatation and protection of basilar artery (BA) from vasospasm (VS), which could yield neuroprotective and vasodilatator effects. In addition, PR appears to be involved in relieving oxidative damage, with an antioxidant-antiapoptotic-antinecrotic effect that may contribute to vascular dilation.

Neuronal regeneration in injured rat spinal cord after human dental pulp derived neural crest stem cell transplantation

OBJECTIVE

This study aimed to analyze the effect of human Dental Pulp-Neural Crest Stem Cells (hDP-NCSCs) delivery on lesion site after spinal cord injury (SCI), and to observe the functional recovery after transplantation.

METHODS

Neural Crest Stem Cells (NCSCs) were isolated from human Dental Pulp (hDP). The experimental rat population was divided into four groups (n = 6/24). Their behavioral motility was scored regularly. After 4-weeks, rats were sacrificed, and their spinal cords were examined for Green Fluorescent Protein (GFP) labeled hDP-NCSCs by immunofluorescence (IF) staining.

RESULTS

In early post-injury (p.i) period, the ultrastructure of spinal cord tissue was preserved in Group 4. The majority of cells forming the ependymal region around the central canal were found to be hDP-NCSCs. While the grey-and-white-matter around the ependymal region was composed of e.g. GFP cells, with astrocytic-like appearance. The scores showed significant motor recovery in hind limb functions in Group 4. However, no obvious change was observed in other groups.

CONCLUSION

Cells e.g., mesenchymal (Vimentin+) which express GFP+ cells in the gray-and-white-matter around the ependymal region could indicate the potential to self-renewal and plasticity. Thus, transplantation of hDP-NCSCs might be an effective strategy to improve functional recovery following spinal cord trauma (Fig. 10, Ref. 32).

Lumbosacral Conjoined Root Anomaly: Anatomical Considerations of Exiting Angles and Root Thickness

AIM

Conjoined nerve roots (CNR) can be damaged during lumbar disc surgery and lead to neuropathic pain due to excessive retraction. The purpose of this study was to investigate the factors that facilitate the identification of CNRs that can lead to the loss of fragments in the secondary axilla, nerve root injury or unpleasant surprises during lumbar disc surgery. Accordingly, we aimed to measure the thicknesses and exit angles of the nerve roots close to the pedicle to obtain scientific data regarding rare double roots.

MATERIAL AND METHODS

The data of 612 patients who were operated for lumbar disc disease in our hospital between 2012 and 2014 were reviewed retrospectively. Twenty one cases of CNR were detected in this series.

RESULTS

The mean nerve root thickness was 1.92 ± 0.45 mm for medially located roots and 3.33 ± 0.95 mm for laterally located roots. The comparison of medially located roots versus laterally located roots revealed a significant difference in mean values (p < 0.0001). The mean exit angle was 12.290± 4.890 for medially located roots, and 22.110 ± 5.420 for laterally located roots (p < 0.0001). In addition, the exit angles of the medially and laterally located roots increased as going down to caudal levels, (p=0.005, p=0.042).

CONCLUSION

CNRs are congenital anomalies that are usually diagnosed during the surgical procedure and affect the success of discectomy. The presence of a more medially located or thinner root during surgical exploration and the absence of the fragment in the axilla in extruded or sequestered discs usually indicate a conjoined nerve root closer to the pedicle.

Patient Selection and Efficacy of Intradiscal Electrothermal Therapy with Respect to the Dallas Discogram Score

AIM

Intervertebral disc degeneration can cause severe low back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption unresponsive to conservative medical care. We aimed to evaluate 12-month pain and functional outcomes and predictors of clinical success in patients with discogenic back pain treated with IDET with respect to the Dallas Discogram Scale (DDS).

MATERIAL AND METHODS

This was a retrospective analysis of patients undergoing IDET for low back pain from 2009 through 2014 at Baskent University, Department of Neurosurgery. A total number of 120 consecutive patients data were collected retrospectively. The degree of disc degeneration was graded using the DDS during discography, and the presence of a high intensity zone (HIZ) on magnetic resonance (MR) imaging was noted. The primary outcome measure was assessment of back pain severity based on the Visual Analogue Scale (VAS); function was assessed by the Oswestry Disability Index (ODI). Follow-up examinations for ODI and VAS scores were assessed at 1, 6, and 12 months post-treatment. Outcomes were discussed with respect to morphological changes in intervertebral discs on discogram.

RESULTS

There was an average 57.39% and 47.16% improvement in VAS and ODI scores, respectively, between pretreatment and 12 months follow-up (p < 0.0001 for both comparisons). Predictors of 12-month clinical success was depended on DDS (p < 0.0001), a HIZ on MR imaging (p < 0.0001).

CONCLUSION

Durable clinical improvements can be realized after IDET in select surgical candidates with mild disc degeneration and HIZ, discography, and low-grade DDS, with more effective treatment results.

Atypical Presentation of an Epidural Hematoma in a Patient Receiving Rivaroxaban After Total Hip Arthroplasty

The authors report a case of a 69-year-old woman who presented with a spontaneous spinal epidural hematoma (SSEH) 10 days after a total hip arthroplasty. The patient had been receiving 10 mg/d of rivaroxaban for 5 days for venous thromboembolism prophylaxis. She had a sudden onset of severe neck pain, followed by quadriplegia below C4. A dorsal SSEH was revealed by computed tomography. While preparing for the emergency evacuation of the SSEH, the neurological symptoms resolved spontaneously in 4 hours. The 1-month follow-up magnetic resonance imaging confirmed that the SSEH had completely resolved. The pathogenesis of SSEH is unclear, but anticoagulant therapy is a known risk factor. It is a relatively rare disorder. Only 1 case of SSEH has been reported, and that patient was receiving a nonsteroidal anti-inflammatory drug besides rivaroxaban, which is another known risk factor for bleeding disorders. [Orthopedics. 2016; 39(3):e558-e560.].

Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain

AIM

The study was conducted to compare the clinical effectiveness of FJ injections (FJI) and FJ radiofrequency (FJRF) denervation in patients with chronic low back pain.

MATERIAL AND METHODS

This study included 100 patients; 50 in FJI 50 in FJRF group. VNS, NASS and EQ-5D were used to evaluate the outcomes. All outcome assessments were performed at baseline, 3 months, 6 months and 12 months.

RESULTS

FJI in early post-op but FJRF in 1st, 6th and 12th month VNS showed better results (p < 0.001). There was no significant difference in the 1st (p=1) and 6th month (p=0.13) but in 12th month (p=0.04) in NASS. Increase in level number showed positive effect in NASS in FJRF group (p=0.018) but no effect in FJI group (p=0.823) in the 12th month follow-up. There was no significant difference with respect to 1st month (p=0.17), 6th month (p=0.22) and 12th month (p=0.11) post-procedure follow-ups in EQ-5D. At the short term FJI was more effective than FJRF however in midterm follow-up FJRF had more satisfying results than FJRF.

CONCLUSION

To our knowledge, the first choice should be the FJI and if pain reoccurs after a period of time or injection is not effective, RF procedure should be used for the treatment of chronic lumbar pain.

Transforaminal epidural steroid injection via a preganglionic approach for the treatment of lumbar radicular pain

AIM

To evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) for lumbar radiculopathy with respect to effect of injection levels, gender, and age group.

MATERIAL AND METHODS

Hundred-fifty-three consecutive patients who underwent to lumbar TFESI were enrolled. The outcomes were measured by using a visual numeric scale (VNS), NASS and EQ-5D. The relationship between possible outcome predictors and the therapeutic effect were evaluated.

RESULTS

All the patients completed the 2nd year follow-up visits. Significant differences were observed between the pre-procedure and post-procedure VNSs, NASS patients' satisfactions scores and EQ-5D (P < 0.01) except 1st and 2nd year follow-up (P=0.12, P=0.27and P=0.19 respectively). Gender (higher in female patients) showed significant effect to pre-procedure VNS (P=0.04). An increase in the level number was significantly associated with an increase in the 6th month (P=0.005, P=0.004 respectively) and the 1st year (P=0.05, P=0.029 respectively) NASS and EQ-5D. No complication was occurred except discitis in two chronic renal failure patients.

CONCLUSION

Especially in the patients with severe co-morbidities TFESI is an option to provide higher life quality. The clinical course of the success of the TFESI decreases in one year and becomes stable thereafter. In the patients with immune deficiency, the practitioners should always be aware for an infectious complication.

Giant intradiploic calvarial abscess of posterior fossa behaving progressive mass lesion

A unique case of a large intradiploic abscess involving posterior fossa osseous structures is reported. A 16-year-old boy presented with a hard mass in the calvarium of posterior fossa region, fever and confusion. Radiological examination revealed an intradiploic collection with compression to cerebellum, fourth ventricle and brain stem, resulting in syringomyelia in cervical and thoracic spinal cord. After drainage and resection of the abscess wall, closure of a round dural defect was performed. The medical history of the patient and the intraoperative observations support the contention that the abscess in the reported case was a result of chronic and subclinical process of an intraosseous infection. The features concerned with diagnosis, differential diagnosis and pathogenesis of this rare entity are discussed.

The shrinking of an anterior sacral meningocele in time following transdural ligation of its neck in a case of the Currarino triad

In this paper we present an adult patient with the Currarino triad, associated with six habitual abortuses and chronic constipation. Our aim is to report the effectiveness of a simple surgical technique in the treatment of anterior sacral meningocele in the Currarino Syndrome. The presentation of the Currarino Syndrome in adulthood is extremely uncommon. We performed a posterior procedure via lumbar and sacral partial laminectomy and transdural ligation of the neck of the meningocele mass. There were no additional neurological deficits and no recurrence of the presacral mass over the 2-year follow up period. When an adult female with habitual abortus and chronic constipation is seen, the possible presence of the Currarino Triad should be investigated and treated. The anterior sacral meningocele in a case of the Currarino Triad regresses over time following transdural ligation of its neck.