Clinical significance of cerebrospinal fluid nitric oxide concentrations in degenerative cervical and lumbar diseases

Phosphodiesterase 5 Inhibitor Use in Patients Undergoing Decompression Surgery for Lumbar Spinal Stenosis

OBJECTIVE

Our objectives were to explore the association between phosphodiesterase 5 inhibitor use and lumbar decompression surgery by evaluating the prevalence of lumbar decompression surgery in a treatment group of patients with lumbar spinal stenosis compared with a control group.

DESIGN

We performed database review and extracted data including lumbar decompression surgery prevalence, phosphodiesterase 5 inhibitor dosage, and fill dates. Treatment group was defined as those with phosphodiesterase 5 inhibitor fill dates of less than 30 days before surgery, and control group was defined as those with phosphodiesterase 5 inhibitor fill dates at any other time. Lumbar decompression surgery prevalence rates for both groups were calculated.

RESULTS

Our study found 599 lumbar spinal stenosis patients who were prescribed phosphodiesterase 5 inhibitor. Three hundred thirty-eight underwent lumbar decompression surgery. Of these, 71 (21%) filled their prescription of less than 30 days before surgery, whereas 267 (79%) filled their prescription during a different period. The majority (94.6%) of surgical patients received decompression at two or more spinal levels.

CONCLUSIONS

Prevalence of lumbar decompression surgery for lumbar spinal stenosis was significantly lower in patients in the treatment group on phosphodiesterase 5 inhibitor therapy compared with the control group. Among many potential explanations, the vasodilatory effect of phosphodiesterase 5 inhibitor may have contributed to a lower surgical rate. This is the first study to explore this novel association. Future prospective studies are necessary to better define the utility of phosphodiesterase 5 inhibitor in lumbar spinal stenosis.

Surgical outcomes of single stage surgery for Tandem spinal stenosis (TSS) in elderly and younger patients: A comparative study

STUDY DESIGN

Retrospective study.

OBJECTIVE

To evaluate and compare the outcomes of single stage surgery for Tandem Spinal Stenosis (TSS) in elderly (Age ≥65 years) and younger patients (Age <65 years).

SUMMARY OF BACKGROUND DATA

Tandem spinal stenosis among elderly is common and often missed diagnosed with delayed presentation. Literature evaluating efficacy and safety of single staged surgery for TSS in elderly patients is scanty.

METHODS

Analysis of 74 patients with TSS managed with single stage posterior surgery from 2007 to 2016 was done. A total of 62 patients who satisfied our inclusion criteria were evaluated and subdivided into two groups based on age; Study group (age ≥65years)] (n = 32) and control group (age <65years) (n = 30). Perioperative, clinical/radiological parameters and postoperative complications and recovery rate were noted.

RESULTS

The Mean ODI and mJOA showed significant improvement post-operatively in both groups however there was no significant difference between the two groups at final follow-up. There was no statistical difference in operative time, blood loss and hospital stay between the groups. As per Odom's criteria, 78.1% had excellent to good results in study group, while 83.3% had excellent to good results in control group. Postoperative complications were more in elderly group however, there was no significant difference among neurological or cardiopulmonary complications between both groups.

CONCLUSIONS

Single stage surgery is safe & efficacious modality with less morbidity and optimal results in elderly patients with proper preoperative risk assessment. Our study showed that increased age does not proved to be deterrent in the outcome of single staged surgery in tandem spinal stenosis.

Neuromodulation via the Cerebrospinal Fluid: Insights from Recent in Vitro Studies

The cerebrospinal fluid (CSF) occupies the brain's ventricles and subarachnoid space and, together with the interstitial fluid (ISF), forms a continuous fluidic network that bathes all cells of the central nervous system (CNS). As such, the CSF is well positioned to actively distribute neuromodulators to neural circuits in vivo via volume transmission. Recent in vitro experimental work in brain slices and neuronal cultures has shown that human CSF indeed contains neuromodulators that strongly influence neuronal activity. Here we briefly summarize these new findings and discuss their potential relevance to neural circuits in health and disease.

Prioritized cervical or lumbar surgery for coexisting cervical and lumbar stenosis: Prognostic analysis of 222 case

BACKGROUND CONTEXT

Single-stage surgery is usually applied to improving the symptoms of coexisting cervical and lumbar stenosis. In most cases, patients' willingness, surgery affordability, surgical trauma, surgical complications and patients' tolerance to surgery all limit the application of single-stage surgery. For patients who cannot receive single-stage surgery, we hope that we can find out by weighing up merits and flaws of the two surgical sites in order to make decision of prioritize one of the two surgery, so as to bring more benefits to the patients.

OBJECTIVE

To confirm which one of prioritized cervical surgery and prioritized lumbar surgery has a better effect in alleviating the symptoms of patients with coexisting cervical and lumbar stenosis.

STUDY DESIGN

A retrospective analysis and a cohort study for 15 years.

PATIENT SAMPLE

The information of 222 patients who were diagnosed with coexisting cervical and lumbar stenosis over the past 15 years was collected, including 144 patients who underwent prioritized cervical surgery and 78 prioritized lumbar surgery, thereafter the changes in the patients' postoperative neurological functions were evaluated.

OUTCOME MEASURES

Primary outcome variables are the clinical diagnosis event and the event of surgical site positioning. Secondary variables are the event of postoperative function changes and the symptom improvement event.

METHODS

The information about 222 patients with coexisting cervical and lumbar stenosis who had a follow-up of more than 1 year during January 2000 and December 2014 was collected. The effects of prioritized staged cervical and lumbar surgeries on the prognosis for the above-mentioned patients were respectively evaluated via relevant evaluation indexes.

RESULTS

The follow-up time was 18-156 months (58.0 ± 36.5). The lumbar reoperation rate after prioritized cervical surgery was lower than the cervical reoperation rate after prioritized lumbar surgery (22.91% < 57.69%) (P < 0.01). The JOA score and Nurick grade significantly improved (P < 0.01) and the ODI score improved (P < 0.05) after prioritized cervical surgery. No obvious improvement in the JOA score and Nurick grade (P > 0.05) was shown but the ODI score markedly improved (P < 0.01) after prioritized lumbar surgery.

CONCLUSIONS

For patients with coexisting cervical and lumbar stenosis, prioritized cervical surgery is safe and effective and is superior to prioritized lumbar surgery on the improvement of cervical and lumbar symptoms, the postoperative recovery of limb function and the rate of reoperation on another site.

The Presence of the Neuronal Nitric Oxide Synthase Isoform in the Intervertebral Disk

Intervertebral disk degeneration is a progressive and debilitating disease with multifactorial causes. Nitric oxide (NO) might contribute to the cell death pathway. We evaluated the presence of the constitutive form of the neuronal NOS (nNOS) in both health and degenerated intervertebral disk through qPCR and immunohistochemistry. We also analyzed the potential role of nNOS modulation in the tail needle puncture model of intervertebral disk degeneration. Male Wistar rats were submitted to percutaneous disk puncture with a 21-gauge needle of coccygeal vertebras. The selective nNOS pharmacological inhibitor N ^(ω)-propyl-L-arginine (NPLA) or a nNOS-target siRNA (siRNAnNOShum_4400) was injected immediately after the intervertebral disk puncture with a 30-gauge needle. Signs of disk degeneration were analyzed by in vivo magnetic resonance imaging and histological score. We found that intact intervertebral disks express low levels of nNOS mRNA. Disk injury caused a 4 fold increase in nNOS mRNA content at 5 h post disk lesion. However, NPLA or nNOS-target siRNA slight mitigate the intervertebral disk degenerative progress. Our data show evidence of the nNOS presence in the intervertebral disk and its upregulation during degeneration. Further studies would disclose the nNOS role and its potential therapeutical value in the intervertebral disk degeneration.

Alteration in chondroitin sulfate proteoglycan expression at the epicenter of spinal cord is associated with the loss of behavioral function in Tiptoe walking Yoshimura mice

The objective of this study was to explore the correlation between the alteration in chondroitin sulfate proteoglycan (CSPG) expression at the epicenter of spinal cord and the loss of behavioral function in tiptoe walking Yoshimura mice. The tiptoe walking Yoshimura mice (twy) and Institute of Cancer Research (ICR) mice, aged 20 and 26 weeks, were used in the present study. The behavior assessment, micro-computed tomography and immunofluorescent staining were performed. The compressed spinal cord was histologically analyzed. The results showed that the expression of CSPG was statistically higher at the compressed spinal cord for twy mice compared with that at the normal spinal cord for ICR mice. At the 26th week, a large ossification block at the posterior longitudinal ligament of C1-3 was obviously observed at the micro-CT image We observed the BMS Score was significantly correlated with the expression of glial fibrillary acidic protein, CSPG and hyaluronan (P < 0.05). These findings suggest that compression injury induces the higher CSPG expression at the compressed spinal cord in the twy mice. Furthermore, the alteration in CSPG expression at the epicenter of spinal cord is associated with the loss of behavioral function in twy mice.

Effects of curcumin on acute spinal cord ischemia-reperfusion injury in rabbits

Object

The object of this study was to conduct a prospective, randomized, laboratory investigation of the neuroprotective effects of curcumin functionally, biochemically, and histologically in an experimental acute spinal cord ischemia-reperfusion injury on rabbits.

Methods

Eighteen rabbits were randomly assigned to 1 of 3 groups: the sham group, the ischemia-reperfusion group, or the curcumin group. Spinal cord ischemia was induced by applying an infrarenal aortic cross-clamp for 30 minutes. At 48 hours after ischemia, neurological function was evaluated with modified Tarlov criteria. Biochemical changes in the spinal cord and plasma were observed by measuring levels of malondialdehyde (MDA), advanced oxidation protein products (AOPP), glutathione (GSH), superoxide dismutase (SOD), catalase (CAT), nitrite/nitrate, and tumor necrosis factor-α (TNF-α). Histological changes were examined with H & E staining. Immunohistochemical staining with antibodies against caspase-3 was performed to evaluate cell apoptosis after ischemia.

Results

In the curcumin group, neurological outcome scores were statistically significantly better compared with the ischemia-reperfusion group. In the ischemia-reperfusion group, MDA, AOPP, and nitrite/nitrate levels were significantly elevated in the spinal cord tissue and the plasma by the induction of ischemia-reperfusion. The curcumin treatment significantly prevented the ischemia-reperfusion–induced elevation of nitrite/nitrate and TNF-α. In addition, the spinal cord tissue and the plasma SOD, GSH, and CAT levels were found to be preserved in the curcumin group and not statistically different from those of the sham group. Histological evaluation of the tissues also demonstrated a decrease in axonal damage, neuronal degeneration, and glial cell infiltration after curcumin administration.

Conclusions

Although further studies including different dose regimens and time intervals are required, curcumin could attenuate a spinal cord ischemia-reperfusion injury in rabbits via reducing oxidative products and proinflammatory cytokines, as well as increasing activities of antioxidant enzymes and preventing apoptotic cell death.

Coexisting lumbar and cervical stenosis (tandem spinal stenosis): an infrequent presentation. Retrospective analysis of single-stage surgery (53 cases)

STUDY DESIGN

Retrospective analysis of 53 patients who underwent single stage simultaneous surgery for tandem spinal stenosis (TSS) at single centre.

OBJECTIVE

To discuss the presentation of combined cervical and lumbar (tandem) stenosis and to evaluate the safety and efficacy of single-stage simultaneous surgery. Combined stenosis is an infrequent presentation with mixed presentation of upper motor neuron and lower motor neuron signs. Scarce literature on its presentation and management is available. There is a controversy in the surgical strategy of these patients. Staged surgeries are frequently recommended and only few single-stage surgeries reported.

METHODS

All the patients were clinico-radiologically diagnosed TSS. Surgeries were performed in single stage by two teams. Results were evaluated with Nurick grade, modified Japanese Orthopedic Association score (mJOA), oswestry disability index (ODI), patient satisfaction index, mJOA recovery rate, blood loss and complication.

RESULTS

The mJOA cervical and ODI score improved from a mean 8.86 and 68.15 preoperatively to 13.00 and 30.11, respectively, at 12 months and to 14.52 and 24.03 at final follow-up. The average mJOA recovery rate was 48.23 ± 26.90 %. Patient satisfaction index was 2.13 ± 0.91 at final follow-up. Estimated blood loss of ≤400 ml and operating room time of <150 min showed improvement of scores and lessened the complications. In the age group below 60 years, the improvement was statistically significant in ODI (p = 0.02) and Nurick's grade (p = 0.03) with average improvement in mJOA score.

CONCLUSION

Short-lasting surgery, single anaesthesia, reduced morbidity and hospital stay as well as costs, an early return to function, high patient satisfaction rate with encouraging results justify single-stage surgery in TSS. Age, blood loss and duration of surgery decide the complication rate and outcome of surgery. Staged surgery is recommended in patients above the age of 60 years.

Neurological impairment score in lumbar spinal stenosis

BACKGROUND AND AIM

The Oswestry Disability Index (ODI) is an interview-based instrument generally accepted as a measure of disability in patients with lumbar spinal stenosis (LSS). There is, however, no generally accepted measure for neurological impairment in LSS. We therefore developed a scoring system [neurological impairment score in lumbar spinal stenosis (NIS-LSS)] for the assessment of neurological impairment in the lower limbs of patients with LSS, then performed a validation study to facilitate its implementation in the routine clinical evaluation of patients with LSS.

METHODS

The NIS-LSS is based on the combined evaluation of tendon reflexes, tactile and vibratory sensation, pareses, and the ability to walk and run; the total score ranges from 0 (inability to walk) to 33 points (no impairment). A group of 117 patients with LSS and a control group of 63 age- and sex-matched healthy volunteers were assessed with the NIS-LSS to evaluate capacity to discriminate between LSS patients and controls. A correlation with the ODI was performed for assessment of construct validity.

RESULTS

The median NIS-LSS was 27 points in LSS patients compared with 33 points in controls. The NIS-LSS discriminated LSS patients from healthy controls to a high degree of significance: the optimum NIS-LSS cut-off value was 32 points with a sensitivity of 85.5% and a specificity of 81.3% (p < 0.001). Overall NIS-LSS correlated significantly with the ODI score (p < 0.001). Vibratory sensation (p = 0.04), presence of paresis (p = 0.01) and especially the ability to walk and run (p < 0.001) were the NIS-LSS elements that correlated most closely with the degree of disability assessed by the ODI.

CONCLUSIONS

The NIS-LSS is a simple and valid measure of neurological impairment in the lower limbs of patients with LSS (without comorbidity), discriminating them from healthy controls to a high degree of sensitivity and specificity and correlating closely with the degree of disability. It extends our ability to quantify neurological status and to follow changes arising out of the natural course of the disease or the effects of treatment.