Analgesic Effects of Preoperative Combination of Oral Pregabalin and Intravenous Magnesium Sulfate on Postoperative Pain in Patients Undergoing Posterolateral Spinal Fusion Surgery: A 4-arm, Randomized, Double-blind, Placebo-controlled Trial

BACKGROUND

Multimodal perioperative pain management including nonopioid analgesia is a major pillar of enhanced recovery after surgery programs. The aim of this study was to investigate the analgesic efficacy of the preoperative combination of 2 nonopioid drugs, oral pregabalin and intravenous magnesium sulfate, in patients undergoing posterolateral lumbar spinal fusion.

METHODS

This 4-arm, randomized, double-blind, placebo-controlled trial included 104 patients randomly allocated to receive: magnesium sulfate and pregabalin (MP), magnesium sulfate and oral placebo (M), 0.9% saline and oral pregabalin (P), and 0.9% saline and oral placebo (C). The study drugs were administered 1 hour preoperatively. The primary outcome was the cumulative morphine consumption on postoperative day 1. Secondary outcomes included visual analog scale scores for leg pain at rest and with movement, and postoperative nausea and vomiting (PONV) in the first 48 hours after surgery.

RESULTS

Cumulative morphine consumption on postoperative day 1 was lower in group MP (19.6±8.0 mg) compared with group M (32.6±9.5 mg; P <0.001), group P (28.9±9.4 mg; P =0.001), or group C (38.8±10.3 mg; P <0.001). Multiple linear regression demonstrated a significant association between group MP and cumulative morphine consumption (B=-5.4 [95% CI, -7.1, -3.7], P <0.001). Visual analog scale scores for leg pain at rest and with movement were lower in group MP compared with other groups ( P =0.006 and <0.001). The incidence of PONV was also lowest in group MP ( P =0.032).

CONCLUSIONS

Preoperative administration of oral pregabalin and intravenous magnesium sulfate resulted in reduced morphine consumption and greater analgesic effect than the use of each drug individually or placebo in patients undergoing posterolateral lumbar spinal fusion.

Hyperbaric Oxygen Therapy as an Alternative Therapeutic Option for Radiation-Induced Necrosis Following Radiotherapy for Intracranial Pathologies

BACKGROUND

Radiotherapy (RT) is a feasible adjuvant therapeutic option for managing intracranial pathologies. One of the late complications of RT that frequently develops within months following RT is radiation necrosis (RN). Corticosteroids are the first-line therapeutic option for RNs; however, in case of unfavorable outcomes or intolerability, several other options, including bevacizumab, laser interstitial thermal therapy, surgery, and hyperbaric oxygen therapy (HBOT). Our goal was to investigate the feasibility and efficacy of the application of HBOT in RNs following RT and help physicians make decisions based on the latest data in the literature.

METHODS

We provide a comprehensive review of the literature on the current issues of utilization of HBOT in RNs.

RESULTS

We included 11 studies with a total of 46 patients who underwent HBOT. Most of the cases were diagnosed with brain tumors or arteriovenous malformations. Improvement was achieved in most of the cases.

DISCUSSION

HBOT is a noninvasive therapeutic intervention that can play a role in adjuvant therapy concurrent with RT and chemotherapy and treating RNs. HBOT resolves the RN through 3 mechanisms, including angiogenesis, anti-inflammatory modulation, and cellular repair. Previous studies demonstrated that HBOT is a feasible and well-tolerated therapeutic option that has shown promising results in improving clinical and radiological outcomes in intracranial RNs. Complications of HBOT are usually mild and reversible.

CONCLUSIONS

HBOT is a feasible and effective therapeutic option in steroid-refractory RNs and is associated with favorable outcomes and a low rate of side effects.

Effects of Preoperative Use of Povidone-Iodine-Impregnated Dressing on Postoperative Rate of Surgical Site Infection in Patients Undergoing Posterolateral Lumbar Spinal Fusion Surgery: A Randomized, Nonblinded, Active-Controlled Trial

BACKGROUND AND OBJECTIVES

No study has evaluated the efficacy of using preoperative antiseptic dressings in reducing the rate of surgical site infection (SSI) in spine surgery thus far. To investigate the efficacy of the use of preoperative povidone-iodine-impregnated antiseptic dressings in patients undergoing instrumented posterolateral lumbar spinal fusion.

METHODS

This was a randomized, nonblinded, active-controlled, parallel-group clinical trial. Patients were randomly assigned to the 2 study groups, including treatment and control. Patients in the treatment group received povidone-iodine-impregnated antiseptic dressing applied to the anticipated incision site 12 hours before the operation. The control group merely received the standard perioperative care with no additional intervention or placebo. Patients were followed up for 90 days, and SSIs were recorded.

RESULTS

A total of 200 patients were included in this study (100 in each arm). Three cases of SSI were observed in the treatment group compared with 12 in the control one. A significant reduction in the postoperative rate of SSI was observed in the treatment group compared with the control one (P = .029). In addition to study intervention (P = .029), body mass index (P = .005), smoking status (P = .005), duration of the procedure (P = .003), American Society of Anesthesiologists class (P = .002), and diabetes mellitus (P < .001) were significantly associated with the postoperative rate of SSI.

CONCLUSION

To the best of our knowledge, this study for the first time showed that preoperative use of antiseptic dressings is significantly effective in reducing the rate of SSI in instrumented posterior lumbar spinal fusion surgery. Future studies are warranted to evaluate the efficacy of different preparations or the effectiveness of the present one in patients undergoing spine procedures with other surgical characteristics.

Beneficial effects of the combination of BCc1 and Hep-S nanochelating-based medicines on IL-6 in hospitalized moderate COVID-19 adult patients: a randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

In the severe forms of COVID-19 and many other infectious diseases, the patients develop a cytokine storm syndrome (CSS) where pro-inflammatory cytokines such as IL-6 and TNF-α play a key role in the development of this serious process. Selenium and iron are two important trace minerals, and their metabolism is tightly connected to immune system function. Numerous studies highlight the role of selenium and iron metabolism changes in the procedure of COVID-19 inflammation. The immunomodulator effect of nanomedicines that are synthesized based on nanochelating technology has been proved in previous studies. In the present study, the effects of the combination of BCc1(with iron-chelating property) and Hep-S (containing selenium) nanomedicines on mentioned cytokines levels in hospitalized moderate COVID-19 patients were evaluated.

METHODS

Laboratory-confirmed moderate COVID-19 patients were enrolled to participate in a randomized, double-blind, placebo-controlled study in two separate groups: combination of BCc1 and Hep-S (N = 62) (treatment) or placebo (N = 60) (placebo). The blood samples were taken before medications on day zero, at discharge, and 28 days after consumption to measure hematological and biochemical parameters and cytokine levels. The clinical symptoms of all the patients were recorded according to an assessment questionnaire before the start of the treatment and on days 3 and discharge day.

RESULTS

The results revealed that consumption of the nanomedicines led to a significant decrease in the mean level of IL-6 cytokine, and at the end of the study, there was a 77% downward trend in IL-6 in the nanomedicine group, while an 18% increase in the placebo group (p < 0.05). In addition, the patients in the nanomedicines group had lower TNF-α levels; accordingly, there was a 21% decrease in TNF-α level in the treatment group, while a 31% increase in this cytokine level in the placebo was observed (p > 0.05). On the other hand, in nanomedicines treated groups, clinical scores of coughing, fatigue, and need for oxygen therapy improved.

CONCLUSIONS

In conclusion, the combination of BCc1 and Hep-S inhibits IL-6 as a highly important and well-known cytokine in COVID-19 pathophysiology and presents a promising view for immunomodulation that can manage CSS.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials RCT20170731035423N2 . Registered on June 12, 2020.

Management of Glioblastoma Multiforme During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic: A Review of the Literature

BACKGROUND

Patients with glioblastoma multiforme (GBM) and other patients with cancer are at a greater risk of developing severe complications as a result of coronavirus disease 2019 (COVID-19) infection. Therefore, it is crucial to adjust therapeutic approaches to reduce exposure and complications and achieve the most appropriate treatment outcomes.

OBJECTIVE

Our goal was to help physicians to make decisions based on the latest data in the literature.

METHOD

We provide a comprehensive review of the literature on the current issues of GBM and COVID-19 infection.

RESULTS

The mortality of patients with diffuse glioma as a result of COVID-19 infection was 39%, which is higher than in the general population. The statistics showed that 84.5% of patients with diagnosed brain cancer (mostly GBM) and 89.9% of their caregivers received COVID-19 vaccines. The decision to apply different therapeutic approaches must be made individually based on age, tumor grade, molecular profile, and performance status. The advantages and disadvantages of adjuvant radiotherapy and chemotherapy after the surgery should be evaluated carefully. In the setting of the follow-up period, special considerations must be considered to minimize COVID-19 exposure.

CONCLUSIONS

The pandemic altered medical approaches worldwide, and the management of patients in an immunocompromised state, such as patients with GBM, is challenging; therefore, special considerations must be considered.

Gliomatosis cerebri with blindness: A case report with literature review

Cerebral gliomatosis (GC) is a rare diffuse infiltrative growth pattern of glioma with nonspecific clinical manifestations like visual impairment that may involve bilateral temporal lobes. Herpes simplex encephalitis (HSE) and limbic encephalitis (LE) can also lead to temporal lobe involvement. Differentiating these entities is necessary for patients with misleading presentations and imaging findings. To the best of our knowledge, this is the third case of GC presenting with blindness. The patient was a 35 years-old male in a drug rehabilitation center for heroin addiction. He presented with a headache, a single episode of seizure, and a 2-month history of bilateral decrease in visual acuity, which had acutely worsened. Magnetic resonance imaging (MRI) and computed tomography (CT) showed bilateral temporal lobe involvement. Ophthalmological studies showed bilateral papilledema, absence of visual evoked potential, and thickening of the retinal nerve fiber layer. Due to this clinical presentation, normal laboratory data, and suspicious MRI findings, further investigation with magnetic resonance spectroscopy (MRS) was performed. Results showed a greatly increased ratio of choline to creatinine(Cr) or N-acetyl aspartate (NAA), suggesting a neoplastic nature of the disease. Subsequently, the patient was referred for a brain tissue biopsy with a suspicion of malignancy. The pathology results revealed adult-type diffuse glioma with isocitrate dehydrogenase (IDH) mutation. Bilateral blindness, as well as bilateral temporal lobe involvement, each has many different causes. However, as demonstrated in this study, adult-type diffuse glioma must be considered a rare cause of concomitant bilateral temporal lobe involvement and blindness.

Suicide gene therapy using allogeneic adipose tissue-derived mesenchymal stem cell gene delivery vehicles in recurrent glioblastoma multiforme: a first-in-human, dose-escalation, phase I clinical trial

BACKGROUND

Glioblastoma multiforme (GBM) is associated with remarkably poor prognosis, and its treatment is challenging. This investigation aimed to evaluate the safety of suicide gene therapy using allogeneic adipose tissue-derived mesenchymal stem cells (ADSCs) carrying herpes simplex virus-thymidine kinase (HSV-TK) gene for the first time in patients with recurrent GBM.

METHODS

This study was a first-in-human, open-label, single-arm, phase I clinical trial with a classic 3 + 3 dose escalation design. Patients who did not undergo surgery for their recurrence were included and received this gene therapy protocol. Patients received the intratumoral stereotactic injection of ADSCs according to the assigned dose followed by prodrug administration for 14 days. The first dosing cohort (n = 3) received 2.5 × 10⁵ ADSCs; the second dosing cohort (n = 3) received 5 × 10⁵ ADSCs; the third dosing cohort (n = 6) received 10 × 10⁵ ADSCs. The primary outcome measure was the safety profile of the intervention.

RESULTS

A total of 12 patients with recurrent GBM were recruited. The median follow-up was 16 (IQR, 14-18.5) months. This gene therapy protocol was safe and well tolerated. During the study period, eleven (91.7%) patients showed tumor progression, and nine (75.0%) died. The median overall survival (OS) was 16.0 months (95% CI 14.3-17.7) and the median progression-free survival (PFS) was 11.0 months (95% CI 8.3-13.7). A total of 8 and 4 patients showed partial response and stable disease, respectively. Moreover, significant changes were observed in volumetric analysis, peripheral blood cell counts, and cytokine profile.

CONCLUSIONS

The present clinical trial, for the first time, showed that suicide gene therapy using allogeneic ADSCs carrying the HSV-TK gene is safe in patients with recurrent GBM. Future phase II/III clinical trials with multiple arms are warranted to validate our findings and further investigate the efficacy of this protocol compared with standard therapy alone.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT), IRCT20200502047277N2. Registered 8 October 2020, https://www.irct.ir/ .

Safety and Potential Efficacy of Selective Dorsal Rhizotomy in Adults with Spinal Cord Injury-Induced Spasticity: An Open-Label, Non-Randomized, Single-Arm Trial

BACKGROUND

Despite the abundant literature on the use of selective dorsal rhizotomy (SDR) in spastic cerebral palsy, no investigation has evaluated its use in adult patients with chronic spinal cord injury (SCI)-induced spasticity. The present investigation aimed to evaluate the safety and potential efficacy of SDR in chronic SCI-induced spasticity for the first time.

METHODS

In this open-label, single-arm, non-randomized clinical trial, all patients were assigned to the single study intervention arm and underwent SDR. The primary outcome measure was the safety profile of SDR. Secondary outcome measures were Modified Ashworth Scale, Penn Spasm Frequency Scale, visual analog scale for spasticity, Spinal Cord Injury Spasticity Tool, Spinal Cord Independence measure version III, and Short Form 36 Health Survey Questionnaire.

RESULTS

Six patients with cervical SCI and 4 with thoracic SCI were allocated to the single study intervention arm. No adverse event attributable to the SDR was found. Moreover, all secondary outcome measures of the study improved significantly over the study period (P < 0.001). Multiple regression analysis also found a significant association between level of injury and changes in average Modified Ashworth Scale scores (P = 0.041), Spinal Cord Injury Spasticity Tool score (P = 0.013), and Spinal Cord Independence measure version III total (P = 0.002) and mobility domain scores (P = 0.004) at 12-month postoperatively.

CONCLUSIONS

This clinical trial indicated that SDR is a safe and potentially effective procedure in patients with severe and intractable SCI-induced spasticity. However, future clinical trials with larger sample sizes and adequate power are required to validate our findings regarding efficacy.

Global and Regional DNA methylation silencing of PPARγ Associated with Glioblastoma Multiforme Pathogenesis

BACKGROUND

The relationship between peroxisome proliferator-activated receptor gamma (PPARγ) expression level and epigenetic modifications occurring in glioblastoma multiforme (GBM) pathogenesis is largely unknown. Herein, we examine the association of PPARγ expression with its promoter and genomic global DNA methylation status, as well as DNA methyltransferases (DNMTs) gene expression in GBM patients.

METHODS

We examined the patterns of promoter methylation and PPARγ expression in 26 GBM tissues and 13 adjacent non-tumor tissues by methylation-specific PCR (MSP), real-time PCR, and ELISA, respectively. Also, we examined the genomic global 5-methyl cytosine levels and DNMTs gene expression using ELISA and real-time PCR methods, respectively.

RESULTS

We found that hypermethylation on a specific region of the PPARγ promoter is significantly associated with the downregulation of the PPARγ gene and protein level in GBM patients. Interestingly, the amount of 5-methyl cytosine level was significantly reduced in GBM patients and positively correlated with PPARγ protein expression. Furthermore, the expression level of DNMT1, DNMT3A, and 3B were upregulated in GBM patients and the average expression level of all three DNMTs was positively correlated with tumor area. Also, we found that tumors from cortical regions exhibited a higher global DNA hypomethylation and PPARγ hypermethylation was related to the increase in GBM risk.

CONCLUSION

Our study demonstrated that global DNA methylation and PPARγ epigenetic silencing is associated with the GBM risk. Our data provide a novel molecular mechanistic insight into epigenetic silencing of PPARγ in GBM patients that may be relevant as a key tumor marker for GBM pathogenesis.

Case report: Stem cell-based suicide gene therapy mediated by the herpes simplex virus thymidine kinase gene reduces tumor progression in multifocal glioblastoma

Introduction

The prognosis for glioblastoma multiforme (GBM), a malignant brain tumor, is poor despite recent advancements in treatments. Suicide gene therapy is a therapeutic strategy for cancer that requires a gene to encode a prodrug-activating enzyme which is then transduced into a vector, such as mesenchymal stem cells (MSCs). The vector is then injected into the tumor tissue and exerts its antitumor effects.

Case presentation

A 37-year-old man presented to our department with two evident foci of glioblastoma multiforme at the left frontal and left parietal lobes. The patient received an injection of bone marrow-derived MSCs delivering the herpes simplex virus thymidine kinase (HSV-tk) gene to the frontal focus of the tumor, followed by ganciclovir administration as a prodrug for 14 days. For follow-up, the patient was periodically assessed using magnetic resonance imaging (MRI). The growth and recurrence patterns of the foci were assessed. After the injection on 09 February 2019, the patient's follow-up appointment on 19 December 2019 MRI revealed a recurrence of parietal focus. However, the frontal focus had a slight and unremarkable enhancement. On the last follow-up (18 March 2020), the left frontal focus had no prominent recurrence; however, the size of the left parietal focus increased and extended to the contralateral hemisphere through the corpus callosum. Eventually, the patient passed away on 16 July 2020 (progression-free survival (PFS) = 293 days, overall survival (OS) = 513 days).

Conclusion

The gliomatous focus (frontal) treated with bone marrow-derived MSCs carrying the HSV-TK gene had a different pattern of growth and recurrence compared with the non-treated one (parietal).

Trial registration

IRCT20200502047277N2. Registered 10 May 2020-Retrospectively registered, https://eng.irct.ir/trial/48110.

Effects of local intraoperative epidural use of triamcinolone acetonide-soaked Gelfoam on postoperative outcomes in patients undergoing posterolateral lumbar spinal fusion surgery: a randomized, placebo-controlled, double-blind trial

OBJECTIVE

Prior evidence has supported the use of local intraoperative epidural steroids in lumbar discectomy for improvements in postoperative pain and outcomes. However, currently there is a paucity of data regarding the efficacy of local epidural steroids in spinal fusion procedures. The present investigation aimed to evaluate the impact of local epidural administration of triamcinolone acetonide-soaked Gelfoam on postoperative pain and patient-reported outcomes in patients undergoing instrumented posterolateral lumbar spinal fusion.

METHODS

In this randomized, double-blind, placebo-controlled trial, patients were randomly divided into two groups (treatment and control). Patients in the treatment group received a Gelfoam carrier soaked in 1 ml of triamcinolone acetonide (40 mg), which was placed over the nerve roots in the epidural space before the closure. Patients in the control group received a Gelfoam carrier soaked in normal saline in a similar fashion to the treatment group. Patients were followed up during their hospital stay and at 4 and 12 weeks postoperatively. The primary outcome measure was early postoperative visual analog scale (VAS) scores for pain both at rest and with movement.

RESULTS

A total of 100 patients were recruited in this study and were randomly allocated to the treatment or control group. No significant difference was found in baseline demographic, clinical, and surgical characteristics between the two groups. Postoperative VAS scores for pain both at rest and with movement were comparable between the treatment and control groups. Cumulative morphine consumption, length of hospital stay, and incidence of postoperative complications such as surgical site infection were also similar between the two groups. There was no significant difference in patient-reported outcomes including VAS scores for back and leg pain as well as the Oswestry Disability Index at 4 and 12 weeks postoperatively. The proportion of patients who achieved a minimum clinically important difference for patient-reported outcomes were also similar between the two groups.

CONCLUSIONS

In contrast to the existing literature on the beneficial use of local intraoperative epidural steroids in conventional lumbar discectomy, the present study did not demonstrate such significant efficacy for the use of local epidural steroids in instrumented posterolateral lumbar spinal fusion. However, there is still a lack of evidence in this regard and further high-quality clinical trials are required to evaluate the efficacy of local epidural steroids in this group of patients.

Protein Supplement and Enhanced Recovery After Posterior Spine Fusion Surgery: A Randomized, Double-blind, Placebo-controlled Trial

STUDY DESIGN

This was a randomized, double-blind clinical trial study.

OBJECTIVE

The objective of this study was to evaluate the effect of protein supplementation on vertebral fusion and enhanced recovery after posterior spine fusion (PSF) surgery.

SUMMARY OF BACKGROUND DATA

Nonfusion is one of the most common complications of lumbar spine surgery. It has been shown that protein plays an important role in bone repair; however, its correlation to vertebral fusion following PSF surgery is unknown.

PATIENTS AND METHODS

In this randomized, double-blind clinical trial study, the intervention group received a diet with 1.2 g of protein plus high-protein supplement (36 g whey protein), and the control group received a similar diet, except for starch as a placebo from 48 hours before to 1 month after surgery.

RESULTS

The intervention group showed a significantly higher rate of vertebral fusion compared with the control group (P=0.019). Surgical site infection and pain were significantly lower in the intervention group. A significant difference was found in the wound healing rate in favor of the intervention group. The rates of decrease in serum high-sensitivity C-reactive protein levels and increase in serum levels of insulin-like growth factor 1, albumin, total protein, and alkaline phosphatase were greater in the intervention group than in the control group (P<0.001).

CONCLUSIONS

Increased protein intake improves vertebral fusion and enhances recovery in patients undergoing PSF. This was the first study to investigate the effect of protein on fusion and healing factors; as a result, further clinical trials are needed to confirm the current results.

The Effect of Vitamin D Deficiency on Outcomes of Patients Undergoing Elective Spinal Fusion Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Vitamin D plays a major role in bone metabolism, regulating calcium and phosphorus homeostasis, along with bone growth and remodeling processes. The objective of the present study was to assess the effect of vitamin D deficiency on clinical outcomes following elective spinal fusion surgery by conducting a meta-analysis on the relevant literature.

METHODS

Studies included in this analysis involved patients older than 18 years who underwent elective spinal fusion surgery. The number of patients as well as visual analog scale (VAS) and Oswestry Disability Index (ODI) in groups with and without vitamin D deficiency were required to be reported in eligible studies. Of the 179 articles identified, 7 met the inclusion criteria and were included in the analysis.

RESULTS

Seven studies, including 1188 patients, reported the relationship between vitamin D deficiency and clinical outcomes in patients undergoing elective spinal fusion surgery. Five studies reported VAS as a primary outcome. The combined results using a random-effects model showed reduction in VAS after elective spinal fusion surgery in group with vitamin D deficiency, but no statistically significant association was identified between vitamin D deficiency and VAS. ODI was assessed and reported as an outcome measure in 5 of the included studies. The combined results showed an increase in ODI following elective spinal fusion surgery in the vitamin D-deficient group compared to the group with normal levels of vitamin D. In addition, a significant association was observed between ODI and vitamin D deficiency.

CONCLUSIONS

Vitamin D deficiency may negatively affect the postoperative outcomes in elective spinal fusion surgery. Preoperative optimization of vitamin D levels would seem appropriate. Future high-quality studies are highly warranted to evaluate this.

CLINICAL RELEVANCE

This meta-analysis demonstrated a significant association between vitamin D deficiency and postoperative ODI scores in patients undergoing elective spinal fusion surgery.

LEVEL OF EVIDENCE: 2

Safety of intraparenchymal injection of allogenic placenta mesenchymal stem cells derived exosome in patients undergoing decompressive craniectomy following malignant middle cerebral artery infarct, a pilot randomized clinical trial

Background:

Malignant middle cerebral artery infarct (mMCAI) largely contributes to high mortality and physical disability among adults. Surviving individuals may not have proper outcomes and suffer from severe lasting disabilities. Utilization of stem cells and paracrine factor for regenerative purposes is considered as a potential strategy for patients with neurological deficits. While preclinical stroke studies have shown that mesenchymal stem cells (MSCs) reduce post-treatment neurological deficits and prevent disability and also promote recovery, few randomized clinical trials (RCT) have assessed exosome therapy in humans.

Methods:

In this RCT, we assessed the safety of intraparenchymal injection placenta MSC-derived Exosome in mMCAI patients with average age of 62 years between January, 2019, till September, 2020. The study was done in a single-center as an open-label RCT, with a 3-months follow-up. Primary outcomes assessed the safety and also disability indexes were followed.

Results:

Five mMCAI patients were included with mean NIHSS: 17.6 ± 5.02. The mean MRS was 3.25 ± 0.95 in three patients. No serious adverse events were observed. Hematoma or local reaction as excessive edema were not seen at the site of injection.

Conclusions:

Intraparenchymal implantation of MSC-EXO showed no post-interventional adverse effects in five ischemic stroke patients. It is proposed Local injection Exosome treatment following mMCAI can be safe and in future, it would be applied as a supportive, restorative and preventive treatment in patients who suffer from acute ischemic stroke and post ischemic disability.

Factors Associated With Neurogenic Bowel Dysfunction Severity in Spinal Cord Injury: A Cross-sectional Study

Background: Neurogenic bowel dysfunction (NBD) caused by spinal cord injury (SCI) is a major life limiting issue for many patients. However, studies detailing the factors contributing to bowel problems are scarce. The aim of this cross-sectional questionnaire-based study was to evaluate the associations between different aspects of bowel problems and characteristics of SCI, such as time since injury (TSI), level of injury (LOI), and the cause of injury. Methods: Two questionnaires (the NBD score questionnaire and the Cleveland clinic constipation system score questionnaire) were administered to complete, traumatic patients with SCI that matched the designated criteria. The total scores and the subscales were then regressed to TSI and LOI, and the distribution patterns of NBD score severity according to LOI and cause of injury were shown in a diagram. Results: Within the subscales of the NBD score, frequency of defecation, digital stimulation or evacuation of the anorectum, and perianal skin problems were all significantly and positively correlated with the TSI, yet the frequency of fecal incontinence was negatively associated with this variable. Moreover, uneasiness, headache, or perspiration during defecation and regular use of drops against constipation were negatively associated with the LOI. In the diagrams, patterns of NBD score severity were similar according to LOI, but visibly differed according to cause. With respect to the CCCS score (Cleveland Clinic Constipation Scoring System), the score itself was shown to be positively associated with TSI. Within the subscales, difficulty, time spent in lavatory, and duration of constipation were positively correlated with TSI. Furthermore, type of assistance was negatively associated with the LOI. Conclusion: Different characteristics of SCI, TSI, LOI, and cause, each are significantly and distinctly associated with different aspects of the bowel problems that patients with SCI face.

Safety and feasibility of autologous olfactory ensheathing cell and bone marrow mesenchymal stem cell co-transplantation in chronic human spinal cord injury: a clinical trial

STUDY DESIGN

This is a phase I clinical trial.

OBJECTIVES

Our objective was to assess the safety and feasibility of autologous mucosal olfactory ensheathing cell (OEC) and bone marrow mesenchymal stem cell (MSC) co-transplantation in people with chronic, complete (American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification A) spinal cord injury (SCI).

SETTING

This study was performed at Shohada Tajrish Hospital, Tehran, Iran.

METHODS

Three individuals with the traumatic SCI of the thoracic level were enrolled. They received the autologous OEC and MSC combination through the lumbar puncture. All adverse events and possible functional outcomes were documented performing pre- and post-operative general clinical examination, magnetic resonance imaging (MRI), neurological assessment based on the International Standard of Neurological Classification for SCI, and functional evaluation using Spinal Cord Independence Measure version III (SCIM III).

RESULTS

No serious safety issue was recorded during the 2 years of follow-up. MRI findings remained unchanged with no neoplastic tissue formation. AIS improved from A to B in one of the participants. SCIM III evaluation also showed some degrees of progress in this participant's functional ability. The two other research participants had negligible or no improvement in their sensory scores without any changes in the AIS and SCIM III scores. No motor recovery was observed in any of the participants.

CONCLUSIONS

Overall, this 2-year trial was not associated with any adverse findings, which may suggest the safety of autologous OEC and bone marrow MSC combination for the treatment of human SCI.

Combining cell therapy with human autologous Schwann cell and bone marrow-derived mesenchymal stem cell in patients with subacute complete spinal cord injury: safety considerations and possible outcomes

Background

Cellular transplantations have promising effects on treating spinal cord injury (SCI) patients. Mesenchymal stem cells (MSCs) and Schwann cells (SCs), which have safety alongside their complementary characteristics, are suggested to be the two of the best candidates in SCI treatment. In this study, we assessed the safety and possible outcomes of intrathecal co-transplantation of autologous bone marrow MSC and SC in patients with subacute traumatic complete SCI.

Methods

Eleven patients with complete SCI (American Spinal Injury Association Impairment Scale (AIS); grade A) were enrolled in this study during the subacute period of injury. The patients received an intrathecal autologous combination of MSC and SC and were followed up for 12 months. We assessed the neurological changes by the American Spinal Injury Association’s (ASIA) sensory-motor scale, functional recovery by spinal cord independence measure (SCIM-III), and subjective changes along with adverse events (AE) with our checklist. Furthermore, electromyography (EMG), nerve conduction velocity (NCV), magnetic resonance imaging (MRI), and urodynamic study (UDS) were conducted for all the patients at the baseline, 6 months, and 1 year after the intervention.

Results

Light touch AIS score alterations were approximately the same as the pinprick changes (11.6 ± 13.1 and 12 ± 13, respectively) in 50% of the cervical and 63% of the lumbar-thoracic patients, and both were more than the motor score alterations (9.5 ± 3.3 in 75% of the cervical and 14% of the lumbar-thoracic patients). SCIM III total scores (21.2 ± 13.3) and all its sub-scores (“respiration and sphincter management” (15 ± 9.9), “mobility” (9.5 ± 13.3), and “self-care” (6 ± 1.4)) had statistically significant changes after cell injection. Our findings support that the most remarkable positive, subjective improvements were in trunk movement, equilibrium in standing/sitting position, the sensation of the bladder and rectal filling, and the ability of voluntary voiding. Our safety evaluation revealed no systemic complications, and radiological images showed no neoplastic overgrowth, syringomyelia, or pseudo-meningocele.

Conclusion

The present study showed that autologous SC and bone marrow-derived MSC transplantation at the subacute stage of SCI could reveal statistically significant improvement in sensory and neurological functions among the patients. It appears that using this combination of cells is safe and effective for clinical application to spinal cord regeneration during the subacute period.

The Impact of the Coronavirus Disease 2019 Pandemic on Neurosurgical Practice and Feasibility of Safe Resumption of Elective Procedures During this Era in a Large Referral Center in Tehran, Iran: An Unmatched Case-Control Study

Objective

The coronavirus disease 2019 (COVID-19) pandemic has considerably affected surgical practice. The present study aimed to investigate the effects of the pandemic on neurosurgical practice and the safety of the resumption of elective procedures through implementing screening protocols in a high-volume academic public center in Iran, as one of the countries severely affected by the pandemic.

Methods

This unmatched case-control study compared 2 populations of patients who underwent neurosurgical procedures between June 1, 2019 and September 1, 2019 and the same period in 2020. In the prospective part of the study, patients who underwent elective procedures were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection postoperatively to evaluate the viability of our screening protocol.

Results

Elective and emergency procedures showed significant reduction during the pandemic (59.4%, n = 168 vs. 71.3%, n = 380) and increase (28.7%, n = 153 vs. 40.6%, n = 115, respectively; P = 0.003). The proportional distribution of neurosurgical categories remained unchanged during the pandemic. Poisson regression showed that the reduction in total daily admissions and some categories, including spine, trauma, oncology, and infection were significantly correlated with the pandemic. Among patients who underwent elective procedures, 0 (0.0%) and 26 (16.25%) had positive test results on days 30 and 60 postoperatively, respectively. Overall mortality was comparable between the pre–COVID-19 and COVID-19 periods, yet patients with concurrent SARS-CoV-2 infection showed substantially higher mortality (65%).

Conclusions

By implementing safety and screening protocols with proper resource allocation, the emergency care capacity can be maintained and the risk minimized of hospital-acquired SARS-CoV-2 infection, complications, and mortality among neurosurgical patients during the pandemic. Similarly, for elective procedures, according to available resources, hospital beds can be allocated for patients with a higher risk of delayed hospitalization and those who are concerned about the risk of hospital-acquired infection can be reassured.

Frequency of Lactobacillus plantarum, Lactobacillus acidophilus, and Enterococcus faecalis in Patients Suffering From Glioma Compared to Healthy Individuals

Background: Glioma is a type of the primary tumors that progresses in the spinal cord and brain. Probiotics have probably a protective impact against the disease, especially when treated as a microbial flora in the gut. Objectives: Given the effective role of microbiota in body function, this study aimed to investigate the frequency of Lactobacillus plantarum, Lactobacillus acidophilus, and Enterococcus faecalis in patients suffering from glioma compared to healthy subjects. Materials and Methods: To achieve our study objectives, 20 patients with glioma tumors as well as 20 healthy individuals were enrolled. Stool samples were taken from the subjects and stored at minus 20 degrees after processing. Real-Time PCR technique was employed to assess the change in the copy number of L. acidophilus, L. plantarum, and E. faecalis in patients with glioma in comparison to healthy individuals. Results: The results showed significant difference between the population of L. plantarum in the patients and healthy individuals (P=0.0004). The patients with glioma were in the 35-60 age range and the mean age of healthy individuals was 45 years (P=0.48). Conclusion: It was concluded that L. plantarum had potential for tumor induction.

Cauda equina syndrome due to herpes simplex virus type 2-associated meningoradiculitis (Elsberg syndrome) after posterior lumbar spinal fusion surgery: Case report and review of literature

Elsberg syndrome is a rare but well-defined clinical condition, including acute or subacute lumbosacral meningoradiculitis, which might be accompanied by myelitis and is often associated with herpes simplex virus type 2 (HSV-2) infection. We report the case of an immunocompetent 24-year-old man who presented with perineal pain, saddle hypoesthesia, and urinary retention associated with Elsberg syndrome due to HSV-2 infection 20-day after the posterior lumbar spinal fusion surgery. Lumbar magnetic resonance imaging (MRI) with gadolinium enhancement showed mildly enhanced and swollen right sacral nerve roots. One week after the admission, electromyography and nerve conduction studies (EMG-NCS) demonstrated severe axonal damage and radiculopathy at right S3 and S4 roots. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, elevated protein, positive HSV-2 IgG index, and positive HSV-2 polymerase chain reaction (PCR). The patient was treated with intravenous acyclovir for 14 days and showed a gradual improvement in anal sphincter control and urination. Therefore, according to our findings, surgery might have an immunosuppressing role, and in cases with symptoms of cauda equina syndrome (CES) and systemic infection, in the postoperative setting, viral meningoradiculitis should be considered.

Effect of Protein Supplement on Paraspinal Muscles in Spine Fusion Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Dysfunction and weakness due to atrophy of the paraspinal muscles is a major issue after posterior spinal fusion (PSF) surgery, resulting in pain and disability. Considering the role of protein in muscle regeneration, it seems that protein supplements after surgery may prevent muscle atrophy. To date, to our knowledge, no intervention study has investigated the effect of protein supplementation on the volume of paraspinal muscles, pain, or disability after PSF.

METHODS

In this randomized, double-blind, placebo-controlled clinical trial, patients were randomly assigned to a control (placebo + diet with 1.2 g/kg body weight of protein, n = 40) or a protein supplementation (36 g/day + a diet with 1.2 g/kg body weight of protein, n = 40) group, which received intervention from 48 hours before to 1 month after surgery. The cross-sectional area (CSA) of the paraspinal muscles was measured by thin-slice computed tomography, and pain and disability were assessed using the visual analog scale and Oswestry Disability Index.

RESULTS

After 4 weeks of protein supplementation, the CSAs of multifidus and psoas muscles on both sides were significantly higher in the supplementation group than the placebo group (P <.001). Less atrophy was seen in the right erector spinae and quadratus lumborum muscles in the group receiving protein supplements than the placebo group (P < .001). In addition, protein supplementation was significantly negatively correlated with both pain (P < .001) and disability (P < .001).

CONCLUSIONS

In conclusion, we demonstrated that 36 g/day protein supplementation significantly increased the CSA of muscles and reduced the atrophy, pain, and disability after PSF surgery.

LEVEL OF EVIDENCE

2.

Changed pattern of hospital admission in stroke during COVID-19 pandemic period in Iran: a retrospective study

BACKGROUND

Some previous reports have shown a reduced number of admission in stroke cases during the coronavirus disease 2019 (COVID-19) pandemic period. The present study aimed to investigate this changing pattern and the potential causes behind it at an academic neurology and neurosurgery center in Iran.

METHODS

Patients admitted to our center with the diagnosis of ischemic and hemorrhagic stroke, between March 1, 2019, Jun 1, 2019, and the similar 3-month period in 2020 (COVID-19 pandemic period), were compared in terms of clinical characteristics and outcome. Poisson regression was also conducted to assess the correlation between daily admissions and the COVID-19 pandemic period.

RESULTS

A total of 210 patients with stroke (ischemic and hemorrhagic) in 2019 were compared with 106 patients in 2020. COVID-19 pandemic period was significantly associated with the decline in the number of daily admissions in ischemic stroke (IRR, 0.51 [95% CI, 0.4-0.64]). A significant reduction (P = 0.003) in time from onset to arrival at hospital from median 12 h [IQR, 5-32] in 2019 to median 6 h [IQR, 4-16] in 2020 was found in ischemic stroke cases. National Institute of Health Stroke Scale (NIHSS) was significantly increased (P < 0.001) from median 4 [IQR, 2-7] in 2019 to median 9 [IQR, 4-14] in 2020. Glasgow coma scale (GCS) was significantly decreased from 13.9 (SD, 2) in 2019 to 12.8 (SD, 2.9) in 2020 (P < 0.001).

CONCLUSIONS

The present study provided new pieces of evidence regarding the changed pattern of hospital admission in stroke especially the possible reasons for its decline.

Stem Cell-Derived Exosomes as Treatment for Stroke: a Systematic Review

BACKGROUND

The therapeutic potential of stem cells may largely be mediated by paracrine factors contained in exosomes released from intracellular endosomes. A systematic review was performed to identify the effects of stem cell-derived exosomes for their ability to induce restorative effects in animal models of stroke.

METHODS

PubMed, Scopus, and ISI Web of Science databases were searched for all available articles testing stem cell-derived exosomes as therapeutic interventions in animal models of stroke until April 2020. The STAIR scale was used to assess the quality of the included studies.

RESULTS

A total of 994 published articles were identified in the systematic search. After screening for eligibility, a total of 16 datasets were included. Type of cerebral ischemia was transient in majority studies and most studies used rat or mice adipose tissue-derived stem cells/bone marrow-derived stem cells. Eight studies indicated improved functional recovery while 8 were able to show reduced infarct volume as a result of exosome therapy. The beneficial effects were mainly attributed to reduced inflammation and oxidative stress, enhanced neurogenesis, angiogenesis, and neurite remodeling. Also, 4 studies demonstrated that exosomes hold great promise as an endogenous drug delivery nano-system.

CONCLUSION

In preclinical studies, use of stem cell-derived exosomes is strongly associated with improved neurological recovery and reduced brain infarct volume following stroke. Improved preclinical study quality in terms of treatment allocation reporting, randomization and blinding will accelerate needed progress towards clinical trials that should assess feasibility and safety of this therapeutic approach in humans. Graphical abstract.

Covering of Plate after Anterior Cervical Fusion in Patients with Complete Spinal Cord Injury to Prevent Esophageal Injury: Technical Note

BACKGROUND

 Esophageal injury after anterior corpectomy and fusion is a rare but life-threatening complication. It may cause mediastinitis due to anatomical continuity between the retropharyngeal space and the mediastinum, with reported high mortality rates. The acute and subacute injuries are most commonly of iatrogenic origin, while late perforation has been described several weeks to years later as a result of continuous friction or pressure of the instruments against the posterior wall of the esophagus, leading to ischemia and necrosis. This phenomenon is more common among quadriplegic patients who have undergone corpectomy and insertion of expandable or mesh cages and plate probably due to chronic erosion by hardware at the supine position.

METHODS

 Since 2015, we have applied the technique of using a patch of autologous fascia lata to cover the anterior cervical plate by suturing to the longus colli muscles in 58 quadriplegic patients; the mean follow-up was 35.2 (28-41) months.

RESULTS

 Since we started using this procedure, based on our follow-up at our center, there have been no cases of late esophageal perforation among quadriplegic patients.

CONCLUSION

 As a technical note, it seems like this method would be able to reduce the prevalence of esophagus injury among quadriplegic patients. However, to substantiate the efficacy of this technique, long-term follow-up and larger sample size are needed because esophageal injury occurs rarely.

Effects of perioperative magnesium sulfate infusion on intraoperative blood loss and postoperative analgesia in patients undergoing posterior lumbar spinal fusion surgery: A randomized controlled trial

OBJECTIVE

Many studies have suggested the anti-nociceptive role for magnesium either as an adjunct for postoperative pain. Although several studies have been carried out to evaluate the anti-nociceptive effect of magnesium, there is still considerable uncertainty.

PATIENTS AND METHODS

Eighty patients who underwent posterior spinal fusion were randomly divided into two groups (magnesium and saline). Changes in cell count, magnesium concentration and coagulation status were assessed one hour after operation at both group and compared to baseline. At recovery room, their pain score was assessed according to 10 points visual analogue scale (VAS). Morphine consumption was evaluated at regular times after the surgery by patient controlled analgesia (PCA) device.

RESULTS

VAS scores were significantly lower in the magnesium group. Cumulative PCA morphine consumption after the surgery was significantly lower in the magnesium group. Pre and postoperative values for haemoglobin, platelet count, Prothrombin Time (PT), fibrinogen were not significantly different. There was a significant increase in activated Partial Thromboplastin Time (aPTT), International Normalized Ratio (INR), and bleeding time (BT), one hour after the operation in the magnesium group but intraoperative blood loss was similar in both groups.

CONCLUSIONS

Perioperative magnesium sulfate infusion improves the postoperative analgesia, decreases the amount of morphine consumption after the operation and does not change the intraoperative bleeding in patients undergoing posterior spinal fusion surgery.

Down-regulation of 14-3-3 zeta sensitizes human glioblastoma cells to apoptosis induction

Strong 14-3-3 zeta protein expression plays an important role in tumorigenesis, including in the maintenance of cell growth, resistance increase, and the prevention of apoptosis. In this study, we focus on two targets: (1) the expression of 14-3-3 zeta in the different grades of human astrocytoma (II-IV), (2) suppression of 14-3-3 zeta protein expression in glioblastoma derived astrocytes by 14-3-3 zeta shRNA lentiviral particles. The tissues of human astrocytoma were provided from 30 patients (ten of each grade of astrocytoma). Control tissues were obtained from the peritumoral brain zone of those patients with glioblastoma. The protein and mRNA expression levels of each astrocytoma grade were assessed via western blotting and RT-PCR, respectively. Results indicated that 14-3-3 zeta was significantly expressed in glioblastoma multiforme (grade IV) and 14-3-3 zeta expression levels enhanced according to the increase of astrocytoma malignancy. In the cellular study for knock down of the 14-3-3 zeta protein, surgical biopsy of glioblastoma was used to isolate primary astrocyte. Astrocytes were transduced with 14-3-3 zeta shRNA or non-targeted shRNA lentiviral particles. Furthermore, reduction of the 14-3-3 zeta protein expression in the astrocytes evaluated through qRT-PCR and western blot after transduction of 14-3-3 zeta shRNA lentiviral particles. Moreover, apoptosis properties, including DNA fragmentation and ratio increase of Bax/Bcl-2 were observed in astrocytes following reduction of 14-3-3 zeta protein expression. Further observation indicated that the mitochondrial pathway through release of cytochorome c and caspase-3 activity was involved in the apoptosis induction. Hence, this study demonstrates a key role of the 14-3-3 zeta protein in tumorigenesis but also indicates that 14-3-3 zeta can be considered as a target for the astrocytoma treatment specially glioblastoma.

Evaluating the Origin of the Brain Metastatic Tumors by Using DWI Parameters

Background: Brain metastases are the most common tumors in the human central nervous system (CNS), with an occurrence 10 times higher than primary brain tumors in adults. A radiologist usually diagnoses these tumors. Typically, magnetic resonance imaging (MRI) has been used to evaluate the status and number of metastases, the design of surgical treatment or radiotherapy, and the response to treatment. This study aimed to consider the origin of metastatic tumors of the brain using diffusionweighted imaging sequence. Methods: In this study, 95 lesions observed in 51 patients with different types of brain metastasis who analyzed with standard brain MRI protocols such as T2-weighted fast spin-echo in sagittal, coronal and axial planes and T1-weighted spin-echo sequences before and after injection of contrast enhancement and diffusion-weighted imaging. The diffusion-weighted imaging included an echoplanar spin-echo sequence with two b values (0,1000 s/mm) and calculated apparent diffusion coefficient (ADC) maps. We measured the ADC-value on normalized ADC maps and compared them with different methods. ANOVA was used to compare ADC among all groups as well as T-test for every two groups. Results: The results showed that patients with lung cancer (squamous cell carcinoma, SCC) had the lowest mean ADC (658.70*10-3 mm2 /s) and breast cancer patients with the highest mean ADC(935.52*10-3 mm2 /s). This study demonstrated that most Brain metastases had low and intermediate ADC values. The analysis showed no significant difference among all groups. However, ADC values in breast cancer and kidney and lung (adenocarcinoma) were statistically higher in comparison to other groups. There were no critical discrepancies between ADC values in brain metastases from Breast cancer and lung cancer (adenocarcinoma) and kidney. Conclusion: It seems that evaluating the origin of the brain metastatic tumors by using diffusion imaging (DWI) parameters could be helpful to prevent invasive methods like biopsies in some situations. Although it needs more studies to achieve this purpose.

Cytocompatibility of a conductive nanofibrous carbon nanotube/poly (L-Lactic acid) composite scaffold intended for nerve tissue engineering

The purpose of this study was to fabricate a conductive aligned nanofibrous substrate and evaluate its suitability and cytocompatibility with neural cells for nerve tissue engineering purposes. In order to reach these goals, we first used electrospinning to fabricate single-walled carbon-nanotube (SWCNT) incorporated poly(L-lactic acid) (PLLA) nanofibrous scaffolds and then assessed its cytocompatibility with olfactory ensheathing glial cells (OEC). The plasma treated scaffolds were characterized using scanning electron microscopy and water contact angle. OECs were isolated from olfactory bulb of GFP Sprague-Dawley rats and characterized using OEC specific markers via immunocytochemistry and flow cytometery. The cytocompatibility of the conductive aligned nano-featured scaffold was assessed using microscopy and MTT assay. We indicate that doping of PLLA polymer with SWCNT can augment the aligned nanosized substrate with conductivity, making it favorable for nerve tissue engineering. Our results demonstrated that SWCNT/PLLA composite scaffold promote the adhesion, growth, survival and proliferation of OEC. Regarding the ideal physical, topographical and electrical properties of the scaffold and the neurotrophic and migratory features of the OECs, we suggest this scaffold and the cell/scaffold construct as a promising platform for cell delivery to neural defects in nerve tissue engineering approaches.

Neuroregenerative effects of olfactory ensheathing cells transplanted in a multi-layered conductive nanofibrous conduit in peripheral nerve repair in rats

Background

The purpose of this study was to evaluate the efficacy of a multi-layered conductive nanofibrous hollow conduit in combination with olfactory ensheathing cells (OEC) to promote peripheral nerve regeneration. We aimed to harness both the topographical and electrical cues of the aligned conductive nanofibrous single-walled carbon nanotube/ poly (_L-lactic acid) (SWCNT/PLLA) scaffolds along with the neurotrophic features of OEC in a nerve tissue engineered approach.

Results

We demonstrated that SWCNT/PLLA composite scaffolds support the adhesion, growth, survival and proliferation of OEC. Using microsurgical techniques, the tissue engineered nerve conduits were interposed into an 8 mm gap in sciatic nerve defects in rats. Functional recovery was evaluated using sciatic functional index (SFI) fortnightly after the surgery. Histological analyses including immunohistochemistry for S100 and NF markers along with toluidine blue staining (nerve thickness) and TEM imaging (myelin sheath thickness) of the sections from middle and distal parts of nerve grafts showed an increased regeneration in cell/scaffold group compared with cell-free scaffold and silicone groups. Neural regeneration in cell/scaffold group was very closely similar to autograft group, as deduced from SFI scores and histological assessments.

Conclusions

Our results indicated that the tissue engineered construct made of rolled sheet of SWCNT/PLLA nanofibrous scaffolds and OEC could promote axonal outgrowth and peripheral nerve regeneration suggesting them as a promising alternative in nerve tissue engineering.