Lumbar sacralization and L4-L5 microdiscectomy, a prospective cohort study on radiologic and clinical outcomes

Aim

To evaluate the role of lumbar sacralization (LS) on the surgical outcomes of L4-L5 microdiscectomy.

Methods

This prospective cohort study was conducted in a university referral hospital. The patients with L4-L5 disc herniation and eligible for microdiscectomy were enrolled and allocated in G1 (with LS) and G2 (no LS). After the L4-L5 microdiscectomy patients were followed, clinical and radiological parameters were collected to investigate the influence on the outcomes. Recurrence, low back outcome score (LBOS), and the Oswestry disability index (ODI) were defined as main outcomes.

Results

Two hundred and forty patients (n = 120, each), were reviewed in the final analysis. There was no difference between groups regarding baseline characteristics. Postoperative radicular and back pain was more severe in LS(P < 0.05). Univariate analysis showed recurrence was significantly higher in LS with a direct correlation with postoperative back pain persistence and low LBOS (p = 0.001). Age had a negative impact on G2 recurrence(p = 0.008). LS had a negative impact on LBOS and ODI scores. Postoperative radicular pain and higher lumbar lordosis were associated with a higher disability (ODI) index.

Conclusion

L4-L5 microdiscectomy in patients with lumbar sacralization was associated with higher recurrence rates, worse ODI and LBOS scores, persistent postoperative axial back pain, and radicular pain. Postoperative axial back pain and poor LBOS results could effectively predict a higher recurrence rate following L4-L5 microdiscectomy in lumbar sacralization.

Spondylodiscitis instrumented fusion, a prospective case series on a standardized neurosurgical protocol with long term follow up

PURPOSE

To investigate the fusion construct properties, construct length, intervertebral prosthesis (IVP) selection, bone grafting methods, complications management, and follow-up outcomes of spondylodiscitis fusion.

METHOD

This case series was conducted in Al-Zahra University referral hospital from March 2016 to November 2021. All the surgery-eligible patients were enrolled. Those who did not participate or failed the neurosurgical intervention were excluded. A unified neurosurgical protocol was defined. After operation and follow-up, all variables were documented. IBM SPSS v.26 was used for data analysis. P-value ≤ 0.05 was considered significant.

RESULT

Ninety-two patients were reviewed in the final analysis with 65.2 % males. The mean age was 55.07 ± 14.22 years old. The most frequent level of pathology and surgery was the lumbar spine (48.9 %). Short and long constructs were almost equally used (57.6 and 42.4 %, respectively). Bone graft mixture was the dominant IVP (75 %). The most frequent persistent postoperative symptom was back pain (55.4 %), while the neurological deficits resolution rate was 76.7 %. The fusion rate was 92.3 %. Proximal junctional kyphosis incidence was 16.3 % and had a significant association with on-admission neurological symptoms, thoracic and thoracolumbar junction involvements (p < 0.05). Follow-up Oswestry disability index scores showed 44.6 % of the patients had mild or no functional disabilities. Advanced age, On-admission deficits, comorbidities, titanium cages, and poor fusion status were associated with poor functional outcomes and higher mortality rates (P < 0.05).

CONCLUSION

The introduced neurosurgical protocol could effectively achieve acceptable SD treatment, spine stabilization, and fusion with low long-term surgical complications. Autologous bone graft mixture in comparison to titanium cages showed a higher fusion rate with a lower mortality rate. Patients with older age, neurological symptoms, and comorbidities are expected to experience less favorable clinical outcomes.

Treatment refractory acute necrotizing myelitis after COVID-19 vaccine injection: a case report

Introduction and importance

Post-vaccination myelitis is a rare and debilitating clinical situation. There are few reports of post-COVID-19 infection and vaccination neurological sequela.

Case presentation

A 69-year-old lady was admitted to the emergency department due to weakness and hypoesthesia in her hands 1 week after the Sinopharm vaccine injection. MRI showed a cervicothoracic cord haemorrhagic lesion that deteriorated within 48 h. The clinical course was refractory to conservative treatments. She underwent an emergency cervical laminectomy as a salvage treatment. Intraoperative samples were in favour of acute necrotizing myelitis.

Discussion

In the review of the literature, the inflammatory storm, vasculitis, and many unknown etiologies are deemed to be the possible causes of encephalopathy and myelitis after COVID-19 infection and vaccination. There are few cases of post-COVID-19 myelitis and hematomyelia, but this case was the first report of post-vaccination necrotizing myelitis.

Conclusion

Post-vaccination necrotizing myelitis is a lethal medical situation requiring intensive and emergent neurosurgical vigilance. Early clinical diagnosis in the beginning and full neurosurgical-neurological treatment armamentarium options are cornerstones of treatment paradigms. Salvage treatment options such as extensive laminectomy may play a life-saving role in treatment refractory cases of acute necrotizing myelitis.

Spontaneous spinal epidural haematoma following COVID-19 vaccination: a case report

Introduction

COVID-19 vaccination side effects are rare but important medical situations. Spine-affecting side effects are amongst the rarest, but exceedingly important. Haemorrhagic spinal manifestations of COVID-19 and its vaccines are less reported with little knowledge about them.

Case presentation

An 80-year-old male who received his first shot of the COVID-19 vaccine had developed COVID-19 pneumonia, weakness, and sensory problems in his legs followed by sphincter incontinence within 5 days period. MRI showed a spontaneous epidural spinal epidural haematoma (SSEDH) in T10-L1. He underwent laminectomy and haematoma evacuation. One month follow-up showed no clinical improvement.

Discussion

To our knowledge, this was the first post-vaccination SSEDH and second in haemorrhagic spinal complications following COVID-19 vaccination. Considering the neuropathogenesis pathway of COVID-19 and its vaccines, there are common mechanisms of action that could potentially justify post-vaccination SSEDH such as seen in COVID-19 infection, itself. Early Neurosurgical intervention and better preoperative neurological status could be a beneficial modifier for favourable clinical outcomes.

Conclusion

SSEDH and COVID-19 vaccine coincidence is a rare clinical event, still no solid association could be scientifically explained. Further studies are required for a reliable pathophysiologic association. Early diagnosis, interdisciplinary medical approach, and faster intervention are the cornerstone of the treatment paradigm.

Effect of epigenetics on vitamin D levels: a systematic review until December 2020

BACKGROUND

The association between epigenetic modification of the genes involved in the vitamin D metabolic pathway and vitamin D metabolites' status has been elucidated incompletely. This study aims to review the studies on the mentioned association and create a brighter view of this topic.

METHODS

A systematic literature search was conducted in Medline database (PubMed), Scopus, and Web of Science up to the end of November 2020. Original articles which reported the effect of epigenetic alteration-methylation level or its changes-of genes involved in vitamin D regulation on the vitamin D metabolites serum level or its changes were included. The National Institutes of Health (NIH) checklist was used to assess the quality of included articles.

RESULTS

Among 2566 records, nine reports were included in the systematic review according to the inclusion and exclusion criteria. Studies discussed the contribution of methylation status of members of the cytochrome P450 family (CYP2R1, CYP27B1, CYP24A1), and Vitamin D Receptor (VDR) genes to vitamin D level variance. CYP2R1 methylation status could regulate the contributing factors affecting the vitamin D serum level and predict response to vitamin D supplementation. Studies revealed that impaired methylation of CYP24A1 occurs in response to an increase in serum level of 25-hydroxyvitamin D (25(OH)D). It is reported that the association between methylation levels of CYP2R1, CYP24A1, and VDR genes and 25(OH)D level is not affected by the methyl-donors bioavailability.

CONCLUSIONS

The epigenetic modification of the vitamin D-related genes could explain the vitamin D levels variation among populations. Large-scale clinical trials in various ethnicities are suggested to find the effect of epigenetics on vitamin D response variation.

REGISTRATION

The systematic review protocol was registered on PROSPERO (registration number: CRD42022306327).