Optimal Timing and Outcome of Transforaminal Epidural Steroid Injection for the Management of Radicular Pain due to Extruded Lumbar Disc Herniation

AIM

To evaluate the optimal timing and outcome of fluoroscopically guided transforaminal epidural steroid injections (TFESI) for the management of radicular pain due to extruded lumbar disc herniation (LDH).

MATERIAL AND METHODS

In this clinical study, 305 individuals received fluoroscopically guided TFESI for the management of radicular pain due to extruded LDH. Preprocedural and 12-week postprocedural Visual Analog Scale (VAS) scores measuring radicular pain were statistically compared. The neurological conditions of the patients and the complications of the procedure were also recorded.

RESULTS

The intensity of radicular pain evaluated by the mean preprocedural and 12-week postprocedural VASs were 8.765 ± 0.559 and 2.281 ± 0.401, respectively (p=0.001, and t=119.01). A correlation was noted between the short duration of symptoms before the procedure and the effectiveness of the procedure. After 12 weeks of the procedure, 32 of the 58 patients showed improvement in terms of neurological deficit. There was no major complication. Nine patients required lumbar disc surgery after the procedure.

CONCLUSION

This clinical research demonstrated that TFESI for the management of extruded LDH may alleviate radicular pain and may decrease the neurological deficit and that it is more effective when performed at the earliest possible time point.

The Evaluation of Survivin and Bcl-2 Expression on the Medical Radiation Doses for Neural Tube Defect Development

AIM

To investigate the effects of different radiation doses on the development of the neural tube defect in chick embryos using computed tomography (CT), and assess its correlation with survivin and Bcl-2 expressions.

MATERIAL AND METHODS

A total of 150 chicken eggs were used and grouped into five categories. In Group 1 (n=30), the embryos were not exposed to radiation. In Group 2 (n=30), the embryos were irradiated using lung cancer screening chest CT protocol. In Groups 3 and 4 (n=30 each), the abdominopelvic and adult routine head CT protocols, respectively, were used to irradiate the embryos. In Group 5 (n=30), the embryos were irradiated using adult brain perfusion CT protocol. Subsequently, the embryos were examined under a stereomicroscope to assess the presence of neural tube developmental abnormalities. Moreover, immunohistochemical staining was performed to determine the survivin and Bcl-2 expression levels.

RESULTS

The risk of developing neural tube defect increased with the amount of exposed radiation. Moreover, no significant correlation was observed between the survivin and Bcl-2 expression levels and the radiation dose.

CONCLUSION

Overall, the results of this study indicate that the radiation from CT may cause neural tube defect in chicken embryos.

Exome sequencing implicates genetic disruption of prenatal neuro-gliogenesis in sporadic congenital hydrocephalus

Congenital hydrocephalus (CH), characterized by enlarged brain ventricles, is considered a disease of excessive cerebrospinal fluid (CSF) accumulation and thereby treated with neurosurgical CSF diversion with high morbidity and failure rates. The poor neurodevelopmental outcomes and persistence of ventriculomegaly in some post-surgical patients highlight our limited knowledge of disease mechanisms. Through whole-exome sequencing of 381 patients (232 trios) with sporadic, neurosurgically treated CH, we found that damaging de novo mutations account for >17% of cases, with five different genes exhibiting a significant de novo mutation burden. In all, rare, damaging mutations with large effect contributed to ~22% of sporadic CH cases. Multiple CH genes are key regulators of neural stem cell biology and converge in human transcriptional networks and cell types pertinent for fetal neuro-gliogenesis. These data implicate genetic disruption of early brain development, not impaired CSF dynamics, as the primary pathomechanism of a significant number of patients with sporadic CH.

Transforaminal Epidural Steroid Injection in the Treatment of Pain in Foraminal and Paramedian Lumbar Disc Herniations

AIM

To compare the effect of fluoroscopically guided transforaminal epidural steroid injections on radicular pain in foraminal and paramedian lumbar disc herniations.

MATERIAL AND METHODS

This study included patients who did not benefit from previous medical treatments or are not suitable for surgery. Transforaminal epidural steroid injections for the treatment of foraminal and paramedian lumbar disc herniation were performed in 370 and 1262 patients, respectively. Every group’s preprocedural visual analogue scale (VAS) and 12-week postprocedural VAS scores were recorded, and statistical analysis was performed. The complications noted were also recorded.

RESULTS

The preprocedural and postprocedural mean VAS scores for radicular pain in foraminal disc herniation were 67.11 ± 4.28 and 34.78 ± 3.64, respectively. However, the preprocedural and postprocedural mean VAS scores in paramedian disc herniation were 62.16 ± 6.65 and 19.07 ± 4.50, respectively. Statistical analysis of the varying preprocedural and postprocedural VAS scores showed that transforaminal epidural steroid injections were more effective for paramedian disc herniation than for foraminal disc herniation (p < 0.05).

CONCLUSION

Transforaminal epidural steroid injections were more effective for paramedian lumbar disc herniation than for foraminal disc herniation, 12 weeks after the procedure.

Effects of Different Therapeutic Radiation Doses on the Development of Neural Tube Defects in Chick Embryos and the Correlation with Bone Morphogenetic Protein 4 and 7 Expression Levels

AIM

To investigate the effects of different therapeutic radiation doses on the prevalence of neural tube defects (NTDs) in chick embryos and bone morphogenetic protein (BMP) 4 and BMP7 expression levels.

MATERIAL AND METHODS

The chick embryos (n=143) were derived from fertile, specific pathogen-free eggs of domestic fowl. The presence of NTDs was analyzed using a stereomicroscope, and BMP4 and BMP7 expression levels were assessed by immunohistochemical staining. The chick embryos were divided into five groups: control (no radiation exposure) (n=23), exposure to thorax computerized tomography (CT) (n=30); exposure to abdominopelvic CT (n=30), exposure to cranium CT (n=30), and exposure to brain perfusion CT (n=30).

RESULTS

The prevalence of NTDs and BMP4 and BMP7 expression levels in the different groups were compared. In the cranium CT dose group, both the NTD prevalence (20%, p=0.002) and BMP7 (p=0.031) expression levels were significantly higher than those in the other groups. However, none of the medical doses of irradiation altered BMP4 expression levels (p=0.242). No NTDs were detected in the thorax CT and abdominopelvic CT groups.

CONCLUSION

Exposure to irradiation at cranium CT doses may induce the development of NTDs and increase BMP7 expression. Dose radiation exposure using thorax CT and abdominopelvic CT protocols does not appear to induce NTDs.

The Effects of Total Knee Arthroplasty on Sleep Quality

Introduction: Symptomatic osteoarthritis is one of the most common indications for total knee arthroplasty (TKA) operations. Pain in every stage of the disease causes sleep disturbances in patients. The primary objective of this study was to evaluate the effect of TKA on the quality of sleep in patients with symptomatic osteoarthritis.

Materials and Methods: This retrospective, descriptive study was performed on 80 patients diagnosed with symptomatic osteoarthritis who underwent TKA. The patients responded to the Pittsburgh Sleep Quality Index (PSQI), which is widely used to evaluate sleep quality. Additionally, the effects of demographic and clinical variables such as age, gender, body mass index, smoking and alcohol consumption were also evaluated before and after surgery.

Results: There was no correlation between demographic variables and PSQI scores pre- and postoperatively. There was a decrease in sleep quality on the sixth postoperative week compared to the preoperative period however this difference was not statistically significant. On the other hand, there was a statistically significant difference between preoperative and postoperative sixth month PSQI scores. Mean values of overall sleep quality and daily function were significantly higher in the postoperative sixth compared to the preoperative period (p<0.001)

Conclusion: Treatment of symptomatic OA with TKA will improve sleep quality in the long term.

Comparison of the Effect of Single Lumbar Transforaminal Epidural Steroid Injections for the Treatment of L4-5 and L5-S1 Paramedian Disc Herniation

AIM

To compare the outcomes of fluoroscopically guided transforaminal epidural steroid injections between L4-L5 paramedian disc herniation and L5-S1 paramedian disc herniation for the treatment of radicular pain.

MATERIAL AND METHODS

A total of 593 patients treated by transforaminal epidural steroid injections for the treatment of L4-5 paramedian disc herniation and 504 patients treated by transforaminal epidural steroid injections for the treatment of L5-S1 paramedian disc herniation were included in the study. All the patients were regularly followed up for 12 weeks. Preprocedural Visual Analogue Scale (VAS) scores, 12-week post-procedural VAS scores and complications were recorded.

RESULTS

The mean preprocedural and postprocedural VAS scores for L4-5 paramedian disc herniation were 63.09 ± 5.37 and 15.81 ± 3.58, respectively, and the mean preprocedural and postprocedural VAS scores for L5-S1paramedian disc herniation were 61.15 ± 5.45 and 27.06 ± 3.62, respectively, for radicular pain. There was a statistically significant difference between preprocedural and postprocedural VAS scores for L4-5 and L5-S1 paramedian disc herniation (p < 0.05). Transforaminal epidural steroid injections for L4-5 paramedian disc herniation were more effective than transforaminal epidural steroid injections for L5-S1 paramedian disc herniation.

CONCLUSION

This study showed that transforaminal epidural steroid injections for L4-5 paramedian disc herniation were more effective than transforaminal epidural steroid injections for L5-S1 paramedian disc herniation in the 12-week follow-up period.

The Correlation of SCL-90-R Anxiety, Depression, Somatization Subscale Scores with Chronic Low Back Pain

AIM

To investigate the correlation of the Symptom Checklist-90-R (SCL-90-R) anxiety, depression, and somatization subscale scores with chronic low back pain (LBP).

MATERIAL AND METHODS

Seventy-five patients who were admitted with the complaint of chronic LBP (patient group) and 75 healthy persons (control group) were evaluated. SCL-90-R anxiety, depression, and somatization subscale scores of patients having chronic LBP and healthy persons were measured. The mean values were paired and using two tailed t test they were statistically evaluated.

RESULTS

The difference between SCL-90-R anxiety subscale subscores of patients having chronic LBP and healthy persons was not statistically significant (p > 0.05). The difference between SCL-90-R depression subscale subscores of patients having chronic LBP and healthy persons was not statistically significant (p > 0.05). The difference between SCL-90-R somatization subscale subscores of patients having chronic LBP and healthy persons was statistically significant (p < 0.05).

CONCLUSION

SCL-90-R somatization subscale subscores are higher in patients with low back pain. The treatment of low back pain can be more successful when combined with the treatment of somatization.

De Novo Mutation in Genes Regulating Neural Stem Cell Fate in Human Congenital Hydrocephalus

Congenital hydrocephalus (CH), featuring markedly enlarged brain ventricles, is thought to arise from failed cerebrospinal fluid (CSF) homeostasis and is treated with lifelong surgical CSF shunting with substantial morbidity. CH pathogenesis is poorly understood. Exome sequencing of 125 CH trios and 52 additional probands identified three genes with significant burden of rare damaging de novo or transmitted mutations: TRIM71 (p = 2.15 × 10^-7), SMARCC1 (p = 8.15 × 10^-10), and PTCH1 (p = 1.06 × 10^-6). Additionally, two de novo duplications were identified at the SHH locus, encoding the PTCH1 ligand (p = 1.2 × 10^-4). Together, these probands account for ∼10% of studied cases. Strikingly, all four genes are required for neural tube development and regulate ventricular zone neural stem cell fate. These results implicate impaired neurogenesis (rather than active CSF accumulation) in the pathogenesis of a subset of CH patients, with potential diagnostic, prognostic, and therapeutic ramifications.

Successful Application of the Ventriculo-Gallbladder Shunt: A Salvage Procedure

Ventriculo-gallblader shunt is very rarely used in the treatment of hydrocephalus. A 44-year-old male with ventriculoatrial shunt dysfunction was evaluated. His ventriculoatrial shunt was not working. His medical history revealed that his hydrocephalus was treated five times by venrtriculoperitoneal shunt, and four times by ventriculoatrial shunt. Another trial for ventriculoperitoneal or ventriculoatrial shunting was not considered feasible. A ventriculo-gallbladder shunt was placed to the patient as a potential salvage procedure. Remarkably, the patient benefited from the ventriculo-gallbladder shunt and was discharged from the hospital. We think that ventriculo-gallbladder shunting is a safe and effective treatment for hydrocephalus as the last resort in complicated cases of shunt dysfunction.

Masticatory parameters of children with and without clinically diagnosed caries in permanent dentition

AIM

Mastication turns food into a bolus and prepares it for chemical digestion. Any condition affecting tooth structure and position may have an impact on mastication. The aim of this study is to compare masticatory performance (MP) and maximum bite force (MBF) between children with and without clinically visible caries in permanent first molars.

MATERIALS AND METHODS

The study was conducted with 50 children in good general condition aged 12-14 years (25 girls, 25 boys) with no orthodontic/skeletal anomalies and no missing teeth due to dental trauma or extraction. Maximum bite force was measured bilaterally using strain gauge sensors. Masticatory performance was evaluated by silicone tablet comminution test.

RESULTS

Masticatory performance was superior in caries-free children when compared to children with caries. Maximum bite force values in children with and without caries were not statistically different.

CONCLUSIONS

Caries reduces masticatory performance. Therefore, treatment is crucial for masticatory efficiency.

Spontaneous Resolution of a Sylvian Arachnoid Cyst in a Child: A Case Report

We report the case of a 7-year-old boy with an incidentally diagnosed left sylvian arachnoid cyst. At a clinical follow-up of 2 years, cranial computed tomography scans found the cyst to be totally resolved. The mechanism of this rare spontaneous resolution of an arachnoid cyst is discussed.

Ten-year follow-up results of posterior instrumentation without fusion for traumatic thoracic and lumbar spine fractures

BACKGROUND

This retrospective study aims to present and evaluate the long follow-up results of posterior instrumentation without fusion in patients with traumatic thoracic and lumbar fractures.

METHODS

45 patients were operated. The mean follow-up period was 147.6 months. Sagittal plane kyphosis (SPK) and anterior wedge angle (AWA) were evaluated in preoperative and follow-up.

RESULTS

SPK and AWA improved significantly in the early postoperative. However, the correction was lost in the 10-year follow-up. The loss of correction was statistically significant in SPK and AWA.

CONCLUSION

Posterior instrumentation without fusion is still among the most useful in treatment of traumatic thoracolumbar fractures.

Computerized tomography imaging in adolescent idiopathic scoliosis: prone versus supine

BACKGROUND

The aim of the present study was to assess the degree of apical vertebral rotation values in Adolescent Idiopathic Scoliosis (AIS) that were obtained on CT scans, and to analyze the influence of patient position (supine versus prone) on the degree of rotation.

METHODS

The study included 50 apical vertebra rotation measurements of 34 patients with Type 1A and Type 3C curvature according to the Lenke classification. CT imaging was applied to the patients in supine and prone positions to measure the apical vertebral rotation (AVR). The average AVR angles were measured using the Aaro-Dahlborn method and the results were compared.

RESULTS

No significant differences were found between the vertebral rotation measured in the prone and supine positions for the Lenke 1A subgroup and the Lenke 3C thoracic group (p = 0.848; p = 0.659, respectively). In the Lenke 3C lumbar group, however, the vertebral rotation in the supine position was found to be significantly lesser than that in the prone position (difference -1.40° ± 1.79°, p = 0.007).

CONCLUSION

The assessment of the apical vertebra rotation is crucial in AIS. Even though the vertebral rotation in the supine position was found to be significantly lesser than that in the prone position, CT imaging in a prone position could not be considered clinically more relevant than the CT images in a supine position as there was less than 3° difference.

The Effect of Ankaferd Blood Stopper? on Epidural Fibrosis After Laminectomy in Rats: An Experimental Study

AIM

Lumbar epidural fibrosis is increasingly recognized as a cause of persistent back pain. The aim of this study was to examine the effect Ankaferd Blood Stopper on epidural fibrosis following laminectomy in rat models.

MATERIAL AND METHODS

Twenty Sprague-Dawley male rats were randomly allocated to 2 groups of 10 each. The dura mater and nerve root were exposed after L1 unilateral laminectomy. Close attention was paid not to traumatize the dura, the nerve roots, or the dissected muscles. Immediate muscle and skin closure was made in sham group. In the Ankaferd Blood Stopper group, cotton wool soaked with 1 mL Ankaferd Blood Stopper was applied to the exposure site for 5 minutes, and muscle and skin closure was then made. Histological analysis was performed at four weeks postoperatively.

RESULTS

Epidural fibrosis formation evaluation and fibroblastic activity evaluation revealed that there was a significant difference between the sham and the Ankaferd Blood Stopper treated groups (p = 0.011, p = 0.009). Severe epidural adhesions were observed in the Ankaferd Blood Stopper group. Dissection of these epidural adhesions was difficult and accompanied by bleeding and disruption of the dura mater.

CONCLUSION

The results of this study showed that there was no positive effect of Ankaferd Blood Stopper on the prevention of epidural fibrosis, which is one of the most significant problems following spinal surgery, and the epidural fibrosis actually increased.

Cavernous sinus meningiomas: imaging and surgical strategy

Cavernous sinus (CS) meningiomas which are by definition those meningiomas which originate from the parasellar region are difficult skull base tumors to deal with. For deciding the most appropriate surgical strategy, surgeons need detailed preoperative neuroimaging. The vicinity of the tumor with the vital and highly functional neurovascular structures, tumor extensions into the basal cisterns and skull base structures, and the arterial vascularization and venous drainage pathways, as they shape operative strategy, are important preoperative data to take into account. Thin section CT scan with bone windows, 3D spiral CT reconstruction, MRI, MR angiography, and DSA performed with selective arteriography including late venous phases give those required detailed informations about the tumor and its relation with neurovascular and bony structures. The type of craniotomy and complementary osteotomy and the usefulness of an extradural anterior clinoidectomy with unroofing the optic canal can be decided from preoperative neuroimaging. Data collected also help in determining whether extensive exposure of the middle cranial fossa is necessary to ensure substantial devascularization of the tumor and whether proximal control of the internal carotid artery (ICA) at its intrapetrosal portion might be useful. Study of the capacity of blood supply of the Willis circle is wise for deciding the need and way of performing an extra-intracranial bypass together with tumor removal. Currently the concept of operating only the tumors with extracavernous extensions and to limit resection to only their extracavernous portions is the most accepted way of treating these tumors. It was that strategy that was adopted in the senior author's 220-patient series.Radiosurgery or stereotactic fractionated radiotherapy may complement surgery or can be only reserved for growing remnants.

Brain malformations associated with Knobloch syndrome--review of literature, expanding clinical spectrum, and identification of novel mutations

BACKGROUND

Knobloch syndrome is a rare, autosomal recessive, developmental disorder characterized by stereotyped ocular abnormalities with or without occipital skull deformities (encephalocele, bone defects, and cutis aplasia). Although there is clear heterogeneity in clinical presentation, central nervous system malformations, aside from the characteristic encephalocele, have not typically been considered a component of the disease phenotype.

METHODS

Four patients originally presented for genetic evaluation of symptomatic structural brain malformations. Whole-genome genotyping, whole-exome sequencing, and confirmatory Sanger sequencing were performed. Using immunohistochemical analysis, we investigated the protein expression pattern of COL18A1 in the mid-fetal and adult human cerebral cortex and then analyzed the spatial and temporal changes in the expression pattern of COL18A1 during human cortical development using the Human Brain Transcriptome database.

RESULTS

We identified two novel homozygous deleterious frame-shift mutations in the COL18A1 gene. On further investigation of these patients and their families, we found that many exhibited certain characteristics of Knobloch syndrome, including pronounced ocular defects. Our data strongly support an important role for COL18A1 in brain development, and this report contributes to an enhanced characterization of the brain malformations that can result from deficiencies of collagen XVIII.

CONCLUSIONS

This case series highlights the diagnostic power and clinical utility of whole-exome sequencing technology-allowing clinicians and physician scientists to better understand the pathophysiology and presentations of rare diseases. We suggest that patients who are clinically diagnosed with Knobloch syndrome and/or found to have COL18A1 mutations via genetic screening should be investigated for potential structural brain abnormalities even in the absence of an encephalocele.

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Neuroprotective effects of agmatine in experimental peripheral nerve injury in rats: a prospective randomized and placebo-controlled trial

AIM

The purpose of this study was to demonstrate the activity of agmatine, an inducible nitric oxide synthase (iNOS) inhibitor and selective N-methyl-D-aspartate receptor (NMDAR) antagonist, on reducing tissue damage in distal part of traumatic nerve in an experimental rat peripheral nerve injury model.

MATERIAL AND METHODS

Sciatic nerves of 30 Sprague Dawley male rats were used. Rats were divided into 5 groups; group 1 (n=6), control group; group 2 (n=6), axonotmesis + placebo group; group 3 (n=6), axonotmesis + 50 mg/kg agmatine treatment group; group 4 (n=6), neurotmesis + placebo group; group 5 (n=6), neurotmesis + 50 mg/kg agmatine treatment group. Axonolysis, axon degeneration, edema, hemorrhage, and inflammation were evaluated in histopathologic examinations of all the groups.

RESULTS

When group 2 was compared with group 3 in histopathologic sections, axonolysis was less in group 3 (p=0.007), as was axon degeneration (p=0.022) and edema (p=0.018). When group 4 was compared with group 5, axonolysis was less in group 5 (p=0.009), as was axon degeneration (p=0.006) and edema (p=0.021).

CONCLUSION

This study demonstrated agmatine to have antioxidant and antineurotoxic effects in an experimental rat peripheral nerve injury model.

Surgical management of symptomatic T8 vertebral hemangioma: case report and review of the literature

Vertebral hemangiomas are benign vascular lesions of the vertebral column; only 0.9-1.2% of all vertebral hemangiomas cause spinal cord compression. We report a 34-year-old female who was admitted to the neurosurgery clinic with a history of back pain, poor quality of life and easy fatigability for 1.5 years. Her medical history revealed a fall from a height of 2 meters 1.5 years ago. Neurology examination revealed bilateral hypoesthesia below the T8 level and hyperactive deep tendon reflexes in her left leg. Computed tomography scan of the thoracic spine showed T8 vertebral hemangioma, and magnetic resonance imaging showed a T8 hemangioma compressing the spinal cord. Surgical intervention was planned and T8 total laminectomy was performed. The tumor extending into the anterior spinal cord was resected, and T8 vertebroplasty with short segment posterior stabilization and fusion was performed. We aimed to present a new treatment approach for symptomatic vertebral hemangiomas and reviewed the relevant literature.

The effect of copper on vasospastic femoral artery in rats

AIM

The aim of this study was to investigate the effect of copper, which is the cofactor and regulator of the superoxide dysmutase enzyme, on preventing experimental peripheral vasospasm in rats through antioxidative mechanisms.

MATERIAL AND METHODS

Twenty-four female Wistar-Albino rats were divided into 3 groups: group 1 (n=8), control group; group 2 (n=8), vasospasm group; and group 3 (n=8), vasospasm + copper treatment group. Morphometric measurements of wall thickness and lumen diameter of femoral arteries were performed.

RESULTS

Statistical comparison of groups 1 and 2, regarding thickness of vascular walls, revealed a significant increase in group 2 (p=0.037) and regarding lumen diameters, revealed a significant decrease in group 2 (p=0.043). Comparison of diameters of the vascular lumen of groups 1 and 3 showed no significant difference (p=0.19), whereas the comparison of the thicknesses of the vascular walls displayed a significant increase in group 3 (p=0.028). Comparison of groups 2 and 3 regarding diameter of vascular lumens showed a significant decrease in group 2 (p=0.042), whereas group 3 displayed a significant decrease, in terms of thickness of the vascular walls (p=0.029).

CONCLUSION

This study showed quantitatively that copper could prevent the development of experimental peripheral vasospasm in rats.

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

BACKGROUND

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS.

METHODS

The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery.

RESULTS

After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (-) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year.

CONCLUSION

Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.

Mutation in MEOX1 gene causes a recessive Klippel-Feil syndrome subtype

Background

Klippel-Feil syndrome (KFS) is characterized by the developmental failure of the cervical spine and has two dominantly inherited subtypes. Affected individuals who are the children of a consanguineous marriage are extremely rare in the medical literature, but the gene responsible for this recessive trait subtype of KFS has recently been reported.

Results

We identified a family with the KFS phenotype in which their parents have a consanguineous marriage. Radiological examinations revealed that they carry fusion defects and numerical abnormalities in the cervical spine, scoliosis, malformations of the cranial base, and Sprengel’s deformity. We applied whole genome linkage and whole-exome sequencing analysis to identify the chromosomal locus and gene mutated in this family. Whole genome linkage analysis revealed a significant linkage to chromosome 17q12-q33 with a LOD score of 4.2. Exome sequencing identified the G > A p.Q84X mutation in the MEOX1 gene, which is segregated based on pedigree status. Homozygous MEOX1 mutations have reportedly caused a similar phenotype in knockout mice.

Conclusions

Here, we report a truncating mutation in the MEOX1 gene in a KFS family with an autosomal recessive trait. Together with another recently reported study and the knockout mouse model, our results suggest that mutations in MEOX1 cause a recessive KFS phenotype in humans.

Bilateral thoracic ganglion cyst : a rare case report

Ganglion cysts usually arise from the tissues around the facet joints. It is usually associated with degenerative cahanges in facet joints. Bilateral thoracic ganglion cysts are very rare and there is no previous case that located in bilateral intervertebral foramen compressing the L1 nerve root associated with severe radiculopathy. We report a 53 years old woman who presented with bilateral groin pain and severe numbness. Magnetic resonance imaging revealed bilateral cystic mass in the intervertebral foramen between 12th thoracal and 1st lumbar vertebrae. The cystic lesions were removed after bilateral exposure of Th12-L1 foramens. The result of hystopathology confirmed the diagnosis as ganglion cyst. The ganglion cyst may compromise lumbar dorsal ganglion when it located in the intervertebral foramen. The surgeon should keep this rare entity in their mind for differential diagnosis.

An optoelectromechanical tactile sensor for detection of breast lumps

We developed a compact tactile imaging (TI) system to guide the clinician or the self-user for noninvasive detection of breast tumors. Our system measures the force distribution based on the difference in stiffness between a palpated object and an abnormality within. The average force resolution, force range, and the spatial resolution of the device are 0.02 N, 0-4 N, and 2.8 mm, respectively. To evaluate the performance of the proposed TI system, compression experiments were performed to measure the sensitivity and specificity of the system in detecting tumor-like inclusions embedded in tissue-like cylindrical silicon samples. Based on the experiments performed with 11 inclusions, having two different sizes and two different stiffnesses located at three different depths, our TI system showed an average sensitivity of 90.8 ± 8.1 percent and an average specificity of 89.8 ± 12.7 percent. Finally, manual palpation experiments were performed with 12 human subjects on the same silicon samples and the results were compared to that of the TI system. The performance of the TI system was significantly better than that of the human subjects in detecting deep inclusions while the human subjects performed slightly better in detecting shallow inclusions close to the contact surface.

Anatomical study of the central myelin portion and transitional zone of the vestibulocochlear nerve

BACKGROUND

The aim of this study was to evaluate gross and microscopic anatomical features of the vestibulocochlear nerve or eighth cranial nerve (CNVIII) from fresh cadavers, especially the nerve's central myelin portion (CMP) and transitional zone (TZ), and to consider any pathological implications.

METHODS

Six fresh cadavers were used to examine the CNVIII. Its cisternal length from brainstem to internal auditory meatus was measured. Longitudinal sections were stained to make following measurements: the diameter where the nerve enters the brainstem, the diameter where the TZ begins, the distance to the most distal part of TZ from the brainstem, and the depth of the TZ. The volume of the CMP was calculated as well.

RESULTS

The cisternal length of ten CNVIIIs measured between 14.2 and 19.2 mm (16.48 ± 1.78 mm). The thickness where the CNVIII enters the brainstem was between 1.21 and 3.16 mm (2.31 ± 0.68 mm); the thickness where the TZ begins was between 1.07 and 2.21 mm (1.44 ± 0.38 mm); the distance of the most distal part of the TZ from the brainstem was between 9.28 and 13.84 mm (11.50 ± 1.56 mm); the depth of the TZ was between 0.56 and 1.28 mm (0.81 ± 0.27 mm). The volume of the CMP was between 17.34 and 53.87 mm(3) (33.98 ± 13.74 mm(3)). The measurements were compared to trigeminal, facial, glossopharyngeal and vagus nerves. CNVIII was the nerve with the longest CMP.

CONCLUSIONS

The measurements showed that the CMP of CNVIII was very long. The implication of this length in the dysfunctional syndromes of this nerve, its propensity to harbor schwannomas, which most frequently arise at the porus of the auditory meatus, and the vulnerability to damages are discussed.

Cranial nerve vascular compression syndromes of the trigeminal, facial and vago-glossopharyngeal nerves: comparative anatomical study of the central myelin portion and transitional zone; correlations with incidences of corresponding hyperactive dysfunctional syndromes

OBJECTIVE

The aim of this study was to evaluate the anatomy of the central myelin portion and the central myelin-peripheral myelin transitional zone of the trigeminal, facial, glossopharyngeal and vagus nerves from fresh cadavers. The aim was also to investigate the relationship between the length and volume of the central myelin portion of these nerves with the incidences of the corresponding cranial dysfunctional syndromes caused by their compression to provide some more insights for a better understanding of mechanisms.

METHODS

The trigeminal, facial, glossopharyngeal and vagus nerves from six fresh cadavers were examined. The length of these nerves from the brainstem to the foramen that they exit were measured. Longitudinal sections were stained and photographed to make measurements. The diameters of the nerves where they exit/enter from/to brainstem, the diameters where the transitional zone begins, the distances to the most distal part of transitional zone from brainstem and depths of the transitional zones were measured. Most importantly, the volume of the central myelin portion of the nerves was calculated. Correlation between length and volume of the central myelin portion of these nerves and the incidences of the corresponding hyperactive dysfunctional syndromes as reported in the literature were studied.

RESULTS

The distance of the most distal part of the transitional zone from the brainstem was 4.19  ±  0.81 mm for the trigeminal nerve, 2.86  ±  1.19 mm for the facial nerve, 1.51  ±  0.39 mm for the glossopharyngeal nerve, and 1.63  ±  1.15 mm for the vagus nerve. The volume of central myelin portion was 24.54  ±  9.82 mm(3) in trigeminal nerve; 4.43  ±  2.55 mm(3) in facial nerve; 1.55  ±  1.08 mm(3) in glossopharyngeal nerve; 2.56  ±  1.32 mm(3) in vagus nerve. Correlations (p  < 0.001) have been found between the length or volume of central myelin portions of the trigeminal, facial, glossopharyngeal and vagus nerves and incidences of the corresponding diseases.

CONCLUSION

At present it is rather well-established that primary trigeminal neuralgia, hemifacial spasm and vago-glossopharyngeal neuralgia have as one of the main causes a vascular compression. The strong correlations found between the lengths and volumes of the central myelin portions of the nerves and the incidences of the corresponding diseases is a plea for the role played by this anatomical region in the mechanism of these diseases.

Reconstruction of vein of Labbé in temporo-occipital meningioma invading transverse sinus: technical report

OBJECTIVE AND IMPORTANCE

Meningiomas invading major venous sinuses and veins are not uncommon. However, meningiomas involving both the transverse sinus and vein of Labbé are exceedingly rare. Venous reconstruction can be challenging after radical removal of the meningioma which invades major venous sinuses and veins. In this report, we present reconstruction of vein of Labbé in the surgery of temporo-occipital meningioma invading the transverse sinus.

CLINICAL PRESENTATION

A 55-year-old woman was admitted to our institution with a 13-year history of focal epilepsy in the form of transient aphasia with vertigo. Cranial magnetic resonance imaging revealed a homogeneously contrast enhancing lesion measuring 40 mm in diameter in the left temporo-occipital area. Cerebral magnetic resonance venography and venous phase of cerebral digital subtraction angiography revealed invasion of the upper wall of left transverse sinus and total occlusion of the lumen of the vein of Labbé.

TECHNIQUE

After removal of all the tumors except the piece attached to the transverse sinus and vein of Labbé with standard neurosurgical techniques, the left transverse sinus lumen and vein of Labbé lumen were explored. The tumor tissue inside the transverse sinus and vein of Labbé were removed along with tumor-invaded venous wall. Venous reconstruction of the transverse sinus and vein of Labbé was performed using autologous dura mater as a patch for the defect.

CONCLUSION

This is the first report in the literature in which the vein of Labbé was reconstructed in the surgery of temporo-occipital meningioma invading the vein of Labbé and transverse sinus together.

[Structural anatomy of cranial nerves (V, VII, VIII, IX, X)]

This study reports a review of the literature on the structural anatomy of the Vth, VIIth, VIIIth, IXth, and Xth cranial nerves, known to harbor dysfunction syndromes in humans. Because these dysfunctions are hypothesized to be caused by neurovascular conflicts at the root entry/exit zone and the transitional zone between central and peripheral myelinization, this investigation focused on the study and description of this junction. All the cranial nerves, except the optic and olfactory nerves, which are considered to be more a direct expansion of the central nervous system, have a transitional zone between central myelin (coming from oligodendrocytes) and peripheral myelin (produced by Schwann cells). The human studies reported in the literature argue in favor of a dome-shaped transitional zone directed to the periphery. It seems that this junctional region is situated more peripherally in sensory nerves than in motor nerves. The transitional zone is situated very peripherally for the cochlear and vestibular nerves, and on the contrary very close to its exit from the brain stem for the facial nerve.

Trauma and Adult Attention Deficit Hyperactivity Disorder

This study investigated the relationship between adult attention deficit hyperactivity disorder (ADHD) and trauma. Fifty-eight adults admitted to hospital with musculoskeletal trauma were evaluated using scales that determine the presence of ADHD in childhood and adulthood. Each patient was also interviewed by an adult psychiatrist and a child and adolescent psychiatrist. The control group consisted of 30 adult patients with complaints other than trauma who did not have a history of repetitive traumas. There were 36 (62.2%) cases of ADHD in the patient group compared with four (13.3%) in the control group; this difference was statistically significant. When the level of trauma was evaluated, ADHD was identified in 23 of the 26 (88.5%) patients with high energy traumas compared with 14 of the 32 (43.8%) patients with low energy traumas; this difference was also statistically significant. This study shows that patients with adult ADHD are more prone to injuries, particularly high energy traumas such as motor vehicle accidents. Patients who have repeated high energy traumas should be evaluated by a psychiatrist for ADHD.

Coccygectomy for coccygodynia: do we really have to wait?

AIM

To determine the results of 21 cases of persistent coccygodynia unresponsive to conservative management and treated with coccygectomy.

METHODS

Of 81 patients with coccygodynia, 21 underwent surgical excision of the coccyx with a minimum 5 days of antibiotic prophylaxis. All 21 patients were followed for at least 2 years and questioned about their satisfaction with the operation and its timing. Pain levels were recorded preoperatively and during the postoperative period using the VAS scale.

RESULTS

The mean VAS score was 51.88 (40-70), and this decreased to 3.17, 2.94 and 2.76 in the 6th, 12th and 24th months, respectively. This change was statistically significant. Of the 21 cases, 17 had an excellent result and 4 had a good result. None had a wound healing problem or infection. All were satisfied with the operation, and all stated that they would have liked to have undergone it sooner.

CONCLUSION

For unstable coccygeal fracture and persistent coccygodynia, coccygectomy is a reliable method of treatment with a high satisfaction and a low complication rate.

Mutations in apoptosis-related gene, PDCD10, cause cerebral cavernous malformation 3

OBJECTIVE

To identify the CCM3 gene in a population of 61 families with a positive family history of cerebral cavernous malformations (CCM), 8 of which had suggestive linkage to the CCM3 locus.

METHODS

We searched for mutations within the CCM3 interval using a high-throughput screening technique, temperature-gradient capillary electrophoresis. Mutations detected by this device were subsequently sequenced, and the results were analyzed.

RESULTS

A recent study by Bergametti et al. established Programmed Cell Death 10 (PDCD10) as the gene responsible for CCM3. We hereby confirm PDCD10 as the CCM3 gene by reporting four novel mutations in 61 CCM families. Two of these mutations were identical and produced a stop codon in exon 7. Another two resulted in frameshift mutations in exon 6, although the mutations occurred at different points along the exon. The last mutation caused a frameshift in exon 9. Of note, mutations in these families completely cosegregated with the trait. Three of the five families had prior linkage data suggestive of the CCM3 locus, whereas the remaining two were identified in index patients with a positive family history but no linkage data.

CONCLUSION

Our data establish PDCD10 as the gene responsible for CCM in families linking to the CCM3 locus. The discovery of the third gene involved in inherited forms of CCM, after KRIT1 and Malcavernin, is an important step toward dissecting the molecular pathophysiology of this disease.

Molecular genetic analysis of two large kindreds with intracranial aneurysms demonstrates linkage to 11q24-25 and 14q23-31

BACKGROUND AND PURPOSE

Both environmental and genetic factors contribute to the formation, growth, and rupture of intracranial aneurysms (IAs). To search for IA susceptibility genes, we took an outlier approach, using parametric genome-wide linkage analysis in extended IA kindreds in which IA is inherited as a simple Mendelian trait. We hereby present the molecular genetic analysis of 2 such families.

METHODS

For genome-wide linkage analysis, we used a 2-stage approach. First, using gene chips in affected-only analysis, we identified genomic regions that provide maximum theoretical logarithm of odds (lod) scores. Next, to confirm or exclude these candidate loci, we genotyped all available family members, both affected and unaffected, using polymorphic microsatellite markers located within these regions.

RESULTS

We obtained significant lod scores of 4.3 and 3.00 for linkage to chromosomes 11q24-25 and 14q23-31, respectively.

CONCLUSIONS

Molecular genetic analysis of 2 large IA kindreds confirms linkage to chromosome 11q and 14q, which were suggested to contain IA susceptibility genes in a previous study of Japanese sib pairs. Independent identification of these 2 loci strongly suggests that IA susceptibility genes lie within these regions. While demonstrating the genetic heterogeneity of IA, these results are also an important step toward cloning IA genes and ultimately understanding its pathophysiology.

CCM2 Expression Parallels That of CCM1

Background and Purpose— Mutations in CCM2 (MGC4607 or malcavernin) cause familial cerebral cavernous malformation (CCM), an autosomal dominant neurovascular disease. Both the function of this molecule and the pathogenesis of the disease remain elusive.

Methods— We analyzed the mRNA expression of Ccm1 and Ccm2 in the embryonic and postnatal mouse brain by in situ hybridization. Subsequently, we generated CCM2-specific polyclonal antibodies and tested their specificity using transient transfection experiments in various cell lines. We then investigated CCM2 protein expression in cerebral and extracerebral tissues by Western blot analysis as well as immunohistochemistry and compared these results with CCM1 (KRIT1) protein expression.

Results— In situ analysis shows similar temporal and spatial expression patterns for Ccm1 and Ccm2, although Ccm1 expression appears more widespread. Immunohistochemical analysis shows that CCM2 is expressed in various human organs, most noticeably in the arterial vascular endothelium. As is the case with CCM1, CCM2 is not expressed in other vascular wall elements such as smooth muscle cells or the venous circulation. Within cerebral tissue, it is also expressed in pyramidal neurons, astrocytes, and their foot processes. In extracerebral tissues, CCM2 is present in various epithelial cells necessary for blood-organ barrier formation.

Conclusions— CCM1 and CCM2 have similar expression patterns during development and postnatally thereafter. Given the fact that the disease phenotypes caused by mutations in either gene are clinically and pathologically indistinguishable, the significant overlap in expression pattern supports the hypothesis that both molecules are involved in the same pathway important for central nervous system vascular development.

Cerebral venous malformations have distinct genetic origin from cerebral cavernous malformations

BACKGROUND AND PURPOSE

Pathogenesis of cerebral venous malformation (CVM) is unknown. Because of coexistence of CVM and cerebral cavernous malformations (CCM), some studies have suggested that these 2 entities share a common origin and pathogenetic mechanism.

METHODS

We have identified and ascertained over 200 families with CCM. Among these, 1 unique family was found to have members affected by both disorders. We have performed mutational analysis in all 3 CCM genes, KRIT1, Malcavernin, and PDCD10, to identify the causative gene in the family.

RESULTS

Mutational analysis revealed a frameshift mutation affecting exon 19 of the CCM1 gene (KRIT1) in members with CCM, whereas no such mutation was observed in the member with CVM.

CONCLUSIONS

These findings support the hypothesis that CVM and CCM are 2 distinct entities with different pathogenetic mechanisms. This data further supports the hypothesis that CVM has a distinct biology and clinical behavior when compared to CCM. CVM is a benign developmental anomaly and should be managed separately from CCM.

Mapping a Mendelian form of intracranial aneurysm to 1p34.3-p36.13

The identification of pathways that underlie common disease has been greatly impacted by the study of rare families that segregate single genes with large effect. Intracranial aneurysm is a common neurological problem; the rupture of these aneurysms constitutes a frequently catastrophic neurologic event. The pathogenesis of these aneurysms is largely unknown, although genetic and environmental factors are believed to play a role. Previous genomewide studies in affected relative pairs have suggested linkage to several loci, but underlying genes have not been identified. We have identified a large kindred that segregates nonsyndromic intracranial aneurysm as a dominant trait with high penetrance. Genomewide analysis of linkage was performed using a two-stage approach: an analysis of ~10,000 single-nucleotide polymorphisms in the 6 living affected subjects, followed by the genotyping of simple tandem repeats across resulting candidate intervals in all 23 kindred members. Analysis revealed significant linkage to a single locus, with a LOD score of 4.2 at 1p34.3-p36.13 under a dominant model with high penetrance. These findings identify a Mendelian form of intracranial aneurysm and map the location of the underlying disease locus.