Hyaluronic acid in tobacco-exposed rats. Inflammatory reaction, and duration of effect

Abstract Purpose: To evaluate the hyaluronic acid (HA) inflammatory reaction, fibroblasts, fibrosis and duration of effect in the dorsal region of tobacco-exposed rats. Methods: Ten Wistar rats were divided into two groups: tobacco-exposed-group (TEG;n=5) and air-control-group (CG;n=5). The TEG animals were tobacco-exposed twice a day, 30-minutes/session, during 60 days. After this period, all animals received 0.1 mL HA subcutaneous injection in the dorsal area. The volume of HA was measured immediately after HA injection and weekly using a hand-caliper in nine weeks. After this period, all the animals were euthanized, and a specimen of was collected to evaluate inflammatory cells, fibroblasts, and fibrosis by HE. Results: This study showed a higher inflammatory reaction in TEG than CG: inflammatory cell-count (CG: 1.07±0.9; TEG: 8.61±0.36, p<0.001); fibroblast count (CG: 2.92±0.17; TEG: 19.14±0.62, p<0.001), and fibrosis quantification (CG: 2.0; TEG: 3.75, p<0.001). The analysis of the HA volume in nine weeks in the dorsal region did not show a difference between groups (p=0.39). Conclusions: This study suggested that the HA injection in the TEG caused an increase in inflammatory cell count, fibroblast, and fibrosis quantification when compared to the CG. There was no difference in the duration of effect of HA between the groups.

Lipomatose epidural idiopática familiar: relato de três casos e revisão da literatura / Familiar Idiopathic Spinal Epidural Lipomatosis: Report of Three Cases and Review of the Literature

Lipomatose epidural é a doença causada pelo aumento da quantidade de gordura no espaço epidural da coluna vertebral, levando à compressão medular ou radicular. A medula toracolombar é a mais comumente envolvida. É geralmente encontrada em homens. As principais causas são a obesidade, altos níveis de corticoides exógenos ou endógenos e hipotireoidismo. A forma idiopática é rara, correspondendo a 17% dos casos. Manifesta-se como mielopatia compressiva ou das raízes da cauda equina. A ressonância magnética é o exame de escolha; sugere-se o diagnóstico quando a espessura da camada de gordura epidural ultrapassa 6 mm. Nós adotamos neste caso a laminectomia com ressecção da gordura epidural, citada como uma das possíveis formas de tratamento. A maioria dos trabalhos demonstramelhora gradual, acentuada ou completa, do déficit neurológico nos primeiros 2 anos após a cirurgia.

Epidural lipomatosis is a disease caused by increased fat content in the epidural space of the spine, leading to root or spinal cord compression. The thoracolumbar spinal cord is themost commonly involved. It is usually found in men. Themain causes are obesity, high levels of exogenous or endogenous steroids and hypothyroidism. The idiopathic form is rare, accounting for 17% of cases. It manifests as compressive myelopathy or radiculopathy. MRI is the test of choice, suggests the diagnosis when the thickness of the epidural fat exceeds 6mm. We adopt in this case laminectomy with fat resection, cited as one of the possible forms of treatment. Most studies show a gradual improvement, marked or complete neurological recovery in the first two years after surgery.

Achados de ressonância magnética em cistos epidurais de origem discal em pacientes não operados e após microdiscectomia / Magnetic resonance imaging findings of disc-related epidural cysts in nonsurgical and postoperative microdiscectomy patients

OBJECTIVE: To demonstrate five discal cysts with detailed magnetic resonance imaging findings in nonsurgical and following postoperative microdiscectomy. MATERIALS AND METHODS: Five discal cysts in four patients who underwent magnetic resonance imaging were found through a search in our database and referral from a single orthopedic spine surgeon. Computed tomography in two cases and computed tomography discography in one case were also performed. RESULTS: Five discal cysts were present in four patients. Three patients had no history of previous lumbar surgery and the other patient presented with two discal cysts and recurrent symptoms after partial laminectomy and microdiscectomy. All were oval shaped and seated in the anterior epidural space. Four were ventrolateral, and the other one was centrally positioned in the anterior spinal canal. One showed continuity with the central disc following discography. Three were surgically removed. CONCLUSION: Magnetic resonance imaging can easily depict an epidural cyst and the diagnosis of a discal cyst should be raised when an homogeneous ventrolateral epidural cyst contiguous to a mild degenerated disc is identified.

OBJETIVO: Demonstrar os achados de imagem em cinco casos de cisto discal em pacientes sem cirurgia prévia e após microdiscectomia. MATERIAIS E MÉTODOS: Cinco cistos discais em quatro pacientes submetidos a exames de ressonância magnética foram identificados após procura em nossos sistemas de dados e por referência de um cirurgião ortopédico especialista em coluna. Exames de tomografia computadorizada também estavam disponíveis em dois casos e discografia por tomografia computadorizada em um caso. RESULTADOS: Três pacientes não tinham história prévia de cirurgia lombar e o outro paciente, que tinha dois cistos discais, apresentava recorrência dos sintomas após laminectomia parcial e microdiscectomia. Todos os cistos mostravam aspecto ovalado e estavam localizados no espaço epidural anterior, sendo quatro ventrolaterais, e o outro estava posicionado na região central do espaço epidural anterior. A discografia por tomografia computadorizada, disponível em um caso, demonstrou continuidade do cisto com o disco. Três foram submetidos a ressecção cirúrgica. CONCLUSÃO: A ressonância magnética pode facilmente identificar um cisto epidural e o diagnóstico de cisto discal deve ser considerado quando uma imagem cística homogênea, localizada no espaço epidural anterior, ventrolateral, e em contato com um disco parcialmente degenerado for identificada.

Primary spinal epidural hydatid cyst with intrathoracic extension

Spinal epidural localization of hydatid cyst is quite rare. We report a case of a 33-year-old patient who experienced paraparesis over 2 years, with an umbilical sensitive level. A CT scan and MRI showed an intrathoracic multilobar lesion, probably of intra-spinal origin. An anterolateral transpleural surgical approach confirmed the hydatic character of the observed lesion and enabled total spinal cord decompression. No osseous involvement was noted. We report a case of spinal epidural hydatid cyst successfully managed by an anterior approach, and we discuss epidemiological, diagnosis, and therapeutical features of this rare localization of hydatid cyst

Efficacy of Adcon-L gel or Healon-GV in epidural fibrosis after lumbar microdiscectomy

To evaluate the efficacy of anti-adhesion barrier agents following lumbar microdiscectomy. Healon GV or Adcon-L was applied to a laminectomy defect overlying the duramater in 60 patients assigned to 3 randomized groups: Group I - Adcon-L [n=21], Group II - Healon GV [n=21], and Group III - control group, no adhesion barrier used [n=18]. We conducted this study between 2004 and 2006 at Selcuk University, Konya, Turkey. No significant difference was found between the 3 groups either in the outcome measurements according to visual analogue score and the Oswestry Disability Index or in the radiological evaluation of epidural fibrosis by application of those anti-adhesion barrier agents. When comparing group III with groups I and II, we could not find a statistically significant difference in the clinical results and in the outcome measures [p>0.01]. The epidural application of popular anti-adhesion barriers, after lumbar microdiscectomy was not found to be effective regarding outcome measures in human spinal surgery

Estudo de membrana biológica em ratos na prevenção de fibrose pós laminectomia / Inhibition of peridural fibrosis after laminectomy using biological sheet in rat model

Os autores investigaram a aplicação de uma membrana biológica, constituída de cortical óssea bovina descalcificada, em cirurgias de coluna vertebral de ratos, com o intuito de tratar o defeito ósseo minimizando ou impedindo a herniação do tecido muscular para dentro do canal raquidiano pós laminectomia, inibindo a formação de fibrose pós-operatória e avaliando a biocompatibilidade do material. O estudo foi feito utilizando-se de ratos Wistar-EPM, que após intervalos de 8, 16 e 24 semanas, foram sacrificados, sendo removidas as peças cirúrgicas para análise anatomopatológica. A membrana biológica evitou a herniação do tecido muscular para o canal raquidiano, sendo totalmente reabsorvida em todas as peças analisadas, demonstrando sua biocompatibilidade e favorecendo a neoformação óssea e evitando aderências.

Approaches to minimize the risk of epidural fibrosis after lumbar disc surgery: [clinical - and MRI-based outcome evaluation]

Epidural fibrosis [EF] after lumbar disc surgery is a consequence of normal wound healing. Previous clinical studies have demonstrated a significant association between the presence of extensive post-lumbar discectomy EF formation and the recurrence of low-back and radicular pain with poor surgical outcomes in 5% up to 60%; in the nearly absent curable surgical solutions. Moreover, the presence of fibrosis may lead to nerve root tethering and renders reoperations risky. Theoretical approaches to minimizing the risk of developing EF include decreasing the chance of its development by decreasing the amount of postoperative hematoma by suction drainage [SD] and hence its invasion of by dense fibrous tissue; providing a barrier like autogenous fat between the exposed dura and the healing connective tissues; or applying a drug locally which is supposed to decrease scar tissue formation as steroids. In the present study, we aimed to evaluate the results of these theoretical approaches in the clinical and imaging outcomes of patients after lumbar disc surgery. The present study is a prospective, pragmatic, cohort study conducted and designed to evaluate the clinical outcome and efficacy of SD alone and combined with local application of fat grafts and/or steroids in prevention of post-lumbar discectomy EF. These outcomes were compared with outcomes in patients in whom neither the drain nor the barrier or steroids was implanted. A total of 58 patients [25 women, 33 men] indicated for surgery for a symptomatic, unilateral or bilateral, single-level lumbar disc herniation was included in this study. All patients underwent randomization and surgery. Patients were divided into 2 major groups with 33 patients in Group I [intervention group] and 25 patients in Group II [control group]. Group II served as the control, with decompressive surgery of their symptomatic nerve root alone without SD, local fat or steroid application. Group I was subdivided into 4 subgroups [Ia, Ib. Ic, and Id] according to the procedure done, whether decompressive surgery followed by SD alone or SD combined with local fat and/or steroid application. The barrier tested was autogenous fat graft. Thirty one patients underwent surgery at L4-5, and twenty-seven at L5-S1. Clinical outcome was assessed pre-and postoperatively by evaluating pain intensity, and patients' functional outcome. Pain intensity was evaluated in our study by numeric verbal rating [NVR] scale; and the patients' functional clinical outcome was measured by the range of motion and straight leg raising [SLR] tests. Imaging outcome was assessed on the basis of follow-up magnetic resonance imaging [MRI] findings. We proposed an MRI-based grading system for the extent of EF. No operative or early post operative complications were reported, and no new neurological deficits occurred. A significant proportion of patients in group I showed pain relief compared to the control group, as well as compared to the baseline findings. Analysis of functional outcome showed significant improvements in the intervention group compared to the baseline, as well as the control group at intervals of 3 months, 6 months, and 12 months. The results of pain relief and recovery of the functional status at the end of the study [12m] was best in group Id [SD + fat graft + steroids], followed by group Ib [SD + fat graft], group Ic [SD + steroids], and group Ia [SD alone] respectively. The worst results were obtained in the control group II. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain and functional status. At 1-year follow-up MRI examination, there was a trend toward better outcome in the intervention group. Both suction drainage and fatlsteroid combinations consistently reduced the frequency and the extent of epidural fibrosis on MRI. We conclude that, in patients operated on for unilateral, single-level lumbar disc herniations, implantation of suction drainage into the operation site results in less formation of EF radiologically and yields better clinical outcome. Fat grafts further reduced epidural fibrosis and did not impair normal healing. Local steroid is an effective adjuvant in a significant number of patients without adverse effects. Thus, the use of SD with addition of peridural fat barrier and steroids may improve outcome in these patients

Idiopathic spinal epidural lipomatosis: case report and review of the literature

Idiopathic spinal epidural lipomatosis [ISEDL] is a rare condition. Spinal epidural lipomatosis [SEDL] is usually associated with the use of steroids as treatment. It may also result from elevation of endogenous steroids. The term idiopathic epidural lipomatosis is used only when there is no exogenous or endogenous steroid elevated level. We present a case of ISEDL treated at our hospital. The patient, who was a 38-year-old male, improved spontaneously after weight reduction

Vigorous pelvic traction as an adjuvant therapy in FBSS

Failed back surgery syndrome [FBSS] is a condition where there is a failure to improve satisfactorily following back surgery for herniated discs, stenosis and instability. The syndrome is difficult to treat due to the variability of pain generators. Eighteen patients were evaluated in a prospective study. All had post-operative enhanced magnetic resonance imaging which showed no surgically treatable lesions and no infection but all had variable degrees of epidural fibrosis [EDF]. Vigorous pelvic traction [VPT] was applied twice a week for 4 weeks and patients followed up 3 months post-traction. The mechanical and physiological effects of VPT on the tethering fibrous bands and surroundin 9 structures is the concept of this study. The aim of therapy was focused on the reduction of pain and the enhancement of function. The results showed a definite improvement in many clinical parameters in 16 [88.88%] patients. In conclusion, patients with surgically repairable problems cannot benefit from anything but surgery. However, there is a group for whom surgery is not an option and another group in those where surgery is an alternative but not necessarily one that must be pursued. In both groups, a comprehensive programme of spinal rehabilitation including VPT may be beneficial

Diagnóstico y tratamiento del absceso epidural espinal / Diagnosis and treatment of spinal epidural abcess

El absceso epidural espinal es una enfermedad poco común y de difícil diagnóstico. Presentamos tres casos ocurridos en nuestro medio. En ninguno de ellos se consideró el diagnóstico antes de su internación. Los tres pacientes fueron internados con dolor espinal y dos de ellos presentaron fiebre previo a su ingreso. Las imágenes de resonancia magnética fueron de gran utilidad para el diagnóstico y para definir la extensión del absceso previo a la cirugía. La identificación microbiológica y el drenaje quirúrgico permitieron la recuperación neurológica.

Fibrosis epidural lumbar postoperatoria con refuerzo periférico en las RM / Postoperative lumbar epidural fibrosis

Una paciente de 80 años de edad con un dolor lumbociático y una historia de dos cirugías lumbares previas (10 y 30 años antes), fue estudiada con RM. Las imágenes axiales y sagitales ponderadas en T1 (TR 540-TE 18), mostraron una masa iso-hipointensa en L3-L4 que desplazaba el saco dural. Las imágenes axiales ponderadas en T2 (TR5000-TE80), revelaron una masa hipointensa. Luego de la administración de godolinio la maza reforzó en formas periféricas. En cirugía se vio que la lesión era fibrosa, sin material discal. Las imágenes fueron consideradas atípicas para una fibrosis lumbar postoperatoria. Probablemente fue una cicatriz fibrosa mixta con diferentes edades y propiedades imagenológicas

Non-Hodgkin's lymphoma presenting with spiral cord compression

To describe clinical features staging, histology, treatment, functional outcome and survival of 70 patients with histologically confirmed diagnosis of Non Hodgkin's Lymphoma of Epidural Space presenting with spinal cord compression at the outset. Design: A retrospective study of 70 patients of Non Hodgkin's Lymphoma presenting with spinal cord compression seen between March, 1983 and March 1994. Setting: Dept. of Neuro-surgery, Radiotherapy Oncology and Internal medicine of Nishtar Medical College/Hospital Multan. Subjects: Seventy patients out of 825 with biopsy proven diagnosis of Non-Hodgkin's Lymphoma and presenting with spinal cord compression and having stage 1e at initial presentation and treated with chemotherapy [CT] and radiotherapy [RT] after initial decompressive surgery. There were 70 patients with a median age of 35 years. Chronic backache in all the patients and leg weakness [Paraplegia or Severe Paraparesis] in 62 patients were the commonest complaints at the time of initial presentation. 42 patients were non ambulatory. Intermediate grade type was the commonest histology [90% of cases]. Postoperative treatment included Radiotherapy alone in 11 patients, C.T. alone in 22 patients and combination of both Chemotherapy + Radiotherapy [CT + RT] in 37 patients. Out of 70 patients only 23 patients were evaluable for long term follow up and functional results. 13 patients [56%] out of 23 who had combined modality treatment C.T. + R.T. had relapse free median survival of 5 years [0.5-8years] 10 patients out of 23 who either had C.T. alone and RT alone relapsed after a median survival of 2 years [range 0.5-3years]. Functional outcome was better in 13 patients who received combined Chemotherapy + Radiotherapy [CT +RT]. Conclusions: oSpinal Epidural Non-Hodgkin's Lymphoma [S.E.L.] had younger median age i.e. 35 years. This is a significant divergence from reports in the literature. oThere is poor follow-up of patients. oCombined modality treatment i.e. with CT and RT after initial decompressive surgery appears to have improved local control and survival. oLymphoma with involvement of spinal cord should be suspected in cases of spinal cord compression and appropriate neuroimaging be performed to exclude secondary involvement

Paragonimiasis espinal epidural / Epidural paragonimiasis

Presentamos un caso de Paragonimiasis de localización epidural dorsal, en una paciente de 43 años de edad, natural y procedente de la sierra central del Perú, que presentó un síndrome compresivo medular dorsal con nivel D-9 y a quien por medio de una laminectomía se le resecó un tejido tumoral epidural. La histopatología correspondió a una reacción granulomatosa crónica, ocasionada por huevos de Paragonimus sp.; la paciente recuperó la totalidad de la función motora y sensitiva. Revisamos la literatura a propósito de esta rara localización de Paragonimus sp

Lipomatosis extradural idiopática: a propósito de un caso / Idiopatic extradural lipomatosis

La lipomatosis extradural, es una rara entidad que se caracteriza por la proliferación de tejido adiposo epidural. Habitualmente se desarrolla como consecuencia de la administración prolongada de corticoides. Reportamos el caso de un paciente con lipomatosis extradural que se presenta como complicación de su obesidad. La TC y la RM permiten evidenciar con claridad el sitio, extensión y características de esta patología

Manejo quirúrgico de la patología de la médula espinal / Surgical management of the spinal cord pathology

Gracias al aporte de nuevos métodos diagnósticos, como Resonancia Magnética, la patología medular ha aparecido más frecuente en nuestra clínica. Se analiza una experiencia personal en distintas patologías de la médula: tumores intramedulares, tumores extramedulares e intradurales, aracnoiditis espinal, siringomielia y malformaciones vasculares durales espinales. Se logró hacer una extirpación amplia en los casos de tumores con mínima morbilidad, se discuten los casos y hallazgos de aracnoiditis, se analizan los casos de siringomielia (con buen resultado clínico y de RM en su postoperatorio) y se discute el problema de las malformaciones vasculares durales espinales. No hubo mortalidad operatoria en la serie. Si bien es poco frecuente en la patología medular, los procedimientos quirúrgicos obtienen un muy buen rendimiento

Analgesia post-operatoria ketamina en el espacio peridural / Postoperatory analgesy: Ketamine in epidural space

Se valoró la eficiencia y los efectos secundarios derivados de la administración de ketamina peridural a dosis de 0.4 mg/kg. Para el alivio del dolor post-operatorio en 40 pacientes embarazadas en edades comprendidas entre 16 y 39 años a quienes se les practicó operación cesárea. Las pacientes fueron divididas en dos grupos de 20 cada uno, se les colocó un catéter peridural lumbar a través del cual se les administró 400 mg de lidocaina al 2 por ciento. Una vez concluido el acto quirúrgico, a 20 pacientes se les inyectó ketamina peridural 0,4 mg/kg obsevándose una analgesia de 2 a 8,4 horas, con un promedio de 4,6 horas en el 60 por ciento de las pacientes, no observándose efectos secundarios indeseables. En el grupo control, en que no se utilizó la ketamina el dolor apareció al cesar el efecto del anestésico local. Se demuestra que la administración de la ketamina peridural a dosis de 0,4 mg/kg es eficaz y segura en el tratamiento del dolor post-operatorio inmediato