A modified technique for the treatment of isthmic spondylolisthesis.

AIM: To describe a modified technique for the treatment of single level, isthmic spondylolisthesis (IS) MATERIAL and METHODS: Forty-two patients who underwent posterior lumbar interbody fusion (PLIF) with spinolaminar autologous bone graft for the treatment of isthmic spondylolisthesis between May 2007 and November 2011, were retrospectively reviewed. All patients underwent total removal of the spinolaminar process, total discectomy and endplate decortication, and proper size spinolaminar autologous bone graft was sequentially inserted into the disc space with posterior instrumentation. Outcomes of the study included visual analogue scale (VAS), Oswestry disability index (ODI), and radiographic fusion. RESULTS: The average duration of follow-up was 3.5 years. Neither has implant failure been observed nor has revision been required so far. The mean Oswestry Disability Index improved from 53% to 9.5%, and visual analog scale for back pain from 8.5 to 3.8 at the first month and 1.3 at the sixth month postoperatively. Visual analog scale for leg pain from 8.3 to 1.4 at the first month and 0.8 at the sixth month postoperatively. All patients had clinical and radiographic evidence of solid fusion without any need for revision. CONCLUSION: The modified posterior lumbar interbody fusion and posterior instrumentation technique is a safe and effective treatment for isthmic spondylolisthesis.

Surgical treatment of a Malgaigne fracture.

Sacral fractures are generally accompanied by pelvic ring fractures. They rarely develop in an isolated form. Sacroiliac dislocation without sacral fracture is extremely rare. We report a case with a sacroiliac dislocation without sacral fracture, which was treated surgically. Lumbopelvic stabilization was applied using iliac wing plates. The case was evaluated according to his clinical condition and visual analogue score (VAS), American Spinal Injury Association (ASIA) and Oswestry scales. Considering the role of the sacrum, which transmits the load of the entire spine to the pelvis, meticulous care must be given to ensure the mechanic stability of the spine when evaluating patients with sacral and pelvic fractures. Very serious spinopelvic instability is present in sacroiliac dislocations even in the absence of sacral fractures. Caudal migration of the sacrum together with the cranial migration of the iliac wings can cause serious pelvic imbalance and difficulties in walking and maintaining a standing position. Aggressive stabilization and fusion are required, and these must be performed in the early period.

Surgical treatment in sacral fractures and traumatic spinopelvic instabilities.

AIM: Sacral fractures are generally seen together with pelvic ring fractures. They can also develop in isolated form rarely. Instability is observed in these fractures in rates reaching 30%. MATERIAL AND METHODS: Spinopelvic stabilization was applied to 10 cases with pelvic fractures together with sacral fractures and spinopelvic instability. Two cases were treated with adductive screws extending from the iliac wing to the sacrum, 5 cases with standard lumboiliac instruments and 3 cases were treated with iliac wing plates that are our own design. The cases were evaluated according demographic data, VAS, ASIA and Oswestry scores and the types of the trauma and fracture. RESULTS: Six cases had unilateral sacroiliac instability while the instability was bilateral in 4 cases. Follow-up periods range between 6 and 91 months. Preoperative VAS was 8.4, Oswestry mean value was 91.2, postoperative late VAS was 2.2, and Oswestry was 24.4. CONCLUSION: Serious spinopelvic instability can be talked of in sacral fractures accompanied by pelvic fractures, particularly when the anterior and posterior integrity of the pelvic ring is interrupted together. An aggressive stabilization and fixation must be performed without delay.

Transforaminal approach in thoracal disc pathologies: transforaminal microdiscectomy technique.

Objective. Many surgical approaches have been defined and implemented in the last few decades for thoracic disc herniations. The endoscopic foraminal approach in foraminal, lateral, and far lateral disc hernias is a contemporary minimal invasive approach. This study was performed to show that the approach is possible using the microscope without an endoscope, and even the intervention on the discs within the spinal canal is possible by having access through the foramen. Methods. Forty-two cases with disc hernias in the medial of the pedicle were included in this study; surgeries were performed with transforaminal approach and microsurgically. Extraforaminal disc hernias were not included in the study. Access was made through the Kambin triangle, foramen was enlarged, and spinal canal was entered. Results. The procedure took 65 minutes in the average, and the mean bleeding amount was about 100cc. They were mobilized within the same day postoperatively. No complications were seen. Follow-up periods range between 5 and 84 months, and the mean follow-up period is 30.2 months. Conclusion. Transforaminal microdiscectomy is a method that can be performed in any clinic with standard spinal surgery equipment. It does not require additional equipment or high costs.

Stem cell therapy in spinal cord injury: in vivo and postmortem tracking of bone marrow mononuclear or mesenchymal stem cells.

OBJECTIVE: The aim of this study was to address the question of whether bone marrow-originated mononuclear cells (MNC) or mesenchymal stem cells (MSC) induce neural regeneration when implanted intraspinally. MATERIALS AND METHODS: The study design included 4 groups of mice: Group 1, non-traumatized control group; Groups 2, 3 and 4 spinal cord traumatized mice with 1 g force Tator clips, which received intralesionally either no cellular implants (Group 2), luciferase (Luc) (+) MNC (Group 3) or MSC (Group 4) obtained from CMV-Luc or beta-actin Luc donor transgenic mice. Following the surgery until decapitation, periodical radioluminescence imaging (RLI) and Basso Mouse Scale (BMS) evaluations was performed to monitor neural activity. Postmortem immunohistochemical techniques were used to analyze the fate of donor type implanted cells. RESULTS: All mice of Groups 3 and 4 showed various degrees of improvement in the BMS scores, whereas there was no change in Groups 1 and 2. The functional improvement was significantly better in Group 4 compared to Group 3 (18 vs 8, p=0.002). The immunohistochemical staining demonstrated GFP(+)Luc(+) neuronal/glial cells that were also positive with one or more of these markers: nestin, myelin associated glycoprotein, microtubule associated protein or myelin oligodendrocyte specific protein, which is considered as indicator of donor type neuronal regeneration. Frequency of donor type neuronal cells; Luc + signals and median BMS scores were observed 48-64% and 68-72%; 44-80%; 8 and 18 within Groups III and IV respectively. DISCUSSION: MSCs were more effective than MNC in obtaining neuronal recovery. Substantial but incomplete functional improvement was associated with donor type in vivo imaging signals more frequently than the number of neuronal cells expressing donor markers in spinal cord sections in vitro. Our results are in favor of functional recovery arising from both donor MSC and MNCs, contributing to direct neuronal regeneration and additional indirect mechanisms.

An attempt to treat patients who have injured spinal cords with intralesional implantation of concentrated autologous bone marrow cells.

BACKGROUND AIMS: Spinal cord injury is common among young subjects involved in motor vehicle accidents. Mechanisms and attempts to reverse post-traumatic pathophysiologic consequences are still being investigated. Unfortunately no effective and well-established treatment modality has been developed so far. The regeneration capability of the human nervous system following an injury is highly limited. METHODS: The study involved four patients (two male, two female) who had suffered spinal cord injury as a result of various types of trauma. On neurologic examination, all the patients were determined to be in American Spinal Injury Association (ASIA) grade A. All patients were treated with decompression, stabilization and fusion for vertebral trauma anteriorly, as well as intralesional implantation of cellular bone marrow concentrates using a posterior approach 1 month after the first operation. The patients were then treated and followed-up in the physical rehabilitation clinic. RESULTS: At the end of the post-operative 1-year follow-up, two of the patients were classified as ASIA C while one was classified as ASIA B. One patient showed no neurologic change; none of the patients suffered from any complications or adverse effects as a result of intralesional application of bone marrow cells. CONCLUSIONS: The results of this experimental study show the potential contribution of intralesional implantation of bone marrow to neuronal regeneration in the injured spinal cord, with neuronal changes. In light of the results of this experimental study, the potential for regenerative treatment in injuries of the human spinal cord is no longer a speculation but an observation.

Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy.

OBJECTIVE: Pain, usually a response to tissue damage, is accepted as an unpleasant feeling generating a desire to escape from the causative stimulus. Although, in the early stages of malignant diseases, pain is seen in 5% to 10% of cases, this rate reaches nearly 90% in the terminal stage, and pain becomes a primary symptom. Cordotomy is one of the treatment choices in pain caused by malignancies localized unilaterally to the extremities as well as the thorax and the abdomen. METHODS: The target of computed tomography (CT)-guided percutaneous cordotomy is the lateral spinothalamic tract located in the anterolateral region of the spinal cord at the C1-C2 level. Between 1987 and 2007, CT-guided percutaneous cordotomies were performed in 207 patients; most (193 patients) suffered from intractable pain related to malignancy. The patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively. RESULTS: The initial success rate of CT-guided percutaneous cordotomy was 92.5%. The success rate was higher in the malignancy group. In the cancer group, selective cordotomy (pain sensation denervated only in the painful region of the body) was achieved in 83%. In 12 cases, bilateral selective percutaneous cordotomy was successfully applied. CONCLUSION: In the treatment of intractable pain, CT-guided cordotomy is an option in specially selected cases with malignancy. In this study, anatomic and technical details of the procedure and the experience gained from treating 207 patients over a 20-year period are discussed.

Antibacterial effects of electrically activated vertebral implants.

Bio-implants in the human body act as passive surfaces that are prone to bacterial adhesion potentially leading to deep body infections. Pedicle screws made of uncoated or silver-coated titanium alloy were used both in vitro and in vivo to determine whether silver-coated materials have antimicrobial properties when they are anodized. Twenty-four New Zealand Albino rabbits were divided into four groups with six in each. In Group 1, the rabbits were exposed to 8 muA direct current (DC) via silver-coated screws. In Group 2, the rabbits were not exposed to any electrical current, but silver-coated screws were used. In Group 3, the rabbits were exposed to 8 muA DC using uncoated screws. In Group 4, the rabbits were not exposed to any electrical current, but uncoated screws were used. Staphylococcus aureus (106 cfu) was inoculated into the rabbits before any electrical current was applied. All the animals were killed, and the areas surrounding the screws were histologically and microbiologically examined. Silver-coated titanium screws prevented implant-associated deep bone infections when they were polarized anodically. The antibacterial effects of the same screws with the same bacterium were confirmed in in vitro experiments on agar plates. When the screws were anodized with the same electrical parameters in vitro, a marked inhibition zone was detected around the silver-coated screws but not around the uncoated screws. Our findings suggest that silver-coated titanium implants can be used to prevent implant-associated deep bone infections when they are polarized anodically.

Electron microscopic study of the progeny of ependymal stem cells in the normal and injured spinal cord.

BACKGROUND: Spinal cord injury (SCI) is a common and often irreversible lesion that can incapacitate patients. Precursor cells in the spinal cord proliferate in response to trauma, and this proliferation can be enhanced by exogenous stimuli such as specific growth factors. In the present study, we examined electron microscopic detection of the proliferation, distribution, and phenotypic fate of these precursor cells in the injured adult rat spinal cord. METHODS: Adult female Sprague-Dawley rats weighing 250 to 300 g were divided into 3 groups. The first group consisted of spinal cord-injured animals with application of a 2.4-g clip extradurally around the spinal cord at the T1 level. A 26-g clip was applied in the second group. The third group included normal uninjured animals. Rats were sacrificed at 3 days, 3 weeks, and 6 weeks after injury. A segment of the spinal cord, 0.4 cm in length, encompassing the injury site was removed and was prepared for electron microscopy. RESULTS: Three days after mild injury (2.4-g clip), ependymal cells had begun to proliferate and had migrated from the central canal. They had a tendency to surround perivascular spaces close to the axons. The central canal rostral to the lesion site was widely dilated at 6 weeks postoperative in the moderately injured groups (26-g clip). The layer of ependymal cells lining the dilated canal showed reduction in cell height. Traumatic syringomyelic cavities were observed in all of the animals. There was an active proliferative response of the ependymal cells to injury. Large clusters of displaced ependymal cells associated with the dilated central canal were observed. Rests of ependymal cells were observed remote from the central canal with a tendency to form rosettes and accessory lumina 6 weeks after trauma. Fascicles of 3 to 8 fibers enclosed within an ependymal cell were a common finding among the ependymal clusters. There were also debris and some ependymal cells in the lumen. CONCLUSION: Trauma induces active proliferation of precursor cells in the ependymal region. These cells may replace neural tissue lost to SCI and may assist in axonal regeneration.

Olfactory groove meningiomas.

Meningiomas originating from the olfactory groove account for approximately 10% of all intracranial meningiomas. They represent only 2% of all intracranial tumors. We present the diagnostic, clinical and pathological features of olfactory groove meningiomas and describe our surgical results and complications in a series of 25 patients. In 19 patients, surgery was via a bifrontal approach, and in the remaining six a pterional approach was used.

Schwannoma of the conus medullaris.

We report a rare case of schwannoma of the conus medullaris. A 38-year-old female presented with pain and numbness in her lower limbs. Magnetic resonance imaging confirmed a heterogenous tumour of the conus medullaris. A subtotal resection was performed and histology confirmed schwannoma. The literature regarding these rare tumours, and their cell of origin, is reviewed.