Non-contiguous multilevel spinal tuberculosis: A case report of unusual spinal tuberculosis resembling spinal metastasis.

Spinal tuberculosis (TB) is diagnostically challenging, particularly in atypical forms. Non-contiguous multilevel spinal TB (NMLST) is a rare presentation of spinal TB, mimicking spinal malignancies. We reported an unusual NMLST case with a paraspinal and epidural abscess in a young patient with misleading clinical and imaging presentations.

Prognostic factors in traumatic atlanto-occipital dislocation.

Traumatic atlanto-occipital dislocation (AOD) is an ominous injury with high mortality and morbidity in trauma patients. Improved survival has been observed with advancements in pre-hospital and hospital care. Furthermore, high quality imaging studies are accessible at most trauma centers; these are crucial for prompt diagnosis of AOD. The objective of this study is to perform a comprehensive literature review of traumatic AOD, with specific emphasis on identifying prognostic factors for survival. A review of the literature was performed using the Medline database for all traumatic atlanto-occipital articles published between March 1959 and June 2015; 141 patients from 60 total studies met eligibility criteria for study inclusion. A binary logistic regression model was utilized to identify prognostic factors. The analysis assessed age, sex, spinal cord injury (SCI), traumatic brain injury (TBI), polytrauma injury (PI), and Traynelis AOD Classification. Only TBI was statistically significantly associated with death (OR 8.05 p<0.05); SCI did not reach statistical significance for predicting mortality in AOD patients (OR 1.25 p>0.05). Age, sex, PI, and Traynelis AOD Classification did not meet significance to predict mortality in AOD patients. We found that patients with TBI are eight times more likely to die than patients without TBI. A high degree of suspicion for AOD during pre-hospital care, as well as, prompt diagnosis and management in the trauma center play a key role in the treatment of this devastating injury. The relationship between survival and factors such as TBI and SCI should be further explored.

Peribrachiocephalic approaches to the anterior cervicothoracic spine.

This cadaveric study aims to reexamine the corridors to the anterior cervicothoracic junction, relative to the left brachiocephalic vein, and to present these working corridors as either supra- or infra-brachiocephalic. The anterior cervicothoracic junction incorporates the seventh cervical vertebrae through the fourth thoracic vertebrae (C7-T4) and involves critical anatomical structures. Operative approaches to this area are well described in the literature, with the predominant implementation of three surgical corridors. We used three embalmed, human, cadaveric specimens for this study. No pathology involving the cervicothoracic junction was noted. While dissecting, we tried to imitate the actual surgery. For each surgical step, photographs were taken, drawing attention to the critical structures and highlighting the different corridors to the spine relative to the left brachiocephalic vein. It is possible to access the cervicothoracic junction relative to the brachiocephalic vein from the left. The supra-brachiocephalic approach gives access to the C7-T4 vertebrae, whereas if T4-T5 is the goal, the infra-brachiocephalic approach may be utilized. In the supra-brachiocephalic approach, the brachiocephalic artery can be either medialized or lateralized as needed. A re-examination of the anterior cervicothoracic junction anatomy has allowed us to classify approaches relative to the left brachiocephalic vein. Identifying and understanding the approaches relative to this structure will assist in safe and effective spinal surgery in this area.

Anatomic considerations of the anterior upper cervical spine during decompression and instrumentation: a cadaveric based study.

We evaluated the anatomical considerations specific to the high anterior retropharyngeal approach to the cervical spine. Surgical exposure of the anterior upper cervical spine can sometimes be challenging due to the surrounding neurovascular structures. Using three adult cadavers, we performed high anterior retropharyngeal cervical dissection of the left and right side for a total of six approaches (six sides). During the dissection, all important neurovascular elements were noted and photographed, and anatomical relationships to the spinal vertebral bodies and disc spaces were analyzed. There are certain anatomic considerations that are unique to the high anterior cervical spine. The unique structures include the hypoglossal nerve and the superior thyroid artery/nerve. Only the superior thyroid artery in this region has numerous anatomical variations. Awareness of other structures, including the carotid artery, recurrent laryngeal nerve, and esophagus also remains important. Awareness of the anatomical structures in the anterior upper cervical spine is essential for performing safe anterior upper cervical spinal surgery, avoiding serious complications.

The efficacy of Cyclosporine-A on Diffuse Axonal Injury after Traumatic Brain Injury.

BACKGROUND: To evaluate the efficacy and side-effects of cyclosporine-A (CsA) in improvement of consciousness and cognitive dysfunction of patients with diffuse axonal injury (DAI) after traumatic brain. MATERIALS AND METHODS: This study is designed as a randomized double-blind placebo-controlled with 100 patients suffered from DAI. CsA was administered to the intervention group (n = 50) as 5 mg/kg/24 h via 250 ml dextrose water (DW) 5% solution (DW 5%) during the first 8 h after trauma. The control group (n = 50) received only DW 5% in the same course. The presenting Glasgow coma scale in addition to the Glasgow outcome scale-extended (GOS-E) and mini-mental state examination (MMSE) in the 3(rd) and 6(th) months after trauma were documented. The serum values for complete blood count (CBC), blood urea nitrogen (BUN), creatinine (Cr), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were checked to assess for complications. RESULTS: Most patients in both groups had type II DAI (46%). There was no significant difference between groups in the GOS-E scores after 3 and 6 months. All participants were in moderate or severe classes of MMSE with no statistically significant difference. Except for the higher BUN level in the cyclosporine treated group, 48 h after admission (P = 0.012), the difference in the level of Cr, AST, ALT, and ALP was not significant and all were in the normal range. The CBC results showed only significant difference for White Blood Cell (WBC) count at 12 h (P = 0.000). CONCLUSION: The administration of CsA is not effective in the improvement of consciousness and cognitive function. However, it brings about no adverse effects.

Analyzing the effects of intra-operation video-clip display on hemodynamic and satisfaction of patients during lumbar discectomy under spinal anesthesia.

OBJECTIVE: Most neurosurgeons and anesthesiologists prefer the less invasive intervention for most surgeries; recently, the lumbar anesthesia is more popular method. In this study we have tried to distract the attention of the patients to their favorite video-clip instead of their surrounding operating room background to evaluate the hemodynamic as well as their satisfaction during the operation. METHODS: 80 patients who were scheduled for an elective one level discectomy under the regional spinal anesthesia enrolled in this prospective randomized clinical trial. The patients were randomized with sealed envelope method and each envelope was randomly assigned from this set of envelops to be either in case group one (video group) or control groups two (no audio and video and only head phone on their ears) group. In all patients, systolic and diastolic blood pressure, pulse rate and SPO2 were measured and recorded in the questionnaire charts. RESULTS: Of the 80 patients with Lumbar disk herniation, 53 patients were male and 27 female. The mean age for all patients was 44 year. Systolic and diastolic blood pressure at the end of surgery was significantly lower in video group (P=0.045 and 0.004). Systolic Blood pressure differences between 3(rd) and 5(th) and the end of the surgery with minute zero was significantly less in the video group. (P=0.025, 0.018 and 0.030). Diastolic blood pressure differences between 3(rd) and 5(th) and the end of the surgery with minute zero was significantly less in the video group.(P=0.051, 0.019 and 0.15). Pulse rate differences between first, 3(rd), 5(th) and exactly before leaving the recovery room with minute zero was significantly less in the video group. (P=0.015, 0.028, 0.030 and 0.008). CONCLUSION: According to our study, by displaying patient's favorite video clip during the surgical intervention we could highly reduce the patient's attention to what is happening in operating room and therefore, decrease their anxiety and stress.

A 12-year epidemiologic study on primary spinal cord tumors in Isfahan, Iran.

BACKGROUND: Although primary spinal cord tumors (PSCTs) comprise a minority of primary central nervous system tumors, they often impose a great deal of morbidity on their victims. Few epidemiologic studies have addressed PSCTs in Iran. MATERIALS AND METHODS: We analyzed the demographic/clinical features of all primary intraspinal tumors (with a specific focus on primary intradural spinal cord tumors) identified between 1992 and 2004 in three of the major related hospitals in Isfahan, Iran. We also tracked the malignant cases until 2012. RESULTS: 102 patients with primary intraspinal tumors were found; 82 tumors were Intradural (36 intramedullary and 46 extramedullary) and 20 extradural. The principal intradural histological subtypes were nerve sheath tumor (33%), ependymoma (22%), astrocytoma (16%), and meningioma (15%). 20 (19%) of the tumors were malignant. Local pain (43%) and motor disabilities (36%) were the most common first-presenting symptoms in the patients. Male-to-female ratio was significant only in ependymoma (male:female ratio = 3.6, P < 0.05). The mean age in meningioma (57 years, standard error [SE]: 15.7) was significantly higher than other types (one-way ANOVA, P < 0.05). CONCLUSION: Our results reflect analogous frequency of distribution for PSCTs compared with most of the previous counterpart studies worldwide. The only notable exception was the comparatively fewer frequency of spinal cord meningioma in our study.

Multiple intracranial hemorrhages in a normotensive demented patient: A probable cerebral amyloid angiopathy.

Cerebral amyloid angiopathy (CAA) is the most common cause of lobar intracerebral hemorrhage. Repeated bleeding may be presented with vascular dementia. We have reported a 68-year-old normotensive demented patient with probable CAA presented with hemiparesia, headache and vomiting. According to the experience of this case, it is recommended to consider CAA for normotensive elderly patients presented with multiple and superficial intracerebral hemorrhage.

The effect of aminophylline on renal colic: a randomized double blind controlled trial.

OBJECTIVE: To evaluate the efficacy of aminophylline infusion as a painkiller compared with placebo in patients with acute renal colic. PATIENTS AND METHODS: From March to August 2005, 141 patients with clinical renal colic, who were under 60 years of age, had no history of heart or hepatic failure, asthma, theophylline or beta blocker use, reaction to methylxantines, pregnancy or breast feeding, and were not prescribed spasmolytic or analgesics, entered our study. They were randomly assigned to receive either 375 mg of aminophylline or placebo infusion under double blind conditions. Pain intensity was recorded using a visual analog scale (VAS), before drug administration and 30 and 60 minutes afterwards. The drug effectiveness was defined as > or =40% decrease in pain intensity 60 minutes after the onset of infusion, without exacerbation during the following 4 hours. RESULTS: Seventy patients received aminophylline; it was effective in 45 (64%; 95% confidence interval 52-75%). Alternatively, placebo was effective in 12 of 71 control patients (17%; 95% confidence interval 9-28%); (P < 0.001). Thirty and 60 minutes after administration, aminophylline reduced pain by 24% and 39% respectively, as compared with 6% and 8% pain reduction in the placebo group. CONCLUSION: This prospective study provides remarkable information about the efficacy of aminophylline on pain relief and decreasing narcotic usage in symptomatic urinary calculi. It is safe, inexpensive, with minute side effects and can be considered a good alternative or additive to narcotic analgesics in the management of renal colic.