Treatment of symptomatic lumbar spinal degenerative pathologies by means of combined conservative biochemical treatments.

Research in spine surgery has proposed new soft and less invasive techniques. These are the results of our experience with oxygen-ozone therapy, which we could experiment within the Italian National Health System over 3 years. A total of 1,920 patients were admitted on the basis of unselected enrolment because of lumbosciatic pain. Patients were divided into three groups: (A) Patients with degenerative disc disease and arthropathy: 509 (26.5%), (B) Patients with failed back surgery syndrome (FBSS): 1,027 (53.489%), and (C) Patients with pure herniated lumbar disc: 384 (20%). The rationale of the treatment for all these different pathologies we have taken into consideration is the biochemical mechanism by which they can engender pain and dysfunction. Treatment for group A: paravertebral injection and phleboclysis (two cycles of 6 sessions, one each 3 days) +endoscopic neurolysis. Treatment for group B: paravertebral injection and phleboclysis (two cycles of 6 sessions, one each 3 days) + endoscopic neurolysis with intradiscal procedure (named percutaneous peridurodiscolysis). Treatment for group C: paravertebral injection (two cycles of 6 sessions, one each 3 days) + percutaneous discolysis.The perceived quality of result for this minimally invasive procedure makes oxygen-ozone therapy an interesting weapon in the hands of doctors. Furthermore, if the technique loses its clinical effectiveness, it can be repeated without harm for the patient, and costs for the health organization are notably very low, above all if compared to surgical procedures.We underline the need that this treatment should be performed in protected structures, in operative rooms, under anesthesiologic control, and in the hands of specialists.

Liposome-DNA complexes infused intravenously inhibit tumor angiogenesis and elicit antitumor activity in dogs with soft tissue sarcoma.

Intravenous gene delivery using liposome-DNA complexes (LDC) has previously been shown to elicit antitumor activity, but only in rodent tumor models. Therefore, we conducted a study to determine in a large animal spontaneous tumor model whether intravenous infusions of LDC could target gene expression to cutaneous tumor tissues and whether repeated treatments had an effect on tumor growth or angiogenesis. A total of 13 dogs with cutaneous soft tissue sarcomas were enrolled in the study and were randomized to receive a series of 6 weekly infusions of LDC containing either canine endostatin DNA or DNA encoding an irrelevant gene (luciferase). Serial tumor biopsies were obtained to assess transgene expression, tumor microvessel density (MVD), and intratumoral leukocyte inflammatory responses. We found that intravenous infusion of LDC did not result in detectable gene expression in cutaneous tumor tissues. However, two of 13 treated dogs had objective tumor responses and eight dogs had stable disease during the treatment period. In addition, a significant decrease in tumor MVD was noted in six of 12 treated dogs at the completion of six treatments. These results suggest that intravenous infusions of LDC may elicit nonspecific antitumor activity and inhibit tumor angiogenesis.

Thoracic outlet syndrome due to hyperextension-hyperflexion cervical injury.

Posttraumatic brachial plexus entrapment in fibrotic scarring tissue is taken into consideration as the cause of complaints for patients who suffered a hyperextension-hyperflexion cervical injury. All 54 patients included in this analysis where symptom-free before the accident and subsequently complained for pain, paresthesia and slight weakness in the arm. In 14 neurological signs of brachial plexus entrapment were observed. Electroneurophysiological, summary index testing was positive for a brachial plexus involvement in all cases. Conservative measures, comprising physical therapy and vasoactive drugs were applied for a period of 6 to 12 (mean 8.4) months; surgical procedure of neurolysis was then proposed in 39 cases to solve the problem. Thirty-two patients were operated on. Twenty of these had a neat improvement on a 6-month to 1-year follow-up. Seven patients had refused surgery; of these 6 patients had clinical worsening at the same follow-up period while 1 remained unchanged. All patients with clinical symptoms not reversed after some time post-injury should be investigated for a possible brachial plexus entrapment.

Suprascapular nerve entrapment.

It is important to be aware of neuropathy involving the suprascapular nerve. While direct trauma to the suprascapular nerve is the usual cause (direct blow to the base of the neck or posterior shoulder, shoulder dislocation or fracture), the problem may result from overuse injuries (such as repetitive tennis serving or spiking of a volley ball), excessive horizontal adduction, weight lifting, backpacking or no apparent reason. These last three years we have operated 8 cases of suprascapular nerve neurolysis at the level of suprascapular incision, and section of the transverse scapular ligament through the back supraspinal approach.

Femoral nerve entrapment.

We present 30 cases of femoral nerve entrapment (1999-2003, age range 35-65 yrs), in 13 patients with diagnosis of idiopathic compression and 7 patients of neurovascular conflict. The compression, in the other 10 patients, was iatrogenic: 3 patients following cardiac catheterization for balloon valvotomy, 2 patients following intra-abdominal vascular surgery and 5 patients following laparoscopic hernia treatment. Microsurgical nerve decompression, and the elimination of neurovascular conflict gave satisfactory results. The best result has been observed in neurovascular conflict cases.

Microsurgical treatment of lumbosacral plexus injuries.

Surgical treatment of lumbar and sacral plexus lesions is very rarely reported in the literature. The incidence of the involvement of these nervous structures in traumatic lesions of different etiology is probably much higher than believed, and surgical treatment should be taken into consideration more often. In this paper the experience derived from the surgical treatment of 15 cases is reported. Different surgical approaches have been employed according to ethiology, to level of nerve lesion and concomitant lesions of other organs. Patients who suffered a lesion in the lumbar or sacral plexus may have a very severe problem with deambulation since the leg may not be stable or may be unable to withstand the weight of the body. Pain syndrome in these patients may be a very severe obstacle to rehabilitation programs and to deambulation and everyday activity. Microsurgical nerve treatment in the retroperitoneal space is demanding both for the surgeon and for the patient but neurolysis and grafting procedures are possible also in this area. The resulting improvement of motor performance and the relief of pain are strong arguments in favor of this choice. Muscles benefitting most from surgery are the gluteal and femural muscles; more distant muscles, and particularly the anterior tibial nerve dependent muscles will gain minimal benefit from surgery. The relief from pain is relevant in all cases.

Intradiscal injection of oxygen-ozone gas mixture for the treatment of cervical disc herniations.

For disc herniations the use of open surgical approaches is reduced since new percutaneous methods allowing shrinkage of the disc and improvement of the radicular function are gaining interest. Studies on the spontaneous disappearance of disc fragments have demonstrated autoimmune responses with a chronic inflammatory reaction. Also radicular pain has been shown to be mostly due to biochemical mechanisms. Researchers in different fields surprisingly noticed that a brief, calculated, oxidative stress by ozone administration may correct a persistent imbalance due to excessive, chronic oxidative injury. Oxygen-ozone gas injection in painful patients has a dramatic effect on clinical symptoms. On these bases the intradiscal injection of oxygen-ozone gas has been conceived. We report the treatment on a series of patients affected by cervical disc pathology, treated by intradiscal injection of oxygen-ozone gas mixture. The effects both on pain and on radicular dysfunction are impressive. The morphological effect of the treatment was also evaluated by pathological examination.

Percutaneous nucleoplasty for discoradicular conflict.

Minimally invasive techniques for the treatment of degenerative pathology of the spine have come to be preferred by surgeons since the destructive effect on bony structures is eliminated and scar formation is dramatically reduced. A critical review of the pathogenetic mechanisms for low back pain and sciatalgia has recently yielded that mechanical compression is one but non essential component of the matter. The importance of chemical irritative processes is stressed. Coblation nucleoplasty is one of these minimally invasive techniques. It provokes ablation of the nucleus of the disk by a controlled thermal effect produced by radiofrequency. By this procedure one to two ml of tissue are colliquated in a few minutes. From February 2001 to May 2003 we treated 1390 patients for of lumbosciatalgic pain caused by disc pathology. The alteration consisted of disc bulging or contained disc herniation. Exclusion criteria as provided by the protocol of the multicentric study conceived by Conor O'Neill have been respected. This technique has been conceived in order to obtain progressive results in cases of contained disc herniation which has scanty natural tendency to shrinkage, as demonstrated by several studies on the natural history of evolution of this pathology. Contained disc herniation is a pathology most difficult to manage by conservative procedures, physiotherapy and drugs, but we all agree that open surgery should be avoided. By this minimally invasive procedure the patient will not be compelled to abandon physiotherapy and his normal daily activities for more than a few days.

Long term follow up of radiofrequency catheter ablation of atrial flutter: clinical course and predictors of atrial fibrillation occurrence.

OBJECTIVES: To evaluate the time to onset and the predictors of atrial fibrillation (AF) during long term follow up of patients with typical atrial flutter (AFL) treated with transisthmic ablation. DESIGN: Prospective multicentre study. METHODS AND RESULTS: 383 patients (75.4% men, mean (SD) age 61.7 (11.1) years) who underwent transisthmic ablation for typical AFL were investigated. In 239 patients (62.4%) AF was present before ablation. Ablation proved successful in 367 patients (95.8%). During a mean (SD) follow up of 20.5 (12.4) months, 41.5% of patients reported AF. The cumulative probability of postablation AF increased continuously as time passed: it was 22% at six months, 36% at one year, 50% at two years, 58% at three years, and 63% at four years. CONCLUSIONS: AF occurred in a large proportion of patients after transisthmic catheter ablation of typical AFL. The occurrence of AF was progressive during follow up. Preablation AF, age < 65 years, and left atrial size > 50 mm are associated with postablation AF occurrence.

The duration of atrial fibrillation influences the long-term efficacy of low-energy internal cardioversion.

BACKGROUND: It is commonly held that long-lasting atrial fibrillation (AF), especially if associated with marked enlargement of the left atrium, is a negative predictive factor for both the recovery and the maintenance of sinus rhythm. The aim of the present study was to identify the clinical features of patients who have a greater likelihood of success both in the acute phase and, especially, in the medium-long term. METHODS: Since June 1997, we have performed low-energy internal cardioversion to 93 patients (66 males, 27 females, mean age 62 +/- 9 years, range 26-80 years) with a mean duration of AF of 922 +/- 1032 days. Seventy-four patients had heart disease and 19 isolated AF. External cardioversion had been previously performed in 79 patients to no avail. All patients underwent antiarrhythmic therapy and were followed for a period of 13 +/- 7 months. RESULTS: Low-energy internal cardioversion proved efficacious, restoring sinus rhythm, in 92% of patients (86/93) and inefficacious in 8% (7/93). In 24% (21/86) the procedure, although efficacious, was followed by early recurrence of AF which proved to be intractable in 52% (11/21). At the end of the session, 81% (75/93) of the patients maintained sinus rhythm. At the end of follow-up, 40% (38/93) maintained sinus rhythm. Of all the parameters considered in the two groups, the duration of AF was the only one which differed significantly between the group in sinus rhythm and that in AF, with regard to both the efficacy of the procedure in the acute phase (755 +/- 868 vs 1618 +/- 1359 days, p < 0.001) and the long-term outcome (655 +/- 5.8 vs 1107 +/- 1098 days, p < 0.05). CONCLUSIONS: AF lasting more than 2 years constitutes a negative predictive factor for both the recovery and the long-term maintenance of sinus rhythm.

Pacemapping of the triangle of Koch: a simple method to reduce the risk of atrioventricular block during radiofrequency ablation of atrioventricular node reentrant tachycardia.

Slow pathway ablation in common AVNRT can be complicated by total AV block. When radiofrequency energy is delivered to the posterior aspect of the triangle of Koch, total AV block may be the consequence of the absence of anterograde conduction along the fast pathway or of inadvertent damage to a fast pathway abnormally located close to the slow pathway. To localize the anterogradely conducting fast pathway, the triangle of Koch was pacemapped in 72 patients who underwent the ablation of common AVNRT. In all cases, before ablation the St-H interval was calculated by stimulating the anteroseptal (AS), mid-septal (MS), and posteroseptal (PS) aspect of the triangle of Koch at a rate slightly faster than the sinus rate. In all patients, common AVNRT was induced. In 64 (89%) of 72 patients (group A) the shortest St-H interval was recorded on stimulating the AS region. In six (8%) patients (group B) the shortest St-H interval was recorded on stimulating the MS region. Finally, in two (3%) patients (group C) the shortest St-H interval was recorded stimulating in the PS region. In group C, AH interval, calculated on stimulating in the AS region, was significantly longer than in patients of groups A and B (200 +/- 99 ms vs 64 +/- 18 and 62 +/- 3, respectively). In group A, on stimulating in the AS, MS, and PS regions, the AH interval remained constant in all patients. In contrast, in groups B and C on stimulation in the MS and PS regions, AH interval shortened (in group B from 56 +/- 8 to 27 +/- 37 and 37 +/- 14, respectively; in group C from 200 +/- 99 to 170 +/- 100 and to 137 +/- 109, respectively). In groups A and B, a posteroseptal slow pathway, and in group C, an anteroseptal retrograde fast pathway were successfully ablated without AV block. Pacemapping of the triangle of Koch can help to recognize patients in whom the anterograde conducting fast pathway is abnormally located far from the anteroseptal region or in whom anterograde conduction of the fast pathway is absent. In these cases the risk of AV block can be reduced by performing slow pathway ablation in a site sufficiently far from the site of the anterograde fast pathway or ablating the retrogradely conducting fast pathway.

Clinical usefulness of slow pathway ablation in patients with both paroxysmal atrioventricular nodal reentrant tachycardia and atrial fibrillation.

Some patients with atrioventricular (AV) node reentrant tachycardia (AVN RT) also presented with atrial fibrillation (AF). In this study we demonstrate that slow pathway ablation is able to suppress both AVN RT and AF in subjects without structural heart abnormalities, whereas in patients with structural heart abnormalities after ablation AF frequently recurs.

[The endocavitary and transesophageal electrophysiological findings in idiopathic atrial fibrillation]. / Rilievi elettrofisiologici endocavitari e transesofagei nella fibrillazione atriale idiopatica.

BACKGROUND: We studied 105 patients (pts) in order to help clarify the pathogenetic mechanisms of idiopathic atrial fibrillation (AF). Eighty of these pts (Group I) had experienced paroxysmal AF, and 25 were normal control subjects (Group II). Twenty-two pts out of Group I had idiopathic paroxysmal AF (Group IA), while the remaining 58 (Group IB) presented with a heart disease or a WPW pattern. METHODS: All pts underwent endocavitary (EEPS) (69) or transesophageal (TEPS) (36) electrophysiologic study. In all pts the inducibility of a sustained AF (greater than 1 min) was tested by aggressive stimulation protocols including high frequency atrial bursts. RESULTS: In Group I a sustained AF was induced in 82% of cases vs 4% of Group II cases (p less than 0.001). In Group I there was no difference between pts with or without idiopathic AF (IA 73% vs IB 86%, NS). In two pts with idiopathic AF a concealed Kent bundle was identified and a reciprocating atrioventricular tachycardia was induced, which in one case spontaneously degenerated into AF. Four athletes with idiopathic AF were studied before and after autonomic blockade. AF was induced in all during the basal state, lasting several hours, and after autonomic blockade in 3 pts, lasting again for several hours. In 1 patient (pt) the arrhythmia spontaneously resolved within 50 sec. CONCLUSIONS: 1) The induction of a sustained AF by EEPS or TEPS is a pathologic phenomenon which is frequently observed in pts with clinical episodes of paroxysmal AF, while it is very rare in normal control subjects. 2) Pts with idiopathic AF have an electrophysiologic behaviour similar to pts with non-idiopathic AF. This fact suggests that among the former, most cases probably have a concealed atrial anomaly. In some cases this atrial anomaly can be related to the existence of a Kent bundle. 3) In athletes with paroxysmal AF the inducibility of a sustained AF both in the basal state and after autonomic blockade suggests that the vagal prevalence typical of such subjects probably plays a secondary role.

[Clinical and prognostic value of evaluation of atrial vulnerability in an electrophysiological endocavitary and transesophageal study]. / Valore clinico e prognostico della valutazione della vulnerabilità atriale con lo studio elettrofisiologico endocavitario e transesofageo.

UNLABELLED: Atrial fibrillation or flutter is frequently inducible during endocavitary or transesophageal electrophysiologic study. However, its clinic and prognostic significance has not yet been clarified. We studied 443 patients: 276 underwent endocavitary electrophysiologic study, 228 underwent transesophageal electrophysiologic study and 61 underwent both methods. In 343 of them a satisfactory echocardiogram was obtained. Patients were divided in three groups: gr. I, 93 patients with documented episodes of paroxysmal atrial fibrillation or flutter; gr. II, 257 patients with or without heart disease without clinical atrial fibrillation or flutter; gr. III, 93 symptomatic or asymptomatic Wolff-Parkinson-White patients without clinical atrial fibrillation or flutter. Gr. I included patients without overt heart disease (20), with WPW (11), mitral valve prolapse (4), and miscellaneous (58). Gr. II included patients without overt heart disease (49), with concealed Kent bundles (7), Mahaim (1) or James fibers (1) mitral valve prolapse (6), sick sinus syndrome (40), miscellaneous (91), or syncope of an unknown origin (62). Atrial vulnerability was evaluated both by endocavitary and transesophageal electrophysiologic study using two different protocols; the first protocol was moderately aggressive (prot. A), while the second was aggressive (prot. B). Endocavitary electrophysiologic study. Prot. A: single and double extrastimuli at the three heart rates (sinus, 100 and 150/m'), 10/m' incremental atrial pacing from 160 to 250/m; prot. B: prot. A + incremental atrial pacing from 260/m' up to 2:1 St-A block. Transesophageal electrophysiologic study. Prot. A: 10" atrial burst at 100-600/m' prot. B: prot. A + 6-9" increasing rate bursts from 200 to 800/m'. End point of all protocols: initiation of greater than 1' atrial fibrillation or atrial flutter. RESULTS: Endocavitary electrophysiologic study. A greater than 1' atrial fibrillation or atrial flutter was induced with the two protocols respectively in 67% (52/78) and 85% (51/60) of gr. I, in 17% (26/150) and 36% (38/105) of gr. II and in 35% (17/48) and 44% (21/48) of gr. III (gr. I vs gr. II p less than 0.001 for prot. A and p less than 0.01 for prot. B; gr. II vs gr. III p less than 0.001 for prot. A and NS for prot. B). Induced atrial fibrillation or atrial flutter using the two protocols had a greater than 5' duration respectively in 83 and 78% of gr. I, 62 and 42% of gr. II and in 41 and 38% of gr. III.(ABSTRACT TRUNCATED AT 400 WORDS)