An Insight into the Prospects and Drawbacks of Stem Cell Therapy for Spinal Cord Injuries: Ongoing Trials and Future Directions.

Spinal cord injury (SCI) is a devastating neurological disorder that has a substantial detrimental impact on a person's quality of life. The estimated global incidence of SCI is 40 to 80 cases per million people and around 90% of cases are traumatic. Various etiologies can be recognized for SCI, and post-traumatic SCI represents the most common of these. Patients worldwide with SCI suffer from a persistent loss of motor and sensory function, which affects every aspect of their personal and social lives. Given the lack of effective treatments, many efforts have been made to seek a cure for this condition. In recent years, thanks to their ability to regenerate tissue and repair lost or damaged cells, much attention has been directed toward the use of stem cells (embryonic, induced pluripotent, mesenchymal, hematopoietic), aimed at restoring the functional integrity of the damaged spinal cord and improving a functional recovery including sensory and motor function. In this paper, we offer an overview of the benefits and drawbacks of stem cell therapy for SCI based on clinical evidence. This report also addresses the characteristics of various stem cell treatments, as well as the field's likely future. Each cell type targets specific pathological characteristics associated with SCI and demonstrates therapeutic effects via cell replacement, nutritional support, scaffolds, and immunomodulation pathways. SCI accompanied by complex pathological processes cannot be resolved by single treatment measures. Stem cells are associated with the adjustment of the expression of neurotrophic factors that help to achieve better nutrition to damaged tissue. Single-cell treatments have been shown in some studies to provide very minor benefits for SCI in multiple preclinical studies and a growing number of clinical trials. However, SCI damage is complex, and many studies are increasingly recognizing a combination approach such as physical therapy, electrical stimulation, or medication therapy to treatment.

Fusion versus nonfusion treatment for recurrent lumbar disc herniation.

BACKGROUND: Recurrent lumbar disc herniation (RLDH) is one of the major causes for failure of primary surgery. The optimal surgical treatment of RLDH remains controversial. AIM: Retrospectively, we evaluate 135 patients and compare the clinical outcomes between fusion and nonfusion treatment of RLDH. METHODS: Records of 75 men and 35 women aged 28-60 years for conventional revision discectomy alone (nonfusion) and 15 men and 10 women aged 30-65 years for revision discectomy with transforaminal lumbar interbody fusion (TLIF) and transpedicular screw fixation (fusion) were reviewed. Demographics, surgical data, and complications were collected and pre- and postoperative assessment were done by the Visual Analogue Scale (VAS) scale and Japanese Orthopaedic Association (JOA) score. The results after surgery were assessed according to the recovery rate as excellent, good, fair, and poor. RESULTS: The mean follow-up period was 28.8 and 24.6 months in Group A (nonfusion) and Group B (fusion group), respectively. The preoperative data between both the groups showed no statistically significant difference. The postoperative mean VAS and JAO scores, recovery rate, and satisfaction rate showed no statistically significant difference except postoperative low back pain and occasional radicular pain and neurological deficit in nonfusion group which was significantly higher than that of fusion group. In comparison to fusion group, nonfusion group required significantly less operative time, less intraoperative blood loss, less postoperative hospital stay, no blood transfusion, and less total cost of the procedure. Satisfaction rate was 80% and 88% in nonfusion and fusion groups, respectively. CONCLUSIONS: Both convention revision discectomy (nonfusion) and discectomy with instrumented fusion (TLIF) surgery are effective in patients with RLDH.

Diagnosis and treatment of noncommunicating extradural spinal thoracolumbar arachnoid cyst.

BACKGROUND: Noncommunicating extradural spinal arachnoid cysts are extremely rare. They are believed to arise from congenital defects in the dura mater and become enlarged as a consequence of increased cerebro-spinal fluid (CSF) pressure within the subarachnoid space. Most retain a communicating pedicle through which the extradural cyst maintains connection with the subarachnoid space, and only rarely does this communication become sealed. The optimal treatment consists of complete surgical removal of the cyst with ligation of the communicating pedicle. CASE DESCRIPTION: A 29-year-old male presented with a progressive spastic paraparesis of 6 months' duration. The MRI showed a circumscribed intradural extramedullary cystic lesion located from D11-L2. Notably, peroperatively, the cyst appeared to be entirely extradural, without a communicating intradural pedicle. Further, no CSF leak was observed even after Valsalva maneuvers. Following surgical extirpation of the cyst, the patient sustained an uneventful recovery within 1 postoperative month. CONCLUSION: Noncommunicating extradural arachnoid cysts are extremely rare causes of spinal cord compression and should be fully excised.

Conservative versus operative management of postoperative lumbar discitis.

BACKGROUND: Treatment option of postoperative discitis (POD) is either conservative or operative, but till date, there are no established validated protocols of the treatment of postoperative lumbar discitis. AIM: The aim of this study was to assess the outcome of conservative versus operative management of POD following single-level lumbar discectomy. METHODS: We prospectively studied a total of 38 cases of POD. The patients were diagnosed clinically, radiologically, and by laboratory investigations and followed up with serial erythrocyte sedimentation rate (ESR), C-reactive protein, X-ray, computed tomography (CT), and magnetic resonance imaging. Demographic data, clinical variables, length of hospital stay, duration of antibiotic treatment, and posttreatment complications were collected, and pre- and postoperative assessment was done using the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) score. Functional outcome of the study was measured by the modified criteria of Kirkaldy-Willis. RESULTS: VAS score for pain was significantly decreased in both groups after treatment. However, posttreatment differences were not statistically significant. In posttreatment mean JOA score, differences were not statistically significant in both groups except the mean difference (-0.47) of restriction of daily activities, which was statistically significant (95% confidence interval: -0.88--0.07, P = 0.025, unpaired t-test). About 73.7% and 84.2% of the patients had a satisfactory functional outcome in conservative and operative management groups, respectively, at the end of 12-month follow-up. CONCLUSIONS: Operative management yielded better outcomes than traditional conservative treatment in terms of functional outcomes, length of hospital stays, and duration of antibiotic treatment as determined by both the pain and daily activity levels.

Exploring the critical determinants of environmentally oriented public procurement using the DEMATEL method.

This study explores the critical determinants of environmentally oriented public procurement in Singapore, and investigates the causal relationships among the determinants that influence this procurement. Using the extant literature and basing our examination on natural-resource-based theory, we develop a conceptual framework for the implementation of environmentally oriented public procurement using three high-level dimensions and ten determinants. Sixteen interviews were conducted with 16 senior executives working in various ministries and statutory boards in Singapore who are closely involved in the public-procurement process. The decision-making trial and evaluation laboratory (DEMATEL) method, which is a multicriteria decision-making tool, is employed to analyse the interview data and information. The results of the analysis reveal that the two most critical determinants for environmentally oriented public procurement in Singapore are energy-efficiency strategy and environmental standards. These two determinants were also found to be the primary drivers of the implementation of environmentally oriented public procurement in Singapore. Through further analysis using the level of influence, a cognition map is developed to illustrate the relationships among the ten determinants. Understanding the dynamic nature of public procurement through these causal relationships is essential for the formulation of environmentally oriented public procurement implementation strategies.

Single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis.

PURPOSE: To review the outcome of single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis in 45 patients. METHODS: Records of 16 men and 29 women aged 20 to 59 (mean, 34.1) years who underwent single-stage posterior instrumentation for active thoracic (n=27) or thoracolumbar (n=18) tuberculosis by a single surgeon and were followed up for a minimum of 5 years were reviewed. Neurological status was evaluated using the Frankel grading system. Pain was assessed using the visual analogue score (VAS). Disability status was assessed using the Oswestry Disability Index (ODI). Outcome was graded according to the Kim and Lee criteria. Kyphosis at presentation, preoperation (after one month of conservative therapy), immediate postoperation, and 5-year follow-up was measured on radiographs to determine the kyphosis progression, correction of deformity, postoperative loss of correction, and residual deformity. RESULTS: Respectively for 27 and 18 patients with thoracic or thoracolumbar involvement, at 5 years the mean VAS score improved from 5.5 to 1.9 (p<0.001) and from 6.8 to 1.5 (p<0.001), whereas the mean ODI improved from 60.8 to 11.7 (p<0.001) and from 57.5 to 7.6 (p<0.001). The outcome was excellent in 17 and 11, good in 7 and 5, and fair in 3 and 2 patients, respectively. The mean kyphosis progression from presentation to preoperation was from 20.2º to 26.2º and from 10.3º to 14.1º, respectively, whereas the corresponding mean predicted kyphosis progression was from 15.5º to 48.1º and from 13.8º to 50.4º. The respective mean correction of deformity was -8.1º and -8.5º; the respective mean residual deformity was 4.1º and 6.8º; and the respective mean loss of correction at 5 years was 1.9 and 1.9. Two patients had a dural tear, and 3 patients had a transient root injury. Two diabetic patients had superficial wound infection. One patient had downward migration of one rod at 30 months but remained asymptomatic. CONCLUSION: Single-stage posterior instrumentation combined with continued chemotherapy for a minimum 12 months is a viable option for early progressive thoracic and thoracolumbar tubercular kyphosis.

Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability.

BACKGROUND: Transforaminal lumbar interbody fusion (TLIF) has been preferred to posterior lumbar interbody fusion (PLIF) for different spinal disorders but there had been no study comparing their outcome in lumbar instability. A comparative retrospective analysis of the early results of TLIF and PLIF in symptomatic lumbar instability was conducted between 2005 and 2011. MATERIALS AND METHODS: Review of the records of 102 operated cases of lumbar instability with minimum 1 year followup was done. A total of 52 cases (11 men and 41 women, mean age 46 years SD 05.88, range 40-59 years) underwent PLIF and 50 cases (14 men and 36 women, mean age 49 years SD 06.88, range 40-59 years) underwent TLIF. The surgical time, duration of hospital stay, intraoperative blood loss were compared. Self-evaluated low back pain and leg pain status (using Visual Analog Score), disability outcome (using Oswestry disability questionnaire) was analyzed. Radiological structural restoration (e.g., disc height, foraminal height, lordotic angle, and slip reduction), stability (using Posner criteria), fusion (using Hackenberg criteria), and overall functional outcome (using MacNab's criteria) were compared. RESULTS: Pain, disability, neurology, and overall functional status were significantly improved in both groups but PLIF required more operative time and caused more blood loss. Postoperative hospital stay, structural restoration, stability, and fusion had no significant difference but neural complications were relatively more with PLIF. CONCLUSIONS: Both methods were effective in relieving symptoms, achieving structural restoration, stability, and fusion, but TLIF had been associated with shorter operative time, less blood loss, and lesser complication rates for which it can be preferred for symptomatic lumbar instability.

Discectomy for primary and recurrent prolapse of lumbar intervertebral discs.

PURPOSE: To reviewed 416 patients who underwent discectomy for primary or recurrent prolapse of lumbar intervertebral discs (PLID). METHODS: Records of 296 men and 102 women aged 19 to 60 (mean, 39) years who underwent discectomy for a primary PLID, and 14 men and 4 women aged 28 to 50 (mean, 40) years who underwent revision discectomy for a recurrent ipsilateral (n=14) or contralateral (n=4) PLID at L4-5 (n=14), L5-S1 (n=3), or L3-4 (n=1) were reviewed. The pain-free interval, side and degree of herniation, operating time, length of hospital stay, and pre- and post-operative visual analogue score (VAS) for pain were recorded. Clinical outcomes were evaluated using the modified Macnab criteria and the Oswestry Disability Index. RESULTS: Patients were followed up for one to 4 years. The mean operating time was significantly longer in revision discectomy (65 vs. 141 minutes, p<0.001, unpaired t-test). There was no significant difference between revision and primary discectomy in terms of length of hospital stay or clinical improvement rates. Age, gender, smoking, profession, level and extent of herniation, and pain-free interval did not affect clinical outcomes. In the 18 revision cases, the mean pain-free interval until recurrence was 31 (range, 1-42) months. At the one-year follow-up, results were excellent in 8, good in 6, fair in 3, and poor in one. Three of the patients had persistent pain despite taking analgesics. 14 of the patients had returned to their normal daily activities. Complications included foot drop (n=1), dural tear (n=3), and superficial wound infection (n=1). CONCLUSION: Discectomy achieved satisfactory results for both primary and recurrent PLIDs.