Clinical Outcomes Following Decompression of Central Canal and Lateral Recess Simultaneous Stenosis, with a Focus on Multilevel Stenosis: A Randomized Comparison of Microscopic Bilateral Laminotomy versus Total Laminectomy with Posterior Spinal Fusion.

BACKGROUND: In patients with simultaneous lumbar central spinal stenosis (LCSS) and lateral recess stenosis (LRS) at multiple levels, spinal decompression using microscopic bilateral laminotomy was compared to total laminectomy plus medial facetectomy and fusion (LF). METHODS: From 2017 to 2022, this trial was performed to examine 96 patients with concomitant LCS and LRS at multilevel. Of the 96 patients, 48 were allocated to the following groups: LF (group I) or microscopic bilateral laminotomy (group II). However, 76 patients completed the study. We compared the outcomes in these 2 groups. RESULTS: Microscopic bilateral laminotomy was superior in most outcome measures. Delta-visual analog scale leg pain in group II was significantly greater than in group I (mean-group I: 4.368 vs. group II: 5.368, P value = 0.001). Complication and revision rates were lower in the microscopic bilateral laminotomy than in group I, except for incidental durotomy occurrence (group II: 31.58% -group I: 7.89%, P value = 0.0190). The rate of revision surgery for group I compared with group II was 44.74% versus 13.16% (P value = 0.0047), indicating the superiority of laminotomy over LF. The mean length of hospital stay was 3.551 ± 0.6349 in group II versus 6.774 ± 1.197 in group I (P value <0.0001). Also, blood loss during surgery was significantly lower in group II (P value <0.0001). CONCLUSIONS: The findings indicate that microscopic bilateral laminotomy provides favorable clinical and radiological outcomes for individuals experiencing multilevel lumbar central canal and LRS. However, a higher frequency of durotomy may occur during microsurgical procedures.

Pedicle Screw Fixation With Cement Augmentation Versus Without in the Treatment of Spinal Stenosis Following Posterior Spinal Fusion Surgery, Superiority According to Bone Mineral Density: A Three-Arm Randomized Clinical Trial.

OBJECTIVE: To investigate whether cement augmentation has an impact on clinical and radiologic outcomes following posterior spinal fusion (PSF) in low-density bones and whether its performance is comparable to regular bone density. METHODS: Between 2017 and 2021, 114 patients with spinal canal stenosis were enrolled to undergo PSF. They were initially stratified based on their bone mineral density: T-score ≥ -1.5: Group I (n = 34), and T-score < -1.5: Group II (n = 80). Furthermore, group II was randomly subdivided: II-A (unaugmented, n = 35) and II-B (bone cement augmented, n = 45). The primary and secondary endpoints of the study were evaluated using visual analog scales (VAS) and radiologic parameters, including screw loosening, screw or rod fractures, proximal junctional kyphosis (PJK), proximal junctional vertebral fracture (PJVF), and adjacent segment disease (ASD), at 1 year postoperatively. RESULTS: All 3 groups showed improvement in VAS scores, but the most significant improvements were seen in groups I and II-B. Group II-B had lower incidence rates of ASD, PJVF, PJK, rod, and screw fracture compared to group II-A, but only screw loosening was statistically significant (P < 0.0001). Contrary, there were statistically significant differences in all variables except for ASD and screw fracture (P = 0.0576 and 0.670, respectively) when comparing groups I and II-A. In both groups I and II-A, screw loosening was the most common complication following PSF, while only 5.41% of patients in group II-B experienced it. CONCLUSIONS: The efficacy of cement augmentation in mitigating pain and screw loosening following PSF surgery in low-density bones is comparable to that of normal-density bone.

Optimal vitamin D status at admission appears to improve survival after craniotomy in patients with brain malignancies.

BACKGROUND AND AIMS: Survival from diagnosis of brain malignancies is often very short. Craniotomy in turn may be associated with morbidity and even post-operative mortality. Vitamin D and calcium were known as protective factors on all-cause mortality. However, their role is not well-understood in post-surgery survival of brain malignant patients. METHODS: Totally, 56 patients completed the present quasi-experimental study, comprising the intervention group (n = 19) under intramuscular administration of 300 000 IU vitamin D3, the control group (n = 21), and the group of patients with optimal vitamin D status at admission (n = 16). RESULTS: The mean ± SD of preoperative 25(OH)D levels in the control, intervention, and optimal vitamin D status groups were 15.15 ± 3.63 ng/mL, 16.61 ± 2.56 ng/mL, and 40.03 ± 10.56 ng/mL, respectively (P < 0.001). Crude survival was significantly greater in the optimal vitamin D status group than those in another two groups (P = 0.005). Also, Cox proportional hazard model showed that the risk of mortality was higher in the control group and the intervention group than in the group of patients with optimal vitamin D status at admission (P-trend = 0.03). However, this correlation weakened in the full-adjusted models. Preoperative total calcium had an inverse significant correlation with mortality risk [HR value 0.25, (95%, CI: 0.09-0.66), P = 0.005], and age had a positive correlation [HR value 1.07, (95%, CI: 1.02-1.11), P = 0.001]. CONCLUSION: Total calcium and age were predictive factors in six-month mortality and optimal vitamin D status appears to improve the survival in these patients, which should be examined more closely in future studies.

Spinal hydatid cyst initially diagnosed as spinal tumor: A case report and review of the literature.

The spinal hydatid cyst is a benign pathology but has considerable morbidity. It should be considered as a differential diagnosis in patients having signs and symptoms of spinal compression, particularly in endemic areas.

Grading of gliomas using transfer learning on MRI images.

OBJECTIVE: Despite the critical role of Magnetic Resonance Imaging (MRI) in the diagnosis of brain tumours, there are still many pitfalls in the exact grading of them, in particular, gliomas. In this regard, it was aimed to examine the potential of Transfer Learning (TL) and Machine Learning (ML) algorithms in the accurate grading of gliomas on MRI images. MATERIALS AND METHODS: Dataset has included four types of axial MRI images of glioma brain tumours with grades I-IV: T1-weighted, T2-weighted, FLAIR, and T1-weighted Contrast-Enhanced (T1-CE). Images were resized, normalized, and randomly split into training, validation, and test sets. ImageNet pre-trained Convolutional Neural Networks (CNNs) were utilized for feature extraction and classification, using Adam and SGD optimizers. Logistic Regression (LR) and Support Vector Machine (SVM) methods were also implemented for classification instead of Fully Connected (FC) layers taking advantage of features extracted by each CNN. RESULTS: Evaluation metrics were computed to find the model with the best performance, and the highest overall accuracy of 99.38% was achieved for the model containing an SVM classifier and features extracted by pre-trained VGG-16. DISCUSSION: It was demonstrated that developing Computer-aided Diagnosis (CAD) systems using pre-trained CNNs and classification algorithms is a functional approach to automatically specify the grade of glioma brain tumours in MRI images. Using these models is an excellent alternative to invasive methods and helps doctors diagnose more accurately before treatment.

Comparison of Transthecal Approach With Traditional Conservative Approach for Primary Closure After Incidental Durotomy in Anterior Lumbar Tear.

BACKGROUND: Incidental durotomies (IDs) are frequent complications of spinal surgeries which are mostly posterior or lateral. Anterior IDs are rare; however, they may lead to severe complications. We compared the transthecal approach with the conservative approach for primary closure after durotomy in anterior lumbar dural tear to assess the efficacy of these approaches to decrease postsurgical complications and clinical outcomes. METHODS: A total of 21 patients undergoing L2-S1 laminectomy with anterior ID were randomly divided into a transthecal group (n = 9) and a conservative group (n = 12) based on the surgical dural closure technique. Postoperative pseudomeningocele, wound infection, rootlet herniation, pneumocephalus, cerebrospinal fluid (CSF) leakage, headache, meningitis, in addition to surgery duration and length of hospitalization were examined and compared in both groups. RESULTS: The frequency of pseudomeningocele and CSF leakage in patients undergoing the transthecal approach was significantly lower than those undergoing the conservative approach (P = .045 and .008, respectively). Furthermore, although the differences in the frequency of meningitis, pneumocephalus, headache, and wound infection were not statistically significant between the 2 groups, the effect sizes of the comparison were obtained as 49.4, 19.8, 7.1, and 2.6, respectively. This indicated that the differences were clinically significant between the 2 groups. CONCLUSIONS: We found that the transthecal approach was significantly more successful in managing CSF leakage as well as its complications and clinical outcomes. However, further clinical trials with bigger sample sizes are needed to substantiate this claim.

Single high-dose vitamin D3 injection and clinical outcomes in brain tumor resection: A randomized, controlled clinical trial.

BACKGROUND & AIMS: Vitamin D is known as a neuroprotective hormone with anti-inflammatory and immune-modulatory properties. We evaluated the effect of vitamin D3 injection on vitamin D status and clinical outcomes in patients with low serum levels of 25-hydroxyvitamin D [25(OH)D] undergoing craniotomy for brain tumor resection. METHODS: Patients with benign brain tumors and serum 25(OH)D levels ≤20 ng/mL were randomized to two groups with an equal number of subjects. The study group (n = 30) received intramuscular injection of 300,000 IU vitamin D3 prior to surgery. The control group (n = 30) was left without intervention, and both groups underwent routine therapies. RESULTS: On day 5 after craniotomy, the serum 25(OH)D levels increased significantly in the study group (P= <0.001). The length of ICU and hospital stay was significantly lower in the study group compared to the control group (P = 0.01 and P = 0.008, respectively). It was true when the age, tumor size, tumor type, Karnofsky Performance Scale (KPS) score, and calcium and albumin levels at baseline entered the logistic regression model (OR = 0.17 (95%CI = 0.04-0.72, P = 0.01), and OR = 0.19 (95%CI = 0.04-0.82, P = 0.02), respectively). With and without the application of logistic regression analysis, there was no significant difference in perioperative complications. CONCLUSIONS: Intramuscular injection of 300,000 IU of vitamin D3 in patients with low serum levels of 25(OH)D undergoing craniotomy, could rise safely the serum 25(OH)D level. This intervention, significantly reduced the length of ICU stay and hospitalization. REGISTERED UNDER: Clinicaltrials.gov.identifier no: NCT03248544. Date: 8/14/2017.

Preoperative Serum Level of Vitamin D is a Possible Protective Factor for Peritumoral Brain Edema of Meningioma: A Cross Sectional Study.

Meningioma is associated with the development of vasogenic edema defined as disrupted blood brain barrier. Vitamin D3 through its own nuclear receptor can regulate the expression of many effective agents on the integrity of the blood brain barrier. This study aimed to investigate the association between preoperative serum levels of 25(OH)D and peritumoral brain edema in patients with meningioma. One hundred and twelve patients with meningioma completed the study. Serum 25(OH)D levels assessment and magnetic resonance imaging (MRI) were done for all patients at the beginning of the study. The percentage of edema index (EI) was used to estimate the extent of peritumoral brain edema through preoperative MRI. The median serum level of 25(OH)D in the patients with the percentage of EI < 100% was significantly higher than those with > 100% (65.58 vs. 37.33, P < 0.001). The median percentage of EI was 24.9. Preoperative serum levels of 25(OH)D had an inverse and significant correlation with the percentage of EI as by increasing each 1 ng/mL of serum 25(OH)D, EI was decreased approximately 4% (95% CI; -5.984 to -1.952, P < 0.001). Vitamin D may be a protective factor for peritumoral brain edema of meningioma.

Investigation of promoter methylation of MCPH1 gene in circulating cell-free DNA of brain tumor patients.

INTRODUCTION: Despite advanced diagnostic and therapeutic techniques, many brain tumors are still diagnosed at high grades and, therefore finding novel molecular markers may assist in early detection and reducing brain tumors-related mortality rate. Owing to the previous reports on the importance of MCPH1 gene in tumorigenesis, the present study was aimed to study the promoter methylation of MCPH1 gene in paired circulating cell-free DNA (cfDNA) and tumor tissues of brain tumor patients. MATERIALS AND METHODS: Fourteen fresh paired serum and tumor tissue samples in addition to 18 isolated serum samples were collected from patients affected by different grades of brain tumor. Genomic DNA and cfDNA was isolated from tissue and serum samples using QIAamp DNA Mini Kit Norgen Bioteck Kit, respectively. Methylation DNA immunoprecipitation Real-time polymerization chain reaction (MeDIP-Real-time PCR) was performed on isolated DNA samples using EpiQuik MeDIP Ultra Kit and specific primer pairs. cfDNA quantity was determined through Real-time PCR analysis using specific primer pairs designed for GAPDH gene. RESULTS: MCPH1 was methylated in 54% of cfDNA samples which was significantly associated with tumor grade, as well (P-value = 0.02). The methylation rate of MCPH1 was found as 78% in the tissue samples which was meaningfully associated with tumor grade (P-value = 0.03). Moreover, methylation of the MCPH1 gene was consistent in 57% of the same cfDNA and tissue samples. Methylation of MCPH1 gene in neither tumor tissues nor cfDNA was not correlated with age and sex of the patients. DISCUSSION AND CONCLUSION: Due to the conformity of methylation of MCPH1 gene in cfDNA and tissue samples in more than half of the enrolled patients, especially in higher grades of tumors, it seems that MCPH1 promoter methylation could be a potential epimarker in not only detection of brain tumors but also in response to chemo- and radiotherapy which warranted further assessment.

Pulmonary Edema Following Intrathecal Fluorescein Injection; a Case Report.

Intrathecal Fluorescein has been used widely for detection of cerebrospinal fluid (CSF) leakage. After administration of fluorescein many serious complications may happen. Pulmonary edema is one of the most serious complications that require emergency responses. In this study, we report a complicated case of pulmonary edema following Intrathecal fluorescein injection.

Effect of Vitamin D Supplementation on Postcraniotomy Pain After Brain Tumor Surgery: A Randomized Clinical Trial.

OBJECTIVE: To determine the effect of vitamin D supplementation on postoperative pain and analgesic requirement in brain tumor surgery. METHODS: A total of 60 patients with vitamin D serum levels ≤20 ng/dL were randomly assigned to 2 groups equally. The study group (n = 30) received intramuscular injection of 300,000 IU vitamin D before surgery. RESULTS: Preoperative serum level of vitamin D was 15.9 ± 3.8 ng/dL and 14.5 ± 3.6 ng/dL in the study and control groups, respectively (P = 0.13). Serum level of vitamin D on day 5 of surgery was 22.5 ± 4.3 and 13.7 ± 3.8 in the study and control groups, respectively (P < 0.001). A percentage of 50% had pain scores >4 on the first postoperative day, which decreased with time. The median (interquartile range) of the visual analogue scale score during the 3 postoperative days was 3 (5), 3 (5), 1 (3), and 5 (7), 2 (5), 1 (3) in the study and control groups, respectively, with no significant difference. There was no difference in analgesic consumption between the 2 groups. Analysis through the generalized estimating equation model indicated that patients who had received vitamin D for a longer time before the operative time had an insignificantly less pain score. CONCLUSIONS: On the basis of the study results, one half of our patients reported moderate-to-severe pain scores on the first day after surgery. The pain in the study group was insignificantly less than that in the control group, but it seems that chronic high level of vitamin D may lead to promising results.

Somatic CPEB4 and CPEB1 genes mutations spectrum on the prognostic predictive accuracy in patients with high-grade glioma and their clinical significance.

BACKGROUND: Glioblastoma (grade IV glioma/GBM) is characterized by extremely aggressive invasion and proliferative nature. OBJECTIVE: The main goal of this study was to evaluate the expression patterns of CPEB1 and CPEB4 in glioma patients. METHODS: 41 paraffin-embedded tissue samples with glioma (WHO I-IV) were collected between January 2008 and December 2012 in Tehran, Iran. MRI of patients was done before and within 24 h after surgery and gliomas investigated using quantitative real-time PCR and immunohistochemistry. Kaplan-Meier survival and Cox regression were applied to assess the prognosis of patients. RESULTS: The mRNA level of CPEB4 was strongly increased in tumor tissues (0.67±3.154 vs. 1.671±0.51; P=0.001). Furthermore, CPEB1 mRNA was significantly decreased in tumor tissues compared to normal tissues (2.852±0.587 vs. 1.471±0.862; P=0.025). Our findings showed that CPEB4 levels was markedly increased in patients with advanced grade gliomas (P=0.003). In addition, CPEB1 mRNA levels were not associated with clinicopathological features. Of the 41 cases, high CPEB4 expression was found in 29 patients (70.73%), while 12 cases (29.26%) showed weak expression levels, while the protein expression of CPEB4 were remarkably weak in normal tissues (P=0.001). However, no correlation was found between expression levels of CPEB1 and clinicopathological characteristics. Kaplan-Meier survival and log-rank test indicated that high expression of CPEB4 was correlated with shorter overall survival (log-rank test P<0.001). Furthermore, low expression of CPEB1 was linked to shorter overall survival (log-rank test P=0.021). Multivariate Cox proportional hazards model showed that high CPEB1 (P=0.027), low CPEB4 expressions (P=0.021), and advanced tumor grade (P=0.036) were independent predictor of overall survival. CONCLUSION: Our data indicated expressions levels of CPEB4 and CPEB1 are correlated with overall survival in patients with glioma.

Examination of The Predictive Power of Electromyography and Urodynamic Study in Patients with Cauda Equina Syndrome (Horse Tail Syndrome).

BACKGROUND: Cauda equina syndrome is a rare disorder that causes loss of Lumbar plexus function (nerve roots) lower than conus medullaris. No risk factor has been defined for this disease yet. Due to the high morbidity of Cauda equina syndrome and lack of sufficient information about the connection between the disease and urodynamic findings and EMG (Electromyography) findings, the need for this comprehensive study is felt. OBJECTIVE: The aim is to determine the predictive power of findings resulted from urodynamics and electromyography of perineal region and around sphincter in the clinical cure rate of urination in patients with urinary retention followed by Cauda equina syndrome. METHOD: Patients referred to Shohadaye Tajrish Hospital during the years 2009 to 2013, in case of having Cauda equina syndrome symptoms (confirmed with Lumbar MRI), were undergone urodynamic examination and perineal electromyography after surgical decompression action. These both assessments (urodynamic study and electromyography) were repeated during the follow-up of 15 patients in the first and sixth months after surgery and findings were compared with each other. RESULTS: Among the Urodynamic findings, Qmax (maximum urine flow) during three studies had a significant relationship with long-term recovery rate of patients (P <0.05). The relationship had been more valuable in follow-ups after one month (P = 0.0001). Also, BCI (Bladder Contractility Index) in all three studies had a significant relationship with clinical improvement in the ability to urinate (P <0.001). The residual urine (PVR) compared to two previous urodynamic findings showed a less significant relationship with clinical cure rate (P = 0.04). Among the findings of muscle-nerve (MUAP Fibrillation, Positive sharp way) none of them had a significant relationship with cure rate. CONCLUSION: Urodynamic finding, especially Qmax and bladder contractility index, can be considered as predictive indicators for patients' recovery after surgery.