Investigating the possibility of intervertebral disc regeneration induced by granulocyte colony stimulating factor-stimulated stem cells in rats.

Intervertebral disc (IVD) degeneration is a multifactorial process that is influenced by contributions from genetic predisposition, the aging phenomenon, lifestyle conditions, biomechanical loading and activities, and other health factors (such as diabetes). Attempts to decelerate disc degeneration using various techniques have been reported. However, to date, there has been no proven technique effective for broad clinical application. Granulocyte colony-stimulating factor (GCSF) is a growth factor cytokine that has been shown to enhance the availability of circulating hematopoietic stem cells to the brain and heart as well as their capacity for mobilization of mesenchymal bone marrow stem cells. GCSF also exerts significant increases in circulating neutrophils as well as potent anti-inflammatory effects. In our study, we hypothesize that GCSF can induce bone marrow stem cells differentiation and mobilization to regenerate the degenerated IVD. We found that GCSF had no contribution in disc regeneration or maintenance; however, there were cell proliferation within end plates. The effects of GCSF treatment on end plates might deserve further investigation.

Anterior percutaneous endoscopic cervical discectomy for cervical intervertebral disc herniation: outcome, complications, and technique.

STUDY DESIGN: Clinical study of percutaneous endoscopic surgery for cervical intervertebral disc herniation (CHIVD). OBJECTIVES: Our aim was to evaluate the efficacy of anterior percutaneous endoscopic cervical discectomy (APECD), previously known as percutaneous endoscopic cervical discectomy, for CHIVD. In addition, the ways to avoid major complications, including case selection and surgical techniques, are highlighted. SUMMARY OF BACKGROUND DATA: CHIVD is a common disease and can cause cervical radiculopathy, namely, radiating arm pain, numbness or weakness of the upper extremity, or myelopathy. If conservative treatment failed, most patients were treated by anterior cervical discectomy and fusion. METHODS: From October 2002 to July 2008, a total of 107 consecutive patients with clinically symptomatic CHIVD who underwent APECD were enrolled. The clinical outcomes were evaluated using the visual analog scale, Neck Disability Index, and modified MacNab criteria. Radiographic follow-up included static and dynamic plain cervical radiographs and magnetic resonance imaging. RESULTS: Eighty-six patients (80%) could be followed up for at least 12 months (range: 12 to 60 mo; mean, 22.4 mo) for outcome evaluation. The visual analog scale and Neck Disability Index improved significantly (P<0.001) after the operation. According to the modified MacNab criteria, excellent and good outcome were achieved in 29 (34%) and 49 (57%) patients, respectively. Two patients (2 of 107, 2%) experienced operation-related complications: 1 patient sustained carotid artery injury and was treated with angiographic stenting, whereas the other patient had postoperative headache and recovered after conservative treatment. CONCLUSIONS: APECD is not only minimally invasive but can also avoid the morbidities of conventional open cervical discectomy. Patients have a more rapid postoperative recuperation. Nevertheless, it carries the risk of major complications. With careful patient selection and use of meticulous surgical techniques, it is still a safe and effective alternative to open surgical modalities for CHIVD.

Application of neuroendoscopy in the treatment of obstructive hydrocephalus secondary to hypertensive intraventricular hemorrhage.

OBJECTIVE: Neuroendoscopy has become an integral part of neurosurgery, in particular in the ventricular system. Obstructive hydrocephalus secondary to intraventricular hemorrhage (IVH) is a good indication for neuroendoscopic surgery. We evaluated its efficacy and limitations in these patients. MATERIALS AND METHODS: During a 5-year period, 13 patients with obstructive hydrocephalus secondary to hypertensive IVH were studied. Patients with IVH with no evidence of obstructive hydrocephalus or with a large parenchymal hematoma or IVH of vascular origin were excluded. Rigid endoscope was used to evacuate hematoma in lateral ventricles and third ventricle in all patients. Glasgow Coma Scale (GCS), Graeb score and ventriculo-cranial ratio were evaluated before and after endoscopic intervention and Glasgow Outcome Scale (GOS) was appraised at 1 month and 12 months, postoperatively. RESULTS: Of the 13 patients, eight (61.5%) patients had thalamus hemorrhage. A successful endoscopic removal of intraventricular hematoma was achieved in all patients. Complications observed included, fornix contusion (1) and meningitis (1) and there was no procedure-related mortality. The mean Graeb score reduced from 8.69 ± 1.89 to 6.00 ± 2.68 (P=0.001) and ventriculo-cranial ratio decreased from 0.41 ±0.05 to 0.39 ± 0.05 (P=0.085) following the procedure. The mean GOS scores at 1 month and 12 months both were 2.7, but a bipolar distribution was observed at 12 months. The Graeb score changed significantly with positive correlation to GCS score change (=0.565 and P<0.05). CONCLUSIONS: Endoscopic management of severe IVH with obstructive hydrocephalus allows effective reduction of the amount of ventricular blood and improves level of consciousness. Future refinement in instrumentation and discreet case selection may make this method more applicable and effective.

Microsurgical supraorbital keyhole approach to the anterior cranial base.

We evaluated treatment of patients with anterior cranial base lesions with supraorbital keyhole surgery. Limited supraorbital craniotomy through an eyebrow skin incision was performed on 21 adult patients between August 2007 and January 2009 at one institution. Each patient's cosmesis was evaluated after the operation using a visual analog scale for cosmesis (VASC). Thirteen patients were treated for ruptured intracranial aneurysms and eight patients for mass lesions in the anterior cranial fossa. The mean follow-up duration was 16.5 months. No identifiable neurological or vascular complications related to this procedure were noted during follow-up; however, two patients died from causes unrelated to the procedure. Of the 19 patients who were followed-up, 89% of patients, and 84% by physician evaluation, were satisfied with the cosmetic result, noting > 75 mm on the VASC. Anterior cranial fossa lesions can be adequately and safely treated via a minimally invasive supraorbital craniotomy when performed on suitable patients by an experienced surgeon. This approach decreases brain manipulation and results in a pleasing cosmetic outcome while minimizing the likelihood of procedure-related morbidity.

Sellar xanthogranuloma manifesting as obstructive hydrocephalus.

Xanthogranuloma of the sellar region is rare. It typically causes symptoms of pituitary dysfunction or visual change due to compression of the optic chiasm. However, to the best of our knowledge, no case of xanthogranuloma-associated hydrocephalus has been documented in the literature. This study describes a 32-year-old man afflicted with xanthogranuloma of the sellar region who presented with acute change in consciousness and associated obstructive hydrocephalus. A literature review and discussion regarding therapeutic options for this condition are presented.

"Migration" of traumatic subarachnoid hematoma? A case report.

BACKGROUND: Traumatic spinal SAH with neurologic deficits is rare and easily misdiagnosed, especially after traumatic intracranial hemorrhage. CASE DESCRIPTION: We report a case of spinal SAH with root compression occurring after a scooter accident. CONCLUSIONS: Physicians should be aware of descending migration of intracranial SAH as a possible cause of spinal cord or root compression, especially in the patient with late onset spinal symptoms.

Transforaminal percutaneous endoscopic lumbar discectomy.

BACKGROUND: In this study we analyzed and presented our experience of performing transforaminal percutaneous endoscopic lumbar discectomy (TPELD). METHODS: A retrospective study of 142 TPELD was conducted on 134 consecutive patients from 2001 through 2005. The inclusion criteria for patients were those who had leg pain with or without low back pain and magnetic resonance imaging (MRI) that revealed soft contained or noncontained but contiguous lumbar disc herniation (LDH). All patients failed at least 6 weeks of conservative treatment or could not tolerate it. RESULTS: The patients had an average age of 38 years. The mean follow-up period was 8 months. The outcomes were evaluated using the modified MacNab criteria. The percentage of successful outcomes (excellent or good) was 89%. Among the remainder of the patients, six (4.5%) had open surgery later. Moreover, eight patients (6%) sustained temporary dysesthesia over the proximal lower limb of the operated side. No major neurovascular injuries or deaths occurred. CONCLUSIONS: In experienced hands, TPELD is minimally invasive, safe and effective for treating soft contained or noncontained but contiguous LDH.

Brown-Sequard syndrome caused by ossification of the ligamentum flavum.

Ossification of the ligamentum flavum (OLF) commonly occurs in the thoracic and lumbar regions. We present a patient with OLF at the C4-5 level with presentation as Brown-Sequard syndrome. Symptoms were relieved following a laminectomy and total lesion excision. The relevant literature is reviewed to discuss the racial distribution, unique presentation and pathogenesis of OLF.

Symptomatic hematoma of cervical ligamentum flavum: case report.

STUDY DESIGN: A case of symptomatic hematoma of cervical ligamentum flavum. OBJECTIVE: To report the first ligamentum flavum hematoma in the cervical spine and review the reported cases. SUMMARY OF BACKGROUND DATA: A herniated nucleus pulposis, spondylosis, epidural hematoma or abscess, neoplasm, or some pathology of the ligamentum flavum, such as hypertrophy, ossification, or calcification, are the most common causes of spinal cord and nerve root compression. A ligamentum flavum hematoma has also been reported as a cause of compression of the cauda equina and lumbar nerve roots but has never been found in the cervical spine. METHODS: A 72-year-old man presented with left upper arm pain and left hemiparesis following traditional massage therapy. Admission magnetic resonance images showed a posterior oval-shaped mass that was continuous with the ligamentum flavum at C3-C4 level. RESULTS: A C3-C4 laminectomy for decompression and resection of the lesion was performed. One year after surgery, the patient remained neurologically intact and symptom-free. CONCLUSIONS: Hematoma of the ligamentum flavum occurring in the cervical spine has never been reported previously. Repeated trivial injury on a degenerative ligamentum flavum might be the leading predisposing factor. Spine surgeons should be aware of a hematoma in the ligamentum flavum as a possible cause of spinal cord or root compression, especially in the mobile cervical and lumbar spine.

Midpalmar accurate incision for carpal tunnel release.

BACKGROUND: Carpal tunnel syndrome is the most common entrapment neuropathy in humans today. For patients in whom conservative treatment fails, surgical decompression is indicated. Among the various surgical techniques currently in use, endoscopic techniques are becoming increasingly popular. Due to the rapid postoperative recovery shown after endoscopic operations, midpalmar accurate incision for carpal tunnel release is a comparative alternative. METHODS: From February 1998 through January 2003, 84 patients had undergone 96 midpalmar carpal tunnel releases with accurate skin incisions under regional block or general mask anesthesia. The postoperative evaluations were performed via subjective assessment with a standardized telephone interview over an average follow-up period of 22.4 months. RESULTS: The average operation time was 16 minutes (range, 5 to 40 minutes). A total of 87 hands (91%) had excellent or good recovery in terms of symptom relief (improvement of 70% or greater). The incidence of postoperative sensory morbidity, i.e., pillar pain or scar tenderness, was 7% (7 hands). The motor functional morbidity of a persistent subjective decrease in grip strength was noted in 8% (8 hands), and the mean period for returning to work was 4.5 weeks. In addition, no operation-induced neurovascular or tendinous injury occurred in any patient. CONCLUSIONS: The outcomes were similar to those of endoscopic carpal tunnel release. Based on these results, midpalmar carpal tunnel release with accurate location of skin incision is as effective as any other surgical procedures for carpal tunnel release. Furthermore, it is also a safe and simple procedure.

Spinal epidural abscesses: a retrospective analysis of clinical manifestations, sources of infection, and outcomes.

BACKGROUND: Spinal epidural abscess (SEA) is uncommon but has a potentially disastrous outcome. Its early recognition and management may lead to satisfactory results. We analyzed the clinical manifestations, sources of infection, and outcomes of patients with SEA. METHODS: Between 1997 and 2003, 17 patients in the Department of Neurosurgery at Keelung Chang Gung Memorial Hospital had SEA. We retrospectively reviewed their records to analyze their clinical presentations, image findings, laboratory data, and clinical outcomes. RESULTS: All 17 patients (mean age, 63 years) underwent surgery and received antibiotics. Back and/or neck pain (82%), motor deficits (70%), and elevated C-reactive protein levels or erythrocyte sedimentation rates (64%) were the most common symptoms and signs. The most common etiological organism was oxacillin-resistant Staphylococcus aureus. The SEA was most commonly located in the lumbar spine, anterior to the spinal canal. Outcomes were poor in 29% of the patients, fair in 18%, and good in 53%. CONCLUSIONS: Abdominal complications in patients with spinal disease are not uncommon, especially when the thoracic level is involved. The abdominal symptoms may initially mask neurological deficits due to spinal cord involvement, however, spinal pain and motor deficits present in most cases under more thorough investigation. In a suspected SEA patient with a history of gouty arthritis, tissue biopsy should include additional crystal analysis. Although the increasing availability of MRI makes diagnosis easier and quicker, repeated neurological examination and full evaluation are essential in any patient with an unknown focus of infection and spinal pain or tenderness.

Primary intraspinal mesenchymal chondrosarcoma: a case report and literature review.

Mesenchymal chondrosarcomas are rare malignant tumors of the bone and soft tissue. Extraskeletal mesenchymal chondrosarcomas, especially those that arise in the central nervous system, are even rarer. Most of those described were intracranially located, with only a very few cases having been reported in an intraspinal region. Therapeutic experience with primary spinal mesenchymal chondrosarcomas is also extremely limited. We report on a case of a 21-year-old man with back pain and bilateral progressive weakness and numbness of the lower extremities. A T1-weighted magnetic resonance image revealed a hypointense tumor located at the T8 level. The tumor was completely excised through a posterior approach. Microscopic examination and immunohistochemical studies confirmed the diagnosis of mesenchymal chondrosarcoma. Spinal irradiation and chemotherapy were also administered for prevention of local recurrence and metastasis. The patient has been symptom-free for 1 year after surgery. Herein, we review the 22 cases of primary intraspinal mesenchymal chondrosarcomas in the literature and discuss their clinical presentations, pathology, imaging studies, treatments, and outcomes.

Huge retroperitoneal germinoma presenting with pathological fracture of the spine.

Primary retroperitoneal germ cell tumors are extremely rare neoplasms. The most common presenting features are abdominal pain and palpable abdominal masses. Pathological fractures of the spine presenting as bilateral lower leg weakness are exceptionally rare. We describe a 16-year-old girl who developed progressive paraplegia after a minor falling injury. Radiological study demonstrated a huge retroperitoneal tumor with invasion of the T12 vertebral body and spinal canal. A posterior surgical approach was used to perform laminectomy (T12, L1), removal of the intraspinal tumor and internal fixation with transpedical screws (T10, T11 to L2,3), and posterolateral fusion. Postoperative combination chemotherapy for six cycles with cisplatin (100 mg/m2 per day for 1 day every 3 weeks), bleomycin (15 units intravenously weekly for 18 weeks) and etoposide (100 mg/m2 per day for 3 days every 3 weeks) were given and the tumor responded dramatically. The patient had fully recovered without evidence of sequelae or recurrence at 2 years after operation. To the authors' knowledge, this is the first case in which a huge retroperitoneal germinoma presented as pathological fracture of the spine and spinal cord compression. The effectiveness of the postoperative cisplatin-based chemotherapy against this tumor made major retroperitoneal surgery to remove the main tumor mass unnecessary is also demonstrated.