Effectiveness of Percutaneous Pedicle Screw Fixation for Traumatic Thoracolumbar Spine Fracture

Introduction: Surgical treatment of thoracolumbar fracture without neurological damage has resulted in better clinical and radiological outcome than conservative treatment. Traditional open approach is associated with extensive paravertebral muscle damage and postoperative morbidity so percutaneous pedicle screw fixation is highly valuable alternatives. Aims: to evaluate the efficacy and outcome of percutaneous pedicle screw fixation in the treatment of traumatic thoracolumbar fracture without neurological deficit. Methods: This study was conducted in Nepalgunj Medical College, Nepalgunj in a time span of one year; total of 40 patients were included and treated with percutaneous pedicle screw fixation and followed up for 6months. They were evaluated clinically and radiologically. Results: 40 patients with thoracolumbar fractures were managed with percutaneous pedicle screw fixation with a mean operative time of 77.30 min and intraoperative blood loss was 88.38ml. There was significant improvement in cobb’s angle (mean difference 13.92 degree), vertebral body height loss (mean difference 37.7%) and visual analogue scale (mean difference 3.55) postoperatively. These improvements remained statically significant at 6months follow up. Conclusion: Percutaneous pedicle screw fixation is safe, valid and effective treatment of thoracolumbar fracture without neurological deficit.

CONCEPTUAL UNDERSTANDING OF TRANSVERSE MYELITIS IN AYURVEDA: A CRITICAL REVIEW

Transverse myelitis (TM) is a rare neurological disease of spinal cord inflammation. Onslaught inflammation damage the myelin is leading to nervous system scaring. Consequently, the patient presents devastating neurological effects. It can afflict people of any age, gender or race. Symptoms per usual evolve over hours or days and then deteriorate over days to weeks. Symptoms include pain, sensory problems, weakness in the legs and arms, and bladder and bowel problems. Most people partially recover within three months; others may be permanently disabled. There is no cure for TM thus far, but neurological deficit can be minimised. From the purview of Ayurveda, TM can be categorised under the spectrum of Vata disorder. Recent research report the successful treatment of TM. However, each explains the pathology differently. This review will discuss the concepts of TM apropos to Mishravarana (combined occlusion) and its management. We suggest that symptoms and pathology of TM simulate closely with Avaranajanya Vatavyadi (disease of Vata due to occlusion). Mishravarana (combined occlusion) illustrates the complexity of the disease process involved.

The prognosis and recovery of major postoperative neurological deficits after corrective surgery for scoliosis

Aims The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. Methods A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. Results The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher’s exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. Conclusion For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103–111.

Melatonin and calpeptin synergistically protect against post-reperfusion injury in a rat middle cerebral artery occlusion stroke model

Cerebral ischemia induces oxidative injury and increases the intracellular calcium ion concentration to activate several calcium-dependent proteases such as calpains. Calpain activation leads to various necrotic and apoptotic processes. Calpeptin is a potent, cell-permeable calpain inhibitor. As a strong antioxidant and free radical scavenger, melatonin shows beneficial effect in rodent models of focal cerebral ischemia when given prior to ischemia or reperfusion. This study was focused on the neuroprotective effects of melatonin and/or calpeptin given after onset of reperfusion. For this purpose, right-sided middle cerebral artery occlusion (MCAO) for 90 minutes followed by 24 or 72 hours of reperfusion was performed in male Sprague Dawley rats, then, melatonin 50 or 150 µg/kg, calpeptin 10, 15 or 50 µg/kg or a combination of melatonin 50 µg/kg plus calpeptin 15 or 50 µg/kg were injected via an intracerebroventricular route at 15 minutes after onset of reperfusion. Melatonin or calpeptin tended to reduce the relative infarct volume and significantly decreased the neurological deficit at 24 hours. The combination achieved a greater protection than each of them alone. Melatonin, calpeptin or the combination all decreased Fluoro-Jade B (FJB)+ degenerative neurons and cleaved/total caspase-3 ratio at 24 hours. These treatments did not significantly impact the density of surviving neurons and ED-1+ macrophage/activated microglia. At the 72-hour-reperfusion, melatonin or the combination decreased the relative infarct volume and neurological deficit. Nevertheless, only the combination reduced FJB+ degenerating neurons at 72 hours. In conclusion, a combination of melatonin and calpeptin exerted synergistic protection against post-reperfusion injury in a rat MCAO stroke model.

Astragaloside IV Alleviates Cerebral Ischemia-Reperfusion Injury through NLRP3 Inflammasome-Mediated Pyroptosis Inhibition via Activating Nrf2

As one of the fundamental components of Astragalus membranaceus, astragaloside IV (AST IV) exerts protective effects against cerebral ischemia-reperfusion injury (CIRI). Nevertheless, the underlying mechanisms have not yet been conclusively elucidated. To do so, here, we report on the regulatory effects of Nrf2 on NLRP3 inflammasome-mediated pyroptosis. CIRI was induced by middle cerebral artery occlusion-reperfusion (MCAO/R) in Sprague Dawley rats and modeled by oxygen and glucose deprivation/reoxygenation (OGD/R) in SH-SY5Y cells. Cerebral infarct volume and neurological deficit score served as indices to evaluate MCAO/R injury. In addition, the CCK-8 assay was used to assess cell viability, the LDH leakage rate was used as a quantitative index, and propidium iodide (PI) staining was used to visualize cells after OGD/R injury. The NLRP3/Caspase-1/GSDMD pathway, which produces the pores in the cell membrane that are central to the pyroptosis process, was assessed to investigate pyroptosis. Nrf2 activation was assessed by detecting Nrf2 protein levels and immunofluorescence analysis. We show that after MCAO/R of rats, the infarct volume and neurological deficit score of rats were strongly increased, and after OGD/R of cell cultures, cell viability was strongly decreased, and the LDH leakage rate and the proportion of PI-positive cells were strongly increased. In turn, MCAO/R and OGD/R enhanced the protein levels of NLRP3, Caspase-1, IL-1β, GSDMD, and GSDMD-N. Moreover, Nrf2 protein levels increased, and Nrf2 translocation was promoted after CIRI. Interestingly, AST IV (i) reduced the cerebral infarct volume and the neurological deficit score in vivo and (ii) increased the cell viability and reduced the LDH leakage rate and the proportion of PI-positive cells in vitro. AST IV reduced the protein levels of NLRP3, Caspase-1, IL-1β, GSDMD, and GSDMD-N, inhibiting NLRP3 inflammasome-mediated pyroptosis. AST IV also increased the protein levels of Nrf2 and promoted the transfer of Nrf2 to the nucleus, accelerating Nrf2 activation. Particularly revealing was that the Nrf2 inhibitor ML385 partly blocked the above effects of AST IV. Taken together, these results demonstrate that AST IV alleviates CIRI through inhibiting NLRP3 inflammasome-mediated pyroptosis via activating Nrf2.

Evaluation of the neuroprotective activity of a new allylmorpholine derivative in a rat model of traumatic brain injury

Introduction. The search for and development of new drugs capable of reducing the severity of neurological deficit in traumatic brain injury are a critical task for investigational pharmacology. Chromone-containing allylmorpholines are a new group of neuroprotective drug candidates that have been shown to inhibit acetylcholinesterase and butyrylcholinesterase, and block N-methyl-D-aspartate receptors in vitro.Aim. This study aimed to evaluate the neuroprotective activity of the allylmorpholine derivative (E)-4-[3-(8-bromo-6-methyl-4-oxo-4H-chromen- 3-yl)-1-cyclohexylallyl]morpholin-4-ium chloride (33b) in vivo using a rat model of traumatic brain injury.Materials and methods. Traumatic brain injury was induced using the controlled cortical impact model. The allylmorpholine derivative was administered intraperitoneally at 1, 10, or 50 mg × kg-1 b.w. at 1 h after trauma induction, and then daily for the next 6 d. The neurological deficit was assessed using the Limb Placing, Open Field, Elevated Plus Maze, Beam Walking, and Cylinder tests.Results and discussion. At all doses administered, the allylmorpholine derivative had no positive effect on the motor function or exploratory behavior following traumatic brain injury. In the Elevated Plus Maze, 10 mg × kg-1 b.w. of the compound further suppressed exploratory behaviour in the injured animals, which appears to be consistent with its sedative properties observed previously in zebrafish.Conclusion. Despite the previously described in vitro affinity of allylmorpholines towards several molecular targets crucial for the pathogenesis of brain trauma and posttraumatic functional recovery, an allylmorpholine derivative had no neuroprotective effect in a rat model of traumatic brain injury in this study. These results further emphasize the importance of in vivo evaluation of potential neuroprotective drug candidates.

Actual concepts of classification, diagnosis and treatment of atlanto-occipital dislocations in adults: non-systematic literature review

Objective. To review the literature on atlanto-occipital dislocation (AOD) in adults to determine the optimal classification, diagnostic method and treatment.Material and Methods. A search was conducted in the PubMed database for the period from 1966 to 2020. The initial search revealed 564 abstracts of articles. A total of 95 studies were selected for a detailed study of the full text, of which 47 studies describing data from 130 patients were included in this review.Results. The paper describes all the available AOD classifications, and discusses their advantages and disadvantages. The clinical picture, features of the diagnosis in published observations of AOD in adults, as well as the applied treatment methods and their results are presented.Conclusion. Atlanto-occipital dislocation is one of the most severe types of injuries of the cervical spine in adults, which is accompanied by damage to the medulla oblongata and gross neurological deficit in 70 % of cases. The sensitivity of radiography for the diagnosis of AOD was 56.3 %. In 18.5 % of patients, its use led to untimely diagnosis and could cause subsequent deterioration. The CT sensitivity was 96.8 %. The most accurate method of AOD verification was to determine the atlanto-occipital interval (100 % sensitivity and specificity). The optimal method of treating victims with AOD is surgical one.

Classification of Adverse Events Following Surgery in Patients With Diffuse Lower-Grade Gliomas

BackgroundRecently, the Therapy-Disability-Neurology (TDN) was introduced as a multidimensional reporting system to detect adverse events in neurosurgery. The aim of this study was to compare the novel TDN score with the Landriel–Ibanez classification (LIC) grade in a large cohort of patients with diffuse lower-grade glioma (dLGG). Since the TDN score lacks validation against patient-reported outcomes, we described health-related quality of life (HRQoL) change in relation to TDN scores in a subset of patients.MethodsWe screened adult patients with a surgically treated dLGG World Health Organization (WHO) grade 2 and 3 between 2010 and 2020. Up until 2017, it consists of a retrospective cohort (n = 158). From 2017 and onwards, HRQoL was registered using EuroQoL-5-dimension, three levels of response (EQ-5D 3L) questionnaire at baseline and 3 months follow-up, in a prospectively recruited cohort (n = 102). Both the LIC grade and TDN score were used to classify adverse events.ResultsIn total, 231 patients were included. In 110/231 (47.6%) of the surgical procedures, a postoperative complication was registered. When comparing the TDN score to LIC grades, only a minor shift towards complications of higher order could be observed. EQ-5D 3L was reported for 45 patients. Patients with complications related to surgery had pre- to postoperative changes in EQ-5D 3L index values (n = 27; mean 0.03, 95% CI −0.06 to 0.11) that were comparable to patients without complications (n = 18; mean −0.06, 95% CI −0.21 to 0.08). In contrast, patients with new-onset neurological deficit had a deterioration in HRQoL at follow-up, with a mean change in the EQ-5D 3L index value of 0.11 (n = 13, 95% CI 0.0 to 0.22) compared to −0.06 (n = 32, 95% CI −0.15 to 0.03) for all other patients.ConclusionsIn patients with dLGG, TDN scores compared to the standard LIC tend to capture more adverse events of higher order. There was no clear relation between TDN severity and HRQoL. However, new-onset neurological deficit caused impairment in HRQoL. For the TDN score to better align with patient-reported outcomes, more emphasis on neurological deficit and function should be considered.

Unilateral versus bilateral anterograde cerebral perfusion in acute type A aortic dissection repair: A systematic review and meta-analysis

Objectives: The aim of the study is to compare the safety and efficacy of unilateral anterograde cerebral perfusion (UACP) and bilateral anterograde cerebral perfusion (BACP) for acute type A aortic dissection (ATAAD). Methods: A systematic review of MEDLINE (PubMed), Scopus, and Cochrane Library databases (last search: August 7 , 2021) was performed according to the PRISMA statement. Studies directly comparing UACP versus BACP for ATAAD were included. Random-effects meta-analyses were performed. Results: Eight retrospective cohort studies were identified, incorporating 2416 patients (UACP: 843, BACP: 1573). No statistically significant difference was observed regarding in-hospital mortality (odds ratio [OR]:1.05 [95% Confidence Interval (95%CI):0.70-1.57]), permanent neurological deficit (PND) (OR: 0.94 [95%CI:0.52-1.70]), transient neurological deficit (TND) (OR: 1.37 [95%CI:0.98-1.92]), renal failure (OR: 0.96 [95%CI:0.70-1.32]), and re-exploration for bleeding (OR: 0.77 [95%CI:0.48-1.22]). Meta-regression analysis revealed that PND and TND were not influenced by differences in rates of total arch repair, Bentall procedure and concomitant CABG in UACP and BACP groups. Cardiopulmonary bypass time (Standard Mean Difference [SMD]:-0.11 [95%CI:-0.22, 0.44]), Cross clamp time (SMD:-0.04 [95%CI:-0.38, 0.29]) and hypothermic circulatory arrest time (SMD:-0.12 [95%CI:-0.55, 0.30]) were comparable between UACP and BACP. Intensive care unit stay was shorter in BACP arm (SMD:0.16 [95%CI:0.01, 0.31]), however, length of hospital stay was shorter in UACP arm (SMD:-0.25 [95%CI:-0.45, -0.06]). Conclusions: UACP and BACP had similar results in terms of in-hospital mortality, PND, TND, renal failure and re-exploration for bleeding rate in patients with ATAAD. ICU stay was shorter in the BACP arm while LOS was shorter in the UACP arm.