Blockade of sodium channels by phenytoin protects ultrastructure and attenuates lipid peroxidation in experimental spinal cord injury

Summary Spinal cord injury (SCI) involves a series of pathological events. Abnormal sodium influx has been implicated as one of the key events in the pathophysiology of the SCI. Pharmacological blockade of sodium channels can reduce secondary injury and increase recovery from trauma. The aim of the present study was to show the neuroprotective effect of phenytoin, a sodium channel blocker, after experimental SCI.Control and laminectomy-only groups were not injured. 50g-cm weight drop injury was produced in the trauma group. In the treatment groups, methylprednisolone (30mg/kg) and phenytoin (1mg/kg, 10mg/kg, or 30mg/kg) were given intraperitoneally immediately after injury. Malondialdehyde (MDA) levels in the spinal cord samples were examined for lipid peroxidation. Spinal cord ultrastructure was evaluated and grading system was used for quantitative evaluation.Trauma increased tissue MDA levels. Treatment with methylprednisolone and phenytoin decreased MDA levels compared to trauma in all doses. Significant ultrastructural neuroprotection was observed with 30mg/kg of phenytoin treatment according to general neural score. This ultrastructural neuroprotection of phenytoin was not different from methylprednisolone. Phenytoin appears to protect spinal cord against injury by decreasing lipid peroxidation and lessening neuronal damage associated with SCI in rats.     

Efficacy of high dose amino acid solution on spinal cord injury induced by focal Nd : YAG laser irradiation

Summary In this experimental study, a neodymiumyttrium-aluminium-garnet (NdYAG) laser was used to induce highly reproducible focal spinal cord lesions in anaesthetized guinea pigs. The efficacy of high dose amino acid solution (HDAAS) on this injury is investigated. Experiments were performed on 36 animals divided into three groups; sham operated controls, laser irradiated surgical controls, and amino acid groups. Acute responses to injury were evaluated with somatosensory (SSEP) and motor evoked potentials (MEP) and functional recovery was assessed for 8 weeks using the inclined plane technique.In the laser irradiated surgical control group, MEP disappeared one hour after the laser injury, but SSEP revealed changes of amplitude and latency. In this group, the average value of the inclined plane at 24 hours after the laser application was 45.3±1.4 degrees. In the amino acid group, at the sixth hour of injury, MEP and SSEP changes improved with infusion of HDAAS for 4 hours. This improvement was statistically significant (for latency of SSEP U=140 p<0.05). Inclined plane value at 24 hours after the laser application was 65.5±1.2 degrees in this group.This study showed that application of NdYAG laser irradiation on the spinal cord induced spinal cord injury which presented as paraparesis, HDAAS may provide significant therapeutic protection in secondary damage following this injury and may have a potential role in the treatment of acute spinal cord injury.     

Change pattern of somatosensory-evoked potentials after occlusion of segmental vessels: possible indicator for spinal cord ischemia

Paraplegia was reported after occlusion of the segmental vessels during anterior spinal surgery. The aim of this study was to investigate the effect of occlusion of the segmental vessels on the somatosensory-evoked potential (SEP) monitoring and analyze its potential risk for cord ischemia. Thirty-one patients with thoracic scoliosis underwent anterior spinal surgery. T₅–T₁₁ segmental vessels on the convexity were occluded with microvascular clamps at the point 2 cm from the intravertebra foramen. The SEPs were recorded 5 min before occlusion and 2, 7, 12 and 17 min after occlusion. The SEPs were analyzed with two indices i.e. P40 latency and P40 amplitude. All SEP waveforms recorded during the test were regular and recognizable. Compared to 5 min before occlusion, the P40 latencies at 2 min and 7 min after occlusion significantly increased 3.39% and 2.76% on an average, the P40 amplitudes at 2 min after occlusion significantly declined 26% (peak to peak) or 22% (peak to baseline) on an average (P<0.05). But the changes of SEPs were temporary. The SEPs began to restore at 12 min after occlusion and returned to the pre-occlusion level at 17 min after occlusion. No neurologic complications occurred in all patients after surgery. These results suggest that SEP is a possible indicator for ischemia of the spinal cord which is a dynamic course and cannot be considered an all-or–none phenomenon. Without the factors such as developmental deformities of the spinal cord, vascular variation and potential cord ischemia, occlusion of the segmental vessels would be safe during the anterior spinal surgery.     

Benign mixed glial-mesenchymal tumour (“glio-fibroma”) of the spinal cord

Summary An intramedullary tumour of the cervical spinal cord, occurring in a female aged 45, was found to be composed of an isomorphous astrocytoma densely intermingled with desmoid tumour tissue.Such a benign mixed glial-mesenchymal tumour or gliofibroma, has not been previously reported.     

经颅磁刺激运动诱发电位监测脊髓创伤的实验研究

目的：观察脊髓创伤与运动诱发电位的关系，了解运动诱发电位在脊髓中的传导通路。方法：对３９只猫采用脊髓Ａｌｅｎ损伤模型和部分切断伤模型进行经颅磁刺激运动诱发电位（ＴＭＳ－ＭＥＰ）监测。结果：脊髓轻度打击伤时，ＭＥＰ潜伏期即有明显延长，但恢复良好；中度打击伤时，ＭＥＰ潜伏期延长更明显，且不能完全恢复；重度打击伤时，大部分动物ＭＥＰ不能引出，至２４ｈ不能恢复。ＭＥＰ的改变与后肢功能变化及镜下脊髓病理改变一致。ＴＭＳ－ＭＥＰ对脊髓前索和外侧索的损伤敏感，并可间接反应脊髓柱后索损伤。结论：ＴＭＳ－ＭＥＰ经脊髓前索和外侧索传导，可敏感而准确地反映脊髓损伤后功能改变，是一种有效的监测脊髓功能的手段     

Time-level relationship for nitric oxide and the protective effects of aminoguanidine in experimental spinal cord injury

Summary. Background. The secondary injury process following spinal cord trauma has been shown to involve different mechanisms such as excessive release of excitatory amino-acids, and induction of free radical induced lipid peroxidation. In this experimental study, the time-level relationship of the nitric oxide and the neuroprotective effects of aminoguanidine were investigated in a rat spinal cord trauma model.Methods. The experiments were performed on 63 Wistar albino rats divided into three groups; sham-operated control (Group 1), trauma created control (Group 2) and aminoguanidine group (Group 3). In groups 2 and 3, spinal cord trauma was produced at thoracic level by using weight the drop technique (at a severity of 50gr-cm). After the trauma, the rats in Group 3, received an intraperitoneal injection of 100mg/kg aminoquanidine twice a day for 3 days. The effects of the injury and the efficacy of aminoguanidine were determined based on biochemical parameters (lipid peroxidation and nitric oxide levels in tissue), and on light microscopy findings in cord tissue collected at different times post-injury. Biochemical parameters were performed one hour, three and five days after injury. Functional recovery was assessed at 3, and 5 days after cord trauma with the inclined-plane technique and Tarlovs motor grading scale.Findings. Although there was no statistically significant difference at the 1^st hour, the values of the tissue nitric oxide in trauma created controls were 42% higher on the 3^rd day and 40% higher on the 5^th day when compared with those in sham controls. The levels of the tissue lipid peroxidation in trauma created controls were 88% higher at the 1^st hour and 52.8% higher on the 5^th day when compared with shame controls, but there was no meaningful difference on the 3^rd day. In the trauma created control group, the mean motor function scores decreased to 1.16±0.40 and to 1±0 on the 3^rd and 5^th day, respectively. In this group the mean values of the inclined plane were 39.16±2.04 on the 3^rd day and 37.91±1.02 on the 5^th day. No statistically significant difference was observed in both tissue lipid peroxidation and nitric oxide levels for all time points between the aminoguanidine group and the sham-operated controls (p>0.01). The motor function scores were observed as 2.16±0.40 on the 3^rd day and as 3±0 on the 5^th day in aminoguanidine group. These values were significantly higher than the trauma created controls (p<0.01). Aminoguanidin treatment also improved the inclined plane performance of the rats; In this group, the mean values of the inclined plane scores were 44.58±2.92 and 52.91±1.88 on the 3^rd and 5^th days, respectively. These values were significantly higher than the trauma created controls (p<0.01).Interpretation. This study shows that the nitric oxide level does not increase in the spinal cord tissue during the first hour after the spinal cord trauma. It increases significantly in the spinal cord tissue not only three days but also five days following the trauma. Aminoguanidine treatment, which is started just after the trauma, can prevent both the nitric oxide production and lipid peroxidation in spinal cord tissue and it can improve the functional status of the animals. In this respect, aminoguanidine may have a potential role in the treatment of acute spinal cord injury.     

Ischemic Changes in Evoked Spinal Cord Potentials During Profound Hypothermic Circulatory Arrest in Thoracic Aortic Surgery

Purpose We examined the changes in evoked spinal cord potentials (ESCP) during profound hypothermic circulatory arrest to estimate the safe ischemic time.Methods We monitored ESCPs during surgery for descending thoracic or thoracoabdominal aneurysms in five patients. Evoked spinal cord potential recordings were obtained before cooling (baseline), then every few minutes during circulatory arrest, and at the end of the operation.Results After circulatory arrest, the amplitude of ESCPs decreased with time. We calculated the simple linear regression between the amplitude of ESCPs and the circulatory arrest time by the least-squares method, and found a highly linear relationship between amplitude and arrest time in all five patients. The time until disappearance of ESCPs was estimated as 50.7 ± 20.4min (95% level of confidence).Conclusion When an ESCP disappeared, ischemic spinal cord injury had occurred. This demonstrates the potential value of estimating the time of disappearance of ESCPs to prevent ischemic spinal cord injury during descending thoracic aortic surgery.     

TMS—MEP与CSEP诊断脊髓损伤的作用比较

目的比较脊髓损伤后经颅磁刺激运动诱发电位和皮层体感诱发电位检测的诊断价值。方法 １５只家猫脊髓部分切断和６９例ＳＣＩ的ＭＥＰ和ＣＳＥＰ检测。结果 ＭＥＰ对脊髓前柱损伤，前后柱混合损伤和肌力异常极敏感，对后柱损伤不敏感；而ＣＳＥＰ对脊髓后柱损伤，前后柱混合损伤和关节位置觉异常十分敏感，对前柱伤却相反。     

Intersomatic fusion with calf bone “Kiel bone splint” in the anterior surgical approach for the treatment of myelopathy in cervical spondylosis

Summary The Authors employed calf bone (Kiel bone splint) in 16 cases of myelopathy from cervical spondylosis, which were treated by anterior surgical approach.The patients were observed for as long as 3 years following operation. Results proved to be fully successful.

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Wirbelkörperfusion von einem vorderen Zugang aus mit Kalbsknochen (Kieler Knochenspan) für die Behandlung von Myelopathien bei der zervikalen Spondylose

Zusammenfassung Die Autoren verwendeten bei 16 Fällen von Myelopathie infolge zervikaler Spondylose Kalbsknochen (Kieler Knochenspan) zur ventralen Wirbelkörperfusion. Die Patienten wurden bis zu drei Jahren nach der Operation beobachtet. Die Ergebnisse waren voll zufriedenstellend.

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Fusión de los cuerpos vertebrales por via anterior con huesos de ternera (Kieler Knochenspan) para el tratamiento de mielopatias en la espondilosis cervical

Resumen Los autores usaron en 16 casos de mielopatia ocasionada por una espondilosis cervical huesos de ternera (Kieler Knochenspan) para la fusión de los cuerpos vertebrales por vía anterior. Los pacientes fueron observados hasta 3 annos después de la operación. Los resultados han sido totalmente satistactorios.

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Fusion intersomatique avec de l'os de veau (Kiel bone splint) dans l'approche chirurgicale antérieure pour le traitement des myélopathies dans les spondyloses cervicales

Résumé Les auteurs utilisent de l'os de veau (Kiel bone splint) dans 16 cas de myélopathies par spondyloses cervicales qui furent traitées par approche chirurgicale antérieure.Les malades furent surveillés pendant 3 ans après l'opération. Les résultats furent un succès total.

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Fusione dei corpi vertebrali a mezzo di osso di vitello (Kieler Knochenspan) in caso di intervento per via anteriore per il trattamento di mielopatia spondiloartrosica

Riassunto Gli AA. in 16 casi di mielopatia da spondiloartrosi cervicale operati per via anteriore con la tecnica di Cloward, hanno impiegato corne trapianto un cilindro di osso spugnoso di vitello (osso di Kiel). Le fusioni ottenute, controllate fino a tre anni dopo l'intervento, sono state eccelenti ed in taluni casi migliori di quelle con autotrapianto.

     

Effect of nimodipine and N-acetylcysteine on lipid peroxidation after experimental spinal cord injury

The effectiveness of nimodipine and N-acetylcysteine in experimental spinal cord injury was evaluated by measuring tissue lipid peroxidation levels of the damaged spinal cords 1 hour after the injury. We used the clip compression method to produce acute spinal cord injury in 40 female Sprague-Dawley rats were used. The rats were divided into four groups of 10 each. Lipid peroxidation was assessed by measuring the tissue content of malonil dialdehyde (MDA). In group 3, nimodipine, and in group 4,n-acetylcysteine, was administered i.p. as a single dose immediately after the injury. The rats were sacrificed 1 hour after clip application. The tissue mean MDA content was 3,992 mol MDA/gww in group 1 (sham operated), 10,192 mol MDA/gww in group 2 (trauma), 10,449 mol MDA/gww in group 3 (nimodipine treatment) and 9,009 mol MDA/gww in group 4 (n-acetylcysteine treatment). These results demonstrated that a single dose of nimodipine andn-acetylcysteine had no effect on peroxidation of lipid membranes in the early period of experimental spinal cord injury.     

Spontaneous spinal epidural hematomas: is the role of dural arteriovenous malformations underestimated?

Two recent observations of spinal epidural hematomas (SEH) are presented: one of them was associated with iatrogenic coagulopathy, the other, apparently spontaneous, required reoperation for early recurrence and was finally attributed to ruptured epidural arteriovenous malformation missed during the first procedure. Both patients underwent complete recovery. Although modern neuroimaging provides quick, noninvasive, and sensitive assessment of spinal epidural bleeding, we believe that preoperative spinal angiography is indicated in spontaneous SEH with subacute clinical course. Demonstration of underlying vascular anomaly would allow better surgical planning, complete obliteration of abnormal vessels, and prevention of recurrences. Essential epidemiological, pathogenetical, and clinical aspects of SEH are reviewed.     

Spinal functions in sensorimotor control of movements

The transformation of sensory information to movement patterns in spinal interneuronal systems is far from just being a stereotyped reflex pattern. Information from the different sensory modalities (skin-, muscle, and joint receptors) is integrated at the interneuronal level and transformed into patterns of coordinated movements which are adapted to the current position and the phase of movement of a limb. In addition, spinal interneuronal systems are capable of generating rhythmic motor activities like locomotion or scratching without a sensory feed-back from the periphery and without a corresponding drive from supraspinal structures.The same interneuronal systems which are engaged in the reflexogenic control and generation of movements at the spinal level also convey information for the performance of supraspinally-induced, goal-directed (voluntary) movements. The inherent convergence between descending and peripheral afferent information onto common interneuronal systems implies an improved coordination and adaptation of movements in dependence on the peripheral conditions. Disturbance of the supraspinal control of these interneuronal systems leads to an impairment of the transformation of sensory inputs into motor acts. Spasticity is probably partly caused by such a disturbed control of the transmission in the interneuronal systems.     

Ileal Perforation in a Patient with High Spinal Cord Injury: Report of a Case

Assessing abdominal complications in patients who have previously suffered high spinal cord injury is very difficult because the resultant loss of sensory, motor, and reflux function of the abdominal wall can mask the typical signs of acute abdomen such as tenderness, muscle rigidity, and peritoneal rebound pain. We recently diagnosed a small intestinal perforation in a 77-year-old man with a C6–7 spinal cord injury sustained 14 years earlier. The patient was correctly diagnosed as having an acute abdominal condition, despite palsy of abdominal wall sensation. An emergency laparotomy was done and a 40-cm length of affected ileum, about 180cm distal to the Treitz ligament, including a 1-cm perforation, was resected, followed by an end-to-end anastomosis. We report this case to raise awareness of the need for appropriate diagnosis and early surgical treatment of abdominal complications in spinal-cord-injured patients.     

Parameters in electrode positioning in thoracic percutaneous facet denervation: an anatomical study

Summary The purpose of the present study was to verify if needle placement in thoracic percutaneous facet denervation (PFD), based on bony landmarks, and under fluoroscopic guidance, would lead to constant anatomical positioning; and hence to an adequate placement at the assumed target, i.e., the medial branch of the dorsal ramus of the spinal nerve; and furthermore to determine if interpretation of the needle position by CT is more reliable than by fluoroscopy.The procedures were carried out bilaterally at all 12 levels on two cadavers, simulating the clinical setting as much as possible. In 44 cases the position of the needles was determined on hard copies of fluoroscopic images, 1.5 mm interval CT-images, surface-photographs, and on counterstained 25 m sections obtained by a multirange heavy duty cryomicrotome.The sections established that standardized use of bony landmarks under fluoroscopic control can result in reproducible anatomical needle positioning in thoracic PFD. Nervous tissue was hit in 27 (61 %) cases, but the supposed target structure, i.e., the medial branch stem was never hit. In none of the procedures was an accidental pleural puncture observed. The correlation between fluoroscopic images and sections was poor. The correlation between CT and sections was better, except for the mediolateral direction.The results of the present study suggest that pure anatomical positioning based on bony landmarks analogous to those used in the lumbar region is not reliable enough for thoracic PFD, and that corrections after electrostimulation substantially contribute to obtaining an adequate position of the needle.     

Spinal cord stimulation in 112 patients with epi-/intradural fibrosis following operation for lumbar disc herniation

Summary A total of 112 patients with epi-/intradural fibrosis following operation for lumbar disc herniation were treated by spinal cord stimulation. Lumbosacral spinal fibrosis is seen particularly often after extensive and repeated operations. Radicular pain responds better to stimulation than back pain. A favourable long-term effect on radicular pain has been observed in 67% of patients treated by epidural implantation, the corresponding average follow-up period being 4 1/2 years. 40% of these patients needed less analgesics after the operation, while 25% of them showed an improved fitness for work. Among about 5,000 patients who underwent surgical treatment for lumbar disc herniation, an indication for spinal cord stimulation was found in 1,5%. By comparison, the frequency of the last resort procedure of microsurgical cordotomy was 0.3%. We no longer use other ablative methods like extirpation of spinal ganglia.     

An experimental study on spinal cord ischemia during cross-clamping of the thoracic aorta: The monitoring of spinal cord ischemia with motor evoked potential by transcranial stimulation of the cerebral cortex in dogs

The usefulness of spinal motor evoked potential by transcranial stimulation of the motor cortex (MEPt) in detecting spinal ischemia and predicting postoperative neurological dysfunction was evaluated using a model of spinal ischemia. Group 1 was comprised of 11 dogs used for measuring the basic wave form of spinal MEPt. The normal spinal MEPt response curve consists of two major peaks: peak I and peak II. The latency of peak I and peak II at T13–L1 was 6.0±0.6 and 7.1±0.6 msec, and the amplitude, 3.3±1.6 and 6.1±2.6 V, respectively. Group 2 was comprised of six animals subjected to spinal ischemia, in which a time-related deterioration of the MEPt as well as evoked spinal cord potential (ESP) was demonstrated. The time taken until the loss of peak I and peak II was 19.2±5.3 and 21.7±6.2 min, respectively, while the time taken until the loss of ESP was 36.7±14.0 min. In group 3, comprised of seven animals, the aorta was unclamped and the animals were allowed to recover when the spinal MEPt had disappeared. Four had paraparesis immediately after the operation, two had a normal gait, one died, and one developed spastic paraplegia after 24h. We concluded that the change in spinal MEPt during spinal ischemia occurred earlier than the change in ESP, and that the loss of MEPt suggested irreversible spinal cord damage.     

Huge epidural hematoma after surgery for spinal cord stimulation

Summary Objective and importance. Spinal epidural haematoma (SEH) following implantation of an epidural spinal cord electrode is a very rare complication but one that must not be overlooked. This case is unusual because of the almost holocord extension of the haematoma and the excellent recovery obtained by prompt surgical treatment.Clinical presentation. A 69 years old man with normal serum coagulation parameters was submitted to spinal cord stimulation (SCS) for chronic pain syndrome. After a minimal L1 laminotomy the patient developed paraplegia due to a large haematoma at D4-L2.Intervention. Surgical removal of the entire clot by a D4-L2 laminectomy was performed immediately.Conclusion. Large epidural haematoma can result from SCS and this complication may be cured by appropriate and prompt surgery.     

Cranioplasty of an extremely large cranial defect caused by transitional meningioma with a knitted polypropylen-polyester prothesis “Codubix”

Summary The authors report a case of transitional cell meningioma of the convexity which destroyed a large portion of the calvarium and invaded subcutaneous tissue. The tumour was totally removed and a large cranial defect/430 cm² in size/ was filled with a polypropyleno-polyester knitted prothesis Codubix with an excellent result.The problems of chronioplastic closure of such an unusually large skull defect and the advantages of the use of the material Codubix are discussed.     

31. Über das Problem,Appendicitis" in unserem 10jährigen Krankengut

Zusammenfassung An der dritten chirurgischen Klinik der Semmelweis Universität Budapest haben wir von 1976 bis 1985 862 Patienten wegen Verdacht auf akute Appendicitis operiert. Bei 111 Patienten konnte ein Beweis einer Entzündung weder makroskopisch noch histologisch nachgewiesen werden. Diese Patienten wurden unter der Diagnose chronische Appendicitis geführt, die Letalität betrug 0,8%. Bei den 751 wegen akuter Appendicitis operierten Fällen betrug die Letalität 0,5%. Bei den Patienten, die wegen chronischer Appendicitis operiert wurden und bei denen der Eingriff als sogenannte prophylaktische Appendektomie gilt, waren die Komplikationen sowie die Letalität größer, als in der wegen akuter Appendicitis operierten Gruppe. Deshalb werden die aus prophylaktischen Gründen durchgeführten Appendektomien bei uns nicht befürwortet.     

242. Korrelation klinischer und biochemischer Befunde mit dem Schweregrad einer bakteriellen Peritonitis

Zusammenfassung Anhand von Verlaufsdaten 66 chirurgischer Patienten mit einer bakteriologisch gesicherten Peritonitis sollten harte und weiche Kriterien zur Beurteilung des Schweregrades differenziert werden. Untersuchungskriterien: 1) regionale Ausbreitung, 2) Entwicklung eines Organod. Systemversagens, 3) Leukocytose/Thrombopenie, Körpertemperatur, 4) die Plasmamediatoren Endotoxin/Prostaglandin F₂ (PGF₂), 5) Anamnesedauer (Erstsymptom bis OP), 6) Anzahl erforderlicher Reoperationen und 7) Lebensalter. Zuzuordnende Schweregrade: Grad 1: überlebt, Grad 2: mit Komplikationen überlebt, Grad 3: nicht überlebt. Danach erweisen sich als harte Kriterien: 1) Lokalisation, 2) Anamnesedauer, 3) Leukocytose, 4) Endotoxin > 100 Eu/ml, PGF₂ > 500 pg/ml, 5) Körpertemperatur 38,5°C.