Primary and revision lumbar discectomy: A three-year review from one center

Background:

Despite variations in technique, the results of primary and revision lumbar discectomy have been good. The aim of this study was to retrospectively review cases of primary and revision lumbar discectomy performed in our institute over a three-year period.

Materials and Methods:

The case records of 273 patients who underwent lumbar discectomy between January 2001-2004 and fulfilled our inclusion and exclusion criteria were reviewed. Of these, 259 were primary discectomies and 14 were revision surgeries. Recurrence was defined as ipsilateral disc herniation at the previously operated level. Demographic parameters, magnetic resonance imaging of the disc, patient satisfaction and rate of recurrence were analyzed.

Results:

The primary surgery group had 52 (20.08%) contained and 207 (79.92%) extruded or sequestered discs, while the numbers in the revision group were three (21.43%) and 11 (78.57%) respectively. “Satisfactory” outcome was noted in 96.5% of the primary surgeries, with a recurrence rate of 3.5%. In the revision group 78.6% had “satisfactory” outcome. In 9.4% of the primary group we encountered complications, while it was 21.43% in the revision group.

Conclusions:

Lumbar discectomy is a safe, simple and effective procedure with satisfactory outcome in 96.5% of primary disc surgery and 78.6% of revision disc surgery.     

Spontaneous posterior fossa hemorrhage associated with low-molecular weight heparin in an adolescent recently diagnosed with posterior reversible encephalopathy syndrome: case report and review of the literature

Background Posterior reversible encephalopathy syndrome (PRES) constitutes a well-described clinical entity, classically entailing characteristic edematous lesions on imaging studies in a patient with altered mental status, visual disturbances, headache, and seizures. PRES is reversible in the vast majority of cases, although progression to ischemia and hemorrhage has been documented.Methods We report a case of a 16-year-old male with chronic renal failure who developed PRES during a hypertensive crisis. The hypertension was successfully managed and PRES-associated symptomatology showed complete regression. However, approximately 2 months later, the patient returned with a spontaneous posterior fossa hemorrhage. Two weeks before this second admission, treatment with low-molecular weight heparin had been initiated. The patient finally succumbed, despite surgical evacuation. The pertinent literature is reviewed.Conclusion We suggest that the administration of low-molecular weight heparin in the setting of recent PRES might increase the risk for the development of intracranial hemorrhage.     

The role of intraoperative micro-Doppler ultrasound in verifying proper clip placement in intracranial aneurysm surgery.

We present the results of a retrospective study employing intraoperative micro-Doppler ultrasonography (MDU) in verifying proper clip placement during cerebral aneurysmal surgery. One hundred and thirty-four patients surgically treated for 147 intracranial aneurysms were studied. Thirteen patients harboring 17 aneurysms were surgically treated on an elective basis, while 121 patients with 130 aneurysms, presented with subarachnoid hemorrhage (SAH). Blood flow velocities of the parent and adjacent vessels as well as the aneurysmal sac were measured using a Conforma Micro-Doppler (Cook Vascular Inc., Leechburg, PA, USA). Pre- and post-operative cerebral angiography was obtained in all our patients. In 23 aneurysms (15.6%) there was decreased or absent flow in the parent vessel or in one of the adjacent vessels after clipping. In another 19 aneurysms (12.9%), MDU demonstrated flow through the aneurysmal dome even though the aneurysmal neck appeared to be totally obliterated. Presence of SAH, anatomic location and size of the aneurysm were associated with improper clip placement in a statistically significant fashion. The false positive rate for MDU was 2% while there were no false negative findings in our study. MDU appears to be a non-invasive, reliable alternative methodology to intra-operative angiography. This inexpensive method may lend itself to routine usage in aneurysm surgery.     

Anti-cancer activity of withaferin A in B-cell lymphoma

Withaferin A (WA), a withanolide from the plant, Ashwagandha (Withania somnifera) used in Ayurvedic medicine, has been found to be valuable in the treatment of several medical ailments. WA has been found to have anticancer activity against various solid tumors, but its effects on hematological malignancies have not been studied in detail. WA strongly inhibited the survival of several human and murine B cell lymphoma cell lines. Additionally, in vivo studies with syngeneic-graft lymphoma cells suggest that WA inhibits the growth of tumor but does not affect other proliferative tissues. We demonstrate that WA inhibits the efficiency of NF-κB nuclear translocation in diffuse large B cell lymphomas and found that WA treatment resulted in a significant decrease in protein levels involved in B cell receptor signaling and cell cycle regulation. WA inhibited the activity of heat shock protein (Hsp) 90 as reflected by a sharp increase in Hsp70 expression levels. Hence, we propose that the anti-cancer effects of WA in lymphomas are likely due to its ability to inhibit Hsp90 function and subsequent reduction of critical kinases and cell cycle regulators that are clients of Hsp90.     

Large-volume Paracentesis versus Dialytic Ultrafiltration in the Treatment of Cirrhotic Ascites

We compared the clinical efficacy and safety of large-volumeparacentesis and dialytic ultrafiltration in the treatment ofrefractory ascites in cirrhotic patients. A group of cirrhoticsubjects (age 49–80 years) were randomly allocated toeither continuous paracentesis (1–1.5 1/hour) or dialyticultrafiltration until disappearance of ascites. Each patientwas maintained on bed rest, fluid restriction (1 1/day) anda low (25 mmol/day) sodium diet for 14 days. Five patients (threein the paracentesis group and two in dialytic ultrafiltrationgroup) developed massive ascites 3–5 months later, andreceived the crossover treatment. The average volume of fluidremoved was similar in the two groups (4.70±1.47 1 fordialytic ultrafiltration versus 4.69±1.84 1 for paracentesis),but the treatment period was significantly shorter with dialyticultrafiltration. The plasma creatinine significantly increasedthree days after paracentesis but did not increase in patientstreated with dialytic ultrafiltration. There was an initialfall in mean arterial pressure during the first two hours ofeither treatment; a further fall in blood pressure was observedwith paracentesis but not with dialytic ultrafiltration. Pretreatmentplasma renin activity was elevated, but was not altered by eithertreatment. Plasma atrial natriuretic peptide levels were inthe high-normal range before treatment. Paracentesis was associatedwith a delayed fall in plasma atrial natriuretic peptide, whiledialytic ultrafiltration induced a modest but significant rise.No complication was experienced with dialytic ultrafiltrationin the two weeks following treatment, but four of the eightpatients who underwent paracentesis had developed severe complications.Dialytic ultrafiltration of ascitic fluid is a safe procedurein cirrhotic patients. Large-volume paracentesis without intravenouscolloid reinfusion causes complications and carries the potentialrisk of reducing the effective intravascular volume.