Katarina Šakić

Efficacy of Interlaminar vs Transforaminal Epidural Steroid Injection for the Treatment of Chronic Unilateral Radicular Pain: Prospective, Randomized Study

UNLABELLED OBJECTIVE, DESIGN AND SETTINGS: The purpose of this randomized, prospective study is to compare the efficacy of two different routes in administering epidural steroid injections interlaminar (IL) vs transforaminal (TF) in patients with unilateral radicular pain. PATIENTS We randomly enrolled and followed 64 patients with chronic radiculopathy. RESULTS Significant improvements were maintained throughout 6 months (24 weeks) of follow-up (P<0.001, respectively). The average visual analog scale (VAS) pain scores at 24 weeks improved to 4.0 ± 2.2 cm in the IL group and 3.8 ± 2.1 cm in the TF group (P=0.717). Baseline functional capacity was comparable for the IL and the TF group (52% vs 53%) when assessed using Oswestry (P=0.647). At 6 months, both groups improved, 39% for the IL group and 38% for the TF group, suggesting change from severe to moderate disability scoring range. There were 24 out of the 32 (75%) patients in the IL group at 24 weeks who improved more than 2 cm on the VAS scale and 17 patients (53%) had >50% of the pain relief. In the TF group, there were 27 out of the 32 (84%) patients with >2 cm improvement on VAS pain scale, and 20 of 32 (63%) with >50% improvement at 24 weeks. Functional capacity changes were similar, 16 out of the 32 patients (50%) improved 10 points or more on the Oswestry scale in the IL group and 21 out of the 32 in the TF group (66%). CONCLUSIONS Using either route of epidural injections to deliver steroids for unilateral chronic radiculopathy secondary to herniated intervertebral disc provided significant improvements in patients function and pain relief. However, we could not find a statistically significant difference between two indicated groups either in functional improvement or in reduction in pain, although half-dose of steroids delivered via TF route provided somewhat better long-term pain relief and functional capacity improvements.

The in vivo genotoxicity of cisplatin, isoflurane and halothane evaluated by alkaline comet assay in Swiss albino mice

The aim of this study was to evaluate the genotoxicity of repeated exposure to isoflurane or halothane and compare it with the genotoxicity of repeated exposure to cisplatin. We also determined the genotoxicity of combined treatment with inhalation anaesthetics and cisplatin on peripheral blood leucocytes (PBL), brain, liver and kidney cells of mice. The mice were divided into six groups as follows: control, cisplatin, isoflurane, cisplatin–isoflurane, halothane and cisplatin–halothane, and were exposed respectively for three consecutive days. The mice were treated with cisplatin or exposed to inhalation anaesthetic; the combined groups were exposed to inhalation anaesthetic after treatment with cisplatin. The alkaline comet assay was performed. All drugs had a strong genotoxicity (P < 0.05 vs. control group) in all of the observed cells. Isoflurane caused stronger DNA damage on the PBL and kidney cells, in contrast to halothane, which had stronger genotoxicity on brain and liver cells. The combination of cisplatin and isoflurane induced lower genotoxicity on PBL than isoflurane alone (P < 0.05). Halothane had the strongest effect on brain cells, but in the combined treatment with cisplatin, the effect decreased to the level of cisplatin alone. Halothane also induced the strongest DNA damage of the liver cells, while the combination with cisplatin increased its genotoxicity even more. The genotoxicity of cisplatin and isoflurane on kidney cells were nearly at the same level, but halothane caused a significantly lower effect. The combinations of inhalation anaesthetics with cisplatin had stronger effects on kidney cells than inhalation anaesthetics alone. The observed drugs and their combinations induced strong genotoxicity on all of the mentioned cells.

Effect of spinal and general anesthesia on serum concentration of pro-inflammatory and anti-inflammatory cytokines.

BACKGROUND Surgery induces release of neuroendocrine hormones, cytokines and acute phase proteins. The aim of this study was to assess the effect of spinal and general anesthesia on serum concentration of pro-inflammatory and anti-inflammatory cytokines, and cytokines which are secreted by Th1 helper lymphocytes. METHODS 30 patients with American Society of Anesthesiologists status I and II who were scheduled for TURP (Transurethral Resection of the Prostata) were anesthetized in regional (spinal) or general anesthesia. Peripheral venous blood samples were collected 2 h before surgery on the first, third and fifth postoperative days. We measured pro-inflammatory cytokines, anti-inflammatory cytokines and cytokines which are secreted by Th1 helper lymphocytes in order to establish differences in patients before and after surgery. RESULTS Statistically significant differences were found in serum levels of interleukin-2 (IL-2) between general and spinal anesthesia (p=0.043). The concentration of IL-2 was continuously elevated in general anesthesia, but not in spinal anesthesia. It is important to note that the preoperative serum IL-2 concentration in general anesthesia group was significantly higher in comparison to spinal anesthesia group (p=0.028). There was also statistically significant increase of interleukin-6 (IL-6) in spinal (p=0.043) and general anesthesia (p=0.03) in comparison to preoperative value. CONCLUSION Surgery-related postoperative release of the pro-inflammatory cytokine IL-6 was increased in patients after spinal and general anesthesia. In our study, increased levels of the typical Th1 cytokine IL-2 were found in patients anesthetized by general anesthesia compared to spinal anesthesia. Serum concentrations of other pro-inflammatory cytokines, anti-inflammatory cytokines and cytokines which are secreted by Th1 helper lymphocytes showed no statistical difference before and after surgery under general and spinal anesthesia.

Genotoxicity and Cytotoxicity of Cisplatin Treatment Combined with Anaesthetics on EAT Cells In Vivo

In this study, DNA damage in tumour cells, as well as irreversible cell damage leading to apoptosis induced in vivo by the combined application of cisplatin and inhalation anaesthetics, was investigated. The genotoxicity of anaesthetics on Ehrlich ascites tumour (EAT) cells of mice, alone or in combined application with cisplatin, was estimated by using the alkaline comet assay. The percentage of EAT cell apoptosis was quantified by flow cytometry. Groups of EAT-bearing mice were (i) treated intraperitoneally with cisplatin, (ii) exposed to repeated anaesthesia with inhalation anaesthetic, and (iii) subjected to combined treatment of exposure to anaesthetics after cisplatin for 3 days. Sevoflurane, halothane and isoflurane caused strong genotoxic effects on tumour cells in vivo. The tested anaesthetics alone showed no direct effect on programmed cell death although sevoflurane and especially halothane decreased the number of living EAT cells in peritoneal cavity lavage. Repeated anaesthesia with isoflurane had stimulatory effects on EAT cell proliferation and inhibited tumour cell apoptosis (6.11%), compared to the control group (10.26%). Cisplatin caused massive apoptosis of EAT cells (41.14%) and decreased the number of living EAT cells in the peritoneal cavity. Combined cisplatin and isoflurane treatment additionally increased EAT cell apoptosis to 51.32%. Combined treatment of mice with cisplatin and all anaesthetics increased the number of living tumour cells in the peritoneal cavity compared to cisplatin treatment of mice alone. These results suggest that the inhalation of anaesthetics may protect tumour cells from the cisplatin-induced genotoxic and cytotoxic effects.

Intradiscal biacuplasty (IDB) for the treatment of thoracic discogenic pain.

ObjectivesDiscogenic pain in the thoracic region is a challenging condition characterized by refractoriness to conservative treatments. Unlike lumbar discogenic pain there is a lack of effective surgical options. Reported here is the treatment of thoracic discogenic pain in 3 patients using a new minimally invasive procedure named intradiscal biacuplasty. MethodsClinical case series in outpatient clinical setting. The procedure is detailed and step-by-step fluoroscopic imaging is presented. ResultsNo intraoperative and postoperative complications were reported. Improvements in functional capacity and pain scores were noted in 2 patients. Visual analog scale pain scores changed from 10 to 2 cm and 7 to 3 cm in 2 patients who claimed improvements at 12 months follow-up. In patient 1 visual analog scale went from 7 to 8 cm claiming no improvements after the procedure. In patients 1 and 3, Oswestry Disability Index improved from 24 to 8 and 10 points, respectively, and SF-36 physical function score changed from 55 to 80 and 45 to 82, respectively. The patient 2 showed no improvements with Oswestry (28 to 32) and SF-36 physical function score (50 to 45) at 12 months after intradiscal biacuplasty. Patient 1 stopped using his oxycodone/acetaminophen 5/325 mg that he used previously at 6 tablets a day, patient 3 decreased use of his duragesic patch from 75 μg/h to 25 μg/h. Patient 2 continued with significant use of opioids (100 μg/h of transdermal fentanyl). DiscussionCooled, bipolar radiofrequency may be an effective and readily available treatment for thoracic discogenic pain if future comparison studies show benefits of such procedure.

Recombinant Factor VIIa in the Treatment of Hemostatic Disorders in Patients with Solid Tumors

In the University Hospital for Tumors, we used recombinant factor VIIa to treat 5 patients with solid tumors who developed severe bleeding during oncology treatment. Patients were aged 32 67 years, of which there were 4 men and one woman. Two men had a gastric cancer, one had a colon cancer, one the embryonic extragonadal tumor with metastases in the lungs and liver and one patient had breast cancer with liver metastases. Recombinant factor VIIa is a serine protease similar to trypsin, glycoprotein, consisting of 406 amino acids, that activates outer clotting path and initiates thrombin generation. It is applied for the purpose of stopping major bleeding in the states of disseminated intravascular coagulation (DIC) and when there is no other way to stop the bleeding. In our Institution it was used to stop bleeding in patients during irradiation, both, postoperativly and during chemotherapy in a single dose of 1.2 mg IV, after the standard treatment: SSplasm, cryoprecipitate, packed red blood cells and thrombocytes, could not have stopped the bleeding. The result was the momentary cessation of bleeding in patients. Recombinant factor VIIa can be successfully applied in oncology, in cases where conservative treatment of bleeding has no success.