Khalil Salame

AGMATINE TREATMENT IS NEUROPROTECTIVE IN RODENT BRAIN INJURY MODELS

Agmatine is a naturally occurring guanidino compound, found in bacteria and plants, with several proposed nervous system-related functions suggestive of beneficial effects in central nervous system injury. Here evidence is presented that agmatine can exert potent neuroprotection in both in vitro and in vivo rodent models of neurotoxic and ischemic brain injuries. The cumulative evidence lead us to suggest that agmatine, a relatively nontoxic compound, be tried for potential therapeutic use after neurotrauma and in neurodegenerative disorders.

Paraganglioma of the pituitary fossa: diagnosis and management

Paraganglioma of the sellar area is extremely rare with only six cases having been reported in the literature. Surgical removal of these tumors is difficult, and the transsphenoidal approach usually results in limited resection. Most authors who published reports on this tumor recommended radiation therapy after partial removal of the tumor. However, considering the benign nature of these tumors, the risk of radiation-induced endocrine insufficiency and optic neuropathy and the lack of proven effectiveness of radiotherapy, its value remains controversial.We describe a 48-year-old woman with parasellar paraganglioma who presented with headaches, visual loss and oligomenorrhea. Magnetic resonance imaging (MRI) showed an invasive tumor in the sellar and parasellar areas which extended to both cavernous sinuses and compressed the optic chiasm and the left internal carotid artery. Surgery by the transsphenoidal approach enabled only limited biopsy of the tumor. The patient was reoperated by an extended pterional approach which resulted in a subtotal removal of the tumor and adequate decompression of the adjacent structures. She received no adjuvant treatment during the 8-year postsurgical follow-up and remained in good health. A repeated MRI showed no change in the size of the residual tumor. Contrary to the therapeutic recommendations described in previous reports, we favor postoperative adjuvant therapy only if the symptoms or signs of cranial nerve compression persist following maximal tumor removal, or if there is evidence of subsequent growth of residual tumor.

Primary intramedullary spinal melanoma: Diagnostic and treatment problems

A 76-year old female patient with 9 year history of right mastectomy for an infiltrating ductal breast cancer and no evidence of recurrent nor metastatic disease, was admitted due to pain in the lower thoracic area radiating bilaterally to the posterior aspect of the chest wall at the same level, difficulties in micturition, urinary hesitancy, and progressive weakness of the lower limbs. Primary intramedullary spinal tumor was demonstrated by a MRI study of the spine, partially resected, and found to be a malignant melanoma on pathological study. Postoperative irradiation and administration of dexamethasone did not improve the neurologic status.

Shape variation of the neural arch in the thoracic and lumbar spine: Characterization and relationship with the vertebral body shape

Quantifying the human vertebral geometry is important for accurate medical procedures. We aimed to characterize the neural arch (NA) shape at T1‐L5. All T1‐L5 dry vertebrae (N = 4,080) of 240 individuals were measured and analyzed by age, gender, and ethnicity. A 3D digitizer was used to measure the dimensions of the spinous (SP) and transverse (TP) processes, vertebral canal (VC), laminae, and isthmus. Most parameters were independent of age and ethnicity, yet greater in males than in females. Isthmus length increases from T1 (9.8 mm) to T12 (19.87 mm) and decreases from T12 to L5 (9.68 mm) with right > left in the thorax and oppositely in the lumbar region. The SP is longer than its thickness both decreasing in the upper thorax (by ca. 4mm), increasing in the lower thoracic and upper lumbar vertebrae (by 7 mm for length and ca. 14.5 mm for thickness) and decreasing again along the lower lumbar vertebrae (both by 8 mm). The TP length decreases at T1‐T12 (by 13 mm) and increases at L1‐L5 with left > right at T1‐L5 (P < 0.003). The laminar length decreases from T1 (8.72 mm) through T5 (4.76 mm) and increases toward L5 (8.4 mm) with right > left at T1‐L5 (P < 0.003). The VC is oval‐shaped at T1 and T11‐L5 (width > length), rounded‐shape at T2 and T10 (width = length), and inverted oval‐shaped at T3‐T9 (length > width). In conclusion, the NA is systematically asymmetrical and dynamic in shape along the thoracic and lumbar spine. The inter‐relationship with the vertebral body and articular facets is discussed. Clin. Anat. 24:858–867, 2011.

Facial Nerve Reconstruction Using a Split Hypoglossal Nerve with Preservation of Tongue Function

A prospective study conducted on 13 patients suffering from complete facial nerve injury (for 4 months up to 2 years) aimed to show that using the split hypoglossal nerve allows for reconstruction of the facial nerve with preservation of tongue function. The hypoglossal nerve was split longitudinally. For each half, a split of the hypoglossal nerves response was measured intraoperatively by recording the compound muscle action potential of the tongue muscle. The half that showed the least response was selected for anastomosis. The facial nerve was transected at the stylomastoid foramen, and its distal part underwent a direct anastomosis with the selected half of the hypoglossal nerve. The six grades of the House-Brackman grading system were used to analyze the results. The average postoperative follow-up period was 3 years. Before surgery, 12 patients in this study were graded VI, with total paralysis, and 1 was graded V. After surgery, 2 of the 13 patients showed mild dysfunction (grade II), 7 patients showed moderate dysfunction (grade III), 3 patients showed moderately severe dysfunction (grade IV), and 1 patient showed a severe dysfunction (grade V). Microsurgical facial nerve reconstruction using a split hypoglossal nerve results in functional facial nerve improvement with preservation of tongue function.

Minimally Invasive Spinal Decompression in Patients Older Than 75 Years of Age: Perioperative Risks, Complications, and Clinical Outcomes Compared with Patients Younger Than 45 Years of Age

OBJECTIVE Minimally invasive spinal decompression for the treatment of spinal stenosis or disk herniation is often indicated if conservative management fails. However, the influence of old age on the risk of postoperative complications and clinical outcome is not well understood. We therefore sought to compare complication rates and outcomes after minimally invasive surgery decompression and discectomy in elderly patients with a cohort of younger patients undergoing similar procedures. METHODS We evaluated medical records of 61 patients older than 75 years and 69 patients younger than 45 years that underwent minimally invasive lumbar decompression between April 2009 and July 2013 at our institute. Medical history, American Society of Anesthesiologists score, perioperative mortality, complications, and revision surgery rates were analyzed. Patient outcomes included visual analog scale and EuroQol-5 Dimension scores. RESULTS The average age was 78.66 ± 4.42 years in the elderly group and 33.59 ± 6.7 years in the younger group. No major postoperative complications were recorded in either group, and all recruited patients were still alive at the time of the last follow-up. No statistically significant difference existed in the surgical revision rate between the groups. Both groups showed significant improvement in their outcome scores after surgery. CONCLUSIONS Our results indicate that minimally invasive decompressive surgery is a safe and effective treatment for elderly patients and does not pose an increased risk of complications. Future prospective studies are necessary to validate the specific advantages of the minimally invasive techniques in the elderly population.

Traumatic Facial Diplegia and Horner Syndrome: Case Report

Traumatic facial diplegia is an uncommon pathology, and is usually associated with bitemporal bone fractures. Traumatic Horner syndrome is mostly associated with carotid artery dissection. We present a case with traumatic facial diplegia and a unilateral Horner syndrome where the mechanisms of injury were unusual. The patient had developed his neurological deficits 9 days following trauma. We discuss the mechanisms of the facial palsy and Horner syndrome and the importance of their diagnosis.

Resection of benign vertebral tumors by minimally invasive techniques

BACKGROUND CONTEXT Benign tumors of the vertebrae are generally an uncommon cause for surgery. Complete removal of these tumors requires in most cases extensive surgical technique that consists of generous surgical exposure followed by laminectomy, facetectomy, and sometimes even an instrumented fusion. PURPOSE The aim was to describe our experience in performing resection of benign vertebral tumors, using a minimally invasive surgical (MIS) approach. STUDY DESIGN This was a retrospective review of case records. PATIENT SAMPLE Patients who underwent MIS, resection of benign vertebral tumors. OUTCOME MEASURES Complete neurologic examination and pain evaluation, as measured by the visual analog scale (VAS). Secondary outcomes included postoperative spinal instability assessment and surgical margins examinations. METHODS Patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months intervals clinically and radiographically using plain radiographs and postoperative computed tomography (CT) scans. Final pathologic report, operative time, blood loss, complications, and hospital length of stay were also recorded. RESULTS Between 2009 and 2013, 14 patients underwent MIS, resection of benign vertebral tumors at our institution. Mean follow-up time was 4 years. There were eight men and six women with a mean age of 27 years (range 16-68 years). For tumors located in the posterior elements, a direct posterior approach was used. Tumors located at the pedicle of the vertebra were excised using a transpedicular approach, and tumors protruding into the foramen were excised using the transforaminal approach. The transcanal approach was used when decompression of the thecal sac or nerve root was required, and the retroperitoneal transpsoas approach was used for tumors located in the vertebral body. Complete removal of these tumors was achieved in all cases, and was verified by a follow-up CT scan. Pathology revealed osteoid osteoma in five patients, osteoblastoma in three patients. Eosinophilic granuloma, fibrous dysplasia, and fibroid adenoma were found in one case each. Average VAS pain score improved from 7.7 (7-9) to 2.8 (0-7) after surgery. CONCLUSIONS Minimally invasive techniques are a valuable choice for the treatment of benign osseous tumors of the spine. A larger, long-term study is in progress. In the meantime, we suggest surgeons experienced with both open and MIS surgery should consider these techniques.

Effect of Fibromyalgia Symptoms on Outcome of Spinal Surgery

Objectives To evaluate the effect of presurgical symptoms characteristic of fibromyalgia on the postsurgical outcome of patients undergoing spinal surgery. Methods In this observational cohort study, participants were patients scheduled for spinal surgery, including cervical or lumbar laminectomy and foraminectomy. Presurgical evaluation included physical examination and manual dolorimetry. Questionnaires included the widespread pain index (WPI), symptom severity scale (SSS), and SF-36. Postsurgical evaluation performed at 10-12 weeks included questionnaires, physical examination, and dolorimetry. Results Forty patients (21 male, 19 female) were recruited. Four patients (10%) fulfilled American College of Rheumatology (ACR) 1990 fibromyalgia; nine patients fulfilled 2010 criteria (22.5%). Overall, a significant 34% reduction in WPI was observed postsurgically ( P  < 0.01), but no significant change was observed in SSS. Comparing outcomes for patients fulfilling and not fulfilling fibromyalgia criteria, fibromyalgia syndrome (FMS)-negative patients experienced highly significant reductions of both SSS and WPI (-50.1% and -42.9%, respectively, P  < 0.01), while FMS-positive patients experienced no reduction of SSS symptoms and only a marginally significant reduction in WPI (-20.3%, P  = 0.04). A significant negative correlation was observed between results of presurgical WPI and change in physical role functioning SF-36 component postsurgically. A significant negative correlation was observed between presurgical SSS and change in composite physical functioning SF-36 component. Regression analysis demonstrated a difference in trend between FMS-positive and FMS-negative patients regarding postop changes in SSS, as well as a difference in trend regarding the general health role limitation due to emotional problems and pain components of the SF-36. Conclusions Fibromyalgia symptoms were highly prevalent among patients scheduled for spinal surgery. A negative correlation was observed between presurgical severity of fibromyalgia symptoms and components of postsurgical SF-36. Patients with symptoms typical of fibromyalgia may have a less favorable outcome after spinal surgery. The clinical utility of surgical intervention in such patients should be carefully evaluated, and treatment specific for fibromyalgia might be considered before embarking on a surgical course.

The Torg ratio of C3-C7 in African-Americans and European-Americans: A skeletal study: Skeletal study of Torg ratio

The ratio between the sagittal diameter of the spinal canal and the sagittal diameter of the vertebral body, known as the “Torg ratio”, is often used to test for spinal canal narrowing. Here, we investigate this ratio in a large population, consisting of two ethnicities, both sexes and three age groups. Measurements were taken on the dry cervical verterbrae (C3–C7) of 277 individuals using a digital apparatus allowing for the recording of 3D coordinates of a set of landmarks on the vertebral body. Vertebral body and vertebral foramen lengths were compared across the different subgroups. Vertebral body and vertebral foramen lengths differ significantly between males and females and between African Americans and European Americans. With age, the vertebral body length increases while the foramen length does not undergo significant changes. These anatomical differences are reflected in differences in the Torg ratio calculated for the different subgroups. In conclusion, our findings suggest that a hard cutoff on the Torg ratio used to define a pathological narrowing of the cervical spine should be adapted to the population the patients come from. Clin. Anat. 32: 84‐89, 2019.