Ukrainian Neurosurgical Journal

Results of interventions on the celiac plexus in treating patients with chronic pharmacoresistant abdominal pain

Vadym V. Biloshytsky — 2024-09-29

Patients with chronic abdominal pain are a complex cohort of patients who undergo treatment by many specialists for a long time: surgeons, urologists, gynecologists, neurologists, psychiatrists, etc. However, despite all diagnostic and treatment measures, the pain syndrome persists or worsens.

Objective ‒ evaluation of the effectiveness, safety and long-term results of treating patients with abdominal pain syndromes, which includes the use of various methods of minimally invasive interventions on the celiac plexus (CP) taking into account the peculiarities of the origin, nature and localization of pain.

Materials and methods. An analysis of the results of 26 interventions on CP in 21 patients was performed. Inclusion criteria for participants in the study were individuals with persistent pharmacoresistant abdominal pain for ≥3 months, aged 19 to 73 years. There were 13 (62.0%) male and 8 (38.0%) were female. Mean age was 55.2±15.2 years. Patients were divided into two groups. The first (n=16) included patients with pancreatic cancer, the second (n=5) included patients with non-oncological chronic abdominal pain syndromes: functional abdominal pain syndrome was diagnosed in three cases, and one observation each of solaritis and chronic pancreatitis.

All procedures were performed under CT. To assess the intensity of the pain syndrome, a visual analogue scale (VAS) of pain from 1 to 10 cm was used, where 0 cm is the absence of pain, 10 cm is unbearable pain; functional status (FS) - according to the Karnofsky scale (KS) from 0 to 100%. Estimation of the daily dose of opioid analgesics was estimated using the oral morphine equivalent daily dose (oMEDD). Patients were observed for 6 months, evaluations were carried out after 1 week, 1, 3 and 6 months, respectively.

Results. In the first group, 17 interventions on CP were performed in 16 participants, sympatholysis was performed twice in one patient. In the second group - 9 interventions in 5 patients: 4 Celiac Plexus Blocks (CPBs) of the central nervous system using "Depo-Medrol®" (methylprednisolone) and 5 neurolysis with 96% ethyl alcohol. Two patients were initially treated with CPB and then sympatholysis due to the recurrence of pain syndrome with the aim of a more stable sympatholytic and analgesic effect. In one patient, neurolysis of CP was performed three times. In all cases, no complications were recorded during the procedures.

VAS before the procedure in the general group (n=26) was 9.6±0.6 cm, one week after the intervention it was 4.5±1.6 cm (P<0.0001), after one month it was 3.2±1 .5 cm (P<0.0001), after 3 months – 3.0±1.6 cm (P<0.0001), after six months – 4.4±1.6 cm (P<0.0001). The FS indicator according to the KS before the procedure in the general group was 65.8±7.0%, one week after the intervention – 80.8±8.0% (P<0.0001), one month later – 81.5±8.3 % (P<0.0001), after 3 months – 75.0±9.5% (P<0.0010), after six months – 68.0±9.4% (P=0.4042). The oral morphine equivalent daily dose before the procedure in the general group was 123.8±86.0 mg per day, one week after the intervention on CP oMEDD was 57.3±61.2 mg (P<0.0001), after 1 month – 41.0±47.3 mg (P<0.0001), after 3 months – 44.0±51.3 mg (P<0.0001), after 6 months – 80.6±77.2 mg (P<0,0001).

Conclusions. Computed tomography-guided celiac plexus neurolysis is a useful and effective tool in treating patients with both abdominal pain caused by inoperable pancreatic cancer and chronic non-oncological pharmacoresistant abdominal pain. Minimally invasive interventions on CP provide a significant reduction of pain syndrome according to the VAS scale (p<0.001), reduce the need to take opioids analgesics (p<0.001) after 1, 3, 6 months and increase the FS of patients according to the KS (p<0.001) after 1, 3 months. Taking into account the high percentage of recurrence of pain syndrome in the studied patients of the group of non-oncology pain, the need for repeated interventions for the purpose of long-term pain control, interventions on CP in this cohort of patients require further research with an increase in the number of observations.

Impact of transpedicular fixation on thoracolumbar junction burst fracture stability: a biomechanical perspective

Oleksii S. Nekhlopochyn — 2024-09-29

Introduction. The treatment of burst fractures at the thoracolumbar junction remains a contentious issue in vertebrology. Despite a broad array of surgical interventions available, many surgeons favor isolated posterior stabilization, which can be performed using either minimally invasive or open approaches. However, the biomechanical properties of these methods have not been thoroughly investigated.

Objective: This study aims to evaluate the biomechanical stability of the thoracolumbar junction following transpedicular stabilization of a burst fracture at the Th12 vertebra, under different system configurations influenced by lateral flexion.

Materials and Methods: A mathematical finite element model of the human thoracolumbar spine, featuring a burst fracture at the Th12 vertebra, was developed. The model included a transpedicular stabilization system with eight screws, simulating “long” stabilization. We examined four variants of transpedicular fixation using both mono- and bicortical screws, with and without the inclusion of two cross-links.

Results: The study found that the load borne by the damaged Th12 vertebral body varied depending on the fixation system employed. Specifically, stress levels were 24.0 MPa, 27.3 MPa, 18.4 MPa, and 25.8 MPa for models with short screws without cross-links, long screws without cross-links, short screws with cross-links, and long screws with cross-links, respectively. At the screw entry points in the vertebral arch, the highest stress values were recorded at the L2 vertebra, showing 11.8 MPa, 14.0 MPa, 9.4 MPa, and 13.4 MPa for each respective model. Among the metal construct elements, the connecting rods consistently exhibited the highest stress, with values of 226.7 MPa, 313.4 MPa, 212.4 MPa, and 293.98 MPa, respectively.

Conclusion: The results underscore that utilizing cross-links in the stabilization of burst fractures at the thoracolumbar junction, which is only feasible through an open installation, somewhat mitigates stress within the stabilized spinal segment. Meanwhile, the modeling of lateral flexion revealed only minimal differences in stress values between open and minimally invasive installations.

Comparison of the effects of photodynamic exposure with the use of chlorine E6 on glioblastoma cells of the U251 line and human embryonic kidney cells of the HEK293 line in vitro

Volodymyr D. Rozumenko — 2024-09-29

Malignant gliomas of the brain are a global medical and social problem with a trend toward a steady increase in morbidity and mortality rates. A method that enables the visual identification of tumor tissue and simultaneously selectively destroys it is photodynamic therapy, which involves the introduction of a photosensitizer (PS) followed by its activation at a certain wavelength of light. The selectivity of the accumulation of PS in the tumor tissue of the malignant gliomas is one of the key issues in the problem of increasing the effectiveness of photodynamic therapy.

Objective: to compare the effects of photodynamic exposure using PS chlorin E6 on human glioblastoma (GB) cells of the U251 line and non-malignant human embryonic kidney cells of the HEK293 line.

Material and methods. Groups of cell cultures were formed depending on the conditions of cultivation and exogenous influence: 1) control - cultivated in a standard nutrient medium (Modified Eagle's Medium (MEM)) with L-glutamine, 1 mmol of sodium pyruvate, 10% fetal bovine serum) and experimental: 2) cultivated under the conditions of adding chlorin E6 (concentrations 1.0 and 2.0 μg/ml); 3) cultivated on a nutrient medium without the addition of PS and exposed to laser irradiation (LI) (λ=660 nm, power in the range 0.4-0.6 W, dose in the range 10-75 J/cm², continuous or pulse mode); 4) cultured under conditions of chlorin E6 addition and subsequent exposure to LI (power in the range 0.4-0.6 W, dose in the range 10-75 J/cm², continuous or pulse mode). After exposure to the specified experimental factors, dynamic observation with microphotographic registration was performed for 24 h, followed by microscopic and micrometric studies (number of viable cells, total number of cells, mitotic index (MI,%)).

Results. PS chlorin E6 is incorporated into the cytoplasm of cells of U251 and HEK293 cell lines, the intensity of fluorescence is comparable. Upon exposure to chlorin E6 (1.0 and 2.0 μg/ml), cytodestructive and antimitotic effects are increased in a dose-dependent manner in the culture of human GB cells of the U251 line. The cytodestructive effect of chlorin E6 on cell cultures of the HEK293 line is less pronounced, but the antimitotic effect is comparable in both types of cell cultures. Under the influence of LI, cytodestructive and antimitotic effects increase in a dose-dependent manner in the culture of human GB cells of the U251 line. The level of cytodestructive and antimitotic effects is significantly lower in the cultures of non-neoplastic HEK293 cells. The most significant drop in the mitotic activity of GB U251 cells (~100%) was recorded at the lowest LI dose of 25 J/cm², power of 0.6 W in pulse mode. For HEK293 cells, the most significant decrease in mitotic activity (~80%) was recorded at LI with a power of 0.6 W and dose of 75 J/cm² in continuous mode. Under the combined effect of chlorin E6 (1 and 2 μg/ml, pre-incubation of 4 h) and LI in different modes, the viability of tumor cells in U251 culture decreases in a dose-dependent manner; the smallest dose of LI to achieve the maximum cytotoxic effect is 25 J/cm², with a power of 0.6 W in pulse mode when using chlorin E6 at a concentration of 2 μg/ml. The specified characteristics of photodynamic exposure do not cause irreversible effects in HEK293 cultures (reference cells).

Conclusions. An effective mode of photodynamic exposure to achieve a cytodestructive and antimitotic effect in the culture of human GB cells of the U251 line, which is relatively safe for non-malignant cells, has been established: the combined application of a laser irradiation dose of 25 J/cm², with a power of 0.6 W in pulse mode during the preliminary incubation of the cell culture with chlorin E6 at a concentration of 2 μg/ml for 4 h.

Comparative evaluation of surgical procedures for trigeminal neuralgia: a literature review

Vyacheslav S. Botev — 2024-09-29

Trigeminal Neuralgia (TN) has been described in the literature as one of the commonest types of craniofacial pain disorders. TN refers to recurrent lancinating pain that occurs in the distribution of one or more branches of the fifth cranial nerve. The pain perception is typically unilateral, abrupt in onset, brief in duration, and usually starts after trivial stimuli.

The overall prevalence of TN was reported around 0.7/1000 persons, but it tends to be higher in more advanced age groups since the initial onset of the symptoms most frequently starts at the age of 50–60 years.

Although TN is more commonly seen in adults, pediatric TN represents <1.5% of all cases. Pediatric TN differs from adult TN primarily being bilateral in nature (42%) and associated with compression of multiple cranial nerves (46%).

This review will evaluate the current surgical procedures used for the treatment of TN. Operative interventions for TN include microvascular decompression (MVD), balloon compression (BC), radiofrequency thermocoagulation (RF TC), glycerol rhizotomy (GR), and stereotactic radiosurgery (SRS). We review the historical development, advantages, and limitations of these operations.

Additionally, we compare specific parameters for all current surgical procedures. We evaluated the short- and long-term outcomes, risk factors, complications and side effects in patients with TN who underwent operations. Arguments for and against the use of surgery for TN are presented.

Next, surgical decision-making algorithm for refractory classical or idiopathic TN is proposed for patients who require surgery. This algorithm may be used by neurosurgeons in selecting the best surgical treatment.

Lastly, we show the data on current clinical trials, the role of genetics to search for genes predisposing to TN. This project begins with the presumption that the risk for developing classical TN is in large part determined genetically. If so, given the power of modern genetic analysis, it should be possible to identify the underlying gene(s).

At present, there is no ideal surgical procedure for trigeminal neuralgia—one that is minimally invasive, uniformly effective, lacking complications, and without failures or recurrences. MVD still remains the standard by which all other contemporary procedures are measured. MVD provides the longest pain-free interval, yet it is not free of morbidity and mortality. Stereotactic radiosurgery provides a reasonable noninvasive option, but it has delayed onset and a recurrence interval (a few years).

Meningocele manqué. Case report of a rare disorder

Ajay Sebastian Carvalho — 2024-09-29

A case of meningocele manqué with its management is presented and the literature of this rarely reported condition is reviewed.

A one-year-old child was admitted with a small sac like lesion in the upper dorsal region with a soft swelling in the dorso lumbar region, was also associated with congenital bilateral talipes equinovarus which was being treated by a paediatric orthopedic surgeon.

Methods. Craniospinal MRI was suggestive of dorso lumbar lipomyelomeningocele, and corresponding to the dorsal sinus/sac at DV3/DV4 level there was another tethering seen on the MRI due to a band and associated with syrinx of the dorsal cord below that, s/o meningocele manqué.

Treatment. This patient underwent in 1^st stage, DV2 to DV5 laminoplasty, excision of the sinus, durotomy, dissection of the multiple arachnoid cysts, and cutting of the dorsal band. In second stage will undergo surgery for Lipomyelomeningocele

Conclusion: Meningocele Manque is rare, it can present in isolation or associated with other spinal dysraphism. With other spinal dysraphism they can be either at the same or at another location, as was seen in our case. Before operating all cases of spinal dysraphism it is of paramount importance to MRI screen the entire neuraxis and study images thoroughly. In our case along with the dorso lumbar lipomyelomeningocele, there was a Meningocele manqué at DV3/DV4 level. It is essential that the meningocele manqué be addressed first; if not the returning/recoiling cord after de-tethering at the lower level can get tugged/sheared at the tethered meningocele manqué causing deficits.

Surgical Treatment of Spinal Intra-Extradural Meningioma: A Clinical Case

Vitaliy Y. Molotkovets — 2024-09-29

Spinal meningiomas are rare, predominantly benign tumors that exhibit slow growth and typically have a non-invasive pattern of development. They originate from arachnoid cells and fibroblasts of the dura mater. Despite their benign nature, some meningiomas can exhibit intra-extradural extension, complicating both diagnosis and treatment. This article presents a clinical case involving a patient with an intra-extradural spinal meningioma. Despite radiological imaging suggesting a neurinoma, the final diagnosis confirmed a meningioma.

Case Report: A female patient underwent surgical tumor resection through a posterolateral approach with laminectomy and facetectomy at the C4-C5 vertebral levels. The tumor, extending through the intervertebral foramen, was completely resected along with the affected nerve root. Histological examination verified a Grade II meningioma.

Discussion: Despite advancements in neuroimaging and surgical techniques, intraoperative findings can be unpredictable, necessitating an adaptive approach to tumor resection. The article emphasizes the importance of adequate preoperative planning and the use of intraoperative neurophysiological monitoring to reduce the risk of complications and improve treatment outcomes.

Conclusions: The primary treatment for spinal meningiomas is surgical. For dorsal and lateral localizations, total resection with the involved dura mater (Simpson Grade I) is optimal. For ventral localizations, tumor resection with coagulation of the dural attachment site (Simpson Grade II) is preferred. Preoperative and intraoperative use of electrophysiological methods is recommended to assess the functional status of neural structures. Intra-extradural localization of meningiomas is rare and presents significant challenges in preoperative diagnosis, requiring specific skills for effective removal.