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Aim To investigate association of factor V Leiden, prothrombin G20210A, MTHFR C677T and PAI-1 4G/5G polymorphisms with recurrent pregnancy loss in Bosnian women. Methods A total of 60 women with two or more consecutive miscarriages before 20 weeks of gestation with the same partners and without history of known causes or recurrent pregnancy loss were included. A control group included 80 healthy women who had one or more successful pregnancies without history of any complication which could be associated with miscarriages. Genotyping of factor V Leiden, prothrombin G20210A, MTHFR C677T and PAI-1 4G/5G polymorphisms were performed by polymerase chain reaction/restriction fragments length polymorphism method (PCR/RFLP). Results Both factor V Leiden and MTHFR C677T polymorphisms were significantly associated with recurrent pregnancy loss (RPL) in Bosnian women while prothrombin G20210A and PAI-1 4G/5G polymorphisms did not show strongly significant association. Conclusion The presence of thrombophilic polymorphisms may predispose women to recurrent pregnancy loss. Future investigation should be addressed in order to find when carriers of those mutations, polymorphisms should be treated with anticoagulant therapy.

SUMMARY The aim of the study was to analyze correlation between morphological characteristics of intracranial meningiomas and Ki67 labeling index (Ki67 LI), and their influence on peritumoral brain edema (PTBE). There were 41 consecutive patients with intracranial meningiomas surgically treated at the Department of Neurosurgery, Zenica Cantonal Hospital, Zenica, Bosnia and Herzegovina, during the period from January 2010 to December 2015. We reviewed clinical data including patient age, gender, magnetic resonance imaging (MRI) characteristics of the tumor and peritumoral edema, tumor margins, intraoperative characteristics, histopathologic grade and Ki67 LI. In all cases, follow up MRI was obtained at about three months after resection and PTBE was analyzed. Our research showed the tumor volume, tumor margins, and intraoperative signs of arachnoidal and pial invasion to be associated with PTBE in intracranial meningiomas. Ki67 LI expression correlated with PTBE. This study showed the resolution of PTBE to depend on invasive behavior of meningioma and KI67 LI. PTBE, pial/cortical and arachnoidal invasion significantly influence the extent of surgical resection.

Aim To investigate the presence, type and distribution of spontaneous brain and arachnoid herniation into the dural venous sinuses as well as a clinical significance of these herniations. Methods This retrospective - prospective, non-randomised anatomical and clinical study included 990 patients who were referred to Magnetic Resonance Imaging at the Department of Radiology of the Cantonal Hospital in Zenica in the period from January to December 2016. The T1 and T2 sequences in axial, sagittal, and coronary section were used for brain or arachnoid herniation analysis. In all patients with intra-sinusal herniation health records were analysed and symptoms and reasons to refer for MRI examination were evaluated . Results In 26 (2.6%) patients (19 females; 73.08%) the arachnoid or brain herniation was found. Average age of patients was 40.269±16.496 years. Arachnoid herniation was presented in 15 (57.69%) and brain herniation in 11 (42.31%) patients. Statistical significance in relation to type of herniation was not found (p=11.070). Statistical significance between the symptoms and localisation of herniation (except for nausea and vomiting and posterior fossa herniations) (p=0.05) as well us between symptoms and type of herniation was not found (p0.05). Conclusion The results suggest that there is a possibility of interconnection between arachnoid or/and brain herniations and some clinical symptoms such as nausea and vomiting.

Aim To emphasize the importance of early recognition, diagnostic processing and emergent surgical treatment of spontaneous spinal epidural hematoma (SSEH). Methods A 39-year-old female presented with sudden onset of severe pain between the shoulder blades followed by paraparesis and alerted sensibility in the lower extremities. An hour later she developed paraplegia with sensory deficits below ThIV level, absence of patellar reflex, ankle jerk reflex and sphincter dysfunction. Results Magnetic resonance imaging (MRI) demonstrated acute extensive epidural mass of thoracic spinal segments (ThI-ThIII). The patient underwent emergent decompressive laminectomy ThI-ThIII with epidural hematoma evacuation within 24 hours of symptoms onset. After the surgical treatment, because of suspicion on spinal arteriovenous malformation, complete diagnostic evaluation with spinal angiography was done and no form of vascular malformation was found. Idiopathic SSEH was diagnosed. Two months later the patient reached complete neurological improvement. Conclusion The SSEH is a rare condition that should be kept in mind in patients presenting with neurological deficit and a sudden onset of back pain like it was in our case. For early diagnosis, immediate MRI is essential. Prompt surgical decompression such as laminectomy is an absolute surgical indication widely accepted for patients with progressive neurological deficit. The SSEH should be considered as one of the important differential diagnoses in patients who have developed acute myelopathy.

Aim To analyze the relationship between timing of surgery and outcome in patients with cauda equina syndrome caused by lumbar disc herniation. Methods A retrospective, non-randomized clinical study included 25 consecutive patients with cauda equina syndrome (CES) caused by lumbar disc herniation. All patients were operated within 24 hours after hospitalization at the Department of Neurosurgery, Cantonal Hospital Zenica, Bosnia and Herzegovina, between January 2000 and December 2010. All patients were evaluated before surgery on the basis of complete history, neurological examination and neuroimaging evaluations using CT (computed tomography)and MRI (magnetic resonance imaging). Results Statistically significant difference between preoperative and postoperative bladder (p=0.05) and bowel (p=0.05) function was found. A significant number of patients had bladder and bowel recovery after surgery, nine (36%) and 11 (44%), respectively. Significant recovery of muscle strength was noted with complete recovery(5/5) in 12 (48%) and partial recovery in 13 (52%) patients. Complete sensory recovery was noted in 16 (64%), incomplete in four (16%), and in five (20%) patients there were no changes. Most commonly, patients with complete sensory recovery were operated within 48 hours of symptom onset. In most patients early surgery was associated with better outcome. Conclusion This research showed that early decompression correlated with better outcome. Patients with cauda equina syndrome must be cleared for surgery in optimal conditions and, if it possible within optimal timing for recovery (within 48 hours).

Aim To establish presence of segmental instability in patients operated with standard discectomy comparing measurement of translation and rotation on postoperative functional radiographs of lumbosacral spine with reference values,and to explore difference between patients operated on one or two levels. Methods The study included 71 patients, who were operated due to herniated lumbar disc. They were divided into two groups operated on one level (group A) or two adjacent levels (group B). All patients had been imaged in a standing position with functional lateral radiography. Radiographic images were digitized and then computerized measurement of translation and rotation was made. Measurement data were compared between the groups and with reference values obtained in healthy adults. Results Standard lumbar discectomy leads to an increase in translation, however, it reached statistical significance only for L4/L5 level and a decrease of rotation, which showed statistical significance for all samples, relative to the reference values. There was no statistically significant difference in the values of translation and rotation between the groups for corresponding levels, except for the value of the rotation for L4/L5 level as adjacent, unoperated level. Comparison of translation and rotation between the operated and adjacent levels did not show a statistically significant difference. When it comes to comparing the measured and predicted translation, there was a statistically significant difference only at the L5/S1 as anunoperated level. Conclusion Standard discectomy does not lead to radiologically significant segmental instability, and two-level surgery has not caused more pronounced signs of instability comparing to onelevel surgery.

To examine two modalities of surgical treatment of diabetic foot based on two different approaches, classical and multidisciplinary.A retrospective-prospective study including 120 consecutive patients with diabetic foot treated in the Department of Surgery, General Hospital Tešanj in the period 1999-2006. Since 2003 a new multidisciplinary approach to the treatment of diabetic foot based on a more conservative approach has been introduced. Two groups of patients were analyzed according to two treatment approaches: the first group included patients treated with classical method (in the period 1999-2002), and the second group included patients treated with multidisciplinary approach (in period 2003- 2006). An age distribution, gender, local changes in the extremities, results of microbiological analysis of wound swabs, and modalities of surgical treatment of diabetic foot were analyzed.Duration of the disease (p=0.24), the level of blood glucose (p=0.52) and glycosylated hemoglobin (p=0.10) had no statistically significant effect to the outcome of the treatment of diabetic foot, while the level of hematocrit (p less than 0.006), fibrinogen (p less than 0.003), cholesterol (p less than 0.000001), and the absence of a pulse in the peripheral arteries (p less than 0.000002), and the outcome of surgical treatment of diabetic foot had the influence to the outcome of the treatment of diabetic foot with statistical significance.Aggressive and appropriate medical and surgical treatment according to a grade of disease could improve the outcome and reduce the morbidity and mortality of diabetic foot. The results of this study showed the importance of proper diabetes treatment, prevention of complications and a multidisciplinary approach to the treatment of diabetic foot.

Aim To investigate a potential difference in postoperative morphological changes of two-level lumbar disc surgery as comparedto one level surgery. Methods The standard lateral radiographs of lumbar spine obtained preoperatively and postoperatively were used in the study . The morphological study included 60 adult patients of both sexes who had undergone the surgery in the period 2002-2006. The first group comprised patients operated on one level (L4/L5 and L5/ S1), and the second included patients operated on two levels (L3/L4/L5; L4/L5/S1 and L5/S1/S2). Using lateral radiographs, after digitalization, the height of intervertebral disc space (HD), anglebetween vertebral bodies (A) and translation (T) were measured. Results Comparing preoperative and postoperative values, statistically significant difference has been found for HD in the first group and HD and A in the second group. In neither groups therewas statistically significant difference for T, which is one of radiological signs of segmental instability. The comparison of postoperative values for both groups has not shown any statisticallysignificant difference. Conclusion The standard lumbar discectomy on two levels has not shown more pronounced morphological changes or changes suggesting an increased risk of segmental instability as compared to one level discectomy.

The systematic analyses of secondary muscle potentials of H-reflex and F-wave type were done in multicentric study. The examinations were carried out in healthy volunteers with 9 muscles analysed on the legs and 9 on the lower arms and hands. The H-reflex potential was found regularly in thigh muscles (vastus medialis 100%, biceps femoris 97%, semitendinosus 93%). Less frequently but still with high incidence it appeared in posterior lower leg muscles (soleus 93%, caput mediale gastrocnemii 73%). In anterior tibial muscle and extensor digitorum brevis it did not appear at all. Only exceptionally it was found in short peroneal muscle (3%) and occasionally, only on proximal nerve stimulation, in flexor hallucis brevis. The similar distribution pattern was found in lower arm and hand muscles with analysis on both sides. In flexor digitorum superficialis (73-70%) and flexor carpi radialis (73-57%) the percentage of H-potential muscles was the highest, in flexor carpi ulnaris (47-40%) lesser but still remarkable. Brachioradialis (37-30%) and extensor digitorum communis (27-27%) percentage decreased further. The even more distal, pronator quadratus (21-20%) and abuctor digiti minimi (17-17%) presented as muscles with low incidence of H-reflex positivity. In extensor indicis proprius (3%) the lowest H-potential incidence was found and in opponens pollicis no H-potential at all. F-waves if evaluated as "F-frequency" follow the similar distribution pattern. The lowest "F-frequency" was found on the legs in anterior tibial, short peroneal and extensor digitorum brevis muscles. In the last one more than one half of stimuli failed to evoke the F-potential. Those are the muscles in which H-potentials almost never appeared. The highest "F-frequency" was recorded in thigh, posterior lower leg muscle and flexor hallucis brevis. Some of the examinees displayed in almost all examined muscles H-potential (6 of 30), the others (9 of 30) had it in neither one or in a single muscle. It looks like as if a kind of H-reflex or F-wave individuals exist. If the H- or F-potentials distribution pattern got projected on the homunculus in quadrupedal position the following idea appears. The thigh muscles, the plantar flexors of the feet and hand and finger flexors are first of all tonic muscles mostly involved in standing or holding. The extensors of the foot/toes, respectively of hand/fingers interrupt phasically the sustained action of standing by lifting the foot/hand from the ground. The muscles with mostly tonic function produce much H-reflexes, transitional forms or at least F-wave with high "F-frequency". Is that a kind of phylogenetical remnants, better developed in the motorically less differentiated legs? Have the H-reflex muscles if compared with F-wave muscles different motor units structure? Have they different motoneurons, with different liability to produce recurrent discharges?

Twenty-nine patients with myasthenia gravis in pregnancy have been presented. These patients represent a total of 31 deliveries and 33 newborns. Despite that myasthenia gravis is an illness that poses potentially grave complications for both mother and infant, there were no maternal and neonatal deaths. Only two patients experienced significant exacerbation of their disease during pregnancy. Most of patients underwent vaginal delivery. Cesarean section is not indicated unless there are obstetrical reasons. Incidence of cesarean section delivery was 16.1%. Vacuum extractor has been used to shorten the second stage of labor and its incidence was 16.1%. In the seven (22.6%) patients myasthenic signs and symptoms got worse during the postpartal period. Neonatal myasthenia gravis was observed in 13 (39.4%) newborns. Inverse relationship was found between neonatal myasthenia and duration of disease in mothers. Incidence of neonatal myasthenia was higher in newborns born by mothers with short duration of myasthenia gravis.

In 33 patients, 30 to 64 years old, with spinal amyotrophy and brachial paresis, the sensory symptoms and electrophysiologic signs were analyzed. The paresthesias were felt most often in the ulnar nerve innervation region. The motor conduction velocities, terminal latency quotient, sensory conduction on direct nerve stimulation were within the limits of normal in both median and ulnar nerve. On percutaneous stimulation normal values were obtained for median nerve, and significantly slower for ulnar nerve innervation region. In four cases no nerve potential was obtained over the ulnar nerve with stimulation of the fifth finger. The nerve potential over the ulnar nerve was elicited mostly by stimulation of median nerve innervated fingers. Congenital variations of sensory innervation pattern were considered, which may increase the liability to destruction.