Endoscopic Untethering of Tight Filum Terminale: An Operative Technique.

AIM: To demonstrate the various technical advantages of minimally invasive endoscopic untethering of tight filum terminale for the treatment of tethered cord syndrome (TCS). MATERIAL AND METHODS: In five pediatric cases of TCS, we performed untethering by using the endoscopic technique. The age of the patients were 6, 7, 8, 9, and 12 years old. We used a nasal speculum of the transsphenoidal approach during the endoscopic surgical procedure. RESULTS: All the procedures were performed uneventfully, except for one case with a split cord malformation that showed neurologic deterioration caused by excision of the diastematomyelic fibrous septum at the thoracic level (unrelated to the endoscopic procedure at the L5-S1 level). This patient was referred to a rehabilitation clinic 5 days after surgery and showed significant improvement by the third postoperative month. The other four patients were discharged 1 day after the operation. CONCLUSION: Endoscopic release of filum terminale is a safe technique especially if it is performed with neuromonitoring. This technique may shorten the length of hospital stay and reduce perioperative blood loss. However, futher studies with a larger number of patients and long-term follow-up are needed.

A New Less Invasive Technique for Multiple-Level Spontaneous Spinal Epidural Hematomas: Wash-and-Go Technique.

Aim Spinal epidural hematomas are rare entity in neurosurgery practice. Most of them are spontaneous due to anticoagulant therapy and called spontaneous spinal epidural hematomas (SSEHs). Laminectomy or hemilaminectomy for affected levels is still the first choice in the operative treatment of an SSEH. We describe a new less invasive surgical technique, performing single-level laminectomy and washing with 0.9% sodium chloride through a thin soft catheter for a 12-level thoracic-cervical SSEH in a patient under anticoagulant therapy. Patient and Operative Technique A 55-year-old woman was brought to the emergency department with a rapid onset of pain in her upper back and both legs with weakness of her lower extremities. An urgent magnetic resonance imaging (MRI) of the whole spine showed a SEH. During the operation, after T2 laminectomy, a thin soft catheter was epidurally placed under the T1 lamina and gently pushed forward rostrally. Then continuous saline irrigation was utilized and aspiration made via the catheter to wash out the hematoma. Drainage of blood was observed. The procedure was performed for 15 minutes. Then the catheter was epidurally placed under the T3 lamina, and the procedure for the hematoma in the lower segment was repeated. Decompression of spinal cord and nerve roots was observed. Result Postoperative early MRI of the thoracic-cervical spine showed gross total evacuation of the SEH. Accordingly, the patient's muscle strength improved. Conclusion Although multiple laminectomy or hemilaminectomy for affected levels to evacuate the hematoma and decompress the spinal cord is the main choice of surgical treatment, single-level laminectomy and irrigation plus aspiration via a thin soft catheter can be performed successfully with good results in SSEH.

Initial Discectomy Associated with Aging Leading to Adjacent Disc Disease and Recurrence.

AIM: Failure of surgery for lumbar disc herniation (LDH) can be commonly caused by recurrence. There are many debates regarding the risk factors of recurrent LDH (rLDH) and it is very difficult to define them because many clinical and complicated biomechanical parameters are involved. The purpose of study was to evaluate the long term result of re-discectomy for LDH at the same level and adjacent segments. MATERIAL AND METHODS: Between 1999 and 2009, 1898 cases were operated and 142 (6.4%) patients underwent re-discectomy following initial operation. The study included 65 patients who were operated for single level discectomy, and their charts were analyzed retrospectively. RESULTS: There were 33 (50.8%) women and mean age was 45.5 years (24-73 years). rLDH was diagnosed at the initial level in 40 (61.5%) but adjacent and/or opposite level herniation (with or without the first level) was found in the remaining 25 cases (39.1%). Recurrence at the same level (SLG) and adjacent level groups (ALG) were similar according to the clinical outcomes in follow-up (mean 34.1 months). Admission period after initial operation was also parallel in SLG and ALG (54.7 and 53.1 months, respectively). However, the mean age of ALG (49.4 years) was significantly higher (p≤0.05) than SLG (42.8 years). CONCLUSION: After discectomy, collapsed discs are biomechanically more stable than those with preserved disc heights, and responses to axial compression on intervertebral disc pressure produced deformations of adjacent levels despite limitations. Altered biomechanical loading next to a fusion resulted in ongoing degeneration with aging at the affected entire lumbar spine.

Leptomeningeal Dissemination of Intraventricular Rhabdoid Meningioma: Imaging Findings.

A 20-year-old male patient was admitted to our clinic with a 1-year history of headache. The patient's systemic-neurological examination and laboratory findings were normal. Computed tomography and magnetic resonance imaging were performed. Imaging findings showed calcified intraventricular mass and subependymal and gyral nodular lesions. There was a slight increase in ventricular volume. Surgical treatment was performed. Pathological specimens revealed the diagnosis of rhabdoid meningioma. Leptomeningeal dissemination refers to diffuse seeding of the leptomeninges by tumor metastases. To our knowledge, leptomeningeal dissemination of intraventricular rhabdoid meningioma is very rare in the literature. We aimed to discuss imaging findings and differential diagnosis of leptomeningeal dissemination of rhabdoid meningioma.

Tobacco-induced neuronal degeneration via cotinine in rats subjected to experimental spinal cord injury.

OBJECTIVES: Cigarette smoke contains over 4000 chemicals including well-characterized toxicants and carcinogens, among which is cotinine. Cotinine is the principal metabolite of nicotine that has adverse affects on the microcirculation via vasoconstriction, hypoxia and the wound-healing cascade. Its impact on spinal cord injury (SCI) has not been investigated yet. The aim of the present study is to investigate the cotinine effect on SCI. METHODS: 48 male Wistar rats were divided into six groups as follows: sham-control, sham-trauma, vehicle-control, vehicle-trauma, cotinine-control, and cotinine-trauma. Initially, a defined concentration of cotinine blood level was maintained by daily intraperitoneal injection of cotinine for 14 days in the cotinine groups. The concentration was similar to the cotinine dose in the blood level of heavy smokers. Only ethyl alcohol was injected in the vehicle groups during the same period. Then, SCI was performed by a Tator clip. The cotinine groups were compared with rats subjected to vehicle and sham groups by immunohistochemical biomarkers such as glial fibrillary acidic protein (GFAP) and 2,3-cyclic nucleotide 3-phosphodiesterase (CNP) expressions. Electron microscopic examination was also performed. RESULTS: GFAP-positive cells were noted to be localized around degenerated astrocytes. Marked vacuolization with perivascular and perineural edema was seen in the cotinin consumption groups. These findings showed the inhibition of regeneration after SCI. Similarly, vacuolization within myelin layers was noted in the cotinine groups, which was detected through reduced CNP expression. CONCLUSION: Cotinine, a main metabolite of nicotine, has harmful effects on SCI via GFAP and CNP expression. The findings of the present study support the hypothesis that tobacco causes neuronal degeneration via cotinine.

Brain injury due to air gun shot: report of three adult cases.

Air guns (AGs) are arms that use air or another compressed gas to propel a projectile. Generally, brain injury may occur in children due to their incomplete skull development; however, the less-resistant and thin region of the skull in adults may also be penetrated by an AG shot. In this paper, we present three adult cases treated in our clinic for brain injury caused by an AG. The first case had brain and skull damage related to the high pressure of the compressed gas, and the others additionally had foreign bodies in their brain. All of the patients were operated. Two were discharged without neurological deficit; the third case had a permanent slight hemiparesis. Average follow-up was 11 months and no abscess formation was observed in this period. AGs are known as low-velocity arms; however, they have the potential to cause brain injury, and brain penetration may occur especially in the relatively less resistant and thin sites of the skull such as the orbit and temporal and occipital bones. As cerebrospinal fluid leakage is one of the expected conditions, urgent surgery is usually required.

Lateral orbitotomy approach to orbital tumors: report of 10 cases.

AIM: Lateral orbitotomy is a well-known approach for lesions of the lateral orbital cone. It is still appropriate for laterally situated tumors although contemporary cranial base approaches were defined and developed within the last decades. MATERIAL AND METHODS: Here we report 10 orbital lesions operated with lateral orbitotomy, nine of which were extraconal. Cholesterol granuloma, arachnoid cyst, pleomorphic adenoma, malign epithelial tumor, dermoid cyst, inflammatory granuloma and cavernoma were the pathologies encountered. RESULTS: The extent of lateral orbitotomy should depend on the size, consistency and nature of the lesion for easy removal and less bony resection. In this regard, contrast enhanced CT scans give useful information for operative strategy. The success of surgery can be improved and cosmetic problems can be minimized if meticulous care is taken during orbital rim resection. CONCLUSION: Although there is a wide range of histopathological diagnosis for orbital tumors, lateral orbitotomy is a safe approach, particularly if the lesions are extraconal.

Single-stage posterolateral Corpectomy and circumferential stabilization without laminectomy in the upper thoracic spine: cadaveric study and report of three cases.

AIM: Surgical approach to the upper thoracic spine diseases is challenging since anterior interventions to this region are quite complicated with the presence of major vascular elements or important visceral and soft-tissue structures. MATERIAL AND METHODS: Operative technique was performed initially on eight cadavers and then on three consecutive patients. Costotransvesectomy was performed on the left side and pediculectomy were added on the contralateral side to achieve wide visual angle during corpectomy. A cage was implanted into the field of corpectomy from the left side and the stabilization procedure was completed with posterior instrumentation. RESULTS: Anterior low cervical approach is less invasive than posterior approach for T2 level and above.The area below T3 level includes the heart, aorta, common carotid or brachiocephalic artery and thoracic duct favoring the safety of posterior approach which provides a sufficient surgical window for corpectomy and circumferential stabilization at a single operation. CONCLUSION: The corpectomy procedure could be clearly performed under bilateral visualization of healthy bony margins with this technique. Although preserved laminae and spinous process lose the connection to the involved segment and hanged to adjacent levels only with posterior ligamentous complex, we propose that a chance of interlaminar fusion could further contribute to spinal stabilization rather than posterior instrumentation only.

Spontaneous resolution of calcified cephalhematomas of infancy: report of two cases.

Cephalhematoma (CH) is less commonly encountered problem of infancy with an incidence of 1 % however calcified CHs are seldom. The exact reason of calcification remains unclear. We report two cases of calcified CHs that developed as a complication of vacuum extraction during vaginal delivery. Calcified CHs generally present with cosmetic reasons like skull asymmetry and calvarial mass. Although Doppler ultrasonography is useful in the diagnosis of CHs, computerized tomography or direct X-rays help more in the detection of calcified ones. Follow-up should be considered for cases below 2 years of age since the cranium continues to grow and there appears to be a chance of spontaneous resolution. Surgical intervention should be reserved for cases with neurological deficits or persistent lesions on follow-up.

Vertebral artery insult at the transverse foramina by gun shot wounds: report of two cases.

The vertebral artery (VA) is well protected through its course at the cervical transverse foramina and penetrating injuries of VA are mostly caused by gun shot wounds. The mechanism of injury in these wounds is described as the kinetic energy transferred by the bullet, which always depends on its mass and speed. Thus, the size of the pellet is the most important factor for the tissue damage, shock waves and direct injury. Civilian gun shot wounds are generally caused by low velocity firearms, In this report, we described two cases with cervical gunshot wound characterized with transverse foramina damage and VA insult. The first patient was assaulted by bullet that resulted in vertebral artery occlusion, whereas a smaller pellet was found in the second one and arterial flow was not influenced on the site of the damaged transverse foramina. Successful management of these injuries should include careful analysis of the bullet characteristics that is directly related to the intensity of damage.

The revised Acute Physiology and Chronic Health Evaluation System (APACHE II) is more effective than the Glasgow Coma Scale for prediction of mortality in head-injured patients with systemic trauma.

BACKGROUND: The Glasgow Coma Scale (GCS) is popular, simple, and reliable, and provides information about the level of consciousness in trauma patients. Nevertheless, the necessity of using a more complex system than GCS has been questioned recently. The revised Acute Physiology and Chronic Health Evaluation system (APACHE II) is a physiologically based system including 12 physiological variables, and it also includes GCS. In addition, it is thought to be superior to GCS due to recognition of increasing age and significant chronic health problems, which adversely affect mortality. METHODS: This retrospective study included 266 patients (195 males, 71 females; mean age 60.5; range 14 to 87 years) with head injury associated with systemic trauma in 2003 and 2004. RESULTS: Mortality increased in the elderly group (p<0.001). Mean survival score in APACHE II was 38.0 and death score was 68.7 (p<0.001); these values in GCS were 10.4 and 6.3, respectively (p<0.001). APACHE II at the cut-off point was better than GCS in the prediction of death and survival in patients (p<0.01). The area under the receiver operating characteristic curve for sensitivity and specificity was larger in APACHE II (0.892+/-0.028) than GCS (0.862+/-0.029). CONCLUSION: For the assessment of mortality, the GCS score still provides simple, less-time consuming and effective information concerning head injury patients, especially in emergencies; however, for the prediction of mortality in multitrauma patients, APACHE II is superior to GCS since it includes the main physiologic parameters of patients.

The effect of risedronate on posterior lateral spinal fusion in a rat model.

OBJECTIVE: To evaluate the potential effects of risedronate (RIS) which shows a higher anti-resorptive effect among bisphosphonates, after a posterolateral lumbar intertransverse process spinal fusion using both autograft and allograft in a rat model. METHODS: A totoal of 28 Sprague-Dawley rats were randomized into 2 study groups. A posterolateral lumbar intertransverse process spinal fusion was peformed using both autograft and allograft in a rat model. Group I (control) received 0.1 mL of steril saline (placebo) and Group II (treatment) received risedronate, equivalent to human dose (10 microg/kg/week) for 10-weeks period. RESULTS: The fusion rates as determined by manual palpation were 69% in the group I and 46% in the group II (p = 0.251). According to radiographic score, the spinal segment was considered to be fused radiographically in 7 (53%) of the 13 controls and 9 (69%) of the 13 rats treated with RIS (p = 0.851). The mean histological scores were 5.69 +/- 0.13 and 3.84 +/- 0.43 for the control and treatment groups, respectively. There was a significant difference between the both groups (p = 0.001). The mean bone density of the fusion masses was 86.9 +/- 2.34 in the control group and 106.0 +/- 3.54 in the RIS treatment group. There was a statistical difference in mean bone densities of the fusion masses comparing the two groups (p = 0.001). CONCLUSION: In this study, risedronate appears to delay bone fusion in a rat model. This occurs as a result of uncoupling the balanced osteoclastic and osteoblastic activity inherent to bone healing. These findings suggest that a discontinuation of risedronate postoperatively during acute fusion period may be warranted.

High dose cotinine may induce neural tube defects in a chick embryo model.

AIM: Nicotine is a well-known agent among 4000 chemicals in cigarettes. About 70 to 80% of nicotine is converted to cotinine, a major metabolite. The aim of the present study is to investigate the effect of cotinine on neural tube development in a chick embryo model. MATERIAL AND METHODS: Sixty fertile, specific pathogen free eggs were divided into 6 groups for this study. In the first group, a fixed cotinine concentration for each egg was calculated just to simulate the concentration of a smoker's blood level. A second experimental group was designed at a higher cotinine concentration. Embryos that succeeded to reach Hamburger-Hamilton stage 12 from each group were then embedded into paraffin for permanent sections. These two groups were compared with eggs subjected to vehicle (standard alcohol and ten times more alcohol concentration) and control groups (saline and sham groups). RESULTS: Embryos of the cotinine (regular dose), vehicle and control groups were normal, but embryos subjected to higher cotinine concentrations were malformed at the cranial part of the thoracic neural tube. CONCLUSION: Association of cotinine with neural tube defects was demonstrated in the present study. Cigarette smoking may induce hazardous effects on neural tube development.

Choroid plexus papillomas in two siblings: case report.

Choroid plexus papilloma (CPP) is a rare, benign epithelial brain tumor of the nervous system seen particularly in infants. Familial cases are extremely uncommon. Some other form of malignant tumors was noted in the relatives of patients with CPPs, and some genetic defects regarding this coincidence were reported in the literature. These neoplasms are occasionally bilateral and hydrocephalus is an associated sign in most of the cases. We report three lateral ventricle CPPs in two siblings, at the age of 7 month and 2 years respectively. All tumors were resected with parietotemporal craniotomy and a superior temporal sulcus approach to the lateral ventricle. To avoid a concomitant need of ventriculoperitoneal shunt insertion, external ventricular drainage was inserted for a week in the postoperative period relieving symptoms of hydrocephalus. Search for a hereditary defect in the p53 gene of the second infant (7 months old) revealed no mutation. Postoperative courses were uneventful and the patients were followed for three years without any recurrence. Bilateral CPPS are rare and unusual in two siblings. A genetic predisposition such as the p53 mutation should be investigated in bilateral CPPs in particular.

Cerebral leukoencephalopathy with calcifications and cysts operated for signs of increased intracranial pressure: case report.

BACKGROUND: Association of leukoencephalopathy with calcifications and cysts is extremely rare. It should be differentiated from FD or bilateral striopallidodentate calcinosis and astrocytoma. Yet, there are many other clinical syndromes featuring bilateral symmetric cerebral calcifications. Neuroradiologic and histopathologic findings are more helpful than clinical picture in differentiating these 3 entities from each other. CASE DESCRIPTION: We report a sporadic case operated for signs of increased ICP and cerebellar cystic mass. The patient had symmetric bilateral cerebral and cerebellar calcifications, white matter edema, and a secondary thalamic cyst as well. After resection of the cerebellar mass, clinical picture returned to normal and edematous findings on MRI resolved in addition to a decrease in size of the thalamic lesion on follow-up. CONCLUSION: Patients with findings of cystic cerebral calcifications on CT scans should be followed cautiously for acute deterioration because surgery is indicated in cases having signs of increased intracranial pressure.

Cystic olfactory schwannoma of the anterior cranial base.

Olfactory groove schwannomas are extremely uncommon and less than 30 cases are reported in the literature. We report a 21-year-old developmentally-retarded boy who experienced severe headache and aggressive behaviour for 5 months. Imaging showed a cystic mass in the subfrontal region, which was removed by craniotomy. The lesion had a vascular supply from the anterior ethmoidal arteries and it was noted to be attached to the right olfactory nerve. It was removed completely and histology showed it to be a schwannoma. Olfactory groove schwannomas are rare lesions and should be differentiated from meningiomas, neuroblastomas and dural-based metastatic lesions of the anterior cranial base.

Cerebral abscess caused by Nocardia nova.

Primary cerebral nocardiosis is very rare and the subgroup of the isolate has usually been defined as Nocardia asteroides. We report an unusual patient with a cerebral abscess whose cultures were typical for N. nova. It was first isolated from an HIV-1 infected individual and has a distinctive antibiotic susceptibility among the species of N. asteroides. Aggressive surgical and medical intervention is a must for these unusual pathogens. Although our surgical strategy was successful, treatment of nocardial cerebral abscess is quite hard and long lasting, and N. nova in particular necessitates a specific antibiotic regimen.

Dural sinus thrombosis following head injury: report of two cases and review of the literature.

Dural sinus thrombosis (DST) usually involves the sagittal, transverse and sigmoid sinuses and is more common in women due to pregnancy, puerperium and oral contraceptive use. Other etiologies include coagulopathies, infection and head injury. We have present two DST cases following head injury. The first case was a 35-year-old man hospitalized because of one-week history of headache and repeated vomiting after a mild head injury. Thrombosis of the superior sagittal sinus, right transverse and sigmoid sinuses and right jugular vein was determined on angiography. The second case was a 25- year-old man operated on for epidural hematoma at the posterior fossa. Meningitis developed and an abducens palsy was determined. Magnetic resonance imaging demonstrated thrombosis of the right transverse and sigmoid sinus. Low molecular weight heparin was administrated for three months. Both cases had good recovery, but one had recanalisation of the thrombosis. Intracranial hematomas, depressed skull fracture or skull fracture that cross the sinus can obstruct the blood flow in the sinus. Moreover, closed head injury may cause to DST. Because of undefinitive pathophysiology, a consensus was not obtained on overall strategy concerning conservative, radiosurgical, or surgical therapy yet.

Delayed chiasmal herniation after transsphenoidal removal of a pituitary adenoma - case report.

We report a 41-year-old woman who experienced visual deterioration after successful removal of a pituitary adenoma. Possible mechanisms of this visual deterioration and contribution of chiasmal herniation into the sella as well as defect in the diaphragma sellae are discussed with emphasis on the regulation of medical treatment for pituitary adenomas. We conclude that medical therapy after pituitary surgery should be carefully managed together with periodic visual examinations.