Osteoplastic Pterional Craniotomy: Success Rate of Surgery in Patient Aspect.

AIM: To evaluate the effect of osteoplastic pterional craniotomy on temporal hollowing and its sequelae. MATERIAL AND METHODS: A total of 97 patients who underwent pterional craniotomy for an aneurysm were analyzed retrospectively. Of these 97 patients, 63 underwent surgery via the conventional pterional approach and 34 underwent surgery via the osteoplastic pterional approach. The temporal muscle volume was calculated bilaterally on CT images obtained in the sixth postoperative month. The results obtained in the conventional and osteoplastic approaches were compared. RESULTS: Of the 97 included patients, 45 were female and 52 were male. The mean patient age was 50.37 years. In the conventional group, 31 were female and 32 were male. In the osteoplastic group, 14 were female and 20 were male. The temporal muscle volume difference between the operated and non-operated side was not statistically significant in the osteoplastic group. However, the volume was slightly lesser on the operated side than on the non-operated side in the conventional group. CONCLUSION: The osteoplastic pterional approach is superior to the conventional approach in preserving the muscle volume and function. Patients who underwent osteoplastic craniotomy demonstrated higher levels of satisfaction with their facial appearance compared to those who underwent craniotomy using the conventional pterional approach.

Surgical Management Thoracolumbar Fractures in Patients with Ankylosing Spondylitis: Technical Note with Case Series.

OBJECTIVE: Ankylosing spondylitis (AS) is a chronic inflammatory joint disease. Complications such as traumatic spinal fractures are mostly caused by hyperextension and are unstable. We report the cases of 5 patients with AS surgically treated for thoracolumbar fractures. METHODS AND RESULTS: We shared our experience of posterior stabilization surgery performed for the treatment of thoracolumbar fractures after traumas such as fall-accident in patients with AS. Patients were all men, and their ages were between 52 and 77 years. The first 3 patients woke up with neurologic deficits and were managed surgically under general anesthesia. We managed the last 2 patients with unilateral short-level stabilization under local anesthesia followed by bilateral long-level stabilization under general anesthesia. No neurologic deterioration was found in the postoperative examination of these 2 patients. We assume that the reason for neurologic deterioration after general anesthesia is the relaxation of muscles. All 3 columns of the spine are affected in patients with AS and the stability is provided by the tone of the muscles around the spine. CONCLUSIONS: To prevent postoperative neurologic complications after the surgical treatment of traumatic hyperextension thoracic and lumbar fractures in patients with AS, we recommend securing the fracture level with unilateral short-level stabilization under local anesthesia and then completing the operation with general anesthesia.

Spinal Schwannomas: A Proposal for a New Classification to Aid Surgical Planning.

Background The treatment of spinal schwannomas, which is the most common nerve sheath tumor, is total microsurgical resection. The localization, size and relationship with the surrounding structures of these tumors are crucial in terms of preoperative planning. A new classification method is presented in this study for the surgical planning of spinal schwannoma. Methods All patients who underwent surgery for spinal schwannoma between 2008 and 2021 were reviewed retrospectively, along with radiological images, clinical presentation, surgical approach, and postoperative neurological status. Results A total of 114 patients, 57 male, and 57 females were included in the study. Tumor localizations were cervical in 24 patients, cervicothoracic in one patient, thoracic in 15 patients, thoracolumbar in eight patients, lumbar in 56 patients, lumbosacral in two patients, and sacral in eight patients. All tumors were divided into seven types according to the classification method. Type 1 and Type 2 groups were operated on with a posterior midline approach only, Type 3 tumors were operated on with a posterior midline approach and extraforaminal approach, and Type 4 tumors were operated on with only an extraforaminal approach. While the extraforaminal approach was sufficient in type 5 patients, partial facetectomy was required in 2 patients. Combined surgery including hemilaminectomy and extraforaminal approach was performed in the type 6 group. A posterior midline approach with partial sacrectomy/corpectomy was performed in Type 7 group. Conclusion Effective treatment of spinal schwannoma depends on preoperative planning, which includes correctly classifying tumors. In this study, we present a categorization scheme that covers bone erosion and tumor volume for all spinal localizations.

Peritumoural Oedema as a Predictor of Overall Survival for Patients with Posterior Fossa Metastases.

OBJECTIVE: To analyse the relationship between peritumoural oedema volume and tumour volume in relation to the impact of metastatic posterior fossa tumour survival rates. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Umraniye Training and Research Hospital, Istanbul, Turkey, from 2011-2021. METHODOLOGY: Fifty-six cancer patients who had been operated upon for cerebellar metastases were analysed retrospectively. To investigate the effect of oedema on survival, patients with a single cerebellar metastasis were evaluated retrospectively. Those patients had a single metastasis located in the cerebellum and did not receive radiotherapy or corticosteroids before surgery. OsiriX MD DICOM viewer was used to calculate the volumes of the tumour and the oedema using fluid-attenuated inversion recovery (FLAIR) and contrast-enhanced magnetic resonance imaging (MRI). The patients were separated into two groups, and the cut-off limit for the oedema to-tumour ratio was set to two. Survival analysis was performed on the two groups. RESULTS: When the primary sites of the tumours were evaluated, 60.7% were located in the lungs (n = 34), 10.7% were located in the breasts (n = 6), 10.7% were located in the gastrointestinal tract (n = 6), 7.1% were located in the renal region (n = 4), 5.4% were located in the gynaecologic tract (n = 3), and 5.4% were located in other parts of the body (n = 3). A univariate analysis showed that overall survival duration was significantly longer in the subgroup with breast cancer (83.3%) and in those patients with a peritumoural oedema volume to tumour volume ratio of less than two (27.6%, p <0.05). Negative prognostic factors were lung cancer and high peritumoural oedema volume. CONCLUSION: Significant peritumoural oedema was linked to a poor prognosis for cancer patients with a single cerebellar metastasis, especially with lung cancer as the primary source. KEY WORDS: Cerebellar metastases, Cerebellum, OsiriX MD, Tumour volume.

Short-Term Results of Simpson Grade 2 Resection in Spinal Meningiomas.

BACKGROUND: Spinal meningiomas are benign and slow-growing intradural tumors. Surgery is the choice of treatment. In this retrospective study, results of minimally invasive Simpson grade 2 resection and its impact on recurrence in 44 spinal meningiomas are reviewed. METHODS: Clinical data of 44 cases who underwent surgery for spinal meningiomas between 2010 and 2020 have been reviewed retrospectively. Demographics, preoperative and postoperative clinical states, pathologic type, location of the meningioma relative to the spinal cord, resection amount of the tumor according to Simpson's grading scale, postoperative complications, recurrence rate, and correlation between preoperative and intraoperative data and recurrence were analyzed. RESULTS: The tumor was located in the thoracic spine in 31 cases, in the cervical spine in 12 cases, and in the lumbar spine in one case. Dural attachment of tumor was ventral to the spinal cord in 15 cases, lateral to the spinal cord in 15 cases, and posterior to the spinal cord in 14 cases. All cases underwent microsurgical Simpson grade 2 resection. Two cases were recurrent and reoperated. Recurrences were observed in cases younger than 18 years old, in cervical spines and in cases with long dural tails. CONCLUSIONS: Simpson grade 2 resection is safe and effective in spinal meningiomas. Patients younger than 18 year old, and those with cervical location and long dural tail may be under risk of recurrence after Simpson grade 2 resection.

Factors Associated with Nontraumatic Spontaneous Subdural Hematomas in Pediatric Patients.

OBJECTIVE: In our study, we aimed to summarize the etiology of subdural hematoma that was not traumatic and required operation in pediatric patients. The subdural hematoma characteristics, possible etiologies, and treatment, as well as the patient outcomes, were analyzed. METHODS: A retrospective examination was made of pediatric patients with subdural hematoma who were operated on at Ümraniye Training and Research Hospital. Patients with a history of trauma were excluded. Data on patient sex, age, bleeding location, type of hematoma based on computed tomography imaging, surgical treatment, presenting symptoms, presence of comorbidities, Glasgow Coma Scale, thrombocyte counts, and international normalized ratio values were recorded. RESULTS: Of the 19 patients included in the study, 4 were female and 15 were male. Their ages ranged between 0 and 15 (mean = 5.84) years. In 57.8% of the patients, comorbidities, including acute myeloid leukemia, a history of shunt operation, epilepsy, mucopolysaccharidosis, known subdural effusion, autism, coagulopathy, ventricular septal defect/tetralogy of Fallot, cerebrospinal fluid leakage after baclofen pump administration, Marfan's syndrome, and late neonatal sepsis were present, while 21% had arachnoid cysts and 21% had no reported comorbidities. CONCLUSION: This study suggests that, in pediatric patients with subdural hematoma with an amount of bleeding requiring surgical management, any underlying comorbidities should be investigated regardless of the presence of a history of trauma. While investigating systemic diseases, special attention should be paid to the presence of arachnoid cysts or disruption in cerebrospinal fluid dynamics along with a history of hematologic diseases.

Comparison of clinical and radiological results of dynamic and rigid instrumentation in degenerative lumbar spinal stenosis.

Objective: Lumbar spinal stenosis is defined as a clinical syndrome characterized by neurogenic claudication or radicular pain due to the narrowing of the spinal canal or neural foramen and the compression of its neural elements. Surgical treatment is applied to decompress the neural structures. In some cases, transpedicular instrumentation and fusion may also be applied. In this study, we aimed to investigate and compare the preoperative and postoperative, clinical and radiological aspects of patients with lumbar spinal stenosis who underwent lumbar instrumentation using a polyetheretherketone (PEEK) rod or a titanium rod. Materials and Methods: In this study, the files of 293 patients who underwent posterior lumbar transpedicular stabilization between January 2015 and February 2018 in the Neurosurgery Clinic of Ümraniye Training and Research Hospital were reviewed retrospectively. Patients who did not meet the study criteria were excluded, and 127 patients who met the criteria and underwent posterior lumbar transpedicular stabilization due to lumbar spinal stenosis and/or lumbar degenerative disc disease were retrospectively reviewed. The patients were divided into two groups, dynamic and rigid, according to the rod types used. The two groups were compared using various postoperative clinical and radiological parameters. Results: The demographic data, surgical data, Visual Analog Scale-Oswestry Disability Index (VAS-ODI) data, and radiological data of both groups were carefully examined. There were 63 patients in the rigid group and 64 patients in the dynamic group. The age range in both groups was from 30 to 78 years, with a mean age of 56.44 years; 99 of the cases were female and 28 were male. The analysis of the participants' demographic data showed no significant differences between the two groups. Compared with the preoperative data, the postoperative evaluations revealed a significant decrease in VAS and ODI, but no significant difference was observed between the two groups. There was no difference between the two groups in terms of duration of surgery, follow-up time, operating distances, hospitalization duration, pseudoarthrosis, or fusion. Regarding the total and segmental range of motion, the affection was less in the dynamic group, which allowed for more movement. While there was no difference in disc height index between the two preoperative groups, it was observed that it was better maintained in the rigid group in the postoperative long term. Regarding foraminal height (FH), there was no difference between the two groups in the preoperative and early postoperative periods, but in the long term, FH was better maintained in the dynamic group. The long-term follow-ups revealed that adjacent segment disease (ASD) had developed in 19 patients in the rigid group, whereas ASD developed in only nine patients in the dynamic group. Based on these results, the probability of developing significant ASD in the rigid group was higher. Conclusion: Previous experience with PEEK rod systems has demonstrated physiological spine movement, increased fusion rates, minimal complications, reduction in adjacent segment degeneration, and biomechanical compatibility. Although further long-term studies are needed and the cost of PEEK systems is likely to be a barrier, the results of the present study support the use of PEEK rods and other dynamic systems in spinal surgery.

Surgical Treatment of Spinal Arachnoid Cysts: Cyst Excision or Fenestration?

AIM: Arachnoid cysts in the spinal canal account for 1%-3% of all spinal canal lesions. There is no consensus on surgical treatment yet. Dural defect repair is crucial in surgical treatment patients with an extradural component. Fenestration or total resection of the spinal arachnoid cyst is among the preferred methods. This study aimed to examine a series of surgically treated spinal arachnoid cysts in light of the literature. MATERIAL AND METHODS: This was a retrospective study of patients treated in the Istanbul Umraniye Training and Research Hospital Neurosurgery Clinic. A total of 18 patients with spinal arachnoid cysts underwent surgical treatment between 2012 and 2021. All patients were assessed before and after surgery for muscle strength, pain, sensory changes, and bowel-bladder symptoms. All patients underwent magnetic resonance imaging and computed tomography for diagnosis and treatment. RESULTS: Among the 18 patients, 8 were men and 10 were women, with a mean age of 43.7 (25-66) years. Congenital conditions were discovered in 15 of the patients, 2 after lumbar drainage and 1 after spinal anesthesia. Intradural extramedullary and intra-extradural cysts were found in 17 patients and 1 patient, respectively. The cyst was smaller than level 3 in 14 patients and greater than level 3 in 4 patients. Cyst excision and cyst fenestration were performed in 11 and 7 patients, respectively. Cyst excision was performed in four of the patients who underwent cyst fenestration because their complaints did not improve. CONCLUSION: Surgery should be considered in patients with symptomatic spinal arachnoid cysts. Fenestration may be a suitable alternative, especially if magnetic resonance imaging reveals no intracystic adhesion or trabeculation. Residual and recurrence rates are high in patients with a history of intradural intervention, adhesions, or trabeculation. When there is trabeculation, the best option is cyst removal.

Results of percutaneous cervical vertebroplasty using an anterolateral approach for cervical spine tumors.

OBJECTIVE: The aim of this study was to report the results of percutaneous vertebroplasty in managing symptomatic osteolytic cervical spine tumors. METHODS: This study comprised a retrospective examination of patients who received percutaneous vertebroplasty between 2008 and 2020 for the treatment of tumor-induced symptomatic cervical vertebra involvement. The study summarized the demographics, vertebral levels, pain control rates, clinical results, and complications of percutaneous vertebroplasty using an anterolateral approach. RESULTS: The study sample consisted of 6 female and 2 male patients aged between 20 and 56 (mean=41.37) years. Tumors were located at C2 in 6 cases, at C3 in 1 case, and at C5 in another. The mean volume of poly (methyl methacrylate) injected was 1.5 mL (range: 1-2 mL). Biopsy results showed the presence of metastasis in 5 cases and plasmacytoma in 3. No postoperative complications or mortality were observed after the procedure. Preoperative mean 7.75 visual analog scale score decreased to 2.62. Pain control was reported to be 66.2%. CONCLUSION: Anterolateral cervical vertebroplasty seems to be a safe, effective, and helpful therapeutic alternative for the treatment of cervical spine tumors. It reduces the risk of infection compared to the transoral method. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Management of Spinal Lymphomas: Spinal Instability Assessment Using the Spinal Instability Neoplastic Score and a Proposed Treatment Algorithm.

AIM: To propose a treatment algorithm, and to assess spinal instability in patients diagnosed with spinal lymphoma. MATERIAL AND METHODS: Demographics, symptoms, tumor level and location, and presence of spinal instability were reviewed in 22 patients with spinal lymphomas. Each patient's neurological state was reviewed using the American Spinal Injury Association and modified McCormick scale scores, and spinal instability was assessed using the Spinal Instability Neoplastic Score (SINS). RESULTS: Initially, percutaneous biopsy was performed in 16 patients, and open biopsy was performed in 6 patients. Eight of the patients who underwent percutaneous biopsy were followed up with hematological examination alone, as they had no additional complaints. The SINS was used to evaluate the presence of spinal instability, and the type of surgery to be performed was decided accordingly. In the second surgery, decompression and stabilization were performed in 5 of the remaining 8 patients, and only decompression was performed in 3 of them. Neurological improvement was observed in 6 of 7 patients with acute neurological deficit. CONCLUSION: Percutaneous biopsy for tissue diagnosis is the first step in the management of spinal lymphomas. Patients without neurological deficit should be referred for hematological examination. Those with acute neurological deficit require emergency surgery, and those with chronic symptoms must undergo operation for decompression and/or stabilization. This study confirmed the safety of the SINS in the evaluation of spinal instability in spinal lymphoma cases.

Role of Spinal Instability Neoplastic Score in Management of Spinal Plasmacytoma.

OBJECTIVE: The decision to perform surgery in cases of spinal plasmacytoma (SP) is controversial. This study aimed to evaluate the reliability of the Spinal Instability Neoplastic Score (SINS) in evaluation of spinal instability in patients with SP. METHODS: Clinical and radiological characteristics of 10 patients with SP were retrospectively evaluated. Age, sex, preoperative symptoms, duration of symptoms, pain score, American Spinal Injury Association score, and SINS were analyzed. RESULTS: The 10 patients included 6 men and 4 women. Plasmacytoma was located in the sacrum in 1 patient, in the lumbar spine in 2 patients, in the thoracic spine in 6 patients, and in the cervical spine in 1 patient. Biopsy was performed in 2 patients, biopsy and vertebroplasty were performed in 2 patients, and biopsy and acute decompression and stabilization surgery were performed in 6 patients. SINS was <7 in 1 patient, 7-12 in 5 patients, and >12 in 4 patients. Two patients with a low SINS (<13) underwent only biopsy, and 2 patients underwent biopsy and vertebroplasty. Decompression and stabilization surgery was performed in 2 patients with SINS 7-12 and 4 patients with SINS >12. CONCLUSIONS: Decision making regarding augmentation, decompression, and stabilization in patients with SP is controversial. SINS may play a role during the decision-making process. Augmentation can be performed in patients with painful SPs with osteolytic changes with or without fracture (SINS <13). Decompression and stabilization surgery is the first-choice treatment in patients with SINS >12.

Can Posterior Midline Approach Provide Adequate Exposure for All Craniovertebral Junction Tumors?

INTRODUCTION: The surgical treatment of craniovertebral junction (CVJ) lesions remains a difficult process requiring advanced experience. The aim of this study was to present our experience and the clinical results of a posterior and posterolateral approach used for CVJ lesions in our clinic, and to discuss these in light of current literature. METHODS: Clinical, radiologic, and surgical aspects of 30 patients with CVJ tumors were retrospectively evaluated. Age, sex, symptoms, tumor localizations, pre- and postoperative neurologic examinations, performed surgical techniques, postoperative complications, and tumor pathologies were analyzed. The modified McCormick classification was used in the evaluation of the neurologic examination. RESULTS: There were 30 patients (12 men, 18 women; mean age: 41.8 years). Hemilaminectomy was performed in 14 cases, and total laminectomy or laminoplasty in 16 cases; additional suboccipital craniectomy was performed in 6. Postoperative mortality was observed in 1 (3.3%) patient in the early postoperative period following tetraparesis, motor deficit in 2 (6.6%), cerebrospinal fluid leakage in 2 (6.6%), and wound site infection in 1 (3.3%). A tumor rest was detected in 2 patients (6.6%). CONCLUSIONS: A posterior or a posterolateral approach is a safe surgical technique that can provide total tumor resection for CVJ region lesions, including posterior, posterolateral, lateral, and anterolaterally located tumors. Isolated anterior and anterolateral tumors with small lateral extension may require a far lateral or extreme lateral approach combined with other cranial base techniques.

Posterior Transpedicular Screw Fixation of Subaxial Vertebrae: Accuracy Rates and Safety of Mini-laminotomy Technique.

BACKGROUND AND AIM: Posterior cervical transpedicular screw fixation has the strongest resistance to pullout forces compared with other posterior fixation systems. Here, we present a case on the use of this technique combined with a mini-laminotomy technique, which serves as a guide for accurate insertion of posterior cervical transpedicular screws. MATERIALS AND METHODS: We retrospectively analyzed data from 40 patients who underwent this procedure in our clinic between January 2014 and March 2017. RESULTS: The study population comprised 27 males (67.5%) and 13 females (32.5%) aged 15-80 years (median, 51.5 years). Surgical indications included trauma (n = 18, 45%), degenerative disease (n = 19, 47.5%), spinal infection (n = 2, 5%), and basilar invagination due to systemic rheumatoid disease (n = 1, 2.5%). In the 18 trauma patients, 14 short-segment (1-2 levels) and 4 long-segment (≥3 levels) posterior cervical instrumentation and fusion procedures were performed. The mini-laminotomy technique was used in all patients to insert, direct, and achieve exact screw fixation in the pedicles. Pedicle perforations were classified as medial or lateral and were also graded. Among the 227 cervical pedicle fixations performed, 48 were at the C3 level, 49 at C4, 60 at C5, 50 at C6, and 20 at C7. Axial computed tomography scan measurements showed that 205 of 227 (90.3%, Grade 0 and 1) screws were accurately placed, whereas 22 (9.69%, Grade 2 and 3) were misplaced. However, no additional neurological injury due to misplacement was observed. CONCLUSION: As negligible complications were observed when performed by experienced surgeons, the mini-laminotomy technique can be safely used for posterior transpedicular screw fixation in the subaxial vertebrae for single-staged fusion.

Central liponeurocytoma as a clinical entity.

INTRODUCTION: Liponeurocytomas are mostly localized in cerebellar hemispheres and the second most common location is the vermis. It is rarely observed within the intracranial ventricles. Here, we present a case of liponeurocytoma located in the right lateral ventricle and the systematic review of the literature. STATE OF THE ART: We searched PubMed with keyword 'central liponeurocytoma' and the references of the related articles. There were no language or year restrictions. We included articles focusing on liponeurocytomas located in the central nervous system leaving a total of 17 articles and 21 reported cases. CLINICAL IMPLICATIONS: A 62-year-old female presented with confusion and mental disorientation without any other neurological deficit. Her magnetic resonance imaging (MRI) revealed a lateral ventricle located mass lesion which was hypointense on T1-weighted images (WI) and heterogeneously hyperintense on T2-WI with cystic component. Via craniotomy, yellow-beige colored, soft and moderately vascularized mass lesion was gross totally resected. Despite postoperative MRI revealed total resection, patient had left-sided hemiparesis. The patient recovered well in her postoperative period and there was no recurrence on her 6th month follow-up MRI. FUTURE DIRECTIONS: Intraventricular liponeurocytoma has a favorable clinical course, and radiological features may be useful in the diagnosis of this rare tumor before surgery. Supratentorial intraventricular location should be kept in mind in the differential diagnosis of the lateral ventricular tumors.

Is there a relationship between blood lipids and lumbar disc herniation in young Turkish adults?

INTRODUCTION: Atherosclerosis might diminish the nutrient supply to intervertebral discs (IVD), leading to disc herniation. Therefore, there is interest in determining the possible association between the blood lipid profile and lumbar disc herniation (LDH). We aimed to evaluate the association between blood lipids and LDH in a homogeneous group of patients, controlling for age- and sex-specific effects. MATERIAL AND METHODS: This is a case-control study which consisted of 100 individuals (mean age: 41.25 ±9.09; 50 men and 50 women), classified into two groups, as follows. Group I (G-I) consisted of 50 patients who underwent surgery for symptomatic LDH, while group II (G-II) consisted of 50 patients with nonspecific complaints of a headache, but with no previous history of back and/or leg pain, recruited among patients admitted to the outpatient clinic at the time of the study, and whose age and sex were matched to the study group. Total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), fasting blood glucose, and hemoglobin A1c levels were measured. The TC/HDL-C ratio was calculated. Blood pressure, waist circumference, body mass index, and the history of smoking were included in the analysis. RESULTS: The mean values of the TC, TG, LDL-C, HDL-C levels and TC/HDL-C ratio were 198.38, 132.76, 131.9, 40.38 mg/dl and 5.09, respectively. No statistically significant relationship between the blood lipid profile and LDH was identified in this population. CONCLUSIONS: Blood lipid levels in this young adult Turkish population did not predict LDH, and may not be a leading cause of IVD ischemia and IVD degeneration.

Tension pneumocephalus causing brain herniation after endoscopic sinus surgery.

Endoscopic sinus surgery (ESS) may rarely be complicated by intracranial complications; the most common of them is a cerebrospinal fluid fistula. Pneumocephalus as a complication of ESS is quite rare. Here, we presented a unique case of tension pneumocephalus causing brain herniation as a complication of ESS, to whom emergent craniotomy was performed.