Recurrence of lumbar disk herniation after microdiscectomy: a two-center retrospective analysis of 1214 cases and identification of risk factors.

Background/aim: To present the incidence of recurrent lumbar disc herniation (RLDH) and to identify radiological and patient-related risk factors that lead to recurrence after lumbar disc herniation (LDH) treatment with microdiscectomy. Materials and methods: Between January 2013 and December 2021, 1214 patients who had undergone microdiscectomy for LDH were included in this retrospective study. Patients were divided into two groups, the recurrent group and the non-recurrent group, and their demographic, clinical and radiologic characteristics were recorded. The association between the variables and RLDH was assessed by univariate and multivariable logistic regression analyses. Results: Mean ages were similar in the recurrent (51.48 ± 13.63) and non-recurrent(50.38 ± 14.53) groups (p=0.232). Males represented 59.6% of the recurrent group and 49.8% of the non-recurrent group (p=0.002). Multivariable logistic regression revealed that being a male (p=0.009), diabetes mellitus (p=0.038), smoking (p<0.001), grade 4&5 disc degeneration (p<0.001), and having protruded (p=0.002), extruded LDH (p<0.001), paracentral (p=0.008) and foraminal LDH (p=0.008) were independently associated with recurrence. Conclusion: To reduce RLDH frequency and need for revision surgery, modifiable risk factors should be minimized before and after the initial surgery. Also, in patients with unmodifiable risk factors, patients should be clearly informed about the risk for recurrence and possible alternative treatment methods should be considered.

Primary pituitary abscess mimicking meningitis in a pediatric patient.

INTRODUCTION: Pituitary abscess is a rare lesion of the pituitary gland that can cause morbidity and mortality in the absence of appropriate treatment. They are classified as primary and secondary pituitary abscesses. Primary pituitary abscesses occur in patients with no previous pituitary pathology. Secondary pituitary abscesses are detected in patients with existing pituitary pathologies. CASE PRESENTATION: We report a 16-year-old female patient with primary pituitary abscess who was misdiagnosed initially and treated as meningitis. Following the visual disturbances, pituitary abscess was diagnosed, and she underwent abscess drainage via endoscopic endonasal transsphenoidal surgery and antibiotic treatment. CONCLUSION: Primary pituitary abscess can be clinically confused with other pathologies affecting the central nervous system. In order to avoid permanent sequelae in such patients, it should be kept in mind by physicians in similar cases. Satisfying results are obtained in these patients after appropriate treatment and dramatic improvement is achieved.

Comparison of dorsal intercostal perforator artery flap and primary closure in myelomeningocele repair.

PURPOSE: Of the many suggested techniques, we used dorsal intercostal perforator artery flap (DIPAF) for the closure of myelomeningocele defects. This study compared the outcomes of primary closure and DIPAF in the closure of myelomeningoceles. METHODS: Data of 24 patients that underwent myelomeningocele surgery at a single institution between November 2015 and September 2019 were retrospectively reviewed. RESULTS: The primary closure group had 13 patients (54.17%) and the DIPAF group had 11 (45.83%). The mean age was 7.91 ± 13.27 days (1-60 days). Twelve patients were female and 12 were male. In 22 patients, the myelomeningocele sacs were in the lumbosacral region, while in 2, they were in the thoracolumbar region. The mean defect sizes were 14.20 ± 4.62 cm2 and 18.44 ± 3.49 cm2 in the primary closure and DIPAF groups, respectively. In each group, four patients had a kyphotic deformity. In the primary closure group, three patients had wound necrosis, two had wound dehiscence, and four had cerebrospinal fluid (CSF) leakage. In the DIPAF group, one patient had wound necrosis and one had CSF leakage. Significantly fewer complications related to the operation area were observed in the DIPAF group (p < 0.05). Increased defect size, kyphotic deformity, and presence of hydrocephalus were found to be risk factors for complications related to the operation area. CONCLUSION: This surgical treatment protects neural tissue, prevent CSF leakage, and reduce central nervous system infection rates in myelomeningocele patients. Closure technique with the fasciocutaneous skin flap has more satisfying results than primary closure.

Posterior realignment of basilar invagination with facet joint distraction technique.

PURPOSE: We describe our experience with management of basilar invagination (BI) with the atlantoaxial dislocation (C1/C2) joint reduction technique, including posterior atlantoaxial internal fixation. MATERIALS AND METHODS: From 2008 to 2018, eleven patients with atlantoaxial dislocation (AAD) and BI underwent surgical reduction using C1/C2 the joint reduction technique with a fibular graft/peek cage placement followed by C1 lateral mass/C2 pedicle screw fixation. In two cases that we originally planned to perform C1/C2 joint reduction, occiput-C2 pedicle screw fixation was performed instead due to intraoperative challenges. Post-operative course and surgical complications will be discussed. RESULTS: A total of 13 patients, with an average age of 30.46 ± 13.23 years (range 12-57), were operated. In one patient, iatrogenic vertebral artery injury occurred without any neurological complication. JOA score improved from 10.45 ± 1.128 to 15.0 ± 1.949 (p < 0.0001, paired t-test). All radiological indices were improved (p at least < 0.001). No construct failure was seen in any of the patients with C1-2 facet joint distraction technique during follow-up, and no additional anterior decompression surgery was required. CONCLUSIONS: C1/C2 joint reduction technique with fibular graft/cervical PEEK cage of BI patients together with AAD seems to be an effective and safe surgical method of treatment.

Course of Urological Problems in Children with Spinal Dysraphism: Long-Term Follow-Up Results.

BACKGROUND/AIMS: We aimed to evaluate the course of urinary problems in children with spinal dysraphism. METHODS: This multicenter study evaluated data on pediatric patients diagnosed with spinal dysraphism between 2010 and 2019. The neurological and urological conditions of the patients were examined retrospectively. This study focused on the course of urological problems. Urodynamic examinations including urodynamic bladder capacity, bladder pressure in maximal capacity, compliance, detrusor hyperactivity, uroflowmetry, and residual urine amount were evaluated. All patients underwent urinary system ultrasonography, urinalysis, hemogram and biochemical tests, and urodynamics at admission and follow-ups. RESULTS: A total 62 patients (35 males, 27 females) with a mean age of 7.50 ± 4.01 years and age range of 1-16 years were included in the study. Ultrasonographic evaluation revealed normal results in 32 patients and abnormal findings, including moderate-to-severe calyceal dilatation, parenchymal thinning, and residual urine, in 30 patients. At the time of diagnosis, culture-positive urinary tract infection was detected in 22 patients, and leukocyte and/or bacterial positivity was detected in 18 patients. The differences between bladder capacity, bladder pressure at maximal capacity, compliance, and detrusor hyperactivity at first admission and post-treatment were statistically significant (p < 0.05). Vesicoureteral reflux was also detected in 25 patients. Thirty patients underwent oral anticholinergic and antibiotic prophylaxis, while 17 additionally underwent clean intermittent catheterization. Five patients underwent intravesical Botox injection, clean intermittent catheterization, and medical treatment, and 10 patients underwent augmentation cystoplasty. CONCLUSION: The prevalence of urinary tract problems is high in patients with spinal dysraphism for whom early diagnosis is very important for both urologic and neurosurgical considerations. Early follow-up of urodynamics should be performed, and treatment should be carried out if necessary. Regular follow-up and appropriate treatment have positive effects on the quality of life of these patients and may also prevent the occurrence of severe renal dysfunction.

Spine Metastasis of Thymic Carcinoma in a Pediatric Patient: A Case Report and Comprehensive Literature Review.

INTRODUCTION: Thymic carcinoma metastases of the spinal column are very rare, especially in pediatric patients. To our knowledge, this is the first such pediatric case in the literature. CASE PRESENTATION: We report the case of a 14-year-old male patient with T12 and L1 metastases of thymic carcinoma. He had history of thymectomy and intrathoracic tumor resection 7 months previously. The patient's neurological condition deteriorated; therefore, tumor resection and decompression of the spinal canal were performed. He underwent instrumentation and fusion procedures to prevent spinal instability. CONCLUSION: The main purpose of the treatment is gross total resection of the thymic carcinoma. However, adjuvant methods such as radiotherapy and chemotherapy should be added to the treatment protocol in patients who have higher stage diseases or those in whom total tumor resection cannot be achieved.

Giant cell tumor of the eleventh thoracic vertebra in a pediatric patient: an interesting case report and comprehensive literature review.

INTRODUCTION: Giant cell tumors of the mobile spinal column are very rare tumors, especially in the pediatric age group. Although they are benign tumors, they have locally aggressive growth pattern and high risk of recurrence. CASE PRESENTATION: We report a 15-year-old female patient with thoracic giant cell tumor who underwent percutaneous vertebroplasty and had cement extravasation into the spinal canal. Because of the deterioration of the patient's neurological condition, total enbloc spondylectomy and cement excision were performed. She underwent instrumentation and fusion procedures in order to prevent spinal instability. CONCLUSION: The main purpose of the treatment is gross total resection of the giant cell tumor. However, adjuvant methods such as denosumab should be added to the treatment protocol in patients who are older than 2 years old and can not undergo gross total resection due to tumor size and anatomic localization.

Outcome of Primary Bone Fragment Replacement in Pediatric Patients with Depressed Skull Fracture.

OBJECTIVE: To evaluate pediatric patients who were operated with the diagnosis of depressed skull fracture. METHODS: The records of pediatric patients who presented with traumatic head injury to multicenter neurosurgery clinics between 2002 and 2018 and who were operated with a diagnosis of depressed skull fracture were retrospectively reviewed. All of the patients underwent primary bone fragment replacement operation, and the patients' own bone flaps were used to repair depressed skull fractures in all of them. RESULTS: A total of 78 patients were included in the study. Of the study group, 20 patients presented with mild head injury, 37 had moderate head injury, and 21 had severe head injury. Dural injury was present in 67 patients (86%) and the dura was intact in 11 patients (14%). After surgery, 63 patients (81%) had good outcome, 8 patients (10%) had moderate disability, and 5 patients (6.5%) had severe disability. Two patients with multiple accompanying cranial pathologies died and the mortality rate was 2.5%. Infection was detected in only 2 of the 78 patients who were treated within the first 72 h after trauma. One of them had meningitis and the other skin infection. Both patients were treated with appropriate antibiotherapy. None of the patients in the study group had an infection involving the bone, such as osteomyelitis, or the tissues under the bone, such as subdural-epidu-ral empyema or abscess. None of the patients required reoperation and removal of the bone. CONCLUSION: In the present study, as the pathologies accompanying the depressed skull fractures of the patients increased, Glasgow Coma Scale scores at arrival and Glasgow Outcome Scale scores at discharge decreased. Regardless of whether the depressed fracture is simple or compound, primary bone fragment replacement with appropriate decontamination of the fractured bone and operation area via single-session intervention gives good results. It is important to perform the surgery as soon as possible to reduce the risk of contamination. Primary bone fragment replacement seems to be an appropriate treatment option for depressed skull fractures.

Unusual Clinical Presentation and Association of Cranial Dermoid Tumor and Tethered Cord Syndrome.

Tethered cord syndrome (TCS), a neurological disorder characterized by the lower settlement of the conus medullaris, is a congenital spinal disease which is caused by split cord syndrome, meningomyelocele, and spinal tumors. Cranial dermoid tumor (CDT) is a congenital benign tumor which is generally located on the midline of the cranium. Even though TCS is highly associated with spinal dermoid tumor, the relationship of CDT and TCS is unusual. We pre-sent a case with an unusual symptom of CDT, motion-dependent pain, and an uncommon togetherness with TCS.

The effects of intravenous immunoglobulin on cerebral ischemia in rats: An experimental study.

Stroke is one of the major reasons of death in the United States and related to adult disability. Despite aggressive research, the treatment approaches of stroke still remains a major clinical problem. Intravenous immunoglobulin (IVIg) is a polyspecific Ig G preparation obtained from plasma of several thousand healthy people (donors). IVIg is an important treatment approach and used for several disorders. The aim of this study was to investigate the potentially beneficial effects of IVIg therapy in experimentally induced ischemia in middle cerebral artery occlusion (MCAo) models of rats. A total of 30 adult male Sprague Dawley rats were used. The rats were divided into two equal groups, each consisting of 15 randomly selected rats: control group (n = 15) and IVIg group (n = 15). Intraluminal filament method was used for establishment of cerebral ischemia. Intraluminal filament was withdrawn after 2 h of MCAo and reperfusion started again and passed to therapeutic stages for all the groups. Physiologic saline solution of 0.5 ml/kg was administered to the control group and 400 mg/kg IVIg was given to the IVIg group rats intravenously. In neurological evaluation, the worst score was determined as 3 and the best score as 0. After routine process, the brain tissue was prepared histopathological investigation. The IVIg group showed significantly better recovery with respect to the control group by neurological examination. The observation of specimens obtained from IVIg groups showed that findings correlate with grade 1 and -2 histopathologically. Nevertheless, ischemic amendments were observed to comply with grade 3 in ischemic areas in control group. IVIg therapy can be used in the treatment of ischemic stroke patients.

Results of treatment of unstable thoracolumbar burst fractures using pedicle instrumentation with and without fracture-level screws.

BACKGROUND: Two different techniques of short-segment instrumentation, with and without a pedicle screw at the fracture level, were compared in thoracolumbar burst fractures in neurologically intact (ASIA-E) patients. The sagittal index, kyphosis angle (Cobb), canal compromise ratio, and compression ratio of the anterior vertebral height were analyzed. METHODS: Seventy patients who underwent short-segment stabilization for thoracolumbar (T11-L2) burst fractures in our clinic between 2008 and 2012 were included in this retrospective study. In 35 patients (group 1), a pedicle screw was placed only one level down and one level up from the fracture level. In another 35 patients (group 2), a screw was placed at the fracture level in addition to the short segment. Only neurologically intact patients with burst fractures according to the Denis classification were included. The patients were evaluated according to their age/gender, trauma etiology, and fracture level. Their preoperative and most recent postoperative follow-up radiographs and CTs were evaluated in terms of the sagittal index, kyphosis angle (Cobb), ratio of canal compromise, and anterior vertebral height. RESULTS: The two groups were similar in their ages, follow-up periods, and severity of the deformity and fracture. When the pedicle screw was placed at the fracture level in addition to short-segment stabilization, statistically significant improvements in the sagittal index (p < 0.001), local kyphosis (Cobb) angle (p = 0.006), and compression ratio of the anterior vertebral height (p = 0.002) were observed. Concerning the ratio of canal compromise according to the CT findings (p = 0.189), moderate differences were found. CONCLUSIONS: Short-segment stabilization in thoracolumbar burst fractures with additional screws at the level of the fracture results in an improved kyphosis correction, sagittal index, and compression ratio of the anterior vertebral height. However, long-term follow-up is needed to determine the clinical significance of these findings.

Intracranial extra-axial chondromas: clues to computed tomography and magnetic resonance imaging diagnosis.

AIM: We aimed to describe the computed tomography (CT) and magnetic resonance (MR) imaging findings of intracranial extra-axial chondroma. MATERIAL AND METHODS: We retrospectively evaluated the imaging findings of CT and MR examinations of six patients (three men and three women, aged 21-66 years) with histopathological diagnoses of intracranial extra-axial chondroma. RESULTS: Four tumors were located in the frontal region and two in the cavernous sinus. All the tumors showed low signals on diffusion-weighted images and high signals on apparent diffusion coefficient maps without restricted diffusion. There was no perifocal edema in all the tumors. Cavernous sinus chondromas were associated with bone erosion and anterior displacement of the internal carotid arteries, but without calcification. Calcification was present in all frontal chondromas. All the tumors revealed low signals on T1-weighted MR images. Frontal chondromas revealed mixed signals, but cavernous sinus chondromas were brightly hyperintense on T2-weighted MR images. No enhancement was detected in the two chondromas. An intense homogeneous enhancement was detected in a cavernous sinus chondroma. CONCLUSION: The imaging appearances of frontal extra-axial chondromas and cavernous sinus chondromas may have different imaging appearances. Although there is a wide range of imaging findings, the absence of restricted diffusion, perifocal edema, enhancement, and presence of low signals on T1-weighted MR images in a well-circumscribed calcified extra-axial mass should suggest an intracranial chondroma.

Intracranial arachnoid cyst family with autosomal recessive trait mapped to chromosome 6q22.31-23.2.

BACKGROUND: Arachnoid cysts are congenital fluid-filled compartments within the cerebrospinal fluid cisterns and cerebral fissures. They most commonly occur sporadically, and familial occurrence has rarely been reported. In this study, we showed the first genetic linkage in the literature in a pure intracranial arachnoid cyst family with autosomal recessive trait. METHODS: We identified an intracranial arachnoid cyst family in southern Turkey whose six of seven offspring had intracranial arachnoid cysts in different localizations, and collected venous blood from seven offspring of the family. Whole-genome linkage analysis was performed in all offspring. RESULTS: A theorical maximum logarithm of the odds score of 4.6 was identified at chromosome 6q22.31-23.2. This result shows strong genetic linkage to this locus. CONCLUSIONS: We present the first genetic linkage analysis result in a pure intracranial arachnoid cyst family in literature. Further investigation of this linkage area can reveal a causative gene causing the intracranial arachnoid cyst phenotype and can illuminate the pathogenesis of this disease.

Childhood Pineal Glioblastoma: Case Report.

Pineal glioblastomas (GBMs) are extremely rare tumors. Herein we will present a pediatric patient with GBM located in pineal region who was admitted with the symptoms of increased intracranial pressure and treated with surgical resection and radiotherapy. Introduction: Pineal region tumors are extremely rare accounting for less than 1% of all brain tumors. The most common type of pineal region tumors is germ cell tumor, followed by pineal parenchymal tumors, gliomas, atypical tumors, and the others. Case Report: A 5-year-old girl was admitted with complaints of headache, dizziness, imbalance in walking, and impaired vision for 1 month. Her neurological examination revealed a tendency to sleep, anisocoric pupillae, mesh eye pupil, dilated lateral gaze paralysis, and left hemiparasia (4/5 muscle strength). In magnetic resonance imaging, a mass was observed in the pineal region that infiltrates the right thalamus and right superior peduncle, isointense and hyperintense in T1 sections, hyperintense in T2 sections, having centrally contrasted areas in post-contrast sections. Due to the presence of evident hydrocephalus, a ventricular shunt was inserted and then through supracerebellar to infratentorial approach the lesion was removed subtotally. The histopathological diagnosis was GBM. GBMs in the pineal region are extremely rare tumors carrying poor prognosis. The patients are generally presented with the signs and symptoms of increased intracranial pressure. GBMs should be kept in mind in differential diagnosis of tumors in the pineal region.

Reoperation does not provide a survival advantage in patients with recurrent Glioblastoma treated with irinotecan/bevacizumab treatment.

BACKGROUND: Treatment options for recurrent glioblastoma (GBM) have limited efficacy. Although reoperation is useful for both the confirmation of the diagnosis of recurring disease and the relief of the symptoms, its effect on survival is unknown. The aim of this study was to evaulate the impact of second surgery in recurrent GBM. METHODS: Patients with GBM followed in our center between January 2015 and April 2018 were analyzed retrospectively based on the treatment options. RESULTS: 25 patients diagnosed with recurrent GBM were analyzed. Ten patients (40%) were treated with chemotherapy following reoperation, and 15 patients (60%) were treated with only chemotherapy. No benefits of reoperation were observed in the univariate analysis. CONCLUSION: The second surgery in recurrent GBM has limited effect in clinical course.

Neuro-Behçet's Disease Mimicking Low-Grade Glioma Presenting with Drop Foot.

Behçet's disease is a multisystem inflammatory disease that manifests with oral-genital ulcers, skin lesions, arthritis, and ophthalmologic and neurovascular findings. Neurological involvement of Behçet's disease is called neuro-Behçet's disease, and it is a difficult entity to diagnose because of insufficient symptoms. We present a 26-year-old male patient with complaints of headache, dizziness, and drop foot in the right lower extremity. He underwent gross total tumor resection with the preliminary diagnosis of low-grade glioma, according to the preoperative magnetic resonance imaging. Histopathological examination and further investigation revealed an interesting neuro-Behçet's disease case because of the localization and clinical occurrence of the lesion.

Efficacy of prophylactic application of vancomycin powder in preventing surgical site infections after instrumented spinal surgery: A retrospective analysis of patients with high-risk conditions.

OBJECTIVE: This study aimed to determine the efficacy of prophylactic use of vancomycin powder against surgical site infections in patients with high-risk conditions who underwent posterior spinal instrumentation. METHODS: Data obtained from 209 patients who underwent posterior spinal instrumentation at a single institution from 2014 to 2017 were retrospectively reviewed. Patients were then divided into two groups: control group, including 107 patients (61 females, 46 males; mean age=54 years; age range=16-85 years), and treatment group, including 102 patients (63 females, 39 males; mean age=53 years; age range=14-90 years). All patients received the same standard prophylactic antibiotic regimen. In addition to the prophylactic antibiotic, vancomycin powder was applied locally to the surgical site in the treatment group. All patients were followed up for at least 90 days postoperatively. Infections were categorized as superficial and deep infections. Subgroup analysis of high-risk patients (Syrian refugees) was also performed. RESULTS: The infection rates were 1.96% (two patients) in the treatment group and 6.54% (seven patients) in the control group. A significant decrease in the infection rates was observed with local vancomycin powder application. Advanced age (>46 years) and prolonged surgical duration (>140 min) were found to be the main risk factors for surgical site infections (p=0.004 and p=0.028, respectively). The infection rates were 3.22% and 8.11% in the treatment and control groups of refugees, respectively. There were three superficial and four deep infections in the control group and one superficial and one deep infection in the treatment group. A dominance of staphylococcus infections was observed in the control group, whereas no significant dominance was observed in the treatment group. Three patients in the control group and one patient in the treatment group received implant removal. CONCLUSION: Evidence from this study has revealed that local application of vancomycin powder reduces the rate of surgical site infections after instrumented spinal surgery. The benefit of vancomycin application may be most appreciated in higher risk populations or in clinics with high baseline rates of infection. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Factor X deficiency presenting with bilateral chronic subdural hematoma.

Factor X deficiency is a rare coagulation defect that can result in several hemorrhagic manifestations including central nervous system hematomas in infants and children. In this case report, we present computed tomography (CT) and magnetic resonance (MR) imaging findings of bilateral chronic subdural hematomas due to factor X deficiency. Cranial CT and MR imaging in a hypoactive 7-month-old male infant with right hemiparesis revealed bilateral chronic subdural hematomas at different stages. Laboratory findings showed a severe factor X deficiency, with a level of 0.7%. After fresh frozen plasma replacement, the patient was operated and the large hematoma on the left side evacuated. The patient recovered uneventfully and remained asymptomatic during the 1-year follow-up.

Multiple intracranial melanoma metastases: case report and review of the literature.

Although intracerebral metastases of malignant melanoma are common, those located in the sellar region and within the pontocerebellar area are extremely rare. Furthermore, to our knowledge, there is no report about melanoma metastasis to the epiphysis published so far. We report here a 46-year-old patient who had metastatic lesions in the sellar region, cerebellopontine area and epiphysial gland, preceded by a primary melanoma at her left shoulder. The diagnosis of sellar metastasis was confirmed histopathologically following a stereotactic biopsy. The patient received whole-brain irradiation therapy combined with chemotherapy. After 10 months, she died from a severe hemorrhage in the cerebellopontine angle. Autopsy findings confirmed melanoma metastases both in the cerebellopontine angle and additionally in the epiphysial gland. To our knowledge, this is the first case of multiple intracranial melanoma metastases including the suprasellar region, the pontocerebellar and epiphysial area.