Bowel perforation of ventriculoperitoneal shunt catheter: endoscopically treated two cases.

PURPOSE: Many techniques were used for the treatment of hydrocephalus, and ventriculoperitoneal shunt surgery is a widely used procedure. Ventriculoperitoneal shunt surgery has been associated with several complications like obstruction of the tube, infection, cerebrospinal fluid loculation, intestinal obstruction, migration of the shunt, and perforation of the intestinal organs. Perforation of the bowel owing to protrusion of ventriculoperitoneal shunt catheter from the anus is an extremely rare complication. Mini or exploratory laparotomy and revision of peritoneal part of shunt and repair of bowel perforation, or pulling out the ventriculoperitoneal shunt catheter and using external ventricular drainage and antibiotics, or colonoscopic removal of ventriculoperitoneal shunt catheter and repair of the bowel can be performed. Retrograde contamination of cerebrospinal fluid and meningitis is a very important part of the treatment in these cases. We aimed to present two cases with bowel perforation who treated with endoscopically. METHODS: We report the cases of 2 patients with transanal protrusion of VPS catheter and the management via endoscopic therapeutic options. RESULTS: Successful treatment of the patients was achieved by endoscopic removal of the catheter and endoscopic repair of the bowel perforation. CONCLUSION: If peritonitis, bowel obstruction, or abscess does not occur, endoscopic removal of shunt and bowel repairing with endoclips may be enough.

Shunt timing in meningomyelocele and clinical results: analysis of 80 cases.

PURPOSE: Meningomyelocele is a serious pathology that requires immediate surgical treatment. Its management is difficult due to accompanying other pathologies and hydrocephalus. Shunt timing is still controversial. Therefore, this study retrospectively assessed 80 patients in order to improve the shunt timing and management of patients with meningomyelocele. METHODS: A total of 80 patients were followed up for 18-48 (average, 23) months. Patients were analyzed for the following variables: delivery method and time, head circumference monitoring, shunt timing, complication rates of patients who underwent shunting, during the early or follow-up period, accompanying pathologies, size, and localization of lesion. RESULTS: Patients including 46 males and 34 females have been operated. In 40% of patients, the accompanying pathology was determined. Approximately 85% of patients had hydrocephalus, and a ventriculoperitoneal shunt was placed on 36 symptomatic and 22 patients with hydrocephalus that developed during the follow-up. Differences in shunt-related and general complications were not significant between patients who underwent shunt placement during the same session and patients who underwent shunt placement during the follow-up. However, the incidence of cerebrospinal fluid fistula formation from the wound in patients who underwent shunt placement during the same session was significantly lower than those who underwent shunt placement during follow-up. CONCLUSIONS: Immediate surgery (within the first 48 h) provides positive results, which is consistent with the existing literature. According to the logistic regression analysis, the placement of the meningomyelocele sac in the lumbosacral region is decisive in shunt insertion. Placing the shunt in the same session for patients with hydrocephalus and later for patients who developed hydrocephalus during the follow-up is recommended as a favorable treatment.

Paediatric High-Grade Intracranial Mesenchymal Chondrosarcoma: A Case Report with 6 Years of Follow-Up without Recurrence.

INTRODUCTION: Intracranial mesenchymal chondrosarcoma (MSC) is an extremely rare tumour that constitutes only 0.015% of all central nervous system tumours. These tumours usually originate from skull base synchondrosis and are often observed in young adults during their second and third decades of life. Despite the absence of a consensus regarding adjuvant radiotherapy, radical excision remains crucial for the prognosis of MSC. CASE PRESENTATION: We herein present the case of a young male patient with intracranial MSC, a malignant tumour, for which no consensus regarding its treatment has yet been established. The patient underwent radical excision followed by adjuvant radiotherapy. Histological analysis revealed a poorly differentiated tumour containing necrotic areas. Notably, no signs of recurrence had been observed after 6 years. CONCLUSION: The absence of recurrence over a long follow-up duration suggests the importance of radical excision and adjuvant radiotherapy.

Pediatric Traumatic Pneumorrhachis: Case Report.

The existence of air in the spinal canal is referred to as pneumorrhachis. It is classified as extradural (epidural) or intradural (subdural or subarachnoid) according to the location where it is found. Nontraumatic, traumatic, and iatrogenic causes have been attributed to its occurrence. Traumatic pneumorrhachis is very rare and rarely seen in children. In our article, a 16-year-old male child in which air formation within the spinal canal was detected after an injury by a penetrating and cutting (knife) tool is discussed. Observing air within the spinal canal due to traumatic causes is an important situation rarely seen in the pediatric age group. In general, this situation, which can be seen after multiple trauma, may be encountered following a minor trauma. The correct assessment of the radiologic imaging methods ensures not to miss the manifestation of the disease.

Surgical Outcomes of C1-2 Posterior Stabilization in Patients With Chiari Malformation Type 1.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Chiari malformation (CM) is characterized by a downward displacement of the cerebellar tonsils through the foramen magnum. This tonsillar herniation may sometimes be accompanied by syringomyelia and/or basilar invagination (BI). In this study, we examined the surgical outcomes of patients by underwent C1-2 reduction + fixation (C1-2RF), which is a new method defined by Goel, in the literature. METHODS: Between 2015 and 2018, 21 patients (mean age and duration of follow-up: 39 years and 20 months, respectively) with CM were treated with atlantoaxial fixation. We found syringomyelia in all patients and BI in 9 of them. In all cases, radiography, computed tomography, and magnetic resonance imaging were performed radiologically. C1-2RF was performed in all patients. Preoperative and postoperative clinical Japanese Orthopaedic Association scores were obtained. Syrinx size and cerebrospinal fluid flow rate were compared radiologically. RESULTS: All patients were treated with C1-2RF. None of the patients underwent foramen magnum decompression or intervention for the syrinx. Occipital bone and subaxial spinal structures were not included in the fixation. In addition to significant clinical improvement, significant improvement in syringomyelia and cerebrospinal fluid flow rate was seen on the radiographs of all patients. CONCLUSIONS: Although posterior fossa decompression and/or duraplasty is a common treatment modality in CM, we propose that the C1-2RF method described by Goel is a radiologically and clinically effective treatment method, whether or not BI and/or syringomyelia in CM are present. This article is the first article of central and axial atlantoaxial dislocation, except for Goel's writings in the literature.

Is C1-C2 Reduction and Fixation A Good Choice in the Treatment of Recurrent Chiari-Like Symptoms With Syringomyelia?

BACKGROUND: Foramen magnum decompression (FMD) is the first-choice treatment for Chiari malformation (CM). However, it has been suggested that cerebellar herniation and syringomyelia occur as a natural protective event to prevent neural damage caused by atlantoaxial instability. It is argued that treating instability is the main treatment. Positive results of atlantoaxial fusion have been reported in the literature, but there are no studies including the results of atlantoaxial fusion as the second treatment in patients in whom classical decompression failed. In our study, we report the results of these patients to help in the selection of treatment and we present our treatment algorithm for CM with syringomyelia. METHODS: Thirteen patients who had undergone FMD and duraplasty due to CM and syringomyelia in our clinics and who had recovered clinically and radiologically but had recurrent complaints during long-term follow-up were evaluated. C1-C2 distraction and fusion were performed. We evaluated these patients radiologically and clinically. RESULTS: The mean age of the 13 patients was found to be 32.4 years. Male to female ratio was 6:7. The complaints recurred after an average of 2.1 years. Also, 3 cases were presented with their clinical characteristics and radiologic findings. CONCLUSIONS: FMD may fail even with duraplasty, and treatment of CM in recurrent cases is still controversial. Recently, atlantoaxial instability has been reported to be the main pathology of CM, and the cure for pathology is to treat instability. Recurrent CMs with syringomyelia in which FMD has failed should be treated by atlantoaxial fixation.

Surgical Outcomes of Subaxial Cervical Fractures in Patients with Ankylosing Spinal Disorder.

AIM: To evaluate the patient groups with ankylosing spinal disorder (ASD) in terms of patients? characteristics, applied surgical approaches, and the outcomes. MATERIAL AND METHODS: Between 2008-2019, 50 ASD patients (35?80 years) were operated on subaxial cervical fracture. The mean follow-up time was 48 months. According to the surgical approach, the patients were divided into three groups: patients who only underwent anterior fusion [AF], patients who only underwent posterior fusion [PF], and patients who underwent anteroposterior fusion [APF]. In this retrospective study, we examined the patients? files and outpatient checks to evaluate the history, operations, neurological results, and complications in cases. RESULTS: After undergoing respective surgical interventions, 1 of the 7 patients in the AF group (14%), 2 of the 18 patients in the PF group (18%), and 3 of the 25 patients in the APF group (12%) died. The postoperative American Spinal Injury Association scores were statistically better in all groups than in the preoperative scores. Among the surgical interventions, improvement in the APF group was significantly better than in other groups. CONCLUSION: Although there is a higher amount of surgery related complications in the APF group, the biomechanical and clinical results are better than the other two surgical interventions.

The Outcomes of Endoscopic Third Ventriculostomy in the Treatment of Hydrocephalus: 317 Pediatric and Adult Cases.

AIM: To evaluate the role of endoscopic third ventriculostomy (ETV) as a primary or secondary treatment for hydrocephalus and factors affecting ETV success. MATERIAL AND METHODS: Pediatric and adult patients with symptomatic hydrocephalus treated with ETV during 11 years (2008?2019) in our clinic were retrospectively evaluated. Patients were divided into primary ETV group, in which ETV was the first method of hydrocephalus treatment, and secondary ETV group, in which cerebrospinal fluid (CSF) drainage procedures were initially attempted. Statistical data analyses were performed to compare the outcomes of primary and secondary ETV groups. RESULTS: In total, 317 patients treated with ETV [140 (44%) patients aged 3?18 years and 177 (55%) aged 19?80 years] were followed-up for a mean duration of 60 months. Primary and secondary ETV groups comprised 207 and 110 patients, respectively. Further, 170 (82%) patients in the primary ETV group and fifty-nine patients (53%) in the secondary ETV group benefited from ETV. Primary ETV was associated with the highest probability of success (OR: 11.87). Increasing age (OR: 0.97) and male sex (OR: 4.719) increase the probability of achieving success. The overall prediction accuracy of the model was 72.2%. Kaplan?Meier survival analysis showed no significant difference between categorical groups in terms of time to failure (1.3 and 5 years), sex, ETV type, and categorized age (below 18 and above) (p > 0.05). Complications occurred during or after ETV in 14 patients. CONCLUSION: Unlike most studies, our study includes both adult and pediatric groups. According to the findings obtained in our study, the recovery rate was higher in the primary ETV group (82%) than in the secondary ETV group (53%). According to the model we created, our prediction rate of recovery was 72%. Primary ETV, male sex, and advanced age are important predictors of success in ETV.

The Impact of Myeloperoxidase in the Rupturing of Cerebral Aneurysms.

OBJECTIVE: In this study, we aimed to examine the effect of myeloperoxidase on aneurysm rupture in patients with cerebral aneurysms with and without rupture. METHODS: The study included 53 patients with subarachnoid hemorrhage operated on due to cerebral aneurysm in our clinic, and 49 patients without subarachnoid hemorrhage. After the operation, the domes taken from the aneurysms were embedded in paraffin blocks and scored after hematoxylin and eosin and immunohistochemical staining was carried out. RESULTS: The myeloperoxidase score was 1 in 29.4% of the patients, 2 in 40.2%, 3 in 12.7%, and 4 in 17.6%. Multiple aneurysms were detected in 24.5% of the patients. The median myeloperoxidase score was higher in patients with bleeding aneurysms than those that did not bleed (3 vs. 1; P < 0.001). In addition, the ratio of patients with a myeloperoxidase score of 2 or above was higher among patients with bleeding aneurysms. CONCLUSIONS: In our study, finding myeloperoxidase scores higher in cases of ruptured aneurysms compared with unruptured aneurysms reveals the relationship of myeloperoxidase with ruptured cerebral aneurysms.

Extracranial Metastasis of IDH-1 Wild Type Glioblastomas.

AIM: To identify the effects of different immunohistochemical features of glioblastomas with spinal metastases based on the metastatic spread and survival rate. MATERIAL AND METHODS: A total of 214 patients who were diagnosed with and operated for brain tumor in our clinic between 2007 and 2018, and pathologically diagnosed with glioblastoma were retrospectively evaluated. Among them, 141 medical records were reviewed, and 23 of them underwent spinal magnetic resonance imaging postoperatively due to various complaints. RESULTS: All patients with glioblastoma with spinal metastases had negative isocitrate dehydrogenase 1 (IDH-1) in the immunohistochemical examination. The incidence of spinal metastasis is 1.91%. The median Ki-67 index is 30 (range, 4-90; median Ki-67 index: 30+/-18.5). IDH mutation is wild in 55%, mutant in 33%, and not otherwise specified in 12%. Four patients with spinal metastasis has wild-type IDH with mean Ki-67 index of 60, and one of them was a woman (25%) and the remaining three were men (%75), with mean age of 32 years. CONCLUSION: Gliomas with high immunohistochemical proliferation indexes and wild-type IDH with poor prognostic features based on the new classification tended to metastasize to the spine in the early disease stage; therefore, early spinal scanning and radiation therapy might extend the life expectancy. High Ki-67 index and the presence of wild-type isocitrate dehydrogenase may be the predictive factors for spinal screening.

The Effect of Distal Fusion Level on Functional and Radiographic Parameters in Degenerative Spine Following Long Posterior Instrumentation and Fusion.

AIM: To investigate the effect of distal fusion level on radiographic parameters and functional outcome in patients with degenerative spine disease who undergo long posterior fusion with instrumentation. MATERIAL AND METHODS: This study included 78 adult patients aged > 60 years who underwent long posterior fusion ( > 6 levels) for spinal deformity with a minimum 2-year follow-up. The patients were divided into two groups based on distal fusion level (L5 group and iliac group). Spinopelvic parameters, including lumbar lordosis (LL) and sagittal vertical axis (SVA), were evaluated. Functional outcome was evaluated with the pain visual analog scale (VAS) and the Oswestry Disability Index (ODI) questionnaire. Correlations between clinical and radiographic parameters were calculated statistically. RESULTS: In the L5 group, the mean SVA and LL significantly improved after surgery (p=0.025 and 0.008, respectively). Similarly, the SVA and LL also improved significantly in the iliac group (p=0.002 and 0.001, respectively). In both groups, lumbar VAS, leg VAS and ODI scores significantly improved (p < 0.001). The change in ODI score was significantly greater in the iliac group than the L5 group (p=0.013). CONCLUSION: Although patients did not achieve the desired optimal spinal saggital balance, both L5 and iliac groups showed significant improvement in VAS and ODI scores. The iliac group showed slightly better improvement in ODI score.

Surgical Results of Brainstem Cavernous Malformation Haemorrhage.

AIM: To evaluate surgical treatment options, complications and neurological outcomes of patients with cavernous malformations (CMs) in the pons and medulla oblongata. MATERIAL AND METHODS: We retrospectively evaluated 25 brain stem CMs that we operated between 2009 and 2019. We operated all cases in the first month with suboccipital retrosigmoid and paramedian approach. The cases were evaluated concerning their demographic characteristics, lesion characteristics, radiological imaging results, surgical approach and neurological status. RESULTS: Overall, 15 patients had CMs in the pons and 10 in the medulla oblongata. The mean age of the patients was 33.48 years, and the cases included 15 male and 10 female patients. The average modified Rankin Score (mRS) score had a mean of 2.36 and median of 2 at the time of admission (Table I). The mean follow-up period was 4.64 years (1?10 years). In the last follow-up assessment, the average mRS score was mean = 1.84 and median = 1. In addition, 14 (56%) patients recovered, 7 (28%) did not show any changes, 3 (12%) got worse, and 1 (4%) died. In our case series, the admission complaints were cranial nerve paralysis (24%) in 6 cases, nausea and vomiting in 1 (4%) and hemiparesis in 17 (68%). CONCLUSION: Experience, correct surgical approach and good knowledge of neuroanatomy are important in brainstem CM haemorrhages. Imaging methods, neuronavigation and neuromonitoring use are essential for patients undergoing surgery. In the presence of all these factors, the prognosis of patients will be better.

Sodium Fluorescein for Spinal Intradural Tumors.

Technological innovations in spinal intradural tumor surgery simplify treatment. Surgical treatment of cranial benign and malignant pathologies under microscope with sodium (Na)-fluorescein guidance has often been reported, but few studies have focused on spinal intradural tumors. We aimed to investigate the usefulness of Na-fluorescein under yellow filter in intradural spinal tumor surgery by retrospectively reviewing cases involving intramedullary and extramedullary tumors operated under the guidance of Na-fluorescein. Forty-nine adult patients with a diagnosis of spinal intradural tumor operated under a yellow filter (560 nm) microscope using Na-fluorescein dye were included in the study. Demographic data, such as age and sex, neurological status, extent of tumor resection, histopathological diagnosis, Na-fluorescein staining pattern, and its usefulness during surgery were noted and statistically analyzed. Of all recruited patients, 26 women (53.1%) and 23 men (46.9%), were included for analysis. The age range of the patients was 18-64 years, with a mean age of 41.6 ± 13.9. An intradural intramedullary mass was found in 30.6% (n = 15) of the patients, and an intradural extramedullary mass in 69.4% (n: 34). While Na-fluorescein staining was homogeneous in all intradural extramedullary tumors, 73.3% (n: 11) of intradural intramedullary tumors were homogeneous, and 13.3% (n: 2) moderately heterogeneous. In the whole study group, the Na-fluorescein staining pattern was helpful in surgical resection in 47 cases (95.9%). While 34/34 (100%) found it helpful for extramedullary tumors, 13/15 (86.7%) did in intramedullary tumors, and for 2/15 (13.3%) it was not. In conclusion, Na-fluorescein helps in distinguishing tumor from healthy tissue in intradural extramedullary and intramedullary tumor surgery under a yellow filter microscope in most cases, thus providing convenient assistance to surgeons.

Relationship of spontaneous subarachnoid haemorrhage and cerebral aneurysm to serum Visfatin and Nesfatin-1 levels.

OBJECTIVES: Visfatin and nesfatin are recently discovered peptides that play a role in various metabolic reactions exhibiting inflammatory and neuroprotective effects, and their levels are known to increase in cerebral ischaemia and haematomas. Inflammation plays a role in the development of aneurysm, and spontaneous subarachnoid haemorrhage (SAH) is typically caused by rupture of the aneurysmal sac because of the increased inflammation. In the present study, we investigated the relationship between serum visfatin and nesfatin levels and the clinical and radiological findings in patients with SAH. PATIENTS AND METHOD: Overall, 62 patients with spontaneous SAH who were followed-up in our clinic between September 2018 and July 2019 and 35 healthy patients who presented to our outpatient clinic with complaints of back, lumbar and neck pain were included in the study. ELISA method was used to study the visfatin and nesfatin levels in the serum samples of both groups. The visfatin and nesfatin levels of patients with spontaneous SAH were compared with the healthy population. In addition, the relationship between visfatin and nesfatin levels and the radiological and clinical findings of patients with spontaneous SAH were also investigated. All findings were evaluated statistically. RESULTS: The median nesfatin and mean visfatin levels were higher in patients with SAH compared with the control group. The median nesfatin and mean visfatin levels were higher in patients with aneurysm than those without aneurysm. A positive correlation was observed between aneurysm length and nesfatin and visfatin levels. In patients with perimesencephalic haemorrhage, the mean visfatin level was determined to be lower compared with patients with classical aneurysmatic SAH, and the median nesfatin level did not differ significantly. The cut-off value of nesfatin for predicting SAH in patients compared with controls was >598.4 with 82.8 % sensitivity and 80 % specificity (P <  0.001). The cut-off value of visfatin for predicting SAH was >10.3 with 85.3 % sensitivity and 91.4 % specificity (P <  0.001). The diagnostic performance of visfatin and nesfatin levels was similar in predicting SAH. CONCLUSION: In the present study, we demonstrated that the presence of aneurysm, size of aneurysm, number of aneurysms correlate with visfatin and nesfatin levels in patients with SAH, and visfatin and nesfatin may be biomarkers for predicting SAH and presence of aneurysm. Nonetheless, future studies can include patients with unruptured aneurysm and investigate their serum visfatin and nesfatin levels to prove whether visfatin and nesfatin can serve as biomarkers in the follow-up of these patients.

The Effect of Straight or Lordotic Rods on Cervical Subaxial Alignment While Fusing C1-C2.

BACKGROUND: The C1 lateral mass and C2 pedicle screw with rod fixation system has been used commonly in recent years. Despite the numerous reports on this technique in the literature, there are no studies regarding the effect of the angle of the rod used. We investigated the effect of rod angle on subaxial lordosis, cervical sagittal balance, and pain scores. METHODS: Clinical records and radiologic images of 58 patients who underwent procedures between 2011 and 2016 at our clinic were assessed retrospectively. We recorded clinical findings, visual analog scale (VAS) scores, angles of cervical and segmental lordosis, and the distance between the C2 sagittal vertical axis (SVA) and the C7 posterior-superior corner. RESULTS: A total of 36 male and 22 female patients were enrolled. A negative correlation was found between the C1-C2 lordosis angle and the C2-C7 lordosis angle irrespective of surgical technique. In patients who were operated on using 30°-angled rods, there was a postoperative increase in C1-C2 lordosis degree and an improvement in C2 cervical SVA values. Postoperative month 6 VAS scores were significantly better in the patients who were operated on with angled rods compared with those who received straight rods. CONCLUSIONS: We believe this is because of the positive effect of the angled rod on sagittal balance. Nevertheless, prospective case-control studies should be conducted with larger groups of subjects. Furthermore, every patient should be evaluated considering the whole spinal sagittal balance.

Our surgical experience in foramen magnum meningiomas: clinical series of 11 cases.

INTRODUCTION: We aimed to discuss surgical approaches and results that we applied foramen magnum meningiomas. METHODS: We retrospectively investigated 11 foramen magnum meningioma cases, who had been operated between the dates of February 2012 and March 2017. RESULTS: Eight of the patients were females and 3 of the patients were males, the age range was 32-75 and the age average was 60.8. 5 of the tumors were anatomically localized as posterolateral, 2 of them were localized as anterolateral, 2 of them were localized as lateral and 2 of them were localized as anterior according to the brain stem or spinal cord. Posterior far lateral (4 patients) approach including C1 laminoplasty (7 patients) and 1/3 condyle resection was surgically applied to the patients with median suboccipital craniotomy. Gross total excision was applied to 82% of the patients (9 patients) and subtotal mass excision was applied to 18% (2 patients) of the patients. The most frequent post-operative complications were temporary lower cranial nerve (CN IX and X ) palsy in our 2 anterior localized cases (18%) and also cerebrospinal fluid (CSF) fistula in our 1 anterior localized case with difficulty in swallowing (dysphagia). Karnofsky scores of the patients, who were followed for 18 months in post-operative 12 and 48 months of average, in the last follow-up were 80 and no post-operative mortality occurred. CONCLUSION: Posterior midline suboccipital and far lateral approaches that we apply in our own series were appropriate approaches for foramen magnum meningiomas.

Clinical Results of Median Corpectomy in Cervical Spondylotic Patients with Myelopathy.

AIM: To determine the factors in choosing the right surgical technique for patients with cervical spondylotic myelopathy. MATERIAL AND METHODS: 60 patients were operated with anterior median corpectomy and anterior fusion for cervical myelopathy in Ankara Atatürk Education and Research Hospital between the years 2006-2011. All data were obtained from patient files retrospectively. Patients were evaluated in the preoperative and early postoperative stages and 45 days after discharge by referring to their neurological examinations, Japanese Orthopaedic Association (JOA) and Nurick scores and radiological findings. RESULTS: The average age of the patients was 53.8 ± 9.9 years (38-78) and 45 were male (75%) and 15 were female (25%). Diabetics made up 16.7% (n=10) of the group and nondiabetics 83.3% (n=50). Of the nondiabetic patients, the Nurick score on the first month after surgery was statistically lower than the preoperative and after 24 hours Nurick score (p < 0.001). In the patients in the group that had 1 or 2 myelopathic findings, the Nurick score on the first month after surgery was statistically lower than the preoperative and after 24 hours Nurick score (p < 0.001). The JOA score one month after surgery was statistically lower in patients with myelomalacia than in patients without myelomalacia (p=0.002). CONCLUSION: Median corpectomy and anterior fusion technique had better scores in patients that had few and early myelopathic symptoms, no myelomalacia on MRI, and no systemic disease.