Comparison of Clinical and Radiologic Outcomes between Dural Splitting and Duraplasty for Adult Patients with Chiari Type I Malformation.

BACKGROUND: The most used surgical procedure in the treatment of patients with Chiari type I malformation (CIM) is posterior fossa decompression. However, no consensus has been reached regarding the superiority of either dural splitting or duraplasty. Thus, the aim of this study was to compare clinical and radiologic outcomes between the two techniques used in consecutive patients. METHODS: We retrospectively reviewed 74 adult patients with CIM who were diagnosed and treated surgically between 2015 and 2020 at our neurosurgery department. The patients were divided into two groups: dural splitting in group 1 and duraplasty in group 2. Clinical outcomes based on Chicago Chiari Outcome Scale (CCOS) scores at the last control visits were compared between the groups. Radiologic outcomes were compared in terms of tonsillar regression rate based on 12-postoperative-month magnetic resonance images. RESULTS: Overall improved, unchanged, and worsened neurologic statuses were observed in 75.6% (n = 56), 17.5% (n = 13), and 6.7% (n = 5) of our patients, respectively. The mean last visit CCOS scores in groups 1 and 2 were 12.3 ± 2.1 and 13.5 ± 1.7, respectively. The difference between the groups was statistically significant (p < 0.01). The mean tonsillar regression rates were 34.7 ± 17.0% and 52.1 ± 15.3% in groups 1 and 2, respectively, with a statistically significant difference (p < 0.001). CONCLUSION: Adult patients undergoing duraplasty had better clinical and radiologic outcomes than those treated with dural splitting. Therefore, we recommend decompression with duraplasty for adult CIM patients.

A Combined Diagnosis and Treatment Algorithm for Spine Infection Management: A Single-Center Experience.

Background and objective Spinal infection (SI) is an infectious disease affecting the vertebral column, spinal cord, and adjacent structures. The infection can occur following interventions or spontaneously. The aim of this study was to highlight the importance of employing a methodological approach for the accurate and rapid diagnosis of SI and to share information on the most effective treatment method, which involves using a diagnostic-treatment algorithm that can help with SI management. Methodology This study included 50 patients diagnosed with SI between 2016 and 2020. The treatment follow-up period was limited to six months, and the study was conducted as a retrospective cohort analysis. The sample consisted of 22 female patients and 28 male patients, and the mean age of the patients was 50.2 years. All patients received diagnosis and treatment according to the algorithm described in this article. Results In the study group, 60% of patients had an infection in the lumbar spine, 4% in the thoracal spine, 12% in the cervical spine, and 8% in the sacral spine. Previously operated patients were diagnosed on the 30.16th day on average. A total of 19 patients (38%) had no history of undergoing surgery. Radiologically, the most common finding was spondylodiscitis/discitis (32%). Osteomyelitis was detected in one (2%) patient. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most commonly isolated organism in culture results and was detected in 13 patients (26%). The culture results of 12 patients (24%) were negative. The number of patients with active SI who were unstable and stabilized at the time of diagnosis was 11 (22%), and stabilization materials were removed in two patients (4%). In the 6th month of control, the patients did not have any complaints, signs of an infection, or unstable vertebral column. Conclusions We conclude that the combined algorithm we recommend for the diagnosis and treatment of patients with SI can prevent negative deviation and is an effective treatment for this condition.

An endoscope-assisted craniometric cadaveric study for the brain stem and the cisternal segment of the trochlear nerve.

Background and purpose: This study analyzed the relationship of trochlear nerve with neurovascular structures using craniometric measurements. The study was aimed to understand the course of trochlear nerve and minimize the risk of injury during surgical procedures. Methods: Twenty trochlear nerves of 10 fresh cadavers were studied bilaterally using endoscopic assistance through the view afforded by the lateral infratentorial-supracerebellar, and the combined presigmoid-subtemporal transtentorial approaches. Trochlear nerves were exposed bilaterally taking seven parameters into consideration: the distance between the cisternal segment of trochlear nerve and vascular structures (superior cerebellar artery/SCA; posterior cerebral artery/PCA), the origin of the trochlear nerve in the brain stem, the angle in the level of tentorial junction, length, diameter, and length of nerve in the cisternal segment. Results: We identified the brain stem and cisternal segments of the trochlear nerve. The lateral infratentorial supracerebellar approach allowed the exposure of the cisternal segments (crural and ambient cisterns), including the origin of the nerve in the brain stem. The combined presigmoid-subtemporal transtentorial approaches provided visualization of the cisternal segment of the nerve and the free edge of the tentorium. In this study, the mean length and width of the trochlear nerve in the cisternal segment were 30.3 and 0.74 mm, respectively. Length of the trochlear nerve from its origin to its dural entrance was 37.2 mm, tentorial dural entrance angle of the trochlear nerve and exit angle of the trochlear nerve from the brain stem were 127.0 degrees and 54 degrees, PCA to trochlear nerve in mid ambient cistern and SCA to trochlear nerve in mid ambient cistern were 7.3 mm and 6.8mm. Conclusion: Trochlear nerve is vulnerable to injury during the surgical procedures. Therefore, it is necessary to have a sufficient knowledge of the anatomy of cisternal segment and its relationship with adjacent neurovascular structures. The anatomical and craniometric data can be helpful in middle and posterior fossa surgery in minimizing the potential injury of the trochlear nerve.

Hypopharynx injury in anterior cervical discectomy: Failure of surgical repair: Case report.

Hypopharynx injury is a very rare complication of the anterior cervical spine surgery. It is imperative that the complication is managed appropriately with a multidisciplinary approach. In this case, 52 year old male patient underwent C3-4, C4-5, and C5-6 anterior cervical microdiscectomy with interbody fusion and anterior cervical plate surgery. Patient was discharged on the postoperative day 2 with full recovery. During the first follow up at week 1, the patient was found to have leakage of sputum from the incision line. Radiological imaging studies revealed a hypopharynx fistula. First prophylactic course of antibiotic therapy was given; upon persistent leakage from the incision site, it was deemed appropriate to perform hypopharynx repair surgery. However, surgical treatment was not successful, and leakage continued. Thereupon, a controlled sterile environment for secondary granulation was created. Eventually, the leakage was stopped with antibiotic and supporting treatment at the end of week 6. The patient was closely followed for one year. During the one year follow up, the patient did not have any complaints, such as discharge, nor he had any infections. The use of methylene blue in the diagnosis of esophagus perforation, which has high mortality and morbidity rate, provided great benefit. The risk of infection was prevented by creating a sterile environment with a mini colostomy bag.

The Endoscopic Trans-Sinusoidal Trans-Pterygopalatine Route to the Foramen Rotundum Approach in Trigeminal Neuralgia Treatment.

AIM: To describe a new, minimally invasive, and safe access to foramen rotundum via the endoscopic endonasal trans-sinusoidal route for trigeminal nerve blockage. MATERIAL AND METHODS: We studied 5 fresh cadavers bilaterally, and 10 pterygopalatine fossae and maxillary nerves using the endoscopic endonasal trans-sinusoidal trans-pterygopalatine approach. RESULTS: The proposed approach enabled the maxillary nerve to be visualized after revealing the foramen rotundum with the help of some craniometric measurements. Distance between sphenoid sinus lateral wall and maxillary sinus posterior wall was measured. This measurement was found to be an important triangulation point to determine the location of the entrance to the pterygopalatine fossa. The distance between the foramen rotundum and the sphenopalatine artery was found to be significant. The foramen rotundum diameter was calculated, and the maxillary nerve was found to be situated inferolateral to the foramen rotundum. Therefore, the safe entry zone was determined superomedially. No significant difference was found between male and female and the right and left nostrils. CONCLUSION: Various surgical procedures have been applied to treat drug-resistant trigeminal neuralgia. Nevertheless, their cure rates remain less than anticipated. Recurrences up to 30% have been reported in the literature. In this study, the endoscopic endonasal transmaxillary trans-pterygopalatine route offers a new perspective on the foramen rotundum approach and provides a panoramic and safe view in previously high-risk percutaneous interventions.

Hypopharynx injury in anterior cervical discectomy: Failure of surgical repair: Case report.

Hypopharynx injury is a very rare complication of the anterior cervical spine surgery. It is imperative that the complication is managed appropriately with a multidisciplinary approach. In this case, 52 year old male patient underwent C3-4, C4-5, and C5-6 anterior cervical microdiscectomy with interbody fusion and anterior cervical plate surgery. Patient was discharged on the postoperative day 2 with full recovery. During the first follow up at week 1, the patient was found to have leakage of sputum from the incision line. Radiological imaging studies revealed a hypopharynx fistula. First prophylactic course of antibiotic therapy was given; upon persistent leakage from the incision site, it was deemed appropriate to perform hypopharynx repair surgery. However, surgical treatment was not successful, and leakage continued. Thereupon, a controlled sterile environment for secondary granulation was created. Eventually, the leakage was stopped with antibiotic and supporting treatment at the end of week 6. The patient was closely followed for one year. During the one year follow up, the patient did not have any complaints, such as discharge, nor he had any infections. The use of methylene blue in the diagnosis of esophagus perforation, which has high mortality and morbidity rate, provided great benefit. The risk of infection was prevented by creating a sterile environment with a mini colostomy bag.

Chitosan Channels Stuffed with Mesenchyme Originated Stem/Progenitor Cells for Renovate Axonal Regeneration in Complete Spinal Cord Transection.

AIM: To examine the implantation of chitosan channels stuffed with mesenchyme-originated stem/progenitor cells (MSPCs) derived from adult rats in a spinal cord transection model. The level of axonal regeneration, the effect of chitosan channels on the survival of MSPCs, and the functional recovery results were also evaluated. MATERIAL AND METHODS: Chitosan channels stuffed with MSPCs were implanted at the level of T8 in a transected rat spinal cord. MSPCs were harvested from the pelvic bone marrow of adult rats, and the MSPC?chitosan channel group was compared with three control groups. The axonal regeneration capacity, the effect of chitosan channels on the survival of MSPCs, and the functional recovery results were compared among four groups. The survival of MSPCs was evaluated using histopathological techniques and electron microscopy, axonal regeneration/germination was evaluated by confocal microscopy, and locomotor function was assessed for 4 weeks using the Basso, Beattie, and Bresnahan locomotor score. RESULTS: The MSPC-chitosan channel group exhibited enhanced survival of transplanted MSPCs compared with MSPCs transplanted directly into the lesion cavity, although no significant difference was detected in locomotor function between the treatment and control groups. The MSPC-chitosan channel group demonstrated thicker myelination of axons than the other groups. CONCLUSION: Chitosan channels promoted the survival of transplanted MSPCs and created a tissue bridge after complete spinal cord transection. They also induced axonal regeneration and germination. No significant improvement in functional recovery was found between the groups.

Spontaneous nonpulsatile aneurysm of the superficial temporal artery mimicking a subcutaneous mass lesion.

True superficial temporal artery (STA) aneurysms are extremely rare and usually atherosclerotic in origin. Here the authors report a 62-year-old man with a nonpulsatile mass lesion at the trace of the right STA that was surgically excised with a preoperative diagnosis of subcutaneous mass lesion, preoperatively and histopathologically found out to be a thrombosed true STA aneurysm. Preoperative evaluation, differential diagnosis, and management of such lesions are discussed.