Patient presenting with frontal subperiosteal abscess and headache: a case of Pott's puffy tumour.

Chronic sinusitis can be complicated with erosion of anterior or posterior wall of the sinus; causing Pott's puffy tumour in the anterior, or epidural abscess in the posterior communication. A 65-year old man with a painful swelling in his forehead is presented. Pott's puffy tumour was diagnosed. CT, MRI, and DTI studies were obtained. Epidural or dural involvement was not present. In the first operation, anterior wall of the frontal sinus wall was opened. Osteomyelitis debridement was performed and the frontonasal duct was enlarged endoscopically. Antibiotics were commenced and were continued for 6 weeks. In the second operation, nasal septum deviation was fixed. Postoperative course was uneventful. The presented case suggests that treatment of sinus osteomyelitis should comprise immediate surgical drainage and osteomyelitis debridement followed by long-term administration of antibiotics. MRI study with contrast should be obtained to rule out epidural abscess and dural infiltration.

A new multipartite plate system for anterior cervical spine surgery; finite element analysis.

BACKGROUND: There are numerous available plates, almost all of which are compact one-piece plates. During the placement of relatively long plates in the treatment of multi-level cervical pathologies, instrument related complications might appear. In order to overcome this potential problem, a novel 'articulated plate system' is designed. We aimed to delineate finite element analysis and mechanical evaluations. MATERIAL AND METHODS: A new plate system consisting of multi partite structure for anterior cervical stabilization was designed. Segmental plates were designed for application onto the ventral surface of the vertebral body. Plates differed from 9 to13 mm in length. There are rods at one end and hooks at the other end. Terminal points consisted of either hooks or rods at one end but the other ends are blind. Finite element and mechanical tests of the construct were performed applying bending, axial loading, and distraction forces. RESULTS: Finite element and mechanical testing results yielded the cut off values for functional failure and breakage of the system. CONCLUSIONS: The articulated system proved to be mechanically safe and it lets extension of the system on either side as needed. Ease of application needs further verification via a cadaveric study.

Pituitary macroadenomas (>3 cm) in young adulthood: Pathologic and proliferative characteristics.

BACKGROUND: There are scarce data regarding the significance of the tumor size, hormonal activity and size of the pituitary tumor of the young; therefore, the study was designed to define the relation of the hormonal status of the large pituitary adenomas. OBJECTIVE: We compared those features with tumors of the elderly (>40) with the young patients, and analyzed the clinicopathologic and proliferative features of pituitary macroadenomas in young adulthood (≤40). METHODS: 20-year archives of pituitary tumors in our clinics were reviewed and macroadenomas with diameter≥3 cm were included in the study. We identified 46 pituitary adenomas and immunohistochemically stained them with pituitary hormones, p53 and Ki-67. Twenty-four cases were ≤40-year with an age range of 11-40 years (mean 28.0). Twenty-two cases were >40 with an age range of 44-78 years (mean 58.8). RESULTS: In the young patient group, 15 (62.5%) were functional adenomas (6 prolactinomas, six growth hormone [GH], one adrenocorticotrophic hormone [ACTH] adenoma, two multihormonal [GH+ACTH]) and nine (37.5%) were either gonadotrophic or null cell adenomas. In the elderly group, five (22.7%) were functional adenomas (two adrenocorticotrophic hormone [ACTH] adenoma, one prolactinoma, one growth hormone [GH], one multihormonal [GH+ACTH]) and 17 (77.3%) were either gonadotrophic or null cell adenomas. Ki-67 proliferation index in adenomas of the young was approximately two-folds higher than the elderly (2.7% vs. 1.2%). CONCLUSION: In both groups, rare p53 positivity was identified. In conclusion, pituitary macroadenomas of the young show hormonal expression frequently with relatively high Ki-67 proliferation indices.

An alternative approach to determination of Covid-19 personal risk index by using fuzzy logic.

COVID-19 disease is an outbreak that seriously affected the whole world, occurred in December 2019, and thus was declared a global epidemic by WHO (World Health Organization). To reduce the impact of the epidemic on humans, it is important to detect the symptoms of the disease in a timely and accurate manner. Recently, several new variants of COVID-19 have been identified in the United Kingdom (UK), South Africa, Brazil and India, and preliminary findings have been suggested that these mutations increase the transmissibility of the virus. Therefore, the aim of this study is to construct a support system based on fuzzy logic for experts to help detect of COVID-19 infection risk in a timely and accurate manner and to get a numerical output on symptoms of the virus from every person. The decision support system consists of three different sub and one main Mamdani type fuzzy inference systems (FIS). Subsystems are Common- Serious symptoms (First), Rare Symptoms (Second) and Personal Information (Third). The first FIS has five inputs, fever-time, cough-time, fatigue-time, shortness of breath and chest pain/dysfunction; the second FIS has four inputs, Loss of Taste/Smell, Body Aches, Conjuctivitis, and Nausea/Vomiting/Diarrhea; and the third FIS has three inputs, Age, Smoke, and Comorbidities. Then, we obtain personal risk index of individual by combining the outputs of these subsystems in a final FIS. The results can be used by health professionals and epidemiologists to make inferences about public health. Numerical output can also be useful for self-control of an individual.

Early surgical treatment protocol for sciatic nerve injury due to injection--a retrospective study.

BACKGROUND AND PURPOSE: We retrospectively researched 119 patients with buttock level traumatic injury to sciatic nerves and 42 cases of sciatic nerve injuries due to intramuscular injections were observed among them. Our aim was finding out the post-operative outcomes of early intervention and describing a timing schedule for surgical intervention. METHODS: Between 1984 and 2004 a total of 73 patients were operated on to explore the nerve lesion. These injuries consisted of post-injection injury, hip fracture/dislocation, contusion, compression, gunshot wound, hip arthroplasty and laceration. Our study took into account 29 cases operated because of injection injury. The most common presenting symptom was pain, which often masked underlying loss of function. Findings at operation were analysed according to the type of sciatic nerve damaged following intramuscular injection, the nature of this injury and the referring speciality. Some of the more common causal operations and procedures are discussed. Preventive measures are listed, and early diagnosis and treatment are recommended. The aim of the operation was to establish the diagnosis, to resolve pain and to improve function by epineural or interfasciculary neurolysis. RESULTS: We analysed the findings at operation according to the nature of the injury and the procedures which the patients underwent. Seven patients (24.1%) had an excellent outcome, 14 patients (48.2%) had good outcome and 4 patients (13.8%) had fair outcome. The other four patients (13.8%) had poor outcome. No patients suffered from additional post-operative neurological deficits or from worsening of pre-operative deficits. CONCLUSIONS: Based on our experiences, we recommend measures by which the morbidity rate of these injuries may be reduced. We stress, however, that if the clinical evidence points to transection of a nerve, that nerve may be explored without waiting for electrophysiological confirmation. Delay in recognition and therefore treatment was a cause of litigation, and contributed to the poor outcome in many cases.

Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach.

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36-96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.

The effects of meloxicam on neural tube development in the early stage of chick embryos.

AIM: The aim of this study is to demonstrate the effect of meloxicam in early stage chick embryos on neural tube development. MATERIAL AND METHODS: One hundred specific pathogen-free (SPF) chicken eggs were used to investigate the neurulation. SPF eggs were invastigated in four groups (n:25). All of the groups were incubated at 37.2 +/- 0.1 degrees C and 60 +/- 5 % relative humidity for 30 hours, and an embryological development in the ninth stage as classified by Hamburger and Hamilton was obtained. In the end of the 30th hour, group A(control group) was administered 0.1 ml of saline (0.9% NaCl) in ovo and the other groups were administered meloxicam in increasing doses. At the end of 72 hours, all of the embryos were extracted from eggs and they underwent pathological examination with hematoxylin eosine and immunohistopathological examinations with CD138 and tubulin beta II. RESULTS: While the groups Aand B showed no neural tube defects, totally eight defective embryos were detected in the groups C and D (three in group C and five in group D. CONCLUSION: Our results suggested that meloxicam, a nonselective COX inhibitor, caused neural tube closure defects when injected at supratherapeutic doses. However, further studies with larger numbers of subjects are needed for its use in lower doses.

Use of ultrasonography in ulnar nerve entrapment surgery--a prospective study.

The purpose of our study is to assess the usefulness of high-resolution ultrasonography in observing the morphology and dynamics of the ulnar nerve in the cubital tunnel and also the efficacy of ultrasonography in a more accurate diagnosis and appropriate surgical treatment decision. Cross-sectional area of the ulnar nerves of 40 healthy volunteers in the control group were measured bilaterally at the level of the epicondyle, 2 cm proximal to and 2 cm distal to the epicondyle. Measurements were obtained for elbows both in extension and flexion. Then, we prospectively obtained the cross-sectional area values of 18 patients at the same levels, elbows in extension and flexion position, and compared the data obtained from the patient group and the control group. The differences between the cross-sectional areas of the ulnar nerves in extension and flexion were statistically significant in the patient population (p < 0.001). Mean cross-sectional area of the ulnar nerve in the patient population was calculated as 0.16 cm(2), and we accepted the cut-off point as 0.1 cm(2). This value for cross-sectional area yielded a sensitivity of 90% and a specificity of 100% in diagnosis of ulnar nerve entrapment. Results substantiated conspicuous morphological changes in ulnar nerve during flexion and extension of the elbow. We also observed that as the degree of the nerve displacement by virtue of elbow flexion that is discerned by ultrasonography increased, a more aggressive decompressive surgery was needed for an appropriate treatment.

Two-level contiguous cervical disc disease treated with peek cages packed with demineralized bone matrix: results of 3-year follow-up.

Interbody cages are widely used instruments for cervical fusion operations. Long-term follow-up studies are needed to clarify if these devices are dependable. In this prospective study, 79 patients (42 women and 37 men) with a mean age of 51 years operated between January 2000 and December 2005 for treatment of degenerative cervical disc disease and spondylosis associated with radiculopathy or myelopathy were evaluated. Patients underwent two-level contiguous anterior cervical discectomy and fusion operations with standard anterior Smith-Robinson approach. To achieve fusion PEEK cages packed with demineralized bone matrix mixed with autologous blood were used. Clinical outcome was evaluated with Odom's criteria and results were evaluated as 'excellent', 'good', 'fair' and 'poor'. Spinal curves, mobility and fusion status were assessed with anterior-posterior and lateral (neutral, flexion and extension) radiographs obtained before surgery and at 3, 12, 24 and 36 months postoperatively. The Ishihara curvature index (ICI) was used for spinal curve evaluation. Lateral dynamic (flexion and extension) radiographs at postoperative 12th month revealed the fusion status classified as 1A, 1B, 2A and 2B. The radiological outcomes were classified as 'non-fusion' when 2B healing was observed, and as 'fusion' when 1A, 1B or 2A healing was observed at the levels subjected to surgery. According to Odom's criteria, clinical outcomes were classified as 'excellent' or 'good' in 69 patients (success rate: 87.3%). Eight patients were graded as 'fair' and two as 'poor'. Preoperative mean ICI was 10.4+/-3.72 and postoperative mean ICI was 10.1+/-3.14. The difference was statistically insignificant (P>0.05); therefore, preoperative lordosis was said to be preserved at final follow-up. Final fusion rate (Types 1A, 1B, and 2A) was 91.7% (145/158 levels). Radiological imaging showed no cage failure or dislodgement and reoperation due to non-fusion was not needed.

A less invasive surgical approach in the lumbar lateral recess stenosis: direct approach to the medial wall of the pedicle.

The lateral recess is one of the main compression sites in lumbar spinal canal stenosis. Lumbar nerve root is mainly entrapped by bony tissue in compression syndrome. The patient has a long history of back pain in conjunction with claudication symptoms. Besides laminotomy and facetectomy techniques, several specific surgical approaches to treat the lateral recess stenosis have been described. The surgical technique of bilateral lateral recess decompression via subarticular fenestrations used in this study is a less invasive technique, which enables to decompress the neural structures while preserving as much of the bony structures and ligamentum flavum as preferred. In 16 patients, we measured lateral recess heights with computerized tomography. The number of involved lumbar segments was one in 11 patients and two in 5 patients. The visual analogue scale (VAS) results were maintained before, 3 and 12 months after the operation. All patients benefited from the operations. Mean VAS scores were 7.0, 5.5, and 4.0, respectively. There were not any surgery-related complications. Mean follow-up period is 22.6 months. The surgical technique described and used in this study provides easy access to every zone of lateral recess and is safe and effective in treating the lumbar lateral recess stenosis syndrome.

Recurrent carpal tunnel syndrome: Evaluation and treatment of the possible causes.

AIM: To investigate the causes of the recurrent carpal tunnel syndrome (CTS) and implemented surgical interventions. METHODS: Four hundred and eighty-seven patients, who were diagnosed with CTS and underwent surgical intervention between October 2016 and September 2007, were evaluated in this retrospective study. The age, gender, physical evaluation findings, electrophysiological examination reports and implemented surgical treatment methods were analyzed. RESULTS: Thirty-nine of the cases were operated due to recurrent CTS. Further examination of the patients with recurrent CTS revealed that ten cases had diabetic polyneuropathy, three cases had hypothyroidism, two cases had rheumatoid arthritis and one case had systemic amyloidosis. Postoperative electromyography confirmed the neuropathy was due to systemic diseases. The remaining 23 patients with recurrent CTS did not have any systemic disease and all of them had applied previously to another health center. CONCLUSION: We concluded that the recurrence rates in CTS might be decreased with exploration and incision of the entire transverse ligament. Damage to the motor and sensory branches of the median nerve could be avoided with an incision on the ulnar side.

Use of sonography in carpal tunnel syndrome surgery. A prospective study.

The diagnosis of carpal tunnel syndrome (CTS) is mainly based on the characteristic symptoms and confirmed with nerve conduction studies. Sonography can provide measurements of the increased cross-sectional area of median nerve. The use of sonography was evaluated for the diagnosis and postoperative follow up of 48 wrists in 26 consecutive patients with CTS. Clinical evaluation and sonography were effective for the diagnosis in 40 wrists. Nerve conduction studies were needed in eight wrists, because of the decrease in cross-sectional area of the nerve as a result of degenerative changes. After 3 months, sonography detected statistically significant decreases in the cross-sectional areas of the median nerves. The sonographic studies were well tolerated by all patients. Sonography was both time-saving and cost-effective.

The Role of the Features of Facet Joint Angle in the Development of Isthmic Spondylolisthesis in Young Male Patients with L5-S1 Isthmic Spondylolisthesis.

OBJECTIVE: To investigate facet tropism and its role in development of lumbar isthmic spondylolisthesis (IS) in young men. METHODS: From March 2013 to May 2016, bilateral facet joint angles were measured axially at L3-4, L4-5, and L5-S1 on lumbar computed tomography (CT) in 97 participants (46 patients with IS and 51 control subjects) 20-29 years old. A difference between the 2 corresponding facet angles of <6° was classified as no tropism; a difference of 6°-12°, moderate tropism; and a difference of >12°, severe tropism. RESULTS: We measured 276 facet angles from 46 patients with IS and 306 facet angles from 51 control subjects. For patients with IS, there was no tropism in 43.5% (n = 20), moderate tropism in 50% (n = 23), and severe tropism in 6.5% (n = 3) at L3-4. For L4-5, there was no tropism in 28.3% (n = 13), moderate tropism in 60.9% (n = 28), and severe tropism in 10.9% (n = 5). For L5-S1, there was no tropism in 32.6% (n = 15), moderate tropism in 39.1% (n = 18), and severe tropism in 28.3% (n = 13). For the control group, there was no tropism in 86.3% (n = 44), moderate tropism in 13.7% (n = 7), and no severe tropism at L3-4. For L4-5, there was no tropism in 80.4% (n = 41), moderate tropism in 17.6% (n = 9), and severe tropism in 1.9% (n = 1). For L5-S1, there was no tropism in 68.6% (n = 35), moderate tropism in 29.4% (n = 15), and severe tropism in 1.9% (n = 1). CONCLUSIONS: Facet angle tropism is seen in a high proportion of patients with IS and seems to be a predisposing factor in the etiology of IS.

Demographical Aspects of Central Large Lumbar Disc Herniation.

AIM: The purpose of this study was to investigate the risk factors for the development of the central large disc herniations and to compare the demographic data between central mass prolapse and broad-based central disc herniation. MATERIAL AND METHODS: Between 2002 and 2007, 1630 patients underwent surgery and a large disc herniation was the main problem in 59 patients (3.6%). We performed a retrospective analysis of the demographic data of these patients. Magnetic resonance (MR) images were evaluated according to the disc type and level. Variables were evaluated both at baseline and follow-up, with special emphasis on physical job characteristics, sports activities, and MR - based morphologic findings. RESULTS: Central large disc herniation was diagnosed in 59 patients consisting of 41 males and 18 females. The average age was 34.7 years. 36 patients had a central mass prolapse that occupied more than 50% of the spinal canal. Intraoperative observations confirmed that 29 out of 36 central disc prolapse patients (80.5%) had intact posterior longitudinal ligaments. Interestingly, the condition in these 29 patients was found to have a direct relation with age and occupation or other body training sports activities. CONCLUSION: The size of the large central disc herniation, physical activity, age and gender are major factors in the development of disc herniation.

Basal cell adenocarcinoma of the parotid gland with rare scalp metastasis: a case report.

Salivary gland tumors constitute 3% of tumors in the body. Salivary gland tumors constitute 4% to 10.80% of all tumors in the head and neck tumors and most of them originate from the parotid gland. Most salivary gland tumors are benign. Basal cell adenocarcinoma is a rare salivary gland tumour. Most appear to be benign clinically. Metastases have occurred in less than 10% of patients. A 58-year-old female patient was admitted with the complaint of a growing mass at the top of her head. She was operated for parotid adenocarcinoma two years ago. Computed Tomography (CT) was performed to clarify the relationship between the mass with the calvarium and intracranial region. There is a risk of malignancy in scalp and calvarium lesions. Patients must be subjected to preoperative radiological evaluations.

Peripheral nerve injuries due to osteochondromas: analysis of 20 cases and review of the literature.

OBJECT: Nerve compressions due to osteochondromas are extremely rare. The aim of this retrospective study was to investigate the mechanisms, diagnostic evaluations, and treatment of nerve lesions due to osteochondromas, and to review the literature. METHODS: The authors retrospectively reviewed their clinic data archive from 1998 through 2008, and 20 patients who were operated on due to peripheral nerve injuries caused by osseous growth were enrolled in the study. Patients' age, duration of symptoms, localizations, intraoperative findings, and modified British Medical Research Council (MRC) and electromyography data obtained from hospital records were evaluated. The literature on this topic available in PubMed was also reviewed. All 20 patients underwent surgery, which consisted of tumor excision performed by orthopedic surgeons and nerve decompression performed by neurosurgeons. RESULTS: There were 17 men and 3 women included in the study, with a mean age of 21 years (range 18-25 years). Three patients had multiple hereditary exostoses, and 17 had a solitary exostosis. All of the patients underwent en bloc resection. The most common lesion site was the distal femur (45%). The peroneal and posterior tibial nerves were the structures that were affected the most frequently. The mean follow-up was 3.9 years (range 2-7 years). After the surgery, all patients (100%) experienced good sensory recovery (modified MRC Grade S4 or S5). CONCLUSIONS: To the authors' knowledge, no large series have reported peripheral nerve compression due to exostoses. The authors have several recommendations as a result of their findings. First, all patients with peripheral nerve compression due to an osteochondroma should undergo surgery. Second, preoperative electromyographic examinations and radiographic evaluation, consisting of MRI and CT to provide optimal information about the lesion, are crucially important. Third, immediate treatment is mandatory to regain the best possible recovery. And fourth, performing nerve decompression first and en bloc resection of osteochondroma consecutively in a multidisciplinary fashion is strongly recommended to avoid peripheral nerve injury.

Further modified Taylor retractor for spinal surgery.

New techniques have minimized the incision length and thus required modifications of surgical instruments. The Taylor retractor is one of these instruments. We therefore designed several modifications of the classical Taylor retractor. The following structural modifications were made on the classical Taylor retractor: First, we provided detachable blades with three different lengths (60, 70, 80 mm). Second, we breached a slit wide enough to let the intervertebral disc rongeurs to nestle down in it. Third, instead of a single sharp tip at the end of the blade, an arched blade that had two smooth tips was designed. Adjustable blades allowed placing the retractor just on the skin without any space between the retractor and skin by sliding the retractor over its blade downwards, thus providing a low-profile surgical retraction. The slit facilitated reaching the other side of the disc by leaning against the retractor. Pressing slightly and lowering the retractor subsided the skin and the paravertebral muscle, consequently facilitated motion of rongeurs and provided better exposure owing to low profile retraction. The arched blade with two tips served better placement with less traumatization at the facet joint. The relevant modifications facilitated the surgical procedure. We believe one retractor with adjustable blades is enough for more comfortable surgery at any depth.

Concomitant tubercular and fungal cerebellar abscess in an immunocompromised girl.

Concomitant tubercular and fungal cerebellar abscess is rare and we report the first concomitant recurrent multi-lobulated tubercular and fungal cerebellar abscess in an immunocompromised girl with Histiocytosis-X. She presented with cerebellar abscess history diagnosed during the ongoing treatment for tuberculous meningitis. The abscess was drained. Upon the detection of cerebellar abscess recurrence and pulmonary infection, she was referred to our clinic five weeks after the first surgical intervention. Patient was conscious, co-operating but confused. She had severe cachexia, stiff neck and fever. Fundus examination showed bilateral papilledema. Cranial MR images revealed multiple lobulated lesions. Suboccipital craniectomy was performed and abscess was evacuated in toto. Lesion was multi-lobulated. Thick, yellow-gray purulent material was drained. Histopathological examinations yielded Langhans giant cells,budding and branching fungal structures. Fungal infection was identified. We emphasize that posterior decompression and total resection should be considered first in the management of lesions with mass effect in the posterior fossa. Also the presence of concomitant fatal fungal abscess highlights that although the clinic and former diagnoses of the patient may direct the clinician to a certain pathogen, unusual resistant organisms should not be.

Surgical results of degenerative spondylolisthesis patients over 70 years old: a single-center experience and clinical outcomes.

AIM: The aim of this study is to evaluate results of surgery in Degenerative Spondylolisthesis (DS) patients over 70 years old. MATERIAL AND METHODS: This is a non-randomized retrospective analysis of the clinical outcome of 34 patients older than 70 years who underwent surgery. At the end of two-year follow-up period, preoperative and postoperative courses were assessed by Oswestry Disability Index (ODI) and Visual Analog Scales (VAS). RESULTS: The mean age was 75 years (range 70-86 years). The mean duration of symptoms was 13.5 years (range 2-30 years). All patients underwent physiotherapy and also 15 (11 female, 4 male) patients used brace. L4-L5 was the most commonly affected level (n=26), Preoperative ODI and VAS scores were mean 71,63 (range 34-100) and 6,77 (range 2-9) (p < 0,05). Postoperative ODI and VAS scores were mean 22,73 (range 0-100) and 2,13 (range 0-10) (p < 0,05). Patients were asked if they had known the outcome, would they accept surgical treatment or not. 86.6% (n=26) of the patients answered the question positively. CONCLUSION: A conventional decompressive laminectomy with foraminotomy and posterolateral fusion in situ with transpedicular instrumentation is necessary and reduces pain and recovers functional disability in elderly patients over 70 years old with DS.