Posterior Endoscope-Assisted Diskectomy Is an Effective Technique for Cervical Soft Disk Herniation.

OBJECTIVE: To evaluate the clinicoradiologic conditions of patients with a herniated cervical disk who were treated with percutaneous endoscope-assisted cervical diskectomy. MATERIALS AND METHODS: The medical data of 27 patients (16 men and 11 women; mean age: 40.9 years) who were operated on with the posterior endoscope-assisted cervical diskectomy method were reviewed retrospectively. The mean follow-up was 35.1 months, and the patients were assessed with combined preoperative and postoperative visual analog scale (VAS), Prolo Functional Economic Outcome Rating scale, MacNab scale, and clinical imaging. RESULTS: The mean preoperative VAS level was 8.6 (range: 7-10), and mean Prolo score was 2.5 (range: 2-5). A postoperative assessment performed 1 week postsurgery found a mean VAS level of 2.1 (range: 0-4). At the final examination, the mean VAS level was 0.81 (range: 0-3), and the mean Prolo score was 4.5 (range: 3-5). The final MacNab scale scores were 62.9%, excellent; 25.9%, good; 7.4%, moderate; and 3.7%, poor. CONCLUSION: Percutaneous endoscope-assisted cervical diskectomy is a suitable and effective treatment method for soft cervical disk herniation.

Initial Discectomy Associated with Aging Leading to Adjacent Disc Disease and Recurrence.

AIM: Failure of surgery for lumbar disc herniation (LDH) can be commonly caused by recurrence. There are many debates regarding the risk factors of recurrent LDH (rLDH) and it is very difficult to define them because many clinical and complicated biomechanical parameters are involved. The purpose of study was to evaluate the long term result of re-discectomy for LDH at the same level and adjacent segments. MATERIAL AND METHODS: Between 1999 and 2009, 1898 cases were operated and 142 (6.4%) patients underwent re-discectomy following initial operation. The study included 65 patients who were operated for single level discectomy, and their charts were analyzed retrospectively. RESULTS: There were 33 (50.8%) women and mean age was 45.5 years (24-73 years). rLDH was diagnosed at the initial level in 40 (61.5%) but adjacent and/or opposite level herniation (with or without the first level) was found in the remaining 25 cases (39.1%). Recurrence at the same level (SLG) and adjacent level groups (ALG) were similar according to the clinical outcomes in follow-up (mean 34.1 months). Admission period after initial operation was also parallel in SLG and ALG (54.7 and 53.1 months, respectively). However, the mean age of ALG (49.4 years) was significantly higher (p≤0.05) than SLG (42.8 years). CONCLUSION: After discectomy, collapsed discs are biomechanically more stable than those with preserved disc heights, and responses to axial compression on intervertebral disc pressure produced deformations of adjacent levels despite limitations. Altered biomechanical loading next to a fusion resulted in ongoing degeneration with aging at the affected entire lumbar spine.

Metamizole Sodium Induces Neural Tube Defects in a Chick Embryo Model.

AIM: The aim of this study was to investigate the effects of metamizole sodium on neural tube development in the early stage chick embryo model that complies with the first month of embryonic development in mammals. MATERIAL AND METHODS: A total of 40 fertilized chicken eggs were divided into 4 equal groups. The eggs were incubated in the incubator at a temperature of 37.8±2°C with 60±5% humidity. Group A was the control, Group B was administered physiological saline, Group C was administered 30 mg/kg metamizole sodium (based on the therapeutic index range of it used in humans) and Group D was administered 90 mg/kg metamizole sodium. All embryos were removed from the egg at the 48th hour and morphologically and histologically examined. RESULTS: Normal development was seen and the neural tube was closed in 17 embryos in Groups A and B. A neural tube defect was seen in 2 embryos in group A and in 1 embryo in group B. A neural tube closure defect was seen in all embryos in group C and 9 embryos in group D. There was 1 dead embryo in Group D. CONCLUSION: Metamizole sodium was seen to produce a neural tube defect in the chicken embyro model.

Neuroprotective effects of adalimumab on rats with experimental peripheral nerve injury: An electron microscopic and biochemical study.

BACKGROUND: Adalimumab, a new-generation anti-inflammatory agent, exerts its effect through tumor necrosis factor α (TNF-α), secreted from immune response cells such as macrophages and lymphocytes. TNF-α has been shown to play an important role in the processes of apoptosis and demyelination, and blockage of its activity may improve neural healing. Investigated in the present study is the probable neuroprotective influence of adalimumab in rats using a peripheral nerve injury model with biochemical and electron microscopic methods. METHODS: Forty adult Wistar albino rats were randomly divided into control, sciatic nerve trauma, low-dose adalimumab, and high-dose adalimumab groups. Six rats from each group were assigned biochemical microscopy, and 4 were assigned electron microscopy. Neural injury was induced with clip compression following dissection of sciatic nerves. Adalimumab was simultaneously injected. The rats were sacrificed after 2 weeks of adalimumab treatment. RESULTS: Nerve tissue lipid peroxidation values were found to be significantly decreased in both the low- and high-dose adalimumab treatment groups, compared to the group subjected only to sciatic nerve trauma. CONCLUSION: Results demonstrate that adalimumab is an effective neuroprotective agent for neural healing, particularly in the early phase.

Multilevel Noncontiguous Spinal Fractures: Surgical Approach towards Clinical Characteristics.

STUDY DESIGN: The study retrospectively investigated 15 cases with multilevel noncontiguous spinal fractures (MNSF). PURPOSE: To clarify the evaluation of true diagnosis and to plane the surgical treatment. OVERVIEW OF LITERATURE: MNSF are defined as fractures of the vertebral column at more than one level. High-energy injuries caused MNSF, with an incidence ranging from 1.6% to 16.7%. MNSF may be misdiagnosed due to lack of detailed neurological and radiological examinations. METHODS: Patients with metabolic, rheumatologic diseases and neoplasms were excluded. Despite the presence of a spinal fracture associated clearly with the clinical picture, all patients were scanned within spinal column by direct X-rays, computed tomography and magnetic resonance imaging. When there were ≥5 intact vertebrae between two fractured vertebral segments, each fracture region was managed with a separated stabilization. In cases with ≤4 intact segments between two fractured levels, both fractures were fixed with the same rod and screw system. RESULTS: There were 32 vertebra fractures in 15 patients. Eleven (73.3%) patients were male and age ranged from 20 to 64 years (35.9±13.7 years). Eleven cases were the American Spinal Injury Association (ASIA) E, 3 were ASIA A, and one was ASIA D. Ten of the 15 (66.7%) patients returned to previous social status without additional deficit or morbidity. The remaining 5 (33.3%) patients had mild or moderate improvement after surgery. CONCLUSIONS: The spinal column should always be scanned to rule out a secondary or tertiary vertebra fracture in vertebral fractures associated with high-energy trauma. In MNSF, each fracture should be separately evaluated for decision of surgery and planned approach needs particular care. In MNSF with ≤4 intact vertebra in between, stabilization of one segment should prompt the involvement of the secondary fracture into the system.

An uncommon intramedullary tumor: primary spinal cord melanoma.

A 47-year-old woman was admitted with complaints of progressive weakness in the lower extremities and pain in the back and left leg. Thoracic magnetic resonance imaging (MRI) revealed a spinal intramedullary tumor between the T9 and L1 levels, which were iso- to hypointense on T2 and slightly hyperintense on T1-weighted images. The tumor was resected as total, and the diagnosis was malignant melanoma confirmed with histopathology. Neurological findings improved at the postoperative period and no residual or recurrence was noted on postoperative MRI at the 9-month follow-up. Primary melanoma of the spinal cord, particularly intramedullar localization, is seldomly reported in the literature. We report a primary malignant melanoma of the spinal cord and emphasize the diagnostic and prognostic challenges.

Preliminary experience with squid: a new liquid embolizing agent for AVM, AV fistulas and tumors.

AIM: The aim of the present study was to analyze our experience with a new liquid embolic agent, Squid, for the treatment of cerebral vascular lesions. MATERIAL AND METHODS: We present 28 patients who were treated with two formulations of Squid (Squid 18 and Squid 12). The lesions included 16 arteriovenous malformation (AVM)s (Spetzler-Martin grade 2 in 8, 3 in 6 and 4 in 2), 9 arteriovenous (AV) fistulas, 2 tumors (glomus tumor and angiofibroma) and 1 AICA aneurysm. Of the 9 patients presenting with hemorrhage, 6 were AVM, 2 were AVF and 1 was aneurysm. RESULTS: The total obliteration rate of the AVMs was 37.5%. Fistulas were closed completely after combined treatment with surgery in 6 out of 9 patients, and one was sent to radiotherapy. There was no mortality. Two reported hemorrhages and thromboembolic complications resulted in permanent deficits in 3 patients. Pathologic examination revealed mild inflammatory reaction with infiltration of polymorphonuclear cells in 5 patients in whom surgery was performed immediately after embolization. Technical problems such as rupture, inability to remove or premature occlusion of the microcatheter related to the embolic agent were not recorded. CONCLUSION: Squid is a safe and effective embolic agent for treatment of cerebral AVMs, AV fistulas, tumors and aneurysms with satisfactory obliteration rate.

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

AIM: This study aimed to investigate the effects of a new generation antiepileptic agent, levetiracetam, on the neural tube development in a chick embryo model that corresponds to the first month of vertebral development in mammals. MATERIAL AND METHODS: Forty-five Atabey® breed fertilized chicken eggs with no specific pathogens were randomly divided into 5 groups. All of the eggs were incubated at 37.8±2°C and 60±5 % relative humidity in an incubator. Group A was control group. The other eggs were applied physiological saline and drugs at a volume of 10 µL by the in ovo method at the 28th hour of the incubation period. Group B was given distilled water; Group C, physiological saline; Group D, Levetiracetam (L8668) at a dose equivalent to the treatment dose for humans (10 mg/ kg), and Group E, Levetiracetam (L8668) at a dose of 10 times the treatment dose. The embryos in all of the groups were removed from the shells at the 48th hour and morphologically and histologically evaluated. RESULTS: Of the 45 embryos incubated, neural tubes of 41 were closed and the embryos displayed normal development. CONCLUSION: Levetiracetam, at a dose equivalent to human treatment dose and 10 times the treatment dose, was shown not to cause neural tube defects in chick embryos.

Tobacco-induced neuronal degeneration via cotinine in rats subjected to experimental spinal cord injury.

OBJECTIVES: Cigarette smoke contains over 4000 chemicals including well-characterized toxicants and carcinogens, among which is cotinine. Cotinine is the principal metabolite of nicotine that has adverse affects on the microcirculation via vasoconstriction, hypoxia and the wound-healing cascade. Its impact on spinal cord injury (SCI) has not been investigated yet. The aim of the present study is to investigate the cotinine effect on SCI. METHODS: 48 male Wistar rats were divided into six groups as follows: sham-control, sham-trauma, vehicle-control, vehicle-trauma, cotinine-control, and cotinine-trauma. Initially, a defined concentration of cotinine blood level was maintained by daily intraperitoneal injection of cotinine for 14 days in the cotinine groups. The concentration was similar to the cotinine dose in the blood level of heavy smokers. Only ethyl alcohol was injected in the vehicle groups during the same period. Then, SCI was performed by a Tator clip. The cotinine groups were compared with rats subjected to vehicle and sham groups by immunohistochemical biomarkers such as glial fibrillary acidic protein (GFAP) and 2,3-cyclic nucleotide 3-phosphodiesterase (CNP) expressions. Electron microscopic examination was also performed. RESULTS: GFAP-positive cells were noted to be localized around degenerated astrocytes. Marked vacuolization with perivascular and perineural edema was seen in the cotinin consumption groups. These findings showed the inhibition of regeneration after SCI. Similarly, vacuolization within myelin layers was noted in the cotinine groups, which was detected through reduced CNP expression. CONCLUSION: Cotinine, a main metabolite of nicotine, has harmful effects on SCI via GFAP and CNP expression. The findings of the present study support the hypothesis that tobacco causes neuronal degeneration via cotinine.

Alveolar hydatid cyst mimicking cerebellar metastatic tumor.

BACKGROUND: Echinococcus multilocularis is a rare infestation in the world with a particularly increased incidence mainly in South America, Central Europe and Asia. Progression of alveolar Echinococcosis is more aggressive that can metastasize to lungs, brain and bones however brain involvement is usually rare with an incidence about 1%. CASE DESCRIPTION: We report a 23-year-old man with a cerebellar Echinococcosis multilocularis mimicking a metastatic cerebellar tumor. Suboccipital craniotomy was performed for gross total removal of the tumor. Histopathological specimens confirmed the diagnosis of Echinococcosis multilocularis. CONCLUSION: Radical surgical excision should be recommended for single Echinococcosis multilocularis lesions particularly at infratentorial localization.

The Royal Book by Haly Abbas from the 10th century: one of the earliest illustrations of the surgical approach to skull fractures.

Haly Abbas was one of the pioneering physicians and surgeons of the Eastern world in the 10th century who influenced the Western world by his monumental work, The Royal Book. The book was first partly translated into Latin by Constantinus Africanus in the 11th century without citing the author's name. Haly Abbas was recognized in Europe after full translation of The Royal Book by Stephen of Antioch in 1127. The Royal Book has been accepted as an early source of jerrah-names (surgical books) in the Eastern world. The chapters regarding cranial fractures in Haly Abbas' work include unique management strategies for his period with essential quotations from Paul of Aegina's work Epitome. Both authors preferred free bone flap craniotomy in cranial fractures. Although Paul of Aegina, a Byzantine physician and surgeon, was a connection between ancient traditions and Islamic interpretation, Haly Abbas seemed to play a bridging role between the Roman-Byzantine and the School of Salerno in Europe.

Lateral orbitotomy approach to orbital tumors: report of 10 cases.

AIM: Lateral orbitotomy is a well-known approach for lesions of the lateral orbital cone. It is still appropriate for laterally situated tumors although contemporary cranial base approaches were defined and developed within the last decades. MATERIAL AND METHODS: Here we report 10 orbital lesions operated with lateral orbitotomy, nine of which were extraconal. Cholesterol granuloma, arachnoid cyst, pleomorphic adenoma, malign epithelial tumor, dermoid cyst, inflammatory granuloma and cavernoma were the pathologies encountered. RESULTS: The extent of lateral orbitotomy should depend on the size, consistency and nature of the lesion for easy removal and less bony resection. In this regard, contrast enhanced CT scans give useful information for operative strategy. The success of surgery can be improved and cosmetic problems can be minimized if meticulous care is taken during orbital rim resection. CONCLUSION: Although there is a wide range of histopathological diagnosis for orbital tumors, lateral orbitotomy is a safe approach, particularly if the lesions are extraconal.

Freehand C1 lateral mass screw fixation technique: our experience.

BACKGROUND: Although C1 lateral mass fixation technique is frequently performed in upper cervical instabilities, it requires the guidance of fluoroscopic imaging. The fluoroscopy guidance is time-consuming and has the risks of accumulative radiation. Biplane fluoroscopy is also difficult in upper cervical pathologic conditions because of the use of cranial fixations. This study aimed to demonstrate that unicortical C1 lateral mass screws could be placed safely and rapidly without fluoroscopy guidance. METHODS: Between 2002 and 2008, 32 C1 lateral mass screws were inserted in 17 consecutive patients with various pathologic conditions involving either atlantoaxial or occipitocervical instability. RESULTS: C1 screw lengths ranged from 18 to 32 mm. The atlantoaxial fixation was performed in 13 patients, and C1 lateral mass screws were added to the occipitocervical construct in 3 patients, to the posterior cervical construct in 2 patients, and to the cervicothoracic construct in 1 patient. In 2 patients, because C1 lateral mass screws could not be inserted unilaterally, C1 pedicle screw analogs were inserted. There were no screw malpositions or neurovascular complications related to screw insertion. Operation time and intraoperative bleeding of the isolated atlantoaxial fixations were retrospectively evaluated. The mean follow-up was 32.3 months (range, 7-59 months). No screw loosening or construct failure was observed within this period. Postoperatively, 4 patients complained of hypoesthesia, whereas one patient had superficial wound infection. CONCLUSION: C1 lateral mass screws may be used safely and rapidly in upper cervical instabilities without intraoperative fluoroscopy guidance and the use of the spinal navigation systems. Preoperative planning and determining the ideal screw insertion point, the ideal trajections, and the lengths of the screws are the most important points.

Functional and clinical evaluation for the surgical treatment of degenerative stenosis of the lumbar spinal canal.

OBJECT: This study was designed to evaluate the efficacy of decompressive surgery for degenerative lumbar spinal stenosis (LSS) on a functional and clinical basis. METHODS: A prospective analysis and follow-up of 125 consecutive patients with degenerative LSS between 2000 and 2006 were performed. All patients underwent surgery for lumbar stenosis. Functional evaluations of the patients were performed using a treadmill, the visual analog scale, and the Oswestry Disability Questionnaire (ODQ). These parameters were recorded before surgery and the 3rd month and 1st and 2nd years after treatment. The first symptom time (FST), maximal walking duration (MWD), and thecal sac cross-sectional area (CSA) before and after surgery were also recorded. Statistical relations between variables were calculated. RESULTS: As patient ages increased, the CSA of the thecal sac decreased. Decompressive surgery reached the target according to the difference between the preoperative and postoperative thecal sac CSA. A correlation between the CSA of the thecal sac and FST, and between the CSA of the thecal sac and MWD could not be established. There was a significant correlation between the FST and MWD, and a negative correlation could be established between the MWD and the ODQ score. Surgery led to significant decreases in the ODQ score. Maximal improvement was observed in the 3rd month after decompressive surgery. CONCLUSIONS: The treatment for LSS should be decided using functional criteria; radiological criteria may not correlate with the severity of the disease. Improvements following lumbar decompression surgery continued within 1 year of treatment according to the ODQ and did not change significantly thereafter.

High dose cotinine may induce neural tube defects in a chick embryo model.

AIM: Nicotine is a well-known agent among 4000 chemicals in cigarettes. About 70 to 80% of nicotine is converted to cotinine, a major metabolite. The aim of the present study is to investigate the effect of cotinine on neural tube development in a chick embryo model. MATERIAL AND METHODS: Sixty fertile, specific pathogen free eggs were divided into 6 groups for this study. In the first group, a fixed cotinine concentration for each egg was calculated just to simulate the concentration of a smoker's blood level. A second experimental group was designed at a higher cotinine concentration. Embryos that succeeded to reach Hamburger-Hamilton stage 12 from each group were then embedded into paraffin for permanent sections. These two groups were compared with eggs subjected to vehicle (standard alcohol and ten times more alcohol concentration) and control groups (saline and sham groups). RESULTS: Embryos of the cotinine (regular dose), vehicle and control groups were normal, but embryos subjected to higher cotinine concentrations were malformed at the cranial part of the thoracic neural tube. CONCLUSION: Association of cotinine with neural tube defects was demonstrated in the present study. Cigarette smoking may induce hazardous effects on neural tube development.

Circumferential total resection of cervical tumors: report of two consecutive cases and technical note.

To date, few studies have addressed the subaxial vertebrectomy technique and related anatomical landmarks in this method. Total spondylectomy is performed via piecemeal resection or en bloc removal in a one-stage procedure associated with stabilizing the spine and preserving neurological status. In this presentation, a circumferential total cervical tumor resection for subaxial cervical spine lesions was described. Two cases of subaxial cervical malignancy, one with primary C3 chondrosarcoma and the other with C4 lung adenosarcoma metastasis, were both treated by the anterior-posterior approach. The lesions could be removed macroscopically totally in both cases. The patients did well after surgery with preserved neurological status and they survived a considerable period without tumor recurrence. Subaxial total tumor resection can be performed safely while preserving vertebral arteries with adequate anatomical knowledge and careful surgical planning, and circumferential vertebrectomy (even intralesional) can provide a long recurrence-free survival period for patients suffering from subaxial spine tumors.

Peripheral nerve disorders and treatment strategies according to Avicenna in his medical treatise, Canon of medicine.

The written transmission of knowledge has played a great part in the advancement of medicine, and historical documents hold the key to a full exploration of the history of medicine. Some fields, including disciplines that deal with peripheral nerve disorders, have received little benefit from such valuable material. In particular, peripheral nerve surgery lacks perspectives from historical data. For many years, physicians have obtained positive results in the surgical treatment of peripheral nerve diseases. Relevant documents reveal that the first author who described the surgical repair of damaged peripheral nerves was Avicenna, a leading figure of the medieval era who lived in the Middle East. In his primary medical work, the Canon, he provides a description, albeit sketchy, of a suture procedure for peripheral nerve transection. This treatise influenced physicians for several centuries. In this presentation, we analyze excerpts from the Canon that concern peripheral nerve disorders and strategies for their management.

Effects of raloxifene on cerebral vasospasm after experimental Subarachnoid Hemorrhage in rabbits.

BACKGROUND: The aim of this study was to investigate the ability of a SERM, RLX, to prevent vasospasm in a rabbit model of SAH. METHODS: Thirty-four New Zealand white rabbits were allocated into 3 groups randomly. Subarachnoid hemorrhage was induced by injecting autologous blood into the cisterna magna. The treatment groups were as follows: (1) sham operated (no SAH [n = 12]), (2) SAH only (n = 12), and (3) SAH plus RLX (n = 10). Basilar artery lumen areas and arterial wall thickness were measured to assess vasospams in all groups. RESULTS: There was a statistically significant difference between the mean basilar artery cross-sectional areas and the mean arterial wall thickness measurements of the control and SAH-only groups (P < .05). The difference between the mean basilar artery cross-sectional areas and the mean arterial wall thickness measurements in the RLX-treated group was statistically significant (P < .05). The difference between the SAH group and the SAH + RLX group was also statistically significant (P < .05). CONCLUSIONS: These findings demonstrate that RLX has marked vasodilatatory effect in an experimental model of SAH in rabbits. This observation may have clinical implications suggesting that this SERM drug could be used as possible anti-vasospastic agent in patients without major adverse effects.

Delayed pseudomyelomeningocele: a rare complication after foramen magnum decompression for Chiari malformation.

BACKGROUND: A variety of complications after FMD with or without duraplasty for Chiari malformation have been described. Although cerebellar ptosis through the dural opening and pseudomeningocele are well-known rare complications of this procedure, spinal cord herniation manifesting as pseudomyelomeningocele formation has not previously been cited in the literature. In this report, we present a case of delayed pseudomyleomeningocele after FMD. CASE DESCRIPTION: A 22-year-old man presented with progressive spinal cord compression symptoms 7 years after undergoing FMD for Chiari malformation. Craniocervical MRI of the patient revealed pseudomyelomeningocele at C1 level together with cord distortion. The patient underwent untethering surgery for spinal cord adhesions; neural tissue was freed microsurgically from the adjacent structures and duraplasty was performed with synthetic graft. In the early postoperative period, his symptoms resolved moderately. CONCLUSION: Neural tissue shift including the spinal cord through the dural opening may occur after a large posterior fossa decompression without duraplasty for Chiari malformation. Postoperative inadequate CSF circulation due to arachnoid scarring around the decompression area may facilitate this type condition. Early diagnosis of such a complication is of vital importance to prevent serious neurologic deficits, and release surgery with proper duraplasty and also restoration of CSF circulation is the choice of treatment.

History of peripheral nerve repair: may the procedure have been practiced in Hippocratic School?

BACKGROUND: The literature regarding the history of the peripheral nerve repair is fairly scant. In the past, few physicians dealt with the topic and made prominent contributions. These works certainly eased the way to the modern concept of surgery of peripheral nerves. During the period between 7th and 17th centuries, Paulus Aeginatus, Avicenna, Roger of Salerno, Guglielmo da Saliceto, Guido Lanfranchi, and Gabriele Ferrara, who are universally accepted as the pioneers in this field, introduced the notion of nerve repair. The central predecessor of all these authors and as well as the founder of modern medicine, Hippocrates, also had reliable interest on peripheral nerve injuries; nevertheless, his written works do not include any section concerning peripheral nerve repair. An exciting document from Ottoman era challenges this issue by citing Hippocrates' nerve repair description. In this report, we present this account with a brief history of nerve repair. METHODS: The relevant section of an early 16th century Ottoman surgical treatise was examined in detail. RESULTS: The chapter regarding the treatments of acute wounds includes an anecdotal case report of nerve repair which is attributed to Hippocrates. CONCLUSIONS: Although attainable works of Hippocrates do not contain nerve repair procedures this Ottoman era medical book suggest that Hippocrates or his pupils may have practiced surgical treatment of nerve injury.