Anatomical Features of Neural Foramen at T12â€"L1 Level for Endoscopic Transforaminal Approach of Paramedian and Foraminal Disc Herniations: An Anatomical Study on Fresh Human Cadavers.

AIM: To explore the anatomic features of the neural foramen in particularly at the T12-L1 level in order to assess reveal the safety and efficiency of the endoscopic transforaminal approach for paramedian and foraminal disc herniations at this level. MATERIAL AND METHODS: The study included 15 fresh human cadavers. The soft tissues were removed at the T12-L1 level and bony tissues, were exposed including the transverse processes. The bilateral facets and pars interarticulares at this level were resected revealing the foraminal anatomy and exiting roots. The anatomical structures constituting the triangular safe working zone (TSWZ) were explored. The nerve root length, nerve root width, nerve root angle, TSWZ height, and base of TSWZ base, nerve root width, nerve root angle and disc height were recorded. RESULTS: The root length is the hypotenuse of the TSWZ between the axilla of the exiting root and the lateral margin of the pedicle, and the mean root length was 14.94 ± 2.45 mm. The dural height is the interval between the axilla of the exiting nerve root axilla and the superior end plate of the caudal vertebra, and the mean of the dural height was 10.95 ± 1.74 mm. The base of TSWZ is the distance between the lateral margin of the dural sac and the medial margin of the exiting root, and the mean measurement for the base measurement was 11.83 ± 2.26 mm. CONCLUSION: According to the results data from our cadaveric study, we believe that Kambin’s triangular working zone is a safe area to consider for the endoscopic transforaminal approach at the T12-L1 level, especially for paramedian and foraminal disc herniations.

Percutaneous Balloon Kyphoplasty Vertebral Augmentation for Compression Fracture Due to Vertebral Metastasis: A 12-Month Retrospective Clinical Study in 72 Patients.

BACKGROUND Vertebral compression fracture is common in osteoporosis, but can also occur due to bone metastases, for which current treatment options are limited and include bone-strengthening with cement and supportive care. Kyphoplasty is a surgical method of bone augmentation that can reduce pain, stabilize vertebral bone, and restore some or all of the vertebral body height. The aim of this study was to investigate the clinical results of balloon kyphoplasty in the correction of vertebral deformity due to metastatic vertebral compression fracture. MATERIAL AND METHODS A retrospective clinical study included 72 patients (82 vertebral bodies) with metastases resulting in vertebral compression fracture, treated by percutaneous balloon kyphoplasty; 9 patients were found incidentally to have vertebral metastases. Bone mineral density (BMD) levels were measured. Patient responses from questionnaires, including the visual analog scale (VAS) for pain intensity, and the Oswestry Disability Index (ODI) for disability, were scored. The local kyphosis angle (KA) and the vertebral height ratio (VHR) were measured. All patients were followed up for 12 months. The initial postoperative and 12-month postoperative values, and the preoperative and postoperative values were compared. RESULTS Following balloon kyphoplasty, the KA, VHR, VAS, and ODI scores significantly improved at the final 12-month follow-up compared with preoperative levels (p<0.05, and p<0.001). There was cement leakage in 6 procedures (8.3%) and adjacent segment fracture in 11 procedures (15.2%). CONCLUSIONS Balloon kyphoplasty was an effective method to reduce pain, reduce disability, and improve quality of life by eliminating kyphotic deformity in pathological vertebral compression fractures due to vertebral metastases.

Chronic subdural hematoma associated with arachnoid cyst of the middle fossa : Surgical treatment and mid-term results in fifteen patients.

AIM: We report the neurological and radiological features, surgical management and Mid-term outcome in a series of patients with chronic subdural hematoma (CSDH) and associated ipsilateral arachnoid cyst (AC) of the middle fossa. MATERIAL AND METHODS: Between August 2004 and August 2012, 453 patients were treated with diagnosis of CSDH in our clinic. Of those, 15 patients had ipsilateral arachnoid cyst in the middle fossa. A single burr hole craniostomy was performed to drain the hematoma and the AC left intact at first in 14 patients, one patient had no surgical intervention. Follow-up period ranged from 13 months to 88 months (mean 43.07 ± 23.23 months). RESULTS: The patients having CSDH with AC were found to be younger than the patients with CSDH alone, the mean age was 13.93 ±12.37 years Eleven patients had head trauma 21 to 50 days before admission. Hematoma evacuation through a single burr hole and closed system subdural drainage 2 to 4 days after surgery improved the symptoms in all patients. Two patients developed subdural fluid collection which is treated by subduroperitoneal shunt placement. CONCLUSION: Greater prevalence of ACs in patients with CSDHs has been reported in the literature. We recommend the drainage of the hematoma via a single craniostomy and to leave the AC intact as the first choice of treatment if the associated AC is a Galassi type I or II. Additional subduroperitoneal shunting may be performed in patients with Galassi type III cyst.

Lumbosacral Conjoined Root Anomaly: Anatomical Considerations of Exiting Angles and Root Thickness.

AIM: Conjoined nerve roots (CNR) can be damaged during lumbar disc surgery and lead to neuropathic pain due to excessive retraction. The purpose of this study was to investigate the factors that facilitate the identification of CNRs that can lead to the loss of fragments in the secondary axilla, nerve root injury or unpleasant surprises during lumbar disc surgery. Accordingly, we aimed to measure the thicknesses and exit angles of the nerve roots close to the pedicle to obtain scientific data regarding rare double roots. MATERIAL AND METHODS: The data of 612 patients who were operated for lumbar disc disease in our hospital between 2012 and 2014 were reviewed retrospectively. Twenty one cases of CNR were detected in this series. RESULTS: The mean nerve root thickness was 1.92 ± 0.45 mm for medially located roots and 3.33 ± 0.95 mm for laterally located roots. The comparison of medially located roots versus laterally located roots revealed a significant difference in mean values (p < 0.0001). The mean exit angle was 12.290± 4.890 for medially located roots, and 22.110 ± 5.420 for laterally located roots (p < 0.0001). In addition, the exit angles of the medially and laterally located roots increased as going down to caudal levels, (p=0.005, p=0.042). CONCLUSION: CNRs are congenital anomalies that are usually diagnosed during the surgical procedure and affect the success of discectomy. The presence of a more medially located or thinner root during surgical exploration and the absence of the fragment in the axilla in extruded or sequestered discs usually indicate a conjoined nerve root closer to the pedicle.

Is the presence of linear fracture a predictor of delayed posterior fossa epidural hematoma?

BACKGROUND: Though traumatic posterior fossa epidural hematoma (PFEDH) is rare, the associated rates of morbidity and mortality are higher than those of supratentorial epidural hematoma (SEDH). Signs and symptoms may be silent and slow, but rapid deterioration may set in, resulting in death. With the more frequent use of computed tomography (CT), early diagnosis can be achieved in patients with cranial fractures who have suffered traumatic injury to the posterior fossa. However, some hematomas appear insignificant or are absent on initial tomography scans, and can only be detected by serial CT scans. These are called delayed epidural hematomas (EDHs). The association of EDHs in the supratentorial-infratentorial compartments with linear fracture and delayed EDH (DEDH) was presently investigated. METHODS: A total of 212 patients with SEDH and 22 with PFEDH diagnosed and treated in Göztepe Training and Research Hospital Neurosurgery Clinic between 1995 and 2005 were included. Of the PFEDH patients, 21 underwent surgery, and 1 was followed with conservative treatment. In this group, 4 patients underwent surgery for delayed posterior fossa epidural hematoma (DPFEDH). RESULTS: Mean age of patients with PFEDH was 12 years, and that of the patients with SEDH was 18 years. Classification made according to localization on cranial CT, in order of increasing frequency, revealed of EDHs that were parietal (27%), temporal (16%), and located in the posterior fossa regions (approximately 8%). Fracture line was detected on direct radiographs in 48% of SEDHs and 68% of PFEDHs. Incidence of DPFEDH in the infratentorial compartment was statistically significantly higher than incidence in the supratentorial compartment (p=0.007). Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p<0.05). CONCLUSION: DPFEDH, combined with clinical deterioration, can be fatal. Accurate diagnosis and selection of surgery modality can be lifesaving. The high risk of EDH development in patients with a fracture line in the posterior fossa on direct radiographs should be kept in mind. These patients should be kept under close observation, and serial CT scans should be conducted when necessary.

Giant intradiploic calvarial abscess of posterior fossa behaving progressive mass lesion.

A unique case of a large intradiploic abscess involving posterior fossa osseous structures is reported. A 16-year-old boy presented with a hard mass in the calvarium of posterior fossa region, fever and confusion. Radiological examination revealed an intradiploic collection with compression to cerebellum, fourth ventricle and brain stem, resulting in syringomyelia in cervical and thoracic spinal cord. After drainage and resection of the abscess wall, closure of a round dural defect was performed. The medical history of the patient and the intraoperative observations support the contention that the abscess in the reported case was a result of chronic and subclinical process of an intraosseous infection. The features concerned with diagnosis, differential diagnosis and pathogenesis of this rare entity are discussed.

Re-formation of acute parietal epidural hematoma following rapid spontaneous resolution in a multitraumatic child: a case report.

Acute epidural hematomas resulting from traumatic brain injury remain among the most common causes of mortality and disability. In the literature, there are cases about the resolution and recurrence of spinal epidural hematomas. This case is characterized by the rapid disappearance and re-formation of an acute cranial epidural hematoma (EDH) associated with no overlying skull fracture. Various authors have reported resolution of EDHs managed conservatively, but rapid resolution and recurrence of cranial EDH was not reported before.

Comparison of intrathecal dotarizine and nimodipine treatments in cerebral vasospasm after subarachnoid hemorrhage: an experimental study in rabbits.

BACKGROUND: cerebral vasospasm (CVS) is one of the most considerable complications of subarachnoid hemorrhage (SAH). The aim of this study was to assess and to compare the ability of intrathecal dotarizine and nimodipine to prevent and treat vasospasm in a rabbit model of subarachnoid hemorrhage. METHOD: thirty male New Zealand white rabbits weighing 2,500-3,000 g were allocated into five groups randomly. The treatment groups were as follows: Control, only SAH, SAH/Dotarizine, SAH/Nimodipine, SAH/Vehicle. Forty-eight hours after SAH injection, all animals underwent femoral artery catheterization procedure by open surgery under anesthesia and angiography performed for each animal in the fifth day just before sacrifice. FINDINGS: basilar artery vessel diameters are measured by angiography. Basilar artery vessel diameters and luminal sectional areas are measured in pathology slides. 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 < 0.05). CONCLUSIONS: these findings demonstrate that calcium channel blocker dotarizine has marked vasodilatory effect in an experimental model of SAH in rabbits. Nimodipine is an effect-proven agent in CVS, but dotarizine may take place of it.

Comparison of intrathecal flunarizine and nimodipine treatments in cerebral vasospasm after experimental subarachnoid hemorrhage in rabbits.

BACKGROUND: the aim of this study was to assess and to compare the ability of intrathecal flunarizine and nimodipine to prevent vasospasm in a rabbit model of subarachnoid hemorrhage (SAH). METHOD: forty male New Zealand white rabbits were allocated into 5 groups randomly. The treatment groups were as follows: (1) control (no SAH [n = 8]), (2) SAH only (n = 8), (3) SAH plus vehicle (n = 8), (4) SAH plus nimodipine (n = 8), and (5) SAH plus flunarizine (n = 8). Before sacrifice, all animals underwent femoral artery catheterization procedure by open surgery under anesthesia and angiography performed for each animal. FINDINGS: 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 < 0.05). Basilar artery vessel diameter and luminal section areas in group 4 were significantly higher than in group 2 (p < 0.05). Basilar artery vessel diameter and basilar artery luminal section areas in group 5 were significantly higher than in group 2 (p < 0.05).Basilar artery vessel diameter and basilar artery luminal section areas in group 5 were significantly higher than in group 4 (p < 0.05). CONCLUSIONS: these findings demonstrate that flunarizine has marked vasodilatatory effect in an experimental model of SAH in rabbits.

Pituitary apoplexy after cardiac surgery in a patient with subclinical pituitary adenoma: case report with review of literature.

We report a case of pituitary apoplexy occurring in a 74-year-old patient 6 hours after cardiac surgery. The patient presented with confusion, unilateral ptosis and ophthalmoplegia. Neurological examination revealed right oculomotor nerve palsy and decreased level of consciousness. Magnetic resonance imaging showed a hemorrhagic and necrotic pituitary macroadenoma. After prompt endocrinological replacement therapy with hydrocortisone and levothyroxine, the confusion of the patient resolved. Removal of a non-functional macroadenoma with large necrotic areas resulted in full recovery. The physician should be aware of pituitary adenoma infarction after open cardiac surgery and should remember that it can be fatal or cause permanent neurological or endocrine damage without proper treatment. Surgical and endocrine treatment can be life-saving procedures.