The Spectrum of Underlying Diseases in Children with Torticollis.

AIM: To investigate the underlying conditions in children with torticollis. MATERIAL AND METHODS: Between May 2016 and December 2019, 24 patients (10 girls and 14 boys; mean age, 8 years) presenting with twisted neck, neck pain, weakness of extremities, imbalance, and gait disorder were evaluated retrospectively. RESULTS: Five of the patients had cranial pathologies (cerebellar anaplastic ependymoma and medulloblastoma, brain stem glioma, atypical teratoid rhabdoid tumor, and acute disseminated encephalomyelitis), and five of the patients had spinal pathologies (idiopathic intervertebral disc calcification, vertebral hemangiomatosis, compression fracture, multiple hereditary exostoses, and Langerhans cell histiocytosis at C4). Six of the patients had ocular pathologies (strabismus, Duane syndrome, and Brown syndrome each in two patients). Four patients had otorhinolaryngological infections (Sandifer syndrome, esophageal atresia, reflux, and spasmus nutans, with one patient each). Detailed clinical physical examination and necessary laboratory investigation were performed for all patients. CONCLUSION: Torticollis is a sign that is not always innocent and may herald an underlying severe disease. Misdiagnosis can lead to wrong and unnecessary surgical procedures and treatments, and sometimes, the results can be damaging due to underlying severe conditions if diagnosed late. In addition, we first report a case of vertebral hemangiomatosis and temporomandibular joint ankylosis that presented with torticollis in the English medical literature.

Intraoperative Shortening of Aneurysm Clips: Revisiting an Old Technique in a New Era.

BACKGROUND: It can sometimes be challenging to find a suitable clip to treat an unusual aneurysm, or when the surrounding anatomy is unusual, especially in resource-limited environments. We describe a method to modify aneurysm clips based on the method originated by Sugita et al in 1985. Herein clip modification (Clip-Mod) is used to treat anatomically difficult anterior communicating artery aneurysms. METHODS: The Department of Neurological Surgery database was reviewed to find aneurysm patients treated using modified aneurysm clips. Clip-Mod was performed during surgery by shortening the tines of titanium aneurysm clips by abrasion applied from the side of a standard 3-mm surgical diamond drill bit under constant irrigation. Note that the thickness of the tines and the clip spring were not modified or contacted by the drill. RESULTS: Four cases used modified aneurysm clips, from 648 total clip-treated aneurysms (0.6%) by 2 surgeons over a 14-year period. Three patients presented with subarachnoid hemorrhages that were determined to be due to anterior communicating artery aneurysms. One patient presented with an incidental unruptured anterior communicating artery aneurysm. All 4 patients were treated with 3-mm titanium clips shortened intraoperatively to 1- to 2-mm lengths, to achieve aneurysm obliteration without stenosing parent or perforating vessels. CONCLUSIONS: All 4 patients have done well clinically with no reoccurrences after 2-6 years' follow-up, which included angiographic evaluation. The use of this "Clip-Mod" technique thus appears useful for anterior communicating artery aneurysms. Clip-Mod could also be considered for treating other aneurysms when the "perfect" length clip is not available.

Cervical Hemilaminoplasty with Miniplates in Long Segment Intradural Extramedullary Ependymoma: Case Report and Technical Note.

The surgical approaches for spinal tumors, to a great extent, have been developed in accordance with the developments in medical technology. Today, many surgical techniques are implemented as anterior, anterolateral, posterior, posterolateral and combined approaches. Due to its low morbidity, the posterior approach is the more preferred one. Laminectomy is a widely used technique, especially in neoplastic lesions. However, following laminectomy, there are numerous complications such as instability, kyphotic deformity and scar formation. In this paper, the excision of a tumor that was located intradural-extramedullary at the C3-C7 level with the cervical hemilaminoplasty technique is described. A 47-year-old female patient presented to our clinic with increasing complaints of neck and left arm pain, left arm numbness and searing pain for the last 10 years. On examination, hypoesthesia at the C4-7 dermatomes in the left upper extremity, an increase in deep tendon reflexes, and bilateral positive Hoffmann reflexes were observed. C3-C7 laminae were opened unilaterally on the right side with a midline skin incision. The laminae were drilled with a high-speed drill to provide a wide opening, both on the midline obliquely and from the border of the lamina-facet joint. After the tumor was totally excised, hemilaminae were placed into the previous position and reconstructed with mini-plates and screws. Cervical hemilaminoplasty provides a wide field of vision in tumor surgery of this region. Besides, the reconstruction of hemilaminae is important for stability. As the integrity of the spinal canal is preserved during reoperations of this region, the risk of complications is decreased.

Emergency resection of brainstem cavernous malformations.

Brainstem cavernous malformations (CMs) pose significant challenges to neurosurgeons because of their deep locations and high surgical risks. Most patients with brainstem CMs present with sudden-onset cranial nerve deficits or ataxia, but uncommonly patients can present in extremis from an acute hemorrhage, requiring surgical intervention. However, the timing of surgery for brainstem CMs has been a controversial topic. Although many authors propose delaying surgery into the subacute phase, some patients may not tolerate waiting until surgery. To the best of the authors' knowledge, emergency surgery after a brainstem CM hemorrhage has not been described. In cases of rapidly progressive neurological deterioration, emergency resection may often be the only option. In this retrospectively reviewed small series of patients, the authors report favorable outcomes after emergency surgery for resection of brainstem CMs.

Surgical Strategies for Spondylodiscitis due to Lumbar Disc Surgery.

AIM: Despite different surgical treatment protocols at different centers for spondylodiscitis due to lumbar surgery, there is no consensus on its surgical indications. In this study, we aimed to clarify the steps to be followed in the management and treatment of postoperative spondylodiscitis. MATERIAL AND METHODS: The data of 20 cases with postoperative spondylodiscitis were evaluated. C-reactive protein (CRP) was used for diagnosis and follow-up. According to culture results of the infected material obtained from the operated cases, appropriate antibiotic treatment was initiated. In non-operated cases, parenteral empirical antibiotic treatment was implemented. Surgical treatment was planned for cases with clinical and radiological instability, abscess on imaging and those who were nonrespondent to empirical antibiotic treatment. For the cases that clinically recovered and had normal CRP levels, oral antibiotic treatment was continued after parenteral antibiotic treatment. RESULTS: Of the cases; 13 were male (65%) and 7 were femals (35%). The mean age was 56.3 years (32-74). The most prevalent complaints in referral were waist and leg pain. Except one, all cases had increased CRP levels. All patients had spondylodiscitis on magnetic resonance imaging. Seven had radiological and clinical instability and 3 had epidural abscess. The most commonly growing microorganism in culture was Staphylococcus aureus. Surgical treatment was applied to seven cases and medical treatment to 13 cases. CONCLUSION: In cases with waist pain in the postoperative period, the first potential diagnosis to be considered is spondylodiscitis. Surgical treatment should be implemented for cases resistant to empirical antibiotic treatment, with abscess on imaging, or with lumbar instability.

En Bloc Cervical Laminoplasty While Preserving the Posterior Structure with Arcocristectomy in Cervical Spondylotic Myelopathy.

AIM: To evaluate the clinical success of the en bloc laminoplasty and impact of the arcocristectomy on postoperative axial pain of the patients with cervical spondylotic myelopathy (CSM). MATERIAL AND METHODS: A retrospective review of 81 patients with CSM who underwent en bloc cervical laminoplasty while preserving posterior structure of the cervical spine during the period from 2007 to 2014 was performed. Arcocristectomy was performed if the C6-7 level was included in the surgery. The posterior spinal elements and muscles attached to the spinous process of C2 and C7 were preserved. Thus, postoperative deformity of the cervical spine could be avoided. The neurological status of the patients was assessed using the modified Japanese Orthopedic Association (JOA) scale. The neurological recovery rate was calculated according to the Hirabayashi method. RESULTS: The mean modified JOA scale score was 11.4±2.4 preoperatively and 15.0±3.9 postoperatively. The neurological recovery rate was 68.6%. C7 arcocristectomy was performed in 19 patients. No axial pain was noted in the first 2 postoperative months. Keyhole foraminotomies were performed in 11 patients and radicular pain completely resolved after surgery. Temporary C5 nerve root palsy was observed in 3 patients. Mean cervical spine lordosis was 10.6o±10.5o preoperatively and 8.6o±9.5o postoperatively. No postoperative spinal instability or kyphotic deformity was noted. CONCLUSION: En bloc cervical laminoplasty while preserving posterior structure is useful in preventing postoperative spinal malalignment and axial pain. Arcocristectomy is an effective technique for the prevention of postoperative axial pain in patients with C6-7 spinal stenosis.

Pediatric central nervous system tumors in the first 3 years of life: pre-operative mean platelet volume, neutrophil/lymphocyte count ratio, and white blood cell count correlate with the presence of a central nervous system tumor.

PURPOSE: The aim of this study is to describe the relationship of pre-operative complete blood count parameters [mean platelet volume (MPV), neutrophil/lymphocyte count ratio (NLCR), and white blood cell count (WBC)], with the clinical, radiological, and histopathological features and the management options for patients under 3 years of age with a newly diagnosed central nervous system tumors. METHODS: Children with central nervous system (CNS) tumors in the first 3 years of life admitted in the Erciyes University Hospital between April 2004 and April 2014 were enrolled in this study. The CBC parameters were compared with those of an age- and sex-matched normal control group. RESULTS: In the study group, the means of MPV and WBC were 8.00 ± 1.24 fl, and 10,855 ± 3642/mm3 respectively; the median (25-75%) of NLCR was 0.98 (0.66-1.46). For the control group, the means of MPV and WBC were 6.8 ± 0.73 fl and 8565 ± 2522/mm3; the median (25-75%) of NLCR was 0.52 (0.36-0.70). The MPV, WBC, and NLCR were higher in the study group. The median overall survival (OS) of the patients was 60 months (range 0-81.6 months); and median event free survival (EFS) was 24 months (range 0-70.1 months). The formulation of MPV, NLCR, and WBC was found to be predictive for the diagnosis of CNS tumor in children with nonspecific symptoms. The univariate and multiple binary regression analyses showed a positive association of MPV, NLCR, and WBC and the risk of a diagnosis of CNS tumor. There was no relationship between MPV, WBC, NLCR, and histological subgroups. However, there were no associations between CBC parameters and OS or EFS of the patients. CONCLUSIONS: By causing suspicion, MPV, NLCR, and WBC may provide both an earlier radiological investigation decision and thereby an early diagnosis of CNS tumor in children with nonspecific symptoms in the first 3 years of life.

Intratumoral Ethyl Alcohol Injection for Devascularization of Hypervascular Intracranial Tumors.

AIM: Hypervascular intracranial tumors may cause serious bleeding in surgery. Though pre-operative endovascular embolization of tumor is a widely accepted method, sometimes despite embolization, an effective and safer intraoperative hemostatic technique is needed to prevent or at least decrease the massive bleeding from the tumors. The aim of this study was to investigate the effect of the ethyl alcohol (EA) injection in hypervascular tumors and find out whether it is likely to be an alternative method to prevent massive bleeding from tumor. MATERIAL AND METHODS: Fifty-five cases that had hypervascular intracranial tumor and underwent EA injections into their tumors were included in the study. A small amount (0.1-0.2 ml) of EA was used in every injection. Total EA amount differed from 1.2 to 18 ml for each patient. RESULTS: Most of the tumors were removed with less bleeding, because bleedings stopped or decreased during resection after EA injections. No serious complication that might be related to EA was observed. CONCLUSION: EA injection into the tumor is an easy, cheap and less invasive method to obtain effective and safe tumor devascularization. It may be an alternative method for tumor devascularization when preoperative embolization cannot be performed due to any reason or severe bleeding despite embolization.

Evaluation of Aggressive Behavior and Invasive Features of Pituitary Adenomas Using Radiological, Surgical, Clinical and Histopathological Markers.

AIM: Total surgical resection of pituitary macroadenomas is difficult due to the location of the adenoma and the propensity to invade surrounding tissues. The purpose of this study was to evaluate the risk factors for invasive and aggressive pituitary macroadenomas using radiological, hormonal, clinical, and immunohistochemical markers. MATERIAL AND METHODS: Seventy cases of pituitary macroadenoma were examined. Age, gender, symptoms, the presence of fibrosis within the adenoma, hormonal levels, radiological findings, pathological results and immunohistochemical staining of the patients were evaluated using statistical methods. RESULTS: We observed that the patients with macroadenomas in our study most frequently presented during their 5th decade. The most frequent pituitary adenomas were non-functional, GH-secreting and PRL-secreting macroadenomas. The most frequent complaint was vision loss, headache and acral growth. Based on Magnetic Resonance Imaging (MRI) results, it was observed that the degree of invasion into surrounding tissues increased as the size of the macroadenoma increased. Macroadenomas that had invaded into the cavernous sinus invasion or that had a fibrotic tumor structure had a low probability of being resectable. There were no significant relationships between invasive behavior and p53, telomerase, ghrelin and CD46. CONCLUSION: It is not possible to identify only one factor that affects the prognosis of patients with pituitary macroadenomas. The contribution of the experience of surgeon to the treatment is surely beyond dispute. Fibrotic tumor structure, the surgical technique, the type of hormone, and cavernous sinus invasion affect the ability to perform a total resection and the overall prognosis.

The Results of the Surgical Treatment of Spontaneous Rhinorrhea via Craniotomy and the Contribution of CT Cisternography to the Detection of Exact Leakage Side of CSF.

AIM: To share the results of conventional surgery in rhinorrhea and the contribution of computerized tomography (CT) cisternography to determination of the site of cerebrospinal fluid (CSF) leak. MATERIAL AND METHODS: Twelve cases treated for spontaneous rhinorrhea were included in this study. All the cases underwent cranial CT and magnetic resonance imaging (MRI). CT cisternography was performed in four patients whose bone defect or leakage site could not be detected by CT and MRI. In order to repair the defect, either the galea or galea together with collagen matrix was used and the procedure was supported with fibrin glue. RESULTS: In the cases, postoperative rhinorrhea was seen in neither the early nor the late follow up period. We observed no complications related to CT cisternography or craniotomy. The leakage area was successfully detected with CT cisternography when the other methods failed. CONCLUSION: Bone defect can usually be shown by means of CT. However, when bone-defect cannot be shown or the dura in the defective area is intact, CT cisternography is useful to show the CSF leak. Conventional surgery was very succesful in the treatment of spontaneous rhinorrhea but it was cosmetically problematic. In the patients both treated with galea and galea together with collagen matrix, the repair of the defect was successful.

Microsurgical resection of tumors of the lateral and third ventricles: operative corridors for difficult-to-reach lesions.

Tumors of the lateral and third ventricles are cradled on all sides by vital vascular and eloquent neural structures. Microsurgical resection, which always requires attentive planning, plays a critical role in the contemporary management of these lesions. This article provides an overview of the open microsurgical approaches to the region highlighting key clinical perspectives.

Short Segment Stabilization by Protecting the Alar Ligaments in a Case of Eosinophilic Granuloma Involving the C2 Spine.

BACKGROUND: The craniocervical junction is a complex anatomic location that contains the occipital bone, atlas, axis, and important complex ligamentous structures. The stability of this region is ensured only with the help of ligaments. CASE DESCRIPTION: A 6-year-old boy was admitted to our clinic for neck pain. Computed tomography and magnetic resonance imaging revealed a lytic bone lesion involving the C2 vertebral body and pedicle without odontoid tip. The tumor was resected using an anterior retropharyngeal approach and a wide marginal resection method. The odontoid tip and alar ligaments were protected, and the costal autografts were located between the C1-odontoid tip and the C3 body. The costal graft was stabilized in the C3 body with a miniplate. Then, C1-C3 posterior fixation with fusion was performed. The craniocervical junction was not considered unstable because the occipital bone was not involved in the fusion. Histologic examination confirmed the diagnosis of eosinophilic granuloma. Fusion was detected on a 1-year postoperative cervical computed tomography scan. CONCLUSIONS: The occiput should not be involved in the fusion area when the alar ligaments are preserved during surgery for a C2 lesion.

Torticollis in children: an alert symptom not to be turned away.

PURPOSE: The aim of this study is to investigate the spectrum of underlying disease in children with torticollis. METHODS: We investigated the spectrum of underlying disease and to evaluate the clinical features of the children presented with torticollis in the last 2 years. RESULTS: Of the 20 children (13 girls and 7 boys with the mean age of 8 years, ranging 2 months-12 years), eight of them have craniospinal pathologies (cerebellar tumors in three, exophytic brain stem glioma, eosinophilic granuloma of C2 vertebra, neuroenteric cyst of the spinal cord, Chiari type 3 malformation, arachnoid cysts causing brainstem compression, and cerebellar empyema), followed by osseous origin in five (congenital vertebral anomalies including hemivertebrae, blocked vertebra, and segmentation anomalies), two muscular torticollis (soft tissue inflammation due to subclavian artery catheterization, myositis ossificans with sternocleidomastoid muscle atrophy), and ocular (congenital cataract and microphthalmia), Sandifer syndrome, paroxysmal torticollis, retropharyngeal abscess each in one patients were detected. Ten patients underwent surgery; two patients received medical therapy for reflux and benign paroxysmal torticollis; and one patient with torticollis due to muscle spasm and soft tissue inflammation was treated with physiotherapy. CONCLUSIONS: Various underlying disorders from relatively benign to life-threatening conditions may present with torticollis. The first step should be always a careful and complete physical examination, which must include all systems. Imaging must be performed for ruling out underlying life-threatening diseases in children with torticollis, particularly, if acquired neurological symptoms exist. Besides craniospinal tumors, ophthalmological problems and central nervous system infections should also be kept in mind. Moreover, early diagnosis of these disorders will reduce mortality and morbidity. Therefore, alertness of clinicians in pediatric and pediatric neurosurgery practice must be increased about this alert symptom.

Different etiologies of acquired torticollis in childhood.

INTRODUCTION: Torticollis can be congenital or may be acquired in childhood. Acquired torticollis occurs because of another problem and usually presents in previously normal children. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders. OBJECTIVE: We performed this study to evaluate the underlying causes of torticollis in childhood. MATERIAL AND METHODS: Ten children presented with complaints of torticollis between April 2007 and April 2012 were enrolled in this study. The additional findings of physical examination included neck pain, twisted neck, walking disorder, imbalance, and vomiting The identified etiologies of the enrolled children was acute disseminated encephalomyelitis in a 2.5-year-old boy, posterior fossa tumor in a 10-month-old boy, spontaneous spinal epidural hematoma in a 5-year-old hemophiliac boy, cervical osteoblastoma in a 3-year-old boy, arachnoid cyst located at posterior fossa in a 16-month-old boy, aneurysm of the anterior communicating artery in a 6-year-old girl, pontine glioma in a 10-year-old girl, and a psychogenic torticollis in a 7-year-old boy were presented. CONCLUSION: There is a wide differential diagnosis for a patient with torticollis, not just neurological in etiology which should be considered in any patient with acquired torticollis. Moreover, early diagnosis of etiological disease will reduce mortality and morbidity. Therefore, clinicians managing children with torticollis must be vigilant about underlying neurological complications.