The Effect of Combined Spinal Epidural Anesthesia on Shoulder Pain in Laparoscopic Extraperitoneal Hernia Surgery.

BACKGROUND: Shoulder pain is a condition that seriously discomforts patients and develops caused by a peritoneal tear in laparoscopic extraperitoneal hernia repair (TEP) surgeries. Although surgeons generally prefer general anesthesia for the TEP technique, many studies have been carried out on the use of regional anesthesia in recent years. In our study, we aimed to investigate the efficacy and safety of the combined spinal/epidural anesthesia (CSEA) method to prevent shoulder pain in the TEP technique. METHODS: The patients who operated with the TEP procedure were divided into 2 groups; SA (group 1) and CSEA (group 2). The 2 patient groups were compared in terms of sex, age, body mass index, duration of surgery, total operation time, patient satisfaction, pain scores, length of hospital stay, adverse effects, intraoperative, and postoperative complications. RESULTS: The number of patients in group 1 was 42 and group 2 was 40. The mean operation time was recorded as 55.9 and 80.2 minutes in groups 1 and 2, respectively, which was statistically significantly shorter in group 1 ( P <0.001). Postoperative pain was significantly less in group 2 for the 4th hour ( P <0.0001) and the 12th hour ( P =0.047). There was no difference between the 2 groups in terms of peritoneal tear ( P =0.860). Intraoperative and postoperative shoulder pain was significantly less in group 2 ( P =0.038, P =0015, respectively). CONCLUSION: CSEA is an effective and safe anesthesia method for preventing shoulder pain that develops after TEP surgeries.

Computed Tomography Findings Affecting the Decision of Sternotomy in Substernal Goiter.

Objectives: Although thyroidectomy is completed with a cervical incision in most patients with substernal goiter (SG), sternotomies may be required occasionally. The purpose of this study is to examine computed tomography (CT) findings that may predict the need for sternotomy in SG surgery. Methods: Neck-thoracic CT images of patients who underwent total thyroidectomy with the diagnosis of SG between 2013 and 2022 were retrospectively examined. The patients (n=41) were divided into two groups: sternotomies (n=6) and cervical (n=35). Preoperative pathological data, CT findings, and postoperative complications of the patients were recorded. Results: The total thyroid volume of the sternotomy group (280.75±127.01 mm3) was significantly greater than that of the cervical group (155.38±74.18 mm3) (p=0.015). The retrosternal thyroid volume (mm3), thyroid craniocaudal, and anterior-posterior dimensions (mm) were significantly greater in the sternotomy group (p=0.001, p<0.001, and p=0.004, respectively). While the majority of mediastinal extension degrees in the cervical group were grade 1 (80%), grade 2 (83%) predominated in the sternotomy group (p=0.001). Conclusion: The radiological findings of total thyroid volume, retrosternal thyroid tissue volume, retrosternal thyroid length, thyroid anterior-posterior dimension, and mediastinal extension degree on CT are valuable in predicting the decision to perform a sternotomy in SG surgery.

Comparison of DaVinci Si and Xi robotic platforms for adrenal surgery. Effects on short term outcomes.

OBJECTIVES: To evaluate our experience and short term surgical outcomes between two robotic systems. METHODS: The present study retrospectively analyzed 38 cases, who underwent robotic adrenalectomy between 2012-2019 at our center. The patients were divided into Group Si (n=11) and Group Xi (n=27), and the results of these two groups were compared. RESULTS: Demographic characteristics of both groups were similar between two groups. While, 42% of the patients had Cushing syndrome, 22% had Pheochromocytoma and 22% had Conn syndrome in the Xi group, 72% of the patients were non-secreting adrenocortical adenoma in Si group (p=0.005). The mean docking time in Group Xi was shorter than Si group (p=0.027). Console and total operation times were similar in both groups (p=0.312 and p=0.424; respectively). The intraoperative complication rate (p=0.500) and hospital stay (3.2±1.0 vs. 2.52±1.42 days, respectively, p = 0.077) were similar in both groups. Postoperative 4th and 12th hour Visual Analog Scale (VAS) scores were similar (p=0.213 and p=0.857; respectively). The average cost of robotic consumables was $210 higher in Xi group (p=0.495). CONCLUSION: Our study shows that; the Xi robotic system is as safe as the Si system for adrenalectomy operations. KEY WORDS: Adrenal gland surgery, Minimally invasive adrenalectomy, Robotic surgery.

Comparison of urgent and elective thyroidectomy complications in Graves' disease.

BACKGROUND: Surgical treatment of Graves' disease (GD) has increased risk for bleeding, hypothyroidism and recurrent laryngeal nerve (RLN) palsy compared to other benign thyroidectomy indications. Nevertheless, it can be done safely in high volume centers. In some particular cases (i.e., anti-thyroid drug intolerance or thyrotoxicosis), urgent surgical treatment might be needed. In this study, we aimed to compare the complications of thyroidectomy in urgent and elective management of Graves' disease. METHODS: The patients, who underwent total thyroidectomy due to Graves' disease between 2012-2019 (n=113) were evaluated retrospectively in terms of demographics, pre-operative laboratory results, management, hospital admissions, operative and post-operative short-term outcomes, morbidity and mortality. Patients who were hospitalized to endocrinology department due to uncontrollable hyperthyroidism and related complications and who were prepared for surgery with Lugol's solution, plasmapheresis and steroids were considered as Urgent Group (n=12). Remaining 101 patients who underwent elective surgery considered as Elective Group. Surgical short-term outcomes, morbidity and mortality rates were compared. RESULTS: Of the 113 patients who were operated for GD, 92 were female and 21 were male. In urgently operated group, FT4 and FT3 levels were significantly higher (p<0.001 and p=0.001, respectively). There was no significant difference in transient or permanent hypocalcemia (p=0.821 and p=0.501, respectively), transient or permanent RLN palsy (p=0.356, p=0.634, respectively) and post-operative bleeding (p=0.338), between elective surgery and rapid optimization groups. CONCLUSION: Emergency surgery for Graves' disease can be performed safely with the application of effective pre-operative treatment protocols. KEY WORDS: Graves' Disease, Thyroidectomy complications, Urgent thyroidectomy.

Clinical adaptation of auxiliary methods and multidisciplinary approach to changing trends in parathyroid surgery.

ABSTRACT: To examine the effects of multidisciplinary approach and adjunct methods, on the surgical strategy, complications and treatment success of parathyroid surgery.Patients, who were operated for primary hyperparathyroidism (n = 411) at our institution between 2012 and 2019 were reviewed retrospectively. Preoperative imaging studies, surgical method, additional diagnostic methods used during surgery, frozen section results, and histopathology findings, complications, persistence, and recurrence were examined.Localization was determined by first-line examinations in 79.9% (n = 348). Four-dimensional computed tomography was used with an 83.3% success rate. Lateralization success for angiographic selective venous sampling was 80.3% and exact localization success was 65.1%. Bilateral neck exploration was performed in 10.6% (n = 37) of the patients, and in the remaining 89.4% (n = 311), minimally invasive parathyroidectomy (MIP) was performed. While the complication rate was higher in the bilateral neck exploration group (P = .019), persistence and recurrence rates were similar between 2 groups. During the study period, annual case volume increased from 9 cases to 103 cases (P < .001) and the rate of MIP increased from 44.4% to 92.8% over the years (P < .001).Effective use of adjunct techniques has increased the rates of MIP. The multidisciplinary approach has also provided low complication rates with the increasing number of cases.

Hormonally Active Adrenal tumors; Challenges and Outcomes for Different Surgical Approaches.

OBJECTIVE: The aim of this study is to compare the intraoperative and short-term outcomes of different surgical approaches for hormone active and non-functional adrenal masses. METHODS: The data of 206 patients who underwent adrenal gland surgery in our clinic between 2012 and 2020 were retrospectively analyzed. Pre-operative outpatient clinic records of the patients, imaging methods, laboratory results and surgery records, operation time (OT), amount of bleeding, duration of hospital stay, and complications were evaluated. Patients were divided into two groups as those with non-functional mass (n=80) and those with hormoneactive mass (n=126). RESULTS: The median age of the patients was 52 (range 19-83) and 77.2% of them were female. Tumor size was larger in hormone active group (p=0.311), and the difference was more pronounced in the pheochromocytoma subgroup (p=0.088). The rate of transition to open surgery was similar in both groups (0.959), and no conversion to laparoscopy or conventional open surgery was performed in robotic cases. The duration of surgery (p=0.669), mean amount of blood loss (p=0.834), and mean hospital stay (p=0.195) were also similar between the two groups. Intraoperative and post-operative complications were similar between two groups (p=0.573 and p=0.415, respectively). Considering the subgroup analysis of the patients in hormone active group; the duration of hospital stay was longer in patients with Cushing syndrome (p=0.001), while there was no difference in OT and estimated blood loss between patients who were operated for Conn, Cushing, and pheochromocytoma (p=0.086 and p=0.099; respectively). CONCLUSION: Surgical results of hormone active adrenal masses were found to be similar to non-functional masses. Although the hormonal condition of the mass does not change the difficulty level of the surgical procedure, it may be recommended that the robotic approach be preferred to facilitate manipulation in these masses.

The role of selective venous sampling in patients with non-localized primary hyperparathyroidism.

OBJECTIVES: The aim of this observational clinical study was to evaluate the success of angiographic selective venous sampling (ASVS) in locating parathyroid adenoma in patients with primary hyperparathyroidism (PHPT), in whom the other imaging modalities have failed, and and to evaluate its possible contribution to the applicability of minimal invasive surgery. MATERIAL AND METHODS: Fifty-five patients who were admitted to our hospital's General Surgery department between January 2012 and January 2015 for PHPT in whom ultrasound and sestamibi scintigraphy have failed to localize the diseased gland were included to the study. Patients were divided into two groups: those who underwent ASVS and those who did not. The outcomes of patients were reviewed retrospectively. RESULTS: Among 55 patients, 20 underwent ASVS. ASVS successfully lateralized the diseased gland in 17 (85%) patients, and minimally invasive parathyroidectomy could be performed in 14 (70%) patients. The cut-off value of parathormon gradient was considered 10% for lateralization and the accuracy of ASVS in lateralization was 94.1%. In 11 (59%) patients, the superior-inferior discrimination could be achieved in addition to lateralization. CONCLUSION: ASVS has a high sensitivity in locating the diseased gland in patients with PHPT in whom ultrasound and sestamibi scan have failed, and thereby, rendering the performance of minimally invasive surgery possible. Further studies may reveal the role of ASVS in providing useful information about not only lateralization but also the superior-inferior discrimination.

Pure transoral robotic thyroidectomy; institutional adaptation and early results from a tertiary endocrine surgery centre.

PURPOSE: Novel thyroidectomy techniques have been described to minimize the visible scar. Hereby, we aim to present our experience with transoral robotic thyroidectomy (TORT) without axillary access. MATERIAL AND METHODS: Between August 2018 and March 2019, six eligible patients were enrolled to undergo TORT. Procedures were performed by using the Da Vinci Xi platform under intermittent intraoperative nerve monitoring. RESULTS: All patients were female, and the mean age was 40.0 ± 14.4 years. Three patients underwent total thyroidectomy, and lobectomy was performed for the remaining three patients. In one patient, the procedure was converted to conventional open thyroidectomy due to bleeding. The mean docking time, console time and total operative time were 22.8 ± 5.2 min, 118.5 ± 48.7 min and 218.29 ± 50.6 min for total thyroidectomy and 21.8 ± 4.1 min, 68.6 ± 6.1 min and 177.6 ± 15.1 min for lobectomy, respectively. All patients were discharged uneventfully. CONCLUSIONS: Pure TORT is a safe procedure, when performed in carefully selected patients by experienced surgeons, but further prospective studies with larger number of patients are required.

Transperitoneal laparoscopic surgery in large adrenal masses.

INTRODUCTION: The laparoscopic adrenalectomy (LA) has become the gold standard since the transperitoneal laparoscopic approach was first reported. AIM: To evaluate the applicability, safety and short-term results of laparoscopic surgery in adrenal masses over 6 cm. MATERIAL AND METHODS: Demographic data, hormonal activities, imaging modalities, operative findings, operation time, conversion rates, complications, duration of hospital stay and histopathologic results of 128 patients who underwent laparoscopic adrenalectomy were evaluated retrospectively. Patients included in the learning curve (n = 23), robotic surgery cases (n = 15) and patients with suspected metastasis (n = 4) were excluded from the study. Six cm mass size was taken as a reference and two groups were formed (group 1: < 6 cm, group 2: ≥ 6 cm). The results of the two groups were compared. RESULTS: There were 64 cases in group 1 and 22 cases in group 2. Functional mass ratio and mass sides were similar between the groups (p = 0.30 and p = 0.17, respectively). The mean mass size in group 1 was 36.4 ±11.2 mm and in group 2 82.4 ±15.5 mm. The conversion rate was similar between the two groups (p = 0.18). The duration of surgery was 135.5 ±8.29 min in group 1, 177.0 ±14.9 min in group 2 (p = 0.014). Morbidity and lengths of hospital stay were similar (p = 0.76, p = 0.34 respectively). Adrenocortical carcinoma was detected in three cases in group 1, which were completed laparoscopically, and in two cases in group 2, which were converted to open surgery (p = 0.46). CONCLUSIONS: Although open surgery is still recommended in the guidelines, studies are now being carried out to ensure that laparoscopy can be safely performed on masses over 6 cm. There was no difference between short-term follow-up and histopathologic results in our study.

Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial.

PURPOSE: The use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery. METHODS: The use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission. RESULTS: In our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups. CONCLUSION: Our clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Mean platelet volume in patients with biliary and non-biliary acute pancreatitis.

INTRODUCTION: Acute pancreatitis (AP) is a systemic inflammatory disease. We aimed to detect whether there was a change of mean platelet volume (MPV) level on onset and remission patients with biliary and non-biliary acute pancreatitis. MATERIALS AND METHODS: In our emergency service patients diagnosed with biliary and nonbiliary AP were analyzed retrospectively. Laboratory results measured in onset and remission were recorded and compared. RESULTS: Total number of patients enrolled in our study was 331 (177 female). 194 cases were classified as biliary and 137 were as non-biliary AP. Average age and numbers of female patients of biliary cases were higher than that of nonbiliary cases. Initial MPV values were lower than remission values in all patients with AP. In biliary group initial MPV was 8.42 ± 1.04 and remission value was 8.71 ± 1.12. In nonbiliary group initial MPV was 8.07 ± 1.02 and remission value was 8.4 ± 1.06. In both groups on onset had lower mean MPV levels than those in remission (P = 0.0001 both of them). CONCLUSIONS: MPV values were higher than initial values in remission period in patients both of groups. MPV was lower in non-biliary AP group than biliary AP group that can be an indicator of early-onset infection.

Delayed presentation of posttraumatic diaphragmatic hernia.

BACKGROUND: Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia. METHODS: A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed. RESULTS: Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected. CONCLUSION: Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.

The factors related with postoperative complications in benign nodular thyroid surgery.

Thyroid gland is an important endocrine organ because of its functions. Although the morbidity and mortality of thyroid surgery have decreased markedly, serious complications may still occur. The aim of this retrospective study was to identify the factors influencing the complications in benign nodular thyroid surgery. A total of 332 patients who underwent thyroid surgery between April 2004 and May 2008 were evaluated retrospectively to identify the factors influencing the complications. We found that in surgery lasting more than 90 minutes the risk of permanent recurrent laryngeal nerve (RLN) injury was high, daily drainage more than 50 cc increases the risk of seroma formation, retrosternal goiter surgery have higher risk for bleeding. The flap edema rates were high found in the operations made by resident surgeon and patients with size 3-4 thyroid glands. Low complication rates can be achieved after thyroidectomy with better knowledge of the surgical anatomy of the neck, thyroid pathology and required surgical treatment.

Laparoscopic cholecystectomy and postoperative pain: is it affected by intra-abdominal pressure?

BACKGROUND AND PURPOSE: Intra-abdominal pressure created during laparoscopic cholecystectomy is accepted as a factor for postoperative pain. In this prospective, randomized, clinical study, the goal is to determine the effects of different intra-abdominal pressure values on visceral type pain. MATERIALS AND METHODS: Sixty women who underwent laparoscopic cholecystectomy were included in this study. Low-pressure (8 mm Hg), standard-pressure (SP: 12 mm Hg), and high-pressure (HP: 14 mm Hg) groups were designed for the study. The statistical analysis included mean age, weight, analgesic consumption, postoperative pain assessed by the Numeric Scale, duration of anesthesia, and operation. RESULTS: No statistically significant difference was found between the groups comparing age, weight, analgesic consumption, and Numeric Scale values. In terms of duration of anesthesia, statistically significant difference was found between the groups low-pressure and HP and SP and HP, and statistically significant difference was found regarding operative duration between the groups SP and HP. There was no difference between the others groups. CONCLUSIONS: We think that intra-abdominal pressure has no effect on postoperative visceral pain, but has effect on duration of anesthesia and operation.

Corticosteroid treatment and timing of surgery in idiopathic granulomatous mastitis confusing with breast carcinoma.

Idiopathic granulomatous mastitis (IGM) is an uncommon chronic inflammatory lesion of the breast with an uncertain optimal treatment regimen, the physical examination, and radiologic features of which may be confused with breast carcinoma. In this study, we aimed to describe the clinicopathologic characteristics of 33 patients who admitted to our breast policlinic and took the diagnosis of granulomatous (idiopathic and non-idiopathic) mastitis, and report the place of corticosteroids and the timing of surgery in the treatment of patients with IGM. The clinical features of 33 patients who presented to our breast policlinic with the complaint of breast mass and reached the final diagnosis of GM between March 2005 and October 2009 were reported. The most common symptoms were mass (n: 27) and pain (n: 11). Ultrasonography (USG) and biopsy were performed in all of the patients. Mammography (MMG) was performed in 9, and magnetic resonance imaging (MRI) in 10 patients. The diagnosis of idiopathic lobular granulomatous mastitis (ILGM) was made in 25 patients and tuberculous mastitis (non-idiopathic GM) in the remaining 8 patients. Twenty-four patients received steroid treatment except one who was pregnant. After giving birth, she also received steroids. One of the patients who developed recurrence after 11 months repeated the steroid therapy. Eight patients with tuberculous mastitis were placed on a regimen of antituberculosis therapy for 6 months. In the diagnosis of IGM, physical examination, USG, MMG, and even MRI alone may sometimes not be enough. They should be discussed altogether and the treatment should begin after definitive histopathologic result. Fine needle aspiration biopsy for cytology will result in a high level of diagnostic accuracy, however, core biopsy will reinforce the exact result. Corticosteroid therapy has been shown to be efficacious for IGM, but in the existence of complications such as abscess formation, fistulae, and persistent wound infection, surgical treatment has been the first method of choice.

Impact of slit and nonslit mesh technique on testicular perfusion and volume in the early and late postoperative period of the totally extraperitoneal preperitoneal technique in patients with inguinal hernia.

AIMS: Using slit and nonslit mesh in laparoscopic totally extraperitoneal preperitoneal (TEPP) inguinal hernia repair are well-known approaches. The aim of this prospective, randomized, clinical study was to assess testicular perfusion after these procedures. METHODS: In the study period, 40 male patients with unilateral inguinal hernia were assigned into 2 equal groups as follows: slit (S) and nonslit (NS). TEPP hernia repair was performed in all patients. In the 2 groups, testicular arterial blood flow and testis volumes were measured by Doppler ultrasonography preoperatively, on the 5th postoperative day, and 6 months postoperatively, respectively. RESULTS: No statistically significant difference was found between the preoperative, 5th day postoperatively, and 6-month arterial resistance index (ARI) results when comparing the S and NS groups in ultrasonographic testicular blood flow studies. There was no statistically significant difference of testicular volume between the preoperative period, the 5th postoperative day, and 6 months postoperatively in the 2 groups. CONCLUSIONS: According to the results, no statistically significant difference was found in terms of testicular perfusion and volume between those 2 methods of TEPP repair for inguinal hernia.

Delayed infection 6 years after spinal instrumentation: a case report.

Infection is the major and important complication of spinal instrumentation generally requiring removal of the implant. Although findings of infection usually appear within a few months after operation, they may appear even after few years in some cases. A case with delayed postoperative infection 6 years after surgery is reported. A 27-year-old female with purulent flow from her anterolateral skin incision scar was diagnosed as delayed spinal infection 6 years after anterior and posterior combined spinal instrumentation performed for treatment of giant cell tumor of L3 vertebral body. Staphylococcus aureus was detected from purulent flow. Infection was treated by removal of the implant and antibiotherapy. Spinal infection after instrumentation may appear even a few years later. Patients must therefore be carefully followed for a long time. Staphylococcus aureus can stay silent for a long time.

HER-2, TOP2A and chromosome 17 alterations in breast cancer.

HER-2 amplification is a biomarker for identifying patients who respond to trastuzumab and has been evaluated as a factor predicting the response to anthracyclines. The relationship between HER-2 and response to anthracycline therapy may also be the result of the close localization of TOP2A on 17q. It has been a matter of debate whether these two genes, HER-2 and TOP2A, behave separately on different amplicons or act together thus making it possible to predict the TOP2A status from the HER-2 status. In this study TOP2A, HER-2 and chromosome 17 aneusomy were investigated by fluorescent in situ hybridization (FISH) in 50 consecutive breast cancer patients. HER-2 amplification was detected in 11 patients (22%) and TOP2A changes were seen in 6 patients (12%); two amplifications and two deletions were observed in HER-2-amplified cases and two deletions in HER-2-nonamplified cases. Three of the TOP2A-deleted cases had polysomy 17. HER-2 copy number was higher than the TOP2A copy number in one patient with co-amplification. Polysomy was observed in 9 cases (18%) and monosomy in 6 cases (12%). Aneusomy was the sole anomaly in 11 patients (22%). We conclude that the TOP2A status cannot be predicted from the HER-2 status and evaluation of the TOP2A status only in patients with HER-2 overexpression may lead to missing cases with TOP2A deletion with possible resistance to therapy. Other factors modulating topo II activity may also affect the response to therapy. Studies evaluating different parameters that can modulate topo II activity and the response to the drugs targeting the enzyme are necessary.

Non-contiguous multifocal spinal tuberculosis involving cervical, thoracic, lumbar and sacral segments: a case report.

MAIN PROBLEM: There are only a few cases reported with non-contiguous spinal tuberculosis in the literature. Most of these patients have only two non-contiguous lesions, and in almost all of these cases, surgical treatment is required. METHODS: A 17-year-old girl with non-contiguous multifocal spinal tuberculosis involving cervical, thoracic, thoracolumbar, lumbar and sacral segments is reported. The patient presented with systemic tuberculosis symptoms and signs, and progressive paraparesis. RESULTS: The patient was treated with antituberculous drug therapy and was operated twice for thoracolumbar and cervical spinal lesions. She made an excellent neurological recovery. CONCLUSIONS: In the patients with non-contiguous spinal involvement, there is a high percentage of requirement of surgical treatment. This may be due to "fulminant" behaviour of the disease in these patients. Early surgical treatment of the cases with large abscesses and systemic tuberculosis may provide early improvement, and must probably be the first treatment modality after general support to the patient.