Vertebral arteriovenous fistula due to blunt neck trauma: A case report.

The arteriovenous fistulas (AVFs) of the vertebral artery are usually caused by iatrogenic and penetrating traumas. Vertebral AVF is rarely seen after blunt cervical trauma. A 65-year-old male patient applied to the emergency clinic due to falling from a height of about 3 m. In his neurological examination, he had weakness in the left upper limb and tinnitus in the left ear. The cervical computed tomog-raphy examination showed a Hangman's fracture, a C3 vertebra corpus compression fracture, and a C1 anterior arch fracture. There was a separation on the C1-2 transverse foramen due to the fracture, and there was a fracture in the left C3-4 transverse foramen. In cervical magnetic resonance imaging (MRI), the presence of a contusion in the spinal cord at the C2 corpus level was observed. Through an MRI angiography examination of the vertebral artery, it was determined that the left vertebral artery had developed an AVF at the V2-3 segment level. Stabilization surgery was performed with a posterior approach for unstable vertebrae. Then, vertebral AVF was then closed endovascularly using a stent coil. Improvement in neurological deficit was seen after surgery and endovascular treatment. There were no complications related to the procedure. Transverse foramen should be carefully evaluated, especially in the upper cervical trauma. Vertebral artery imaging should be performed before instability surgery in the presence of a separation in the fracture line to determine whether the damage to the vertebral artery is iatrogenic.

The Effect of the COVID-19 Pandemic on Functioning of Neurosurgery Clinics and the Anxiety Levels of Neurosurgeons in Turkey.

AIM: To reveal the impacts of the novel coronavirus 2019 (COVID-19) pandemic on the functioning of neurosurgery clinics and to determine the anxiety levels and attitudes of Turkish neurosurgeons towards their profession during the pandemic. MATERIAL AND METHODS: The Beck anxiety inventory and a clinical activities scale were utilized as data collection tools and distributed to neurosurgeons in Turkey as an online survey. Descriptive statistical methods, significance tests and correlation and regression analyses were employed to analyze the data. The data analysis was carried out in a 95% confidence interval. RESULTS: Of the 240 neurosurgeons who participated in the study, 63.8% had encountered cases of COVID-19 and 53.8% had handled patients diagnosed with COVID-19. The study results showed that the pandemic did not cause anxiety in 62.9% of the respondents, but it caused mild anxiety in 13.8% and moderate anxiety in 12.12%. The findings also revealed a low linear correlation between the anxiety values and occupational anxiety of the neurosurgeons and low inverse correlation between anxiety values and the protection factor in the pandemic period. CONCLUSION: The COVID-19 pandemic has caused serious disruptions in the routine functioning of neurosurgery clinics and changes in the attitudes of neurosurgeons. Healthcare organizations should take the necessary precautions and measures to resolve the anxiety problems of healthcare professionals, such as providing professional support, and ensure that they can work in a safer environment.

Retinal nerve fibre and ganglion cell inner plexiform layer analysis by optical coherence tomography in asymptomatic empty sella patients.

Purpose: To investigate the clinical importance of the thicknesses of the retinal nerve fibre (RNFL) and ganglion cell and inner plexiform layer (GCL+) by spectral domain optic coherence tomography (SD-OCT) in asymptomatic empty sella (ES) patients.Materials and methods: In this cross-sectional, non-randomized prospective study, 44 ES patients and 74 age- and sex-matched healthy individuals were evaluated. All the patients and controls competed an automated 30-2 visual field (VF) test. The mean deviation (MD), pattern standard deviation (PSD), RNFL, and GCL + thickness values obtained with SD-OCT were compared statistically between the two groups.Results: No marked VF defects were found in either group, and there was no statistically significant between-group difference in MD or PSD values. In terms of RNFL thickness, the average and superior quadrant RNFL values of the ES patients were thinner than those of the controls, with statistical significance (p = 0.013 and p = 0.043, respectively). Although other measured RNFL quadrant thicknesses and foveal thickness (FT), macular volume (MV), and average macular thickness (AMT) values were reduced in the ES group, these differences were not statistically significant. The average GCL + value and GCL + values in six sectors in the patient group were significantly lower than those in the control group.Conclusions: Asymptomatic ES patients have a risk of primary ES syndrome and should be followed up using a multidisciplinary approach. Objective and quantitative RNFL and GCL + thickness measurements obtained with OCT can provide valuable data for monitoring these patients.

Comparison of Unilateral versus Bilateral Pedicle Screw Fixation in Transforaminal Lumbar Interbody Fusion for Single Level Lumbar Degenerative Diseases and Review of Literature.

AIM: There are some recognized treatment modalities in the literature for the treatment of lumbar degenerative diseases,which cause pain and avoidance of daily life activities for the patients.The most widely accepted algorithm in the literature is medical treatment,physical therapy and minimally invasive pain-relieving therapies,if necessary,followed by surgical interventions.The common procedure used in neurosurgery practice is the decompression of neural elements followed by fusion.It is reported in the literature that unilateral pedicle fixation and Transforaminal Lumbar Interbody Fusion(TLIF) procedure have many advantages compared to bilateral pedicle screw implementation(PSF).We examined the clinical and radiological follow-up and results of our patients undergoing fusion procedure by unilateral versus bilateral pedicle screw fixation along with TLIF. MATERIAL AND METHODS: 54 patients were included in the study.33 patients were operated with bilateral PSF and TLIF and 21 had unilateral PSF and TLIF.The patients were evaluated preoperatively,on the postoperative 15th day,6th and 12th month, and at the time of last examination (38 months in average for all patients) using Visual Analogue Scale(VAS) and Oswestry Disability Index(ODI).Fusion rates were examined with direct X-ray films with flexion-extension dynamic views and 3D CT scan. RESULTS: Operation times are shorter and blood loss is less in the unilateral PSF group.Fusion rates are similar in both groups with no statistical significance.For both groups significant clinical improvement was observed in the preoperative and postoperative scores. CONCLUSION: Unilateral PSF along with TLIF procedure is an effective option in selected patients.We need prospective randomized studies with higher number of patients and longer follow-up periods for more reliable results.

Clinical Outcomes of Posterior C1 and C2 Screw-Rod Fixation for Atlantoaxial Instability.

AIM: In this study, we aimed at sharing our experiences and contributing to the literature by making a retrospective analysis of the patients we operated with screw-rod system for atlantoaxial instability in our clinic. MATERIAL AND METHODS: Archive files of adult patients, who were operated for posterior C1-C2 stabilization with screw and rod in our clinic between January 2006 and January 2016, were analyzed. 28 patients, who had pre and post-operative images, follow-up forms and who were followed for at least one year, were analyzed. Preoperative clinical and radiological records, preoperative observations, postoperative complications, and clinical responses were evaluated. RESULTS: The average age of 28 patients (F:13 M:19) was 44.7 (21-73). Fixation was performed with C1-C2 screw-rod system on the basis of the following diagnoses; type 2 odontoid fracture (16), basilar invagination (5), C1-C2 instability (5), and atlantoaxial subluxation secondary to rheumatoid arthritis (2). Lateral mass screws were inserted at C1 segment. C2 screws inserted were bilateral pedicle in 12 cases, bilateral pars in 4, bilateral laminar in 8 and one side pars, one side laminar in 4 cases. There was no screw malposition. Neither implant failure nor recurrent instability was observed during follow-up. Significant clinical improvement was reported according to the assessments done with JOA and VAS scores. CONCLUSION: C1-C2 screw fixation is regarded as a more successful and safe method than other fixation methods in surgical treatment of atlantoaxial instability considering complications, success in reduction, fusion and fixation strength. C2 laminar screw technique is as successful as the other alternatives in fixation and fusion.

Prevention of Epidural Fibrosis Using Ranibizumab in a Postlaminectomy Rat Model.

AIM: One of the most significant reasons for persistent low back pain experienced after spinal surgery is epidural fibrosis seen after laminectomy procedures. This study shows the effects of Ranibizumab on spinal epidural fibrosis in the laminectomy area by blocking the effect of vascular endothelial growth factor. MATERIAL AND METHODS: Twenty Wistar rats were used in this study. Rats were divided into two groups; a control group and a ranibizumab group. Only laminectomy was performed to the control group. In the ranibizumab group, 0.6 mg/kg ranibizumab diluted in 0.9% NaCl with the ratio of 1:10 was applied topically. Three weeks later, the vertebral columns were resected en bloc including the whole laminectomy area in both groups and evaluated histopathologically. Results were compared using statistical tools. RESULTS: Based on the statistical analysis, our data show that less epidural fibrosis was seen in the ranibizumab group compared to the control group (P < 0.05). CONCLUSION: Topically applied Ranibizumab is significantly effective in preventing epidural fibrosis in rats occurred after laminectomy.

Aneurysmal bone cysts of the spine.

PURPOSE: Aneurysmal bone cyst is a benign, relatively uncommon lesion, representing 1.4 % of primary bone tumors. The vertebral column is involved in 3-30 % of cases. This report describes clinical characteristics and treatment results of 18 patients with aneurysmal bone cyst of the spine. METHODS: Between 1991 and 2008, 18 patients with aneurysmal bone cyst of the spine were surgically treated in our department. The clinical records, radiographs, histologic sections, and operative reports were analyzed. RESULTS: There were 11 male and 7 female patients; mean age was 22.1 years (range 7-46 years). Localizations were cervical (3), cervicothoracic (2), thoracic (3), lumbar (4), and sacrum (6). Tumor was localized on the left side in 11 cases, on the right side in 2 and at midline in 5 patients. The two most common clinical features were axial pain (14 patients) and radicular pain (8 patients). Neurological signs were paraparesis in 3, monoparesis in 6. Mean duration of symptoms was 9 months (range 3 months-3 years). All patients underwent surgery: total removal was performed in 13 patients and subtotal resection in 5. Posterior (11), anterolateral (1), or combined anterior-posterior (6) approaches were used. Mean follow-up duration was 112.3 months (range 4-21 years). We detected four recurrences in subtotal excision group (4/5), and one recurrence in total excision group (1/13). CONCLUSION: Treatment options for aneurysmal bone cysts are simple curettage with or without bone grafting, complete excision, embolization, radiation therapy, or a combination of these modalities. Radical surgical excision should be the goal of surgery to decrease the recurrence rate. Recurrence rate is significantly lower in case of total excision.

Giant sacral schwannomas.

Sacral schwannomas are very rare tumors. There are merely around 50 cases reported in the literature most of which are case presentations. In this study we present a 13-case series, which is one of the most extensive series in the literature. Thirteen giant sacral schwannoma cases operated at Ege University, Faculty of Medicine, Neurosurgery Department between 1995 and 2010 are investigated retrospectively. All patients were assessed with direct radiography, computerized tomography (CT) and magnetic resonance imaging (MRI). The patients were operated, after the diagnosis through biopsy patients with Sridhar Type V classification are included in the study. Five patients were male, eight were female and the average age was 37.1 (ranging between 14 and 55). All the patients were suffering from back and leg pain at the time of consultation. Four patients had sphincter problems and three had weakness in the leg. After the biopsy and histological analysis, intralesionary resections were performed. Five patients went through both anterior and posterior interventions, six patients had only posterior and two had just anterior intervention. One patient had iliac vein injury during the anterior surgery. This patient was reoperated for embolectomy and vein graft because of thrombosis. Average follow-up period was 8.1 years (1-15 years). All patients were assessed with MR annually. A small residual tumor was detected in two patients, however they were not reoperated. Although sacral schwannomas are rare tumors, the diagnosis is not so difficult with CT and MRI. In this study, we suggest biopsy for predetermination of the nature of the tumor as it affects the treatment choice and the method of operation. Surgically, a simple intralesionary excision is an appropriate choice.

[Pediatric head injuries, retrospective analysis of 851 patients: an epidemiological study]. / Çocukluk çagi kafa travmalari, 851 olgunun retrospektif degerlendirilmesi: Epidemiyolojik bir çalisma.

BACKGROUND: The aim of this study was to contribute to the epidemiological database of our country about pediatric head injuries. METHODS: We retrospectively analyzed 851 patients younger than 14 years old with head injury, treated in the Neurosurgery Department of Samsun Mehmet Aydin Education and Research Hospital between January 2003 and June 2008. RESULTS: Five hundred and fifty (65%) patients were male and 301 (35%) were female. Falls (70%) were the most common cause of head injury. According to Glasgow Coma Score (GCS), 74% of patients had mild (13-15), 22% moderate (9-12) and 4% severe (3-8) head injury. Eighty-seven (10.5%) patients were operated. The commonest operations were performed for depressed fractures and epidural hematomas. The mortality rate was 3.8% (33). Common causes of mortality were traffic accidents and falls from heights. CONCLUSION: Other reported studies and this study show that the majority of pediatric head injuries occur as a result of preventable causes. It is important to have local epidemiological studies and data about head injuries in order to prevent these traumas before their occurrence.

Experience of Carpal Tunnel Syndrome that operated using a limited uni skin incision.

AIM: Releasing the carpal tunnel for Carpal Tunnel Syndrome (CTS) is the most common surgical procedure in neurosurgical practice. In this study, we aimed to analyze the outcome of patients operated on for carpal tunnel syndrome using a limited uni skin incision. MATERIAL AND METHODS: Between June 2007 and November 2009, we performed 143 carpal tunnel releasing procedures for 126 patients. There were 112 (% 89) female and 14 (% 11) male patients with a mean age of 53 (27-81). 79 operations were performed for the right hand and 64 for the left hand. RESULTS: Each patient was evaluated with their history, physical examination and electromyelography (EMG). All patients had brachialgia paraesthetica nocturna and severe CTS by EMG. Pre- and post-operative Visual Analog Scale (VAS) and Visual Analog Patient Satisfaction Scales (VAPSS) were used for clinical evaluation. There was no complication such as bleeding or nerve injury in the operated patients. The mean follow up period was 13 months (3-24 months). The mean VAS score was 7.9 pre-operatively and 2.8 post-operatively and the mean VAPSS score was 8.1. Three patients underwent re-operation because of the recurrence of symptoms. There was no procedure-related complication during the follow-up period. CONCLUSION: The limited uni skin incision is a safe and effective minimal invasive procedure for releasing the carpal tunnel.

[Retrospective analysis of 954 adult patients with head injury: an epidemiological study]. / Kafa travmasi nedeniyle tedavi edilen 954 eriskin olgunun retrospektif degerlendirilmesi: Epidemiyolojik çalisma.

BACKGROUND: Head traumas are among the most common causes of mortality and morbidity among young adults in urban areas. We aimed to contribute to the epidemiological database of our country with regard to head traumas. METHODS: We retrospectively analyzed 954 patients older than 15 years with head trauma who were treated in the Neurosurgery Department of Samsun Mehmet Aydin Education and Research Hospital between January 2003 and June 2008. Seven hundred twenty-one (75.5%) patients were male and 233 (24.5%) were female. Five hundred twenty-one (52.5%) were between 15-40 years old. RESULTS: Traffic accident (75%) was the most common cause of head trauma. According to Glasgow Coma Score (GCS), 48% of the patients had mild (13-15), 31% moderate (9-12) and 21% severe (3-8) head injury. One hundred seventy-seven (18.5%) patients were operated. The commonest operations were performed for subdural and epidural hematomas. Mortality was 19.4% (185). Common causes of mortality were traffic accidents (77%) and gunshot injuries. CONCLUSION: It is important to have local epidemiological studies and data about head traumas in order to prevent these traumas. In this study, the predominance of young men and the causes of trauma and mortality were similar to that reported in the related literature.

Vertebroplasty and kyphoplasty under local anesthesia: review of 91 patients.

AIM: Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive methods for the treatment of vertebral compression fractures (VCF). In this study, we aimed to present our experience with VP and KP performed under local anesthesia and percutaneously. MATERIAL AND METHODS: Between 2002 and 2008, 91 patients (total 112 vertebrae) with VCF due to osteoporosis, tumor and trauma underwent VP or KP. After radiological and routine evaluations, all patients were operated under local anesthesia. Mean operation time was 20 minutes per vertebrae. We never stopped the operation because of intolerance of any patient and all of them were discharged on the day of operation or the next day except one. RESULTS: All patients had severe back pain. Mean preoperative Visual Analogue Scale (VAS) score for pain was 8.3 and the mean postoperative value was 2.7. Mean anterior wall and mid-vertebral body heights increased by 32% and 43%, respectively. The mean kyphotic angle decreased from 15.4 to 11.2. Cement leakage was observed in 4 patients and one of them underwent an open operation (decompression and stabilization) because of cement leakage to the epidural space. There was no other complication. CONCLUSION: Vertebroplasty and kyphoplasty are safe, effective and minimally invasive procedures. Elderly patients can thefore avoid the potential complications of general surgery and be mobilized and discharged early.