New Laminoplasty Technique for Preserving Paravertebral Muscles: Technical Note.

AIM: To develop a new laminoplasty technique for preserving paravertebral muscles. MATERIAL AND METHODS: In this technique, semispinalis and splenius muscles are cut approximately 1 cm laterally to the muscle insertion point to the spinous process at the laminotomy side. Then, multifidus and rotatory muscles are dissected subperiosteally and retracted laterally. The posterior part of the spinous process is cut horizontally below the insertion point of the semispinalis and splenius muscles. At this point, all the contralateral paravertebral muscles with the cut head of the spinous process are dissected subperiosteally and retracted laterally in the same manner as the laminotomy side. After the open-door laminoplasty for reconstruction of the anatomical formation, we fixed the head of the spinous process on the opening side laminae close to the inferior part of the spinous process with a titanium wire. RESULTS: This technique is unique in that it reconstructs the spine similar to its normal anatomical form by preserving the posterior paravertebral muscles' attachments to the bones and tension ligaments. CONCLUSION: This technique can reduce the risk of axial pain and kyphotic deformity, and prevent the reduction of ROM.

Open-door Laminoplasty with Preservation of Muscle Attachments of C2 and C7 for Cervical Spondylotic Myelopathy: Retrospective Study.

AIM: Some restriction and complications, such as progression of kyphosis, incidence of axial neck pain and decrease of postoperative cervical range of motion are concern. We designed this retrospective clinical study to evaluate the effect of laminoplasty by preserving the muscle attachments of C2 and C7 spinous processes on range of motion (ROM), axial neck pain and cervical lordosis. MATERIAL AND METHODS: Twenty-seven cases with cervical spondylotic myelopathy underwent open-door laminoplasty with the protection of muscle attachments to the C2 and C7 spinous process and laminae between 2007 and 2013. At the end of the followup, cases were evaluated with preoperative and postoperative modified Japanese Orthopedic Association (mJOA) scores, recovery rate, ROM, lordosis angle and visual analogue scale (VAS). Also, patients were divided into two groups and evaluated according to the magnetic resonance imaging (MRI) findings, with or without T2 signal change. RESULTS: The mean age of the patients was 66 years. The mean follow-up duration was 25 months. The postoperative mJOA scores were significantly higher than the preoperative mJOA scores (p < 0.001). The recovery rate was 57.4%. Although the postoperative VAS score was higher than the preoperative VAS score and the mean postoperative ROM was lower than the preoperative ROM there was no significant difference between preoperative and postoperative VAS score and ROM (p > 0.05). The postoperative lordosis angle was significantly lower than the preoperative lordosis angle (p < 0.05). There were no significant differences regarding the postoperative lordosis angle, ROM and mJOA scores with or without T2 signal change on MRI. CONCLUSION: Protection of the anatomic structures around the cervical spine such as the muscles and ligaments provides us better results regarding ROM and cervical axial pain.

Anatomical variations of brachial plexus in fetal cadavers.

AIM: The plexus brachialis is a complex structure with anatomical variations and connections with neighboring tissues. These variations may cause disparity in the motor and sensorial innervations of the upper extremity. The knowledge of anatomy and probable variations are important for performing surgical procedures in the neck, shoulder and axilla. This study was planned to demonstrate the anatomical variations of infantile brachial plexus. MATERIAL AND METHODS: A total of 20 plexus brachialis from 11 fetal cadavers were dissected and examined microscopically. The branching patterns and variations were evaluated. The width of the nerves was assessed at the level of the nerve root, trunk and cord on the basis of all brachial plexuses and they were arranged in terms of thickness. RESULTS: Half of the brachial plexuses were found to be prefixed, while 15% were found to be postfixed. Truncus superior, medial cord and nervus ulnaris were found in normal formation, whereas anatomical variations were detected in the rest of the structures. The plexus brachialis elements were arranged in the following order from large to small according to their average thicknesses: C7 C6 C8 C5 = T1; TS TI TM; PC LC MC. CONCLUSION: Since the risk of injury for variated branches is higher, understanding the anatomical variations of plexus brachialis and its extensions are significant importance during surgical intervention.

The efficacy of bioceramics for the closure of burr-holes in craniotomy: case studies on 14 patients.

PURPOSE: Bioceramics are currently in use to cover bone defects in orthopedics and craniofacial surgery. But their compatibility and efficacy in cranium were not investigated in detail. The aims of this study were to produce, characterize, and assess the biocompatibility and osteointegration of Si-HA, Si-Sr-HA, HA-Wollastonite, and HA-Wollastonite-Frit bioceramics. METHODS: Bioceramics were implanted into the burr holes of 14 craniotomy patients who were followed up from three to 24 months. Radiologic and scintigraphic examinations were performed. RESULTS: Osteoblastic activity quantified by scintigraphy increased from 6.865 to 22.991±1.682 from four to eight months in the HA-Woll group. Adding fritt into HA-Woll decreased osteoblastic activity at 10 months. Si-Sr-HA displayed significantly higher osteoblastic activity when compared to the craniotomy site at 12 months. The scintigraphic ratio of the bioceramic implanted regions to the craniotomy sites varied between 1.10 and 1.57. Osteoblast formation and establishment of the trabecular pattern of bone was observed in the surroundings of bioceramics in two patients. CONCLUSION: These bioceramics can be safely used to cover the burr holes of craniotomy patients, as well as to close the cranial bone defects.

Meta-analyses of intracerebral hematoma treatment.

AIM: The aim of this study is to define the position of surgery preference in the treatment choice for spontaneous intracerebral hematoma (ICH) and to compare the efficacy of surgery with the medical treatment based on data from 18 previously reported randomized prospective studies on this topic. MATERIAL AND METHODS: Literature databases and articles were searched from 1960 to 2010. Eighteen randomized studies on this topic were evaluated. RESULTS: Among these 18 studies, 7 (38.9%) were multicenter and 11 (61.1%) were single center. Totally 204 centers were involved. 1769 patients were treated surgically and 3200 medically. Craniotomy was the most preferred method (n = 14; 77.8%). Follow-up time was mostly 6 months. In general, the effect of surgical versus medical treatment on outcome (mortality/morbidity) after a supratentorial spontaneous ICH do not differ significantly. In individual analysis, the mortality was found to be significantly lower in the operated group than the nonoperated group in only two studies (Kurtsoy's and Miller's studies). Meta-analysis of subgroup analysis revealed surgical treatment results were significantly better for hematoma volume > 40 ml, early surgery (before 24 hours), and Glasgow Coma Scale (GCS)≥ 6. CONCLUSION: Surgical treatment results were found to be superior to medical treatment in cases with hematoma volume > 40 ml, and GCS ≥ 6. The studies are not adequate to analyze the best type of surgery.

Extracranial metastases of anaplastic oligodendroglioma.

Extracranial metastasis of a malignant glioma is rare, possibly due to the lack of lymphatic drainage in the brain and because these tumors are unable to penetrate blood vessels. Extracranial metastasis of an anaplastic oligodendroglioma (ODG) is exceptionally rare. We present a 55-year-old male patient with diffuse extracranial metastases from a temporal anaplastic ODG, 11 months after cranial surgery. Anaplastic ODG, may spread to the other parts of the body. If patients with these tumors have neck or back pain, spinal metastasis should be included in the differential diagnosis and further investigated.

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.

Diffuse cerebral arteriovenous malformation.

Diffuse cerebral arteriovenous malformation (AVM) is a rare disorder of the brain and defined as diffuse infiltration of brain by complex vascular structures. It is usually associated with hereditary syndromes and presented with hemorrhage or seizure. We report a 20-year-old male patient who presented with drooping of the left eyelid. He had no skin lesion. The ophthalmological examination was within normal limits except periorbital bruit on oscultation. Radiological examination revealed a diffuse AVM comprising multiple arteriovenous shunts, draining bihemispherically through numerous dilated veins but without a typical arteriovenous malformation nidus. No hereditary disorder was detected. No treatment was performed and the patient is still under follow-up.

The evaluation of surgical treatment options in the Chiari Malformation Type I.

AIM: There have been several treatment modalities to reduce the volume of the syringomyelic cavity and the pressure on the brainstem in Chiari Malformation Type I (CM-I). Foramen magnum decompression with and without duroplasty were compared in this retrospective study. MATERIAL AND METHODS: From 2003 to 2006, 27 patients suffering from CMI were operated on at our institute. The following were measured: the ratio of the syringomyelic cavity to the spinal cord; pre-operative tonsillar herniation from the foramen magnum; pre- and postoperative tonsillo-dural distance; and spinoposterior fossa dural angle. RESULTS: 83.3 % of the patients in the non-duroplasty and 73.3% of the patients in the duroplasty group were symptom free. The ratio of syrinx regression was 28+/-10% in the non-duroplasty and 36+/-33% in the duroplasty group. The tonsillodural distance was 3.1+/-1.8 mm in the non-duroplasty and 4.6+/-2.1 mm in the duroplasty group (p>0.05). The spino-posterior fossa dural angle was 133.6+/-9.44 degrees preoperatively and 136.7+/-9.78 degrees postoperatively in the non-duroplasty (p=0.376); 123.7+/-11.7 degrees preoperatively and 129.8+/-11.1 degrees postoperatively in the duroplasty group (p=0.885); no significant difference was found postoperatively (p=0.55, z=1.92), respectively. One patient was re-operated in the non-duroplasty group and thereafter duroplasty was performed. CONCLUSION: Almost the same clinical outcomes can be achieved with and without duroplasty. There might be an option to perform duroplasty if simple procedure fails.

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults.

BACKGROUND: The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries. METHODS: Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions. RESULTS: The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis. CONCLUSION: Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.

Traumatic brain injury due to gunshot wounds: a single institution's experience with 442 consecutive patients.

AIM: Traumatic brain injury (TBI) caused by a gunshot wound is a complex injury with a broad spectrum of symptoms and high rates of mortality and morbidity. This study presents an evaluation of TBI caused by gunshot wounds presenting at a single institution and discusses possible predictive factors for the outcome of surgical intervention. MATERIAL AND METHODS: The study sample consisted of 442 patients who underwent surgery for TBI over a 16-year period. All injuries were caused by gunshot wounds, such as bullets and shrapnel. All patients underwent surgical intervention. RESULTS: Almost all patients (99.3%) were male, and the mean patient age was 22.3 years. Wounds were caused by shrapnel in 68 percent of patients. The Glasgow Coma Scale (GCS) score at admission was below 8 in 116 patients (26.2%) and above 8 in 326 patients (73.8%). In total, 47 patients (10.6%) died despite surgical management, with diffuse brain injury the most common cause of death. CONCLUSION: Low GCS scores, ventricular injuries and bihemispheric injuries are correlated with poor prognosis. Early and less invasive surgery in conjunction with short transportation time to the hospital could decrease mortality rates.

Central neurocytoma: proton MR spectroscopy and diffusion weighted MR imaging findings.

PURPOSE: To present proton magnetic resonance spectroscopy and diffusion-weighted imaging (DWI) findings of central neurocytoma (CN). METHODS AND MATERIALS: Imaging findings of seven patients with the histopathological diagnosis of CN (five male and two female; age range, 21-28 years of age) were evaluated retrospectively. In addition to conventional magnetic resonance imaging features, we also assessed the metabolite ratios and tumor normalized apparent diffusion coefficient (NADC), which was calculated by dividing the tumor apparent diffusion coefficient (ADC) values by normal ADC. Approval from our institutional review board was obtained for this review. RESULTS: The tumor choline/creatine ratios were 5.17+/-2.38, while N-acetyl aspartate/choline and N-acetyl aspartate/creatine ratios were 0.33+/-0.15 and 1.84+/-1.38, respectively. On DWI, tumors had heterogeneous hyperintense appearances when compared with the contralateral parietal lobe white matter and tumor NADC values were 0.63+/-0.05. CONCLUSION: Significantly increased choline/creatine and decreased N-acetyl aspartate/choline ratios with lower NADC values in CN resemble high-grade gliomas and complicate the diagnosis. Familiarity its physiologic features would help to presurgical diagnosis of ventricular and exraventricular CNs.

Tumors of the lateral ventricle: the factors that affected the preference of the surgical approach in 46 patiens.

AIM: Optimal surgical pathway for lateral ventricle tumors is still controversial. The purpose of this study is to discuss the factors that affected the preference of the surgical techniques for removing lateral ventricle tumors. MATERIAL AND METHODS: 46 consecutive patients underwent operation for lateral ventricle tumors. The mean age was 36 years. Preoperative magnetic resonance imaging (MRI) images were examined to determine the location, expansion and size of each tumor. The transcallosal approach was used in 25 patients, and the transcortical approach was used in 21 patients. We performed MRI to determine the tumor size and recurrence or increased size of the residual tumor. RESULTS: Total resection was performed in 31 patients. Only one patient, with glioblastoma, died due to hepatic encephalopathy and intraventricular hemorrhage after the operation. Additional neurological deficits were seen 4 patients, and postoperative seizure occurred in one patient. The mean duration of follow-up was 38,37 months. CONCLUSION: Lateral ventricle tumors can be treated best by careful selection of the surgical approach according to localization of the tumor within the ventricle, the expansion side of the tumor, the size of the tumor, the origin of the vascular feeding branches, the venous drainage, and the relationship of the structures, and the histopathological features.

Ossified chronic subdural hematoma with armored brain.

Ossified chronic subdural hematoma is a very rarely seen entity. We present here a 22-year-old male who had presented with severe headache consequent to brain compression caused by bifronto-parieto-temporal ossified subdural hematoma. We evaluated our method and surgical intervention in the light of the literature. The question whether the ossified membrane should be excised or not excised in these cases is a matter of controversy. We think that an ossified membrane causing an armored brain appearance should be excised in symptomatic, young patients with prominent cerebral compression. During this dissection, the relatively thickened arachnoid mater provides a safe border.

Comparison of the efficacies of antibiotic-impregnated and silver-impregnated ventricular catheters on the prevention of infections. An in vitro laboratory study.

BACKGROUND AND OBJECTIVE: Infection of the cerebrospinal fluid is a life-threatening condition which is usually treated with systemic antibiotics and continued ventricular drainage in children. The aim of this study was to analyze the antimicrobial activities of two antimicrobial-agent-impregnated ventricular catheters and to compare their efficacies on the bacterial cultures. METHODS: Antibiotic-impregnated (clindamycin and rifampicin), silver-impregnated, and standard ventricular catheters were used in this study. The experiment was performed in 2 steps. In the first step, small pieces of the catheters were cut and incubated. Then, they were washed and placed in agar medium. Finally, the number of colonies was counted. In the second step, the pieces of catheters were placed on agar plates containing Staphylococcus aureus,Staphylococcus epidermidis, and Pseudomonas aeruginosa. The plates were incubated, and then, the inhibition zone for each catheter was measured. RESULTS: An inhibition zone was observed only in the plates for antibiotic-impregnated catheters. In the other plates, no inhibition zone was detected. The number of colonies was lowest in the plate with the silver-impregnated catheter, followed by the antibiotic-impregnated and standard catheters. CONCLUSION: The antibiotic-impregnated catheter seems more effective for antimicrobial treatment. Although no inhibition zone was found in the plates for silver-impregnated catheters, these catheters allow the lowest bacterial colonization in agar.

Transsphenoidal approaches to the pituitary: a progression in experience in a single centre.

BACKGROUND: Evolving of a single centre by means of different transsphenoidal approaches during the survey of methodological advances in pituitary surgery is presented. MATERIALS AND METHODS: Ninety-three consecutive patients with pituitary adenomas underwent transphenoidal pituitary operations at Gulhane Military Medical Academy from January 1996 to October 2007. Retrospective chart-based analysis of the surgical methods of transsphenoidal pituitary adenoma operations were done. Surgical methods were described. Outcomes and complications were presented. Attention is focused on the methodology of different surgical techniques of pituitary surgery. FINDINGS: During the evaluation period, 12 Sublabial approaches (1996-1998), 13 transseptal transsphenoidal approaches (1999-2000), 15 endonasal transsphenoidal approaches (2000-2004), 25 endoscopy assisted endonasal approaches (2002-2006) and 28 pure endoscopic endonasal approaches (2006-2007) were performed. CONCLUSIONS: Technologic advancements in endoscopy and gaining experience in pituitary surgery drives neurosurgeons toward less invasive approaches.

Tethered cord syndrome in adulthood.

OBJECTIVE/BACKGROUND: The standard treatment for tethered cord syndrome (operative vs nonoperative management) that presents in adulthood remains controversial. A comparative study of tethered cord syndrome in adulthood is needed. DESIGN: A retrospective chart-based analysis. METHODS: Patients admitted to Gulhane Military Medical Academy Department of Neurosurgery for management of caudal spinal cord tethering from June 1999 through December 2006 (N = 22). RESULTS: Conus level was normal in 1 patient with split cord malformation and dermal sinus. Tight terminal filum was found in 21 patients, including postrepair myelomeningocele tethered cord in 4, lipomyelomeningocele/meningocele in 8, split cord malformation in 3, dermal sinus in 7, and syringomyelia in 3. The most common complaints were back pain (15 patients, 68.1%), bladder dysfunction (8, 36.3%), fecal incontinence (2, 9.09%), and leg pain (7, 31.8%). One patient had hydrocephalus (4.5%). Ten of 22 patients underwent surgery; 8 of 10 patients had detethering; and 12 patients refused surgery. Postoperative cerebrospinal fluid leakage requiring reinforcement sutures occurred in 1 patient. There were no infectious complications. Neurologic status and outcomes were compared with preoperative findings. CONCLUSIONS: Some patients refuse surgery despite severe neurologic disturbances. Neurosurgeons should fully explain the risks and benefits of surgery for tethered cord to the patient and family. A much larger and prospective randomized series is needed to determine the effects of operative vs nonoperative management of tethered cord syndrome in adulthood.

Surgical management and outcome of large orbitocranial osteomas.

OBJECT: The goal of this study is to review the surgical management and outcome of patients who were treated for large orbitocranial osteomas at Gulhane Military Medical Academy over a period of 7 years. METHODS: Twenty-one patients with large orbitocranial osteomas were evaluated retrospectively. All patients were male and between 19 and 25 years old. Surgery was performed in all patients. The main surgical procedure was resection of the osteoma using orbitotomy and/or craniotomy followed by orbital reconstruction and cranioplasty. Cranioplasty was performed in 16 patients, using methyl methacrylate in 5 patients (31%) and porous polyethylene in 11 patients (69%). Thin, flexible, porous polyethylene was preferred for orbital reconstruction in 10 patients. The cranioplasty materials were attached to the intact bone using miniplates. RESULTS: There were no severe postoperative complications. Mild transient periorbital ecchymosis was noted in 19 patients. The mean follow-up period was 11.7 months (range 9-24 months) after surgery. No tumor regrowth was observed in any patient at the end of the follow-up period. CONCLUSIONS: Large osteomas of the orbitocranial region must be resected for cosmetic and functional reasons. Selection and planning of the surgical technique should be based on the direction of the tumor growth and on the size of the tumor and the structures that are compressed by the tumor.

Evaluation of spinal missile injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention: a new guideline.

STUDY DESIGN: Analysis of the patients with spinal missile injury (SMI). OBJECTIVE: Choosing the optimum treatment for SMI with respect to bullet trajectory, evaluation of surgical indications, and timing of surgical intervention. SUMMARY OF BACKGROUND DATA: A few guidelines were reported for the management of SMI. But there is still no consensus about the indication and timing of the surgery. The relationship between the surgery and bullet trajectory was not reported previously. METHODS: One hundred twenty-nine patients with spinal missile injury were admitted to our department from 1994 to 2006 and 122 of them could be functionally monitored. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Surgical indications were discussed. The injuries were classified with respect to the bullet's trajectory. Seventy-four patients were treated surgically, of whom 60 (81%) had incomplete injuries. All 17 patients whose vertebral column was injured with side-to-side trajectory were operated on because of instability. RESULTS: In the surgical group, 33 (56.9%) showed improvement, 20 (34.5%) showed no change, and 5 (8.6%) worsened. The best results were obtained by the patients who received operations because of rapid neurologic decline, compression, and instability in the spinal canal (P < 0.0001). Twenty-three (31%) complications and associated injuries were seen in the surgically treated patients and 18 (34.6%) were seen in the conservatively treated patients. CONCLUSION: Anteroposterior and oblique trajectories [Gulhane Military Medical Academy (GATA)-SMI I and GATA-SMI II] of SMI must be recognized as highly infective in the lumbar region. A side-to-side trajectory (GATA-SMI III) missile causing spinal cord injury is unstable and needs further stabilization. The spinal cord is not injured by the GATA-SMI IV trajectory, and thus, the best approach in this case is conservative. The best results from neurosurgical interventions may be achieved after rapid neurologic deteriorations because of spinal compression and/or instability.

Spinal hydatid cyst mimicking arachnoid cyst on magnetic resonance imaging.

BACKGROUND: Primary spinal hydatid cysts are uncommon and account for 1% of all cases of hydatid disease. Echinococcus granulosus is most often responsible for the cyst hydatid. Intradural, extramedullary involvement is rare. When the cysts do not demonstrate typical magnetic resonance imaging findings, the differential diagnosis is more complex. METHOD: Case report. FINDINGS: An isolated primary hydatid cyst of the spine in a 35-year-old man that appeared to be an arachnoid cyst on preoperative radiographic examination. CONCLUSION: Hydatid cysts that lack the typical radiographic appearance may be mistaken for arachnoid cysts. Misdiagnosis has serious implications for surgical intervention and long-term care.