Transconjunctival Approach: A Safe and Effective Access to Mass Lesions in the Anterior Orbit.

BACKGROUND: The orbit is an eloquent organ of the body. Safe surgical access to the orbit could be challenging due to the dense network of critical structures confined to it. There are versatile approaches to different parts of the orbit that could be used by neurosurgeons without causing injury to critical neurovascular structures. In this study, we aimed to present our surgical experience with the transconjunctival approach through the bulbar conjunctiva to anterior intraorbital lesions caused by diverse pathologies. METHODS: We conducted a retrospective review of cases with intraorbital lesions operated via the transconjunctival approach by the same senior surgeon between 2015 and 2017. All patients were evaluated before the surgery by computed tomography, magnetic resonance imaging, and plain anteroposterior and lateral radiographs. RESULTS: Five patients underwent surgery by the transconjunctival approach through the medial or lateral routes for different pathologies: cavernoma, lymphoma, inflammatory reaction, meningocele, and foreign body. No complications were recorded, and all patients were satisfied with their clinical and esthetic results. CONCLUSIONS: The transconjunctival approach is a safe, effective, and time-sparing surgical approach to diverse pathologies in the anterior orbit. Navigation systems enhance the ability to maneuver in selected cases. The transconjunctival approach could be performed in collaboration with ophthalmologists since it provides better esthetic outcomes and higher satisfaction rates in operated patients.

Management of Pregnancy-and Lactation-Related Osteoporosis: Case Series.

AIM: To share the experience regarding management and follow-up of patients with Pregnancy- and lactation-related osteoporosis (PLRO) who were effectively treated. MATERIAL AND METHODS: This case series presented 10 patients diagnosed with PLRO and treated from January 2010 to December 2019. Visual analog scale and laboratory findings were evaluated. Spinal and extremity magnetic resonance imaging was obtained for patients with spinal and extremity pains. Dual energy X-ray absorptiometry was used for the measurement of bone mineral density. Values assessed on dual energy X-ray absorptiometry were L1?L4 T score, L2?L4 T score, and femoral neck T score. RESULTS: In the first-month follow-ups, all patients had meaningful pain relief and symptom resolution. The mean duration of pain control during the treatment period was 2.4 months. Two patients who continued breast-feeding were also the patients whose pain control was achieved at the latest. One patient required vertebroplasty. CONCLUSION: Patients with PLRO should be promptly treated and followed up. Discontinuation of breast-feeding will provide rapid advantage and should be the first step of the management. Early diagnosis and treatment of calcium and vitamin D with conservative procedures with spinal braces are very important for the treatment of PLRO patients. Additionally, bisphosphonates or teriparatide can improve the bone mineral density in patients with PLRO.

Is diabetes mellitus a risk factor for modic changes?: A novel model to understand the association between intervertebral disc degeneration and end-plate changes.

OBJECTIVE: Mechanical failure and inflammatory response are two mechanisms proposed for the development of Modic changes, even though they have not been clearly demonstrated, yet. Diabetes mellitus (DM) harbors micro- and macroangiopathy due to the irreversible glycation of proteins, increased oxidative stress, and inflammation. In this study, we aimed to identify whether DM was associated with Modic changes in terms of inflammatory process. METHODS: We conducted a cross-sectional study using our prospectively collected retrospective database of patients with DM who had visited the outpatient clinics at a university hospital. In 3999 patients with DM, 266 had spinal MRI due to cervical, thoracic or low back pain. We included patients, who had lumbar spine MRIs due to low back and/or leg pain and blood draw for HbA1c simultaneously. We analyzed 48 symptomatic patients with DM. We had also symptomatic patients without DM as control group. RESULTS: Severe intervertebral disc degeneration was significantly associated with Modic changes. Severe intervertebral disc degeneration had no significant association with serum HbA1c percentage and DM duration. Patients with Modic changes at any lumbar level had significantly higher HbA1c percentages, and longer duration of DM than those without Modic changes. Symptomatic patients with DM had higher rates of Modic changes compared to symptomatic ones without DM. CONCLUSIONS: Severity and duration of DM were both closely associated with Modic changes, whereas the association of severity and duration of DM with severe intervertebral disc degeneration remained unclear.

The Effect of Quetiapine on Treatment of Experimental Acute Spinal Cord Injury.

AIM: It is well known that treatment modalities against secondary damage due to spinal cord injury (SCI) are very important. This phase has been researched in many experimental studies. Apoptosis is one of the major mechanisms of secondary damage on spinal cord. The present study was undertaken to determine if quetiapine, a 5-HT2 receptor blocker atypical antipsychotic agent can rescue neuronal cells from apoptosis in a SCI model. MATERIAL AND METHODS: Thirty-two female Wistar rats were separated to 4 equal groups. Total laminectomy was performed at T5-7 level and spinal cord injury was produced by using the clip compression technique. Each rat from groups "1 day" (D-I) and "7 days" (D-II) was daily injected intraperitoneally with Quetiapine (10 mg/kg/day). No treatment was administered to the control groups "1 day" (K-I) and "7 days" (K-II). At the end of follow-up periods, all animals were sacrificed and spinal cords were removed. Apoptotic cells were evaluated by using immunohistochemical technique (TUNEL) in injured spinal cord specimens. RESULTS: There was a statistically significant difference while counting ApopTag positive cells, both at 1 day groups of K-I and D-I (p=0.00000008) and at 7 day groups of K-II and D-II (p=0.000005). Unlike the 1-day period, a statistically significant difference was found between grey and white matter ApopTag positive cells at the 7 < sup > th < /sup > day (p=0.0001). CONCLUSION: Quetiapine has a protective effect on secondary damage caused by SCI, while also can be used in post-traumatic stress disorder, depression and agitation as a versatile agent.

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.

Usefulness of End-to-Side Bridging Anastomosis of Sural Nerve to Tibial Nerve: An Experimental Research.

OBJECTIVE: Repair of sensorial nerve defect is an important issue on peripheric nerve surgery. The aim of the present study was to determine the effects of sensory-motor nerve bridging on the denervated dermatomal area, in rats with sensory nerve defects, using a neural cell adhesion molecule (NCAM). METHODS: We compared the efficacy of end-to-side (ETS) coaptation of the tibial nerve for sural nerve defect repair, in 32 Sprague-Dawley rats. Rats were assigned to 1 of 4 groups: group A was the sham operated group, group B rats had sural nerves sectioned and buried in neighboring muscles, group C experienced nerve sectioning and end-to-end (ETE) anastomosis, and group D had sural nerves sectioned and ETS anastomosis was performed using atibial nerve bridge. Neurological evaluation included the skin pinch test and histological evaluation was performed by assessing NCAM expression in nerve terminals. RESULTS: Rats in the denervated group yielded negative results for the skin pinch tests, while animals in the surgical intervention groups (group C and D) demonstrated positive results. As predicted, there were no positively stained skin specimens in the denervated group (group B); however, the surgery groups demonstrated significant staining. NCAM expression was also significantly higher in the surgery groups. However, the mean NCAM values were not significantly different between group C and group D. CONCLUSION: Previous research indicates that ETE nerve repair is the gold standard for peripheral nerve defect repair. However, ETS repair is an effective alternative method in cases of sensorial nerve defect when ETE repair is not possible.

Purely extradural spinal nerve root hemangioblastomas.

Spinal nerve root hemangioblastomas present mostly as intradural-extradurally. Purely extradural spinal nerve root hemangioblastoma is a very rare entity. In this study, we aimed to analyze epidemiological perspectives of purely extradural spinal nerve root hemangioblastomas presented in English medical literature in addition to our own exemplary case. PubMed/MEDLINE was searched using the terms "hemangioblastoma," "extradural," "spinal," and "nerve root." Demographical variables of age, gender, concomitant presence of von Hippel-Lindau (VHL) disease; spinal imaging and/or intraoperative findings for tumor location were surveyed from retrieved articles. There are 38 patients with purely extradural spinal nerve root hemangioblastoma. The median age is 45 years (range = 24-72 years). Female:male ratio is 0.6. Spinal levels for purely extradural spinal nerve root hemangioblastomas, in order of decreasing frequency, are thoracic (48.6%), cervical (13.5%), lumbar (13.5%), lumbosacral (10.8%), sacral (8.1%), and thoracolumbar (5.4%). Concomitant presence of VHL disease is 45%. Purely extradural spinal nerve root hemangioblastomas are very rare and can be confused with other more common extradural spinal cord tumors. Concomitant presence of VHL disease is observed in less than half of the patients with purely extradural spinal nerve root hemangioblastomas. Surgery is the first-line treatment in these tumors.

Concomitant Double Tumors of Myxopapillary Ependymoma Presented at Cauda Equina-Filum Terminale in Adult Patient.

A 32-year-old man presented with gradually increasing bilateral buttock pain. He had intermittent claudication. Multiple, homogenously enhanced intradural extramedullary lesions at L2-L3 and L5-S1 levels were observed on magnetic resonance imaging. The tumors were debulked and were removed in piecemeal pattern until they had completely been resected. Histopathological examination of the surgical specimens confirmed that both tumors were myxopapillary ependymomas (MPE). MPE presenting as concomitant double tumor at conus-cauda-filum level are very rare. This kind of presentation could not be directly considered as dissemination, since both tumors were in the site of classical origin of MPE. Ten cases of double spinal MPEs have been reported to date. Including the present case, analysis of the 11 patients revealed some facts. There is a male predominance, which is opposite to the ependymomas that are commonly observed in females. Median age at presentation is 15 years. Most pronounced symptom is low back pain that sometimes radiates to lower extremities. Surgical approach was aimed in all tumors, which could be succeeded in all tumors except one. Adjuvant radiation therapy was applied in 5 patients. No recurrences have been reported after surgery or surgery + radiotherapy regimens.

A comparison of the local effectiveness of mitomycin C, aprotinin, and Adcon-L in experimental peridural fibrosis.

BACKGROUND: Peridural fibrosis and leptomeningeal adhesion formation are among the common causes of FBSS. Various materials have been used to prevent the compressive effect of postoperative PF on neural structures. We investigated and compared the effects of 3 agents--aprotinin, mitomycin C, and Adcon-L--to PF after lumbar laminectomy in rabbits. METHODS: Four groups each including 8 rabbits were formed: Adcon-L, aprotinin, mitomycin C, and control groups. L3 laminectomy was performed on each animal. One of the 3 agents was administered locally to laminectomy areas in each group. All the animals were killed 4 weeks after the surgery. Peridural fibrosis, arachnoidal fibrosis, and dural adhesions were evaluated histologically and graded. The results were compared statistically by using a standard chi2 test. RESULTS: There were significant differences in the PF grades among the experimental groups and the control group (P < .05). When the fibroblast density and the inflammatory cell density were evaluated, the grades of the experimental groups were better compared with the grades of the control group, but the difference was not statistically significant (P > .05). CONCLUSION: Various materials have been used to prevent the compressive effect of postoperative PF on the neural structures. Aprotinin, mitomycin C, and Adcon-L are effective in preventing PF and dural adhesions in postlaminectomy areas. However, mitomycin C and Adcon-L were more effective than aprotinin in preventing peridural scarring.

Iniencephaly and long-term survival: a rare case report.

INTRODUCTION: Iniencephaly, a neural tube defect involving occiput and inion and combined with rachischisis of the cervical, thoracic spine, and retroflexion position of the head is a very rare congenital abnormality of the fetus-newborn with a 0.1-10 of 10,000 prevalence. This abnormality's prognosis is thought to be dismal. This abnormality can be associated with other abnormalities such as anencephaly, encephalocele, hydrocephalus, cyclopia, absence of the mandible, cleft lip and palate, cardiovascular disorders, diaphragmatic hernia, renal abnormalities, overgrowth of the arms compared to the legs, and club food and gastrointestinal atresia. DISCUSSION: Most of the patients are dead born, and the others die in a few hours. There are only six previously documented long-term survivors. In our case, our patient with iniencephalic signs and findings is still living. She is 2 years old now. We think that this patient presents a mild form of iniencephaly.