A Clinical Experience with Decompressive Craniectomy.

AIM: To investigate the patients who underwent decompressive craniectomy (DC) for trauma or cerebrovascular disease, and to determine the most suitable treatment protocol for those patients. MATERIAL AND METHODS: Overall, 32 patients with trauma or cerebrovascular disease underwent DC. Clinical, radiological and surgical data of surviving patients was retrospectively analysed. The occurence of favourable and unfavourable outcomes during the course of their treatment were recorded. RESULTS: We detected ventriculomegaly in nine out of the 32 patients (9/32, 28.1%) after DC. Of these nine, four patients (4/9, 44.4%) underwent shunt surgery. Cranioplasty performed in 29 of the 32 patients caused epidural hygroma in 13 of them (13/29, 44.8%). Of these 13 patients, three underwent surgery because of progressive increase in the size of hygromas. In the remaining patients, the epidural hygromas regressed spontaneously. Glasgow coma score (GCS) before and after DC surgery (p=0.011 and p=0.006, respectively), timing of cranioplasty (p=0.028), midline shift (p=0.048) and craniectomy size (p=0.047) were significantly associated with ventriculomegaly. CONCLUSION: Lower GCS, delayed cranioplasty, greater midline shift and larger craniectomy size were found to be associated with hydrocephalus after DC. To avoid hydrocephalus, it may be beneficial to perform shunt surgery first followed by cranioplasty in a single surgical procedure. Additionally, epidural hygromas frequently encountered after a cranioplasty that should be considered and followed up carefully.

The Role of Bone Scintigraphy in Determining Spinal Fusion after Spinal Stabilisation Surgery.

AIM: To evaluate the usefulness of bone scintigraphy in spinal fusion surgery. MATERIAL AND METHODS: This retrospective study included 21 patients who had undergone previous anterior or posterior spinal fusion procedures, or both. Implant failure, fusion failure and adjacent segment disease were the evaluated pathological parameters. Scintigraphic data from all patients were evaluated with intraoperative observational data, radiological data and clinical data. RESULTS: Radiological evaluation revealed adjacent segment disease in 5 patients (23.8%), implant failure in 2 (9.5%), and fusion failure in 1 (4.8%). Scintigraphic evaluation of operating segments revealed pseudo-fusion in 3 patients (14.3%) and fusions in 18 (85.7%). Reoperations were performed in 9 patients (42.9%): in 5 (23.8%) because of adjacent segment disease, and in 4 (19.0%) because they requested removal of the implants. Two patients (9.5%) with implant failure did not undergo reoperation because their scintigraphic data were consistent with fusion and they were almost symptom free, with lower Visual Analogue Scale (VAS) scores. The VAS scores of the rest of the patients were significantly reduced after the reoperations (p < 0.001). CONCLUSION: Bone scintigraphy may be helpful for surgeons in planning appropriate surgical revision strategy by giving proper data about spinal fusion at least one year after the initial surgery.

Contribution of Neural Elements to Thoracic Stability.

AIM: Studies of spinal biomechanics typically do not focus on the contributions to range of motion (ROM) of the primary components of the spinal canal, dura, arachnoid, pia, spinal cord, nerve roots, ligaments, and vessels. We sought to determine the stability offered by these soft tissues in vitro. MATERIAL AND METHODS: Human cadaveric segments were tested intact, after osteoligamentous destabilization, and after transection of T8-9 spinal canal components. Specimens were induced into flexion, extension, axial rotation, and lateral bending using non-constraining, non-destructive pure moment while tracking motion response stereophotogrammetrically. The range of motion (ROM) was compared in each condition after adjusting for soft tissue creep. RESULTS: After spinal canal element transection, ROM increased in all directions (mean 4.7%). This increase was most pronounced during lateral bending (p=0.055). The cumulative ROM from all directions of loading showed a statistically significant mean increase of 3.3% (p=0.040). CONCLUSION: Sectioning of canal elements was found to cause a measurable increase in ROM. Although nonviable tissues were tested, living tissues are also likely to contribute to spinal stability.

Assessing the effects of lumbar posterior stabilization and fusion to vertebral bone density in stabilized and adjacent segments by using Hounsfield unit.

BACKGROUND: Computed tomography (CT) with Hounsfield unit (HU) is being used with increasing frequency for determining bone density. Established correlations between HU and bone density have been shown in the literature. The aim of this retrospective study was to determine the bone density changes of the stabilized and adjacent segment vertebral bodies by comparing HU values before and after lumbar posterior stabilization. METHODS: Sixteen patients who had similar diagnosis of lumbar spondylosis and stenosis were evaluated in this study. Same surgical procedures were performed to all of the patients with L2-3-4-5 transpedicular screw fixation, fusion and L3-4 total laminectomy. Bone mineral density measurements were obtained with clinical CT. Measurements were obtained from stabilized and adjacent segment vertebral bodies. Densities of vertebral bodies were evaluated with HU before the surgeries and approximately one year after the surgeries. The preoperative HU value of each vertebra was compared with postoperative HU value of the same vertebrae by using statistical analysis. RESULTS: The HU values of vertebra in the stabilized and adjacent segments consistently decreased after the operations. There were significant differences between the preoperative HU values and the postoperative HU values of the all evaluated vertebral bodies in the stabilized and adjacent segments. Additionally first sacral vertebra HU values were found to be significantly higher than lumbar vertebra HU values in the preoperative group and postoperative group. CONCLUSIONS: Decrease in the bone density of the adjacent segment vertebral bodies may be one of the major predisposing factors for adjacent segment disease (ASD).

Which Biomarker is most Effective to Determine Severity of Acute Head Trauma in the Experimental Animal Head Trauma Model?

AIM: Because of the need for effective method to determine the severity of head trauma, the importance of biomarkers is recognized recently. This study aims to analyze the values of sera levels of some biomarkers and the relation with their tissue levels in acute head injury. MATERIAL AND METHODS: In this study, rats were divided into three groups (mild head trauma, severe head trauma and control group). All rats were anaesthetized. Weightdrop method was used as trauma method. Blood samples were obtained five minutes after trauma when the acute effects of trauma occurred. Then whole brains of rats were excised. Levels of biomarkers were investigated in the sera samples and homogenized brain tissues biochemically. RESULTS: Significant differences in the sera GFAP (p=0.015) and insulin (p=0.011) levels were observed. Very significant difference in the sera nNOS level was observed. Extremely significant difference in the tissue IL-6 (p < 0.001) level was observed between all groups. CONCLUSION: Sera nNOS and tissue IL-6 are the best biomarkers to predict trauma severity. Sera GFAP and insulin are also capable to show trauma severity in the very acute period of postinjury. Tissue levels of the biomarkers except insulin are higher than their sera levels.

Association of anterior thoracic meningocele and azygos lobe of the lung.

Here we report an anterior thoracic meningocele case. Twoyears- old female patient was presented with kyphosis. Azygos lobe of the lung was also demonstrated during radiological studies. Posterolateral thoracotomy incision and extralpeural approach was performed for excision of the anterior meningocele to untether the cord. Although both anomalies are related to faulty embryogenesis and it is well known that faulty embryogenesis may also reveal coexisting abnormalities, we could not speculate a common mechanism for anterior thoracic meningocele and azygos lobe of the lung association.

Which method is the most effective for preventing postoperative infection in spinal surgery?

BACKGROUND: Several methods have been used to reduce the infection rate in spinal surgeries with instrumentation. PURPOSE: Which method is the most effective for preventing postoperative infection? STUDY DESIGN: Basic science, animal model. OBJECTIVE: In the present study, the efficiency of antibiotic prophylaxis, silver-plated screws, and local rifamycin application to the surgical site was investigated in an experimental animal model. Staphylococcus aureus was used as the pathogen. METHODS: Fifty 6-month-old female Wistar albino rats were used. The animals were randomly numbered and divided into five groups of ten rats each (Group 1, control group; Group 2, titanium screw and S. aureus inoculation; Group 3, titanium screw, 0.1 ml rifamycin application to the surgical area, and bacterial inoculation; Group 4, titanium screw, single preoperative dose of IM cefazolin, and bacterial inoculation; Group 5, silver-plated screw and bacterial inoculation). Titanium micro-screws were placed into the pedicles. The control group received a sterile isotonic solution, and the other four groups received bacterial suspensions containing S. aureus. The animals were killed 15 days later. RESULTS: Intensive S. aureus growth was observed in all tissue and screw samples from Group 2. The results for Group 3 were similar to those for Group 1, no growth was observed in the screw cultures. Intensive growth was observed in the five screw samples in Group 4 and in the eight samples in Group 5. CONCLUSION: Our study suggests that rifamycin application to the surgical area in spinal operations with instrumentation is an effective method to prevent S. aureus infections.

[Atypical teratoid rhabdoid tumor: case report]. / Atipik teratoid rabdoid tümör: olgu sunumu.

Atypical teratoid rhabdoid tumor is a rare highly malignant embryonal tumor of the central nervous system that is often seen in early childhood. It is very important to distinguish it from other brain tumors because it has a very poor prognosis and there are differences in its treatment. A case of atypical teratoid rhabdoid tumor in a six-week-old male baby is presented. The tumor was located at posterior fossa. Histopathologically, the tumor has rhabdoid tumor cells and mesenchymal components beside the undifferentiated small cells. While EMA, vimentin, synaptophysin and smooth muscle actin have been stained with immunohistochemical staining, desmin, chromogranin, CD 99 and CD 56 have not been stained. The patient died four months after surgery despite the chemotherapy given. In conclusion, morphological characteristics can vary to a large extent that it is difficult to recognize atypical teratoid rhabdoid tumor. Immunohistochemical panel and molecular genetic study will help to establish the correct diagnosis.

Comparison of the diagnostic utility of electromyography, ultrasonography, computed tomography, and magnetic resonance imaging in idiopathic carpal tunnel syndrome determined by clinical findings.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common nerve entrapment syndrome. It is sometimes difficult to diagnose, and a late diagnosis may result in permanent nerve damage. Electromyography (EMG), ultrasonography (US), magnetic resonance imaging (MRI), and computed tomography (CT) may be performed for the diagnosis. The diagnostic accuracy of these tests is well documented, but most of these studies accept EMG as the gold standard. OBJECTIVE: To evaluate the diagnostic accuracy of EMG, MRI, CT, and US for the diagnosis of carpal tunnel syndrome with the use of clinical findings as the gold standard. METHODS: Patients suspected to have CTS on presentation to the outpatient clinic were evaluated. The tests were performed after a detailed physical examination. Both wrists of the 69 patients in the study were investigated. RESULTS: : The diagnostic accuracies of all the tests were found to be sufficient. Although EMG seemed to have the highest sensitivity and specificity, there was no statistically significant difference between the tests. CONCLUSION: EMG or US could be used as the first-step test in most cases. If they are both available, EMG should be the first choice. They may be performed together when diagnosis is challenging. CT may especially be preferred for bone-related pathological conditions, whereas MRI may be preferred for soft tissue-related pathological conditions. Even though imaging studies have been proven to be powerful diagnostic tools for CTS, no conclusive information currently exists to support replacing EMG with imaging studies.

Biomechanics of thoracic short versus long fixation after 3-column injury.

OBJECT: Posterior screw-rod fixation for thoracic spine trauma usually involves fusion across long segments. Biomechanical data on screw-based short-segment fixation for thoracic fusion are lacking. The authors compared the effects of spanning short and long segments in the thoracic spine. METHODS: Seven human spine segments (5 segments from T-2 to T-8; 2 segments from T-3 to T-9) were prepared. Pure-moment loading of 6 Nm was applied to induce flexion, extension, lateral bending, and axial rotation while 3D motion was measured optoelectronically. Normal specimens were tested, and then a wedge fracture was created on the middle vertebra after cutting the posterior ligaments. Five conditions of instrumentation were tested, as follows: Step A, 4-level fixation plus cross-link; Step B, 2-level fixation; Step C, 2-level fixation plus cross-link; Step D, 2-level fixation plus screws at fracture site (index); and Step E, 2-level fixation plus index screws plus cross-link. RESULTS: Long-segment fixation restricted 2-level range of motion (ROM) during extension and lateral bending significantly better than the most rigid short-segment construct. Adding index screws in short-segment constructs significantly reduced ROM during flexion, lateral bending, and axial rotation (p < 0.03). A cross-link reduced axial rotation ROM (p = 0.001), not affecting other loading directions (p > 0.4). CONCLUSIONS: Thoracic short-segment fixation provides significantly less stability than long-segment fixation for the injury studied. Adding a cross-link to short fixation improved stability only during axial rotation. Adding a screw at the fracture site improved short-segment stability by an average of 25%.

Biomechanical evaluation of posterior thoracic transpedicular discectomy.

OBJECT: The authors investigated the biomechanical properties of transpedicular discectomy in the thoracic spine and compared the effects on spinal stability of a partial and total facetectomy. METHODS: Human thoracic specimens were tested while intact, after a transpedicular discectomy with partial facetectomy, and after an additional total facetectomy was incorporated. Nonconstraining pure moments were applied under load control (maximum 7.5 Nm) to induce flexion, extension, lateral bending, and axial rotation while spinal motion was measured at T8-9 optoelectronically. The range of motion (ROM) and lax zone were determined in each specimen and compared among conditions. RESULTS: Transpedicular discectomy with and without a total facetectomy significantly increased the ROM and lax zone in all directions of loading compared with the intact spine (p < 0.008). The segmental increase in ROM observed with the transpedicular discectomy was 25%. The additional total facetectomy created an insignificant 3% further increase in ROM compared with medial facetectomy (p > 0.2). CONCLUSIONS: Transpedicular discectomy can be performed in the thoracic spine with a modest decrease in stability expected. Because the biomechanical behavior of a total facetectomy is equivalent to that of a medial facetectomy, the additional facet removal may be incorporated without further biomechanical consequences.

Rapid spontaneous resolution of epidural hematoma: a case report.

Incidence of acute epidural hematoma is estimated as 1.5% of patients treated for head trauma. The condition can be fatal, and urgent surgical evacuation is recommended. Spontaneous resolution may occur in some cases. Herein, rapid spontaneous resolution of an epidural hematoma is reported and possible mechanisms are discussed.

Quantitative analysis of misplaced pedicle screws in the thoracic spine: how much pullout strength is lost?: presented at the 2009 Joint Spine Section Meeting.

OBJECT: The object of this study was to investigate the effects of iatrogenic pedicle perforations from screw misplacement on the mean pullout strength of thoracic pedicle screws. METHODS: Forty human thoracic vertebrae (T6-11) from human cadavers were studied. Before pedicle screws were inserted, the specimens were separated into 4 groups according to the type of screw used: 1) standard pedicle screw (no cortical perforation); 2) screw with medial cortical perforation; 3) screw with lateral cortical perforation; and 4) "airball" screw (a screw that completely missed the vertebral body). Consistency among the groups for bone mineral density, pedicle diameter, and screw insertion depth was evaluated. Finally, each screw was pulled out at a constant displacement rate of 10 mm/minute while ultimate strength was recorded. RESULTS: Compared with well-placed pedicle screws, medially misplaced screws had 8% greater mean pullout strength (p = 0.482) and laterally misplaced screws had 21% less mean pullout strength (p = 0.059). The difference in mean pullout strength between screws with medial and lateral cortical perforations was significant (p = 0.013). Airball screws had only 66% of the mean pullout strength of well-placed screws (p = 0.009) and had 16% lower mean pullout strength than laterally misplaced screws (p = 0.395). CONCLUSIONS: This in vitro study showed a significant difference in mean pullout strength between medial and lateral misplaced pedicle screws. Moreover, airball screws were associated with a significant loss of pullout strength.

A rare brain developmental anomaly in a patient with Usher's syndrome.

We report a rare brain developmental anomaly in Usher's syndrome. We present a 43-year-old male with visual disturbance, hearing loss, and headache. Retinitis pigmentosa and sensorineural hearing loss were determined and he was diagnosed with Usher's syndrome according to the clinical findings. Magnetic resonance imaging showed an arachnoid cyst on the left temporal lobe, cavum septum pellucidum et vergae. Uneventful cataract surgery was performed in both eyes. He was suggested to be followed up periodically for the arachnoid cyst and to use a hearing device. Although auditory and visual disturbances are the typical findings of this syndrome, it may affect other parts of the central nervous system as well. Morphological abnormalities of central nervous system and related disorders can be seen in patients with Usher's syndrome.

Spontaneous syringomyelia resolution at an adult Chiari type 1 malformation.

We present a 41-year-old man with Chiari type 1 malformation and cervical syringomyelia. Although the tonsillar herniation persisted, his syringomyelia was almost completely resolved during an eleven-year time period without surgery.

Spontaneous third ventriculostomy in chronic obstructive hydrocephalus.

INTRODUCTION: Spontaneous ventriculostomy is a rare condition, and only few cases are reported. Cine magnetic resonance imaging can demonstrate the flow from the ventriculostomy. CASE REPORT: A 25-year-old woman with a known tectal glioma and hydrocephalus was proved to have spontaneous third ventriculostomy.

Traumatic L4-L5 spondylolisthesis: case report.

We report a case of L4-L5 traumatic anterolisthesis. The patient was treated surgically 4 months after the injury. His radiological and operative findings showed L4 inferior facet tip fracture, L4-L5 anterior displacement and left L4-L5 foraminal disc protrusion. Decompression, reduction with L3, L4, L5 pedicular screw fixation, L4-L5 disc excision and interbody cage insertion with autologous bone grafts were done. Flexion type injury was thought to be the probable mechanism.

Compressive hyperextension injury of C2-C3 managed with anterior plate fixation: case report.

We report a C2 tear-drop fracture of a 69-year-old patient which occurred after a fall. Although tear drop fractures of the subaxial cervical spine mostly develop due to a flexion type injury, the mechanism is often compressive hyperextension injury at the C2 vertebra. Rigid external stabilization and internal fixation are the treatment alternatives. Internal fixation may be performed using the posterior or anterior approach. This paper describes a C2 tear drop fracture which was treated with an anterior plate fixation.

Unregistered subtracted CT angiography for the visualization of intracranial arteries at or near the skull base: preliminary experience.

PURPOSE: Restrictions with computed tomography angiography (CTA) regarding the visualization of arteries near the skull base are well known. Today, the gold standard for overcoming this is the matched mask bone elimination method. Worldwide use of this method is limited since it requires advanced imaging physics and software. A more simple method was introduced recently that avoided motion artifacts significantly by restraining the patient's head with a vacuum-type head holder. The purpose of this study was to investigate the feasibility of using unregistered subtracted CTA without such head-holding methods. MATERIALS AND METHODS: Of the 42 patients that underwent subtracted CTA, 39 were recruited for this study. Two patients were excluded due to agitation during examination and one due to artifacts of an embolized aneurysm. All the examinations were performed in an 8-channel multidetector CT suite. After performing a non-contrast low-dose CT examination, CTA was carried out using the same scan planes as on the scout images. Images were transferred to a workstation and subtraction was performed. Hard-copy images through identical locations were reviewed by 2 observers, a radiologist and a clinician (neurologist), and visualization of the internal carotid artery and posterior artery systems were scored. Data were analyzed using the Wilcoxon signed-rank test. RESULTS: Significant statistical differences, in favor of subtracted images, were noted in both observers' scores, both for the internal carotid artery and posterior system arteries. The differences in the clinician's scores were more prominent than that of radiologist's. CONCLUSION: These results are promising for the expanded use of the subtraction method, especially in radiology departments that lack the staff and equipment for registered methods.

Orbital metastasis of prostate cancer: a case report.

We report a case with metastatic orbital cancer secondary to prostatic adenocarcinoma. After initiation of total androgen blockade, the visual complaints, pain and periorbital swelling regressed dramatically within 2 months of treatment. However, the disease subsequently progressed and the patient died 12 months after diagnosis.