The Relationship Between Ionized Calcium Levels and Prognosis in Patients with Spontaneous Subarachnoid Hemorrhage.

BACKGROUND: The serum calcium plays a role as a cofactor in critical steps such as cardiac contractility, vascular tone, and the coagulation cascade. This study aimed to determine if the level of ionized calcium can predict outcomes in patients with spontaneous subarachnoid hemorrhage (SAH) in the emergency department. METHODS: The study was a retrospective cross-sectional case series. Patients aged 18 and over diagnosed with spontaneous SAH in the emergency department were included in the study. Patients' demographic characteristics, comorbidities, vital signs, laboratory parameters, World Federation of Neurosurgical Societies score, SAH grading according to the Fisher scale, needs of mechanical ventilation and inotropic treatment, administered treatments, complications, Rankin scores at discharge, and outcome were recorded in a standard data form. RESULTS: A total of 267 patients were studied, with a mean age of 55.5 ± 13.4 years, and 53.9% (n = 144) were female. Hydrocephalus was present in 16.5% of patients. The average hospital stay was 20.4 ± 19.8 days. Mortality rate was 34.8% (n = 93). Mortality was significantly higher in patients with low calcium levels upon admission (P = 0.024). Ionized calcium levels during complication development independently predicted mortality (OR: 0.945, 95% CI: 0.898-0.996, P = 0.034). Patients with poor neurologic outcomes (Rankin: 3-6) had significantly lower initial ionized calcium levels (P = 0.002). CONCLUSIONS: The ionized calcium level is a readily accessible blood gas parameter that assists clinicians in predicting functional independence and mortality at discharge in patients presenting to the emergency department with spontaneous SAH.

The Role of miR-26a, miR-29a and miR-448-3p in the Development of Cerebral Aneurysm.

AIM: To elucidate the role of microRNAs (miRNAs) in the development of cerebral aneurysms. MATERIAL AND METHODS: This study compared the expression levels of miR-26a, miR-29a and miR-448-3p in 50 samples each of cerebral aneurysm tissues and normal superficial temporal artery tissues. The miRNA expression levels were also compared in terms of aneurysm location and rupture status, i.e., presence or absence of rupture. RESULTS: Expression levels of miR-26a, miR-29a and miR-448-3p were increased in aneurysm tissues compared with normal vascular tissues. No significant difference was found in the miRNA expression levels with respect to aneurysm location or rupture status. CONCLUSION: This study showed that miR-26a, miR-29a and miR-448-3p overexpression could play an important role in intracranial aneurysm development independent of aneurysm location and rupture status. miR-26a, miR-29a and miR-448-3p could act as potential therapeutic targets in patients with intracranial aneurysms; however, further studies are needed on this issue.

Different C2 screw placement techniques with mobilization of the vertebral artery in high-riding vertebral artery cases: Cadaver dissection.

Objective: In neurosurgery, posterior approaches intended at the craniovertebral junction are frequently used. The most popular procedures for treating upper cervical instability are C1 lateral mass, C2 pedicle, and C1-C2 transarticular screw stabilization. Due to their proximity to neural structures and the presence of the high-riding vertebral artery (VA), these techniques are complicated. The risk of VA damage can be decreased by mobilizing the VA. Using cadaveric specimens in this study was aimed to demonstrate C2 pedicle and C1-C2 transarticular screw placement with VA mobilization and a novel C2 inferior corpus screw placement technique. Methods: In this study, twelve adult cadaveric specimens and two adult dry cadaveric C2 bones were used with the permission and decision of the University Research Ethics Committee. Colored silicone was injected into the arteries and veins of these twelve cadaveric specimens. Then, muscle dissection was performed stepwise, and the C2 vertebrae of the cadavers were revealed with a surgical microscope. Each specimen and entire stages of the dissections were recorded photographically. After cadaver dissections, screw placement was performed with three different techniques. Finally, radiological imaging was done with fluoroscopy. Results: After dissection, the lateral mass of the C2 vertebra was observed, and lateral to it, the transverse process and foramen were detected with the help of a hook. Next, the posterior wall of the VA groove was removed using a 1 mm thin plate Kerrison rongeur until the VA loop could partially be observed the VA. This enables us to find the top of the loop of the VA and mobilize it inferiorly using a dissector. Following this step, the C1-2 transarticular, C2 pedicle, and the novel C2 inferior corpus screw placement can be performed safely by directly visualizing the artery. Conclusions: Due to the nearby neurologic and vascular structures, placing the C2 pedicle and C1-2 transarticular screw is a challenging procedure, especially in high-riding VA cases. However, it is possible to place the C2 pedicle, C1-2 transarticular, and novel C2 inferior corpus screw after the mobilization of the VA. This study aimed to show all of them together on a cadaver for the first time, to understand the anatomy of the C2 vertebra, and to use screw placement techniques to minimize the risk of complications.

Is Standalone Posterior Cervical Pedicle Screw Fixation Sufficient to Correct Cervical Postlaminectomy Kyphosis?

AIM: To evaluate the clinical processes of patients with cervical postlaminectomy kyphosis (PLK) who underwent standalone posterior pedicle screw fixation surgery. MATERIAL AND METHODS: The results of 21 patients with cervical PLK treated using the pedicle screw method between 2015 and 2018 were retrospectively examined. Patient data included demographic information and indications for surgery. Furthermore, the following criteria were calculated for each patient: cervical sagittal vertical axis (cSVA), C2-7 cervical lordosis (CL) parameters, modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI) score and visual analogue scale score, and these were evaluated preoperatively and postoperatively statistically. RESULTS: A total of 21 patients with PLK were evaluated. In terms of radiographic parameters, postoperative cSVA was significantly lower than the preoperative cSVA, and postoperative CL was significantly higher than the preoperative CL (p < 0.001, p < 0.001, respectively). Postoperative mJOA scores were significantly higher than the preoperative scores (p < 0.001). Both postoperative NDI and VAS scores were significantly lower than the preoperative scores (p < 0.001, p < 0.001 respectively). CONCLUSION: Pedicle screw fixation was found to be an effective treatment for cervical PLK. Although this technique is not preferred by many spine surgeons because of its high complication rate, it has a positive effect on the quality of life scores and provides optimal correction.

Surgical Outcomes of C1-2 Posterior Stabilization in Patients With Chiari Malformation Type 1.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Chiari malformation (CM) is characterized by a downward displacement of the cerebellar tonsils through the foramen magnum. This tonsillar herniation may sometimes be accompanied by syringomyelia and/or basilar invagination (BI). In this study, we examined the surgical outcomes of patients by underwent C1-2 reduction + fixation (C1-2RF), which is a new method defined by Goel, in the literature. METHODS: Between 2015 and 2018, 21 patients (mean age and duration of follow-up: 39 years and 20 months, respectively) with CM were treated with atlantoaxial fixation. We found syringomyelia in all patients and BI in 9 of them. In all cases, radiography, computed tomography, and magnetic resonance imaging were performed radiologically. C1-2RF was performed in all patients. Preoperative and postoperative clinical Japanese Orthopaedic Association scores were obtained. Syrinx size and cerebrospinal fluid flow rate were compared radiologically. RESULTS: All patients were treated with C1-2RF. None of the patients underwent foramen magnum decompression or intervention for the syrinx. Occipital bone and subaxial spinal structures were not included in the fixation. In addition to significant clinical improvement, significant improvement in syringomyelia and cerebrospinal fluid flow rate was seen on the radiographs of all patients. CONCLUSIONS: Although posterior fossa decompression and/or duraplasty is a common treatment modality in CM, we propose that the C1-2RF method described by Goel is a radiologically and clinically effective treatment method, whether or not BI and/or syringomyelia in CM are present. This article is the first article of central and axial atlantoaxial dislocation, except for Goel's writings in the literature.

The loneliness of a long-distance runner. A ten-year survey of a patient diagnosed with Gorham-Stout syndrome at the occipitocervical junction.

This case study presents a 47-year-old male who was diagnosed with Gorham-Stout syndrome (GSS) 10 years ago in the occipitocervical junction. The pathology caused the resorption of the suboccipital bone, clivus, foramen magnum, and C1-C3 laminae. After his first fusion attempt in 2010 using occipital plate-cervical lateral mass screws, he needed many revision surgeries either for the progression of the pathology or for instrumentation failure and wound healing problems. Eventually, a new occipital plate and cervical pedicle screws were applied to obtain the exact solution. The involvement of the craniovertebral junction in GSS may be challenging for spinal surgeons due to the inadequate bone reserve for stabilization. As lateral mass screws cannot provide a strong pull-out force, cervical pedicular screws may be used as the first choice for unstable cervical GSS cases.

The Outcomes of Endoscopic Third Ventriculostomy in the Treatment of Hydrocephalus: 317 Pediatric and Adult Cases.

AIM: To evaluate the role of endoscopic third ventriculostomy (ETV) as a primary or secondary treatment for hydrocephalus and factors affecting ETV success. MATERIAL AND METHODS: Pediatric and adult patients with symptomatic hydrocephalus treated with ETV during 11 years (2008?2019) in our clinic were retrospectively evaluated. Patients were divided into primary ETV group, in which ETV was the first method of hydrocephalus treatment, and secondary ETV group, in which cerebrospinal fluid (CSF) drainage procedures were initially attempted. Statistical data analyses were performed to compare the outcomes of primary and secondary ETV groups. RESULTS: In total, 317 patients treated with ETV [140 (44%) patients aged 3?18 years and 177 (55%) aged 19?80 years] were followed-up for a mean duration of 60 months. Primary and secondary ETV groups comprised 207 and 110 patients, respectively. Further, 170 (82%) patients in the primary ETV group and fifty-nine patients (53%) in the secondary ETV group benefited from ETV. Primary ETV was associated with the highest probability of success (OR: 11.87). Increasing age (OR: 0.97) and male sex (OR: 4.719) increase the probability of achieving success. The overall prediction accuracy of the model was 72.2%. Kaplan?Meier survival analysis showed no significant difference between categorical groups in terms of time to failure (1.3 and 5 years), sex, ETV type, and categorized age (below 18 and above) (p > 0.05). Complications occurred during or after ETV in 14 patients. CONCLUSION: Unlike most studies, our study includes both adult and pediatric groups. According to the findings obtained in our study, the recovery rate was higher in the primary ETV group (82%) than in the secondary ETV group (53%). According to the model we created, our prediction rate of recovery was 72%. Primary ETV, male sex, and advanced age are important predictors of success in ETV.

Significance of Preoperative Prone Position Computed Tomography in Free Hand Subaxial Cervical Pedicular Screwing.

OBJECTIVE: The subaxial cervical pedicle screwing technique shows powerful biomechanical properties for posterior cervical fusion. When applying a pedicle screw using the freehand technique, it is essential to analyse cervical computed tomography and plan the surgery accordingly. Normal cervical computed tomography is usually performed in the supine position, whereas during surgery, the patient lies in a prone position. This fact leads us to suppose that radiological evaluations may yield misleading results. Our study aimed to investigate whether there is any superiority between preoperative preparation on computed tomography performed in the prone position and that performed in the supine position. METHODS: This study included 17 patients (132 pedicle screws) who were recently operated on with cervical vertebral computed tomography in the prone position and 17 patients (136 pedicle screws) who were operated on by conventional cervical vertebral computed tomography as the control group. The patients in both groups were compared in terms of age, gender, pathological diagnosis, screw malposition and complications. A screw malposition evaluation was made according to the Gertzbein-Robbins scale. RESULTS: No statistically significant difference was observed between the two groups regarding age, gender and pathological diagnosis. The screw malposition rate (from 11.1% to 6.9%, p<0.05), mean malposition distance (from 2.18 mm to 1.86 mm, p <0.05), and complications statistically significantly decreased in the prone position computed tomography group. CONCLUSION: Preoperative surgical planning by performing cervical vertebral computed tomography in the prone position reduces screw malposition and complications. Our surgical success increased with a simple modification that can be applied by all clinicians without creating additional radiation exposure or additional costs.

Surgical Outcomes of Subaxial Cervical Fractures in Patients with Ankylosing Spinal Disorder.

AIM: To evaluate the patient groups with ankylosing spinal disorder (ASD) in terms of patients? characteristics, applied surgical approaches, and the outcomes. MATERIAL AND METHODS: Between 2008-2019, 50 ASD patients (35?80 years) were operated on subaxial cervical fracture. The mean follow-up time was 48 months. According to the surgical approach, the patients were divided into three groups: patients who only underwent anterior fusion [AF], patients who only underwent posterior fusion [PF], and patients who underwent anteroposterior fusion [APF]. In this retrospective study, we examined the patients? files and outpatient checks to evaluate the history, operations, neurological results, and complications in cases. RESULTS: After undergoing respective surgical interventions, 1 of the 7 patients in the AF group (14%), 2 of the 18 patients in the PF group (18%), and 3 of the 25 patients in the APF group (12%) died. The postoperative American Spinal Injury Association scores were statistically better in all groups than in the preoperative scores. Among the surgical interventions, improvement in the APF group was significantly better than in other groups. CONCLUSION: Although there is a higher amount of surgery related complications in the APF group, the biomechanical and clinical results are better than the other two surgical interventions.

Predictors of Survival in Turkish Patients with Primary Glioblastoma.

AIM: An increasing number of biomarkers of primary glioblastoma (GBM) have recently been described. We aimed to investigate the biological and clinical factors that affect survival in Turkish patients with primary GBM. MATERIAL AND METHODS: The clinical and demographic data of all patients with primary GBM diagnosed between 2007 and 2016 were evaluated. In all the patients? pathological specimens, O6 methylguanine-DNA methyltransferase (MGMT) methylation and isocitrate dehydrogenase (IDH) 1 mutation were detected retrospectively by immunohistochemistry. Kaplan-Meier survival analysis, log-rank test, and multivariate analyses of the Cox hazard proportional model for all the variables were performed using the SPSS statistical package. The treatment details and other patient-related factors were identified, and their correlations were analyzed. RESULTS: We enrolled 137 primary GBM patients to the study. Median progression free survival (PFS) was 8.57 months (95% CI:6.8-9.5) and median overall survival (OS) was 12 months (95% CI:10.8-13.3). IDH-1 mutations were detected in 21 primary GBMs (15.3%). PFS was 15.43 ± 1.95 months. Survival rates were higher, but no statistically significant difference (p=0.074). MGMT methylation was detected in 40 primary GBMs (29.2%). OS and PFS of MGMT (+) cases were higher than MGMT(-) cases (p=0.001; p=0.001 respectively). Ki67 (%) measurement (10%-90%) average is 32.64 ± 16.56. No statistically significant between higher and lower ki67 levels (p=0.510, p=0.505 respectively). KPS (%) more than 70 at the time of diagnosis statistically significant longer median OS and PFS (p=0.001). PFS and OS were higher in all treatment modalities. CONCLUSION: The most important factors that affected survival were performance score, MGMT methylation status, systemic oncologic therapy, and IDH mutation in the Turkish population with primary GBM. We demonstrated that MGMT methylation and higher KPS levels were associated with significiantly longer OS and PFS.

Is C1-C2 Reduction and Fixation A Good Choice in the Treatment of Recurrent Chiari-Like Symptoms With Syringomyelia?

BACKGROUND: Foramen magnum decompression (FMD) is the first-choice treatment for Chiari malformation (CM). However, it has been suggested that cerebellar herniation and syringomyelia occur as a natural protective event to prevent neural damage caused by atlantoaxial instability. It is argued that treating instability is the main treatment. Positive results of atlantoaxial fusion have been reported in the literature, but there are no studies including the results of atlantoaxial fusion as the second treatment in patients in whom classical decompression failed. In our study, we report the results of these patients to help in the selection of treatment and we present our treatment algorithm for CM with syringomyelia. METHODS: Thirteen patients who had undergone FMD and duraplasty due to CM and syringomyelia in our clinics and who had recovered clinically and radiologically but had recurrent complaints during long-term follow-up were evaluated. C1-C2 distraction and fusion were performed. We evaluated these patients radiologically and clinically. RESULTS: The mean age of the 13 patients was found to be 32.4 years. Male to female ratio was 6:7. The complaints recurred after an average of 2.1 years. Also, 3 cases were presented with their clinical characteristics and radiologic findings. CONCLUSIONS: FMD may fail even with duraplasty, and treatment of CM in recurrent cases is still controversial. Recently, atlantoaxial instability has been reported to be the main pathology of CM, and the cure for pathology is to treat instability. Recurrent CMs with syringomyelia in which FMD has failed should be treated by atlantoaxial fixation.

The Impact of Myeloperoxidase in the Rupturing of Cerebral Aneurysms.

OBJECTIVE: In this study, we aimed to examine the effect of myeloperoxidase on aneurysm rupture in patients with cerebral aneurysms with and without rupture. METHODS: The study included 53 patients with subarachnoid hemorrhage operated on due to cerebral aneurysm in our clinic, and 49 patients without subarachnoid hemorrhage. After the operation, the domes taken from the aneurysms were embedded in paraffin blocks and scored after hematoxylin and eosin and immunohistochemical staining was carried out. RESULTS: The myeloperoxidase score was 1 in 29.4% of the patients, 2 in 40.2%, 3 in 12.7%, and 4 in 17.6%. Multiple aneurysms were detected in 24.5% of the patients. The median myeloperoxidase score was higher in patients with bleeding aneurysms than those that did not bleed (3 vs. 1; P < 0.001). In addition, the ratio of patients with a myeloperoxidase score of 2 or above was higher among patients with bleeding aneurysms. CONCLUSIONS: In our study, finding myeloperoxidase scores higher in cases of ruptured aneurysms compared with unruptured aneurysms reveals the relationship of myeloperoxidase with ruptured cerebral aneurysms.

The Effect of Distal Fusion Level on Functional and Radiographic Parameters in Degenerative Spine Following Long Posterior Instrumentation and Fusion.

AIM: To investigate the effect of distal fusion level on radiographic parameters and functional outcome in patients with degenerative spine disease who undergo long posterior fusion with instrumentation. MATERIAL AND METHODS: This study included 78 adult patients aged > 60 years who underwent long posterior fusion ( > 6 levels) for spinal deformity with a minimum 2-year follow-up. The patients were divided into two groups based on distal fusion level (L5 group and iliac group). Spinopelvic parameters, including lumbar lordosis (LL) and sagittal vertical axis (SVA), were evaluated. Functional outcome was evaluated with the pain visual analog scale (VAS) and the Oswestry Disability Index (ODI) questionnaire. Correlations between clinical and radiographic parameters were calculated statistically. RESULTS: In the L5 group, the mean SVA and LL significantly improved after surgery (p=0.025 and 0.008, respectively). Similarly, the SVA and LL also improved significantly in the iliac group (p=0.002 and 0.001, respectively). In both groups, lumbar VAS, leg VAS and ODI scores significantly improved (p < 0.001). The change in ODI score was significantly greater in the iliac group than the L5 group (p=0.013). CONCLUSION: Although patients did not achieve the desired optimal spinal saggital balance, both L5 and iliac groups showed significant improvement in VAS and ODI scores. The iliac group showed slightly better improvement in ODI score.

Surgical Results of Brainstem Cavernous Malformation Haemorrhage.

AIM: To evaluate surgical treatment options, complications and neurological outcomes of patients with cavernous malformations (CMs) in the pons and medulla oblongata. MATERIAL AND METHODS: We retrospectively evaluated 25 brain stem CMs that we operated between 2009 and 2019. We operated all cases in the first month with suboccipital retrosigmoid and paramedian approach. The cases were evaluated concerning their demographic characteristics, lesion characteristics, radiological imaging results, surgical approach and neurological status. RESULTS: Overall, 15 patients had CMs in the pons and 10 in the medulla oblongata. The mean age of the patients was 33.48 years, and the cases included 15 male and 10 female patients. The average modified Rankin Score (mRS) score had a mean of 2.36 and median of 2 at the time of admission (Table I). The mean follow-up period was 4.64 years (1?10 years). In the last follow-up assessment, the average mRS score was mean = 1.84 and median = 1. In addition, 14 (56%) patients recovered, 7 (28%) did not show any changes, 3 (12%) got worse, and 1 (4%) died. In our case series, the admission complaints were cranial nerve paralysis (24%) in 6 cases, nausea and vomiting in 1 (4%) and hemiparesis in 17 (68%). CONCLUSION: Experience, correct surgical approach and good knowledge of neuroanatomy are important in brainstem CM haemorrhages. Imaging methods, neuronavigation and neuromonitoring use are essential for patients undergoing surgery. In the presence of all these factors, the prognosis of patients will be better.

Relationship of spontaneous subarachnoid haemorrhage and cerebral aneurysm to serum Visfatin and Nesfatin-1 levels.

OBJECTIVES: Visfatin and nesfatin are recently discovered peptides that play a role in various metabolic reactions exhibiting inflammatory and neuroprotective effects, and their levels are known to increase in cerebral ischaemia and haematomas. Inflammation plays a role in the development of aneurysm, and spontaneous subarachnoid haemorrhage (SAH) is typically caused by rupture of the aneurysmal sac because of the increased inflammation. In the present study, we investigated the relationship between serum visfatin and nesfatin levels and the clinical and radiological findings in patients with SAH. PATIENTS AND METHOD: Overall, 62 patients with spontaneous SAH who were followed-up in our clinic between September 2018 and July 2019 and 35 healthy patients who presented to our outpatient clinic with complaints of back, lumbar and neck pain were included in the study. ELISA method was used to study the visfatin and nesfatin levels in the serum samples of both groups. The visfatin and nesfatin levels of patients with spontaneous SAH were compared with the healthy population. In addition, the relationship between visfatin and nesfatin levels and the radiological and clinical findings of patients with spontaneous SAH were also investigated. All findings were evaluated statistically. RESULTS: The median nesfatin and mean visfatin levels were higher in patients with SAH compared with the control group. The median nesfatin and mean visfatin levels were higher in patients with aneurysm than those without aneurysm. A positive correlation was observed between aneurysm length and nesfatin and visfatin levels. In patients with perimesencephalic haemorrhage, the mean visfatin level was determined to be lower compared with patients with classical aneurysmatic SAH, and the median nesfatin level did not differ significantly. The cut-off value of nesfatin for predicting SAH in patients compared with controls was >598.4 with 82.8 % sensitivity and 80 % specificity (P <  0.001). The cut-off value of visfatin for predicting SAH was >10.3 with 85.3 % sensitivity and 91.4 % specificity (P <  0.001). The diagnostic performance of visfatin and nesfatin levels was similar in predicting SAH. CONCLUSION: In the present study, we demonstrated that the presence of aneurysm, size of aneurysm, number of aneurysms correlate with visfatin and nesfatin levels in patients with SAH, and visfatin and nesfatin may be biomarkers for predicting SAH and presence of aneurysm. Nonetheless, future studies can include patients with unruptured aneurysm and investigate their serum visfatin and nesfatin levels to prove whether visfatin and nesfatin can serve as biomarkers in the follow-up of these patients.

Grisel`s syndrome presenting with neck pain: an atypical case.

Grisel`s syndrome is non-traumatic inflammatory subluxation of the atlantoaxial joints presenting clinically as torticollis, neck pain, and reduced neck mobility. Several pathogens have been implicated in its etiology. Early diagnosis and treatment are vital for Grisel`s syndrome to avoid serious neurological complications. This study reports the case of a 6-year-old girl who complained of pain and curvature of the neck following an upper respiratory tract influenza infection. Notably, the patient`s neck pain and curvature worsened toward the end of her normal day for a week. This pattern is rare, but it represents an important example of Grisel`s syndrome as a condition that varies through the day.

Sodium Fluorescein for Spinal Intradural Tumors.

Technological innovations in spinal intradural tumor surgery simplify treatment. Surgical treatment of cranial benign and malignant pathologies under microscope with sodium (Na)-fluorescein guidance has often been reported, but few studies have focused on spinal intradural tumors. We aimed to investigate the usefulness of Na-fluorescein under yellow filter in intradural spinal tumor surgery by retrospectively reviewing cases involving intramedullary and extramedullary tumors operated under the guidance of Na-fluorescein. Forty-nine adult patients with a diagnosis of spinal intradural tumor operated under a yellow filter (560 nm) microscope using Na-fluorescein dye were included in the study. Demographic data, such as age and sex, neurological status, extent of tumor resection, histopathological diagnosis, Na-fluorescein staining pattern, and its usefulness during surgery were noted and statistically analyzed. Of all recruited patients, 26 women (53.1%) and 23 men (46.9%), were included for analysis. The age range of the patients was 18-64 years, with a mean age of 41.6 ± 13.9. An intradural intramedullary mass was found in 30.6% (n = 15) of the patients, and an intradural extramedullary mass in 69.4% (n: 34). While Na-fluorescein staining was homogeneous in all intradural extramedullary tumors, 73.3% (n: 11) of intradural intramedullary tumors were homogeneous, and 13.3% (n: 2) moderately heterogeneous. In the whole study group, the Na-fluorescein staining pattern was helpful in surgical resection in 47 cases (95.9%). While 34/34 (100%) found it helpful for extramedullary tumors, 13/15 (86.7%) did in intramedullary tumors, and for 2/15 (13.3%) it was not. In conclusion, Na-fluorescein helps in distinguishing tumor from healthy tissue in intradural extramedullary and intramedullary tumor surgery under a yellow filter microscope in most cases, thus providing convenient assistance to surgeons.

The Effect of Straight or Lordotic Rods on Cervical Subaxial Alignment While Fusing C1-C2.

BACKGROUND: The C1 lateral mass and C2 pedicle screw with rod fixation system has been used commonly in recent years. Despite the numerous reports on this technique in the literature, there are no studies regarding the effect of the angle of the rod used. We investigated the effect of rod angle on subaxial lordosis, cervical sagittal balance, and pain scores. METHODS: Clinical records and radiologic images of 58 patients who underwent procedures between 2011 and 2016 at our clinic were assessed retrospectively. We recorded clinical findings, visual analog scale (VAS) scores, angles of cervical and segmental lordosis, and the distance between the C2 sagittal vertical axis (SVA) and the C7 posterior-superior corner. RESULTS: A total of 36 male and 22 female patients were enrolled. A negative correlation was found between the C1-C2 lordosis angle and the C2-C7 lordosis angle irrespective of surgical technique. In patients who were operated on using 30°-angled rods, there was a postoperative increase in C1-C2 lordosis degree and an improvement in C2 cervical SVA values. Postoperative month 6 VAS scores were significantly better in the patients who were operated on with angled rods compared with those who received straight rods. CONCLUSIONS: We believe this is because of the positive effect of the angled rod on sagittal balance. Nevertheless, prospective case-control studies should be conducted with larger groups of subjects. Furthermore, every patient should be evaluated considering the whole spinal sagittal balance.

Our surgical experience in foramen magnum meningiomas: clinical series of 11 cases.

INTRODUCTION: We aimed to discuss surgical approaches and results that we applied foramen magnum meningiomas. METHODS: We retrospectively investigated 11 foramen magnum meningioma cases, who had been operated between the dates of February 2012 and March 2017. RESULTS: Eight of the patients were females and 3 of the patients were males, the age range was 32-75 and the age average was 60.8. 5 of the tumors were anatomically localized as posterolateral, 2 of them were localized as anterolateral, 2 of them were localized as lateral and 2 of them were localized as anterior according to the brain stem or spinal cord. Posterior far lateral (4 patients) approach including C1 laminoplasty (7 patients) and 1/3 condyle resection was surgically applied to the patients with median suboccipital craniotomy. Gross total excision was applied to 82% of the patients (9 patients) and subtotal mass excision was applied to 18% (2 patients) of the patients. The most frequent post-operative complications were temporary lower cranial nerve (CN IX and X ) palsy in our 2 anterior localized cases (18%) and also cerebrospinal fluid (CSF) fistula in our 1 anterior localized case with difficulty in swallowing (dysphagia). Karnofsky scores of the patients, who were followed for 18 months in post-operative 12 and 48 months of average, in the last follow-up were 80 and no post-operative mortality occurred. CONCLUSION: Posterior midline suboccipital and far lateral approaches that we apply in our own series were appropriate approaches for foramen magnum meningiomas.

Brucella Case That Led to Atlantoaxial Spinal Instability in Childhood.

BACKGROUND: Atlantoaxial subluxation caused by Brucella infection is rarely seen in children. CASE DESCRIPTION: C1-C2 dislocation, erosion in the odontoid bone, and compression to the brainstem were detected on cervical computed tomography and magnetic resonance imaging in a 6-year-old patient who suffered neck pain, deviation to the right in the neck, fever, and pain in his extremities. He was hospitalized in the Clinic of Pediatric Infectious Diseases. Positive Brucella agglutination tests were obtained, so C1-C2 stabilization and fusion were performed. Antibrucellosis antibiotic treatment was administered for 6 months. It was suggested that the dislocation was related to odontoid erosion and laxity of the atlantoaxial ligamentous structures during Brucella infection. CONCLUSIONS: Atlantoaxial dislocation and instability develops secondarily to paravertebral abscesses, only rarely. Like brucellosis of childhood, granulomatous infectious diseases rarely cause atlantoaxial subluxation or dislocation. Torticollis and neck pains should be taken seriously for the purpose of early diagnosis of patients at risk in endemic regions. Stabilization and fusion should be performed when instability is detected, and these patients should be assessed with both pediatric infectious diseases and neurosurgery clinics. Our case is the first one in the literature in which atlantoaxial instability developed due to Brucella infection and stabilization was performed.