Which vacuum phenomenon is more predictive for future junctional disorders?: Intradiscal or Intrafacet?

Recent spine studies focused on identifying whether intradiscal vacuum phenomenon (VP) was associated with spinal instability. However, none of them reported a direct association between VP and spinal instability following fusion for degenerative lumbar spine disorders (DSDs), namely junctional disorders. In the present study, we aimed to evaluate whether the VP was predictive for junctional disorders in patients who underwent short-segment lumbar decompression and fusion for DSDs at a tertiary spine center. We retrospectively reviewed prospectively collected database of patients who underwent short-segment decompression and fusion for DSDs. Pre-operative sagittal and axial computed tomography (CT) scans were evaluated in terms of intradiscal and intrafacet VP at all lumbar levels, respectively. Each VP was scored as 1 point. Then, the total VP score was calculated as the sum of intradiscal VP score and intrafacet VP score. Then, we analyzed the possible predictivity of VP for junctional disorders at final follow-ups of the patients operated for short-segment lumbar decompression and fusion. Patients with junctional disorders had significantly higher total and intrafacet VP scores compared to those without junctional disorders. Total VP score had an OR of 1.217 (p = 0.014) and intrafacet VP score had an OR of 1.465 (p = 0.008). The ROC analysis depicted that the cut-offs value for total and intrafacet VP scores to predict junctional disorders following short-segment lumbar decompression and fusion were 1.5 points and 0.5 point, respectively. Vacuum phenomenon could be associated with junctional disorders in patients who underwent short-segment lumbar decompression and fusion for DSD. Intrafacet VP was more important than intradiscal VP in predicting junctional disorders. Proper surgical planning including the evaluation of both intrafacet and intradiscal VP at all lumbar levels is crucial to decrease the likelihood of junctional disorders.

Recurrence and Mortality Rate in a 42 Patient Cohort of Giant Meningiomas.

BACKGROUND: Giant meningiomas may show special features in terms of biological behavior and management. We aimed to research recurrence and mortality of giant meningiomas. METHODS: Medical files of patients with meningioma with at least 1 dimension of ≥5 cm in any plane in radiological investigations between December 2012 and January 2022 were retrospectively reviewed. Tumor dimensions were measured on magnetic resonance images except 1. All patients except two underwent clinical follow-up at a mean of 27.19 ± 29.87 (range, 4-112) months. RESULTS: There were 42 patients, 26 (61.9%) women and 16 (38.1%) men who ranged in age from 31 to 85 (mean, 60.31 ± 14.86) years. Headache (57.1%) was the most common symptom. The mean tumor size was 70.14 ± 19.03 (range, 50-152) mm. Tumors were most located at the frontal convexity (40.5%). Simpson grade I resection was achieved in 19% of the cases. The tumors were World Health Organization grade 1 in 74% and grade 2 in 26% of the cases. Major complications developed in 26.1% of the patients. Recurrence happened in 5 (11.9%) cases. The number of World Health Organization grade 2 tumors (P = 0.013; P < 0.05) and tumor size (P = 0.006; P < 0.01) were significantly higher in the recurrent cases. Mortality was % 11.9 and statistically significantly higher in the recurrence group (P = 0.025; P < 0.05). CONCLUSIONS: Giant intracranial meningiomas are challenging because of surgical experience, tumor size, peritumoral edema, blood supply, anatomical changes, and limited visibility. They have a high risk of recurrence and mortality.

Risk Factors for Intracranial Aneurysm Rupture: A Clinical Case Series and Systematic Review of the Literature.

AIM: To evaluate the patients who underwent surgery for an anterior communicating artery (AcomA) aneurysm at our institution. We analyzed our case series and systematically reviewed the literature to identify factors that could predict the rupture of an intracranial aneurysm in patients with AcomA aneurysms or any intracranial aneurysm. MATERIAL AND METHODS: We conducted a cross-sectional analysis of prospectively collected data from patients who underwent surgery for AcomA aneurysms at a single institution between January 2014 and May 2023. Predictors for the rupture of intracranial aneurysm were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Pubmed and MEDLINE databases. RESULTS: Younger age (odds ratio (OR): 0.957, 95% confidence interval (CI): 0.920-0.995, p = 0.028), presence of a daughter sac (OR: 3.209, 95% CI: 1.095-9.408, p = 0.034), and ever-smoking (OR: 0.357, 95% CI: 0.137-0.930, p = 0.035) were significant predictors of increased risk of rupture in patients with AcomA aneurysms. Several aneurysm- and patient-related risk factors for rupture of intracranial aneurysms were retrieved via the literature analysis. CONCLUSION: Younger age, ever-smoking, and presence of a daughter sac increased the risk of AcomA aneurysm rupture. A systematic literature review revealed several more aneurysm- and patient-related risk factors for rupture of the intracranial aneurysms. Our results could aid neurosurgeons during their decision-making process when treating patients with unruptured intracranial aneurysms.

Surgical Management Thoracolumbar Fractures in Patients with Ankylosing Spondylitis: Technical Note with Case Series.

OBJECTIVE: Ankylosing spondylitis (AS) is a chronic inflammatory joint disease. Complications such as traumatic spinal fractures are mostly caused by hyperextension and are unstable. We report the cases of 5 patients with AS surgically treated for thoracolumbar fractures. METHODS AND RESULTS: We shared our experience of posterior stabilization surgery performed for the treatment of thoracolumbar fractures after traumas such as fall-accident in patients with AS. Patients were all men, and their ages were between 52 and 77 years. The first 3 patients woke up with neurologic deficits and were managed surgically under general anesthesia. We managed the last 2 patients with unilateral short-level stabilization under local anesthesia followed by bilateral long-level stabilization under general anesthesia. No neurologic deterioration was found in the postoperative examination of these 2 patients. We assume that the reason for neurologic deterioration after general anesthesia is the relaxation of muscles. All 3 columns of the spine are affected in patients with AS and the stability is provided by the tone of the muscles around the spine. CONCLUSIONS: To prevent postoperative neurologic complications after the surgical treatment of traumatic hyperextension thoracic and lumbar fractures in patients with AS, we recommend securing the fracture level with unilateral short-level stabilization under local anesthesia and then completing the operation with general anesthesia.

Cingulate sulcus morphology and paracingulate sulcus variations: Anatomical and radiological studies.

The sulci and gyri found across the cerebrum differ in morphology between individuals. The cingulate sulcus is an important landmark for deciding the surgical approach for neighboring pathological lesions. Identifying the anatomical variations of anterior cingulate cortex morphology would help to determine the safe-entry route through neighboring lesions. In this study, magnetic resonance imaging data acquired from 149 healthy volunteers were investigated retrospectively for anatomical variations of the paracingulate sulcus. Also, human cadaveric brain hemispheres were investigated for cingulate and paracingulate sulcus anatomy. All participants had cingulate sulci in both hemispheres (n = 149, 100%). Three types of paracingulate sulcus patterns were identified: "prominent," "present," and "absent." Hemispheric comparisons indicated that the paracingulate sulcus is commonly "prominent" in the left hemisphere (n = 48, 32.21%) and more commonly "absent" in the right hemisphere (n = 73, 48.99%). Ten (6.71%) people had a prominent paracingulate sulcus in both the right and left hemispheres. Seven (4.70%) of them were male, and 3 (2.01%) of them were female. Paracingulate sulci were present in both hemispheres in 19 people (12.75%), of which 9 (6.04%) were male and 10 (6.71%) were female. There were 35 (23.49%) participants without paracingulate sulci in both hemispheres. Eleven (7.38%) were male and 24 (16.11%) were female. There were 73 (48.99%) participants without right paracingulate sulcus and 57 (38.26%) participants without left paracingulate sulcus (p = 0.019). In the examinations of the cadaver hemispheres, the paracingulate sulcus was present and prominent in 25%, and the intralimbic sulcus was present in 15%. It has been observed that the paracingulate sulcus is more prominent in the normal male brain compared to females. In females, there were more participants without paracingulate sulcus. This study shows that there are both hemispheric and sex differences in the anatomy of the paracingulate sulcus. Understanding the cingulate sulcus anatomy and considering the variations in the anterior cingulate cortex morphology during surgery will help surgeons to orient this elegant and complex area.

Glioblastoma Shortly after a Normal Conventional Brain Magnetic Resonance Imaging: A Report of Two Cases and Review of the Literature.

Glioblastoma (GB) is the most common malignant tumor of the brain. Most of these tumors are primary or de novo GBs that manifest rapidly with initial presentations such as headache, new-onset epileptic seizure, focal neurological deficits, and altered mental status. The typical radiological features of GB include strong contrast enhancement, central necrosis, and edema with mass effect. Herein, we describe two cases of primary GB - two women aged 60 and 51 years who were diagnosed with GB 3.5 and 4 months, respectively, after their initial admission. These patients presented with right-sided headaches, and their neurological examination was within the normal limits. Their initial radiological investigations revealed no suspicious lesions, either on T1-weighted or T2-weighted magnetic resonance (MR) images. The 60-year-old patient was readmitted with persistent headache, and her T1-weighted MR images revealed a well-demarcated mass lesion in the right temporal lobe with strong contrast enhancement. Moreover, the T2-weighted MR images revealed closed sulci and swollen midline structures because of edema. The 51-year-old patient was readmitted with persistent headache, and her MR image revealed a mass lesion with heterogeneous contrast enhancement and necrosis on T1-weighted images and hyperintense areas with severe edema on T2-weighted images. The patients underwent craniotomy and gross total tumor resection. Notably, in both cases, the lesions were pathologically diagnosed as GB. Therefore, it should be borne in mind that only persistent headache could be a sentinel sign of GB before it becomes radiologically visible, thereby emphasizing the need for follow-up imaging studies at short intervals.

A Brief Look from the Neurosurgical Perspective into the Philosophy of Science.

Philosophy meaning "love of wisdom" is a research product of people who think, produce ideas, and transfer these ideas to each other. The philosophy of science questions the concept of "scientific knowledge" and analyzes the procedures and observations for a logical explanation of facts from a scientific perspective that is important for natural sciences in general and neurosurgery in particular. Observation, experimentation/measuring, and scientific explanations are examples of the methods of the philosophy of science. Besides the theories, facts, and logical/strong evidences, there are numerous concepts of the philosophy of science in neurosurgery that are difficult to understand in practice. For example, do "numbness," "pain," and "visual analog score" mean the same to the patient and the doctor? Can mechanical low back pain and instability be a real subject of the philosophy of science in the same phenomenon; how can a concept of movement-"instability" explain the cause of a concept of sensation-"pain"? Can concepts from entirely different categories like "dynamic stabilization" occur in the same scientific explanation? There are also some problematic terms that remain unsolved such as "observable" and "unobservable," which gradually increase with technological advances in neuroscience. In conclusion, these types of subjects not only affect the basis of our "scientific knowledge" but also the relationships with our patients and colleagues; it is essential to "understand" and be "understandable." We should bring "scientific perspectives" to these issues by using critical, analytical, and integrative features of philosophy.

Cisterns as Vital Structures: Byzantine Cisterns and Subarachnoid Cisterns.

Water is essential for life. It is needed not only to survive but also to sustain daily life activities. The maintenance of daily life activities related to hygiene as well as prevention of epidemic diseases and accidents involving fire was as important in the past as today. Powerful empires built many open-air and covered cisterns for water reservation and constructed aqueducts to bring water from hinterland to these cisterns. The first prototypes of cisterns were constructed in the Neolithic age. Byzantine cisterns such as the Basilica Cistern and Aqueduct of Valens are excellent examples that are remnants from the past to present. Similar to these social measures for water preservation, biological structures exhibit their own measures. In the human body, subarachnoid cisterns of central nervous system are the best-known cisterns, despite the presence of the cisterna chyli and Golgi body. The central nervous system produces and stores water in the form of cerebrospinal fluid in the subarachnoid cisterns for mechanical and immunological protection of the anatomical structures and for autoregulation of cerebral blood flow every day. Any condition that may adversely affect the cisterns, public or subarachnoid, may cause serious and irreversible damage to life. Hence, we should appreciate the importance of water for life; moreover, ?if there is water there is life? is not a great prophecy.

Median Nerve Injury from the Eye of an Artist: Gladiators.

Artists use their work to help us understand the universe. With their creations, we can rest our souls, find some solutions to problems, and even explore new dimensions. A 19th-century artist, Gérôme, has depicted a gesture used to ask for mercy as a benediction sign in two of his works of art dealing with gladiatorial fighting. A warrior defeated in a gladiator combat is well known to ask for mercy with the extended index finger and fist. A benediction gesture by a gladiator after combat could be due to an acute nerve injury. At the sources that inspired the artist, the mercy gesture may have evolved into the benediction sign for an unknown reason. It is probable that a warrior cannot accurately form the mercy gesture following a peripheral nerve injury during combat. While his index finger was extended, the other fingers could not flex in the strict sense of making a fist due to traumatic median nerve injury.

An Unusual Schwannoma in the Proximal Forearm: A Case Report.

Schwannomas are common, well-encapsulated benign tumors of the peripheral nerves. They rarely emerge from the median nerve in the forearm. Here we report a case of an unusual schwannoma measuring 3 × 4 × 3 cm originating from the median nerve in the proximal forearm of a 49-year-old man. The mass was painless, but Tinel's sign was positive. Ultrasonography showed a solid, hypoechoic mass with central cystic areas in the flexor muscle group in the left forearm. Magnetic resonance imaging with contrast enhancement in T1 sequences revealed that it originated from the median nerve. Surgical resection was performed by separating the nerve fibers from the tumor without any complications. Histological examination confirmed it as a schwannoma.

Case Report of an Obstructive Hydrocephalus Caused by an Unruptured Mesencephalic Arteriovenous Malformation in a Boy and a Review of Literature.

OBJECTIVE: Arteriovenous malformation (AVM) is the most common form of intracranial vascular malformations in adults. Intracranial pediatric AVMs are rare. AVM located in the vicinity of the brain stem in children are even more rare. CASE REPORT: This study reports a rare case of acute obstructive hydrocephalus following aqueductal stenosis caused by an unruptured grade IV perimesencephalic arteriovenous malformation. An 11-year-old boy admitted to the hospital with progressive headache, nausea and vomiting throughout a month. A Computerized Tomography (CT) showed an obstructive hydrocephaly. A Magnetic Resonance (MR) imaging revealed a mesencephalic AVM compressing the aqueduct. The patient deteriorated in hours and an emergency ventriculoperitoneal shunting was performed. He did well in the early postoperative period. AVM examined with Digital Subtraction Angiography (DSA) in detail for maintaining the definitive treatment by means of endovascular embolization, microsurgery and stereotactic radiosurgery; but the patient was lost to follow up. CONCLUSION: A Pubmed search revealed 34 cases of hydrocephalus caused by an unruptured AVM in the literature, and only four cases were less than 18 years old with unruptured AVM locating in brain stem or posterior fossa. Although focal neurologic deficit, seizure and headache are the most common symptoms, acute neurologic deterioration due to hydrocephalus may be the presenting symptom in these cases. The decrease in intracranial pressure by changing the flow of cerebrospinal fluid (CSF) via an emergency ventriculoperitoneal (VP) shunting or Endoscopic Third Ventriculostomy (ETV) can be a lifesaving procedure that gives a chance for further treatment modalities.

Traumatic Pseudoaneurysms of the Head in War Time: Report of Two Unusual Cases.

Either intracranial or extracranial pseudoaneurysms due to penetrating head injuries with gunshot are very rare entities. As the pseudoaneurysms of the superficial temporal artery are represented commonly with a pulsating mass lesion beneath scalp, the intracranial pseudoaneurysms are represented with symptoms including decreased conscious level, seizure, or focal neurological deficits. Here, two patients with combat related pseudoaneurysms are reported; one was in distal cortical branch of anterior cerebral artery and one was in superficial temporal artery. Both of the cases were victims of Libyan war. One was admitted with a swelling in his scalp and a pseudoaneurysms on parietal branch of superficial temporary artery diagnosed with computed tomography; and the other was incidentally diagnosed on distal cortical branch of anterior cerebral artery during operation for removal of an intracranial bullet. Both of the aneurysms treated with surgical excision without any complication.

The Histological Effects of Ozone Therapy on Sciatic Nerve Crush Injury in Rats.

OBJECTIVE: Peripheral nerve injury is a common, important problem that lacks a definitive, effective treatment. It can cause neurologic deficits ranging from paresthesia to paralysis. This study evaluated the effect of ozone therapy on sciatic nerve crush injury in rats. MATERIALS AND METHODS: Twenty-four male rats were divided into control sham surgery, sciatic nerve injury, and sciatic nerve injury with ozone groups (each n = 8). The sciatic nerve injury was inflicted via De Koning's crush-force method. The sciatic nerve injury group received medical air and the sciatic nerve injury ozone group received 0.7 mg/kg ozone. Sciatic nerve samples were obtained 4 weeks after injury. Vascular congestion, vacuolization, edema formation, S100 expression, and the thicknesses of the perineurium and endoneurium and diameter of the injured sciatic nerves were evaluated. RESULTS: The diameter of the sciatic nerve and thicknesses of the perineurium and epineurium were significantly greater in the sciatic nerve injury group (P < 0.05) and significantly less in the sciatic nerve injury with ozone group (P < 0.001). High S100 immunoreactivity was seen in the sciatic nerve injury group compared with the other 2 groups (P < 0.05). The distributions of vascular congestion and vacuolization were significantly less in the sciatic nerve injury with ozone group (P < 0.05). CONCLUSIONS: Ozone therapy improved sciatic nerve injury recovery without causing an increase in fibrotic tissue. Ozone reduced fibrosis, vascular congestion, vacuolization, and edema in rodents. Ozone treatment might be used to assist in sciatic nerve injury.

Functional and structural changes of the urinary bladder following spinal cord injury; treatment with alpha lipoic acid.

BACKGROUND & AIM: Alpha lipoic acid (LA) was shown to exert neuroprotection in trauma-induced spinal cord injury (SCI), which is frequently associated with urinary bladder complaints in patients with SCI. Accordingly, the protective effects of LA on biochemical and histological changes in bladder as well as functional studies were assessed. METHODS: Wistar albino rats were divided as control, SCI, and LA (50 mg/kg/day, ip) treated SCI groups (SCI+LA). The standard weight-drop (100 g/cm force at T10) method was used to induce a moderately severe SCI. One week after the injury, neurological examination was performed and the rats were decapitated. Bladder samples were taken for histological examination, functional (isolated tissue bath) studies, and for the measurement of biochemical parameters (malondialdehyde, MDA; gluthathione, GSH; nerve growth factor, NGF; caspase-3, luminol and lucigenin chemiluminescences). RESULTS: SCI caused a significant (P < 0.001) increase in the detrusor muscle thickness. It increased the contractility responses to carbachol and relaxation responses to papaverine (P < 0.05-0.001). There were also significant alterations in MDA, caspase-3, luminol, and lucigenin chemiluminescences with concomitant decreases in NGF and GSH (P < 0.05). LA treatment reversed histological and functional (contraction and relaxation responses) changes induced by SCI (P < 0.05-0.001), but no significant recovery was observed in the impaired neurological functions. CONCLUSION: These results indicate that LA have a beneficial effect in improving the bladder tonus via its antioxidant and anti-inflammatory actions following SCI.