Spontaneous Cervical Epidural Abscess Caused by Serratia Marcescens.

Serratia marcescens infections are very rare and usually occur in the form of nosocomial and opportunistic infections. The subjects usually have severe medical comorbidities such as immunosuppression, diabetes mellitus, and renal failure. Spontaneous Serratia marcescens infection is very rare. In this case, we demonstrate that it can be seen in the spontaneous cervical epidural abscess. A 54-year female patient presented with a complaint of weakness in the left arm. Cervical magnetic resonance imaging revealed a spinal epidural abscess at the C5-6 level. Surgery was planned for this lesion. The abscess that created a cervical mass effect was totally removed and treatment with oral antibiotics was continued due to S. marcescens growth in the culture. This is the first case where S. marcescens has caused the development of a cervical epidural abscess in a patient without any medical comorbidity. Key Words: Serratia marcescens, Spinal epidural abscess, Vertebral osteomyelitis, Cervical discitis.

Combined Preoperative Embolization and Surgical Treatment of a Giant Aneurysmal Bone Cyst in the Lumbar Spine: A Case Study.

An aneurysmal bone cyst (ABC) is a vascular locally proliferative, non-neoplastic, benign lesion observed in children and young adults. 75% of ABCs occur before the age of twenty. The cyst frequently develops in the long bones and comprises 1.4% of primary bone tumors. Spinal ABC is rare and is typically observed in the thoracic and cervical regions. In the spinal region, the posterior elements of a single vertebra are usually involved. The lamina, pedicle, facet joints are more commonly affected. The lesion may also expand toward the corpus. We present a case involving successful total excision of a lumbar spinal giant ABC by combining surgery with preoperative coil embolization. Preoperative arterial embolization contributes to decreased morbidity and mortality rates by reducing the duration of surgery and occurrence of intraoperative hemorrhage.

Comparing the postoperative results of single-level anterior cervical discectomy and fusion, cervical disc prosthesis and minimal invasive posterior cervical disc surgery.

Objective: Comparison of preoperative and postoperative clinical characteristics of patients who underwent single-level anterior cervical discectomy and fusion, cervical discectomy and prosthesis or minimal invasive posterior cervical discectomy.Methods: The preoperative and the postoperative characteristics (0-, 3-, 12- and 24-month results) of patients who had undergone anterior cervical discectomy and fusion (24 patients, 40%), cervical discectomy and prosthesis (21 patients, 35%) or minimal invasive posterior cervical discectomy (15 patients, 25%), for single-level disc hernia of the C3 to C7 region at the Istanbul Yeni Yüzyil University Gaziosmanpasa Hospital between February 2015 and December 2017 were evaluated postoperatively using visual pain scales, neck disability index (NDI) values and Odom's criteria.Results: Postoperative visual analog scale and NDI scores were significantly decreased immediately after surgery in all groups (p < .001). Similarly, these two values at the second year were significantly decreased compared to post-op values (p < .001). When pre-op, post-op, third month, first year and second year scores were compared between the groups, a significant difference was found between the groups (p < .001). It was observed that the minimal invasive posterior cervical discectomy surgery was significantly better than the other two surgeries in all follow-up assessments (p < .001 for all follow-up).Conclusion: The early postoperative values of the visual pain scale and neck disability indicator were found to demonstrate immediate benefits of the surgeries, in addition to the further decrease at the 2-year follow-up in this study.

Cervical spine giant cell bone tumor: a case report.

BACKGROUND: Giant cell tumors (GCTs) of the bone are locally aggressive primary bone tumors with a benign character. Spinal involvement is rare and they are quite rare in the cervical spine. CASE PRESENTATION: A 31-year-old male patient presented with neck pain. Cervical CT revealed a lytic lesion extending posteriorly and causing the collapse of the C4 vertebra corpus. The patient underwent excision of the tumor extending from the anterior to the posterior with a single-stage anterior intervention followed by the placement of an anterior cage and plate-screw system for fusion. The pathology was reported as GCT. CONCLUSIONS: The posteriorly located lesion was widely curetted through an anterior approach in a single session.

Enlarging teratoma syndrome.

INTRODUCTION: Teratomas are derived from all three germ layers and make up 3% of all childhood tumors. They are histologically classified as mature or immature. We present a case that was operated on when 30 days old for a sacrococcygeal mature teratoma and then showed long segment involvement in the thoracolumbar region 9 months after the surgery. The MRI (magnetic resonance imaging) showed a mass starting at the thoracal 4 level and extending to the lumbar 3 level with significant spinal cord compression in the extradural space. RESULT: The laminae between thoracal 4 and lumbar 3 levels were removed en bloc at a single surgical session and laminoplasty was performed after tumor resection. We also removed the tumor growing into the extrapleural space at the thoracal 5, 6, and 9, 10, 11, 12 levels using the costotransversectomy procedure. CONCLUSIONS: We emphasize with this case that mature teratomas can show aggressive growth following surgery and that the development of spinal deformities can be prevented with laminoplasty.

Prevention of Epidural Fibrosis Using Ranibizumab in a Postlaminectomy Rat Model.

AIM: One of the most significant reasons for persistent low back pain experienced after spinal surgery is epidural fibrosis seen after laminectomy procedures. This study shows the effects of Ranibizumab on spinal epidural fibrosis in the laminectomy area by blocking the effect of vascular endothelial growth factor. MATERIAL AND METHODS: Twenty Wistar rats were used in this study. Rats were divided into two groups; a control group and a ranibizumab group. Only laminectomy was performed to the control group. In the ranibizumab group, 0.6 mg/kg ranibizumab diluted in 0.9% NaCl with the ratio of 1:10 was applied topically. Three weeks later, the vertebral columns were resected en bloc including the whole laminectomy area in both groups and evaluated histopathologically. Results were compared using statistical tools. RESULTS: Based on the statistical analysis, our data show that less epidural fibrosis was seen in the ranibizumab group compared to the control group (P < 0.05). CONCLUSION: Topically applied Ranibizumab is significantly effective in preventing epidural fibrosis in rats occurred after laminectomy.

Intramedullary schwannoma of conus medullaris with syringomyelia.

Intramedullary schwannomas of the spinal cord are rare tumors. They are most commonly observed in the cervical region; however, few have been described in the conus medullaris. The association of intramedullary schwannomas with syringomyelia is also rare. In this report, we present a case of intramedullary schwannoma of the conus medullaris with syringomyelia, which was treated surgically.

Punica granatum L. Juice Attenuates Experimental Cerebral Vasospasm in the Rabbit Subarachnoid Hemorrhage Model: A Basilar Artery Morphometric Study and Apoptosis.

Background This study investigated the effect of Punica granatum L. (pomegranate) juice on the rabbit basilar artery in an experimental subarachnoid hemorrhage (SAH) model. Methods Eighteen adult male New Zealand white rabbits were randomly divided into three groups: a control group (n = 6), SAH group (n = 6), and SAH + treatment group (n = 6). Basilar artery diameter was measured with magnetic resonance angiography (MRA) in all groups at the beginning of the study. Experimental SAH was created by injecting autologous arterial blood into the cisterna magna. In the treatment group, the subjects were administered a daily dose of 30 ml/kg pomegranate juice via gastric gavage for 4 days after the SAH. The SAH group and SAH + treatment group underwent cerebral MRA after 72 hours. After a neurologic score assessment, all the animals were killed. The wall thickness and lumen area of the basilar artery were measured histometrically in all groups, and the apoptotic cell percentage in the artery was identified. The mean diameter of the basilar artery during MRA was measured. Results Pomegranate improved neurologic functions compared with the SAH group (p < 0.01). The mean basilar artery diameter on MRA in the SAH + treatment group was larger than in the SAH group and smaller than in the control group (p < 0.01 and p < 0.05, respectively). The mean vessel wall thickness value in the SAH + treatment group was lower than in the SAH group (p < 0.01), whereas there was no difference between the control and the SAH + treatment group (p > 0.05). The apoptotic cell rate in the SAH + treatment group was significantly lower than in the SAH group (p < 0.001). Evaluation of the basilar artery luminal area showed no difference between the three groups (p > 0.05). Discussion Pomegranate was shown to have a vasospasm- attenuating effect on the basilar artery in the rabbit SAH model for the first time in our study.

The Biochemical, Histopathological and Clinical Comparison of the Neuroprotective Effects of Subcutaneous Adalimumab and Intravenous Methylprednisolone in an Experimental Compressive Spinal Cord Trauma Model.

AIM: To evaluate the neuroprotective effects of adalimumab in an experimental spinal cord injury model and compare them with those of the widely-used methylprednisolone. MATERIAL AND METHODS: Forty male Wistar rats were divided into 5 as the sham, trauma, adalimumab, methylprednisolone, and adalimumab+methylprednisolone groups. Only laminectomy was performed in the sham group. Laminectomy and trauma was performed to the trauma group but no treatment was given. A single dose of 40 mg/kg subcutaneous adalimumab was administered after the laminectomy and trauma to group 3. A single dose of intravenous 30 mg/kg methylprednisolone was administered right after laminectomy and trauma to group 4. Single doses of 40 mg/kg adalimumab and 30 mg/kg methylprednisolone were administered together after laminectomy and trauma to group 5. Serum malondialdehyde (MDA), TNF-α, IL-1ß and IL-6 levels were measured and sections were obtained for histopathological study at the end of the 7 < sup > th < /sup > day. RESULTS: MDA, TNF-α, IL-1ß and IL-6 levels in serum were significantly decreased in the adalimumab group with clinical and histopathological improvement not less than the methylprednisolone group. The serum MDA levels were similar when the two drugs were given together or separately but there was a statistically quite significant decrease in TNF-α, IL-1ß and IL-6 levels with concurrent use. Statistically significantly better results were obtained on histopathological evaluation with the use of both drugs together. CONCLUSION: This study revealed that adalimumab is as effective as methylprednisolone in compressive spinal cord injury in rats.

Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarct.

AIM: Decompressive hemicraniectomy for a malignant middle cerebral artery infarct can be a life-saving surgical treatment. We aimed to investigate the surgical treatment results in cases that underwent decompressive hemicraniectomy for a malignant middle cerebral artery infarct in this study. MATERIAL AND METHODS: The clinical condition, radiological findings and surgical treatment results of 42 cases that underwent decompressive hemicraniectomy for a malignant middle cerebral artery infarct were retrospectively evaluated in this study. RESULTS: There were 19 males and 23 females. The age range was 27 to 78 years with a mean age of 57.6 years. The infarct area was the non-dominant hemisphere in 20 cases and the dominant hemisphere in 22 cases. Preoperative Glasgow coma scale (GCS) scores were 5 to 12. The 42 cases with a malignant middle cerebral artery infarct were divided into 2 groups according to the Glasgow outcome scale (GOS) as the unfavorable outcome group (Group 1) with a score of 1 to 3 and the favorable outcome group with a score of 4 to 5 (Group 2). There were 27 cases in Group 1 and 15 in Group 2. There was a statistically significant association between a good result and age, Glasgow coma scale at the time of surgery, duration until surgery, and non-dominant hemisphere involvement. All cases with a Glasgow coma scale score of 7 or below had a poor outcome. CONCLUSION: Decompressive hemicraniectomy in malignant middle cerebral artery infarct can be a life-saving procedure but is not useful in cases with a Glasgow coma scale score of 7 and below.

Timing of Surgery for Spinal Fractures Associated with Systemic Trauma: A Need for a Strategic and Systemic Approach.

AIM: An underestimated evaluation of systemic organs in cases with spinal fractures might jeopardize the intervention for treatment and future complications with an increased morbidity and mortality are almost warranted. In the present study, a retrospective analysis of spinal fracture cases associated with systemic trauma was performed to assess surgical success. MATERIAL AND METHODS: A retrospective analysis of patients with thoracolumbar fractures who were admitted to the emergency unit between September 2012 and September 2014 was used for the study. The cases were categorized according to age, sex, reason of trauma, associated trauma, neurological condition and treatment details and results were analysed using SPSS 14.0 for Windows. RESULTS: The most common reason of trauma is detected as falls in 101 cases (64.3%). Radiological evaluation of spinal fractures revealed a compression fracture in 106 cases (67.5%) and other fractures in 51 cases (32.5%). Surgical treatment for spinal fracture was performed in 60.5% of the cases and conservative approach was preferred in 39.5% cases. In non-compressive spinal fractures, an associated pathology like head trauma, lower extremity fracture or neurological deficit was found to be higher in incidence (p < 0.05). Necessity for surgical intervention was found to be more prominent in this group (p < 0.05). However, the fracture type was not found to be associated with morbidity and mortality (p < 0.05). CONCLUSION: A surgical intervention for a spinal fracture necessitating surgery should rather be performed right after stabilization of the systemic condition which might be associated with decreased morbidity and mortality.

Solitary Metastasis of Renal Cell Carcinoma to the Third Ventricle Mimicking a Colloid Cyst: Case Report.

Colloid cysts are the most common third ventricle lesions and metastasis to this area is rare. We presented a case of solitary metastasis from a renal cell carcinoma to the third ventricle choroid plexus mimicking a colloid cyst. A 53-year-old man, who had a history of renal cell carcinoma 12 years ago, was operated for single third ventricle lesion and hydrocephalus via a transcallosal approach. Total removal could not be performed due to intraoperative massive bleeding. Histological examination revealed a metastatic renal cell carcinoma. The patient died on the postoperative 13th day because of bleeding from the residual tumor. Stereotactic radiosurgery and ventriculoperitoneal shunting might be favorable in such cases in order to avoid serious complications.

Lumbar Epidural Varicose Vein: Early Neurological Improvement and Late Radiological Full Recovery with Surgery; The Importance of Magnetic Resonance Imaging in Follow-Up.

A lumbar epidural varicose vein is a rare clinical condition that can lead to neurological deficits. 3 types of lumbar epidural varicose veins were described according to the magnetic resonance imaging (MRI) findings: Type 1 is a thrombosed dilated epidural vein, type 2 is a non-thrombosed dilated epidural vein and type 3 is a sub-membraneous epidural hematoma. Enlarged epidural venous plexuses must be decompressed if they have lead to a neurological deficit. Surgical treatment is by excision or disrupting the cyst's integrity. We present a case of lumbar epidural varicose vein that was surgically treated twice and showed no radiological change despite the disruption of integrity with a partial excision. The lesion spontaneously and completely disappeared in the late period. We emphasize the importance of MRI in follow-up.

Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap.

OBJECT: Skin grafts, skin flaps, fasciocutaneous flaps, muscle flaps, and musculocutaneous flaps have been used for closure of large meningomyelocele (MMC) defects that cannot be closed primarily. The V-Y rotation advancement flap technique has been used successfully for the reconstruction of defects in different areas of the body. In the present study, the authors report on their novel use of this technique in both a binary and a quadruple (butterfly) flap manner for closure of large MMC defects. They also present an algorithm that they developed for the evaluation of MMC defects. METHODS: Between January 2011 and November 2013, 17 patients (13 girls and 4 boys) with extremely large MMC defects that could not be repaired by direct primary closure underwent reconstruction of the defects with binary and quadruple V-Y rotation and advancement flaps. With the patient prone, the axillary apices, the most craniad point of the intergluteal sulcus, and the posterior axillary lines were marked, and a rectangular area on the back was designed. Edges of the rectangular area and the transverse and longitudinal diameters of the defect were measured and the presence of kyphosis was noted. These measurements and their proportions were used to develop an algorithm for patient assessment. While binary flaps were planned over the transverse diameter of the defects, quadruple flaps were planned over the bisectors of the defects, which were closed by elevating fasciocutaneous flaps. RESULTS: For patients whose defect diameter to back width ratio was between 0.30 and 0.50 and whose mean ratio of defect area to donor area was between 0.09 and 0.15, binary V-Y rotation and advancement flaps were used. When these values were in the range of 0.50-0.66 and 0.16-0.35, respectively, quadruple V-Y rotation and advancement flaps were preferred. The mean duration of postoperative follow-up was 10.4 months. With the exception of minor complications, such as partial necrosis of 0.5 × 0.5 cm in a quadruple flap, all the flaps healed uneventfully. CONCLUSIONS: With this study, closure of MMC defects with V-Y rotation and advancement flaps has been defined for the first time in the literature. The use of this technique with multiple flaps is an effective alternative to other flap options for the closure of large MMC defects. The algorithm developed in the course of this study should facilitate evaluation and reconstruction planning for patients with MMC defects.

The effect of bevacizumab on spinal epidural fibrosis in a postlaminectomy rat model.

AIM: Spinal epidural fibrosis is an inherent result of surgical trauma after laminectomy. The conditions in which epidural fibrosis is excessive are in the etiology of failed back syndrome. There have been many attempts to prevent formation of epidural fibrosis. Bevacizumab which is an anti-angiogenic medication, inhibits the effect of VEGF and thereby decreases the new blood vessel formation and as a result prevents adhesions. This study shows the effect of bevacizumab on spinal epidural fibrosis developing after laminectomy in rats. MATERIAL AND METHODS: In this study, 20 Wistar rats were used. Rats were divided into two groups; a control group, and a bevacizumab group. Three-level laminectomy was performed on the rats. Rats in the control group only had the laminectomy. In the bevacizumab group, 2.5 mg/kg bevacizumab diluted in 0.9% NaCl with a factor of 1:10 impregnated on cotton was applied on the dura topically for 5 minutes. Three weeks later, rats were sacrificed for histopathologic examination. Epidural fibrosis tissue was graded following sacrifice. RESULTS: Statistically, it was found that the bevacizumab group had significantly less epidural fibrosis compared to the control group (p < 0.05). CONCLUSION: Bevacizumab reduced the spinal epidural fibrosis significantly that developed in rats after laminectomy via its anti-VEGF effect by blocking VEGF receptors.

Calcified intracranial hydatid cyst: case report.

We present a 26-year-old patient who did farming related work had an asymptomatic intracranial hydatid cyst. A calcified intracranial cystic mass was found on radiological investigations and the patient underwent surgery. The mass was totally excised. The histopathology result reported a hydatid cyst. There were no postoperative complications. Calcification is quite rare in cerebral hydatid cyst. The computed tomography and magnetic resonance imaging provide information that is especially useful for preoperative diagnosis. Observing membrane detachment and daughter cysts during these investigations is pathognomonic. The presence of calcification in the cyst wall and intracystic membranes indicated hydatid cyst.

A new approach to the treatment of cerebral vasospasm: the angiographic effects of tadalafil on experimental vasospasm.

BACKGROUND: The pathogenesis of cerebral vasospasm is likely to be multifactorial. Strong evidence has indicated that decreasing levels of NO after SAH seem to be important. A PDE-V inhibitor, tadalafil, theoretically increases NO levels. Our study investigated the vasodilatory efficacy of tadalafil on the cerebral arteries with measurement of basilar artery diameters on angiography. METHODS: We used 42 male Wistar-Albino rats to test our hypothesis. They were assigned randomly into the following seven groups: group 1: control (only saline), group 2: SAH only (killed on day 2), group 3: SAH + tadalafil (killed on day 2), group 4: SAH only (killed on day 4), group 5: SAH + tadalafil (killed on day 4), group 6: saline + tadalafil (killed on day 2) and group 7: saline + tadalafil (killed on day 4). The three different parts of basilar artery diameters were measured angiographically. RESULTS: There were statistically significant differences between the SAH and SAH groups treated with tadalafil at days 2 and 4. Comparison between control and tadalafil groups showed no significant differences. This result indicated that tadalafil has a vasodilatory effect on vasoconstricted arteries, but no effect on normal basilar arteries. CONCLUSION: Our study results showed that tadalafil has a vasodilatory effect on both acute and chronic periods of cerebral vasospasm. We also concluded that cerebral angiography can be used safely for investigation of cerebral vasospasm in animal studies.

Bilateral internal carotid artery hypoplasia and multiple posterior circulation aneurysms. Importance of 3DCTA for the diagnosis.

We present a case with bilateral internal carotid artery hypoplasia and multiple posterior circulation aneurysms who was diagnosed following a subarachnoid hemorrhage. The patient was admitted to our clinic with a history of sudden and severe headache with short-term loss of consciousness and being unable to open the right eyelid five days ago. Nuchal rigidity and right partial ophthalmoplegia were found during the examination. Computed tomography revealed a subarachnoid hemorrhage. Digital subtraction angiography showed bilateral internal carotid artery hypoplasia while three-dimensional computed tomographic angiography showed bilateral internal carotid artery hypoplasia and multiple posterior circulation aneurysms. The aneurysms arising from the right posterior cerebral artery (P1 segment) and left superior cerebellar artery region were clipped using the right modified pterional approach. Asymptomatic unilateral or bilateral internal carotid artery hypoplasia may not be an important problem. However, other concurrent anomalies may be potentially life-threatening. These aneurysms must be treated due to the marked hemodynamic stress even if they have not ruptured and are asymptomatic. It may not be possible to see the aneurysm with digital subtraction angiography in these cases due to superimposition. Three-dimensional computed tomographic angiography provides more detailed diagnostic information.

Intracranial foreign body.

Intracranial foreign bodies due to nonmissile intracranial penetrations occur rarely. Most of these penetrating injuries result from industrial accidents or criminal assaults. The complications which cause mortality in early stage are intracerebral hemorrhage, contusion, major vascular injury and meningitis. In case of such injuries, foreign bodies near the major vascular structures should not be attempted to taken out. Total excision of the foreign body via craniotomy should be planned and possible dural and vascular injuries should be repaired during surgery. Urgent surgery should be performed as there is 53% morbidity in case of late surgery and 62% morbidity in nonoperated cases. We herein report a 20-year old man who attempted suicide by introducing a nail into his brain and review the related literature.