Effects of Topically Applied Contractubex® on Epidural Fibrosis and Axonal Regeneration in Injured Rat Sciatic Nerve.

AIM: To investigate the effects of Contractubex® (Cx) on peripheral nerve regeneration and scar formation. MATERIAL AND METHODS: A surgical procedure involving sciatic nerve incision in 24 adult male Sprague-Dawley rats followed by epineural suturing was performed. In weeks 4 and 12 following surgery, macroscopic, histological, functional, and electromyographic examinations of the sciatic nerve were conducted. RESULTS: No significant difference was found between the Cx group and the control group in terms of sciatic function index (SFI) and distal latency results at week 4 (p > 0.05). However, significant improvements in the Cx group were observed in SFI amplitudes and nerve action potentials at week 12 (p < 0.001 and p < 0.001, respectively). Significant improvements were found in the amplitudes of nerve action potentials in the treatment group after weeks 4 and 12 (p < 0.05 and p < 0.001, respectively). Macroscopically and histopathologically, epidural fibrosis decreased (p < 0.05 and p < 0.001, respectively). For both measurement times, the treatment group had significantly higher numbers of axons (week 4, p < 0.05; week 12, p < 0.001), and the treatment group had better results regarding its axon area (weeks 4 and 12, p < 0.001) and myelin thickness (weeks 4 and 12, p < 0.05). CONCLUSION: Cx, which is applied topically in peripheral nerve injury, affects axonal regeneration and axonal maturation positively and reduces the functional loss.

The importance of preoperative planning to perform safely temporal lobe surgery.

Neurosurgeons should know the anatomy required for safe temporal lobe surgery approaches. The present study aimed to determine the angles and distances necessary to reach the temporal stem and temporal horn in surgical approaches for safe temporal lobe surgery by using a 3.0 T magnetic resonance imaging technique in post-mortem human brain hemispheres fixed by the Klingler method. In our study, 10 post-mortem human brain hemisphere specimens were fixed according to the Klingler method. Magnetic resonance images were obtained using a 3.0 T magnetic resonance imaging scanner after fixation. Surgical measurements were conducted for the temporal stem and temporal horn by magnetic resonance imaging, and dissection was then performed under a surgical microscope for the temporal stem. Each stage of dissection was achieved in high-quality three-dimensional images. The angles and distances to reach the temporal stem and temporal horn were measured in transcortical T1, trans-sulcal T1-2, transcortical T2, trans-sulcal T2-3, transcortical T3, and subtemporal trans-collateral sulcus approaches. The safe maximum posterior entry point for anterior temporal lobectomy was measured as 47.16 ± 5.00 mm. Major white-matter fibers in this region and their relations with each other are shown. The distances to the temporal stem and temporal horn, which are important in temporal lobe surgical interventions, were measured radiologically, and safe borders were determined. Surgical strategy and preoperative planning should consider the relationship of the lesion and white-matter pathways.

A new multipartite plate system for anterior cervical spine surgery; finite element analysis.

BACKGROUND: There are numerous available plates, almost all of which are compact one-piece plates. During the placement of relatively long plates in the treatment of multi-level cervical pathologies, instrument related complications might appear. In order to overcome this potential problem, a novel 'articulated plate system' is designed. We aimed to delineate finite element analysis and mechanical evaluations. MATERIAL AND METHODS: A new plate system consisting of multi partite structure for anterior cervical stabilization was designed. Segmental plates were designed for application onto the ventral surface of the vertebral body. Plates differed from 9 to13 mm in length. There are rods at one end and hooks at the other end. Terminal points consisted of either hooks or rods at one end but the other ends are blind. Finite element and mechanical tests of the construct were performed applying bending, axial loading, and distraction forces. RESULTS: Finite element and mechanical testing results yielded the cut off values for functional failure and breakage of the system. CONCLUSIONS: The articulated system proved to be mechanically safe and it lets extension of the system on either side as needed. Ease of application needs further verification via a cadaveric study.

The investigation of the role of the facet joint angle in the development of L5-S1 spondylolysis in young men.

OBJECTIVES: This study aims to evaluate facet tropism in younger patients with lumbar spondylolysis and to investigate the role of facet tropism in the development of spondylolysis. PATIENTS AND METHODS: Between February 2013 and December 2015, a total of 102 male patients with bilateral L5 pars defect including 53 with spondylolysis and 49 control subjects were included in this case-control study. The facet joint angles were measured bilaterally and axially at the level of L3-4, L4-5, L5-S1 using computed tomography (CT). The classification was made as follows: A difference between two reciprocal facet joint angles of <6° indicated no tropism, 6°-12° indicated moderate tropism, and >12° indicated severe tropism. RESULTS: A total of 612 angles including 318 facet joint angles from 53 patients with spondylolysis and 294 facet joint angles from 49 control subjects were measured. L3-4 measurements in the control group showed no tropism in 87.8% (n=43), moderate tropism in 12.2% (n=6), and severe tropism in 0% (n=0). L4-5 measurements in control group showed no tropism in 79.6% (n=39), moderate tropism in 20.4% (n=10), and severe tropism in 0% (n=0). L5-S1 measurements in the control group showed no tropism in 69.4% (n=34), moderate tropism in 28.6% (n=14), and severe tropism in 2.0% (n=1). The mean facet joint angles in the spondylosis group were 32.9±5.1°, 37.5±5.4°, and 41.2±7.8° at the levels of L3-4, L4-5, and L5-S1, respectively. The mean facet joint angles of the control group were 33.2±5.7°, 39.7±4.9°, and 42.2±4.9° at the levels of L3-4, L4-5, and L5-S1, respectively, indicating no significant difference between the right and left mean facet joint angles between the groups (p>0.05). The frequency of facet tropism and the difference between right and left facet joint angles for all three levels were significantly higher in the spondylolysis group (p<0.05). Facet tropism at the level of L5-S1 was significantly more frequent than facet tropism at L3-4 level (p<0.05). CONCLUSION: Our study results show that the rate of facet joint tropism is higher in the patients with spondylolysis, suggesting that facet tropism seems to play a role in the etiology of spondylolysis as a predisposing factor.

Demographical Aspects of Central Large Lumbar Disc Herniation.

AIM: The purpose of this study was to investigate the risk factors for the development of the central large disc herniations and to compare the demographic data between central mass prolapse and broad-based central disc herniation. MATERIAL AND METHODS: Between 2002 and 2007, 1630 patients underwent surgery and a large disc herniation was the main problem in 59 patients (3.6%). We performed a retrospective analysis of the demographic data of these patients. Magnetic resonance (MR) images were evaluated according to the disc type and level. Variables were evaluated both at baseline and follow-up, with special emphasis on physical job characteristics, sports activities, and MR - based morphologic findings. RESULTS: Central large disc herniation was diagnosed in 59 patients consisting of 41 males and 18 females. The average age was 34.7 years. 36 patients had a central mass prolapse that occupied more than 50% of the spinal canal. Intraoperative observations confirmed that 29 out of 36 central disc prolapse patients (80.5%) had intact posterior longitudinal ligaments. Interestingly, the condition in these 29 patients was found to have a direct relation with age and occupation or other body training sports activities. CONCLUSION: The size of the large central disc herniation, physical activity, age and gender are major factors in the development of disc herniation.

Central nervous system involvement of T-cell prolymphocytic leukemia diagnosed with stereotactic brain biopsy: case report.

Prolymphocytic leukemia (PLL) is a generalized malignancy of the lymphoid tissue characterized by the accumulation of monoclonal lymphocytes, usually of B cell type. Involvement of the central nervous system (CNS) is an extremely rare complication of T-cell prolymphocytic leukemia (T-PLL). We describe a case of T-PLL presenting with symptomatic infiltration of the brain that was histopathologically proven by stereotactic brain biopsy. We emphasize the importance of rapid diagnosis and immediate treatment for patients presenting with CNS involvement and a history of leukemia or lymphoma.

Peripheral nerve injuries due to osteochondromas: analysis of 20 cases and review of the literature.

OBJECT: Nerve compressions due to osteochondromas are extremely rare. The aim of this retrospective study was to investigate the mechanisms, diagnostic evaluations, and treatment of nerve lesions due to osteochondromas, and to review the literature. METHODS: The authors retrospectively reviewed their clinic data archive from 1998 through 2008, and 20 patients who were operated on due to peripheral nerve injuries caused by osseous growth were enrolled in the study. Patients' age, duration of symptoms, localizations, intraoperative findings, and modified British Medical Research Council (MRC) and electromyography data obtained from hospital records were evaluated. The literature on this topic available in PubMed was also reviewed. All 20 patients underwent surgery, which consisted of tumor excision performed by orthopedic surgeons and nerve decompression performed by neurosurgeons. RESULTS: There were 17 men and 3 women included in the study, with a mean age of 21 years (range 18-25 years). Three patients had multiple hereditary exostoses, and 17 had a solitary exostosis. All of the patients underwent en bloc resection. The most common lesion site was the distal femur (45%). The peroneal and posterior tibial nerves were the structures that were affected the most frequently. The mean follow-up was 3.9 years (range 2-7 years). After the surgery, all patients (100%) experienced good sensory recovery (modified MRC Grade S4 or S5). CONCLUSIONS: To the authors' knowledge, no large series have reported peripheral nerve compression due to exostoses. The authors have several recommendations as a result of their findings. First, all patients with peripheral nerve compression due to an osteochondroma should undergo surgery. Second, preoperative electromyographic examinations and radiographic evaluation, consisting of MRI and CT to provide optimal information about the lesion, are crucially important. Third, immediate treatment is mandatory to regain the best possible recovery. And fourth, performing nerve decompression first and en bloc resection of osteochondroma consecutively in a multidisciplinary fashion is strongly recommended to avoid peripheral nerve injury.

Lumbar disc herniation in a patient with congenital vertebral body anomaly: a case report.

Lumbar disc herniation is characterized with low back and leg pain resulting from the degenerated lumbar disc compressing the spinal nerve root. The etiology of degenerative spine is related to age, smoking, microtrauma, obesity, disorders of familial collagen structure, occupational and sports-related physical activity. However, disc herniations induced by congenital lumbar vertebral anomalies are rarely seen. Vertebral fusion defect is one of the causes of congenital anomalies. The pathogenesis of embryological corpus vertebral fusion anomaly is not fully known. In this paper, a 30-year-old patient who had the complaints of low back and right leg pain after falling from a height is presented. She had right L5-S1 disc herniation that had developed on the basis of S1 vertebra corpus fusion anomaly in Lumbar computed tomography. This case has been discussed in the light of literature based on evaluations of Lumbar Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). This case is unique in that it is the first case with development of lumbar disc herniation associated with S1 vertebral corpus fusion anomaly. Congenital malformations with unusual clinical presentation after trauma should be evaluated through advanced radiological imaging techniques.

Comparison of deferoxamine and methylprednisolone: protective effect of pharmacological agents on lipid peroxidation in spinal cord injury in rats.

STUDY DESIGN: Experimental study. OBJECTIVE: To investigate the protective effect of deferoxamine (DFO) administration in comparison with methylprednisolone (MP) on lipid peroxidation and antioxidants after spinal cord injury (SCI) in rats. SUMMARY OF BACKGROUND DATA: DFO is used for treating an iron-chelating agent, which is also used in the treatment of iron poisoning and thalassaemia. The neuroprotective effect of DFO was evaulated as a therapeutic agent for SCI. METHODS: Forty Wistar rats were randomly divided into 5 groups as sham laminectomy (n = 8), laminectomy with SCI (n = 8), laminectomy with SCI and 0.9% saline intraperitoneal (i.p.) (n = 8), laminectomy with SCI and 30 mg/kg MP i.p. (n = 8), and laminectomy with SCI and 30 mg/kg DFO i.p. (n = 8). Neurological deficits were examined 24 hours after trauma, and all rats were killed. Spinal cord segments were harvested for both biochemical and histopathological evaluation. RESULTS: At 24 hours post-SCI, whereas malondialdehyde levels were increased, superoxide dismutase, catalase, and glutathione peroxidase levels were decreased in groups I, II, and III. MP and DFO treatment decreased MDA levels and increased superoxide dismutase CAT, and glutathione peroxidase levels in control and study groups. There was no statistically significant difference between treatment with MP and DFO (P> 0.05). All rats were paraplegic after SCI, except in the sham group. Histopathological improvement was observed in control and study groups. CONCLUSION: This study indicates that beneficial effects may be provided and further studies need to investigate the dose-dependent beneficial and side effects of DFO in SCI. LEVEL OF EVIDENCE: N/A.

Ganglioglioma mimicking the cerebral abscess in advanced age: a case report.

Ganglioglioma is one of the rare mixed neuronal glial tumors of the central nerve system. It is responsible for 0.4 - 2% of the intracranial tumors observed in infants and young matures. Its most common localization is the supratentorial region. Typically, the first symptom is epilepsy. Due to the glial structure, that rare tumor can exhibit a malign transformation. Growing slowly through several months or years, it forms neurological dysfunction. The standard treatment of that supratentorial tumor is usually total resection. If an anaplastic quality is observed, the patient undergoes radiotherapy after the surgical intervention. In this article, we presented a 53-year-old patient who presented with headache and dysphasia. The patient was operated for the cystic mass in the left parietal lobe reported as an abscess. The pathology was reported as ganglioglioma and we discussed the case according to the literature.

[Surgical treatment outcomes in peripheral nerve lesions due to gunshot injuries: assessment of 28 cases]. / Atesli silah yaralanmasina bagli periferik sinir lezyonlarinda cerrahi tedavi sonuçlarimiz: 28 olgunun degerlendirilmesi.

BACKGROUND: In this retrospective study, we present the results and outcomes in our clinic of 28 patients over 8 years who received surgical treatment for peripheral nerve lesions due to gunshot injury. METHODS: The patients came to our clinic between January 2002 and February 2010. All came within 1-6 months after the initial gunshot injury and underwent surgery due to the diagnosis of peripheral nerve lesion. Preoperative and postoperative electromyographic analysis (EMG) and motor strength rating were performed on all patients. All patients were called for postoperative follow-up at 1, 6 and 12 months after surgery. RESULTS: The mean time after initial injury before being seen at our clinic was 3.6 months (1 day - 6 months). The most commonly injured nerve was the sciatic nerve, in 14 cases (50%). Of the patients, 23 came due to a bullet injury (9 were civilian injury with a gun, 14 were military injury with a rifle) and 5 came due to shrapnel injury. Since in all cases integrity of the nervous tissue was fully intact, nerve grafting was not required during surgery. Relatively improved EMG findings, and recovery in motor functions were detected in cases who had undergone postoperative external epineurolysis plus decompression. CONCLUSION: We recommend surgical treatment within the first six months in neural lesions, depending on gunshot injury, on the condition that surgical technique rules are obeyed (except infection, skin defect, vascular injury, and the presence of bone fracture).

Spinal textiloma (gossypiboma): a report of three cases misdiagnosed as tumour.

BACKGROUND: Textile products commonly used in surgery (e.g., sponges or gauze) have been known to cause complications after spinal surgery. Associated complications usually arise months or even years after the primary surgery. In case of spine surgery, these bodies are often detected during neuroradiological evaluations to investigate reported back pain; however, this complication often remains asymptomatic. AIMS: The research is intended to increase awareness among both spinal surgeons and neuroradiologists of this potential complication. STUDY DESIGN: Retrospective study. METHODS: This study is a retrospective case series of three patients with retained surgical textile products who had been misdiagnosed with spinal tumour. The medical records of the patients were reviewed and demographic data, clinical aspects, initial diagnosis, surgical procedures, time interval between previous operation and onset of symptoms, laboratory findings, radiological findings, treatment, and outcome were analysed. RESULTS: The three patients included two women and one man aged between 64 and 67 years. All patients had a previous surgery for lumbar disc herniation. The time from the previous surgical procedures to presentation ranged from 3 to 17 years. All patients presented with non-specific lower back pain and/or radiculopathy without clinical findings of infection. Laboratory parameters were otherwise normal. All three cases had been misdiagnosed as a spinal tumor based on magnetic resonance imaging findings. During new surgical procedures, gauze bandages, i.e., surgical textiles left during a previous operation, were found. CONCLUSION: Textiloma is an important and rarely mentioned potential neurosurgical complication that may remain asymptomatic for years. They are more common in obese patients, after emergency surgery, and with unplanned changes in surgical procedure such as bleeding and unintended neurosurgical complications. Neuroradiological findings are variable and non-specific; thus, patients could be misdiagnosed with a spinal tumor or abscess. Likewise, in patients with a history of spinal surgery, spinal abscesses, haematomas, hypertrophic scars, fibrosarcomas, rhabdomyosarcomas, and schwannomas should definitely be considered in the differential diagnosis and considered when planning diagnostic procedures. Appropriate antibiotic therapy is recommended when a suppurative complication is present or suspected. Textiloma is a medico-legal complication that can be prevented by the education of surgical staff, the counting method (preoperatively, at closure, and at the end), and use of products with radiopaque barcodes.

Surgical results of degenerative spondylolisthesis patients over 70 years old: a single-center experience and clinical outcomes.

AIM: The aim of this study is to evaluate results of surgery in Degenerative Spondylolisthesis (DS) patients over 70 years old. MATERIAL AND METHODS: This is a non-randomized retrospective analysis of the clinical outcome of 34 patients older than 70 years who underwent surgery. At the end of two-year follow-up period, preoperative and postoperative courses were assessed by Oswestry Disability Index (ODI) and Visual Analog Scales (VAS). RESULTS: The mean age was 75 years (range 70-86 years). The mean duration of symptoms was 13.5 years (range 2-30 years). All patients underwent physiotherapy and also 15 (11 female, 4 male) patients used brace. L4-L5 was the most commonly affected level (n=26), Preoperative ODI and VAS scores were mean 71,63 (range 34-100) and 6,77 (range 2-9) (p < 0,05). Postoperative ODI and VAS scores were mean 22,73 (range 0-100) and 2,13 (range 0-10) (p < 0,05). Patients were asked if they had known the outcome, would they accept surgical treatment or not. 86.6% (n=26) of the patients answered the question positively. CONCLUSION: A conventional decompressive laminectomy with foraminotomy and posterolateral fusion in situ with transpedicular instrumentation is necessary and reduces pain and recovers functional disability in elderly patients over 70 years old with DS.

An unusual penetrating craniocerebral injury due to landmine explosion: a case report.

Penetrating landmine injuries are the unavoidable consequences of military conflicts. They are potentially life-threatening. The mortality rates in the literature range from 23% to 92% and are considerably higher in patients admitted with poor neurologic state. Penetrating craniocerebral injuries require early surgical management designated to prevent infection and remove foreign objects, necrotic tissue and complicating blood clots, as well as to minimalize post-traumatic sequelae. We report herein an interesting case of penetrating intracerebral injury with giant shrapnel due to landmine in a 20-year-old young man.

Management of head trauma due to landmine explosions: from battle field to operation room.

BACKGROUND: Head injuries due to landmine explosions are not well studied and the management of such injuries is not documented, even though there is, unfortunately, a regrettably high incidence of such injuries in the military and in civilians. METHODS: The data of 119 patients who underwent surgery for the head injuries due to landmine explosions were reviewed retrospectively. All of these patients were military personnel, and the mean age was 23 years. RESULTS: A total 83 (69.7%) of the cases were injured by the anti-personnel devices and 36 (30.3%) by vehicle landmines. Fifty percent of the patients underwent surgery for depressed skull fracture, intraparenchymal foreign body, epidural haematoma or subdural haematoma. Six (0.05%) patients died in the emergency room. CONCLUSION: Landmine explosions can produce classic injury patterns from blunt and penetrating mechanisms to several organ systems, including the brain. They also produce unique injury patterns to the brain. Understanding this important difference is critical in management of these injuries. Early surgical treatment and appropriate management could save more lives.

Early surgical treatment protocol for sciatic nerve injury due to injection--a retrospective study.

BACKGROUND AND PURPOSE: We retrospectively researched 119 patients with buttock level traumatic injury to sciatic nerves and 42 cases of sciatic nerve injuries due to intramuscular injections were observed among them. Our aim was finding out the post-operative outcomes of early intervention and describing a timing schedule for surgical intervention. METHODS: Between 1984 and 2004 a total of 73 patients were operated on to explore the nerve lesion. These injuries consisted of post-injection injury, hip fracture/dislocation, contusion, compression, gunshot wound, hip arthroplasty and laceration. Our study took into account 29 cases operated because of injection injury. The most common presenting symptom was pain, which often masked underlying loss of function. Findings at operation were analysed according to the type of sciatic nerve damaged following intramuscular injection, the nature of this injury and the referring speciality. Some of the more common causal operations and procedures are discussed. Preventive measures are listed, and early diagnosis and treatment are recommended. The aim of the operation was to establish the diagnosis, to resolve pain and to improve function by epineural or interfasciculary neurolysis. RESULTS: We analysed the findings at operation according to the nature of the injury and the procedures which the patients underwent. Seven patients (24.1%) had an excellent outcome, 14 patients (48.2%) had good outcome and 4 patients (13.8%) had fair outcome. The other four patients (13.8%) had poor outcome. No patients suffered from additional post-operative neurological deficits or from worsening of pre-operative deficits. CONCLUSIONS: Based on our experiences, we recommend measures by which the morbidity rate of these injuries may be reduced. We stress, however, that if the clinical evidence points to transection of a nerve, that nerve may be explored without waiting for electrophysiological confirmation. Delay in recognition and therefore treatment was a cause of litigation, and contributed to the poor outcome in many cases.

Capillary hemangioma of the cervical intervertebral disc.

An anterior cervical decompression and fusion operation was complicated by extensive bleeding from the disc space. Histopathological evaluation of the resected specimen revealed the diagnosis as the very first reported case of capillary hemangioma in intervertebral disc space. Retrospective review of the preoperative MRI demonstrated supporting findings of a capillary hemangioma within the cervical intervertebral disc.

Retained surgical sponge in differential diagnosis of paraspinal soft-tissue mass after posterior spinal surgery: report of eight cases.

BACKGROUND: In the postoperative period of posterior spinal surgery, surgeons usually encounter a wide spectrum of complications, including retained surgical sponge, gossypiboma. MATERIALS AND METHODS: Retrospective review of case records of eight patients diagnosed with gossypiboma with emphasis on computed tomography (CT) and magnetic resonance imaging (MRI) findings. RESULTS: All the eight patients presented with low back pain and/or symptoms of infection, such as draining from the incision site, fever, and tenderness. The diagnosis was confirmed by the imaging findings on MRI with gadolinium enhancement. CONCLUSION: Retained paravertebral surgical sponges are seldom reported due to medicolegal implications. Awareness of this complication among neurosurgeons and radiologists is essential to avoid unnecessary morbidity.

Intraosseous schwannoma of thoracic 12 vertebra without spinal canal involvement.

Schwannomas are common tumors of the nerve sheath cells. They present as well-circumscribed masses attached to the peripheral nerves, cranial nerves, or spinal nerve roots. Intraosseous localization of these tumors is rare. The presented case is a 55-year-old female patient, the very first case of intraosseous schwannoma of Th12 vertebra without spinal canal involvement. She was admitted with a progressive back pain and seldom pain and numbness in the right leg for 1 year. Preoperative findings on computed tomography and magnetic resonance images of the lesion resembled that of any primary tumor of the bone. The patient was operated on via posterior approach and the tumor was removed totally. Histopathological examinations revealed schwannoma. Our case emphasizes the heterogeneous presentation of the nerve sheath cell tumors in the differential diagnosis of the primary vertebral column tumors.

Is dysphonia permanent or temporary after anterior cervical approach?

The rate, causes and prognosis of dysphonia after anterior cervical approach (ACA) were investigated in our clinical series. During a 10-year interval, 235 consecutive patients with cervical disc disease underwent surgical treatment using anterior approach. Retrospective chart reviews showed recurrent laryngeal nerve (RLN) injury in 3 (1.27%) patients. All three patients were men and only one patient had multilevel surgery. These patients had RLN injury after virgin surgery. Laryngoscopic examination demonstrated unilateral vocal cord paralysis in all patients who had postoperative dysphonia. No permanent dysphonia was observed in our series and patients recovered after a mean of 2 months (range 1-3 months) duration. Dysphonia after ACA was a rare complication in our clinical series. Pressure on RLN or retraction may result in temporary dysphonia.