A Novel Perspective for Analyzing Craniocervical Sagittal Balance and Horizontal Gaze.

BACKGROUND: This study aimed to analyze craniocervical sagittal balance parameters in an asymptomatic population revealing the interaction of craniocervical compensation with the horizontal gaze and to identify a new parameter that can be evaluated more easily with the horizontal gaze. METHODS: Lateral radiographs were taken of the 75 asymptomatic volunteers. Two independent observers measured the pelvic, spinal, and cranial parameters, spinocranial angle, and C2-7 sagittal vertical axis (C2-7SVA) distances. The correlations between these parameters and the differences in the created subgroups were analyzed. RESULTS: Correlations were found between the sacral slope and L1-L5 lordosis (r = 0.700), between L1-L5 lordosis and thoracic kyphosis (r = 0.363), between thoracic kyphosis and C2-7 lordosis (r = 0.425), and between C2-7 lordosis and C2 slope (C2S) (r = -0.735). In addition, this chain was extended to include the cranium, showing a strong correlation between the C2S and the cranial slope (CS) (r = -0.827). Strong correlations were observed between the CS and C2S (r = -0.827), C2-C7 lordosis (r = 0.583), C2-7 SVA (r = -0.437). The importance of O-C2 lordosis was significantly increased in the patient cohort with a prominent C2S (≥13) and became the main determinant of the CS (r = 0.667) together with the C2S (r = -0.800). CONCLUSIONS: The factors affecting horizontal gaze are C2S, C2-7 lordosis, O-C2 lordosis, and C2-7 SVA. C2S can be used as an indicator of the horizontal gaze in preoperative surgical planning and postoperative evaluation.

Compliance with PECARN head injury decision rules in children under two years old.

BACKGROUND: One of the most common complaints about presentation at the Emergency Department (ED) in childhood is minor head trauma. In recent years, clinical decision rules (CDRs) have been published to assist in determining the need for performing computed tomography (CT) in these patients. The present study aims to investigate the compliance with Pediatric Emergency Care Applied Research Network (PECARN) rules in the decisions for CT examination in children aged below two years old with minor head trauma in our center. METHODS: This retrospective, single-center study was conducted on a patient group aged below two years old, who presented at the ED within 24 hours of a trauma incident and were diagnosed as mild head trauma Glasgow Coma Scale score 14 and 15). RESULTS: A total of 262 patients were included in this study. Of these patients, 214 (81.7%) received CT examination, and 48 (18.3%) patients did not receive any CT examination. None of these 48 patients showed clinically important traumatic brain injury (ci TBI). Among 214 patients who received CT examination, 89 (34%) patients met the PECARN rules criteria and 125 (47.7%) patients did not meet PECARN rules criteria. None of the patients who received CT examination and did not meet the PECARN rules criteria showed ci TBI. Among 89 patients who recieved a CT examination and also met the PECARN rules criteria, only 4 (1.5%) patients showed ci TBI. According to these results, the rate of compliance with PECARN rules in our institution ED was 52.3%. CONCLUSION: In this study, which was conducted by including all the predictor values of the PECARN guidelines, the rate of compliance with PECARN rules was determined to be very low. Using these rules directly or with modification could establish a starting point for clinicians to reduce the rates of unnecessary CT scans. However, the effects of the clinician's experience, parental expectations, medicolegal constraints and economic factors on the decision making process should not be forgotten.

A Simple Cost-Effectiveness Analysis of Bilateral Decompression via Unilateral Approach versus Instrumented Total Laminectomy and Fusion for Lumbar Spinal Stenosis.

AIM: To compare the clinical and economic results of two different surgical approaches (bilateral decompression via unilateral approach and instrumented total laminectomy and fusion) in the treatment of lumbar spinal stenosis. MATERIAL AND METHODS: The clinical, surgical, and economic aspects of 100 surgically treated patients with lumbar spinal stenosis were retrospectively reviewed. RESULTS: Decompression was performed at 158 levels in 100 patients. The most commonly decompressed levels were L4-5 and L3-4. Significant difference was observed between pre- and postoperative visual analog scale scores in both groups (p < 0.05). In Group 1 (instrumented total laminectomy and fusion), the mean surgery cost was 2539.2 USD (mean procedure cost: 1440.1 USD, mean implant cost: 1099.2 USD). In Group 2 (bilateral decompression via unilateral approach) the mean surgery cost was 998.5 USD. The cost difference was significant (p < 0.05). CONCLUSION: Both instrumented total laminectomy and fusion and bilateral decompression via unilateral approach performed with and without stabilization showed similar clinical results in patients with lumbar spinal stenosis. However, the cost of surgery was found to be 2.5-fold higher in the instrumented total laminectomy and fusion group. This study supports the concept that minimally invasive spine surgery is cost-effective.

Osteoblastoma of C2 Corpus: 4 Years Follow-up.

Osteoblastomas are rare neoplasms of the spine. The majority of the spinal lesions arise from the posterior elements and involvement of the corpus is usually by extension through the pedicles. An extremely rare case of isolated C2 corpus osteoblastoma is presented herein. A 9-year-old boy who presented with neck pain and spasmodic torticollis was shown to have a lesion within the corpus of C2. He underwent surgery via an anterior cervical approach and the completely-resected mass was reported to be an osteoblastoma. The pain resolved immediately after surgery and he had radiologic assessments on a yearly basis. He was symptom-free 4 years post-operatively with benign radiologic findings. Although rare, an osteoblastoma should be considered in the differential diagnosis of neck pain and torticollis, especially in patients during the first two decades of life. The standard treatment for osteoblastomas is radical surgical excision because the recurrence rate is high following incomplete resection.

Placement of three-pin head holders in the Concorde position.

AIM: To reevaluate the Concorde position with different surgical interventions to the posterior fossa and cervical pathology and to improve patient comfort in the Concorde position through obtuse angle placement of the three-pin holder while the patient is in the supine position. MATERIAL AND METHODS: Twenty-nine patients with posterior fossa pathology or cervical pathology were included in this study. All patients were operated in the Concorde position. The three-pin holder was placed with an obtuse angle while the patient was in the supine position as shown in figure 1a. The angle between the handle of the three-pin holder and the floor was measured in the supine and prone positions as shown in Figure 1A,B. RESULTS: The average angle between the floor and the handle of the three-pin holder in the supine position and the Concorde position was 135 degrees (SD +/- 5.45) and 95 degrees (SD +/- 3.26) respectively (Figure 4) All the patient's body including the shoulders was within the borders of the operation table. CONCLUSION: The placement of three-pin holders with an obtuse angle in the supine position provides three advantages: easier manipulation during neck flexion especially for cervical vertebral pathology, much less body weight loading on the three-pin holders during surgery, and less flexion of the neck to expose pathology located in the cervical or posterior fossa region.

Rapid Development of Brain Abscess Caused by Streptococcus Pyogenes Following Penetrating Skull Injury via the Ethmoidal Sinus and Lamina Cribrosa

OBJECTIVE: Streptococcus pyogenes is a beta-hemolytic bacterium that belongs to Lancefield serogroup A, also known as group A streptococci (GAS). There have been five reported case in terms of PubMed-based search but no reported case of brain abscess caused by Streptococcus pyogenes as a result of penetrating skull injury. We present a patient who suffered from penetrating skull injury that resulted in a brain abscess caused by Streptococcus pyogenes. METHODS: The patient was a 12-year-old boy who fell down from his bicycle while cycling and ran into a tree. A wooden stick penetrated his skin below the right lower eyelid and advanced to the cranium. He lost consciousness on the fifth day of the incident and his body temperature was measured as 40degrees C. While being admitted to our hospital, a cranial computed tomography revealed a frontal cystic mass with a perilesional hypodense zone of edema. There was no capsule formation around the lesion after intravenous contrast injection. Paranasal CT showed a bone defect located between the ethmoidal sinus and lamina cribrosa. RESULTS: Bifrontal craniotomy was performed. The abscess located at the left frontal lobe was drained and the bone defect was repaired. CONCLUSION: Any penetrating lesion showing a connection between the lamina cribrosa and ethmoidal sinus may result in brain abscess caused by Streptococcus pyogenes. These patients should be treated urgently to repair the defect and drain the abscess with appropriate antibiotic therapy started due to the fulminant course of the brain abscess caused by this microorganism.