Ectopic Pituitary Neuroendocrine Tumors/Adenomas Around the Sella Turcica

Functional or non-secretory ectopic pituitary neuroendocrine tumors (PitNET) can form around the sella turcica during the development of the adenohypophysis by differentiating and detaching from the pharyngeal roof. These tumors usually appear in the sphenoid sinus, clivus, cavernous sinus, infundibulum, and suprasellar cistern. Ectopic PitNETs typically display the characteristic magnetic resonance imaging findings of pituitary adenomas. However, preoperative diagnosis of PitNETs is usually challenging because of the variety of clinical and imaging presentations, locations, and sizes. Ectopic suprasellar PitNETs resemble mass lesions in the pituitary stalk. Ectopic cavernous sinus of PitNETs are typically microadenomas in the medial wall. Ectopic sphenoclival tumors are characterized by more aggressive tumor activity than the other ectopic PitNETs. Although ectopic PitNETs are exceedingly rare, they should be considered as a differential diagnosis for masses around the sella turcica. Treatment of the disease should be individualized and may include medical care, surgical resection, gamma-knife radiosurgery, and radiotherapy.

Spatiotemporal Gait Parameters and Gait Asymmetry in Patients With Lumbar Disc Herniation, Treated With Microdiscectomy: A Prospective, Observational Study.

OBJECTIVE: The aim of this study was to emphasize on the interaction of spatial and temporal gait parameters and analyse the gait asymmetry in the patients with lumbar disc herniation (LDH) before and after microdiscectomy. METHODS: This was a prospective, observational study conducted on 59 cases of LDH planned for lumbar microdiscectomy, and healthy control group with 54 participants for analysis was performed prior to surgery and 15 days after surgery. The spatiotemporal gait parameters were measured using a "Win-Track" gait analysis platform system. All the participants walked barefoot for 10 times with their normal walking speed in the same day. The 3 flawless walking data were recorded and the arithmetic means were computed. The gait symmetry index was used to calculate the walking asymmetry. The pain intensity of the patients was recorded shortly before performing the analysis by a visual analogue scale. RESULTS: In the postoperative assessment LDH patients had significantly shorter temporal parameters, longer spatial parameters, faster walking speed, and more cadence than the preoperative assessment (p < 0.05). There were improvements in the asymmetry values of the postoperative gait parameters compared to the preoperative values, but these differences were not significant (p > 0.05). In addition, there was a significant difference in all parameters in terms of gait asymmetry between the postoperative assessment and the healthy controls (p < 0.05). CONCLUSION: These results can guide the patient-specific evaluating and implementation of gait rehabilitation programs, and design protocols before or after surgery in the LDH patients.

Spinal deformity surgery is accompanied by serious complications: report from the Morbidity and Mortality Database of the Scoliosis Research Society from 2013 to 2020.

PURPOSE: The Morbidity and Mortality (M&M) report of the Scoliosis Research Society (SRS) has been collected since 1965 and since 1968 submission of complications has been required of all members. Since 2009, the SRS has collected information on death, blindness, and neurological deficit, with acute infection being added in 2012 and unintentional return to the operating room (OR) being added in 2017. In this report, we use the most recent data submitted to the SRS M&M database to determine the rate of neurological deficit, blindness, acute infection, unintentional return to the OR, and death, while also comparing this information to previous reports. METHODS: The SRS M&M database was queried for all cases from 2013 to 2020. The rates of death, vision loss, neurological deficit, acute infection, and unintentional return to the OR were then calculated and analyzed. The rates were compared to previously published data if available. Differences in complication rates between years were analyzed with Poisson regression with significance set at α = 0.05. RESULTS: The total number of cases submitted per year varied with a maximum of 49,615 in 2018 and a minimum of 40,464 in 2020. The overall reported complication rate from 2013 to 2020 was 2.86%. The overall mortality rate ranged from 0.09% in 2018 to 0.14% in 2015. The number of patients with visual impairment ranged from 4 to 13 between 2013 and 2015 (no data on visual impairment were collected after 2015). The overall infection rate varied from 0.95 in 2020 to 1.30% in 2015. When the infection rate was analyzed based on spinal deformity group, the neuromuscular scoliosis group consistently had the highest infection rate ranging from 3.24 to 3.94%. The overall neurological deficit rate ranged from 0.74 to 0.94%, with the congenital kyphosis and dysplastic spondylolisthesis groups having the highest rates. The rates of unintentional return to the OR ranged from 1.60 to 1.79%. Multiple groups showed a statistically significant decreasing trend for infection, return to the operating room, neurologic deficit, and death. CONCLUSIONS: Neuromuscular scoliosis had the highest infection rate among all spinal deformity groups. Congenital kyphosis and dysplastic spondylolisthesis had the highest rate of neurological deficit postoperatively. This is similar to previously published data. Contrary to previous reports, neuromuscular scoliosis did not have the highest annual death rate. Multiple groups showed a statistically significant decreasing trend in complication rates during the reporting period, with only mortality in degenerative spondylolisthesis significantly trending upwards. LEVEL OF EVIDENCE: Level III.

The Influence of Mechanic Factors in Disc Degeneration Disease as a Determinant for Surgical Indication.

OBJECTIVE: Low back pain is the most common reason for physician visit in Western population. It's one of the factors that affect health-related quality of life. Intervertebral disc degeneration is one of the leading factors for low back pain and disc degeneration needs serious attention. In this article, we try to summarize biomechanical factors on the degenerative process. METHODS: Patients with low back pain in Neurosurgery Department between January 2012 and June 2019 are searched for this study. The patients were gathered under 2 groups; surgical intervention and conservative treatment groups. Intervertebral disc degeneration was assessed by Pfirrmann grading system. All spinopelvic parameters were measured by using standardized lateral plain standing lumbar radiographs. RESULTS: There were 165 patients in the surgical group (60 females, 105 males) and 84 patients in the conservative group (57 females, 27 males) after randomization. One hundred fifty patients had microdiscectomy and 15 patients had spinal instrumentation with transforaminal lumbar interbody fusion. There was not a statistically significant difference between surgical intervention and conservative treatment groups when comparing disc degeneration status. There was a statistically significant difference in parameters lumbar lordosis (LL), L4-S1, and pelvic incidence-LL (PI-LL) between the 2 treatment groups. In the surgical group when we further analyze the spinopelvic parameters in between the 2 different surgical techniques; L4-S1, pelvic tilt, and PI-LL showed a statistically significant difference. CONCLUSION: Degenerative disc disease is related with multiple factors which can be detailed under the mechanic components and the genetic components. Of these factors, spinopelvic parameters seem highly penetrating to patients' surgery needs with degenerative disc disease independently.

Assessment of Spatiotemporal Gait Parameters in Patients with Lumbar Disc Herniation and Patients with Chronic Mechanical Low Back Pain.

AIM: To assess spatiotemporal gait parameters in patients with lumbar disc herniation (LDH) and chronic mechanical low back pain (CMLBP), and compare with healthy control group. MATERIAL AND METHODS: A total of 70 patients was enrolled in this prospective, controlled cross-sectional study, of which 25 with LDH, 25 with CMLBP and 20 healthy individuals as the control group. Participants completed 10 passes on the "WIN-TRACK" Gait Analysis Platform at their self-selected walking speed. The arithmetic mean of the five flawless walking data was used for analysis. Pain intensity is assessed by the Visual Analog Scale (VAS). RESULTS: The spatiotemporal gait parameters were significantly decreased in LDH and CMLBP groups than the healthy control group, particularly in LDH groups (p≥0.001). It was found that pain intensity is negatively correlated to step and stride length, cadence and velocity (p < 0.001). Results of linear regression analysis showed that 10% of the changes in gait cycle duration of the left extremity and 74% of the changes in the velocity were associated with pain intensity. CONCLUSION: Pain intensity can affect the spatiotemporal gait parameters in patients with Low Back Pain (LBP). Rehabilitation programs with gait optimization should be considered in the management of patients with LDH and CMLBP.

Functional Reorganization in the Primary Somatosensory Cortex of Rat Following Hind-Paw Amputation: A Study of Functional Imaging with 1.5 Tesla MRI.

AIM: To learn how rat primary somatosensory cortex (pSSC) responses to the loss of inputs from hind-paw, using fMRI of an inferior magnetic power (1.5 Tesla) with special designed high-powered rat coil. MATERIAL AND METHODS: Ten adult male Sprague-Dawley rats were enrolled in this study. The rats were anesthetized with ketamine injection. Xylazine was intraperitoneally injected for analgesia and muscle relaxation with careful maintenance of spontaneous respiration. Either right or left hind-paws were amputated under aseptic conditions according to predefined random allocation of the rats. A 12-channel rat surface coil developed for proper image resolution in 1.5 Tesla MR was used. Functional magnetic resonance imaging was obtained before hind-paw amputation; 2, 15 and 30 days after the amputation. RESULTS: Activation signals were detected in 5 rats' contralateral pSSC before the hind-paw amputation with regression and cessation of the signal after the amputation. Signal re-appeared in the contralateral pSSC of only one rat (rat 9) 30 days after the amputation. CONCLUSION: This study showed that functional plasticity might occur in the pSSC following hind-paw amputation of rats. Further studies are necessary to understand the true nature of the plasticity observed in pSSC, with new and novel measurement techniques on cellular basis rather than gross anatomical one.

Spinal meningiomas: 61 cases with predictors of early postoperative surgical outcomes.

BACKGROUND: Spinal meningiomas are benign, well-circumscribed and slowly-growing intradural tumors that compress the spinal cord. Hereby, a retrospective review of 61 spinal meningioma cases evaluated in terms of demographic, clinical, pathological and radiological features to predict the early postoperative functional outcomes. METHODS: Patients' records and MRI images of all the histologically confirmed spinal meningioma cases that underwent surgical resection at two university hospitals from January 2005 to June 2016 were retrospectively reviewed. Demographic data, clinical findings, radiological features and pathology reports were reviewed. Univariate and multivariate logistic regression analyses were used to evaluate the impact of each factor on the early 3-month post-surgical functional outcome. A receiver operating characteristic (ROC) curve was used to predict the power of the model. RESULTS: Sixty-one cases of spinal meningiomas were operated: 13 males (21%) and 48 females (79%). Mean age was 60.5 years and ranged from 24 to 92 years. Patients presented with back pain (57%), motor deficits (47.5%), sensory deficits (18%) and sphincteric dysfunction (11.5%). One case (1.6%) showed an additional extradural growth. There were 40 thoracic, nine cervical, five cervicothoracic, five thoracolumbar, and two lumbar cases. Only four cases (6.6%) showed atypical pathological features (WHO grade II). At 3-month follow-up, 46 patients (75.4%) had either functionally improved or remained stable. Fifteen patients (24.6%) had "worse" functional outcome. Three variables showed statistically significant odds ratio for improved outcomes (OR): pre-surgical motor deficit (OR=5; P=0.005); presurgical sensory disturbance (OR=3.5; P=0.026); pre-surgical myelopathy (OR=3.5; P=0.026). Multivariate analysis showed increased OR for cross-sectional ratio, pre-surgical myelopathy, pre-surgical radiculopathy and non-cervical location of tumor (1.59, 3.46, 3.2, 1.63/3.56, respectively). Although none has reached statistical significance (P>0.05), the receiver operating characteristic (ROC) curve showed an area under the curve (AUC) of 0.74. CONCLUSIONS: The independent predictors of the early postoperative functional outcomes of spinal meningioma resections may include pre-surgical motor deficit, sensory deficit and myelopathy.

Fracture and migration of a retained microcatheter into the cauda equina after endovascular neurointervention for dural arteriovenous fistula as a rare cause of tethered spinal cord: case report.

The evaluation of spinal cord vascular malformations in neuroradiology departments remains valid for both diagnosis and endovascular embolization, and for adjuvant as well as definitive treatment. The most commonly encountered complications of endovascular approaches are the recurrence or the incomplete embolization of the lesion and accidental damage to the medullary arteries, which leads to spinal cord infarction. Failure to remember a microcatheter in the abdominal aorta after catheterization is an underestimated complication. A retained guidewire in the circulation may not necessarily cause symptoms, and it may remain unnoticed for a significant period of time. However, severe complications may be faced even many years later. In this article, a case report on a fracture and migration of a retained microcatheter in the cauda equina is presented. This occurred after an endovascular neurointervention for dural arteriovenous fistula as a rare cause of tethered spinal cord.

Antidepressants in Spine Surgery: A Systematic Review to Determine Benefits and Risks.

Antidepressant drugs can be advantageous in treating psychiatric and non-psychiatric illnesses, including spinal disorders. However, spine surgeons remain unfamiliar with the advantages and disadvantages of the use of antidepressant drugs as a part of the medical management of diseases of the spine. Our review article describes a systematic method using the PubMed/Medline database with a specific set of keywords to identify such benefits and drawbacks based on 17 original relevant articles published between January 2000 and February 2018; this provides the community of spine surgeons with available cumulative evidence contained within two tables illustrating both observational (10 studies; three cross-sectional, three case-control, and four cohort studies) and interventional (seven randomized clinical trials) studies. While tricyclic antidepressants (e.g., amitriptyline) and duloxetine can be effective in the treatment of neuropathic pain caused by root compression, venlafaxine may be more appropriate for patients with spinal cord injury presenting with depression and/or nociceptive pain. Despite the potential associated consequences of a prolonged hospital stay, higher cost, and controversial reports regarding the lowering of bone mineral density in the elderly, antidepressants may improve patient satisfaction and quality of life following surgery, and reduce postoperative pain and risk of delirium. The preoperative treatment of preexisting psychiatric diseases, such as anxiety and depression, can improve outcomes for patients with spinal cord injury-related disabilities; however, a preoperative platelet function assay is advocated prior to major spine surgical procedures to protect against significant intraoperative blood loss, as serotonergic antidepressants (e.g., selective serotonin reuptake inhibitors) and bupropion can increase the likelihood of bleeding intraoperatively due to drug-induced platelet dysfunction. This comprehensive review of this evolving topic can assist spine surgeons in better understanding the benefits and risks of antidepressant drugs to optimize outcomes and avoid potential hazards in a spine surgical setting.

Posterior Cervical Keyhole Laminoforaminotomy: A Cadaveric Comparative Study to Evaluate Limits of Bony Resection.

BACKGROUND: The posterior cervical keyhole (KH) laminoforaminotomy has been described to involve the lateral portion of cervical laminae of the upper vertebra alone (small KH) or of both upper and lower vertebrae (large KH). OBJECTIVE: To microscopically compare the two keyhole techniques in terms of their ability to expose the corresponding cervical roots. METHODS: Ten cadaveric specimens were operated bilaterally from C3-4 to C6-7 level to expose a total of 80 nerve roots. The large KH was applied to the left side, the small KH to the right side. The maximal length of exposed nerve roots was measured under microscope. The virtual optimal KH surface area was determined using digital software. Each root was inspected for exposure of its root and axilla. RESULTS: The maximal exposed nerve root length on the large KH side was significantly larger than on the small KH side at C3-4, C5-6, and C6-7 levels (P = .031, P = .002, P = .003). No significance was reported for C4-5 (P = .06). We could expose right axillae in (3/40) and left axillae in (33/40; P < .001). Optimal keyhole surface areas were 37.9, 38.2, 38.7, and 46.2 mm2 in craniocaudal order. CONCLUSION: Large KH defects involving both upper and lower laminae and facets can expose the roots to greater extent than small KH defects at C3-4, C5-6, and C6-7 levels. Large KH defects may allow better exposure of nerve roots axillae than small KH defects.

An ioMRI-assisted case of cervical intramedullary diffuse glioma resection.

PURPOSE: To date, application of intraoperative magnetic resonance imaging (ioMRI) to enhance surgical quality for spinal intramedullary neoplastic lesions has been rarely reported. Moreover, in developing countries or regions, ioMRI accessibility remains very limited. This report describes a technology design of high-field ioMRI accessible for multioperation rooms via a case presentation of an imaging-assisted surgical excision of human cervical spinal cord diffuse glioma. PATIENT AND METHODS: The patient was a 44-year-old woman with symptomatic and progressive C2-5 intramedullary diffuse glioma (IDG). Our ioMRI system was designed and arranged with accessibility to multiple operation rooms, which was used to assure more complete spinal cord or brain tumor removal. The intraoperational diagnostic aspects and the system setup technical details are presented for future applications of the system in hospitals where a designated ioMRI suite is not available. RESULTS: After a conventionally defined complete removal of C2-C5 IDG using a well-established surgical approach, ioMRI examination was able to detect residual tumor tissues that were indistinguishable under the surgical microscope. The IDG clusters were subsequently excised. The operation regimen resulted in a gross total elimination of the tumor, which enabled the patient to show very satisfactory postsurgery recovery and prognosis. CONCLUSION: ioMRI-assisted surgical removal of cervical spinal cord diffuse glioma should be systematically developed and applied to enhance therapeutic efficacy. The reported logistic flow of operating room tasks and imaging technical management are innovative for performing the tumor removal procedures in hospitals where designated ioMRI surgical suites do not exist. Critically, we emphasize implementation of stringent quality control measures for patient transportation safety and contamination prevention in establishing and maintaining such a system.

Posterior Rigid Instrumentation of C7: Surgical Considerations and Biomechanics at the Cervicothoracic Junction. A Review of the Literature.

BACKGROUND: The cervicothoracic junction is a challenging anatomic transition in spine surgery. It is commonly affected by different types of diseases that may significantly impair stability in this region. The seventh cervical vertebra (C7) is an atypical cervical vertebra with unique anatomic features compared to subaxial cervical spine (C3 to C6). C7 has relatively broader laminae, larger pedicles, smaller lateral masses, and a long nonbifid spinous process. These features allow a variety of surgical methods for performing posterior rigid instrumentation in the form of different types of screws, such as lateral mass screws, pedicle screws, transfacet screws, and intralaminar screws. Many biomechanical studies on cadavers have evaluated and compared different types of implants at C7. METHODS: We reviewed PubMed/Medline by using specific combinations of keywords to summarize previously published articles that examined C7 posterior rigid instrumentation thoroughly in an experimental fashion on patients or cadavers with additional descriptive radiologic parameters for evaluation of the optimum surgical technique for each type. RESULTS: A total of 44 articles were reported, including 22 articles that discussed anatomic considerations (entry points, sagittal and axial trajectories, and features of screws) and another 22 articles that discussed the relevant biomechanical testing at this transitional region if C7 was directly involved in terms of receiving posterior rigid implants. CONCLUSIONS: C7 can accommodate different types of screws, which can provide additional benefits and risks based on availability of bony purchase, awareness of surgical technique, biomechanics, and anatomic considerations.

Proposal of a new radiological classification system for spinal meningiomas as a descriptive tool and surgical guide.

OBJECTIVES: 1) To provide neurosurgeons and radiologists with a new quantitative and anatomical method to describe spinal meningiomas (SM) consistently. 2) To provide a guide to the surgical approach needed and amount of bony resection required based on the proposed classification. 3) To report the distribution of our 58 cases of SM over different Stages and Subtypes in correlation to the surgical treatment needed for each case. 4) To briefly review the literature on the rare non-conventional surgical corridors to resect SM. PATIENTS AND METHODS: We reviewed the literature to report on previously published cohorts and classifications used to describe the location of the tumor inside the spinal canal. We reviewed the cases that were published prior showing non-conventional surgical approaches to resect spinal meningiomas. We proposed our classification system composed of Staging based on maximal cross-sectional surface area of tumor inside canal, Typing based on number of quadrants occupied by tumor and Subtyping based on location of the tumor bulk to spinal cord. Extradural and extra-spinal growth were also covered by our classification. We then applied it retrospectively on our 58 cases. RESULTS: 12 articles were published illustrating overlapping terms to describe spinal meningiomas. Another 7 articles were published reporting on 23 cases of anteriorly located spinal meningiomas treated with approaches other than laminectomies/laminoplasties. 4 Types, 9 Subtypes and 4 Stages were described in our Classification System. In our series of 58 patients, no midline anterior type was represented. Therefore, all our cases were treated by laminectomies or laminoplasties (with/without facetectomies) except a case with a paraspinal component where a costotransversectomy was needed. CONCLUSION: Spinal meningiomas can be radiologically described in a precise fashion. Selection of surgical corridor depends mainly on location of tumor bulk inside canal.

Publication Rates of Presentations at Annual Scientific Meetings of the Turkish Neurosurgical Society.

AIM: National and international society meetings are suitable mediums at which diverse research topics from basic, clinical and translational sciences can be presented to an audience of peers. In this study, our purpose was to evaluate publication rates of presentations in the last recent four years" annual scientific meetings of Turkish Neurosurgical Society (TNS). MATERIAL AND METHODS: Abstracts of both podium and poster presentations were retrieved from the congress booklets of TNS. Study timeline included TNS annual scientific meetings of 2011, 2012, 2013, and 2014. Abstract titles and author names of the abstracts were searched in Pubmed/MEDLINE and Google Scholar databases. RESULTS: In total, 3105 presentations to an audience took place in the annual scientific meetings of TNS organized between 2011 and 2014. Acceptance rate of these studies by peer-reviewed scientific journals was 326 (10.5%). In sub-analysis, there were 2408 electronic posters (148 accepted, 6.1%), 195 poster presentations with discussion (44 accepted, 22.6%), and 502 podium presentations (134 accepted, 26.7%). CONCLUSION: Acceptance rate of podium presentations in annual scientific meeting of TNS is at comparable levels with similar organizations on the world. However, the rate is lower for poster presentations.

Magnetically Controlled Growing Rod in Early-Onset Scoliosis: A Minimum of 2-Year Follow-Up.

PURPOSE: The magnetically controlled growing rod technique decreases complications, costs, and loss of functionality by avoiding successive surgical corrections every 6 months in patients with early-onset scoliosis. However, only a few studies have presented clinical experience with the magnetically controlled growing rod. In this study we aimed to present our single-center experience in patients with early-onset scoliosis who underwent the magnetically controlled growing rod technique and follow-up for at least 2 years. MATERIALS AND METHODS: We made an observational study by evaluating patients with early-onset scoliosis who underwent the magnetically controlled growing rod technique between February 2012 and December 2013. Demographic and clinical data were obtained from the patients charts. We included patients who were followed up for at least 2 years. Radiological data were obtained from plain anterior-posterior and lateral scoliosis X-rays. RESULTS: Eight patients with early-onset scoliosis who underwent surgery using the magnetic system were treated with dual rods. None of the spines were fused to the sacrum. We observed no intra- and/or postsurgical complications. The average number of external rod lengthenings was 7.6. The average amount of lengthening was 30.6 mm on the right side and 27.8 mm on the left side by the time of last clinical follow-up. The average coronal and sagittal Cobb values at the final clinical evaluation were 10.5° (thoracic coronal), 13.75° (lumbar coronal), 6.25° (lumbosacral coronal), 24.5° (thoracic sagittal), and 40° (lumbar sagittal), respectively. CONCLUSIONS: The magnetically controlled growing rod is beneficial in early-onset scoliosis, since it enables spinal growth and decreases additional surgeries, complications, and costs. Even though we had a small sample size, our follow-up period was enough to declare long-term outcomes of our patients. Multicenter and large sample-sized studies are needed to make more conclusive statements regarding this promising scoliosis treatment approach.

Recurrent Cranial Chronic Subdural Hematoma due to Cervical Cerebrospinal Fluid Fistula: Repair of Both Entities in the Same Session.

Cranial chronic subdural hematoma (CSH) occurs secondary to trauma or just spontaneously. In this clinical report, the authors presented a 39-year-old male patient who was admitted with cranial CSH. In further assessment of the patient, the authors found an underlying cerebrospinal fluid (CSF) leak at the level of cervical spine. Following evacuation of the CSH, it recurred. In the second session, the hematoma was re-evacuated and the CSF fistula repaired. The CSH did not recur again. In young adult patients with recurrent CSH and prior presence of bilateral CSH, a survey for an underlying spinal CSF leak should be considered in the differential, especially in the background of trauma. Conservative treatment, epidural blood patching, or microsurgical repair of the dural defect should be conceptualized according to the circumstances of the individual patients with spontaneous intracranial hypotension and spinal CSF fistula.

Perioperative Effects of Different Narcotic Analgesics Used to Improve Effectiveness of Total Intravenous Anaesthesia.

OBJECTIVE: We aimed to evaluate the depth of anaesthesia, perioperative haemodynamics, postoperative pain scores, analgesic consumption in patients receiving remifentanil- or alfentanil-based total intravenous anaesthesia for single-level lumbar discectomy. METHODS: Seventy patients undergoing discectomy were enrolled in the study. Patients were intravenously administered an initial bolus dose of 2 mg kg(-1) propofol and 10 mcg kg(-1) alfentanil or 1 mcg kg(-1) remifentanil, followed by 6 mg kg(-1) h(-1) propofol and either 1 mcg kg(-1) min(-1) alfentanil or 0.25 mcg kg(-1) min(-1) remifentanil infusion. Bispectral index (BIS) values, mean arterial pressure, heart rate, end-tidal carbon dioxide and oxygen saturation were recorded. Postoperative pain scores at 0, 30 and 60 min were measured and recorded with additional opioid requirements. RESULTS: Postoperative pain scores at 0 and 30 min, total analgesic consumption and requirement for additional analgesics were significantly high in the remifentanil group. After the first hour, the pain scores were not significantly different. Mean arterial blood pressure was significantly low at 45 and 60 min preoperatively in the remifentanil group. In the remifentanil group, heart rate at 15, 30, 45, 60 min were significantly lower than those in the alfentanil group. BIS values of the two groups were not significantly different at any measurement time point. BIS values of remifentanil group at 30, 45, 60, 90 and 180 min significantly increased compared with those at 15 min. CONCLUSION: Alfentanil provided more stable BIS and haemodynamic values preoperatively and less opioid consumption, along with lower pain scores, during the early postoperative period compared with remifentanil in patients undergoing single-level discectomy.

Vertebral artery loops in surgical perspective.

PURPOSE: Vertebral artery loop is a congenital or acquired anomaly. Vertebral artery loops are incidentally diagnosed during evaluation of neck problems and trauma. We aimed to present the incidence of VA loops using magnetic resonance angiography in consecutive patients and discuss epidemiological data including the gender, age, location, signs and symptoms, treatment approaches and outcomes of VA loops via analyzing literature. METHODS: In the first leg of our two-legged study, consecutive patients were evaluated using magnetic resonance angiography to detect any medial loop of vertebral arteries. The study period was from October 2015 to March 2016. In the second leg, academic databases about medial loop of vertebral artery were screened. Case reports, case series, abstracts and references of relevant literature were searched manually to avoid any missing cases. RESULTS: We evaluated 239 consecutive patients using magnetic resonance angiography. Twenty-one patients were excluded from the study due to inadequate image acquisition, aplastic vertebral artery and/or concomitant vertebral artery stenosis. Medial loop of V2 vertebral artery was observed in 13 patients (5.9 %): 9 with left, 2 with right and 2 with bilateral medial V2 loop. Patients with medial V2 loop were significantly older than patients with straight vertebral arteries (70.30 vs. 62.36, p = 0.028). In the literature analysis, VA loops were more commonly observed at V2 segment (90.5 %). Vertebral artery loops were mostly diagnosed at the 5th and 6th decades of life predominantly in females. The most common signs and symptoms were radiculopathy and/or neck pain, and signs and symptoms of vertebrobasilar insufficiency. CONCLUSIONS: Concise pre-operative evaluation of the vertebral arteries is essential to avoid the injury of undiagnosed VA loops during surgery, which might result in catastrophic circumstances. Further evaluation of the vertebral arteries using MR angiography is required, especially in elder age, before cervical spine surgeries.

Delayed Onset Intracranial Subdural Hematoma Following Spinal Surgery.

In this case-based review, the authors analyzed relevant literature with an illustrative patient of theirs about subdural hematoma secondary to dural tear at spinal surgery. Intracranial hypotension is a condition of decreased cerebrospinal fluid volume and pressure. Even though intracranial hypotension is temporary and can be managed conservatively, it may progress and result in subdural fluid collections, hematoma formations, "brain sagging or slumping" states, syringohydromyelia, encephalopathy, coma, and even death. The authors present an 81-year-old man admitted with subdural hematoma 50 days following previous spinal surgery for lumbar spinal stenosis. In his previous spinal surgery he had had dural tear, which had been closed primarily. To the literature, only 21 patients have been reported to develop subdural hematoma following spinal surgery. In patients with subdural hematoma following spinal surgery, the female:male ratio was 3:4 and the median age was 55 years. Surgical diagnoses for previous spinal surgeries were intervertebral disc herniation (5), spinal canal stenosis and spondylolisthesis (6), failed back syndrome (2), tethered cord syndrome and myelodysplastic spine (2), spinal cord tumor, spinal epidural hematoma, vertebral dislocation, vertebral fracture, vertebral tumor, and inflammatory spine. Patients presented with signs and symptoms of subdural hematoma within 6 hours to 50 days following the spinal surgery. Source of cerebrospinal fluid leak was most commonly from lumbar region (13 patients, 62%). Ten of 21 (48%) patients were treated conservatively. Late-onset neurological findings should not prevent the evaluation of cranial vault with computed tomography and magnetic resonance imaging. Spinal dural tear should be more aggressively treated instead of suture alone approach, when recognized in older patients during the spinal surgery.

Craniospinal Polyostotic Fibrous Dysplasia, Aneurysmal Bone Cysts, and Chiari Type 1 Malformation Coexistence in a Patient with McCune-Albright Syndrome.

Aneurysmal bone cysts (ABCs) are defined as benign cystic lesions of bone composed of blood-filled spaces. ABCs may be a secondary pathology superimposed on fibrous dysplasia (FD). Concomitant FD and ABC in relation with McCune-Albright syndrome is an extremely rare condition. Here, we report concomitant, double ABCs in bilateral occipital regions and FD from the skull base to the C2 vertebra with Chiari type 1 malformation. A 14-year-old female with a diagnosis of McCune-Albright syndrome presented with swellings at the back of her head. The lesions were consistent with ABCs and were totally resected with reconstruction of the calvarial defects. The coexistence of FD, bilateral occipital ABCs, and Chiari malformation type 1 in a McCune-Albright patient is an extremely rare condition and, to our knowledge, has not been reported to date. Exact diagnosis and appropriate surgical treatment usually lead to a good outcome.