Comparison of clinical and functional outcomes of vertebral body tethering to posterior spinal fusion in patients with adolescent idiopathic scoliosis and evaluation of quality of life: preliminary results.

PURPOSE: This preliminary study was aimed to present the results of the comparison of clinical and functional outcomes of vertebral body tethering (VBT) and posterior spinal fusion (PSF) for the first time in the literature. METHODS: 21 thoracolumbar (T5-L3) VBT patients (VBT group); and 22 age-gender-fusion level and minimum follow-up duration matched thoracolumbar (T3-L3) PSF patients (PSF group) were enrolled. Average FU duration of group 1 and 2 were 37.1/37.8 months (p = 0.33). Patients clinical data together with SRS-22 scores and SF-36 scores were compared. A retrospective, comparative study was undertaken. RESULTS: VBT group was detected to have superior lumbar range of motion; superior anterior-lateral lumbar bending flexibility; superior flexor and extensor endurances of trunk, and superior average motor strength of trunk muscles with high statistical significance. VBT group was also detected to have superior scores regarding life quality, including better average total SRS-22 and better average SF-36 MCS/PCS scores with also high statistical significance. CONCLUSION: This study for the first time in the literature concluded, that in skeletally immature patients with AIS, VBT as a result of the utilization of growth modulation was able to yield significantly superior lumbar range of motion, lumbar anterior and lateral flexibility, trunk flexor-extensor endurance and trunk motor strength as compared to patients who underwent fusion. By yielding significantly superior SRS-22 and SF-36 scores, VBT was detected to provide better life quality and patient satisfaction than fusion. This study concluded hereby, that by applying VBT, spinal motion could be preserved and complications of fusion could be avoided.

Unilateral Posterior Surgery for Severe Osteoporotic Vertebrae Fractures' Sequelae in Geriatric Population: Minimum 5-Year Results of 109 Patients.

OBJECTIVE: This study aimed to evaluate the efficacy and safety of modified posterior vertebral column resection (PVCR) combined with anterior column restoration in elderly patients presenting with thoracic or thoracolumbar osteoporotic fractures with spinal cord compression and severe pain. METHODS: One hundred nine patients with one level thoracolumbar osteoporotic fracture and at least 5 years of follow-up were included. They underwent posterior instrumentation performed with polymethymetachrylate augmented pedicle screws. A modified PVCR (unilateral costotransversectomy+hemilaminectomy) combined with the insertion of an expandable titanium cage for anterior column restoration was undertaken. Patients were evaluated clinically and radiographically. RESULTS: Patients had a mean age of 74.1 and a follow-up duration of 92.3 months. Mean duration of operations, hospital stays, and mean loss of blood were 172.3 minutes, 4.3 days, and 205.4 mL. All of the patients were mobilized immediately after surgery. The mean preoperative local kyphosis angle improved from 39.3° to 4.7° at the last follow-up (p = 0.003). Patients preoperative mean visual analogue score, Japanese Orthopaedic Association, and Oswestry Disability Index scores improved from 7.7/8.6/76.3 to 1.6/26.1/17.4 (p < 0.001 for all), respectively. The average 36-item Short-Form survey physical component summary/mental component summary scores at the last follow-up were 55.1/56.8. A dural tear was detected intraoperatively in 1 patient and repaired immediately. CONCLUSION: Subtotal PVCR combined with the insertion of an expandable titanium cage was detected as a safe and effective method for osteoporotic vertebrae fractures' sequelae in the older population involving spinal cord compression by enabling the decompression of the spinal canal and reconstruction of the resected segment, resulting in significant improvement in clinical and radiographic outcomes.

Double-sided vertebral body tethering of double adolescent idiopathic scoliosis curves: radiographic outcomes of the first 13 patients with 2 years of follow-up.

PURPOSE: In skeletally immature patients with adolescent idiopathic scoliosis (AIS), vertebral body tethering (VBT) as a fusionless minimally invasive treatment option has been shown to correct the deformity by growth modulation. This prospective cohort study aimed to present the minimum 2 years' results of double-sided VBT applied to double curves of 13 skeletally immature patients with AIS. METHODS: Thirteen skeletally immature patients with AIS and double curves were included. All patients were followed up within a brace for at least 6 weeks. A decision to proceed with surgery was established after the detection of curve progression within the brace (> 40° thoracic, > 35° lumbar) with a minimum curve flexibility of 30%. RESULTS: Patients had an average age of 11.8 years, average follow-up duration of 36.4 months (range 24 to 46), average preoperative main thoracic/thoracolumbar or lumbar curve magnitudes of 48.2°/45.3°. An average of 11.8 levels of tethering was undertaken. Thoracic screws were placed thoracoscopically, while mini-thoracotomy/lumbotomy was added for thoracolumbar levels. Postoperatively, an average first erect thoracic/thoracolumbar major curve magnitudes of 17.3°/14.3° were acquired, while they improved to 9.7°/8.2° at the last follow-up. No neurologic or implant-related complications were acquired. CONCLUSION: Double-sided VBT was detected to provide 80% of thoracic (48.2° to 9.7°) and 82% of thoracolumbar-lumbar curve correction (45.3° to 8.2°) as a result of average two years. As being a growth modulating treatment option, double-sided VBT as applied under strict inclusion criteria was shown to be safe and effective for the correction of double curves in skeletally immature patients with AIS, by yielding a gradual, growth-assisted correction of both curves together with the preservation of coronal-sagittal balance without any major complications.

Thoracoscopic Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Minimum of 2 Years' Results of 21 Patients.

BACKGROUND: Anterior vertebral body tethering (VBT) is a growth modulating and fusionless treatment option that is considered as a new promising method for the management of adolescent idiopathic scoliosis (AIS). This prospective cohort study aimed to present the minimum 2-year results of anterior VBT applied to 21 skeletally immature patients with AIS. METHODS: Twenty-one skeletally immature patients with a diagnosis of AIS were included. A decision to proceed with surgery was established after the detection of curve progression despite the brace (>40 degrees) with a minimum curve flexibility of 30%. RESULTS: Patients had an average age of 11.1 and an average follow-up period of 27.4 months. All patients underwent thoracoscopic placement of thoracic screws, from the convex side of curves. An average of 7.1 levels of tethering was undertaken. Average preoperative major thoracic curve magnitudes improved from 48.2 to 16 degrees on the first erect postoperative x-ray, and to 10 degrees at the last follow-up (P<0.001). Immediate postoperatively, 1 case with chylothorax was detected and treated conservatively, and another case with tether breakage was detected at the third postoperative year and replaced thoracoscopically. No other major complication was acquired. CONCLUSIONS: Anterior VBT as a growth modulating treatment option by allowing the correction of the scoliotic deformity and preserving coronal balance was detected to be a safe and effective option for the surgical treatment of AIS in skeletally immature patients, if applied under strict inclusion criteria. VBT by allowing preservation of spinal segmental motion is yielding promising radiographic results without causing any major complications. LEVEL OF EVIDENCE: Level IV.

"Honey" can prevent epidural fibrosis development after laminectomy: an experimental study.

AIM: One of the most important causes of failed back surgery is the development of epidural fibrosis. Many methods and substances have been used to prevent the development of epidural fibrosis after laminectomy. In this study, effects of "manuka honey" on epidural fibrosis development after laminectomy was evaluated in rats. MATERIAL AND METHODS: Subjects were divided into two groups:In Group-1 (n=8);only laminectomy was carried out in the L1 level; in group-2 (n=8), laminectomy was carried out in the L1 level and manuka honey was applied to the area. The related vertebral columns were removed en bloc 6 weeks later. Leveled sections with thicknesses of 6 mm were obtained from paraffin blocks. RESULTS: In the grading made based on the fibroblast count and scar tissue degree, it was found that epidural fibrosis developed significantly less in the group-2 as compared to the group-1, and the difference was statistically significant. CONCLUSION: It was shown in our study that manuka honey reduces the degree of epidural fibrosis in rats following laminectomy. We believe that manuka honey, which can be used safely in the clinic for surgical wounds, can be used routinely to prevent development of epidural fibrosis following laminectomy.

Antibacterial effect of royal jelly for preservation of implant-related spinal infection in rat.

AIM: Implant-related infections are still a significant problem in spinal surgical procedures. Many drugs and methods have been tried to prevent implant-related infections. Our objective in this study was to evaluate whether royal jelly, which was found to hinder the growth of MRSA, has any preventive role in the prognosis of an infection in rats in an implant-related infection model. MATERIAL AND METHODS: Rats were divided into 3 groups of eight rats. Group-1 consisted of rats that underwent only a spinal implant, group-2 included those rats that were inoculated bacteria together with a spinal implant and group-3 was administered royal jelly in addition to a spinal implant and infection. RESULTS: The amount of bacteria that grew in vertebral columns and implants was more in Group-2 than in Group-3, which meant that the number of bacteria colonies that grew was more quantitatively. This difference was found to be statistically significant in vertebral columns, but not in implants. CONCLUSION: Royal jelly could not fully prevent the MRSA infection in this model, but decreased the severity of infection noticeably. More objective and promising results may be obtained if royal jelly can be used at regular intervals in a different model to be designed with respect to implant-related infections.

Can recurrence of chronic subdural hematoma be predicted? A retrospective analysis of 292 cases.

BACKGROUND: Chronic subdural hematomas are the most common type of intracranial hemorrhage among the elderly. There is a substantial recurrence rate after evacuation by burr-hole surgery. In this study, we aimed to determine the predictors of recurrence after single burr-hole evacuation of chronic subdural hematomas. METHODS: We retrospectively analyzed 292 consecutive patients with chronic subdural hematoma. Clinical parameters, anamnesis, and previous anticoagulant drug use have been evaluated with univariate and multivariate analyses to determine predictors associated with recurrence. RESULTS: At least a second surgery was needed in 43 of 292 (14.7%) patients. We showed that recurrence rate was significantly higher in patients with bilateral subdural hematoma, after univariate and multivariate analyses (23.1% versus 11.4%). We did not find any significant relationship between recurrence rate and age, gender, hypertension, and/or diabetes mellitus in anamnesis, preceding head trauma, and time interval between trauma and the operation, previous anticoagulant, and/or antiaggregant therapy. CONCLUSION: After analysis of all evaluated factors, only bilateral hematoma was found correlated with high recurrence rate (p = 0.01), probably due to previous brain atrophy or existing coagulopathy.

Efficiency of antibiotic-loaded polymethylmethacrylate rods for treatment of the implant-related infections in rat spine.

STUDY DESIGN: A study of local treatment of the implant-related infections in animal spine. OBJECTIVE: : This study aims to investigate the efficiency of antibiotic-loaded polymethylmethacrylate rods for treatment of the implant-related infections. SUMMARY OF BACKGROUND DATA: Today's implant-related vertebral infections are challenging in spinal surgery. In addition to resolving this problem, systemic antibiotic treatment is necessary to study and develop the effectiveness of locally applied treatment methods. METHODS: Twenty-four female white Sprague Dawley rats were randomized in 3 different groups, each consisting of 8 animals. Under general anesthesia, 3 mm titanium microscrew was implanted in the thoracic vertebra. All 3 groups were inoculated with the same concentration of Staphylococcus aureus (10 colony-forming units/10 µL). Group 1 was assigned as a control group and received no additional therapy, group 2 was given single intraperitoneal doses of vancomycin, and group 3 was implanted vancomycin buffered acrylic rods. RESULTS: The results were analyzed by Fischer exact test. The comparison between the groups revealed a significantly higher therapeutic effect (P<0.05) in the local therapy group and in the systematic treatment group compared with the control group. The success of the treatment in the systemic treatment group was statistically not significantly different (P>0.05) compared with the outcome of the locally treated group. CONCLUSIONS: This study shows the success of antibiotic-loaded polymethylmethacrylate rods for the treatment of the spinal implant infections. Further research involving clinical studies is required to increase the efficacy and the clinical applicability of the technique.

Lymphocytic hypophysitis: an underestimated disease affecting the sellar region.

Hypophysitis is an inflammation of the pituitary gland and includes a heterogeneous group of diseases presenting with impaired pituitary gland function. Hundreds of cases have been reported after Goudie and Pinkerton's initial report on a young postpartum woman who died after progressive lymphocytic infiltration of the adenohypophysis in 1962. A 17-year-old woman presented with a three-year history of headache, galactorrhoea and excessive weight gain. The patient had used oral contraceptives for several years until one year previously. Her examination demonstrated only bilateral heteronymous hemianopsia. Laboratory investigation revealed elevated prolactin and decreased gonadotropin levels. Magnetic resonance imaging showed a sellar mass with suprasellar extension. Surgical removal of the lesion was performed via a transsphenoidal approach. A diagnosis of lymphocytic hypophysitis was confirmed by histopathological evaluation. Hypophysitis is an underestimated disease affecting the pituitary gland. Cases are usually diagnosed as adenomas and treated with surgical removal. This case is presented due to the extremely rare infiltration of the pituitary gland by predominantly lymphocytes.

Two cases of arachnoid cyst complicated by spontaneous intracystic hemorrhage.

Arachnoid cysts are developmental anomalies which are usually asymptomatic. Intracystic hemorrhage after trauma is a well known complication; however, spontaneous intracystic hemorrhage is rare. This report presents two rare cases of arachnoid cyst complicated by spontaneous intracystic hemorrhage. The first patient was admitted following transient loss of consciousness and speech disturbance, and a subacute subdural hematoma at the left temporal region was diagnosed. The second patient presented with severe headache of four days duration and a subdural hematoma at the left temporoparietal region was diagnosed. In both the patients, both on radiological examination and during surgical intervention, hematomas were found to be intracystic.

Carotid endarterectomy with regional anesthesia: an audit of 71 cases.

AIM: The aim of carotid endarterectomy (CEA) is the successful removal of the atherosclerotic plaque and meticulous anatomical and physiological reconstruction of the carotid artery without any perioperative complications. Endarterectomy can also be carried out with regional anesthesia, which allows monitoring of the neurological status. This study reviews patients who underwent CEA with regional anesthesia. MATERIAL AND METHODS: A total of 71 consecutive patients were planned to undergo carotid endarterectomy under regional anesthesia between 2000 and 2006. All of these patients, assessed by our neurovascular team, were recruited prospectively and the data was analyzed retrospectively. RESULTS: The study group consisted of 23 women and 48 men with a mean age of 62 (range 37-79). 67 patients (94,4%) had symptomatic, and 4 (5,6%) had asymptomatic (5.6%) carotid stenosis. Six patients (8.45%) were intolerant to carotid clamping (8,45%). The stroke morbidity rate was 1.4% and the mortality rate was 1.4%. The mean hospitalization time was 2.07 (range 1-10) days. CONCLUSION: Carotid endarterectomy performed under regional anesthesia can be a safe method which may lead to better neurological outcome. This method offers several advantages including monitorization of the cerebral ischemia during surgery, usage of selective shunting, decreased need for intensive care and shorter hospitalization time.

Spontaneous cervical epidural hematoma causing Brown-Sequard syndrome: case report.

OBJECTIVE: Spontaneously occurring epidural hematoma without any identified etiology is a rare phenomenon. These are often neurosurgical emergencies; therefore, prompt diagnosis and treatment are paramount. Because of the rarity of this condition, we illustrated its presentation, evaluation and management in this recent case. CASE: A 63-year-old male presented to our emergency room with right-sided hemiparesis and contralateral hypoesthesia, consistent with a C5 Brown-Sequard syndrome. An initial evaluation for cerebral infarction was unremarkable, including a negative brain computerized tomography imaging. Cervical magnetic resonance imaging (MRI) revealed a cervical epidural hematoma. The patient underwent emergent laminectomy for decompression and evacuation of the hematoma within 24 hours of presentation to the emergency room. The patient's symptoms improved remarkably after surgery and a 4th-month follow-up MRI evaluation was normal. CONCLUSION: This report highlights the various presentations, evaluation, and management options for this rare diagnosis. It emphasizes the necessity of prompt diagnosis for possible emergent intervention.

Implant-related infection model in rat spine.

OBJECTIVE: The rate of postoperative infections is approximately 1% in spine surgery. However, when metal implants are used, postoperative infection rates significantly increase and were reported between 2.1 and 8.5%. This study aim to set up an infection model in the rat spine with a metal implant. MATERIALS AND METHODS: Forty white male Sprague Dawley rats were randomly divided in four groups. In all rats, under operation microscope, a 3 mm titanium microscrew was implanted in the thoracolumbar area (T10-L1) after laminar decortication. In Group I (control group), sterile isotonic solution and in other three groups, different concentrations of Staphylococcus aureus [Group II: (10(2)), Group III: (10(3)), Group IV: (10(6))] were squirted on the decorticated lamina site. All animals were sacrificed after 2 weeks, and then blood cultures and cultures from fascia, muscle and bone were obtained. Bacterial number in each tissue was measured as colony-forming unit per gram tissue. Titanium microscrews were placed in 0.5 ml tryptic soy broth and vortexed than plated on trypticase soy agar to determine bacterial growth. Two animals from each group were subjected to histological examination. RESULTS: Blood cultures obtained by intra-atrial puncture after 2 weeks were negative in all groups indicating no systemical infection developed. Bacterial cultures were negative in all specimens of Group I (control group). A significant osseous infection was confirmed in Groups II, III and IV. Comparison of bacterial counts in bone cultures showed no significant difference between Group III (10(3) CFU/10 microl) and Group IV (10(6) CFU/10 microl) (P > 0.05), while both groups had significantly higher counts than Group II (10(2) CFU/10 microl) (P > 0.05). Microscopic findings of supurrative inflammation were present only in Group IV (10(6) CFU/10 microl). CONCLUSIONS: This study shows that inoculation of S. aureus in 10(6) CFU/10 microl concentration at the decorticated lamina after implantation of a titanium screw in rat spine is a reproducible model for spinal infection and can be used for the animal model of prophylaxis and treatment and of postoperative infection.

[Traumatic aneurysm of the superficial temporal artery: a case report]. / Süperfisiyel temporal arterde travmatik anevrizma: Olgu sunumu.

Traumatic aneurysm of superficial temporal artery is an uncommon lesion. Blunt traumas of war, firearm, motorized vehicle and sport injuries are common causes. In this case, traumatic aneurysm of superficial temporal artery that occurs after scalp trauma in 74 years old male patient, was reported. Patient who suffers from a mass in his forehead ten days after trauma was admitted to our clinic. Selective angiography of the right temporal artery was performed as traumatic aneurysm was suspected upon the findings of physical examination and cranial computerized tomography studies. The aneurysm was detected. The proximal and distal part of the aneurysm was ligated and it was totally removed under general anesthesia. The histopathological investigation confirmed the presence of the traumatic aneurysm. Especially in hairy skin injuries, traumatic lesions should be considered as an aneurysm. Diagnosis, treatment, and surgical strategy must be planned by the help of these informations.