Optimizing Postoperative Clinical Outcomes in Spinal Surgery Through Preoperative Oral Carbohydrate Loading: A Case-control Study.

PURPOSE: Preoperative oral carbohydrate loading is a component of enhanced recovery after surgery protocols. The aim of this study is to investigate the effects of preoperative oral carbohydrate loading on postoperative clinical outcomes in spinal surgery patients. DESIGN: This is a prospective case-control study. METHODS: This study was conducted with patients who underwent spinal surgery from October 1, 2020 to October 1, 2021 in a neurosurgery clinic of an education and research hospital. The intervention group (n = 46) ingested 800 mL oral carbohydrate drinks at least 8 hours before surgery. The postoperative clinical outcomes were nausea, vomiting, antiemetic and analgesic drug medication, inflammation, and bleeding. The first flatus and defecation time, oral intake time, mobilization time, and length of stay in hospital were assessed postoperatively. Adverse events were monitored up to 24 hours postoperatively. The control group (n = 46) underwent routine fasting protocols. FINDINGS: Lower rates of vomiting and bleeding during and after surgery and earlier defecation time and first mobilization time were determined in the intervention group, and the difference compared with the control group was statistically significant. CONCLUSIONS: Preoperative oral carbohydrate loading is a nonpharmacological intervention that has a positive effect on postoperative clinical outcomes in patients who underwent spinal surgery and should be included in the enhanced recovery after surgery protocol.

Microvascular Decompression for Hemifacial Spasm without the Use of Neuromonitoring and Fix Retraction: A Single-Center Experience.

AIM: To evaluate outcome of patients with hemifacial spasm surgically treated by microvascular decompression without the use of neuromonitoring and fix retraction. MATERIAL AND METHODS: Of the 78 patients with hemifacial spasm operated by the senior author of this study between 2016 and 2020, 60 patients who were followed up were included and retrospectively investigated. The female:male ratio was 32:28, and the mean age was 42.5 ± 11.5 years (range 23?71 years). All the patients were operated via the lateral retrosigmoid suboccipital infrafloccular approach, and no permanent retractor was employed during the procedures. Additionally, intraoperative neuromonitoring was not performed for any of the patients. RESULTS: Single vessel compression was observed in 77% of the patients, whereas 16% and 6% experienced compression in two and three vessels, respectively. Immediate recovery was achieved in 70% of the patients. Half of the remaining 30% fully recovered within 6 months?2 years. Furthermore, the complaints of 5% of the patients were alleviated, whereas no improvement was observed in 10% of the patients. One patient developed a recurrence. CONCLUSION: Microvascular decompression is a highly effective method for the treatment of hemifacial spasm. In this study, we did not resort to intraoperative neuromonitoring and observed that our postoperative complication rates were consistent with the existing literature.

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.

Foramen Magnum Meningiomas: A Report of 10 Cases and Literature Review.

AIM: To present the findings and surgical results of foramen magnum meningioma surgeries performed by the authors. MATERIAL AND METHODS: Ten patients operated between 2014 and 2019 were retrospectively analyzed in terms of age, gender, neurological examination, and postoperative status. The female-to-male (F/M) ratio of the patients was 6/4, and the age range was 19?70 years (mean = 59). All patients presented with occipitocervical pain and were operated using the midline lateral suboccipital approach. RESULTS: One of the operated patients died in the intensive care unit due to upper gastrointestinal tract bleeding. Additionally, one patient had paresis in the early postoperative period, which resolved in the third follow-up month. CONCLUSION: Foramen magnum meningiomas are operated safely by microsurgical methods using the midline lateral suboccipital approach after suboccipital triangle and vertebral artery are exposed.

A Clinical Analysis of Microvascular Decompression Surgery with Sacrification of the Superior Petrosal Venous Complex for Trigeminal Neuralgia: A Single-Surgeon Experience.

AIM: To report the surgical outcomes in patients with trigeminal neuralgia (TN) who underwent microvascular decompression (MVD) with superior petrosal vein sacrification. MATERIAL AND METHODS: Data from 63 patients, whose information was obtained from a group of 113 patients who underwent surgery from 2008 to 2018, were reviewed retrospectively by the first author who was not part of the surgical team, and the pain conditions were evaluated objectively. RESULTS: Following surgery, pain relief occurred in 84% of patients during the early postoperative period and in 69.8% of patients during long-term follow-up. The major offending vessel was the superior cerebellar artery. CONCLUSION: MVD surgery, in particular for patients with typical pain, is one of the most effective treatment strategies for TN. Superior petrosal vein sacrification is a safe method that helps neurosurgeons to visualise the surgical area and perform a better work-up. Neurosurgeons should not be afraid to carry out superior petrosal vein sacrification.

Intraoperative Neurophysiologic Monitoring for Lumbar Intradural Schwannomas: Does It Affect Clinical Outcome?

OBJECTIVE: Intraoperative multimodal neuromonitoring (IONM) is considered valuable for the early detection and prevention of any neurologic compromise during spine surgery. It has also become the standard of care at many institutions to improve the surgical outcome and be a safety net for both clinical and medicolegal concerns. METHODS: Our experience and outcomes in 46 consecutive cases of lumbar intradural schwannoma resection were reviewed with respect to clinical outcomes and patient safety, before and after the integration of IONM into our clinical practice. RESULTS: Total surgical resection of schwannomas in the lumbar spine led to improved health-related quality of life for patients. The standard technique for microsurgical resection of schwannomas requires identifying and resecting the fiber of origin for the schwannoma, guided with triggered electromyographic monitoring. However, whether this changed the surgical strategy, because spinal roots that gave rise to the schwannoma were frequently found to be nonfunctional during surgery, remains unclear. In our series of 46 patients, we did not recognize any additional motor deficit after the surgery, regardless of the use of IONM. CONCLUSIONS: Despite our analysis proving no difference in clinical outcomes with or without the use of IONM during surgical excision of lumbar schwannomas, we still prefer using IONM as a standard approach. It adds to the confidence and ease of mind of the surgeon during resection and also provides valuable data in cases of medicolegal disputes. However, it comes with an increased cost and lengthened surgical procedure.

Natural Course of Myxopapillary Ependymoma: Unusual Case Report and Review of Literature.

BACKGROUND: Spinal cord ependymomas are the most frequent primary intramedullary tumors of the cord in middle age (40-60 years of age). Myxopapillary ependymomas are low-incidence tumors and occur in the cauda equina and conus medullaris. They are typically described as fleshy, sausage-shaped, vascular lesions. CASE DESCRIPTION: In this report, we present a 36-year-old woman who was seen in another hospital with complaints of back pain radiating into both legs 5 years ago. Magnetic resonance imaging (MRI) examinations revealed a lesion releated to the spinal cord. At that point, the patient refused the proposed surgical treatment. Five years later, the patient was referred to our clinic with advancement of the complaint to paraparesis. The new MRI showed an intradural mass at the level of T11 and S1. We performed a total intradural tumor resection. Histopathologic examination revealed a myxopapillary ependymoma. CONCLUSIONS: Myxopapillary ependymomas grow slowly and are well defined by MRI. Advancements in radiologic technology and surgical equipment have allowed this tumor type to be treated successfully. Unfortunately, if untreated, these lesions have poor prognosis and result in clinical symptoms such as paraparesis. Surgical treatment of these lesions using total resection was performed total resection and was associated with an excellent postoperative outcome. We highlight the natural course of myxopapillary ependymomas.

Recurrent carpal tunnel syndrome: Evaluation and treatment of the possible causes.

AIM: To investigate the causes of the recurrent carpal tunnel syndrome (CTS) and implemented surgical interventions. METHODS: Four hundred and eighty-seven patients, who were diagnosed with CTS and underwent surgical intervention between October 2016 and September 2007, were evaluated in this retrospective study. The age, gender, physical evaluation findings, electrophysiological examination reports and implemented surgical treatment methods were analyzed. RESULTS: Thirty-nine of the cases were operated due to recurrent CTS. Further examination of the patients with recurrent CTS revealed that ten cases had diabetic polyneuropathy, three cases had hypothyroidism, two cases had rheumatoid arthritis and one case had systemic amyloidosis. Postoperative electromyography confirmed the neuropathy was due to systemic diseases. The remaining 23 patients with recurrent CTS did not have any systemic disease and all of them had applied previously to another health center. CONCLUSION: We concluded that the recurrence rates in CTS might be decreased with exploration and incision of the entire transverse ligament. Damage to the motor and sensory branches of the median nerve could be avoided with an incision on the ulnar side.

The Role of the Features of Facet Joint Angle in the Development of Isthmic Spondylolisthesis in Young Male Patients with L5-S1 Isthmic Spondylolisthesis.

OBJECTIVE: To investigate facet tropism and its role in development of lumbar isthmic spondylolisthesis (IS) in young men. METHODS: From March 2013 to May 2016, bilateral facet joint angles were measured axially at L3-4, L4-5, and L5-S1 on lumbar computed tomography (CT) in 97 participants (46 patients with IS and 51 control subjects) 20-29 years old. A difference between the 2 corresponding facet angles of <6° was classified as no tropism; a difference of 6°-12°, moderate tropism; and a difference of >12°, severe tropism. RESULTS: We measured 276 facet angles from 46 patients with IS and 306 facet angles from 51 control subjects. For patients with IS, there was no tropism in 43.5% (n = 20), moderate tropism in 50% (n = 23), and severe tropism in 6.5% (n = 3) at L3-4. For L4-5, there was no tropism in 28.3% (n = 13), moderate tropism in 60.9% (n = 28), and severe tropism in 10.9% (n = 5). For L5-S1, there was no tropism in 32.6% (n = 15), moderate tropism in 39.1% (n = 18), and severe tropism in 28.3% (n = 13). For the control group, there was no tropism in 86.3% (n = 44), moderate tropism in 13.7% (n = 7), and no severe tropism at L3-4. For L4-5, there was no tropism in 80.4% (n = 41), moderate tropism in 17.6% (n = 9), and severe tropism in 1.9% (n = 1). For L5-S1, there was no tropism in 68.6% (n = 35), moderate tropism in 29.4% (n = 15), and severe tropism in 1.9% (n = 1). CONCLUSIONS: Facet angle tropism is seen in a high proportion of patients with IS and seems to be a predisposing factor in the etiology of IS.

Parieto-Occipital Interhemispheric Precuneal Approach to the Lesions of the Atrium: Experience with 66 patients.

AIM: The atrium (trigone) is the most common site for intraventricular lesions. The parieto-occipital interhemispheric precuneal approach (POIPA) is one of the particular ways to reach these lesions. The aim of this study was to draw specific attention to the surgical difficulties of these lesions and to present our experience with this operative approach. MATERIAL AND METHODS: Sixty-six patients with lesions located in the atrium of the lateral ventricles underwent surgical treatment in our institution using POIPA over a 13-year period. The clinical, radiological and surgical characteristics of these patients were retrieved and reviewed retrospectively. The histological diagnosis of the cases and postoperative complications were specifically focused on in this study. RESULTS: Thirty-six (54.5%) patients were male and 30 patients were female with a mean age 37.9 years (range between 8 and 74 years). The lesion was in the right atrium in 25 cases and in the left in 41 (62.1%) patients. POIPA was used in all cases to remove the lesions. The most common tumor was glioblastoma (34.8%), followed by glial tumors grade I, II and III and meningiomas. The other lesions were metastases, ganglioglioma, epidermoid cysts and arteriovenous malformations. Gross total resection of the tumors was achieved in 59 patients (89.4%) while subtotal removal was performed in 7 cases. Five (7.5%) patients died within the first month after surgery. Conclusion: POIPA provides a safe and effective way to reach lesions located in the atrium of the lateral ventricle. Knowledge of precise anatomy associated with the meticulous surgical techniques decreases the surgical morbidity and mortality of the patients.

In-situ Cranioplasty after Microvascular Decompression: A Technical Note.

Cranioplasty is not only performed for cosmetic reasons but also for physiological requirements to balance the cerebral hemodynamics and to protect the brain from external traumas. Methyl methacrylate is one of the most preferred materials for cranioplasty. It is usually prepared out of the surgical site and therefore modelling of the cranioplasty material to fit the bone defect is sometimes difficult. In this technical note, we present our new technique of cranioplasty with methyl methacrylate in which the material is prepared on site of the bone defect and very easily shaped. Fixation materials are not needed. This technique is especially suitable for posterior fossa surgeries after craniectomy.

Comparison of Electrophysiological Outcomes of Tethered Cord Syndrome and Spinal Intradural Tumors: A Retrospective Clinical Study.

AIM: Electrophysiological evaluation of the outcomes of spinal procedures is important for neurosurgeons. Somatosensorial evoked potentials (SSEPs) are used for electrophysiological evaluation of tethered cord syndrome (TCS) and spinal intradural tumors (SIT). The aim of this study was to document the electrophysiological outcomes of surgery for TCS and SIT and to compare the results based on the preoperative diagnosis. MATERIAL AND METHODS: The data of 30 patients, who were operated for TCS and SIT between 2011 and 2013, were reviewed retrospectively. Surgical release of the spinal cord was performed for TCS and tumor removal was performed for SIT. Median and tibial nerve SSEPs at the left and right sides were measured at preoperative, early and late postoperative periods and compared statistically based on the diagnosis and the time of electrophysiological assessment. RESULTS: The diagnosis was TCS in 12 (40%) patients and SIT in 18 (60%) patients. There was a significant difference between preoperative, and early and late postoperative SSEPs values. Tibial nerve latencies were prolonged in the early postoperative, but shortened in the late postoperative period. In contrast, median nerve latencies were shortened in the early postoperative, but prolonged in the late postoperative period. There was no significant difference between the TCS and SIT groups based on the surgical intervention. CONCLUSION: Tibial nerve latency may be prolonged in the early postoperative period of TCS and SIT patients. However, electrophysiological changes were not predictive for these patients. Further studies with more patients are needed for other spinal lesions.

Urodynamic outcomes of detethering in children: experience with 46 pediatric patients.

AIM: Tethered cord syndrome (TCS) manifests with neurological and urological complaints. Surgical detethering is the main treatment for TCS. Children with urological symptoms are required objective pre- and postoperative evaluations in order to predict urological outcome. The aims of this study are to investigate the effects of detethering procedure on the urodynamic tests and to determine the relationship between the changes of urodynamic tests and the patients' age and gender. MATERIAL AND METHODS: The data of urodynamic tests in 46 pediatric patients, who underwent surgery for TCS, were retrospectively evaluated. Bladder capacity, post-voiding residual urine volume, maximum intravesical pressure, and bladder compliance of each patient were measured in preoperative period and at the third month after surgery. These parameters were statistically compared, and the correlations of these parameters with age, gender, and etiology of the TCS were also investigated. RESULTS: Bladder capacity and post-voiding residual urine volume were decreased and maximum intravesical pressure and bladder compliance were increased after surgery for TCS. The decrease in bladder capacity was significant in patients older than 10 years (p < 0.05). The increase in maximum intravesical pressure was also positively correlated with age (p < 0.05). But the increase in bladder compliance was negatively correlated with age (p < 0.05). CONCLUSION: Bladder capacity, post-voiding residual urine volume, and bladder compliance are mainly affected by surgery in patients with TCS. From the urological viewpoint, children older than 10 years are most likely to benefit from surgery for TCS.

Percutaneous Laser Disc Decompression: Retrospective Analysis of 197 Cases and Review of The Literature.

AIM: Percutaneous laser disc decompression (PLDD) is a one of the well-known minimal invasive treatment methods of disc herniations. The aim of this study is to present our clinical experience and to show the benefits of this technique. MATERIAL AND METHODS: A total of 197 patients, who met the criteria of PLDD, underwent treatment between 2007 and 2009. The data of the patients was reviewed retrospectively. Among them, 107 (54.3 %) patients were male and 90 were female with a mean age of 46.34 years (ranged between 23 and 86 years). Seventy-two patients underwent one level PLDD, 112 (56.8 %) patients two levels PLDD and 13 patients three levels PLDD procedures. The mean follow-up time was 42 months. RESULTS: Among the 72 patients, the level of PLDD was L3-L4 in 4 patients, L4-L5 in 39 patients and L5-S1 in 29 patients. L4-L5 and L5-S1 levels were the most common 2-level PLDD locations in 71 patients. Twenty-five (12.7 %) patients underwent microsurgical discectomy after PLDD. The procedure was repeated in 3 patients. Discitis secondary to possible thermal injury occurred in 2 (0.1%) patients and this complication was improved with conservative treatment. CONCLUSION: PLDD is a safe and effective procedure in the treatment of discogenic pain if the patient met the selection criteria. However, this technique is not an alternative to open surgery.

Posterior Lumbar Stabilization Surgery under Spinal Anesthesia for High-Risk Patients with Degenerative Spondylolisthesis, Spinal Stenosis and Lumbar Compression Fracture.

AIM: Spinal anesthesia is an appropriate technique for lumbar spine surgeries of two to three hours duration. The aim of this study is to document our experience on spinal anesthesia administered to the patients with degenerative lumbar spine. MATERIAL AND METHODS: A total of 497 patients underwent spinal stabilization surgery with spinal anesthesia for degenerative lumbar spinal disorders in an 8-year period. Spinal anesthesia was performed at the L3-L4 or L4-L5 level and subarachnoid block was achieved with 15 mg of 0.5% plain bupivacaine with 2 µg of fentanyl and 0.2 mg of epinephrine. There was no failure of anesthesia. The patients were closely monitored for complications associated with the SA technique and especially hypotension and bradycardia but no gross alterations in cardiovascular stability were noted. RESULTS: Among the 497 patients, 139 were male and 358 were female with a median age of 51 years. The average anesthesia duration was 130 minutes and the average operative time was 85 minutes. In the postoperative period 36 patients has nausea (7.2%) and 18 of them had vomiting (3.6%) that required one dose of antiemetic. No spinal headache was observed and 36 (7.2%) patients complained of urinary retention. All recovered with urinary cannulation within 24 hours. No respiratory complication occurred and no patient died. CONCLUSION: Spinal anesthesia is a safe and effective procedure for the lumbar spinal stabilization surgery, especially in high-riskpatients. Proper precautions should be taken in order to achieve an effective anesthesia for these operations.

Tethered cord syndrome in children: a single-center experience with 162 patients.

PURPOSE: Tethered cord syndrome (TCS) is not an uncommon clinical problem in children. The aim of this retrospective study is to document our experience on the surgical treatment of TCS in childhood. METHODS: The data of 162 children who underwent surgical treatment for TCS in a 15-year period were reviewed retrospectively. Their demographic, clinical, radiological, and surgical features were documented. They were divided into two groups as primary and secondary TCS, and the surgical technique for each group was demonstrated. Untethering the spinal cord and correction of the associated malformation were the standard surgical technique for each patient. The results of the treatment were summarized. RESULTS: Among the 162 children, 101 (62.3%) of them were female and 61 were male with a mean age of 62 months. Primary TCS was detected in 43 patients while secondary TCS was found in 119 (73.4%) patients. Hypertrichosis was the most common physical finding while back pain was the common complaint. Lipoma, split cord malformation, dermal sinus tract, and myelomeningocele were the associated malformations for secondary TCS. CONCLUSIONS: Children should be individualized for the treatment of TCS. Each patient must be evaluated neurologically and radiologically for the accurate diagnosis. Surgical untethering is the safe and effective method of treatment for children with TCS.

Delayed diagnosis of cleidocranial dysplasia in an adult: a case report.

OBJECTIVE: To describe a rare case of cleidocranial dysplasia, an autosomal dominant inherited disease involving the skeleton and teeth, with delayed diagnosis. CASE REPORT: We report a 24-year-old man with cleidocranial dysplasia admitted with hearing loss, rhinolalia, dyspnea and fatigue. Partial absence of clavicles, a bell-shaped ribcage, an open frontal fontanel, unerupted permanent teeth and broad sutures were identified at radiographic examination. CONCLUSION: Cleidocranial dysplasia is very rare, and is commonly missed or diagnosed late. Radiographic findings are essential for diagnosis. An open frontal fontanel is a particularly important finding for neurosurgeons in diagnosis. We describe this rare case and discuss the clinical features of CCD.

Lumbar epidural varix mimicking perineural cyst.

Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.

Late calcification and rupture: a rare complication of ventriculoperitoneal shunting.

A 10-year old boy who had undergone a ventriculoperitoneal (V/P) shunt because of hydrocephalus at 10 days of age was doing well until 20 days ago, when he began to experience headache and seizures. CT scan revealed dilated lateral ventricles and calcification at the shunt site. X-rays showed an unusual calcification pattern around the shunt tube and rupture of the tube between the mastoid bone and clavicle. The patient underwent surgery and the shunt was changed completely. The ventricles became small in the follow-up. Even though V/P shunts may induce fibrous tissue formation and calcification around the tube, there are a few cases of shunt rupture and calcification of shunts in the literature. Possible mechanisms of the rupture and calcification are discussed in this paper.

Tethered cord syndrome in childhood: special emphasis on the surgical technique and review of the literature with our experience.

AIM: Surgery is the treatment of choice for children who had tethered cord syndrome (TCS). However, a detailed technique for the release of spinal cord is not described yet. The aims of this study are to present our series of TCS in children and to focus on the details of surgical technique. MATERIAL and METHODS: Forty-nine children with tethered cord syndrome underwent surgical treatment for the release of spinal cord between 2004 and 2009. The mean age was 4.6 years (2 days-13 years). Twenty (40.8%) patients were female and 29 (59.2%) were male. Among the 49 children, 41 (83.7%) had different spinal malformations and 8 (16.3%) had no associated lesion. Sectioning of the filum terminale, cutting the arachnoid and fibrous bands, protection of the rootlets and correction of the associated malformations was the standard surgical method to release the spinal cord. RESULTS: Neurological improvement was observed in 4 (8.2%) patients, while the neurological status was unchanged in the others. Cerebrospinal fluid fistula was the main complication and was observed in 3 patients. No mortality or neurological deterioration was encountered. CONCLUSION: Spinal cord release with appropriate technique seems to be beneficial in maintaining neurological functioning in children with TCS.