Spontaneous pyogenic spinal epidural abscess.

AIM: Spontaneous pyogenic spinal epidural abscess (SEA) is a rare condition but might be devastating and fatal. Traditional treatment is surgical decompression and antibiotics. A retrospective study was designed to assess the eff ect of clinical findings and treatment methods on the outcome. MATERIAL AND METHODS: 14 patients were reviewed (10 male, 4 female, mean age 59.14). Six dorsal, seven ventral and one dorsal with ventral SEA were observed. SEA found in thoracal (5), lumbar (4), cervical (3) regions. One patient showed both cervical and thoracal and one patient showed cervical, thoracal and lumbar involvement. All patients received minimum 3 weeks of I.V., followed by minimum 3 weeks of oral antibiotics. All patients complained of spinal pain. Ten patients presented with fever. Neurological deficit was observed in 9 cases. RESULTS: A total of 22 interventions was performed. Instrumentation was applied in 5 cases. Full recovery was achieved in 7 patients, significant improvement was observed in 5 patients. The neurological findings did not change in one patient. One mortality and one morbidity were observed. CONCLUSION: Spontaneous SEA is a rare disease but might result in catastrophic neurological deficits and fatal even with prompt treatment. Therefore, one should always keep SEA in mind if a patient presents with fever, vague and spinal pain.

Thoracoscopic surgical approaches for treating various thoracic spinal region diseases.

AIM: Minimally invasive surgery is currently a goal for surgical intervention in the spine. The effectiveness of endoscopic thoracic spine surgery and technological improvements are two factors that are always under consideration in the practice of spinal surgery. MATERIAL AND METHODS: We present twenty-five patients whose thoracoscopic spinal surgeries were performed between 2002 and 2008 for the treatment of various spinal diseases. Eleven patients with thoracic disc herniation, five patients with traumatic thoracic spinal compressive fracture, six patients with metastatic thoracic spinal tumors and three patients with tubercular spondylitis underwent thoracoscopic spine surgery. Clinical evaluations were performed at 3, 6,12 and 24 months post-surgery. The Oswestry disability questionnaire and linear visual analog scale (VAS) were used for the evaluation of pain. RESULTS: Postoperatively, two patients had lung contusions, one patient had pneumonia and one patient had instability. There were significant initial improvements in both the Oswestry score and the VAS pain score up to 6 months (p<0.05). The average relative difference in pain scores in all groups was not significant at 12 and 24 months (p>0.05). CONCLUSION: The favorable results of thoracoscopic spinal surgery encourage its application to situations in which a conventional thoracic approach is indicated. Thoracoscopic spine surgery is applicable to all patients with various spinal diseases.

Long-term follow-up after open-window corpectomy in patients with advanced cervical spondylosis and/or ossification of the posterior longitudinal ligament.

STUDY DESIGN: Prospective study was performed in case with cervical spondylosis and ossification of the posterior longitudinal ligament (OPLL). OBJECTIVE: A novel anterior approach was defined and some patients were operated in this study. The late results of open-window corpectomy (OWC) were documented in a group of patients. SUMMARY OF BACKGROUND DATA: The aim of this study was to assess long-term clinical and radiologic outcomes after OWC in patients with advanced cervical spondylosis and/or OPLL. METHODS: Data were collected from 15 patients at 3 time points: preoperatively and at 15 months and 92 months postoperatively. The clinical parameters were pain (assessed by visual analog scale) and upper extremity function (assessed by Japanese Orthopedics Association) score. The radiologic parameters recorded from magnetic resonance imaging and computed tomography were lordosis angles (cervical and segmental) and cervical spinal canal diameter. Group means were calculated and findings at the 3 time points were statistically compared. Adjacent-segment degeneration was also evaluated at 92 months. RESULTS: Concerning visual analog scale and Japanese Orthopedics Association results, the 2 postoperative mean scores were both significantly better than the preoperative mean but were not statistically different. The postoperative mean results for cervical and segmental lordosis angles and spinal canal diameter were all significantly better than the respective preoperative means for these parameters. Comparisons of postoperative means revealed no significant change in cervical lordosis, segmental lordosis, or cervical spinal canal diameter from short-term to long-term follow-ups. Five patients showed mild degeneration at adjacent segments in long-term follow-up. CONCLUSIONS: Long-term follow-up indicates that OWC yields satisfactory clinical and radiologic outcomes in patients with anterior compressive cervical spondylosis and/or OPLL. OWC technique creates a more stable construct with 3-point fixation and offers better load sharing among implants and healthy vertebrae. Our observations suggest that OWC is a good surgical option for this patient group.

The results of beta-tricalcium phosphate coated hydroxyapatite (beta-TCP/HA) grafts for interbody fusion after anterior cervical discectomy.

STUDY DESIGN: The efficacy of tricalcium phosphate and hydroxyapatite (beta-TCP/HA) grafts was studied after anterior cervical discectomy (ACD). OBJECTIVE: This study presents our observations about the efficacy of beta-TCP/HA grafts after ACD. SUMMARY OF BACKGROUND DATA: Especially in the last 2 decades, fusion materials such as autograft and allograft, as well as different kind of cages were used to maintain fusion after ACD. METHODS: beta-TCP/HA grafts after ACD were used in 17 patients. The cervical and radicular pain was evaluated via visual analog scale (VAS) score preoperatively, at postoperative third week, and after 20 months (range: 18 to 24 mo) after the operation. The radiologic evaluations were done preoperatively, at postoperative first day and at the latest follow-up. The VAS, intervertebral space ratio, height of intervertebral disc space and neural foramen, and cervical and segmental lordosis angles were recorded preoperatively and during the postoperative follow-up period. The presence of fusion was controlled in computed tomography scans taken at the latest follow-up. RESULTS: Both clinical and radiologic evaluations yielded satisfactory results. VAS scores decreased significantly in all patients. The intervertebral space and neural foramen and intervertebral disc heights increased at postoperative day 1 but were found to be decreased at the latest follow-up (P<0.05). On the contrary the cervical and segmental lordosis angles decreased at postoperative day 1 but were found to be increased at the latest follow-up (P<0.05). There was a solid fusion in 16 out of 17 patients (94.11%). CONCLUSIONS: Although there was a loss of the initially obtained neural foraminal and disc height, the application of beta-TCP/HA graft after ACD resulted in a high rate of fusion and patient satisfaction. Additionally, the cervical and segmental lordosis was preserved. We concluded that it is a good alternative to current methods to maintain cervical alignment and fusion after ACD.

Excision of an asymptomatic cervical intradural neurenteric cyst through the anterior approach: a study of two cases and a review of the literature.

BACKGROUND: Spinal neurenteric cysts are very rare lesions, especially after the second decade of life. They account for 0.3% to 0.5% of all spinal tumors and occur most commonly in ventral locations. The cysts are usually removed via a posterior approach. PURPOSE: To present the clinical and radiologic results of patients with spinal neurenteric cysts who were treated via anterior approach procedures. STUDY DESIGN: This report is composed of two cervical neurenteric cyst cases that are compared with published studies. METHODS: We present two patients, 41- and 39-year-old women, each with a cervical intradural neurenteric cyst. Both of these patients had apparent neck pain without neurological deficit. MRI revealed neurenteric cysts located at C7 and C7-T1 levels. After anterior corpectomy, the intradural cysts were removed, and then fusion was performed. RESULTS: The postoperative period went well. The follow-up cervical MRI studies were performed at 3, 6, and 18 months postoperatively, and there were no abnormalities found. CONCLUSIONS: This study has led to the conclusion that although neurenteric cysts are rare in adults, they can still be present with only persistent neck pain and without neurological deficits. This may lead to misdiagnosis. The importance of MRI is not controversial in the early diagnosis. An anterior approach may be considered the first preference for surgical technique in patients with ventrally located neurenteric cysts.

Anterior cervical microdiscectomy with or without fusion.

BACKGROUND: Anterior cervical microdiscectomy (ACD) is commonly applied in the surgical treatment of cervical disc herniation. However, following discectomy procedure to perform a fusion process is still controversial. Therefore, a controlled, multicentric, prospective, randomized study was designed. MATERIAL AND METHOD: Totally 20 patients were operated. Eleven patients were operated with applying simple anterior microdiscectomy technique. Nine patients were operated via ACD and fusion with a semirigid plate technique. Preoperative and postoperative [immediate; postoperative first day and postoperative 1 y (mean 13.95 mo)] computed tomography studies and plain x-rays were obtained. The cervical disc and bilateral neural foramen heights of the operated level and adjacent segments were calculated. Pain assessment was performed using visual analog pain scale. Mann-Whitney statistical analysis method was applied to compare the outcomes for both groups. RESULTS: Satisfactory result was achieved in both groups. The pain scores for major complaint (arm pain) were decreased significantly in all patients after surgery regardless of the type of technique applied. The improvement in neck pain scores was significant only in patients who were treated with fusion procedure. There were no significant changes in disc height and neural foramen height measurements for both groups in adjacent levels in immediate and 1-year postoperative periods. The patients who were operated with simple ACD technique showed no significant decrease at postoperative first day in disc height and neural foramen height. However, the 1-year postoperative radiologic studies showed a significant decrease in disc height and neural foramen dimensions compared with preoperative values. The patients who were treated with fusion process showed a significant increase in disc height and nonsignificant increase in neural foramen heights at immediate postoperative study. However, with time, all dimensions showed significant decrease compared with preoperative values. CONCLUSIONS: ACD technique offers satisfactory outcome regardless of whether fusion process is applied or not. Fusion with semirigid plate offers an advantage at operated level in immediate postoperative period in regard of disc height and neural foramen height. However, semirigid anterior plates by definition do not stop subsidence and the advantage that is offered by this technique is not persistent. On the other hand, to apply fusion process with semirigid plate system offers significantly less narrowing in disc height compared with simple ACD technique.

G protein mutations in pituitary tumors: a study on Turkish patients.

Activating mutations of the G proteins, Gsalpha (gsp) and Gi2alpha (gip) have been reported in subsets of pituitary tumors. The objective of the study was to assess the frequency of gsp and gip mutations in pituitary tumors from Turkish patients and to investigate the possibility of mutations of protein kinase A catalytic subunit (PKAC) that activates the downstream effectors of adenylyl cyclase. PCR-amplified genomic DNA was analyzed for the presence of mutations in codons 201 and 227 of Gsalpha, codon 179 and 205 of Gi2alpha and codon 196 of PKAC, by single strand conformation polymorphism analysis, allele-specific oligonucleotide hybridization and DNA sequencing. Twenty-two patients from Turkey, 15 females and 7 males were investigated; 7 somatotroph adenomas, 7 clinically non-functioning tumors, 7 prolactinomas and 1 corticotroph adenoma. G protein mutations were identified in 6 of 22 (27.3%) pituitary tumors. Four tumors (3/7 somatotroph adenomas, 43%, 1/7 clinically non-functioning tumor) demonstrated gsp mutations at codon 201 arginine to cysteine and one recurrent somatotroph adenoma demonstrated a mutation of the Gi2alpha gene at codon 193 lysine to arginine. One tumor exhibited a C to T variation in the intervening sequence between codons 179 and 205 of the Gi2alpha gene. No mutations at codon 227 of Gsalpha, codons 179 and 205 of Gi2alpha and codon 196 of the PKAC gene were identified.