Factors Influencing Recurrence Rates and Surgical Outcomes in Lumbar Microdiscectomy: A Retrospective Study of 130 Patients in Turkey.

BACKGROUND Lumbar disc herniation surgery, specifically lumbar microdiscectomy, shows recurrence in 3-24% of patients, necessitating potential re-operations. This study focuses on the outcomes and recurrence causes in 130 cases of lumbar disc herniations. These cases were managed by a single surgeon at a single center, offering a unique perspective on a common issue in neurosurgery. MATERIAL AND METHODS The study involved 130 patients treated for lumbar disc herniations. Analysis considered various factors: age, sex, symptoms, surgical level, complications, pre- and postoperative pain levels, and quality of life indices. RESULTS Of the 130 cases analyzed, all underwent initial surgery by the same surgeon or sought treatment from this surgeon after recurrence. Inclusion criteria were based on radiologic and clinical indications for re-operation. The demographic split was 76 males (56.4%) and 54 females (43.6%). A notable finding was a higher recurrence rate in males and patients under 45 years, although the sex difference was not statistically significant. The average age was 47.5 years. Significant changes were noted in the Oswestry Disability Index (ODI) levels during follow-ups (P<0.001). CONCLUSIONS This study underscores the effectiveness of lumbar microsurgery in treating recurrent lumbar disc herniations. Techniques such as medial facet utilization and laminectomy border expansion show promise. However, determining instability rates requires long-term patient follow-up. Our findings contribute valuable insights into surgical approaches and patient outcomes in recurrent lumbar disc herniation cases.

Investigation of Neuroprotective Effect of Shilajit Extract in Experimental Head Trauma Model Created in Rats.

AIM: To investigate the neuroprotective effect of shilajit extract in experimental head trauma. MATERIAL AND METHODS: Three groups of 33 Sprague Dawley Albino strain male rats were included in the study. Group 1 (n=11): trauma but not treated. Group 2 (n=11): trauma and treated with 0.5 mL / rat saline Group 3 (n=11): 150 mg / kg shilajit extract was administered intraperitoneally in the treatment of trauma. Following the head trauma, the indicated treatments were applied to the 2nd and 3rd groups at the first, twenty-four and forty-eighth hours. Brain tissues and blood samples were taken after the control animals were sacrificed at the 72nd hour in all groups after trauma. Sections prepared from cerebral cortex and ca1 region were examined with hematoxylin eosin and luxol fast blue staining. Total antioxidant capacity, total oxidant capacity and oxidative stress index were measured from blood samples taken after routine procedures. RESULTS: The number of red neurons and the severity of edema were significantly higher in both the cerebral cortex and the ca1 region in the group treated with trauma only and in the group administered saline after trauma compared to the group that received shilajit extract after trauma. The total antioxidant capacity increased significantly in blood samples taken only from the group treated with trauma and saline in post-trauma treatment compared to the group given post-traumatic shilajit extract, while shilajit extract given due to traumatic brain injury significantly decreased the total oxidant capacity and oxidative stress index values compared to the other groups. CONCLUSION: Shilajit extract has been shown to have a neuroprotective effect in the treatment of acute traumatic brain injury. Our study showed that shilajit may be a useful option in the treatment of secondary brain injury, in humans.

A Retrospective Study of Far Lateral Midline Microlumbar Discectomy in 20 Patients at a Single Center in Turkey.

BACKGROUND Microdiscectomy is a minimally-invasive surgical technique for treating far lateral lumbar disc herniation (FLLDH). This retrospective study from a single center in Turkey aimed to evaluate midlinelumbar discectomy in 20 patients with far lateral lumbar disc herniation. MATERIAL AND METHODS We collected clinical data of 20 patients (11 men, 9 women) operated for FLDDH between January 2006 and January 2022. Patients' age, sex, surgical level, examination findings, motor deficit, duration of operation, complications during the operation and preoperative/postoperative 6 month visual analogue Scala (VAS), preoperative/postoperative 6th month Oswestry Disability Index (ODI) scores were evaluated. RESULTS The patients were 11 men (55%) and 9 women (45%), with a mean age of 52.08±11.21 years. The mean duration of symptoms before the operation was 3.4 weeks. Laseque sign positivity was found in 86.4% of the patients. Motor deficit was present in 30% of the patients. After 6-month follow-up, preoperative VAS value decreased from 9.35±0.75 to 0.84±0.75. Preoperative and postoperative VAS score averages were significantly different (P=0.0001). Operation ODI values were 73.63±3.76 before and after surgery, and decreased to 14.81±3.63 at 6 months. CONCLUSIONS The term distal lateral disc herniation was first defined in the literature in 1974 when the disc was seen in a different location than the normal location compared to the facet. Far lateral disc herniation can be operated on successfully with midline skin incision.

Long-term follow-up results of surgically treated patients with foraminal and far lateral disc herniations.

PURPOSE: Foraminal and far lateral disc herniations are rarer cause of nerve root compression. There are reports regarding the outcome, however long-term follow-up results of surgically treated patients are few. The purpose of this retrospective study is to analyze the clinical characteristics and long-term surgical outcomes of the foraminal and far lateral disc herniations. MATERIALS AND METHODS: The 114 patients who underwent an operation for foraminal and far lateral disc herniaitions were reviewed. Visual analogue scale of back and leg pain, the ocurrence of motor deficit and sensory dysesthesia before and after operations were used to compare the results of early and long-term outcome. RESULTS: A total of 114 telephone interviews were conducted. The mean follow up was 134 months. Complete relief of symptoms were reported by 77 patients (67.1%). The average VAS of radicular leg pain was 7.5 Post-operatively the average VAS of radicular pain decreased to 2.2. Preoperatively, 9 patients (7.6%) had motor deficit and 17 (14.4%) patients had sensory dysesthesia. Post-operatively 9 (100%) of the patients showed motor, and 12 (70.6%) of the patients showed sensory improvement. In 17 patients with hypoesthesia the complaints continued during 2 weeks to 6 months. They were given gabapentin as medical treatment, however 5 of these patients still have sensory dysesthesia. The outcome was: 67.1% excellent (77 patients), 26.3% good (30 patients), 6.1% fair (7 patients). CONCLUSION: The far lateral approach is a minimally invasive and safe procedure with low complication rates.

Parapharyngeal prestyloid vagal paraganglioma.

Vagal paragangliomas (VPs) are rare tumors arising from paraganglionic tissue within the vagal nerve's perineurium. Usually, benign vascular tumors, VPs tend to invade the surrounding structures. Herein, we report the case of a VP presenting as a neck mass, which was evaluated as a glomus caroticum tumor preoperatively. A 65-year-old female complaining of a left-sided neck mass and intermittent hoarseness was assessed and operated on for possible glomus caroticum tumor. During the tumor excision, the vagal nerve was also involved, and hence, sacrificed. Histopathological examination revealed an encapsulated tumor associated with a nerve and ganglion and immunohistochemical staining tested positive for succinate dehydrogenase, confirming the diagnosis of VP. Postoperative residual hoarseness was corrected by vocal rehabilitation. While evaluating a retropharyngeal prestyloid neck mass, a VP should always be considered. Surgical excision involving vagal scarification, followed by vocal rehabilitation may be the appropriate treatment strategy.

A rare case of cervical metastatis of glioblastoma after cranial tumor resection: case report and review of literature.

Glioblastoma multiforme (GBM) is the most common and the most malignant primary intracranial tumor in adults. GBM extraneural metastases occur in only approximately 0.2-0.4% of patients. We present a case of a cervical metastasis of glioblastoma after cranial tumor resection. In concord with case presentation, we reviewed the metastatic location and metastasis time of the gliablastomas seen in the literature.

The Prevalence of Lumbar Paraspinal Muscle Fatty Degeneration in Patients with Modic Type I and I/II End Plate Changes.

STUDY DESIGN: Retrospective case control. PURPOSE: The authors of this study assessed whether the prevalence of paraspinal fatty degeneration correlates with the presence of Modic type I and I/II change in patients with low back pain (LBP). OVERVIEW OF LITERATURE: Modic changes are bone marrow and end plate changes visible on magnetic resonance imaging. METHODS: A consecutive series of 141 patients who attended the neurosurgery outpatient clinic between April 2017 and September 2017 for nonspecific LBP were evaluated. Sixty-one patients with single-level Modic type I or I/II change constituted the patient group. Eighty age-, gender-, and body mass index (BMI)-matched patients without any Modic changes were recruited as the control group. A retrospective review was performed in 61 patients with Modic changes and 80 controls without Modic changes. The percentage of fatty muscle degeneration was graded by two reviewers using T2-weighted axial images at the L4-L5 level. The system was graded as follows: grade 0, normal; grade I, minimal focal or linear fat deposition; grade II, up to 25%; grade III, 25%-50%; and grade IV, more than 50%. RESULTS: Sixty-one patients with nonspecific LBP and Modic type I or I/II change and 80 patients without Modic changes were evaluated. There was no difference between these groups in terms of age, gender, and BMI distribution. The mean muscle cross-sectional area in the patient and control groups were 1,507.37±410.63 and 1,681.64±379.69. Regarding fatty degeneration, a chi-square test of homogeneity was run, and the two multinomial probability distributions were not equal within the population analyzed. CONCLUSIONS: The novel finding of this investigation is that patients with Modic type I and I/II changes have greater amounts of fatty degeneration in their lumbar paraspinal musculature.

Prognosis of Hormonal Deficits in Empty Sella Syndrome Using Neuroimaging.

AIM: We have evaluated the anatomic measurements on sellar area of patients who were radiologically diagnosed with empty sella to determine the relation between the amount of pressure on the adenohypophysis and hormonal imbalances. MATERIALS AND METHODS: Sixty-one cases were diagnosed with empty sella and had hormone tests and hypophysis magnetic resonance (MR). The cases were categorized into two groups - patients with hypophyseal hormone anomaly and patients without hormone anomaly. We have measured interclinoid distance, anteroposterior distance from the anterior diaphragm sella to the pituitary stalk, depth of the sella turcica, craniocaudal distance of the optic chiasm from the diaphragm sella, the heights of the right and left adenohypophysis, subcutaneous fat thickness measured orthogonal to the coronal suture and posteriorly at the level of C2-C3 for two groups on hypophysis and cranial MR imaging MRI. RESULTS: Twenty-five hormone-positive cases (40.9%) (hormone test were abnormal) and 36 hormone-negative cases (59.1%) (hormone tests were normal) were included in the study. The most common hormone abnormality was thyroid-stimulating hormone, T3 and T4 deficiency in 12 cases (48%) and increase in prolactin level in 7 cases (28%). Right adenohypophysis height was 1.54 ± 0.840 mm for the 1st group, and 1.96 ± 0.83 mm for the 2nd group. The left adenohypophysis height was 1.66 ± 0.80 mm for the 1st group, and 1.94 ± 0.94 mm for the 2nd group. It was found out that the thickness at right and left side in the hormone-positive group diminished significantly. CONCLUSION: Adenohypophysis height and distance between stalk and optic nerve were good determiner for hormone defect.

The modified lateral supraorbital approach.

PURPOSE: Lateral supraorbital approach is a simpler and quicker method than pterional approach. It provides a more anterior projection when compared to the pterional approach. There are some minor differences of the modified lateral supraorbital approach when compared to lateral supraorbital approach. It is directed more subfrontally and anterior than the pterional and lateral supraorbital approach. MATERIAL AND METHODS: We used modified lateral supraorbital approach in 100 cases between 2012 and 2015 in Medical Park Izmir Hospital/Turkey. The assessed data were as follows: age, gender, Glasgow coma scale at admission, the localization of pathology, the condition of surgical obliteration for aneurysm, excision grade for meningioma, length of stay in the hospital and Glasgow outcoma scale at discharge. RESULTS: Of all patients, 58 (58%) were men and 42 (42%) were women. Our cases were anterior communicating artery aneurysms (41 cases), tuberculum sella and medial sphenoid wing meningiomas (22 cases), middle cerebral artery aneurysms (15 cases), olfactory groove meningiomas (15 cases), anterior choroidal artery aneurysms (4 cases) and posterior communicating artery aneurysms (3 cases). 4 patients died and the mortality rate of the study cohort was 4%. CONCLUSIONS: The MLSA is faster, simpler and less invasive than the PA and LSA.

Nontraumatic Intradiploic Epidermoid Cyst and Older Age: Association or Causality?

BACKGROUND: Intradiploic epidermoid cysts (IEC) are rare, benign lesions derived from ectodermal remnants during neural tube closure. Their origin is still debated or unknown. OBJECTIVE: Analyzing of the patients with intradiploic epidermoid cysts operated in the authors' department. METHODS: The patients with IEC who were operated in the authors' department between January 2014 and December 2015 were investigated from data file. RESULTS: Six patients with IEC were found, reviewed the literature, and noted that these cysts usually occur in adults. There are only 3 young cases that occurred after head injury. CONCLUSION: It was shown that the nontraumatic IEC are more frequent in older ages. In youngs, it can generally be embryologic or rarely of mechanical origin following trauma. Cranial trauma may be important for developing of IEC. Trauma may lead to inclusion of epidermal cells into the diploe of the skull and may be a reason of intradiploic epidermoid cyst in older age. The effect of older age, and gender difference on occurrence should be investigated.

An evaluation of internet use by neurosurgery patients prior to lumbar disc surgery and of information available on internet.

OBJECTIVE: The aim of this study was to evaluate the Internet use of a group of lumbar disc surgery candidates in order to determine the rate of Internet search by the patients on their disorders and more importantly the reliability of the accessed websites. PATIENTS AND METHODS: Fifty patients who were scheduled for lumbar disc surgery were divided into 2 groups, namely patients who accepted the surgery at the first offer and those who wanted to think over. Educational level information was obtained and patients were asked whether they had searched their disorder and offered surgery on the Internet. Then, a questionnaire was administered and the reliability of the websites was evaluated. Correction: The first 30 websites on the first 3 pages of Google® search engine, the most commonly used search engine in Turkey, were evaluated with the DISCERN® instrument. RESULTS: Of 50 patients, 33 (66%) had conducted a search for the surgery on the Internet. All university graduates, 88.2% of high school graduates, and 18.7% of primary-secondary school graduates had conducted an Internet search. The quality and reliability of the information was high (4.5 points) for 2 (7.1%) websites, moderate (2.3 points) for 6 websites (21.4%) and poor (1 point) for 20 websites (71.4%) as scored with the DISCERN® instrument. The mean DISCERN® score of was 1.1 for websites of health-related institutions or healthcare news, 2.75 for personal websites of physicians and 2.5 for personal websites of non-physicians. The mean DISCERN® score of all websites was 1.5. CONCLUSION: Most of the patients undergoing lumbar disc surgery at our clinic had searched information about the surgical procedure on the Internet. We found that 92.9% of the websites evaluated with the DISCERN® instrument had inadequate information, suggesting low-level reliability.

Morphometric Analysis of Lumbar Disc Space in the Turkish Population and Safe Discectomy Distance in Lumbar Disc Surgery.

AIM: Lumbar discectomy is a common surgical intervention in neurosurgical practice. Iatrogenic vascular injury during this surgery is a rare, but serious complication. In this study, our aim was to review the average safe depth of discectomy for both sexes. MATERIAL AND METHODS: This study involved a total of 56 patients between 21 and 79 years old (28 male and 28 female) who had no surgical pathology as documented by lumbar magnetic resonance imaging study. Measurements at L3-4, L4-5, and L5-S1 were performed for both sexes as follows: 1 < sup > st < /sup > measurement, from the furthest lateral part of the dura to the end of the disc (right-left); 2 < sup > nd < /sup > measurement, the anteroposterior length of the cross-section passing through the midline of the disc; 3rd measurement; from the furthest lateral part of the dura to the furthest lateral part of the disc (right-left); 4th measurement, the length from right to left of the cross-section passing through the midline of the disc. RESULTS: Measurement 1 at L3-4, L4-5, and L5-S1, this value was estimated to be 35.9 and 36.7 mm, 35.9 and 36.9, and 34 and 34.9 mm in the right and left sides respectively, for female subjects. The corresponding values for males were 41.4 and 42.1, 40.6 and 40.9, and 37.4 and 37.7 mm at L3-4, L4-5, and L5-S1, respectively. Measurement 3 in L3-4, L4-5, and L5-S1 disc spaces on the right and left sides in female subjects were 14.8 and 16.3 mm, 15.7 and 17.2 mm, and 14.9 and 17.1 mm, respectively, with corresponding figures of 18.6 and 19.5, 19.7 and 20.6, and 18.2 and 18.6 mm among male participants. Measurement 2 and 4 in females for L3-4, L4-5, and L5-S1 were 38.4 and 52.3 mm, 38.9 and 53.4 mm, and 37 and 51.8 mm, respectively. The corresponding figures for males were 43.2 and 57.6 mm, 43.2 and 58.9 mm, and 40.1 and 56.7 mm, respectively. CONCLUSION: Determination of the safe discectomy depth in both males and females, as well as the use of marking disc punches to indicate the safe margins may help clinicians to avoid this unwanted complication.

Spontaneous resolution of post-traumatic chronic subdural hematoma: a case report.

Chronic subdural hematomas often occurs in late middle and old age following trivial head trauma. Surgical intervention is the first treatment option in chronic subdural hematomas which compressed the cerebral parenchym. Hematoma may be calcified or ossified in untreated patients. Spontaneous resolution of post-traumatic chronic subdural hematoma is a rare event. Spontaneous resolution is rarer if the subdural hematoma is bilateral. In the literature, this condition is reported mostly in patients with idiopathic thrombocytopenic purpura. Here, we present a case of spontaneously resolved post-traumatic bilateral chronic subdural hematoma within a period of one month in a 55-year-old male and we discuss the probable mechanisms of pathophysiology in the spontaneous resolution of chronic subdural hematoma.

Evaluation of median nerve T2 signal changes in patients with surgically treated carpal tunnel syndrome.

OBJECTIVE: To determine the accuracy of median nerve T2 evaluation and its relation with Boston Questionnaire (BQ) and nerve conduction studies (NCSs) in pre-operative and post-operative carpal tunnel syndrome (CTS) patients in comparison with healthy volunteers. METHODS: Twenty-three CTS patients and 24 healthy volunteers underwent NCSs, median nerve T2 evaluation and self-administered BQ. Pre-operative and 1st year post-operative median nerve T2 values and cross-sectional areas (CSAs) were compared both within pre-operative and post-operative CTS groups, and with healthy volunteers. The relationship between MRI findings and BQ and NCSs was analyzed. The ROC curve analysis was used for determining the accuracy. RESULTS: The comparison of pre-operative and post-operative T2 values and CSAs revealed statistically significant improvements in the post-operative patient group (p<0.001 for all parameters). There were positive correlations between T2 values at all levels and BQ values, and positive and negative correlations were also found regarding T2 values and NCS findings in CTS patients. The receiver operating characteristic curve analysis for defined cut-off levels of median nerve T2 values in hands with severe CTS yielded excellent accuracy at all levels. However, this accuracy could not be demonstrated in hands with mild CTS. CONCLUSION: This study is the first to analyze T2 values in both pre-operative and post-operative CTS patients. The presence of increased T2 values in CTS patients compared to controls and excellent accuracy in hands with severe CTS indicates T2 signal changes related to CTS pathophysiology and possible utilization of T2 signal evaluation in hands with severe CTS.

Posterior laminoforaminotomy in the treatment of lateralcervical herniated disc and foraminal stenosis.

BACKGROUND/AIM: Posterior cervical laminoforaminotomy is an effective surgical treatment in selected cases of cervical radiculopathy caused by posterolateral herniated discs or foraminal stenosis. The aim of the present study was to evaluate the surgical techniques, rates of complications, long-term outcomes, advantages, and disadvantages of keyhole foraminotomy retrospectively. MATERIALS AND METHODS: Keyhole foraminotomy was performed in 83 patients. In 51 patients (61.5%) soft disc herniation was removed, and in 32 of them (38.5%) osteophytes were evident. The clinical data were evaluated according to Odom's criteria, and the mean follow-up time was 6 months. RESULTS: Postoperative results were classed as excellent in 66 patients (79.5%), good in 13 patients (15.7%), fair in 3 patients (3.6%), and poor in only 1 patient (1.2%). Radiculopathy symptoms regressed in 79 patients (95%). Among the 83 patients, surgical complications (dural injury and level error) were noted in 2 patients (2.4%). CONCLUSION: Posterior laminoforaminotomy is applied to selected patients with a low complication rate. The advantages of this surgery are suitable visualization of the nerve root, preserved motion of the operated segment, avoidance of cervical instability, and a decrease in the length of hospital stay.

Cervical disc hernia operations through posterior laminoforaminotomy.

OBJECTIVE: The most common used technique for posterolateral cervical disc herniations is anterior approach. However, posterior cervical laminotoforaminomy can provide excellent results in appropriately selected patients with foraminal stenosis in either soft disc prolapse or cervical spondylosis. The purpose of this study was to present the clinical outcomes following posterior laminoforaminotomy in patients with radiculopathy. MATERIALS AND METHODS: We retrospectively evaluated 35 patients diagnosed with posterolateral cervical disc herniation and cervical spondylosis with foraminal stenosis causing radiculopathy operated by the posterior cervical keyhole laminoforaminotomy between the years 2010 and 2015. RESULTS: The file records and the radiographic images of the 35 patients were assessed retrospectively. The mean age was 46.4 years (range: 34-66 years). Of the patients, 19 were males and 16 were females. In all of the patients, the neurologic deficit observed was radiculopathy. The posterolaterally localized disc herniations and the osteophytic structures were on the left side in 18 cases and on the right in 17 cases. In 10 of the patients, the disc level was at C5-6, in 18 at C6-7, in 2 at C3-4, in 2 at C4-5, in 1 at C7-T1, in 1 patient at both C5-6 and C6-7, and in 1 at both C4-5 and C5-6. In 14 of these 35 patients, both osteophytic structures and protruded disc herniation were present. Intervertebral foramen stenosis was present in all of the patients with osteophytes. Postoperatively, in 31 patients the complaints were relieved completely and four patients had complaints of neck pain and paresthesia radiating to the arm (the success of operation was 88.5%). On control examinations, there was no finding of instability or cervical kyphosis. CONCLUSION: Posterior cervical laminoforaminotomy is an alternative appropriate choice in both cervical soft disc herniations and cervical stenosis.

Effect of carnosine, methylprednisolone and their combined application on irisin levels in the plasma and brain of rats with acute spinal cord injury.

Spinal cord injury (SCI) might occur to anybody at any time and any age. In its treatment, methylprednisolone (MP) is a first choice worldwide, but there is still no significant breakthrough in truly beneficial treatment due to SCI's complex pathophysiology. We investigated the effect of carnosine, methylprednisolone (MP) and its combination on irisin levels in the plasma, brain and medulla spinalis tissues in SCI using a rat model. The rats were divided into 6 groups: I (Control, saline); II (sham animals with laminectomy without cross-clamping); III (SCI); IV (SCI treated with 150mg/kg carnosine); V (SCI treated with 30mg/kg methylprednisolone); and VI (SCI treated with a combination of carnosine and MP). The animals were given traumatic SCI after laminectomy, using 70-g closing force aneurysm clips (Yasargil FE 721). Irisin concentration was measured by ELISA. The distribution of irisin in brain and spinal cord tissues was examined by immunochemistry. Irisin was mainly expressed in the astrocytes and microglia of brain tissues, and multipolar neurones of the anterior horn of spinal cord tissue in rats of all groups, indicating that irisin is physiologically indispensable. MP and carnosine and the combination of the two, significantly increased irisin in plasma and were accompanied by a significant rise in irisin immunoreactivity of brain and spinal cord tissues of the injured rats compared with control and sham. This finding raises the possibility that methylprednisolone and carnosine regulate the brain and spinal cord tissues in SCI by inducing irisin expression, and may therefore offer a better neurological prognosis.

Why do the patients reject spinal operations? A preliminary study.

AIM: Cases of failed back and spine surgery have increased significantly recently, which leads to patient hesitation in deciding about whether to be operated on. In this article, we present a survey investigating refusal reasons for spinal surgery, and we emphasize the effect of failed back surgery. MATERIAL AND METHODS: A survey was conducted among 100 patients who were admitted to the outpatient clinic of neurosurgery at the Elazig Training and Research Hospital. All of the patients were recommended spinal surgery for various reasons, but did not want to be operated on. Demographic data for the patients, indication of the recommended surgery, the reason for the patient's refusal of the operation, information about previous neurosurgical operations and the history of dissatisfaction with the surgery of an acquaintance were recorded. The data obtained were evaluated statistically and analyzed by percentage. RESULTS: 46 patients stated they had distrust of surgery, and 54 patients did not want to be operated on for personal reasons. When the two groups were compared, neurosurgical operations and the history of dissatisfaction of the patient or an acquaintance was significantly higher in the first group (p < 0.001). It was found that 40% of all the patients (n = 40) had a past unpleasant neurosurgical experience that was either personal or relevant. CONCLUSION: Spinal surgery is a preferred subspecialty of neurosurgery. However, patients' discontent with spinal surgery has been rising gradually in recent years. An accurate indication and proper surgical technique is essential for increasing satisfaction with spinal surgery. Minimally invasive interventions must be considered if necessary. The postoperative expectations of the physician and the patient must also be carefully defined.

Fragmentation to epidural space: first documented complication of Gelstix(TM.).

The knowledge of minimal invasive spinal surgery has increased greatly in recent years. A current issue is the hydrogel implant inserted through nucleus pulposus. In this paper we present a case in which the hydrogel implant was found to be fragmented into the spinal canal at follow up. The patient was a 40-year-old female. She was examined at another clinic because of low back pain about four months ago, and a hydrogel implant was inserted at the L5-S1 level. She was admitted to our clinic due to severe radicular pain. Magnetic resonance imaging (MRI) showed a posterolateral annular tear only and she was explored microneurosurgically as she did not benefit from a foraminal injection. A fragmented hydrogel implant that compressed the spinal root was seen peroperatively and it was excised. Postoperatively the radicular complaints of the patient disappeared and she was discharged with total recovery. Although rare, complications causing compression of neural structures can be seen after placing implants into the disc. In this case, the assessment of the patient according to the clinical presentation and microsurgical exploration if necessary are important.

Cavernous hemangioma of the parietal bone.

PATIENT: Male, 38 FINAL DIAGNOSIS: Cavernous hemangioma Symptoms: Headache • parietal mass MEDICATION: - Clinical Procedure: - Specialty: Neurosurgery. OBJECTIVE: A rare disease. BACKGROUND: Bone hemangioma is a vascular hemartoma of bone structures. In general, this pathology is detected on incidentally investigated patients' films. Bone hemangioma is most commonly seen in 4(th) decade of life and the male/female ratio is 1/1.5. The locations of these lesions are commonly long bones of the vertebral column and the skull. Primary bone hemangiomas constitute less than 1% of all bone tumors, and they are seen at 0.2% in the calvarial region. CASE REPORT: Cases with this pathology are seen on incidental radiological evaluations. We report the case of a 38-year-old man with localized headache and a palpable mass in the left parietal region, admitted and operated on after cranial CT and MRI. Pathology investigation revealed a cavernous hemangioma. CONCLUSIONS: We suspected that in our case head trauma may have been the cause of cavernous hemangioma in the calvarial region, because cavernous hemangiomas are rarely located there. Localized headache and minor discomfort can be seen with this pathology. The best treatment for cavernous hemangiomas is the removal of the mass within the limits of safe surgery.