Tumoral calcinosis and epidural lipomatosis of the lumbar spine.

Lumbar spinal tumoral calcinosis and spinal epidural lipomatosis are rare conditions. We present a 70-year-old female patient with serology negative spondyloarthropathy who developed paresis due to tumoral calcinosis in the left facet joint between L5 and S1 levels and spinal epidural lipomatosis at L5 and S1 levels. Surgery was performed to excise the lesions en bloc. Neural decompression was provided. Neurological symptoms improved after surgery. Here, we report the first serology negative spondyloarthropathy case that had concomitant development of tumoral calcinosis and spinal epidural lipomatosis.

Microvessel density and vascular endothelial growth factor expression as predictors of childrens' survival from cerebellar medulloblastoma.

Cerebellar medulloblastoma is the most common malignant brain tumor of childhood. This neoplasm is highly vascular and has a high growth rate. We aimed to determine whether high microvessel density (MVD) and expression of vascular endothelial growth factor (VEGF) in medulloblastoma tissue is correlated with survival time in children with this tumor. Tissue from 32 cerebellar medulloblastomas in 14 girls and 18 boys was studied. The standard-risk group comprised patients older than 3 years, without metastases of medulloblastoma and a residual post-operative tumor with a surface area less than 1.5 cm(2). The patients assigned to a high-risk group had at least one of the following indicators: younger than 3 years, metastases, or a residual post-operative tumor with a surface area larger than 1.5 cm(2). For each tumor, MVD was determined and the expression of VEGF was assessed using immunohistochemical techniques. The 5-year survival rate for the 32 patients was 56.2%. Five-year survival rates were 70.6% and 40.0% for patients in the standard-risk and high-risk groups, respectively. The mean (+/-standard deviation, SD) MVD for all patients was 22.0+/-9.1 microvessels per 0.7 mm(2). There was no difference in the survival rate between the groups with above-average MVD and below-average MVD (66.7% and 50.0%, respectively). Testing revealed 7 tumors with VEGF expression and 25 without. The 5-year survival rates for these 2 groups were not significantly different (57.1% vs. 56.0%, respectively). The mean (+/-SD) MVD values for the VEGF-positive and VEGF-negative groups were not significantly different (19.1+/-6.5 vs. 22.9+/-9.7 microvessels per 0.7 mm(2), respectively, Mann-Whitney U-test=78.5, Z=-0.41, p=0.68). There were no significant correlations between risk groups and expression of VEGF or MVD. These results indicate that neither high MVD nor the expression of VEGF in tumor tissue predicts poor prognosis in children with cerebellar medulloblastoma.

Outcomes for combined anterior and posterior surgical approaches for patients with multisegmental cervical spondylotic myelopathy.

Corpectomy is widely used to treat cervical spondylotic myelopathy (CSM). However, when this technique alone is performed at 1 or 2 levels for a multisegmental involvement (3 or more vertebrae), the incidence of post-operative complications is high. The optimal treatment for multisegmental CSM is still debatable. The aim of this study was to assess clinical and radiological outcomes for patients with multisegmental CSM who underwent combined anterior and posterior (AP) surgical approaches. Forty adults (17 women and 23 men; age range, 41-76 y) treated at our center between 2004 and 2007 were reviewed retrospectively. Their neurological function was assessed at different times using the Nurick classification (Grades 0 [root symptoms only] to 5 [wheelchair- or bed-bound]). Patients' satisfaction with the surgery was evaluated using Odom's criteria (poor, fair, good, or excellent). Pre-operatively, 20% of patients were assessed as Nurick Grade 0, 60% as Grade 1, and 20% as Grade 2. At the 1-year follow-up, only 10% of patients were assessed as Grade 1. At 1 year after surgery, 85% of patients rated their satisfaction with the operation as "excellent" and 15% rated it as "good". These outcomes suggest that, when surgery is indicated and patients with multisegmental CSM are carefully selected, the combined AP approach yields symptom relief comparable to that of corpectomy alone and a lower incidence of post-operative complications.

Prevention of brisk hyperactive response during selective dorsal rhizotomy in children with spasticity: isoflurane versus sevoflurane maintenance anesthesia.

In children with spasticity, deep tendon reflexes are hyperactive and even stimulation of normal dorsal rootlets can produce exaggerated full-strength, single-twitch responses in the muscles they innervate. This phenomenon is called the brisk hyperactive response (BHR). The aim of this study was to compare the efficacy of 2 volatile anesthetics, isoflurane and sevoflurane, for suppressing the confounding effect of BHR during selective dorsal rhizotomy (SDR) in children with spasticity. The subjects were 54 consecutive children of American Society of Anesthesiology physical status III who were scheduled for SDR. After tracheal intubation, each child was randomly assigned to Group I (isoflurane; n=27) or Group S (sevoflurane; n=27). There was no significant difference between the mean operation times in Groups I and S (200+/-40 vs. 220+/-35 minutes, respectively; p=0.0559). Thirteen patients in Group I (48.1%) and 5 in Group S (18.5%) exhibited BHR during stimulation of the dorsal rootlets (odds ratio 4.086; p=0.0418). Three of these 18 patients (2 in Group I and 1 in Group S) experienced hypertension and tachycardia simultaneously with BHR (odds ratio 4.086; p=1.0). The results suggest that sevoflurane is more effective at preventing BHR and might be a better choice for anesthetic management of children with spasticity undergoing SDR.

Transmandibular approach for upper cervical pathologies: report of 2 cases and review of the literature.

In routine surgical practice, anterior approaches are not often used to treat upper cervical pathologies. Such lesions can be difficult to access surgically. This article describes 2 cases in which the transmandibular approach was used to address anterior upper cervical pathology. One case was a chordoma invading the C2-C3 vertebrae and the other case was atlanto-axial instability. Neurological examination revealed myelopathy in both cases. Each patient had already undergone occipito-cervical fusion at a different center and, thus, had limited neck extension and mouth-opening ability. In the first case, the tumor was totally excised. In the second, the dens was removed. We believe that the transmandibular approach is the best option for patients with limited neck mobility and restricted mouth-opening ability.

The effects of inflammatory response associated with traumatic spinal cord injury in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-beta1) and platelet-derived growth factor (PDGF)-A at the wound site in rats.

At the cellular level, spinal cord injury (SCI) provokes an inflammatory response that generates substantial secondary damage within the cord, but also may contribute to its repair. The aim of this study was to investigate the effects of inflammatory response associated with SCI in cutaneous wound healing and on expression of transforming growth factor-beta1 (TGF-beta1) and platelet-derived growth factor (PDGF)-A at the wound site in rats. At the 14th day analysis, the mean TGF-beta1 score in trauma group (I) was significantly lower than that in control group (C) (2.60 +/- 0.90 vs. 3.64 +/- 0.37, respectively; p < 0.05). The mean score for PDGF-A expression in group I was similar to the corresponding value in group C (2.42 +/- 0.74 vs. 2.94 +/- 0.72, respectively). Compared to group C, group I had significantly lower mean scores for epidermal and dermal regeneration, but higher mean scores for granulation tissue thickness and similar scores for angiogenesis. The dermal layer contains diffuse deposition of collagen fibers that are not organised as in control rat skin, and intraepidermal and subepidermal vasocongestion is distinct. Based on the results on the parameters evaluated in the study, experimental SCI in rats results in delay in wound healing and low intensity of TGF-beta1 in the dorsal wound-tissue specimens.

Congenital dermal sinus of the cervical spine in an adult.

Congenital dermal sinuses are epithelium-lined tracts that extend from an opening in the skin through deeper tissues. Most dorsal congenital dermal sinuses are located in the lumbosacral area; a cervical location is unusual. This report describes a 24-year-old woman who presented with neck pain of 6 months' duration. A dimple in the skin over her cervical spine and a stunted right foot (0.5 cm shorter than the left) were detected on physical assessment. Neurological examination revealed increased deep tendon reflexes in her lower extremities. Magnetic resonance imaging showed a dermal sinus extending from the dimple site to the spinal cord near the C4-C5 vertebrae. Laminectomies were performed at C3-C4 and the tract was totally excised. The patient's neck pain completely resolved and her deep tendon reflexes were normal at 12 months after surgery. Tethered spinal cord alone does not necessarily demand surgery; however, if a congenital dermal sinus is present then surgery is indicated to prevent spinal infection. Even if there are no neurological symptoms, the tract must be surgically removed and the cord must be fully released to prevent future infectious or neurological complications.

Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome.

BACKGROUND: Even with a functioning gastrointestinal tract, it is not always easy to initiate oral feeding in some neurosurgical patients because of their persistently depressed neurologic status or severe lower cranial nerve palsies. Percutaneous endoscopic gastrostomy (PEG) may be required for long-term feeding in these patients. The purpose of the present study is to report our experience with PEG chosen for establishing an enteral route in patients of neurosurgical intensive care unit (ICU). METHODS: The outcome and complications of PEG in neurosurgical ICU patients of Marmara University Institute of Neurological Science between January 2001 and November 2006 were retrospectively evaluated. RESULTS: Thirty-one patients, with the median age of 51 years (range, 14-78 years) underwent PEG placement. PEG was placed before the craniotomy in 2 patients and after in 29. Indications for PEG were absent gag reflex in 10 patients and low Glasgow Coma Scale score in 21. Before the PEG tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (PN), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. Two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. Buried bumper syndrome developed in 1 patient. Two patients died 8 and 34 days after the procedure in the neurosurgical ICU. Twenty-nine patients were discharged from the hospital while being fed via the PEG tubes. In 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. Procedure-related mortality, 30-day mortality, and overall mortality of the patients were 0%, 6.4%, and 45%, respectively. CONCLUSION: PEG is a safe and well-tolerated gastrostomy method for neurosurgical ICU patients with depressed neurologic state or severe lower cranial nerve palsies.

Esophageal balloon dilation in children: prospective analysis of hemodynamic changes and complications during general anesthesia.

STUDY OBJECTIVE: To investigate hemodynamic changes and complications in children during balloon dilation of esophageal strictures. DESIGN: Prospective, controlled study. SETTING: University teaching hospital. PATIENTS: 5 ASA physical status I and II pediatric patients with benign esophageal stricture related to ingestion of caustic substances. INTERVENTIONS: Anesthesia was induced with intravenous propofol two mg/kg and cisatracurium 0.2 mg/kg and maintained with 66% nitrous oxide and one minimum alveolar concentration of sevoflurane in oxygen. In each session, balloon size was increased until the stricture was opened. MEASUREMENTS AND RESULTS: A total of 18 sessions and 99 dilations in 5 children performed over a one-year period were included in the study. In 8 of 18 sessions, esophageal stricture was located in the middle one third of the esophagus; and in the others, in the upper one third. Four cases experienced bleeding; two cases, inability to ventilate due to obstruction of the endotracheal tube tip by the inflated balloon; and two cases, postextubation bronchospasm. In 95 of the 99 dilations, while the balloon was inflated, heart rate was faster and blood pressure increased significantly. CONCLUSION: Anesthesiologists should keep in mind the possibility of hemodynamic instability and possible endotracheal tube tip obstruction by the inflated balloon and safeguard the airway against bleeding, secretions, and radio-opaque fluid during esophageal balloon dilation.

Effects of parenteral fish-oil emulsion (Omegaven) on cutaneous wound healing in rats treated with dexamethasone.

BACKGROUND: The aim was to assess wound healing when parenteral fish-oil emulsion is given to rats receiving dexamethasone. METHODS: For 5 days after skin wounding, group S (control; n = 7) received saline 1 mL/kg intraperitoneal (IP); group D (n = 7), dexamethasone 0.2 mg/kg IP; and group DO (n = 9), dexamethasone 0.2 mg/kg IP plus 1 mL/kg Omegaven (Fresenius Kabi, Austria). Wound specimens were assessed for hydroxyproline level, wound depth, histology (epidermal/dermal regeneration, granulation tissue thickness, and angiogenesis), and expression of transforming growth factor-beta (TGF-beta) and platelet-derived growth factor-AA (PDGF-AA). RESULTS: Compared with D and DO specimens, controls had higher hydroxyproline (p < .01), deeper wounds (p < .05), and better histologic scores (p < .01 angiogenesis; others p < .05). There were no significant differences between the group D and DO means for hydroxyproline level, wound depth, or histologic scores (p > .05 for all). Controls had higher TGF-beta expression scores than the other groups (p < .01 for both) and a higher PDGF-AA expression score than group DO (p < .01). Groups D and DO had statistically similar TGF-beta scores, but group D had a higher PDGF-AA score (2.71 +/- 0.75 vs 1.55 +/- 0.72, respectively; p < .05). CONCLUSIONS: According to the parameters we studied, adding parenteral omega-3 and omega-6 fatty acids to the nutrition regimen of rats treated with dexamethasone does not seem to have adverse effects on wound healing, and effects on wound healing may not need to be considered when determining if these agents should be supplemented in nutrition support regimens.

Foot drop: the first sign of an intracranial tumor?

Isolated foot drop due to a brain lesion is rare. A 48-year-old man complained of inability to dorsiflex the right foot. Right dorsiflexion had 0/5 muscle strength and there were no upper neuron findings on his neurological examination. Magnetic resonance imaging of the brain revealed a left parasagittal brain mass. The lesion was removed and muscle activity returned with 3/5 muscle strength 6 weeks after the operation. The parasagittal area is located at the foot of the homunculus. Therefore, in patients with foot drop, lesions of the parasagittal area should be considered.

Cervical meningocele causing symptoms in adulthood: case report and review of the literature.

Simple meningoceles are infrequent forms of dysraphism and are often benign. These lesions are usually associated with other congenital spinal anomalies, and are typically diagnosed in childhood. Most become symptomatic in childhood because of progressive spinal cord or nerve root tethering. This article describes the case of a 47-year-old man who presented with a sac in his posterior cervical region that had been leaking colorless fluid for 3 months. He was also having difficulty walking and complained of stiffness in his lower extremities. Cervical magnetic resonance imaging revealed a cystic mass in the region of the C4 to C5 laminae. Partial laminectomies were performed (lower portion C4 lamina, upper portion C5 lamina), the sac was totally excised, and tissue tethering the spinal cord were cut. There was no recurrence of symptoms in 12 months of follow-up. Although in cases where a cervical meningocele-myelomeningocele is detected at any time, early treatment is essential to eliminate the high risk of future neurological impairment. This is the first report of an untreated cervical meningocele manifesting symptoms in adulthood.

Factors related to post-treatment chronic pain in breast cancer survivors: the interference of pain with life functions.

The frequency and the intensity of chronic pain, as well as the related factors, were assessed in a cohort of breast cancer patients. The life functions were also questioned in patients who have post-treatment chronic pain. The scope of this retrospective study was a cohort of surgically-treated breast cancer patients with unilateral early stage disease who were under regular follow-up. Patients were eligible if they completed their treatments at least 6 months before and were free of disease. Patients who had a previous history of chronic pain syndrome, chronic debilitating disease, psychiatric diagnosis, and other cancers were excluded. All data regarding their demographics and treatments were recorded. Chronic pain was defined as the pain at treatment-related regions for a duration of at least three months after completion of treatment. Turkish version of "Brief Pain Inventory (Short Form)" was given to the patients with chronic pain in order to assess their pain intensity and life functions. The factors related to chronic pain were compared between patients with and without chronic pain. Eighty-five eligible female patients were included in the study. Thirty-nine (46%) patients declared that they had chronic pain. The mean VAS scale score was 4.1 +/- 2.4 cm in these patients. The mean age of patients with chronic pain (54.3 +/- 12.6 years) was significantly less than that of the ones without pain (60.4 +/- 13.6 years; p = 0.035). Radiotherapy was found to be significantly related to chronic pain (p=0.049; OR: 2.60; 95% CI 1.07-6.30). The VAS scores were 1.5 +/- 2.7 cm, 1.9 +/- 3.2 cm, 1.3 +/- 2.7 cm, 0.9 +/- 2.5 cm for general activity, mood, relations with other people, and sleep, respectively. Although almost half of the early stage breast cancer patients experienced post-treatment chronic pain, they rated the intensity of their pain as mild to moderate. Younger age and receiving radiotherapy were found to be significant contributing factors. The interference of post-treatment chronic pain with life functions was small. Overall, mood was found to be the most affected life function among all.

Ten years of experience with pediatric neuroendoscopic third ventriculostomy: features and perioperative complications of 210 cases.

Obstructive hydrocephalus remains a problem, and improvements in fiberoptic technology have promoted interest in neuroendoscopic ventriculostomy (NTV) as an alternative to standard cerebrospinal fluid shunts. The present study assessed 210 pediatric NTVs performed between 1994 and 2004 in patients aged 2 months to 10 years. Five children needed same-session ventriculoperitoneal shunting due to insufficient bypass of the obstruction. The other 205 procedures were technically successful, but 7 patients needed early-postoperative shunting and 10 required late shunting. During NTV, 86 (40.1%) of the patients developed arrhythmia. One patient arrested during balloon dilatation, but normal rhythm returned after deflation and epinephrine/atropine therapy, with no resultant morbidity. Twenty-six (10.2%) patients developed tachycardia (without hypertension) followed by bradycardia, and 6 children (2.8%) developed hypertension. In 1 case (0.5%), a branch of the basilar artery ruptured during fenestration and the hemorrhage was controlled after craniotomy. In 5 cases, mild venous bleeding was controlled by irrigation. The early complications included transient ocular divergence (n = 1), anisocoria (n = 2), and hyponatremia (n = 5). Five children were diagnosed with temporary diabetes insipidus in the late-postoperative period. The neuroendoscopic approach is considered safe for treating hydrocephalus in children, but complications can be severe or lethal and the anesthesiologist must respond accordingly.