Aortic Injury by Thoracic Pedicle Screw. When Is Aortic Repair Required? Literature Review and Three New Cases.

PURPOSE: Aortic injury by pedicle screw is rare but can cause serious complications. It has not been clearly determined when aortic repair is necessary in cases of screw impingement without perforation of the aortic wall. In this article, we review the treatment and clinical course of pedicle screw aortic impingement and attempt to clarify this issue. METHODS: Cases of aortic injury during thoracic screw procedures were found using a MEDLINE search and analyzed together with 3 new cases that we present. RESULTS: Nineteen cases collected from the literature and 3 new cases were included in the study. In 7 of the cases, aortic impingement by the pedicle screw was detected during postoperative follow-up (day 1) radiologic examinations. In the other cases, time to presentation of aortic impingement ranged between 2 weeks and 60 months after fixation. The main indications for thoracic spinal fixation were post-traumatic vertebral fracture and kyphoscoliosis/scoliosis. Repair of the aortic damage ranged from primary repair to stent and tube graft placement by the thoracic endovascular aortic repair method. CONCLUSIONS: In cases in which the screw impinges less than 5 mm into the aortic wall, hardware revision without aortic repair may be sufficient if recognized early and there are no sign of aortic leakage in vascular imaging. However, cases with more than 5 mm of screw impingement should undergo aortic repair first, even in the absence of aortic leakage, following by screw revision.

Posterior Epidural Migration of a Sequestered Lumbar Intervertebral Disc Fragment.

AIM: Posterior epidural migration of a sequestered lumbar intervertebral disc fragment (PEMSLIDF) is an extremely rare condition published so far only as case reports or small case series (ranging between 2 to 8 cases). Diagnosing this condition is often challenging and the diagnosis is usually made intraoperatively. The affected patients usually suffer cauda equina syndrome (CES). In the present study, we aimed to discuss the clinical and radiological findings, types and features of surgical therapies, and outcomes of 9 patients with PEMSLIDF. MATERIAL AND METHODS: This study included 9 (0.36%) patients with PEMSLIDF among 2470 patients who underwent lumbar disc hernia surgery between August 2002 and September 2012. The preoperative clinical and radiological properties of the patients were evaluated. The postoperative outcomes were assessed using neurological examination, radiological imaging, visual analog scale (VAS) and modified Odom criteria. RESULTS: As far as we know, this study is the largest case series examining the characteristics of PEMSLIDF. Seven (77.8%) of our patients were male and 2 (22.2%) were female and they had a mean age of 49.5 years (range 28-70 years). The mean duration from symptom onset to hospital admission was 7.4 days. Seven patients had CES. All patients underwent sequestrectomy and discectomy via posterior microsurgery. The patient outcomes were evaluated by the Modified Odom criteria and the outcome was excellent in two (22.2%) patients, good in 4 (44.5%), fair in 2 (22.2%), and poor in 1 (11.1%). CONCLUSION: The entire free fragment can usually be excised via the posterior microsurgery technique. Early surgical treatment is of great importance to prevent more serious neurological deficits.

Actigraphic Analysis of Patients with Cervical Disc Herniation.

AIM: To analyze the relationship between the severity of pain and sleep disorder using wrist actigraphy in patients with cervical disc herniation (CDH). MATERIAL AND METHODS: Fifty patients with the diagnosis of CDH underwent subjective tests and actigraphic analysis in preoperative period, and at the end of postoperative first week and postoperative first month. The data of the subjective tests and actigraphic analysis were compared. RESULTS: There was a strong and statistically significant negative correlation between the subjective tests of Visual Analog Scale (VAS) for Pain 0-1-2 and the objective parameters of Sleep Onset Latency (SOL) 0-1-2 (rs= -0.798, p=0.009 - rs= - 0.832, p=0.006 - rs=- 0.710, p=0.004). There was a positive correlation between the subjective tests of VAS for Pain 0-1-2 and the objective parameters of Sleep Efficiency (SEF) 0-1-2 (rs=0.721, p=0.006 - rs= 0.768, p=0.001 - rs= 0.748, p=0.001). CONCLUSION: Actigraphy may be used for the evaluation of cervical disc surgery, as an alternative and objective test for sleep disorders.

Local Tissue Electrical Resistances in Transpedicular Screw Application in the Thoracolumbar Region.

AIM: To determine local tissue electrical resistance differences generated during a screw pass from the pedicle to another tissue rather than determining all individual electrical tissue resistance values. MATERIAL AND METHODS: We attempted to measure electrical resistance values of regional tissues in addition to fluoroscopic imaging during application of fixation via a transpedicular screw. We also attempted to detect local tissue electrical resistance alterations in case of malposition of the screw inside the pedicle. For this purpose, local tissue electrical resistances of 10 transpedicular tracks opened with standard track openers bilaterally in 5 vertebrae, and of spinal cord accessed by puncturing the medial walls of three vertebrae in a cadaver were measured. These resistance differences were not only measured in human cadaveric tissue but also in 36 pedicles belonging to a total of 18 vertebrae between Th 1-S1 vertebrae of a sheep cadaver. Both medial and lateral walls were drilled to measure local tissue resistance differences in a sheep cadaver. RESULTS: Our results indicated that local tissue electrical resistance changes were statistically significant in both human and sheep cadaver. CONCLUSION: It is possible to prevent screw malposition using a simple and cheap electrical resistance measurement. Local tissue electrical resistance measurement during transpedicular screw insertion is a safe, simple, cheap, and practical method.

A Comparison of Bilateral Decompression via Unilateral Approach and Classic Laminectomy in Patients with Lumbar Spinal Stenosis: A retrospective Clinical Study.

AIM: Bilateral decompression via unilateral approach is one of the minimally invasive methods used for degenerative spinal stenosis. The aim of this retrospective study was to observe the clinical and radiological results of classic laminectomy and bilateral decompression via unilateral approach applied for lumbar stenosis. MATERIAL AND METHODS: The data of 40 patients who underwent surgical treatment for lumbar spinal stenosis with different techniques was reviewed retrospectively. The patients were divided into 2 groups according to the surgical technique. In the first group, patients underwent classic laminectomy, while in the second group patients underwent bilateral decompression via unilateral approach. Preoperative and postoperative computed tomography section areas of both groups were examined. Visual analogue scale (VAS) was used to evaluate low back and leg pain in preoperative and postoperative 1, 6, and 12 months. The two groups were compared in respect of surgery time and bleeding. RESULTS: In both groups, postoperative low back and leg pain VAS scores declined compared to the preoperative condition. Low back pain VAS scores were lower at postoperartive 1, 6, and 12 months. The bleeding was higher in the 1st group, whereas the surgery time was higher in the 2nd group. CONCLUSION: Bilateral decompression through unilateral approach is an effective method without instability effect, which provides sufficient decompression in the degenerative stenosis and increases patient comfort in the postoperative period.

Combined therapy for distant metastasis of sacral chordoma.

Chordomas are known as rare primary malign tumours that have formed from primitive notochord remains. Sacral chordomas grow slowly but locally and aggressively. Chordomas are locally invasive and have low tendency to metastasis and have a poor prognosis in long-term follow-up. Metastasis may be seen in a rate of 5-40% of the chordomas. Metastasis of chordomas is common in liver, lung, lymph nodes, peritoneum, and brain. The treatment approaches, including surgery, have been discussed in the literature before. Susceptibility to radiotherapy and chemotherapy is controversial in these tumours. The success of surgical treatment affects survival directly. In this report, we will report a sacral chordoma case in which an intraperitoneal distant metastasis occurred and discuss the surgical approach.

Hyperbaric oxygen treatment in the experimental spinal cord injury model.

BACKGROUND CONTEXT: Spinal cord trauma is a major cause of mortality and morbidity. Although no known treatment for spinal cord injury exists, a limited number of effective treatment modalities and procedures are available that improve secondary injury. Hyperbaric oxygen (HBO) treatment has been used to assist in neurologic recovery after cranial injury or ischemic stroke. PURPOSE: To report the findings on the effectiveness of HBO treatment on rats with experimental traumatic spinal cord injury. Improvement was evaluated through motor strength assessment and nitrite level assay testing. STUDY DESIGN: We randomly distributed 40 rats among 5 groups of 8 rats each: sham incurable trauma, induced trauma, HBO treatment begun at the 1st hour, HBO treatment begun at the 6th hour, and HBO treatment begun at the 24th hour. METHOD: The HBO treatment was administered to rats in three of the groups and conducted in two 90-minute sessions, under an absolute atmospheric pressure of 2.4 at 100% oxygen for 5 days. In the motor strength evaluations, all the rats were observed during the inclined plane test and clinical motor examination on the first, third, and fifth days. In addition, the nitrite levels of spinal cord tissues on the sixth day were also studied. RESULTS: Results from the inclined plane levels and motor strength test from all the three groups undergoing HBO treatment were higher than those from Group 2. It was also determined that early HBO treatment resulted in higher recovery rates (groups 3 and 4). The highest levels were seen in the group in which the HBO treatments were started in the first hour (Group 3). It was noted that nitrite levels of rats in the group exposed to trauma increased, compared with the sham group, but increased levels also diminished after HBO treatments. Again, the greatest decrease in nitrite levels was evident in the group where the HBO treatment was started the earliest (Group 3). CONCLUSIONS: Prompt HBO treatment after trauma significantly contributed to the clinical, histopathologic, and biochemical recovery of the rats.

The effects of lornoxicam on brain edema and blood brain barrier following diffuse traumatic brain injury in rats.

BACKGROUND: In this experiment, the effects of lornoxicam on brain edema and the blood brain barrier (BBB) following diffuse traumatic brain injury (TBI) were studied. METHODS: Twenty adult male Wistar albino rats were anesthetized, and experimental closed head trauma was induced by the Marmarou method. After head injury, the rats were randomly divided into two groups: Group I was the control group, to which 2 ml saline was administered intraperitoneally, and Group II was the lornoxicam group, to which 2 ml 1.3 mg kg-1 lornoxicam was administered intraperitoneally. Twenty-four hours after head trauma, 99 mTc pentetate (DTPA) was injected at a dose of 37 MBq, and posterior planar images of each rat were obtained using an Infinia gamma camera. After imaging of BBB permeability, brain tissues were dissected from the cranium. The brain water content (BWC) of each sample was calculated using the wet-dry method. RESULTS: The lesion/background (L/b) ratio of Group I was 3.76±0.46 and 3.02±0.66 for early (5th min) and late (60th min) imaging, respectively. In Group II, the L/b ratios were 3.52±0.96 and 2.63±0.63 for early and late imaging, respectively (p>0.05). BWC was 79.6±2.5% and 77.5±1.1% for Groups I and II, respectively (p<0.05). CONCLUSION: In this rat model of TBI, lornoxicam reduced brain edema but did not affect BBB permeability.

Preoperative and postoperative evaluation of somatosensorial evoked potentials of upper extremities in cervical intervertebral disc herniation.

This study aims to determine the dysfunction caused by existing pathological condition in structures involved in the transfer of sensory functions of the neural system in cervical disc herniation, and to establish whether or not the level and degree of this anatomical damage can be anticipated by SEP (Somatosensorial Evoked Potentials). We compared the obtained SEP values for statistical significance using the Friedman Variation Analysis. In parameters with statistical significance, the Wilcoxon Signed Rank test was used to identify when significant improvements occurred. The study found that the statistical data of the latency of the N14 wave originating from the dorsal column nuclei of the medulla spinalis and dorsal column gray matter improved (p < 0.05) in the postoperative period compared with the preoperative values. Using the Wilcoxon Signed Rank test, we studied postoperative months separately in regard to the difference in the latency of the N14 wave, and found the statistically significant improvement to be marked particularly in months 3 and 6 postoperatively (p < 0.05). In conclusion, we suggest that SEP is a useful tool to check the functional condition of the dorsal spinal column. The benefit of the SEP utilization is the ability to determine the severity of the pathological condition preoperatively and follow the patient's functional postoperative improvement.

Effect of cepea extract-heparin and allantoin mixture on epidural fibrosis in a rat hemilaminectomy model.

AIM: Epidural fibrosis following a laminectomy procedure is a serious problem that results in failed back surgery syndrome. Aserious number of manuscripts have explained its possible mechanism and results but no effective preventive surgical technique or treatment is currently present. MATERIAL AND METHODS: We used a rat hemilaminectomy model at lumbar fourth level. In the treatment group (n:10), the hemilaminectomy sites were filled with cepea extract-allantoin and heparin mixture as sterile cream form. In the second group, the same surgical procedure was performed and the site was filled with physiological saline. All animals were terminated after 6 weeks and laminectomy sites removed en-bloc. Epidural fibrosis was evaluated and compared using semi-quantitative histopathological scoring scales. RESULTS: In the physiological saline group, the fibrosis score was 10.3 points and 90% of the subjects had acute inflammatory reaction, 80% chronic inflammatory reaction and 100% showed bone destruction and reparation process. In the cepea extract group, these values were fibrosis score 4.2 points, 0% acute inflammatory reaction, 33.3% chronic inflammatory reaction and 10% bone destruction and reparation process, respectively. CONCLUSION: This study showed that aloe cepea extract-allantoin and heparin mixture diminished epidural scarring formation effectively with decreased scores of acute and chronic inflammation, compared to the physiological saline solution group.

Apoptosis seems to be the major process while surface and neural ectodermal layers detach during neurulation.

OBJECTIVE: The aim of this study is to demonstrate the process of detaching neural and surface ectodermal layers soon after the neurulation completes. MATERIALS AND METHODS: Specific pathogen-free chicken egg embryos were used to investigate the neurulation procedure. Ten eggs were saved as controls. The other ten eggs were opened at the 30th hour of embryo development and cultured with Z-VAD-FMK (peptide caspase inhibitor) to investigate the results of the apoptosis inhibition. Embryos were placed and developed up to 48 h in the culture medium. To detect apoptotic cells between neural and surface dermal layers, immunoreactivity of p53 and terminal uridine deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay were used. RESULTS: While the control group shows positive immunoreactivity of p53 and TUNEL-positive apoptotic cells at the site where the neural folds detach from the surface ectoderm, no TUNEL activity and no detachment were detected in the apoptosis-inhibited group. CONCLUSION: As inhibition of apoptosis prevented the detachment of the neural and surface ectodermal layers from each other at the end of the neurulation, inhibition of apoptosis seemed to cause a considerable embryological error accounted for congenital dermal sinus tractus maldevelopment.

Radiologic features of lumbar spine in ochronosis in late stages.

Ochronosis is a rare hereditary disorder of tyrosine metabolism. Severe degenerative arthritis and spondylosis occur in the later stages of this disease. Radiologic examinations may reveal changes considered almost pathognomonic for ochronosis. We present the radiologic features of the lumbar spine in two ochronotic patients who were diagnosed after radiologic examinations in the late stages of the disease.

Penetrating injury of cranium: a case report.

A 38 year-old male patient treated for paranoid schizophrenia for five years was found on a chain saw table at his workplace with a great parasagittal, linear active bleeding wound from left occiput to medial portion of left orbita. He was unconscious.with a Glascow coma score of 5 points as 1-3-1. Cranial radiographies revealed a bone defect from left occipital region to left medial border of orbita. CT scan showed also a great linear tissue damage involving left lateral ventricle, and an intracerebral hematoma located mainly at left frontoparietal region. An emergent left frontoparietal craniotomy was performed. Four centimetres laterally midline, there was a linear, vertical tissue wound. Hemostasis was achieved at first and intracerebral haematoma evacuated. At one week postoperatively, his eyes started to react to verbal commands. At 7 months postoperatively he was attempting to cooperate with eye movements and writing. He was right hemiplegic, aphasic and on the right side deep tendon reflexes were hyperactive. His Karnofsky score was almost 40 points. Cranial injuries due to chain saw accidents are very rare. Early surgical procedures (incl. decompression) combined with aggressive antibiotherapy seem to have a great survival benefits. However best long- term results show that this type of injuries have a great rate of mortality and morbidity despite all surgical and medical treatment procedures.

Effect of difluoromethylornithine on reperfusion injury after temporary middle cerebral artery occlusion.

Polyamines have been shown to play an important role in the disturbance of the blood-brain barrier (BBB) in a number of pathological states including ischemia. BBB disturbances may be almost completely prevented by treating animals with the ornithine decarboxylase (ODC) inhibitor, alpha-difluoromethylornithine (DFMO). DFMO has been also shown to prevent N-Methyl-D-aspartate (NMDA) toxicity in tissue cultures. It has been suggested that the pathological disturbances in polyamine metabolism observed following cerebral ischemia, particularly the post-ischemic increase in putrescine, may contribute to the ischemic injury that is most evident in the CA1 subfield of the hippocampus. In this study, effects of DFMO in cerebral ischemia and reperfusion were examined. The results showed that inhibition of the polyamine system by DFMO decreased ischemic injury volume and brain tissue water content in a dose-dependent manner, without change in vital signs, including systemic arterial blood pressure, arterial partial oxygen pressure, regional cerebral blood flow and body temperature.

High-velocity gunshot wounds to the head: analysis of 135 patients.

Head injuries due to high-velocity missiles and shrapnel as a result of military conflicts have become a very important cause of death or severe neurological deficits. Military-type missiles have high velocities and transfer higher amounts of energy to neural tissue, compared to civil-type missiles. This physical phenomenon also causes greater neural tissue destruction. Shrapnel particles derive from blasts and cause less severe injury because of the irregular particle shape and low energy transmission. This study analyzed 135 patients with head trauma, 80 patients (59%) injured by missiles and 55 patients (41%) by shrapnel. Glasgow Coma Scale (GCS) scores at admission were 3 to 7 in 69 patients, 8 to 10 in 29 patients, and 11 to 15 in 37 patients. The most common anatomical localizations were the right frontoparietal region in 42 patients and the left frontoparietal region in 40 patients. One hundred patients (74%) were operated on immediately and 35 patients (26%) were treated conservatively in the intensive care unit. Ten of the 135 patients died (7.4%), seven from missile injury and three from shrapnel injury. In this study, we found that high mortality was associated with low GCS score at admission, presence of multilobar or skull base injuries, and involvement of ventricles. Early and aggressive surgical intervention decreased the mortality.

L-arginine in focal cerebral ischemia.

Nitric oxide and its precursor, L-arginine, have a great importance in cerebrovascular studies. In this study, we elucidate the dose dependent L-arginine effects on cerebral ischemia. The study involved 96 New Zealand albino rabbits, which were randomly allocated into four groups. The middle cerebral artery was occluded after a modified transorbital approach. Before the occlusion of MCA, each group was intravenously administered three doses of L-arginine i.e. 2.5 mg kg-1 for Group 1, 7.5 mg kg-1 for Group 2, and 12.5 mg kg-1 for Group 3. Thus, each group consisting of 24 animals was listed as 2.5 mg kg-1 (Group 1), 7.5 mg kg-1 (Group 2), 12.5 mg kg-1 (Group 3), and control group (receiving no intervention). Cerebral tissue oxygenazation was measured in parietal area by near infrared spectroscopy in all animals prior to and at 5, 30, and 60 min after MCA occlusion. Six hours after MCA occlusion, all the animals were studied for the area of ischemia (n = 40), edema formation (n = 32), and blood nitrite-nitrate levels (n = 24). At the dose of 2.5 mg kg-1 of L-arginine no differences were detected on ischemic tissue volume, brain edema, cerebral tissue oxygenazation, blood nitrite-nitrate levels when compared to the values of control group. However, with the dose of 7.5 mg kg-1, there were significant improvements in the levels of ischemic tissue volume, brain edema, and nitrite-nitrate levels compared to those of the control group and the 2.5 mg kg-1 group. At a dose of 12.5 mg kg-1, there were further improvements in the levels of ischemic tissue volume, brain edema, penumbral zone nitrite-nitrate levels. After 30 min of occlusion, cerebral tissue oxygenazation values increased in a dose dependent fashion. L-arginine's protective effect on cerebrovascular ischemia shows a dose dependent effect on infract size and tissue water content that may prove beneficial in the treatment of ischemia. However, further dose-dependent studies are needed.

Clear cell meningioma: case report and literature review.

The clear cell meningioma is rare and a recently described histologic variant of meningioma. The most interesting aspect of clear cell meningioma is the high recurrence rate and agressiveness. Until now 17 intracranial clear cell meningioma cases had been reported in the English language literature. We present 2 new cases of clear cell meningioma which is discussed with the relevant literature.