Iatrogenic Vascular Injury Associated with Cervical Spine Surgery: A Systematic Literature Review.

BACKGROUND: Iatrogenic vascular injury is an uncommon complication of anterior and/or posterior surgical approaches to the cervical spine. Although the results of this injury may be life-threatening, mortality/morbidity can be reduced by an understanding of its mechanism and proper management. METHODS: We conducted a literature review to provide an update of this devastating complication in spine surgery. A total of 72 articles including 194 cases of vascular lesions following cervical spine surgery between 1962 and 2021 were analyzed. RESULTS: There were 53 female and 41 male cases (in addition to 100 cases with unreported sex) with ages ranging from 3 to 86 years. The vascular injuries were classified according to the spinal procedures, such as anterior or posterior cervical spine surgery. The interval between the symptom of the vascular injury and the surgical procedure ranged from 0 to 10 years. Only two-thirds of patients underwent intra- or postoperative imaging and the most frequently injured vessel was the vertebral artery (86.60%). Laceration was the most common lesion (41.24%), followed by pseudoaneurysm (16.49%) and dissection (5.67%). Vascular repair was performed in 114 patients. The mortality rate was 7.22%, and 18.04% of patients had 1 or more other complications. Most presumed causes of vascular lesions were by instrumentation/screw placement (31.44%) or drilling (20.61%). Sixteen patients had an anomalous artery. Direct microsurgical repair was achieved in only 15 cases. CONCLUSIONS: Despite increased anatomical knowledge and advanced imaging techniques, we need to consider the risk of vascular injury as a surgical complication in patients with cervical spine pathologies.

Comparison of three methods for the estimation of the pituitary gland volume using magnetic resonance imaging: a stereological study.

Stereological techniques using point counting and planimetry have been used to estimate pituitary gland volume. However, many studies have estimated pituitary gland volume by the mathematical approach the elliptic formula. The objective of the current study was to determine pituitary gland volume using stereological methods and elliptic formula on magnetic resonance imaging (MRI). In this study, pituitary gland volumes were estimated in a total of 28 subjects (22 females, 6 males,) who were free of any pituitary or neurological symptoms and signs. The mean ± SD pituitary gland volumes for the point counting, planimetry and elliptic formulae groups were 582.14 ± 140.16 mm³, 610.08 ± 133.17 mm³, and 432.82 ± 147.38 mm³, respectively. The mean CE for the pituitary gland volume estimates derived from the point counting technique was 8.07%. No significant difference was found between point counting and planimetric methods for the pituitary gland volume (P > 0.05). In addition, there was a 26.14 and 29.71% underestimation of pituitary volume as measured by the elliptic formula compared to the point counting and planimetric techniques, respectively. From these results, it can be concluded that stereological techniques are unbiased, efficient and reliable methods and are ideally suitable for in vivo examination of MRI data for pituitary gland volume estimation. Hence, we suggest that estimating pituitary gland volume using MRI study and stereology may be clinically relevant for pituitary surgeons for the investigation of the structure and function of the pituitary gland.

Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported During Last Century with a Demonstrative Case Report.

OBJECTIVE: Calcified or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurologic symptoms, is a rarely seen entity that may remain asymptomatic for many years. Management of CSDH has improved dramatically in recent years as a result of advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy. METHODS: In this systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, comprising 83 patients operated on and 31 not operated on. RESULTS: In this study, there were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean, 33.7 years), with CSDH caused by head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or after cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as radiography, computed tomography, and magnetic resonance imaging were used, with pathologic confirmation of CSDH and complete recovery in 56.4% of patients. CONCLUSIONS: Incidence of calcified or ossified CSDH is high in certain countries, including the United States, Japan, and Turkey, with a steady increase in recent years. The therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at presentation because of its infrequency and variable clinical manifestation, after shunting in children or head trauma in adults.

Foreign Body Granuloma After Cranial Surgery: A Systematic Review of Reported Cases.

BACKGROUND: In cranial surgery, different foreign body (FB) materials are used and may be left intentionally or unintentionally in the surgical field after closure, inducing a foreign body granuloma (FBG). This is a rare complication in neurosurgery, but it may be a diagnostic dilemma, with sometimes medicolegal implications. METHODS: We performed a systematic review of the English literature between 1965 and 2018 and found a total of 77 articles concerning 100 cases of FBG caused by retained material located within the cranium or surrounding soft tissues. RESULTS: There were 60 females and 40 males, with ages ranging from 1 to 77 years. Most initial diagnoses were cranial/intracranial tumors, trigeminal neuralgia, hemifacial spasm, intracranial aneurysm, hydrocephalus, head injury, infectious disease, and nontraumatic intracerebral hematoma. The interval from the causative surgical operation to presentation of the FBG ranged from 2 weeks to 20 years. Various radiologic modalities were used and histologic study confirmed the presence of FBG in all patients. Intentional FB was used and left in 77 patients, and unintentional FB was found postoperatively in 23 patients. Associated infection was found in 13 patients. Complete recovery was seen in 47.6% of patients with sufficient data. CONCLUSIONS: Despite being unusual, a retained FBG should be considered in the differential diagnosis of any patient after cranial surgery. A history of surgery, clinical symptoms, physical examination findings, laboratory results, and the use of appropriate neuroimaging explorations may provide a correct preoperative diagnosis. In addition, unintentionally retained FBs are preventable errors in the operating room.

Retention of Nonabsorbable Hemostatic Materials (Retained Surgical Sponge, Gossypiboma, Textiloma, Gauzoma, Muslinoma) After Spinal Surgery: A Systematic Review of Cases Reported During the Last Half-Century.

OBJECTIVE: Retention of nonabsorbable hemostatic materials (RNHMs), that is, retained surgical sponge, gauzoma, gossypiboma, muslinoma, or textiloma, is a rarely seen surgical complication after spinal surgery that may remain asymptomatic for many years and may represent a diagnostic difficulty with associated medicolegal implications. METHODS: We performed a systematic review of the English-language literature published between 1965 and 2017, accessed through 4 popular databases. We found a total of 37 articles (24 case reports; 7 image presentations; 5 clinical series, and 1 letter to editor) containing 58 cases of RNHMs located within the spinal canal or around the spinal column after surgery. RESULTS: In this study, there were 29 female and 29 male patients from 13 countries, ages ranging from 17 years to 87 years, with initial diagnoses of lumbar or cervical disc herniation, spinal stenosis, or spondylolisthesis (n = 54), or spinal tumor (n = 4). The interval from the initial surgery to the presentation of RNHMs ranged from 13 days to 40 years, with a mean of 75.9 months. Various imaging techniques such as computed tomography and magnetic resonance imaging were used with histologic study, confirming the presence of RNHMs in the majority of patients with a complete recovery resulting in 93% of patients. CONCLUSIONS: RNHMs is an overreported entity in underdeveloped or developing countries, including Turkey and Morocco, with progression occurring over years. RNHMs should be considered in the differential diagnosis of any patient who presents with back pain, spinal cord, or nerve roots symptomatology after spinal surgery.

Ultrasound assessment of premenopausal bleeding.

Vaginal bleeding is the most common cause of emergency care in the first trimester of pregnancy and accounts for the majority of premenopausal bleeding cases. Ultrasound evaluation combined with a quantitative beta human chorionic gonadotropin test is an established diagnostic tool to assess these patients. Spontaneous abortion because of genetic abnormalities is the most common cause of vaginal bleeding; ectopic pregnancy and gestational trophoblastic disease are other important causes and in all patients presenting with first trimester bleeding, ectopic pregnancy should be suspected and excluded, as it is associated with significant maternal morbidity and mortality. A thorough knowledge of the normal sonographic appearance of intrauterine gestation is essential to understand the manifestations of an abnormal gestation. Arteriovenous malformation of the uterus is a rare but important cause of vaginal bleeding in the first trimester, as it has to be differentiated from the more common retained products of conception, with which it is often mistaken.

Complications and limitations related to periprostatic local anesthesia before TRUS-guided prostate biopsy.

PURPOSE: To assess the frequency of complications specifically related to local anesthetic infiltration prior to transrectal ultrasound (TRUS)-guided prostate biopsy. METHODS: A total of 200 patients receiving 10 cm(3) (5 cm(3) on each side) of 2% lidocaine injected around the periprostatic nerve plexus under TRUS guidance before prostate biopsy were included. Various complications presumed to be associated with local anesthesia were noted during and after the biopsy procedure. Two weeks later, periprostatic tissue integrity and vascularization were re-examined with TRUS Doppler examination to assess for fibrosis or infection. RESULTS: The most common finding was pain due to puncture with the needle used for local anesthesia (27%). Also recorded were the need for repeated injections during the biopsy procedure (4.5%), symptoms associated with systemic lidocaine toxicity (2%), urinary incontinence (1.5%), and degradation of the image resolution due to anesthetic injection (1%). Increased vascularization within the periprostatic region was uncommon (2%) on the 2-week follow-up examination. No TRUS finding consistent with rectal wall hematoma or other periprostatic change and no erectile dysfunction associated with the procedure occurred. There was a significant difference in overall pain scores between the subgroups of patients (p < 0.001). CONCLUSION: TRUS-guided periprostatic nerve blockade is an effective method for relieving discomfort from prostate biopsy with very few complications.

Chronic constipation as a causative factor for development of varicocele in men: a prospective ultrasonographic study.

OBJECTIVE: The purpose of this study was to determine the role of chronic constipation in the etiopathogenesis of varicocele in men. METHODS: In this prospective study, group 1 included 25 male patients who had symptoms of chronic constipation for a mean duration +/- SD of 17.0 +/- 20.3 months (range, 3-96 months), and group 2 included 26 male subjects without any symptoms associated with constipation. All subjects were evaluated by both physical examination and scrotal ultrasonography. For the plexus pampiniformis (PP) veins, a mean diameter exceeding 2 mm and reflux for more than 1 second were accepted as suggestive findings for varicocele, as described previously. RESULTS: Left varicocele was detected in 13 (52%) of the 25 patients in group 1 and in 5 (19%) of the 26 subjects in group 2 (P = .02). The mean diameters of the left PP veins were 2.58 +/- 0.97 mm (range, 1.2-4.3 mm) in group 1 and 1.71 +/- 0.53 mm (range, 1.0-3.0 mm) in group 2 (P < .001). A significant difference was detected between the two groups for varicocele prevalence and the mean diameter of the left PP veins. CONCLUSIONS: Chronic constipation is a significant causative factor for the development of left varicocele, which may be attributable to the accompanying distention of the sigmoid colon and distal part of the descending colon, with resultant compression of the left testicular vein in the retroperitoneum. Therefore, we propose routine ultrasonographic examinations for the possible development of varicocele in men with chronic constipation.

Preoperative ultrasonographic evaluation of testicular volume and blood flow in patients with inguinal hernias.

OBJECTIVE: The purpose of this study was to investigate whether an inguinal hernia would have an impact on the testicular volume and blood flow by scrotal ultrasonography. METHODS: Twenty-six male patients with unilateral inguinal hernias with a mean age of 48.1 years were included in the study. Testicular volumes were calculated, and spectral parameters such as the pulsatility index and resistive index of the testicular artery at supratesticular, subcapsular, and intratesticular levels on both the side with the inguinal hernia and the contralateral side were measured by a preoperative ultrasonographic examination. Comparisons between the dependent groups were performed by a Wilcoxon or paired samples t test where appropriate. RESULTS: The mean +/- SD testicular volume on the side with the inguinal hernia was significantly higher than that on the contralateral testis (15.46+/-4.49 versus 14.54+/-3.65 mL, respectively; P<.05, Student t test). In addition, the mean resistive index of the intratesticular arteries was significantly higher on the side with the hernia compared with the contralateral side (0.66+/-0.06 versus 0.63+/-0.05; P<.05, Student t test). CONCLUSIONS: These data indicate that an inguinal hernia may impair testicular blood flow, which may be attributable to an intermittent mechanical compression effect on the funiculus spermaticus in the inguinal canal.

Effect of premicturitional bladder volume on the accuracy of postvoid residual urine volume measurement by transabdominal ultrasonography: rate of bladder fullness is of great importance for preventing false-positive residue diagnosis.

OBJECTIVE: The purpose of this study was to evaluate the effect of premicturitional bladder volume (V1) on postvoid residual urine volume (V2) measurements and to assess the ideal V1 for an accurate V2 determination. METHODS: Twenty-five healthy men without any urinary symptoms constituted the study group. Measurements by transabdominal ultrasonography for V1 and V2 were performed for each subject at 3 different phases, each of which was preceded by oral intake of 1000 mL of water and accompanied by "mild," "moderate," and "severe" sensations of micturition, respectively. RESULTS: Mean +/- SD V1 and V2 during the first, second, and third phases were 117.7 +/- 70.3 and 1 +/- 1, 356.2 +/- 112.3 and 11.5 +/- 12 and 639.6 +/- 171.8 and 58.8 +/- 35.2 mL, respectively. With 50 mL as the cutoff value for a pathologic V2, 15 (60%) men had V2 in the third phase exceeding this value, whereas the same rate was calculated as 0% for either of the first 2 phases. No patient with V1 of less than 540 mL had V2 of greater than 50 mL. CONCLUSIONS: Postvoid residual urine volume measurements with an uncomfortably full bladder result in high false-positive postmicturitional residue values even in healthy young men. We strongly advise that V1 measurements of the bladder be performed before V2 measurements and that V2 not be measured if V1 is greater than 540 mL.

Morphological, stereological and radiological changes in pinealectomized chicken cervical vertebrae.

Considerable evidence supports the hypothesis that melatonin plays an important role in osteogenesis. We carried out an experiment to investigate histological and radiological changes in the cervical vertebrae of pinealectomized chickens. Thirty new-hatched chicks were divided into two groups: pinealectomized group (n=15) and nonpinealectomized control (n=15). Surgical pinealectomies were performed in Hybro broiler chickens at the age of 3 days. At 8 wk, one animal from each group was examined using computed tomography scanner to obtain density histograms of four consecutive vertebrae between the 4th and 7th cervical vertebral segments of chickens. At the end of the study, all animals were killed for subsequent measurement of bone mineral density (BMD) and macroscopic, radiographic and histopathological evaluation of specimens. We found that the profile of the density histogram in nonpinealectomized control group showed a spike profile for the vertebral body, indicating an increase in the amount of higher density tissues in this region, while a plateau-shaped profile was obtained for the vertebral body in pinealectomy group, indicating the presence of heterogenous bone tissue. Accordingly, the mean value of BMD in pinealectomy group was significantly lower at the vertebral body in chickens compared with control subjects (P<0.001). At the end of the experiment, almost all of the chickens in pinealectomy group developed a scoliotic curvature and the mean weight and length of the cervical vertebral bodies of the pinealectomized chickens were significantly lower than those of control group (P<0.001). Although the numerical density of osteocytes and osteoblasts in pinealectomy group was significantly higher than that from the control group, total number of osteocytes but not osteoblasts in cervical vetrebrae from pinealectomized animals was significantly lower than that from nonpinealectomized control animals (P<0.05). In conclusion, the results of the current study demonstrated for the first time pinealectomy-induced histomorphometrical changes in chicken vertebral column using stereological methods, suggesting that pineal gland/melatonin may have an osteoinductive effect on bone formation, but further studies are needed to elucidate the relationship of our findings with some disorders such as postmenopausal and/or senile osteoporosis.

Hydatidosis of the orbit in Turkey: results from review of the literature 1963-2001.

Hydatidosis can involve almost every organ or tissue in the body via the systemic circulation, but hydatid infestation of the orbit comprises far less than 1% of the total incidence. This study investigated the data on all patients of orbital hydatid disease reported in Turkey since 1963. In this meta-analysis, a total of 25 patients were included and slowly progressive unilateral proptosis, with or without pain, was the most frequent clinical manifestation (80%). The other presenting symptoms were visual loss (48%), periorbital pain (24%), chemosis (16%), and headache (12%). The presumptive diagnosis of hydatid cyst was made on the images obtained from ultrasonography (US), computed tomography (CT) and/or magnetic resonance imaging (MRI) examinations. These diagnostic studies demonstrated a well-circumscribed cystic mass in almost all patients. Total surgical removal without rupture remains the best mode of therapy for orbital hydatid disease. The study indicates that in Turkey hydatidosis remains a serious problem, causing blindness. Orbital hydatid cyst should be included in the differential diagnosis of unilateral proptosis and visual handicap in patients from countries where hydatidosis is endemic.