Dural Tear: A Feared Complication of Lumbar Discectomy.

AIM: To show causes of dural tear in isolated lumbar disc surgery, and to investigate the risk factors. MATERIAL AND METHODS: We retrospectively reviewed 1159 cases (532 females and 627 males) involving patients who underwent a surgery for the treatment of lumbar disc herniation between 2006 and 2013. We have analysed the side of the surgery, level of the operation, first or revision surgery, type of anesthesia and type of surgical procedure for the risk of dural tear. To examine differences between disc levels, we used Chi-square testing for categorical variables and the student's t test for continuous variables. To analyze our data, we used STATA version 12. A "p value" less than 0.05 was considered as statistically significant. RESULTS: A total of 1047 (90.3%) cases were treated with microdiscectomy, and 112 (9.7%) required open discectomy. Overall, 820 (70.7%) and 339 (29.3%) surgeries were performed under epidural and general anesthesia, respectively. Dural tear ratio was 1.20%. In dural tear ratio, there was a significant difference in gender (Female: 1.6%, Male: 0.79%) (p < 0.05). Dural tear ratios at primary disc surgery and at recurrent disc surgery were respectively 0.82% and 7.14% (p < 0.05). Most of the tears were on the right side (11/14) (p < 0.05). 13 dural tear cases (1.58%) were noted in patients who operated under epidural anesthesia (820 cases) compared to 1 (0.29%) under general anesthesia (339 cases) (p < 0.05). CONCLUSION: Recurrent disc surgery, female sex, epidural anesthesia, open discectomy, non-dominant hand usage of surgeon, and upper-level affected lumbar discs were risk factors for intraoperative dural tear during lumbar disc surgery.

Lumbar Disc Surgery with Epidural Anesthesia: Review of 700 Cases.

AIM: Lumbar disc surgery can be performed under general anesthesia or regional anesthesia methods. There are long-standing discussions between neurosurgeons, orthopedic surgeons and anesthesiologists concerning the use of epidural anesthesia in lumbar surgery. The results of this study's 700 lumbar disc surgery cases operated with epidural anesthesia in our clinic between September 2006 and December 2011 will contribute to these discussions. MATERIAL AND METHODS: This study included 700 patients underwent lumbar disc surgery with epidural anesthesia, which consisted of 388 males (55%) and 312 females (45%). Forty-two of these cases had recurrence disc herniation and only 11 of 42 cases were operated in our department. RESULTS: Eleven of 700 cases had dural injury and were repaired intraoperatively by primary sutures and tissue sealants. Infection of the incision site developed in six patients, who healed with appropriate antibiotic treatment with no problems. In addition to those 700 cases, 22 patients received general anesthesia in which we started with epidural anesthesia. Microdiscectomies were performed in 578 of 700 cases, and open surgery in 122 cases. CONCLUSION: This study showed that epidural anesthesia seems more advantageous for some patients since it does not have some of the risks that general anesthesia bears.

Surgical management of recurrent disc herniations with microdiscectomy and long-term results on life quality: Detailed analysis of 70 cases.

BACKGROUND: Aim of this paper is to recall the surgical technique used in the recurrent lumbar disc herniations (LDHs) and to share our experiences. MATERIALS AND METHODS: Out of series of 1115 patients who underwent operations for LDH between 2006 and 2013, 70 patients underwent re-operations, which were included in this study. During surgery, lateral decompression performed over the medial facet joint to the superior facet joint border was seen after widening the laminectomy defect, and microdiscectomy was performed. The demographic findings of the patients, their complaints in admission to hospital, the level of operation, the condition of dural injury, the first admission in the prospective analysis, and their quality of life were evaluated through the Oswestry scoring during their postoperative 1(st), 3(rd), 6(th)-month and 1(st), 3(rd), 5(th) and 7(th)-year follow-up. In the statical analysis, Friedman test was performed for the comparison of the Oswestry scores and Siegel Castellan test was used for the paired nonparametrical data. A P < 0.05 was considered statistically significant. RESULTS: Considering the Oswestry Index during the follow-ups, the values in the postoperative early period and follow-ups were seen to be significantly lower than those at the time of admission to hospital (P < 0.05). None of the patients, who re-operated by microdiscectomy, presented with iatrogenic instability in 7 years follow-up period. CONCLUSION: Microdiscectomy performed through a proper technique in the re-operation of recurrent disc herniations eases complaints and improves the quality of life. Long-term follow-ups are required for more accurate results.

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.

Spontaneous regression of traumatic lumbar epidural hematomas.

BACKGROUND: The aim of this report is to present a case of spontaneous regression of traumatic lumbar epidural hematomas. CASE REPORT: A 45-year-old man presented at our clinic after falling from a height. After admission, anterior compression was detected by X-ray, so lumbar spinal CT was performed. For ligament damage, emergency MR was performed. There was acute hematoma at 1 cm diameter, which began at the L3 vertebra superior surface and spread to L4 vertebra corpus; therefore the patient was informed and surgery recommended. The patient rejected the surgery, and medical management was designed. At day 45, lumbar MRI was performed. There was no evidence of traumatic epidural hematoma. CONCLUSIONS: The purpose of this study is to report a case with post-traumatic spinal epidural hematomas with normal neurologic findings and spontaneous regression.