The Importance of Spinopelvic Parameters in Recurrent Lumbar Disk Herniation.

STUDY DESIGN: Retrospective clinical study. OBJECTIVES: We aimed to investigate preoperative spinopelvic mismatch as a risk factor for recurrent lumbar disk herniation (RLDH) in patients undergoing lumbar disk herniation (LDH) surgery. SUMMARY OF BACKGROUND DATA: Spinopelvic parameters have been associated with lumbar degenerative diseases, particularly LDH. However, the relationship between these parameters and RLDH has yet to be studied. MATERIALS AND METHODS: Data of 1453 patients aged ≥18 who underwent single-level, unilateral fenestration microdiscectomy for the first time in our hospital between 2013 and 2019 were reviewed. The study group comprised 88 patients who underwent surgery for RLDH. The control group comprised 101 randomly selected patients who underwent surgery for LDH but not RLDH. Age, sex, body mass index, occupational activity level, operative level, Roussouly classification type, and time to recurrence were recorded. Moreover, pelvic incidence, lumbar lordosis (LL), interverteberal disk height (IDH), segmental lordosis, sacral slope (SS), pelvic tilt (PT), and sacral table angle (ST) were measured for each patient. Pelvic mismatch was calculated. RESULTS: Mean age was 46.5±11.4 y (range, 20-70). Both groups were similar concerning age, sex, body mass index, occupational activity level, and level of surgery. The mean time to recurrence was 167.3±36.6 d (range, 62-363). Measurements in the RLDH group were as follows: IDH=7.6±1.5 mm, pelvic incidence =54.4°±10.1°, LL=47.3°±13°, segmental lordosis =9.3°±5°, SS=35.1°±9.9°, and PT=19.3°±7.3°. Mean IDH was significantly lower in the RLDH group ( P =0.02). Less LL and lower PT at L3-4 level and increased SS at L5-S1 level were considered risk factors for RLDH. CONCLUSION: This study showed that preoperative low IDH is at higher risk for RLDH in patients undergoing LDH surgery. LL, PT, and SS may be risk factors for specific levels.

A new posterior stabilization technique in pediatric subaxial cervical vertebrae: Stabilization of spinous processes with the microplate/screw system: A radiological anatomy study.

BACKGROUND: There are limited options for posterior stabilization techniques in cases of cervical subaxial instability in children. We designed this study to investigate whether the spinous process (SP) stabilization, which was previously used in adults, can also be used in children. METHODS: Children aged 4-12 years who were admitted to our hospital between 2012 and 2020 and underwent 3D cervical computed tomography (CT) were retrospectively screened. Children without cervical spine fractures, tumors, deformities, or any ab-normalities and motion artifacts on CT were included in the study. Eight hundred seventy children were identified. Then, 360 children randomly selected from the patient pool were divided into nine different age groups or 3 different age groups (4-6 years, 7-9 years, and 10-12 years). The length, height, thickness, and anomalies of subaxial SPs were studied on CT images of children. The suitability of the SPs for the microplate/screw stabilization system was investigated. RESULTS: The suitability rate for screw insertion was 57.6% and the suitability rate for the stabilization in at least one segmental unit was 74.7%. The eligibility rate for stabilization involving C3, 4, 5, 6, and 7 vertebrae was 16.1%. There were nine different stabilization combinations and C6-7 segmental unit (71.9%) were the most common in those combinations. Bifidity prevented screw insertion in 21% of children. We found that the screw acceptance rate of SP started to increase statistically around 8 years of age and the number of segmental units that could be stabilized was at the age of 10-12 at most. CONCLUSION: According to the results of this study, we believe that the SP stabilization method recommended for children can be used as a salvage method, to support anterior stabilization or alone in a small number of selected cases.

Comparison of the effect of bipolar coagulation and fibrillar structured oxidized cellulose on formation epidural fibrosis in rats

Background/aim: Epidural fibrosis (EF) is a common cause of failed back surgery syndrome seen after spinal surgeries. The most frequent reason for the formation of EF is accumulated blood and its products in the operation zone. On the development of EF, the effect of bipolar coagulation and fibrillar oxidized cellulose, which are used frequently to control bleeding, was investigated. Materials and methods: In the study, 45 male Sprague Dawley rats were divided into three groups (control, fibrillar, and bipolar). Lumbar laminectomy was applied to all rats under sterile conditions. In the control group, the epidural area was washed with saline solution. Bleeding was controlled with fibrillar oxidized cellulose in the fibrillar group, with bipolar coagulation in the bipolar group. The area to which laminectomy had been applied was removed as a block 6 weeks later and evaluated histopathologically and genetically in terms of EF development. Fibrosis degree was determined histopathologically by counting fibroblasts using the modified Lubina and EF He grading systems. Interleukin-6 (IL-6), transforming growth factor beta-1 (TGFß-1), and mRNA levels were measured by the droplet digital polymerase chain reaction method. Results: The number of epidural fibroblasts, percentage of modified Lubina, amount of IL-6, and He grading rates were significantly lower in the fibrillar group than in the bipolar and control groups (p ˂ 0.05). On the other hand, there was no significant difference among the control, fibrillar, and bipolar groups in terms of TGFß-1 values (p= 0.525). Conclusion: The use of fibrillar oxidized cellulose was more effective for hemostasis than bipolar coagulation in reducing the development of EF.

Does the Position of the Polyaxial Screw Head in Patients With L5-S1 Stabilization Lead to an Increased Difficulty in L5 Transforaminal Nerve Injection? A Three-Dimensional Computerized Tomography Study.

Background Challenges may be encountered if transforaminal nerve injection (TFNI) is required in patients who have undergone posterior transpedicular stabilization (PTS) surgery to the L5-S1 level. In this study, we investigated the contributory factors that lead to these challenges. Methods We selected 125 patients who underwent PTS surgery involving the L5-S1 segment, between 18 to 70 years of age to be included in the study. The demographic data of the patients, body mass indexes (BMI), postoperative spondylolisthesis grades, heights of the iliac crest, and the positions of the polyaxial screw head were assessed. The shortest trajectory of L5-TFNI, the distance of the needle entry point (NEP) to the midline, and optimum viewing angles (VA) were measured on the three-dimensional computed tomography (CT) sections. Results Pre-PTS surgery, in males compared to females, NEP was noted to be more medial (p=0.007), the needle trajectory was shorter (p=0.001), and the optimal VA was narrower (p=0.001). Increasing BMI and increasing height of the iliac crest caused the TFNI trajectory to become longer. Post-PTS surgery, angulation of polyaxial screw heads of more than 15 degrees laterally in both genders significantly caused a decrease in VA (p=0.001). Conclusions Using the reconstruction technique in 3D CT, we demonstrated that pedicle screw heads angled laterally, a higher iliac crest height, and an increased BMI make L5-TFNI difficult to be performed. Locking the stabilization system while targeting the most neutral position for polyaxial screw heads during surgery may facilitate the L5-TFNI.

The calcimimetic R-568 attenuates subarachnoid hemorrhage-induced vasospasm through PI3K/Akt/eNOS signaling pathway in the rat model.

Cerebral vasospasm (CVS) causes mortality and morbidity in patients after subarachnoid hemorrhage (SAH). The mechanism and adequate treatment of CVS are still elusive. R-568 is a calcimimetic agent known to exert a vasodilating effect. However, there is no report on its vasodilator effect against SAH-induced vasospasm. In the present study, we investigated the therapeutic effect of R-568 on the SAH-induced CVS model in rats. Seventy-two adult male Sprague-Dawley rats were divided into 8 groups: sham surgery; SAH only; SAH + Vehicle, SAH + R-568; SAH + R-568 + Wortmannin (the PI3K inhibitor); SAH + Wortmannin; SAH + R-568 + Calhex-231 (a calcilytic agent); SAH + Calhex-231. SAH was induced by blood (0.3 mL) given by intracisternal injection. R-568 (20 µM) was administered intracisternal immediately prior to experimental SAH. Basilar arteries (BAs) were obtained to evaluate PI3K/Akt/eNOS pathway (immunoblotting) and morphological changes 48 h after SAH. Perimeters of BAs were decreased by 24.1% in the SAH group compared to the control group and the wall thickness was increased by 75.3%. With R-568 treatment, those percentages were 9.6% and 29.6%, respectively, indicating that vasospasm was considerably improved when compared with the SAH group (P < 0.001 in both). While p-PI3K/PI3K and p-Akt/Akt ratio and eNOS protein expression were markedly decreased in the SAH rats, treatment with R-568 resulted in a significant increase in these levels. The beneficial effects of R-568 were partially blocked in the presence of Calhex-231 and completely blocked in the presence of Wortmannin. Herein, we found that treatment with R-568 would attenuate SAH-induced CVS through the PI3K/Akt/eNOS pathway and demonstrate therapeutic promise in CVS treatment following SAH.

Management of Traumatic Epidural Hematoma in Infants Younger than One Year: 50 Cases - Single Center Experience.

AIM AND BACKGROUND: Traumatic epidural hematoma (EDH) is a rare but possibly fatal complication of head trauma in infants. In this study, infants who were younger than 1 year and followed up and treated for TEDH in our clinic were evaluated. Our series is the largest series consisting only infantile cases in the literature. MATERIAL AND METHODS: There were 50 patients younger than 1 year followed up and treated in our hospital between January 2011 and December 2019. Their age, gender, hospital admission signs and symptoms, trauma type, localization and thickness of the hematoma, and accompanying skull fracture were noted from their hospital files. Decisions for conservative or surgical treatment were made according to neurological status, Children Coma Scale (CCS) score, and EDH thickness, degree of the midline shift on cranial computerized tomography (CT), and presence of additional intracranial pathology. RESULTS: Patients' age ranged from 0 day to 12 months (7 months as median), and their male/female ratio was 30/20. Falling from a height (<1 m) was the most frequent trauma mechanism, with a 96% rate. The most common finding was irritability and unusual crying (88%). The CCS score was 5-15 (median 13). The hematoma was located most frequently in the parietal region (48%) and least frequently in the posterior fossa (2%). Linear fracture was observed in 62% of the cases. Thirty-nine (78%) patients were treated conservatively (hematoma thickness ≤17 mm). Eleven (22%) cases were surgically treated (hematoma thickness was between 15 and 40 mm (26.3 ± 6.6 mm, mean ± standard deviation [SD]). The midline shift in the operated cases was between 1.8 and 11.8 mm (6.4 ± 3 mm, mean ± SD). One of them with a hematoma thickness of 15 mm was operated for associated open depression fracture above the hematoma. Other 10 patients were operated for primarily hematoma evacuation. None of the patients treated conservatively worsened neurologically or required operation during or after hospitalization. Two patients died (4%) during hospitalization, and both of them were anisocoric on admission. The hospital stay was between 1 and 10 (median 3) days, and the follow-up period of the living patients was between 1 month and 6 years (median 24 months). All of the living patients were neurologically normal on their last controls. CONCLUSIONS: Because the symptoms and signs in infants are nonspecific, it is difficult to diagnose EDH clinically. Cranial CT should be performed in cases with irritability, swelling of the scalp, pallor, deterioration of consciousness, and anisocoria after head trauma. Traumatic EDHs with normal neurological examination, high CCS score, hematoma thickness below 20 mm, no apparent shift, and without associated brain pathology can be treated conservatively. None of those patients treated conservatively required operation after that.

Suitability of the Subaxial Cervical Laminae for Laminar Screws in the Pediatric Population: A Radiologic Anatomical Study.

INTRODUCTION: The laminar screw method was popularized during recent years. Since no data exist in the literature on its suitability for subaxial levels in the pediatric population, a radiologic anatomical study was planned to evaluate the suitability of the laminae for laminar screws in children. METHODS: The laminar thicknesses from C3 to C7 were measured in axial sections in 120 pediatric patients using computed tomography. The patients were divided into 3 age-groups: ages 4-6, 7-9, and 10-12. Each age-group consisted of 20 boys and 20 girls. The suitability of the laminae was evaluated for 3.5-mm-thick commercially available screws and also for the 3-mm screws that could be produced in the future. If the height of the base of the spinous process is ≥ 9 mm, the segment was accepted as suitable for the bilateral screw, and ≥5 mm is for the unilateral screw. Additionally, laminar thickness and length were measured for possible short screws longer than 15 mm in the laminae that were distally thin but proximally thick. RESULTS: The C4 and C5 levels had the thinnest (2.77 ± 0.6 mm and 2.81 ± 0.6 mm, respectively) and C7 had the thickest laminae (4.66 ± 0.6 mm) in all age-groups. No significant differences were found between boys and girls and right and left laminae. According to the age-groups, an increase in laminar thickness was possible by growing, but only C7 laminae thickness was statistically different between 10-12 and 4-6 age-groups (p < 0.001). The last rate of the suitability was 9.1% for the 3.5-mm-thick screws and 13.75% for the 3-mm-thick screws after deletion of the bilateral insertion due to the short base of the spinous process and adding the possible short screws in the distally thin but proximally thick laminae. The rates increased with age, but the only statistically significant difference was found between 4-6- and 10-12-year-old age-groups (p < 0.001). CONCLUSIONS: Laminar screws may be suitable for some levels of C7, C6, and C3 even in the young pediatric population. The use of thinner screws (3 mm) may increase the suitability rate. Therefore, laminar screw choice may be considered as a salvage method in pediatric patients, and all laminae may be evaluated individually for suitability. This study did not evaluate the safety and efficacy of the method in children, and these issues must be studied further.

Immediate versus delayed primary repair of the sciatic nerve in a nerve transaction model in rats.

BACKGROUND: The debate continues concerning surgical timing in a peripheral nerve injury. This study aims to evaluate the result of immediate versus delayed primary (after seven days) repair of peripheral nerve injury. METHODS: In this study, Wistar rats were divided into four groups as follows: The nerve was sharply transected in Group 1, 2 and 4. It was immediately sutured in Group 1 and sutured seven days later in Group 2, and it was not sutured in Group 4. In Group 3, the left sciatic nerve was only explored. Eight weeks later, tissue samples were extracted from the injured nerve area. Both gastrocnemius muscles were weighed. The nerve samples were examined for axon degeneration. Myelin vacuolization, axon irregularity, and edema/inflammation parameters were evaluated. RESULTS: There were not any significant differences in the score of axon degeneration and the weight of the gastrocnemius muscle between the immediate and delayed primary repair groups. However, these parameters were significantly better in both repair groups than to be in the control group and significantly worse than to be in the sham-operated group. CONCLUSION: To delay the repair about one week did not affect the histological results and weight of the muscle that was innervated by the sectioned nerve comparing to be in the immediate repair in a sciatic nerve transaction model in rats.

Is spinal computed tomography necessary in pediatric trauma patients?

BACKGROUND: To investigate the prevalence of findings of spinal injury on computed tomography (CT) images of pediatric trauma patients and to define indicators for the possible presence of spinal injuries. METHODS: Spinal CT for pediatric trauma patients (age ≤ 12 years) over a 2-year period was retrospectively evaluated for the presence of findings suggestive of spinal injury. RESULTS: Of the 773 patients reviewed, 19 (2.4%) showed traumatic spinal lesions on their spinal CT images. These patients were significantly older than those without spinal lesions (mean age 7.9 ± 3.3 years vs 6.1 ± 3.3 years; P = 0.02). The prevalence of spinal trauma was significantly lower in patients aged 0-8 years than in those aged 9-12 years (P = 0.025). Spinal injury was significantly higher in female patients (P = 0.014). Most of the spinal injuries were located at the lumbar and sacral vertebral levels, and most did not cause neurological complications or require surgical treatment. Important indicators of the possible presence of spinal injuries were pain, tenderness, or ecchymosis over the spine, a low Glasgow Coma Scale score (≤12), head injury (for cervical injuries), or intrathoracic injuries and pelvic fractures (for lumbar and sacral injuries). CONCLUSIONS: Most spinal CT examinations for the diagnosis of spinal injuries in children did not show positive findings. Thus, many children were exposed to an unnecessary high dose of radiation. New clinical evaluation criteria and indicators should be defined to diagnose spinal injuries and avoid unnecessary radiological examinations.

The effectiveness of pedicle screw immersion in vancomycin and ceftriaxone solution for the prevention of postoperative spinal infection: A prospective comparative study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of the local application of vancomycin hydrochloride (HCl)-ceftriaxone disodium hemiheptahydrate onto implants before using them to prevent postoperative infection. METHODS: The study included 239 patients (153 women and 86 men; mean age: 48.23 ± 16.77 years) who had thoracolumbar stabilization with transpedicular screws. All surgeries were performed by the same surgeon. Patients were divided into two groups. In the group 1 (n = 104), implants were bathed in a solution of local prophylactic antibiotics for 5 seconds just before implantation. In the group 2 (n = 135), implants were not bathed before implantation. Local antibiotics used in the study was effective against gram positive bacteria (including methicillin resistant Staphylococcus aureus) and gram negative bacteria. The rate of surgical site infection and wound healing time were compared between the groups. RESULTS: A total of 10 patients (4.1%) had deep wound infection and 20 (8.4%) had superficial infection. The most common bacteria was Staphylococcus aureus. One patient died 21 days after the surgery because of sepsis. The wound healed in a mean of 9.66 ± 2.04 days in patients who had no infection and in 32.33 ± 19.64 days in patients with infection (p < 0.001). The patients in group 1 had significantly less deep infection than the patients in group 2 (p < 0.05). However, there was no statistically significant difference between the groups for superficial infection. Patients with vertebral fracture had significantly lower deep infection rate in group 1. The deep infection rate of group 1 patients with diabetes, with bleeding of more than 2000 mL, transfused with blood transfusions above 3 units and with dural injury was significantly lower than those in the group 2. None of the patients had allergic reactions to the drugs used for local prophylaxis. CONCLUSIONS: This study shown that bathing implants in antibiotics solution was an effective local prophylactic method to prevent deep infections in spinal surgeries with instrumentation. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Effects of alpha lipoic acid on motor function and antioxidant enzyme activity of nerve tissue after sciatic nerve crush injury in rats.

AIM: Background: Alpha lipoic acid (ALA) that is a strong antioxidant drug is tried for both protection and treatment of various diseases of central and peripheral nervous systems. MATERIAL AND METHODS: Material and Methods: Protective effects of ALA on crush type peripheral nerve injury were evaluated. 28 Sprague-Dawley rats were divided into four groups: In Group 1, sciatic nerve was only explored. Sciatic nerve crush injury was performed after serum physiologic injection intraperitoneally in Group 2, and after ALA injection in Groups 3 and 4. In all subjects, Sciatic Functional Index (SFI) was calculated. All subjects were sacrificed 1 hour after injury in first three groups, and 48 hours after in Group 4. Nerve samples were taken. Superoxide dismutase, catalase and glutathione peroxidase activities were measured in nerve tissue. RESULTS: Results: Administration of ALA before injury provided significantly better SFI values and higher levels of antioxidant enzymes than control group. These effects were significantly prominent 48 hours after injury. CONCLUSION: Conclusion: ALA that was given before crush type peripheral nerve injury provided to decrease damage of the nerve. Specific mechanisms of this effect must be clarified and must be shown that it is whether effective when it is given after injury or not.

Use and modifications of cervical and upper thoracic laminar screws in posterior stabilization.

AIM: Laminar screw technique is used to stabilize C2 and other levels when other techniques cannot be performed. MATERIAL AND METHODS: The patients underwent laminar screws at cervical and upper thoracic levels in our clinic during 5 yearswere evaluated retrospectively. RESULTS: In 25 patients, 6 to 82 years old,total 54 laminar screws were used. Most frequent diagnoses were cervical spinal stenosis and craniovertebraljunction anomalies.There were handicaps to perform other type of screwsin 19 out of 25 screws during first 4 years, and 9 out of 29 in the last year (p=0.0009).Two modifications were performed in some cases. In 4 segments with thin lamina, a shorter screw was performed to leave clear the thinnest part, and in 3 C2 levels with almost full length bifid spinous process,shorter screws were inserted from medial sides of the bifid processes with a more vertical orientation. There was ventral cortex penetration in 11 screws without new neurological deficits. One of them was removed because of its full thickness insertion into the spinal canal.Fusion rate was 75% in 16 patients followed radiologically longer than 6 months.In one patient out of 4 without fusion, unilateral screw was loosened, and in others laminar screws were not loosened. CONCLUSION: Laminar screw technique is easy, safe and effective at C2, C7 and upper thoracic levels. Some modifications may be required due to the anatomical variations.It can be used at other subaxial levels also in theselected cases that other techniques could not be performed.

Delayed infection 6 years after spinal instrumentation: a case report.

Infection is the major and important complication of spinal instrumentation generally requiring removal of the implant. Although findings of infection usually appear within a few months after operation, they may appear even after few years in some cases. A case with delayed postoperative infection 6 years after surgery is reported. A 27-year-old female with purulent flow from her anterolateral skin incision scar was diagnosed as delayed spinal infection 6 years after anterior and posterior combined spinal instrumentation performed for treatment of giant cell tumor of L3 vertebral body. Staphylococcus aureus was detected from purulent flow. Infection was treated by removal of the implant and antibiotherapy. Spinal infection after instrumentation may appear even a few years later. Patients must therefore be carefully followed for a long time. Staphylococcus aureus can stay silent for a long time.

Posterior fossa dermoid cysts causing cerebellar abscesses.

Dermoid cysts are uncommon tumors, and posterior fossa dermoid cysts may rarely cause abscess formation or formation of daughter abscesses within the cerebellum. At present, there are only 16 cases with posterior fossa dermoid cysts causing cerebellar abscesses reported in the literature. Two cases, 22 and 14 months old, with posterior fossa dermoid cysts and dermal sinus causing multiple cerebellar abscesses are reported. In the first one, there was also marked hydrocephalus. Retrospective examination of the patients revealed pinpoint-sized dimples in their suboccipital regions. Both patients were treated with antibiotics and underwent posterior fossa surgery. In the patient with marked hydrocephalus, ventriculoperitoneal shunting was performed after treatment of the infection. Both patients were neurologically normal, and there were no complaints, except a light learning difficulty in the patient with ventriculoperitoneal shunting, 133 and 34 months after surgery, respectively. Early detection of congenital dermal abnormalities along the craniospinal axis by routine examination of newborns is highly important before development of serious complications. Because surgery is the only effective treatment modality for these lesions, radical excision should be performed in all cases to avoid tumor recurrence. However, subtotal excision may be performed in selected cases, because the cyst capsule may adhere firmly to vital structures.

Polyostotic monosystemic calvarial and spinal langerhans' cell histiocytosis treated by surgery and chemotherapy.

There are several treatment modalities for Langerhans' cell histiocytosis (LCH) of bone, formerly usually referred to as eosinophilic granuloma, including surgery, radiotherapy and chemotherapy. In spinal lesions, surgery is not recommended generally, because of the potential for reconstitution of vertebral height. We report a case of multifocal monosystemic LCH treated by surgery and chemotherapy for calvarial and spinal lesions. A 7-year-old boy was initially operated for an occipital monostotic LCH of bone. Then, he was treated by surgery for cervical and thoracic lesions, and by chemotherapy with vinblastine. The patient had no complaints at the 24-month follow-up. Although surgery is not recommended for spinal lesions in children with LCH of bone, short segmental fusion and internal fixation may be a suitable choice for selected cases, especially in children who are not likely to comply with activity restrictions and in those who it is difficult to follow up. The treatment must be planned according to the characteristics of the patient.