Effect of Previous Crosslinking on Intraoperative and Postoperative Outcomes and Complication Rates of Big-Bubble Deep Anterior Lamellar Keratoplasty for Keratoconus: A Comparative Study.

PURPOSE: To compare surgical outcomes and intraoperative and postoperative complications of big-bubble deep anterior lamellar keratoplasty (DALK) in patients with and without a history of previous corneal collagen crosslinking (CXL) for keratoconus. METHODS: Patients with keratoconus who underwent DALK surgery with big-bubble technique between January 2013 and January 2018 were retrospectively reviewed. Operative findings, intraoperative and postoperative complications, and visual and refractive outcomes were recorded. Patients were divided into 2 groups: with previous CXL (CXL-DALK group: 27 eyes) and without previous CXL (DALK group: 50 eyes). All parameters were compared between groups. RESULTS: Big bubble was successfully achieved in 24 eyes (88.9%) in the CXL-DALK group and in 45 eyes (90.0%) in the DALK group (P = 0.87). Type 1 bubble was obtained in 22 eyes (91.7%) in the CXL-DALK group and in 42 eyes (93.3%) in the DALK group (P = 0.79). Intraoperative microperforation occurred in 3 eyes (11.1%) in the CXL-DALK group and in 5 eyes (10.0%) in the DALK group (P = 1). Visual and refractive outcomes were similar between groups. The mean endothelial cell loss rates were 5.7% ± 2.3 at 1 year and 10.2 ± 3.1 at 2 years in the CXL-DALK group and 6.4% ± 4.7 at 1 year and 10.9% ± 5.4 at 2 years in the DALK group. Postoperatively, persistent epithelial defect was the most common complication in both groups, and postoperative complication rates were similar between groups. CONCLUSIONS: Our results have shown that previous CXL treatment does not influence the success of bubble formation and does not increase intraoperative or postoperative complication rates of DALK surgery for keratoconus. The improvement in visual acuity and refractive errors and endothelial cell loss rates were similar between CXL treated and untreated eyes after 2 years of follow-up.

Immunohistochemical Grading of Epidural Fibrosis with CD105 Antibody.

OBJECTIVE: Grading of epidural fibrosis (EF) is usually performed by histopathologic staining in experimental studies. Immunohistochemical methods for grading are not available in routine practice yet. In our study, the effect of tranexamic acid (TXA), a commonly used hemostatic agent in surgical interventions, was evaluated for use against the development of EF with classical histopathologic methods and immunohistochemistry using the CD105 antibody, a marker of angiogenesis. METHODS: Sixteen rats were used. The rats were assigned to 2 groups, control and TXA. Laminectomy was performed on the control group. In the treatment group, laminectomy + topical TXA was applied. After sacrificing the rats in the sixth week, histopathologic and immunohistochemical examinations and grading of the EF tissue were performed. RESULTS: Conventional histopathologic parameters of fibroblast count, intensity of fibrosis density, and inflammatory cell density, as well as immunohistochemical evaluation with CD105, showed that the grading of EF was comparable between groups I and II (P < 0.001). DISCUSSION: The results of our study have demonstrated that CD105 is compatible with the conventional histopathologic grading methods and can be used as a marker to determine the grades of angiogenesis and fibrosis in experimental studies. The results of our study have also shown that TXA, administered locally for hemostasis, reduces the grade of EF in rats following laminectomy. TXA has been observed to cause no toxic effects on neural tissue as it is already commonly used in clinical practice.

The assessment of autofluorescence of the crystalline lens in diabetic patients and healthy controls: can it be used as a screening test?

BACKGROUND: Our purpose was to demonstrate if measuring lens autofluorescence (AF) with a scanning confocal biomicroscope may be used to identify subjects with undiagnosed type II diabetes mellitus (DM), and hence, for it to be used as a marker for the severity of diabetic retinopathy in diabetic patients. PATIENTS AND METHODS: In this cross-sectional, comparative study, lens AF was measured with scanning confocal lens fluorescence biomicroscope in diabetic and healthy groups. Full ophthalmological examination was performed. Blood tests of fasting plasma glucose, and glycosylated hemoglobin were also analyzed. The correlation between lens AF results and blood tests was evaluated in both groups. The cutoff value for the diagnosis of DM using lens AF was investigated. RESULTS: The study included 191 subjects with a mean age of 52.09±6.75 years. One hundred and seven (56.0%) subjects were female, and 84 (44.0%) were male. Eighty-two (42.9%) patients had type II DM, and 109 (57.1%) subjects self-reported as normal. The fluorescence ratio (FR) values ranged from 0.09 to 0.46 (0.23±0.06) in the total group. Mean FR measurements of diabetic subjects were significantly higher (0.27±0.06) than those without DM (0.20±0.05), (p=0.001). A statistically significant correlation was found between glycosylated hemoglobin, fasting plasma glucose, and FR. The cutoff point for the FR according to the presence of DM was found to be 0.24 and above (p=0.001), with a sensitivity of 71.95% and a specificity of 80.73%. CONCLUSION: Measuring AF of human lens as an indirect evidence of increased advanced glycaton end products may helpful in detecting impaired glucose metabolism. Our results show highly significant correlation between possibility of DM and FR.

Epithelioid hemangioendothelioma of the craniocervical junction; case report and review.

Epithelioid hemangioendotheliomas are uncommon vascular neoplasms and their spinal location is even rarer. We report clinical course of a 31-year-old man with an epithelioid hemangioendothelioma at the cranio-cervical junction. A cervical magnetic resonance imaging revealed tumor that caused posterior cervical cord compression. C1,2,3 total laminectomy and surgical excision of the tumor was performed. Postoperative external beam radiation was performed on the surgical field especially around the right vertebral artery. At 2-year follow-up there was no neurological deficit and no tumor recurrence.

Anterior cervical fusion with interbody cage containing beta-tricalcium phosphate: Clinical and radiological results.

AIM: Beta tricalcium phosphate (beta-TCP) is an osteoconductive, resorbable material. Its clinical effectiveness has been proved in many indications. This study was clinical and radiographic study report obtained in patients undergoing anterior cervical discectomy and fusion ACDF in which PEEK cages were filled beta-TCP in an injectable form. MATERIAL AND METHODS: Between January 2010 and June 2011, 16 consecutive patients underwent ACDF using PEEK cages with beta-TCP. The cohort compromised 10 men and 6 women with a mean age of 45.2 years. The surgery was performed when the patient had myelopathy or radiculopathy with progressive neurological deficit, or failure of conservative treatment (a minimum of 3 months). The patients were evaluated by Odom criteria preoperatively and postoperative 3rd, 6th, 12th and 24th months. Preop and postop pain was evaluated with visual analogue scala (VAS). Disc height and fusion success rates were evaluated. RESULTS: Preoperative average VAS score was 7.9 (7-10) for neck pain and 8 (7-10) for arm pain. At the final follow-up, these scores became 1.5 and 1.4 for neck and arm pain, respectively. The average improvement rate was 81% for neck pain and 82.5% for arm pain. Postop ODOM's criteria main rate was 3.4. Bone fusion was achieved in 14 segments (70%) at 3rd month, 19 segments (95%) at 12th month follow-up assessment. CONCLUSION: Clinical and radiological results revealed that B-TCP is a good alternative synthetic fusion material for cervical interbody fusion. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Management of Tethered Cord Syndrome in Adults: Experience of 23 Cases.

AIM: Tethered cord syndrome (TCS) is rarely diagnosed in adults. It is a complex clinicopathological entity that remains poorly understood. In this study, clinical outcomes of 23 consecutive congenital TCSs diagnosed in adults have been evaluated to establish a standard approach to treat congenital TCS diagnosed in adults. MATERIAL AND METHODS: Medical records were retrospectively reviewed in 73 cases of TCS who were underwent surgery in our hospital, between 2005 and 2014. Cases which diagnosed and treated surgically in adults (patient age > 18 years) were included in this study. RESULTS: Twenty-three adult cases of TCSs were treated surgically and 15 of them were female and 8 were male. The mean age was 30.3±10.7 years. The mean follow-up period was 75.6±40.5 months. The most common complaint was low back pain. The most common findings in the neurological examinations were muscular weakness and urinary incontinence. The most common co-malformations were diastematomyelia and vertebral fusion anomalies. Conus medullaris was mostly terminated at the L5 level. Detethering procedure was carried out in 87% of patients and bony septum resection without detethering was applied in 13%. Laminoplasty was performed only in 39.1%. 60.9% of patients were recovered good. 34.8% of patients were improved. The most common complication was cerebrospinal fluid leakage. CONCLUSION: Despite the good results obtained in our surgical interventions for symptomatic TCS in adults, tethered cord releasing is complex procedure and has serious complications. Therefore, it is suggested to plan surgery according to symptoms emphasized with full neurological examination, craniospinal imaging and urodynamic tests.

Long-term Surgical Outcomes of Spinal Schwannomas: Retrospective Analysis of 49 Consecutive Cases.

AIM: Spinal schwannomas (SS) represent the most common intradural extramedullary lesions, accounting for approximately 24% of all nerve sheath tumors in adults. Schwannomas have infrequent, but existent possibility of malignancy. In this study, long-term outcomes of 49 consecutive SS have been presented. MATERIAL AND METHODS: Medical records were retrospectively reviewed in 371 cases of spinal tumors who underwent surgery between the years 2005 and 2014. Cases confirmed as schwannoma histopathologically were included in this study. Patients" complaints, localizations, recurrence rate and complications were evaluated. RESULTS: Forty-nine cases were detected in 47 (26 female, 21 male) patients. The mean age was 45.8±13.7 years. The mean follow-up period was 61.4±21.5 months. The most common complaint was local pain. Eleven were cervical, ten thoracic, twentyfour lumbar, and four in the sacral spine. Thirty-three cases were intradural-extramedullary, fifteen cases were the extradural type, and one case was the extra-intradural type. Recurrence rate was 4.08%. Gross-total resection (GTR) was achieved in forty-seven patients. The most common complications were surgical site infection and intraoperative instability that were seen in three patients each. Posterior instrumentation was performed in two patients. CONCLUSION: SS is mostly benign and intradural-extramedullary. To treat patients with SS, there is no need for adjuvant treatments; GTR with preservation of neurological functions is the best treatment to relieve patients" complaints and to reduce the recurrence rate of SS. To avoid serious complications, we recommend intraoperative neurophysiological monitoring and laminoplasty, especially in young patients. Dumbbell SS may require extensive bone resection. Posterior instrumentation can be used if instability occurs.

Non-traumatic myositis ossificans in the lumbar spine.

BACKGROUND: Myositis ossificans is a non-neoplastic benign reactive bone and cartilage matrix-producing pseudotumor that develops in skeletal muscles adjacent to the joint. The clinical and pathologic appearance of myositis ossificans varies depending on the time elapsed after heterotopic bone formation. Although its etiology is unclear, it usually occurs at the site of the injured muscle, most commonly in large muscles of the extremities, especially the quadriceps and brachialis. It rarely occurs in the paravertebral muscle of the lumbar spine. CASE REPORT: We present the rare case of a 31-year-old Turkish man with calcifying myositis ossificans not associated with trauma, referred to our hospital with severe low back pain with restriction of low back motions. Radiological investigation suggested a sclerotic osteoblastic on the left facet joint of L4-5. To confirm the diagnosis, the patient was managed surgically by total excision of the mass, which resulted in a good functional recovery. At his 12-month follow-up examination, he was neurologically intact and no recurrence was seen. CONCLUSIONS: Cases like this should be investigated well, so careful correlation of the clinical and radiologic findings with taking a biopsy is necessary to confirm diagnosis.

Cerebellar Mutism Syndrome After Posterior Fossa Surgery: A Report of Two Cases of Pilocytic Astrocytoma.

Cerebellar mutism is a type of syndrome including decreased speech, hypotonia, ataxia and emotional instability which occurs after posterior fossa surgery. It has been first reported by Rekate et al. and Yonemasu in 1985. It is well known that long tract signs and lower cranial nerve involvement are not seen with this syndrome and understanding is preserved. However, the pathophysiology of cerebellar mutism has not been well clarified yet. It is mainly seen in patients with medulloblastoma and brainstem involvement. In this report, we present two extraordinary cases of cerebellar mutism after posterior fossa surgery. They were considered extraordinary because their hystopathological analysis results yielded pilocytic astrocytoma which is out of the predefined risk factors.

Solitary osteochondroma arising from cervical spina bifida occulta.

Solitary osteochondromas are common benign long bone tumors originating from cartilage. They may produce a wide variety of symptoms and complications depending on their spinal location. These may include compressive myelopathy, nerve root compression, pathologic fracture and malignant degeneration, or in some cases only pain. Solitary cervical spine osteochondromas have been reported mostly in the neural arch or vertebral body. This report describes a patient presenting with neck pain, with a benign osteochondroma arising in the right bifid C5 lamina.

Penetrating keratoplasty versus deep anterior lamellar keratoplasty: comparison of optical and visual quality outcomes.

PURPOSE: To evaluate and compare visual and optical performance outcomes by means of analysis of the contrast sensitivity function (CSF) and ocular higher order aberrations (HOA) in patients with keratoconus who had deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK). METHODS: In this prospective, randomised case series, 174 eyes of 140 consecutive patients with moderate to advanced keratoconus were included. The big-bubble technique was attempted to perform DALK. Intraoperative and postoperative complications, uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), refraction, topographic astigmatism, CSF and ocular HOA were evaluated. RESULTS: The DALK and PK groups consisted of 99 and 75 eyes, respectively. Postoperative BSCVA was 20/40 or better in 64 eyes (85%) in the PK group and and 82 eyes (83%) in the DALK group (p>0.05). The mean spherical equivalent and maximum keratometry were -1.50 (-6.25 to +4.75) and 46.85 (40.60 to 56.00) in the PK group and -2.25 (-8.75 to +4.00) and 46.90 (40.60 to 53.60) in the DALK group, respectively. The differences were not statistically significant (p=0.08 and p=0.66, respectively). No significant differences in photopic contrast sensitivity were found for each of the spatial frequencies (p>0.05 for all). However, mesopic contrast sensitivity for three cycles/degree was significantly higher in the DALK group (p=0.01). No significant differences between groups were detected for any of the aberrometric parameters (p>0.05). CONCLUSIONS: DALK is an alternative treatment option in eyes with moderate to advanced keratoconus, providing comparable results to PK in terms of visual acuity, refraction, CSF and HOA.

The first Anatolian contribution to treatment of sciatica by Serefeddin Sabuncuoglu in the 15th century.

Serefeddin Sabuncuoglu was an early 15th century surgeon in Anatolia. His masterpiece entitled Cerrahiyetül Haniye (Imperial Surgery) is the first illustrated surgical textbook in the Turkish Islamic literature of the Ottoman era Anatolia. It is the first written medical-surgical work in Anatolian history and it covers the treatment of more than 40 illnesses, which range from hydrocephalus to sciatica. This study aims to investigate the contribution of Anatolia to neurosurgery through Sabuncuoglu's treatment of sciatica, a problematic and common illness.