Effects of Surgical Timing on the Prognosis of Far Lateral Disk Herniation.

AIM: To evaluate the effects of surgical timing on the prognosis in far lateral disk herniations. MATERIAL AND METHODS: We retrospectively evaluated 171 patients diagnosed with far lateral disk herniation who underwent surgery between 2015 and 2021. Patients were divided into three groups: Those operated within the first 3 weeks, within 3-6 weeks, and after 6 weeks. Patients with progressive neurologic deficits and severe pain refractory to the analgesic treatment underwent surgery. RESULTS: The mean age was 57±3 (28-85) years. The patients consisted of 96 females and 75 males. Sixty-eight patients underwent surgery at the L4-L5, 45 at the L3-L4, 37 at the L5-S1, and 21 at L2-3 levels. All patients had low back and radicular leg pain. Lasegue test was positive in 67% of patients. Femoral nerve stretch test was positive in 68%. Motor deficits, patellar reflex loss, and sensory deficits were present in 76%, 80%, and 91% respectively. When the postoperative recovery rates of patients who underwent surgery in all three time periods were compared according to visual analog scale, Oswestry disability index, and MacNab criteria, notably, statistically significant improvements in recovery were observed among patients who underwent surgery in the preoperative short time period when compared to those in the other time periods. CONCLUSION: We believe that early surgery is important to prevent the progression of pain from acute to chronic neuropathic pain to promptly eliminate factors that activate the process and to provide faster and clearer symptom treatment.

Surgical Treatment Results of Adult Tethered Spinal Cord Syndrome.

AIM: To present symptoms and surgical results of patients operated on with the diagnosis of tethered cord syndrome (TCS) in adulthood. MATERIAL AND METHODS: In this retrospective study, 20 patients older than 18 years were evaluated. There were 17 female and 3 male patients. Patient demographics, clinical and surgical results were evaluated. RESULTS: The mean age was 29.9 years and the mean follow-up period was 30 months. Of the 20 patients with low back and leg pain, 16 had relief. Two were partially benefited and 2 were unchanged. In nine patients, carrying heavy loads, excessive exercise, childbirth, and walking too long before the onset of symptoms were detected. Complaint of urinary incontinance was improved only in one patient. Three of them continued with frequent urination. There was no change in two of them. There was no improvement in sensory dysfunction and sphincter dysfunction. CONCLUSION: In patients diagnosed with TCS in adulthood, symptoms may begin with physical activity, and clinical recovery is better when early surgery is performed.

The Effects of Regulating Increased Blood Glucose Levels on Plasma Endothelin-1 Levels After Severe Head Trauma in Rats.

AIM: To examine the effects of regulating increased blood glucose levels on plasma ET-1 levels after severe head trauma in rats. MATERIAL AND METHODS: Traumatic diffuse brain injury-induced rats were followed for 7 days and were randomly divided into two groups of 36 rats. Pre- and posttraumatic blood glucose and ET-1 levels were measured in group 1 (control). Posttraumatic blood glucose levels were maintained at normal levels using insulin and both blood glucose and ET-1 levels were measured at 2, 6, 12, 24, and 48 h and 7 days posttrauma in group 2. The study excluded animals that died and had skull fractures. RESULTS: Posttraumatic plasma ET-1 levels (n=36) were significantly higher than baseline values in group 1 (p < 0.05). ET-1 levels in group 2 at the 7-day follow-up after trauma were significantly higher than baseline values (n=36) (p < 0.05). However, the increased ET-1 levels were statistically significantly lower in group 2 than in group 1 (p < 0.05). CONCLUSION: The increased ET-1 levels were significantly prevented by keeping blood glucose levels within normal limits with insulin after severe head trauma. Thus, secondary injury to cerebral blood flow can be prevented by reducing the occurrence of vasospasm that starts in the early posttraumatic period or by stimulating the release of nitric oxide. Therefore, further studies on the role of ET-1 and insulin in developing secondary injuries after severe head trauma would be beneficial.

Vertebral Artery Mobilization and Cervical Tumor Resection.

BACKGROUND: To emphasize the importance of vertebral artery (VA) mobilization by reviewing the anatomy and variations of the VA while performing total resection of VA-associated tumors that develop from different tissues. METHODS: VA mobilization and mass resection were performed after the evaluation and preoperative imaging of 22 patients with VA-related tumors. Anterior, posterior, or both approaches were conducted on the patients and stabilization was also applied to the patients in need. Radiotherapy and/or chemotherapy were planned for patients with malignant tumors as shown by histopathology. RESULTS: Overall, 17 patients with benign and 5 patients with malignant tumors underwent tumor resection with VA mobilizing. There were 13 male and 9 female patients with a mean age of 29.3 years. The average follow-up duration was 53 months. All the patients received gross total tumor resection and had a good postoperative neurological recovery. No complications were observed; local recurrence was observed only in 2 patients. CONCLUSIONS: VA mobilization reduces the need for instrumentation in VA-related cases, especially nerve tumors, and increases the possibility of the surgical resection of vertebral tumors.

Hemilaminectomy and Bilateral Decompression for Thoracic Spinal Stenosis.

AIM: To assess the effectiveness and reliability of hemilaminectomy and bilateral decompression (HLBD) for the treatment of thoracic spinal stenosis (TSS) in selected patients. MATERIAL AND METHODS: Clinical data of 21 consecutive adult patients who underwent HLBD were investigated. Patients diagnosed with TSS by computed tomography or magnetic resonance imaging, with stenosis secondary to posterior element hypertrophy, and who underwent HLBD for the treatment of narrow spinal canal were included in this study. Patients were evaluated based on their pre- and postoperative modified Japanese Orthopedic Association (JOA) scores using their medical records. Recovery rates were evaluated using the Hirabayashi?s method. RESULTS: The mean follow-up period, age, and preoperative JOA score were 37.6 months, 61.6 years, and 5.0 (range: 1?10), respectively. The mean JOA score improved postoperatively, i.e., 10.0 (range: 7?11), during follow-up. The recovery rate was 83.3%. Operation-related transfusion, neurological deterioration, and postoperative instability did not occur during the follow-up examination. CONCLUSION: HLBD is a suitable surgical technique for patients with stenosis primarily caused by posterior element hypertrophy, such as ligamentum flavum (LF) and facet joints because it has a relatively less complication ratio, protects the posterior anatomical structures, prevents post-laminectomy kyphosis and postoperative instability, and promotes successful clinical improvement.

Microsurgery versus Medical Treatment for Neuropathic Pain Caused by Foraminal Extraforaminal Lumbar Disc Herniation: An Observational Study.

AIM: To investigate the incidence of neuropathic pain (NP) in patients with foraminal/extraforaminal lumbar disc herniation (FEFLDH), the prognosis of NP and the effect of microsurgery on patients treatment. MATERIAL AND METHODS: Two patient groups with FEFLDH were investigated: the surgery group underwent surgical treatment, and the medical-treated group received medical treatment. Patients were diagnosed with NP when the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale was ≥ 12 points. The NP scores were evaluated during patient admission and at 1, 6 and 12 months postoperation or during medical treatment. RESULTS: The surgery group included 37 patients (18 women, 19 men); FEFLDHs were localised at the L3-4 (n=9), L4-5 (n=23) and L5-S1 (n=5) levels. NP was detected in 16 patients before surgery (43%). The medical-treated group included 46 patients (19 women, 27 men); FEFLDHs were localised at the L2-3 (n=7), L3-4 (n=12) and L4-5 (n=27) levels. NP was detected in 20 patients before medical treatment (43%). The most common neuropathic symptom for patients was a burning sensation. NP was found more common in patients who were of at advanced age ( > 65 years) (p=0.019), had a longer clinical duration (p=0.007) or had a foraminal disc herniation (p=0.038). CONCLUSION: Chronic compression of the dorsal root ganglion by FEFLDH is a significant cause of NP. If surgical treatment is delayed for FEFLDH, the risk of persistent NP may increase.

Percutaneous Kyphoplasty: Is Bilateral Approach Necessary?

STUDY DESIGN: A multicenter retrospective study of patients who underwent unilateral and bilateral balloon kyphoplasty. OBJECTIVE: The aim of this study was to compare the radiographic and clinical results of unilateral and bilateral balloon kyphoplasty to treat osteoporotic vertebral compression fractures. SUMMARY OF BACKGROUND DATA: Percutaneous kyphoplasty has long been used as a successful method in the treatment of osteoporotic vertebral compression fractures. Although the bilateral approach is considered to be the mainstay application of percutaneous kyphoplasty, the unilateral approach has also been shown to be sufficient and even more effective in some cases. METHODS: A total of 87 patients who underwent percutaneous kyphoplasty due to osteoporotic vertebral compression fractures between 2009 and 2016 were retrospectively evaluated and divided into two groups as patients who underwent unilateral or bilateral percutaneous kyphoplasty. Unilateral percutaneous kyphoplasty was performed in 36 and bilateral percutaneous kyphoplasty in 51 patients. The groups were compared in terms of clinical outcomes, radiological findings, and complications. Clinical outcomes were evaluated using Visual Analogue Scale and Oswestry Disability Index and the radiological findings were evaluated by comparing the preoperative and postoperative day 1 and year 1 values of anterior, middle, and posterior vertebral heights and kyphosis angle. RESULTS: Clinical improvement occurred in both groups but no significant difference was observed. In radiological workup, no significant difference was found between the groups in terms of improvements in vertebral heights and kyphosis angle. Operative time and the amount of cement used for the surgery were significantly lower in the patients that underwent unilateral kyphoplasty. CONCLUSION: Unilateral percutaneous kyphoplasty is as effective as bilateral percutaneous kyphoplasty both radiologically and clinically. Operative time and the amount of cement used for the surgery are significantly lower in unilateral kyphoplasty, which may play a role in decreasing complication rates. LEVEL OF EVIDENCE: 3.

En Bloc Cervical Laminoplasty While Preserving the Posterior Structure with Arcocristectomy in Cervical Spondylotic Myelopathy.

AIM: To evaluate the clinical success of the en bloc laminoplasty and impact of the arcocristectomy on postoperative axial pain of the patients with cervical spondylotic myelopathy (CSM). MATERIAL AND METHODS: A retrospective review of 81 patients with CSM who underwent en bloc cervical laminoplasty while preserving posterior structure of the cervical spine during the period from 2007 to 2014 was performed. Arcocristectomy was performed if the C6-7 level was included in the surgery. The posterior spinal elements and muscles attached to the spinous process of C2 and C7 were preserved. Thus, postoperative deformity of the cervical spine could be avoided. The neurological status of the patients was assessed using the modified Japanese Orthopedic Association (JOA) scale. The neurological recovery rate was calculated according to the Hirabayashi method. RESULTS: The mean modified JOA scale score was 11.4±2.4 preoperatively and 15.0±3.9 postoperatively. The neurological recovery rate was 68.6%. C7 arcocristectomy was performed in 19 patients. No axial pain was noted in the first 2 postoperative months. Keyhole foraminotomies were performed in 11 patients and radicular pain completely resolved after surgery. Temporary C5 nerve root palsy was observed in 3 patients. Mean cervical spine lordosis was 10.6o±10.5o preoperatively and 8.6o±9.5o postoperatively. No postoperative spinal instability or kyphotic deformity was noted. CONCLUSION: En bloc cervical laminoplasty while preserving posterior structure is useful in preventing postoperative spinal malalignment and axial pain. Arcocristectomy is an effective technique for the prevention of postoperative axial pain in patients with C6-7 spinal stenosis.

Short Segment Stabilization by Protecting the Alar Ligaments in a Case of Eosinophilic Granuloma Involving the C2 Spine.

BACKGROUND: The craniocervical junction is a complex anatomic location that contains the occipital bone, atlas, axis, and important complex ligamentous structures. The stability of this region is ensured only with the help of ligaments. CASE DESCRIPTION: A 6-year-old boy was admitted to our clinic for neck pain. Computed tomography and magnetic resonance imaging revealed a lytic bone lesion involving the C2 vertebral body and pedicle without odontoid tip. The tumor was resected using an anterior retropharyngeal approach and a wide marginal resection method. The odontoid tip and alar ligaments were protected, and the costal autografts were located between the C1-odontoid tip and the C3 body. The costal graft was stabilized in the C3 body with a miniplate. Then, C1-C3 posterior fixation with fusion was performed. The craniocervical junction was not considered unstable because the occipital bone was not involved in the fusion. Histologic examination confirmed the diagnosis of eosinophilic granuloma. Fusion was detected on a 1-year postoperative cervical computed tomography scan. CONCLUSIONS: The occiput should not be involved in the fusion area when the alar ligaments are preserved during surgery for a C2 lesion.

Surgical management of symptomatic T8 vertebral hemangioma: case report and review of the literature.

Vertebral hemangiomas are benign vascular lesions of the vertebral column; only 0.9-1.2% of all vertebral hemangiomas cause spinal cord compression. We report a 34-year-old female who was admitted to the neurosurgery clinic with a history of back pain, poor quality of life and easy fatigability for 1.5 years. Her medical history revealed a fall from a height of 2 meters 1.5 years ago. Neurology examination revealed bilateral hypoesthesia below the T8 level and hyperactive deep tendon reflexes in her left leg. Computed tomography scan of the thoracic spine showed T8 vertebral hemangioma, and magnetic resonance imaging showed a T8 hemangioma compressing the spinal cord. Surgical intervention was planned and T8 total laminectomy was performed. The tumor extending into the anterior spinal cord was resected, and T8 vertebroplasty with short segment posterior stabilization and fusion was performed. We aimed to present a new treatment approach for symptomatic vertebral hemangiomas and reviewed the relevant literature.

Microvascular decompression for primary trigeminal neuralgia : short-term follow-up results and prognostic factors.

OBJECTIVE: The aim of this prospective study was to demonstrate the influence of some factors on the prognosis of microvascular decompression in 37 patients with trigeminal neuralgia. METHODS: The results of microvascular decompression (MVD) in 37 patients with trigeminal neuralgia were evaluated at 6 months after surgery and were compared with clinical and operative findings. RESULTS: The sex of the patient, the patient's age at surgery, the side of the pain, and the duration of symptoms before surgery did not play any significant roles in prognosis. Also, the visual analogue scale (VAS) of the patient, the duration of each pain attack, and the frequency of pain over 24 hours did not play any significant roles in prognosis. In addition, intraoperative detection of the type of conflicting vessel, the degree of severity of conflict, and the location of the conflict around the circumference of the root did not play any roles in prognosis. The only factors affecting the prognosis in MVD surgery were intraoperative detection of the site of the conflict along the root and neuroradiological compression signs on preoperative magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA). CONCLUSION: These findings demonstrated that if neurovascular compression is seen on preoperative MRI/MRA and/or compression is found intraoperative at the root entry zone, then the patient will most likely benefit from MVD surgery.

Laminoplasty with miniplates for posterior approach in thoracic and lumbar intraspinal surgery.

OBJECTIVE: A prospective clinical follow-up study of patients who underwent thoracolumbar intraspinal surgery with replacement of the posterior spinal arch and supporting elements is reported. PATIENTS AND METHODS: The surgical procedures of 45 patients who underwent intraspinal surgery with osteotomy and replacement of 122 spinal laminae using an air drill and mini-plates with repair of the supraspinous ligaments were analyzed. Data of a complete clinical and radiological follow-up examination were evaluated in 45 patients. Plain radiographs and computed tomography scans were analyzed for bony healing of the laminae and spinal alignment. RESULTS: No complications due to the technique were observed. None of the patients had kyphosis and/or instability on static or dynamic plain x-ray films. There was no scar tissue invasion in the spinal canal based on MRI findings. CONCLUSIONS: No patient required additional surgery because of progressive spinal instability. This technique is safe and well-suited to serve as a standard posterior approach to intraspinal pathologies and offers distinct advantages over laminectomy and repeat surgery.

Doxycycline plus streptomycin versus ciprofloxacin plus rifampicin in spinal brucellosis [ISRCTN31053647].

BACKGROUND: The optimal treatment regimen and duration of the therapy is still controversial in spinal brucellosis. The aim of this study is to compare the efficacy, adverse drug reactions, complications and cost of ciprofloxacin plus rifampicin versus doxycycline plus streptomycin in the treatment of spinal brucellosis. METHODS: The patients diagnosed as spinal brucellosis between January 2002 to December 2004 were enrolled into the study. Patients were enrolled into the two antimicrobial therapy groups (doxycycline plus streptomycin vs. ciprofloxacin plus rifampicin) consecutively. For the cost analysis of the two regimens, only the cost of antibiotic therapy was analysed for each patient. RESULTS: During the study period, 31 patients with spinal brucellosis were enrolled into the two antimicrobial therapy groups. Fifteen patients were included in doxycycline plus streptomycin group and 16 patients were included in ciprofloxacin plus rifampicin group. Forty-two levels of spinal column were involved in 31 patients. The most common affected site was lumbar spine (n = 32, 76%) and involvement level was not different in two groups. Despite the disadvantages (older age, more prevalent operation and abscess formation before the therapy) of the patients in the ciprofloxacin plus rifampicin group, the duration of the therapy (median 12 weeks in both groups) and clinical response were not different from the doxycycline plus streptomycin. The cost of ciprofloxacin plus rifampicin therapy was 1.2 fold higher than the cost of doxycycline plus streptomycin therapy. CONCLUSION: Classical regimen (doxycycline plus streptomycin), with the appropriate duration (at least 12 weeks), is still the first line antibiotics and alternative therapies should be considered when adverse drug reactions were observed.