Early Postoperative Iatrogenic Neuropraxia After Lumbar Disc Herniation Surgery: Analysis of 87 Cases.

BACKGROUND: Postoperative early neuropraxia after lumbar disc herniation surgery is common. The emergence of new paresthesia findings with increased sensory and motor deficits in the postoperative period suggests iatrogenic neuropraxia. This study aimed to discuss the causes and prognosis of iatrogenic neuropraxia detected in the early postoperative period in patients who have been operated on for lumbar disc herniation. METHODS: Cases with postoperative iatrogenic neuropraxia were determined retrospectively. Deficits were evaluated at intervals of 0-2 hours, 2-12 hours, 12-24 hours, and 24-48 hours. The cases were evaluated in 2 groups as those who underwent aggressive discectomy and simple discectomy. In addition, the treatment results were compared between the 2 groups as the cases that were treated and not treated with methylprednisolone. RESULTS: The iatrogenic neuropraxia rate was significantly higher in patients who underwent aggressive discectomy. Although it was observed that paresthesia findings improved more rapidly in cases treated with methylprednisolone, no difference was found between the 2 groups in terms of its effects on the motor deficit. CONCLUSIONS: Iatrogenic neuropraxia is a finding whose cause cannot be determined by quantitative criteria. It is common in patients who underwent aggressive discectomy. Methylprednisolone treatment is effective in recovering the paresthesia finding faster and may show that the radicular injury is in the neuropraxia stage in the early period.

The Lasegue test: Defining its specificity and sensitivity based on geometry.

The Lasegue test -also known as the straight leg raise test-, used for diagnostic purposes in cases of lumbar disc herniation can be explained by geometrical rules. This study aimed to describe the relationship between the apical and basal size of the herniated disc and the Lasegue test, and to describe the specificity and sensitivity of the herniated disc as a function of its height, location, and size. The study evaluated cases diagnosed with lumbar disc herniation with available MRI scans and Lasegue test results. The radix length to the foramen was calculated by recording the apical length and the base length of the herniated disc. The level and apical direction of the herniated discs were also recorded to determine the specificity and sensitivity of the test. Data from a total of 865 cases were analyzed. The apical length of the herniated disc was the most critical criterion for determining the Lasegue test. The Lasegue test is most sensitive and specific in lateral herniated discs at the level of L4-5. The specificity and sensitivity are decreased in L3-4, migrated, and sequestered disc herniations. In these cases, false-negative results may occur. Sensitivity decreases in the median and paramedian herniated discs. Compression of the sciatic nerve reduces herniated disc straightness. The Lasegue test is a test that can be defined according to the rules of geometry. Knowing the factors that decrease specificity and sensitivity and cause false positive/negative results will facilitate correct diagnosis.

Comparison of the histopathological differences between the spinal material and posterior longitudinal ligament in patients with lumbar disc herniation: A focus on the etiopathogenesis.

BACKGROUND: Lumbar disc herniation (LDH) occurs owing to the inability of the posterior longitudinal ligament (PLL) to preserve the disc material within the intervertebral space. There is apparently no study that has investigated the histopathological changes occurring in both PLL and disc material in patients with LDH. OBJECTIVE: Investigate and compare the histopathological changes occurring in PLL and disc material of the patients who underwent a surgical operation for LDH. DESIGN: Descriptive, cross-sectional. SETTING: Pathology and neurosurgery departments of a tertiary health care institution PATIENTS AND METHODS: The study included patients who underwent surgical operation for LDH from January 2018 to May 2019 and whose PLL and disc material were removed together, and had disc degeneration findings that were radiologically and histologically concordant. MAIN OUTCOME MEASURES: PLL degeneration scores according to the histopathological findings, changes in disc materials according to the MRI findings, disc degeneration scores according to the histo-pathological findings. SAMPLE SIZE: 50. RESULTS: MRI and histological examinations showed fully degenerated black discs (Grade 2) in 12 patients, partially degenerated discs (Grade 1) in 29 patients and fresh/acute discs (Grade 0) in 9 patients. The PLL showed grade 0 degeneration in 2 patients, grade 1 degeneration in 23 patients, and grade 2 degeneration in 25 patients. PLL degeneration grades were higher than the disc degeneration grades (P=.002). CONCLUSION: Longitudinal ligament degeneration can play a significant role in the pathogenesis of LDH. To the best of our knowledge, this study represents the first to focus on the histopathological changes occurring in both the PLL and disc material in patients with LDH. LIMITATIONS: Small sample, retrospective CONFLICT OF INTEREST: None.

Long Term Follow-Up Results of Spinal Concussion Cases: Definition of Late Injuries of the Spinal Cord.

OBJECTIVE: This study aims to evaluate the long-term clinical and radiologic findings of cases diagnosed with spinal concussion and to describe the spinal cord injuries that are detected in the later course. METHODS: Data obtained from 91 cases, who had been diagnosed with spinal concussion, were retrospectively evaluated. These were placed in 2 groups according to the type of trauma (axial forces or vertical forces). Magnetic resonance imaging scans taken >6 months after the trauma were inspected. RESULTS: Axial and vertical forces result in different types of spine injuries. The effect of vertical forces on the spinal cord can involve longer segments and the effect of axial forces remains limited to a few segments. Vertical forces usually result in the development of syringomyelias in the late period, whereas axial forces may cause cavitation and stretch injuries to the spinal cord. CONCLUSIONS: Although patients with spinal concussion manifest complete recovery in the early period after the trauma, findings related to the spinal cord may appear in the later course. The direction of the forces that the spinal cord is subjected to may result in different cord injuries in the late period.

Use of cyanoacrylate to prevent cerebrospinal fluid fistulas after cranial surgery.

PURPOSE: Cerebrospinal fluid (CSF) fistula is one of the most common complications encountered after cranial surgeries. In cases where CSF fistula frequently appears due to surgical technique, dural sealants are used as auxiliary preparations to prevent CSF fistula and provide convenience to the surgeon. MATERIALS AND METHODS: Data obtained from 128 number of cases where cyanoacrylate (CA) had been used for dural repair to prevent CSF fistula was evaluated, retrospectively. The cases of skull base and frontal sinus fractures where the primary repair had not been carried out were also included in the study. RESULTS: The mean follow-up of all cases was 9,7 months. CSF fistula was not encountered in 121 of 128 cases. 4 of the cases developed CSF fistula in the early period. 3 of the cases presented with CSF fistula in the late period after discharge. No side effects due to hypersensitivity or preparation were encountered. CONCLUSION: CA can help dural repair against the development of CSF fistula by taking effect quickly. Also, it is a rapid anti-haemorrhagic agent. It can also be used after posterior fossa surgery, skull base surgery where dural repair is difficult, or during sinus repair.

Lumbar Disc Herniations Causing Contralateral Radicular Symptoms: Can They Be Explained by Hypotenusal Theory?

OBJECTIVE: Cases presenting contralateral radicular symptoms are rarely encountered. It is difficult to decide on the correct side in cases where surgical intervention will be performed. The aim of the study is to explain the symptomatology in cases of lumbar disc herniations causing contralateral radicular symptoms by a hypotenusal effect. MATERIALS AND METHODS: In total, 27 cases were included in the study. Eight cases underwent surgical interventions performed on the side where disc herniation was radiologically detected. Nineteen cases were treated conservatively. Disc herniations were radiologically evaluated in 3 different groups, and the effect on the root on the symptomatic side was explained by a hypotenusal theory. Correlations among symptomatology, clinical findings, magnetic resonance imaging, and electromyography were discussed. RESULTS: Clinical improvement was observed in all cases that were operated on the side where disc herniation was detected radiologically. Neurologic examination findings in the postoperative period also revealed the correctness of the selected surgical approach. Electromyography is insufficient to explain clinical findings and to decide on the surgical side. CONCLUSION: Lumbar disc herniations, which lead to contralateral radicular symptoms, should be operated from the side where the disc is radiologically detected. The top of the disc is responsible for symptomatology. Surgical excision of the top of the disc removes the contralateral root traction and root compression on the same side.

Spinal Concussion in Adults: Transient Neuropraxia of Spinal Cord Exposed to Vertical Forces.

OBJECTIVE: The aim of the study is to discuss along with literature knowledge the post-traumatic clinical progression of cases with symptoms of transient spinal cord impact and cases of spinal concussion following exposure of the vertebral column to vertical forces. MATERIALS AND METHODS: A total of 43 cases, all falls from height, were diagnosed with spinal concussion. It was determined that the vertebral column had been exposed to the effects of vertical forces, and the spinal cord had been affected by vertical forces. In all cases, spinal magnetic resonance imaging and dynamic X-ray examinations were performed at the time of admission. Clinical symptoms of the cases were recorded by scoring based on the Torg Grading System. RESULTS: Cases were started on conservative treatment because radiologic symptoms that would explain the clinical symptoms could not be detected. Most frequently encountered were the neurologic symptoms related to the upper thoracic and lower cervical segments being affected. In 7 cases, urinary incontinence was also detected. Symptoms related to the spinal cord being affected were completely recovered in 1-3 days in all cases. CONCLUSION: As a result of the vertebral column being affected by vertical forces, the most frequently affected are the thoracic segments of the spinal cord. These cases show similarities to real spinal cord injury without radiographic abnormality cases when evaluated along with clinical and radiologic symptoms. Absolute differential diagnosis from real spinal cord injury without radiographic abnormality cases cannot be made until total neurologic recovery takes place.

Spinal Cord Injury without Radiological Abnormality in Adults: Clinical and Radiological Discordance.

BACKGROUND: Patients with spinal cord injury without radiological abnormality (SCIWORA) show varying clinical prognostic courses independent of radiological findings. The fact that patients cannot be evaluated using a specific terminologic standard has led to the emergence of the real SCIWORA definition. In this study, clinical progressions of 11 patients diagnosed with SCIWORA were analyzed, and terminologic differences were discussed. METHODS: The clinical findings of 11 adults with a diagnosis of SCIWORA at the time of diagnosis and in the long term were analyzed according to the ASIA classification scheme. The presence of a correlation between radiological findings from the early and late periods and the clinical findings was investigated. High-dose methylprednisolone treatment was administered to all newly diagnosed patients in the early period, and the clinical response was observed. Clinical, prognostic, and radiological comparisons with SCIWORA cases reported in the literature were conducted. RESULTS: Seven patients received a diagnosis of cervical SCIWORA, and 4 patients had thoracal SCIWORA. Neurologic findings at the time of diagnosis and in the early and late periods vary independent of radiological findings. In the cases where significant neurologic recovery was not observed within the first 3 days, significant recovery also was not seen in the later period. In the cases where neurologic recovery was seen, improvements in sphincter function and sensory and motor deficits were observed. CONCLUSIONS: In patients diagnosed with SCIWORA, early neurologic response is the determining factor for prognosis. Clinical findings and prognosis demonstrate no correlation with radiological findings.

Growth Potential of Subdural Hematomas Under Clinical Observation: Which Subdural Hematomas Tend to Grow and Why They Do.

OBJECTIVE: To study the prognoses of patients with subdural hematoma (SDH) who were not operated on at the time of the first diagnosis and the causes of enlarged hematomas in some patients during the follow-up period. MATERIALS AND METHODS: The records, service files, and radiologic examination results of the patients with diagnoses of SDH were reviewed. The SDH patients were recorded under 5 different categories: acute SDH (ASDH), subacute SDH (SSDH), chronic SDH (CSDH), acute component with chronic SDH (A-CSDH), and subacute component with chronic SDH (S-CSDH). The symptoms, clinical findings, and progression in the patients were correlated with radiologic examinations. RESULTS: A total of 291 patients received diagnoses of SDHs: 80 patients with acute, 29 patients with subacute, and 163 patients with chronic hematoma. Thirty-five patients had diagnoses of SDH with a combination of different components. It was determined that in the follow-up period, patients with A-CSDH showed the greatest increase in hematoma size over time and required surgical intervention the most often. CONCLUSION: SDHs reveal different prognoses in different age groups. Multicomponent SDHs are within the group that shows the greatest increase in size in the follow-up period. SDHs and CSDHs cause recurrent hemorrhages by sustaining the tension on the bridging veins. The greater the hematoma volume, the greater the growth potential of the hematoma tends to be. CSDHs that do not manifest changes in volume for a long time can be monitored without surgical intervention as long as the clinical picture remains stable.

Spinal intramedullary mature cystic teratoma in an adult.

Spinal intramedullary teratoma is a rare tumour characterised with slow progression course. Although symptoms are generally mild, long-term complaints can be observed due to the slow progression. In this report, we discuss a 29-year-old female diagnosed as mature cystic teratoma in thoracolumbar junction.

The effects of valproic acid and levetiracetam on chicken embryos.

For patients with epilepsy, anti-epileptic medication is generally the first line of treatment, but treating pregnant women with epilepsy can be a challenge. Standard anti-epileptic medications have caused developmental abnormalities, so much effort has been put into developing antiepileptic medications with minimal teratogenic effects. In this experimental study, the new-generation anti-epileptic medication levetiracetam and the standard anti-epileptic medication valproic acid were compared in terms of teratogenicity by studying embryonic development in 360 fertile White-Leghorn chicken eggs (conception day 0). We found that levetiracetam may cause severe developmental abnormalities, and is likely not safe for use in pregnant women. As expected, valproic acid caused more frequent developmental abnormalities than levetiracetam, and the risk increased still further when both drugs were administered in combination. Levetiracetam should be used cautiously in pregnant women with epilepsy.

Surgical morbidity of invasive monitoring in epilepsy surgery: an experience from a single institution.

AIM: This paper aimed to provide information related to surgical and neurological complications encountered following intracranial electrode placements in patients with medically intractable epilepsy. MATERIAL AND METHODS: Retrospective review of 70 patients with either subdural grid/strip or depth electrode implanted between 2004 and 2009 at the Epilepsy Unit in Cerrahpasa Medical Faculty. RESULTS: A total of 276 electrode implantations were performed in 70 patients. There were no deaths related to implantation. The occurrence of infection and intracranial hematoma were found to be 1.4 and 1.4%, respectively. A total of 1 patient (1.4%) showed transient neurological complications. The rate of overall morbidity including neurological complications was found to be 4.2% (n=3). CONCLUSION: Based on our experience, intracranial electrode implantation is an effective and safe method with extremely low morbidity rate, especially in experienced hands.

Dysembryoplastic neuroepithelial tumors and gangliogliomas: clinical results of 52 patients.

PURPOSE: Dysembryoplastic neuroepithelial tumors (DNET) and gangliogliomas (GG) are generally associated with epilepsy in young patients. Presurgical work-up and postsurgical results vary from center to center. Seizures are commonly focal with secondary generalization, and surgical treatment is often effective. METHODS: Twenty-eight patients with DNET and 24 patients with GG were eligible for this retrospective study. The authors present clinical, radiological, and pathological characteristics and seizure outcome of 52 patients histopathologically diagnosed with either a DNET or a GG. RESULTS: Characteristically the majority of the tumors showed hypointensity on T(1)-weighted images and increased signal intensity on both T(2)-weighted and FLAIR images. At the last follow-up (mean 54.3 months), overall favorable seizure outcome was 94.2% (n = 49). Twenty-six (92.8%) patients with DNET and 21 (87.5%) patients with GG were seizure free. Complete drug withdrawal was achieved in 26 (50%) patients. Shorter duration of epilepsy (p = 0.02), absence of status epilepticus (p = 0.01), absence of edema on MRI (p = 0.03), absence of seizure within the first month of surgery (p = 0.002), and total resection (p = 0.00001) were associated with favorable outcome with respect to seizure. CONCLUSIONS: Our results indicate that a prompt diagnosis and total resection with additional adjacent structures or cortices when feasible are associated with a high epilepsy cure rate. Not only children but also adults benefit from surgical treatment. Although radiological features of DNETs or GGs are helpful, no definitive differences were found between the two types of tumors. Thus, clinical, radiological, and histopathological findings have to be considered together.