Cerebral Alveolar Echinococcosis Concomitant with Liver and Lung Lesions in a Young Adult Patient: Case Report and Literature Review.

We present the case of a 25-year-old male harboring multiple brain lesions mimicking tumor metastasis that were revealed to be caused by Echinococcus multilocularis. Cerebral echinococcosis with multiple lesions is rare and might be confused with a brain abscess, tuberculoma, or metastatic tumor disease. Brain magnetic resonance imaging and serological studies are helpful in the differential diagnosis. In case of E. multilocularis, cerebral invasion is the late stage of the disease that necessitates an aggressive treatment protocol.

Dose dependent morphological effects of alpha lipoic acid on vasospastic femoral artery in rats.

AIM: The dose dependent effects of alpha lipoic acid (α-LA) were investigated morphologically on rat vasospasm model. MATERIAL AND METHODS: 32 rats were divided into four groups: group I=control; group II=vasospasm; group III=vasospasm +low dose (20 mg/kg) intraperitoneal α-LA administered; and group IV=vasospasm +high dose (100 mg/kg) intraperitoneal α-LA administered. Histological and morphometric examinations were carried out for each groups under light microscope. RESULTS: The mean vascular wall thickness displayed significant increase in group II and III compared with group I (p < .05). Statistical comparison of group II and IV, regarding vascular wall thickness showed a significant decrease in group IV, and regarding vascular lumen area showed a significant increase in group IV (p < .05). CONCLUSION: It is demonstrated α-LA reduces the effects of vasospasm in high dose treatment group by decreasing the wall thickness and increasing the lumen surface area. The present study suggests that adequate dose of α-LA is a potential therapeutic agent in experimental vasospasm model.

Cerebral contusion as a rare cause of foot drop: case report.

A 74-year-old woman, taking anticoagulant therapy for chronic heart failure, presented to our emergency room with left dorsiflexion weakness 8 hours from after multitrauma. A detailed neurological examination revealed only 0/5 strength in the left foot dorsiflexion without any upper motor neuron signs. While there was no spinal cord pathology detected, cranial computed tomography demonstrated a lesion in the right parasagittal localization consistent with hemorrhagic contusion. Clinical follow-ups showed an improvement in neurological findings with muscle power of 3/5 in day 5 and 5/5 in day 45 of admission. The parasagittal region has a foot localization in the homonculus and lesions in this area can rarely present with the foot drop sign. Thus, parasagittal region lesions should always be kept in mind in foot drop cases.

Intraosseous meningioma mimicking osteosarcoma in an adolescent: a case report.

Intaosseous meningiomas (IM) are the one of the less frequent benign tumors of the skull. The etiology of IM has not been cleared yet. The frontoparietal and orbital regions are the most common locations for IM. The average age for IM diagnosis is 50.5. A 16-year-old girl with a right frontoparietal mass was referred to our outpatient clinic. Cranial CT revealed a mass lesion which resulted in expansion in the right parietal and posterior frontal bone, having lytic and sclerotic regions inside with accompanying irregular cortex in inner and outer tables of the calvarium. Prediagnosis was osteosarcoma according to the imaging studies and after the performed biopsy and consecutive surgery, the lesion was diagnosed as IM. Though CT with bone windows is often useful, it is not always diagnostic. Biopsy plays an important role in calvarial vault lesions for planning the treatment. In our case, malignant criteria in radiology did not match the benign histology revealed. Radiological preoperative misdiagnosis of meningioma is possible.

Dose-dependent ultrastructural and morphometric alterations after erythropoietin treatment in rat femoral artery vasospasm model.

PURPOSE: Cerebral vasospasm is the common cause of poor outcome after aneurysmal subarachnoid hemorrhage (aSAH). Although many agents are experimentally and clinicaly used to protect or recover from vasospasm, an effective neurotherapeutic drug is still missing. Erythropoietin (EPO) is recently a promising candidate. The aim of this study is to investigate the dose-dependent effects of recombinant human EPO (rhEPO) on arterial wall in a rat femoral artery vasospasm model. METHODS: Thirty two animals were divided into four groups: vasospasm without any treatment (group A), vasospasm +250 IU/kg rhEPO group (group B), vasospasm +500 IU/kg rhEPO group (group C), and control group (group D). Rat femoral artery vasospasm model was used. For groups B and C, 7 days of 250 IU/kg and 500 IU/kg intraperitoneal rhEPO in 0.3 ml saline were administered respectively; and for groups A and D, 0.3 ml saline were administered intraperitoneally without any treatment. After 7 days, histological and morphometric analyses were carried out. RESULTS: Vasospasm alone group demonstrated the highest vessel wall thicknesses, comparing to other groups (p < 0.001). While for groups B and C, vessel wall thickness values were significantly higher than the control group (p < 0.001), between these two groups, there was no significant difference achieved (p > 0.05). CONCLUSION: In our study, there was no significant difference between the two rhEPO treatment groups, but rhEPO treatment was shown to be histologically and morphometrically effective in vasospasm. However, if dosage of EPO treatment is augmented, successful results may be achieved.

Replacement of vertebral lamina (laminoplasty) in surgery for lumbar isthmic spondylolisthesis. A prospective clinical study.

BACKGROUND: The use of lamina as a graft for fusion in isthmic lumbar spondylolisthesis (LIS) is not known. In the present prospective clinical study, we used the laminoplasty technique and reported on its outcomes. MATERIAL AND METHOD: Twenty cases that have been operated in our clinic due to G1 and G2 ISL between February 2003 and December 2006 were clinically and radiologically examined. The clinical assessment of the patients was carried out with the Prolo Economic and Functional scale. RESULTS: Both interbody fusion and laminoplasty procedures concerning 88 pedicles in total were performed on 20 cases of which 10 were at the L4-5 level, whereas 6 were at the L5-S1 level and 2 were at the L3-4-5 level. Five (25%) cases also had coexisting spinal stenosis. 19 (95%) patients had solid fusion but one (5%) had no solid fusion formation while having posterior fusion along with a clinical neurological examination result similar to the one obtained during the preoperative period. In conclusion, the anterior fusion rate was 95%. The most remarkable finding among the patients was the recovery observed at the 2nd month. The Prolo scale results of the cases were good and the follow-up time was 23.5 months. CONCLUSION: The laminoplasty technique is a method which presents advantages in isthmic spondylolisthesis cases such as short duration of operation, absence of graft donor site complications, preservation of the osteoligamentous structures of the posterior column and a high probability of achievement of fusion through only a posterior approach at a single session; therefore, we believe it is an alternative surgical technique.

Investigation of the dose-dependent antivasospasmic effect of Ginkgo biloba extract (EGb 761) in experimental subarachnoid hemorrhage.

Many drugs with possible effects against the vasospasm that occurs following a subarachnoid hemorrhage continue to be investigated with great enthusiasm. Among these drugs, the effect of Ginkgo biloba extract (EGb 761) on vasospasm has not been studied extensively. A model of vasospasm was constructed using 30 selected Sprague-Dawley rats. There were four groups in this study: Group I were the untreated control group; vasospasm was induced in Group II, but no treatment was administered; and Groups III and IV experienced vasospasm before being treated with 45 and 90 mg/kg per day EGb 761, respectively. In Group I, the luminal structures of the arteries were normal; the mean vessel lumen area, based on the number of microm(2) units counted in the lumen, was 4931 units. In Group II, signs of inflammation were observed, as well as marked luminal constriction and increase in the thickness of the vessel wall; the mean vessel lumen area was 235 units (p<0.001 vs Group I). In Group III, the endothelial lining was the same as in Group I; the mean luminal area was 4336 units. In Group IV, inflammation occurred as in Group II and the luminal radius was clearly narrowed; the mean luminal area was 131 units (p<0.001 vs Group I). When Ginkgo biloba extract was administered at a dose of 45 mg/kg per day in an experimental vasospasm model, it was effective against vasospasm. However, this effect disappeared at a dose of 90 mg/kg per day.

Prospective study of anterior cervical microforaminotomy for cervical radiculopathy.

Cervical radiculopathy caused by a posterolateral disc herniation or spondylosis is a common pathology. Decompression of a stressed cervical nerve root is a routine neurosurgical procedure. To determine the safety and effectiveness of anterior cervical microforaminotomy (ACM), we prospectively studied patients undergoing this treatment at our institution to determine the efficacy of the approach for the treatment of unilateral cervical spondylotic or discogenic radiculopathy. Twenty-five patients were treated with ACM and were followed up for 15-40 months. Clinical signs, neurological results, and complications were recorded. Radiological imaging studies for measurement of post-operative changes were performed to evaluate spinal stability and effectiveness of the ACM procedure. We used MRI, axial cervical CT and reconstructive sagittal cervical CT to assess foraminal decompression. Eight men and 17 women (mean age 51.8 years) were included in this study. Nineteen patients had a single ACM, and six underwent procedures at adjacent 19 levels. The ACM procedure involves microsurgical removal of the lateral portion of the uncinate process to identify the nerve root. Post-operatively, none of the patients' conditions had worsened symptomatically or neurologically. A positive outcome at last follow-up examination was achieved in all patients. The visual analoge scale pain rating was 6.36 pretreatment and 0.64 after 1 year (p<0.0001). ACM appears to be a good alternative procedure, and a good non-fusion disc-preserving technique. Disc and bone resections are minimal in carefully selected patients with unilateral cervical radiculopathy. This method avoids osteoarthrodesis or arthroplasty with disc prostheses.

Cerebellar mutism following posterior fossa tumor resection in children.

AIM: Cerebellar mutism is a documented complication of posterior fossa surgery in pediatric ages. Risk factors such as the type of tumor, size, and location of tumor, hyrdrocephalus, postoperative cerebellar swelling for cerebellar mutism were investigated in this study. MATERIAL AND METHODS: A consecutive series of 32 children with a cerebellar tumor were operated on at the Haseki Educational and Research Hospital, Department of Neurosurgery, between 1990 and 2005. Their speech and neuroradiological studies were systematically analysed both preoperatively and postoperatively RESULTS: Cerebellar mutism developed in ten children (32%) in the early postoperative period. The type of tumor, midline localization, and vermian incision were significant single independent risk factors. In addition, an interdependency of possible risk factors (tumor > 5 cm, medulloblastoma) was found. The latency for the development of mutism ranged from 0 to 90 days (mean 15.6 d). The speech returned to normal in eight patients. All cases were accompanied by cerebellar ataxia. CONCLUSION: Mutism after posterior fossa tumor resection is also associated with ataxia. Cerebellar mutism usually has a self-limiting course and a favorable prognosis.

Diagnosis and management of large occipitocervical cephaloceles: a 10-year experience.

BACKGROUND/AIMS: Cephaloceles are common malformations of the central nervous system. However, the great majority of clinical experiences in large occipitocervical cephaloceles have not been reported previously. The purpose of this report is to investigate the pathogenetic factors involved in the development of cranial dysraphism and to analyze the clinical and pathological factors that influence the outcome in patients. METHODS: Three hundred and twenty infants with craniospinal dysraphism and 12 with large occipitocervical cephaloceles were admitted to our institution in a 10-year interval between 1995 and 2005. Infants with cephaloceles, including newborns and 5 within the first year of life, were all operated by two authors in our institution, and they were analyzed retrospectively. RESULTS: The sex predilection was limited to occipitocervical cephaloceles, where 8 of the 12 cases were females. Hydrocephalus was present in 25% of the patients at the time of diagnosis. Clinical presentation was most often consistent with hydrocephalus, focal neurological findings being a less prominent feature. Associated congenital anomalies were present in 50% of the children. Contemporary neuroimaging techniques including computed tomography and magnetic resonance imaging facilitated the diagnosis. Patients were initially managed by posterior fossa or cervical region exploration, followed by sac excision. Three cases died in the early postoperative period, and the surgical mortality in this series was 25%. They were the ones with the largest encephaloceles and microcephaly. The mean follow-up time was 3.4 years. The overall mortality rate for the whole series was 33.3% (4/12). The size of the cephaloceles and the presence or absence of neural tissue in the sac largely determines the outcome for patients with occipitocervical cephaloceles. CONCLUSION: Infants with lesions greater than 50 mm in diameter, containing a significant amount of neural tissue, have an extremely poor prognosis, especially if associated with microcephaly.

Accuracy of pedicle and mass screw placement in the spine without using fluoroscopy: a prospective clinical study.

BACKGROUND CONTEXT: Spinal instrumentation is accompanied by various problems, including screw malpositioning. One way of preventing this is the employment of intraoperative biplanar fluoroscopy. However, screw malpositioning despite the use of fluoroscopy has been reported, and exposure to radiation is another burden of this method. Therefore, the purpose of this article was to compare the results of instrumentation applications without using scopy versus the harmful effects of radiation exposed during spinal instrumentation. PURPOSE: The aim of this article was to review the literature and this is the first prospective clinical study performed on this subject. STUDY DESIGN: Patient report. PATIENT SAMPLE: One hundred thirty-two patients with spinal instrumentations were included. OUTCOME MEASURES: Radiological investigation with computed tomography (CT) scans was performed 2 days after the procedure. METHODS: Craniosacral posterior spinal instrumentation was performed without using scopy at the Neurosurgery Clinic of Haseki Training and Research Hospital between January 2000 and January 2005. Postoperative CT analyses were performed to evaluate whether the 527 screws used during posterior instrumentation in a total of 132 patients were positioned correctly. In all cases, the screw applications were performed with regard to anatomic landmarks, whereas the distances were determined according to lesion localizations. Screw malpositioning and the functional effects and relations with interactions with neurovascular structures were examined. At the end of the operations, all patients were examined with direct lateral roentgenograms and CT scans for the evaluation of screw positions. RESULTS: According to their locations, 75 cervical screwing in 24 patients, 32 upper thoracic screwing in 7 patients, 30 midthoracic screwing in 7 patients, 306 thoracolumbar screwing in 54 patients, and 84 sacral screwing in 40 patients were performed by the senior spinal surgeon (KK). Among all posterior spinal instrumentation applications, the cervical region analyses revealed penetration of the medial wall of vertebral foramen with two (0.4%) screws, penetration of the lateral wall with one (0.2%) screw, and protrusion into the vertebral foramen without vascular penetration with one (0.2%) screw, whereas in the upper thoracic region there was penetration into the lateral pedicle wall with one (0.2%) screw and deviation toward the disc space through the superior end plate with two (0.4%) screws. In the midthoracic region, there was penetration into the disc space with two (0.4%) screws in only one case, whereas in the thoracolumbar complex, there was deviation toward the superior end plate with seven (1.4%) screws in four cases, deviation toward the disc space with two (0.4%) screws, medial wall penetration with six (1.2%) screws (two of which caused nerve root irritation in three cases), and penetration of the lateral wall of pedicle with four (0.8%) screws. In the sacral instrumentations, malpositioning occurred with only two (0.4%) screws because of deviation toward the medial wall. In summary, malpositioning occurred with 30 (5.6%) of the total 527 screws; none of the cases had neural or vascular damage. Two (1.5%) cases were revised for malpositioning and distance errors. The mean duration for preparation of screw introduction site and placement of the screw was 3 minutes. Infection occurred in only one (0.75%) case. CONCLUSIONS: Screw application without fluoroscopy is performed with calculation of all essential anatomic details, and because of the reduction of surgery time, the absence of exposure to radiation, and very low infection rates as a consequence of reduced surgery time, it is a method recommendable for surgeons experienced with screw placement. Besides, its malpositioning rates are within acceptable limits. Because screw malpositioning is also found after biplanar fluoroscopy, the prevention of screw malpositioning requires knowing the anatomic landmarks accurately.

Neuroprotective effects of acetyl-L-carnithine in experimental chronic compression neuropathy. A prospective, randomized and placebo-control trials.

OBJECTIVE: We designed this experimental study to examine the potential positive influences of the acetylated derivative of acetyl-L-carnithine, an endogenous substance present in the nervous system, on chronic compression neuropathy. This is the first study ever published on the medical treatment of experimental chronic compression neuropathy. MATERIALS AND METHODS: Five groups composed of 5 rats each were used in the study. Group 1: The control group, in which a 1 cm-long segment proximally from the bifurcation point of the right sciatic nerve of each rat was excised, accompanied by removal of the right soleus muscle. Group 2: The compression neuropathy model group, in which the right sciatic nerve of each rat was compressed for 30 days. Group 3: The right sciatic nerves were compressed for 30 days, followed by decompression and assessment on the 60th day. Group 4: The right sciatic nerves were compressed for 30 days, followed by decompression and acetyl-Lcarnithine administration between days 30 and 60. Group 5: The right sciatic nerves were compressed for 30 days, followed by acetyl-L-carnithine administration from day 30 to 60 without decompression. The study continued with the rats in the other 3 groups. Rats in the 3rd group were treated with decompression only and kept for another 1 month. Rats in the 4th group received acetyl-L-carnithine at a dose of 20 mg/kg/day intraperitoneally for 1 month after decompression, whereas rats in the 5th group received only intraperitoneal acetyl-L-carnithine at a dose of 20 mg/kg/day without decompression. Like the rats in groups 1 and 2, these rats were also sacrificed with ether overdose, with their right sciatic nerves and soleus muscles being excised for histopathological examination and weighing, respectively. CONCLUSION: In our study, it was found that decompression significantly improves the recovery rate of peripheral nerve as compared with that without decompression, and that acetyl-L-carnithine coadministered with decompression enhances clinical and histopathological recovery. In addition, the use of silicon tubes in such experiments was found to be likely to have prominent advantages.

Intracranial symptomatic giant arachnoid cyst of the interhemispheric fissure presenting with frontal lobe syndrome.

Symptomatic interhemispheric arachnoid cysts (ACs) are extremely rare lesions seen more frequently in the elderly. Only 13 cases of symptomatic interhemispheric ACs in the elderly have previously been reported. Herein, we describe a 70-year-old female with symptoms of vertigo, memory and behavior disturbances. Magnetic resonance imaging (MRI) revealed a giant arachnoid cyst (AC) on the interhemispheric fissure, which was exerting a mass effect and displacement on the corpus callosum and anterior cerebral vessels, with a massive midline shift. The patient was treated with a cysto-peritoneal shunt. Reports to date have reviewed the pathology, clinical presentation, radiology and surgical management of interhemispheric symptomatic arachnoid cysts in elderly patients.

A ligamentum flavum hematoma presenting as an L5 radiculopathy.

This study reports two patients with ligamentum flavum hematoma, of which only seven cases have been reported in the literature. Two elderly male patients (74 and 80 years) presented with a history of chronic lumbar strain and effort. They had low back pain radiating to both legs. Their neurologic examination findings were consistent with left L5 root compression. Magnetic resonance imaging showed an epidural mass lesion at L4-L5 that was continuous with the ligamentum flavum. After removal of the hematoma, the symptoms completely resolved. The most common cystic lesion in the lumbar spine is synovial cyst associated with the facet joints, but ligamentum flavum hematoma should be included in the differential diagnosis. The clinical, radiological and surgical features are described. Surgery should be the treatment of choice to resolve symptoms in ligamentum flavum hematoma.

Spinal hydatidosis accompanied by a secondary infection. Case report.

Spinal hydatid disease is rarely encountered in nonendemic regions. It is a progressive disease that is associated with risks of serious morbidity. The authors report a case of an isolated primary hydatid cyst of the spine in a 34-year-old woman who presented with back pain, which had lasted for 3 months, as well as lower-extremity pain and fatigue, which had persisted for 2 months. A neurological examination yielded findings indicative of upper motor neuron involvement with complete sensory loss below the level of T-11. Magnetic resonance imaging of the spine showed multiple extradural cystic lesions with an abscess formation at T-11 and involvement of the paraspinal muscles. The patient underwent spinal decompression in which stabilization and total excision of the multiple epidural and psoas abscesses and paraspinal multiloculated cysts were performed. The diagnosis of hydatid disease associated with another infection was confirmed by histopathological evaluation. Albendazole was administered during the postoperative period. Previous reports of secondary infections accompanying this disease in extraspinal locations have been published. However, to the best of the authors' knowledge, there have been no publications about a secondary infection associated with hydatidosis in the spinal cord. One should bear in mind that spinal hydatidosis may be accompanied by other infections in endemic regions. Antihelminthic treatment should be administered for a long period following early decompressive surgery and adequate stabilization.

A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: a prospective study.

BACKGROUND: Among all lumbar disc herniations, L5-S1 far-lateral disc herniations are rare entities. Besides, surgical approach may be difficult because of the very narrow passage at this level. For these 2 reasons, most spine surgeons are not experienced in herniations at this level. According to new microanatomic studies, previous lateral approaches at this level often do not allow access to the neuroforamen without partial or total destruction of the L5-S1 facet joint. To preserve the facet joint, an approach was developed. PURPOSE: To assess the efficacy of a surgical technique that is a minimally invasive intermuscular approach (MIIMA) for decompression of L5-S1 far-lateral level disc herniation (FLLDH). STUDY DESIGN: We present a prospective clinical study analysis of 14 patients with L5-S1 far-lateral disc herniations in a period between 2000 and 2004, treated with microsurgical technique. METHODS: An imaging study revealed consistency with the patient's clinical presentation. In our department, a total of 580 patients underwent discectomy between 2000 and 2004 for lumbar disc herniation. RESULT: Twenty-eight patients had foraminal or extraforaminal herniations (4.8%). Fourteen patients had FLLDH at the L4-L5 level (2.4%), whereas the other 14 were cases of FLLDH at the L5-S1 level (2.4%). One patient had FLLDH at both L5-S1 and L4-L5 levels (7.1%). The mean age of patients was 53.6 years, and the male:female ratio was approximately 5:9. All patients failed to recover after at least 6 weeks of conservative therapy. The mean duration of symptoms until the time of surgery was 7.2 months. Using this MIIMA technique, the authors removed the herniated discs compressing the (L5) nerve roots. Clinical outcome was measured using the visual analog scale. Every patient was discharged within 24 hours. Satisfactory (excellent or good) results were demonstrated in 13 patients (92.9%), because, except for 1 (7.1) permanent dysesthesia case, 4 cases (21.3%) were temporary dysesthesia. Postoperatively all patients reported excellent relief of their sciatic pains, and there were no technique-associated complications. No recurrence was observed during the follow-up period ranging from 10 to 60 months (mean, 29 mo). This is one of the major complications of any approach to a far-lateral disc. CONCLUSIONS: The authors describe a MIIMA for excising herniated discs that is applicable to all types of far-lateral lumbar herniations. Postoperative dysesthesia is the most important complication and may persist as it did in our cases. Consequently, manipulation of the ganglion should be avoided at all costs, if possible. The MIIMA procedure provides a simple alternative for treating lumbar foraminal or lateral exit zone herniated discs in selected cases. This approach is effective, allowing the preservation of the L5-S1 facet joint, saving the facet joint, preventing postoperative instability, and offering a direct view of the L5-S1 neuroforamen.

Management of cervicomedullary compression in patients with congenital and acquired osseous-ligamentous pathologies.

We present our experience in the diagnosis, surgical management and long-term follow-up of congenital and acquired osseous-ligamentous abnormalities or pathologies of the craniovertebral junction. The purpose of this study was: (i) to determine the incidence and degree of cervicomedullary compression in pediatric and young adult patients with congenital and acquired abnormalities, and (ii) to correlate cervicomedullary compression with other imaging and clinical factors to determine to what extend cervicomedullary compression is successfully treated with a posterior decompressive procedure, transoral decompression, and medical management. Between January 1995 and December 2004, 26 cases were managed in our department. These patients had: rheumatoid arthritis (RA) (3); traumatic injury (2); congenital basilar impression (5, in 2 cases a posteriorly oriented or retroflexed odontoid); infection (10); craniovertebral junction Pott's disease (9); os odonteideum (3); condylus tertius (1); and tumor (2). Six of the patients (23.1%) had syringomyelia. Only three (11.3%) were in the pediatric age group. Symptoms and signs included headache (72%), ataxia (38%), lower cranial nerve dysfunction (54%), quadriparesis (44%), hyperreflexia (76%), Hoffman positivity (72%), achilles clonus (72%) nystagmus (33%) and dysphagia (22%). The mean follow-up time was 44 months (range 3-85). Twelve (46.2%) had undergone posterior fossa decompression; seven (26.6%) had ventral decompression. Seven of the patients (26.6%) had medical management. The major morbidity included pharyngeal wound sepsis leading to dehiscence (3.8%), valopharyngeal insufficiency (3.8%), cerebrospinal fluid leakage (3.8%), postoperative macroglossia (3.8%) and inadequate anterior decompression (3.8%). Transient neurological deterioration occurred in two patients (7.6%). Our management paradigm will result in some neurologic improvements and limit the progression of symptoms. Patients with these pathologies are likely to show a good neurologic outcome when treatment, whether with or without surgery, is administered early in the course of the disease.

Serum creatine phosphokinase activity and histological changes in the multifidus muscle: a prospective randomized controlled comparative study of discectomy with or without retraction.

OBJECT: The aim of this study was to determine the extent of muscle injury caused by continuous or intermittent muscle retraction during macro- and microdiscectomy in lumbar disc surgery. Pain scores, serum creatine phosphokinase (CPK) levels, and histological findings obtained in muscle specimens were compared. METHODS: Sixty patients who underwent surgery for a one-level disc herniation during a 1-year period (January 2004-January 2005) and who had similar demographic characteristics were randomly assigned to one of four groups, each consisting of 15 patients: Group A, microdiscectomy in which the retractor was never released; Group B, microdiscectomy in which the retractor was released every 15 minutes; Group C, macrodiscectomy in which the retractor was never released; and Group D, macrodiscectomy in which the retractor was released every 15 minutes. Muscle biopsy samples were acquired in each group, and biochemical studies were conducted to determine serum CPK levels. The duration of muscle retraction was 15 minutes followed by 3 minutes of relaxation in Groups B and D. In all groups, muscle degeneration and elevation in serum CPK levels were observed immediately after surgery. The overall results, however, were different. The decline of serum CPK levels started 1 week after surgery. The smallest degree of muscle injury (reflected by the lowest serum CPK level) was observed in Group B. When the pre- and postoperative CPK values were compared in all groups, the patients in Groups B and D reported the least amount of back pain (p < 0.001). No significant differences in serum CPK levels were observed between Groups A and C or between Groups B and D. The extent of back pain was evaluated using a visual analog scale, and the consumption of analgesics was also assessed. The groups exhibited significantly different responses: the lowest analgesic consumption and the lowest pain scores were demonstrated in Groups B and D. CONCLUSIONS: In this prospective randomized clinical trial, the authors determined that muscle injury during lumbar disc surgery was closely related to muscle retraction and relaxation times whereas the size of the paravertebral skin incision had no effect on postoperative back pain and disability. There was no significant difference among the groups in terms of back pain during the long-term follow-up period (18-19 months).

Spinal metastasis of occult lung carcinoma causing cauda equina syndrome.

Cauda equina syndrome (CES) may be caused by tumor, herniated disc, trauma and spinal infections. However, CES due to occult lung cancer has not been reported in the literature. A 50-year-old man presented with a subacute CES caused by an intradural metastasis of an adenocarcinoma of the lung to the lumbosacral cauda fibers. His lumbosacral magnetic resonance imaging (MRI), showed a well-demarcated, intradural extramedullary mass lesion resembling a neurinoma at the L4/5 level. The patient underwent an L4-L5 laminectomy. The operative findings were also suggestive of neurinoma with involvement of three nerve roots, and a well-demarcated tumor without infiltration into the subarachnoid space. Although the findings of the operation were suggestive of neurinoma, final pathological diagnosis revealed metastatic carcinoma. Immunohistochemistry revealed clear cell adenocarcinoma metastasis. Chest X-ray and high resolution contrasted pulmonary computed tomography were normal. Positron emission tomography (PET) showed a lung mass, at the left apex. The patient was treated with chemotherapy and post-operative spinal radiotherapy was also performed. The CES resolved after the operation and the patient was followed up for 2 years with no recurrence. MRI of intradural cauda equina metastasis may be similar to that of intradural nerve sheath tumor. Surgery and postoperative radiotherapy may be effective for the treatment of CES due to lung carcinoma. Definitive diagnosis is by histopathological examination with immunohistochemistry. If the primary cancer cannot be detected by conventional radiological techniques, PET may be helpful.

Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study.

OBJECT: The aim of this study was to evaluate conservative medical management of 44 patients with Pott disease. The prognostic significance of various clinical, radiological, and long-term follow-up findings in these patients was also evaluated. METHODS: Between January 1990 and January 2005 data were collected prospectively at the authors' clinic in 44 patients with Pott disease in the thoracic or lumbar spine. These patients had no major neurological deficits or severe spinal deformities. The study population consisted of 21 male (48%) and 23 female (52%) patients, with a mean age of 42.1 years (range 10-70 years). The most common region of Pott disease was the thoracolumbar junction (18 cases; 41%), followed by the thoracic (16 cases; 36%) and lumbar (10 cases; 23%) regions. All patients presented with abscesses. With the exception of two cases, all had kyphotic angles smaller than 30 degrees. At presentation, 20 patients had neurological signs of spinal cord compression during clinical examination. Both clinical and biopsy findings were used in all cases for diagnosis. A diagnosis was confirmed by a positive biopsy specimen culture in 19 (43.2%) of 44 cases, and histopathological findings were compatible with the results of these cultures in all cases. All patients were treated with antituberculous chemotherapy, and the diseases in only two (4.5%) was resistant to the regimen. An independent observer assessed the clinical and imaging findings after a mean follow-up duration of 40 months. Forty-two (95.4%) of the 44 patients were successfully treated with conservative medical management and attained acceptable spinal deformity angles, and none of these patients had any residual instability, radiculopathy, or neurological compromise. Only 4.5% of the patients experienced residual spine deformity (as much as a 30 degrees kyphotic angle), which was clinically obvious but biomechanically stable. CONCLUSIONS: Patients with Pott disease in the lumbar or thoracic region, without neurological deficits or kyphosis, can be treated conservatively in the vast majority of cases. Indications for surgery need to be redefined given these new data.