Lumbar disc herniation in a patient with congenital vertebral body anomaly: a case report.

Lumbar disc herniation is characterized with low back and leg pain resulting from the degenerated lumbar disc compressing the spinal nerve root. The etiology of degenerative spine is related to age, smoking, microtrauma, obesity, disorders of familial collagen structure, occupational and sports-related physical activity. However, disc herniations induced by congenital lumbar vertebral anomalies are rarely seen. Vertebral fusion defect is one of the causes of congenital anomalies. The pathogenesis of embryological corpus vertebral fusion anomaly is not fully known. In this paper, a 30-year-old patient who had the complaints of low back and right leg pain after falling from a height is presented. She had right L5-S1 disc herniation that had developed on the basis of S1 vertebra corpus fusion anomaly in Lumbar computed tomography. This case has been discussed in the light of literature based on evaluations of Lumbar Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). This case is unique in that it is the first case with development of lumbar disc herniation associated with S1 vertebral corpus fusion anomaly. Congenital malformations with unusual clinical presentation after trauma should be evaluated through advanced radiological imaging techniques.

Concomitant tubercular and fungal cerebellar abscess in an immunocompromised girl.

Concomitant tubercular and fungal cerebellar abscess is rare and we report the first concomitant recurrent multi-lobulated tubercular and fungal cerebellar abscess in an immunocompromised girl with Histiocytosis-X. She presented with cerebellar abscess history diagnosed during the ongoing treatment for tuberculous meningitis. The abscess was drained. Upon the detection of cerebellar abscess recurrence and pulmonary infection, she was referred to our clinic five weeks after the first surgical intervention. Patient was conscious, co-operating but confused. She had severe cachexia, stiff neck and fever. Fundus examination showed bilateral papilledema. Cranial MR images revealed multiple lobulated lesions. Suboccipital craniectomy was performed and abscess was evacuated in toto. Lesion was multi-lobulated. Thick, yellow-gray purulent material was drained. Histopathological examinations yielded Langhans giant cells,budding and branching fungal structures. Fungal infection was identified. We emphasize that posterior decompression and total resection should be considered first in the management of lesions with mass effect in the posterior fossa. Also the presence of concomitant fatal fungal abscess highlights that although the clinic and former diagnoses of the patient may direct the clinician to a certain pathogen, unusual resistant organisms should not be.

Surgical results of degenerative spondylolisthesis patients over 70 years old: a single-center experience and clinical outcomes.

AIM: The aim of this study is to evaluate results of surgery in Degenerative Spondylolisthesis (DS) patients over 70 years old. MATERIAL AND METHODS: This is a non-randomized retrospective analysis of the clinical outcome of 34 patients older than 70 years who underwent surgery. At the end of two-year follow-up period, preoperative and postoperative courses were assessed by Oswestry Disability Index (ODI) and Visual Analog Scales (VAS). RESULTS: The mean age was 75 years (range 70-86 years). The mean duration of symptoms was 13.5 years (range 2-30 years). All patients underwent physiotherapy and also 15 (11 female, 4 male) patients used brace. L4-L5 was the most commonly affected level (n=26), Preoperative ODI and VAS scores were mean 71,63 (range 34-100) and 6,77 (range 2-9) (p < 0,05). Postoperative ODI and VAS scores were mean 22,73 (range 0-100) and 2,13 (range 0-10) (p < 0,05). Patients were asked if they had known the outcome, would they accept surgical treatment or not. 86.6% (n=26) of the patients answered the question positively. CONCLUSION: A conventional decompressive laminectomy with foraminotomy and posterolateral fusion in situ with transpedicular instrumentation is necessary and reduces pain and recovers functional disability in elderly patients over 70 years old with DS.

Chronic subdural hematoma after endoscopic third ventriculostomy: a case report and literature review.

Chronic subdural hematoma is a very rarely observed complication after endoscopic third ventriculostomy (ETV). A 21-year-old male patient was admitted to our clinic with complaining of headache, weakness and tremor. The fundoscopic examination revealed slightly indistinct border of the papilla and neurological examination findings were normal. The cranial computed tomographic (CT) and magnetic resonance imaging (MRI) findings demonstrated three-ventricular hydrocephalus due to aqueductal stenosis and ETV was performed. The symptoms got better after the operation. At 1½ month postoperatively the patient reapplied to our clinic with a symptom of severe headache. Cranial BT imaging demonstrated enlargement of subdural hematoma. The hematoma was treated by burr-hole evacuation and drainage and totally disappeared in the postoperative period. The follow-up CT scan was evaluated as normal. Nowadays, ETV is accepted as a safe and an alternative method for the treatment of obstructive hydrocephalus instead of shunt operation. Chronic subdural hematoma is a rarely observed complication after ETV.

Existence of two separate facet joints on the same side: case of a congenital anomaly.

We present a case that had two separate facet joints on the same side causing an intervertebral instability. The embryological pathogenesis of the congenital existence of two separate facet joints on the same side of the vertebra is not conclusively known. A 68-year-old woman presented with lower back pain and severe left leg pain. Neuroradiological evaluation including dynamic plain radiography, computed tomography, and magnetic resonance imaging of the lumbar spine revealed the existence of two separate facet joints on the same side of the first sacral vertebra, severe degenerative changes of both right and left L5-S1 facet joints, and Grade II L5-S1 spondylolisthesis. Subsequently, she underwent surgery. Intraoperatively, two separate facet joints on the same side of the first sacral vertebra were confirmed. The patient's symptoms were resolved after decompression and fusion surgery. This is a unique case of the congenital existence of two separate facet joints on the same side of the first sacral vertebra.

Anterior tarsal tunnel syndrome secondary to missed talus fracture: a case report.

The anterior tarsal tunnel syndrome (ATTS) has first been described by Kopell and Thompson in 1963. The anterior tarsal tunnel is formed by the fascia lining the inferior extensor retinaculum and talus as well as the navicular bone. Many ATTS cases with various etiologies have been reported since the first description. We report here an ATSS case resulting from a fibro-osseous structure that occurred after a missed talus fracture. The ATTS diagnosis can be made with a comprehensive clinical neurological examination and electrophysiological study. The treatment is based on the underlying etiology, while surgery is the most common treatment providing successful outcomes in the long term.

Combined hyperbaric oxygen and hypothermia treatment on oxidative stress parameters after spinal cord injury: an experimental study.

BACKGROUND AND AIMS: We undertook this study to investigate the possible beneficial effects of combined hypothermia and hyperbaric oxygen (HBO) treatment in comparison with methylprednisolone in experimental spinal cord injury (SCI). METHODS: Forty eight male Wistar albino rats (200-250 g) were randomized into six groups; A (normothermic control group; only laminectomy), B (normothermic trauma group; laminectomy + spinal trauma), C (normothermic methylprednisolone group; laminectomy + spinal trauma + methylprednisolone treated), D (hypothermia group; laminectomy + spinal trauma + hypothermia treated); E (HBO group; laminectomy + spinal trauma + HBO therapy), F (hypothermia and HBO group; laminectomy + spinal trauma + hypothermia and HBO treated) each containing eight rats. Neurological assessments were performed 24 h after trauma and spinal cord tissue samples had been harvested for both biochemical and histopathological evaluation. RESULTS: After SCI, tissue malondialdehyde (MDA) level of the control group was measured increased, and superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) enzyme activities were measured decreased. In group F, it was also shown that MDA level elevation had been prevented, and group F has increased the antioxidant enzyme activities than the other experimental groups C, D, E (p <0.05). CONCLUSIONS: We concluded that the use of combined hypothermia and HBO treatment might have potential benefits in spinal cord tissue on secondary damage.

Curcumin improves early functional results after experimental spinal cord injury.

BACKGROUND: Curcumin is a polyphenol extracted from the rhizome of Curcuma longa and well known as a multifunctional drug with anti-oxidative, anticancerous, and anti-inflammatory activities. The aim of the study was to evaluate and compare the effects of the use of the curcumin and the methylprednisolone sodium succinate (MPSS) functionally, biochemically, and pathologically after experimental spinal cord injury (SCI). METHOD: Forty rats were randomly allocated into five groups. Group 1 was performed only laminectomy. Group 2 was introduced 70-g closing force aneurysm clip injury. Group 3 was given 30 mg/kg MPSS intraperitoneally immediately after the trauma. Group 4 was given 200 mg/kg of curcumin immediately after the trauma. Group 5 was the vehicle, and immediately after trauma, 1 mL of rice bran oil was injected. The animals were examined by inclined plane score and Basso-Beattie-Bresnahan scale 24 h after the trauma. At the end of the experiment, spinal cord tissue samples were harvested to analyze tissue concentrations of malondialdehyde (MDA) levels, glutathione peroxidase (GSH-Px), superoxide dismutase (SOD) activity, and catalase (CAT) activity and pathological evaluation. FINDINGS: Curcumin treatment improved neurologic outcome, which was supported by decreased level of tissue MDA and increased levels of tissue GSH-Px, SOD, and CAT activity. Light microscopy results also showed preservation of tissue structure in the treatment group. CONCLUSIONS: This study showed the neuroprotective effects of curcumin on experimental SCI model. By increasing tissue levels of GSH-Px, SOD, and CAT, curcumin seems to reduce the effects of injury to the spinal cord, which may be beneficial for neuronal survival.

Balloon compression technique in the management of persistent intraoperative intratumoral hemorrhage resulting from stereotactic biopsy: technical note.

BACKGROUND: Despite its proven safety, intraoperative intratumoral hemorrhage is an uncommon but serious complication of stereotactic brain biopsy. OBJECTIVE: We describe the "balloon compression technique" that was used in the management of persistent intraoperative bleeding that could not be arrested by conventional methods of hemostasis. METHODS: Between January 2001 and March 2009, of 184 image-guided stereotactic brain biopsy procedures, intraoperative intratumoral bleeding occurred in 12 cases (6.5%). In 3 of these 12 cases (1.6%), intraoperative hemorrhage was persistent. In these cases, after adjustment of the optimum length, a balloon catheter (Fogarty) was inserted through the cannula and inflated with a contrast agent. We observed the patient for 10 minutes by checking the position of the balloon with regular intervals, using a frozen C-arm fluoroscope to determine any significant changes in its initial position due to possible enlargement of the hematoma. The patient was also closely observed during this time. RESULTS: Hemostasis was obtained immediately after the inflation of the balloon in all 3 cases. The patients tolerated the procedure well. During and after the procedure no complications related to the technique were observed. None of the cases required craniotomy for evacuation of the hematoma and to secure hemostasis. CONCLUSION: Our preliminary results indicate that the balloon compression technique seems to be a safe, rapid, and effective stereotactic practice in the management of the persistent intraoperative intratumoral bleeding that could not be arrested by standard, conventional hemostatic methods.

The effects of meloxicam on neural tube development in the early stage of chick embryos.

AIM: The aim of this study is to demonstrate the effect of meloxicam in early stage chick embryos on neural tube development. MATERIAL AND METHODS: One hundred specific pathogen-free (SPF) chicken eggs were used to investigate the neurulation. SPF eggs were invastigated in four groups (n:25). All of the groups were incubated at 37.2 +/- 0.1 degrees C and 60 +/- 5 % relative humidity for 30 hours, and an embryological development in the ninth stage as classified by Hamburger and Hamilton was obtained. In the end of the 30th hour, group A(control group) was administered 0.1 ml of saline (0.9% NaCl) in ovo and the other groups were administered meloxicam in increasing doses. At the end of 72 hours, all of the embryos were extracted from eggs and they underwent pathological examination with hematoxylin eosine and immunohistopathological examinations with CD138 and tubulin beta II. RESULTS: While the groups Aand B showed no neural tube defects, totally eight defective embryos were detected in the groups C and D (three in group C and five in group D. CONCLUSION: Our results suggested that meloxicam, a nonselective COX inhibitor, caused neural tube closure defects when injected at supratherapeutic doses. However, further studies with larger numbers of subjects are needed for its use in lower doses.

Management of disc herniations with bi-radicular symptoms via combined lateral and interlaminar approach.

Large lumbosacral disc herniations causing bi-radicular symptoms are very rare clinical entities and may present a surgical challenge. This study was undertaken to evaluate the effectiveness of the simply modified combined lateral and interlaminar approach for the treatment of these unique disc herniations. Between 2000 and 2005, 18 patients with bi-radicular symptoms secondary to large disc herniations of the lumbar spine underwent surgery. There were 13 men and five women, ranging in age between 25 and 64 years (mean 54.3 years). In this three-step operation, the osseous areas that are not essential for the facet joint were removed and both upper and lower nerve roots were decompressed. There were no intraoperative or postoperative complications, except transient dysesthesia in one (5.5%) patient. The mean follow-up period was 62.6 months (range 36-96 months). At the latest follow-up examination, outcomes using the Macnab classification were excellent in 13 patients (72.2 %), good in four (22.2%) and fair in one (5.5%). Recurrent disc herniations and/or instability, either symptomatic or radiographic, have not occurred as a result of the procedure during the follow-up period. The combined approach described here is a safe and effective procedure in the surgical treatment of this subtype of disc herniations with bi-radicular involvement. It permits optimum decompression of both nerve roots, avoiding the risk of secondary spinal instability.

Effect of hyperbaric oxygen therapy on the duration of treatment of spinal tuberculosis.

The aim of this retrospective study was to investigate the effect of adjuvant hyperbaric oxygen (HBO) therapy on the duration of antibiotic treatment and rate of radiological improvement in the management of spinal tuberculosis. We reviewed a total of 51 patients with tuberculous spondylitis of the spine who were treated by percutaneous abscess drainage or radical surgical debridement with chemotherapy, and of whom 16 randomly selected patients also received adjuvant HBO therapy and 35 did not. Serological markers were monitored in the course of treatment. Percutaneous needle biopsy was performed on each patient before treatment. Spine and chest radiographs, CT scans and MRI were performed. Infection control was achieved in all patients and no recurrence occured. To our knowledge this is the first reported series of patients with spinal tuberculosis treated with HBO therapy as an adjunct to antituberculous chemotherapy. This combination provided earlier clinical and radiologic improvement than chemotherapy alone.

Two-level contiguous cervical disc disease treated with peek cages packed with demineralized bone matrix: results of 3-year follow-up.

Interbody cages are widely used instruments for cervical fusion operations. Long-term follow-up studies are needed to clarify if these devices are dependable. In this prospective study, 79 patients (42 women and 37 men) with a mean age of 51 years operated between January 2000 and December 2005 for treatment of degenerative cervical disc disease and spondylosis associated with radiculopathy or myelopathy were evaluated. Patients underwent two-level contiguous anterior cervical discectomy and fusion operations with standard anterior Smith-Robinson approach. To achieve fusion PEEK cages packed with demineralized bone matrix mixed with autologous blood were used. Clinical outcome was evaluated with Odom's criteria and results were evaluated as 'excellent', 'good', 'fair' and 'poor'. Spinal curves, mobility and fusion status were assessed with anterior-posterior and lateral (neutral, flexion and extension) radiographs obtained before surgery and at 3, 12, 24 and 36 months postoperatively. The Ishihara curvature index (ICI) was used for spinal curve evaluation. Lateral dynamic (flexion and extension) radiographs at postoperative 12th month revealed the fusion status classified as 1A, 1B, 2A and 2B. The radiological outcomes were classified as 'non-fusion' when 2B healing was observed, and as 'fusion' when 1A, 1B or 2A healing was observed at the levels subjected to surgery. According to Odom's criteria, clinical outcomes were classified as 'excellent' or 'good' in 69 patients (success rate: 87.3%). Eight patients were graded as 'fair' and two as 'poor'. Preoperative mean ICI was 10.4+/-3.72 and postoperative mean ICI was 10.1+/-3.14. The difference was statistically insignificant (P>0.05); therefore, preoperative lordosis was said to be preserved at final follow-up. Final fusion rate (Types 1A, 1B, and 2A) was 91.7% (145/158 levels). Radiological imaging showed no cage failure or dislodgement and reoperation due to non-fusion was not needed.

Use of ultrasonography in ulnar nerve entrapment surgery--a prospective study.

The purpose of our study is to assess the usefulness of high-resolution ultrasonography in observing the morphology and dynamics of the ulnar nerve in the cubital tunnel and also the efficacy of ultrasonography in a more accurate diagnosis and appropriate surgical treatment decision. Cross-sectional area of the ulnar nerves of 40 healthy volunteers in the control group were measured bilaterally at the level of the epicondyle, 2 cm proximal to and 2 cm distal to the epicondyle. Measurements were obtained for elbows both in extension and flexion. Then, we prospectively obtained the cross-sectional area values of 18 patients at the same levels, elbows in extension and flexion position, and compared the data obtained from the patient group and the control group. The differences between the cross-sectional areas of the ulnar nerves in extension and flexion were statistically significant in the patient population (p < 0.001). Mean cross-sectional area of the ulnar nerve in the patient population was calculated as 0.16 cm(2), and we accepted the cut-off point as 0.1 cm(2). This value for cross-sectional area yielded a sensitivity of 90% and a specificity of 100% in diagnosis of ulnar nerve entrapment. Results substantiated conspicuous morphological changes in ulnar nerve during flexion and extension of the elbow. We also observed that as the degree of the nerve displacement by virtue of elbow flexion that is discerned by ultrasonography increased, a more aggressive decompressive surgery was needed for an appropriate treatment.

Lumbar spinal chondroma presenting with radiculopathy: case report.

Chondroma is a very unusual cartilagenous neoplasm of the spine. Here we are present a case of spinal chondroma with radiculopathy. A 54-year-old female patient consulted with progressive low back pain and left femoral numbness. Lumbar spinal Magnetic resonance (MR) imaging studies showed an extradural mass lesion in the left L2 body. Computerized tomography (CT) did not reveal any osteolytic lesion of the bone. The mass lesion was excised totally by left partial hemilaminectomy and the intradural compartment was also checked. The histopathology of the lesion was confirmed as chondroma. Preoperative evaluation and meticulous pathological analysis are required because of the malignant transformation potential of these rare pathologies.

Lumbar epidural capillary hemangioma presenting as lumbar disc herniation disease: case report.

STUDY DESIGN: A case of lumbar spinal epidural hemangioma is presented. OBJECTIVE: To present the first reported lumbar spinal epidural hemangioma patient clinically mimicking the lumbar disc herniation disease. SUMMARY OF BACKGROUND DATA: Capillary hemangiomas are benign endothelial cell neoplasms that are believed to be hamartomatous proliferations of vascular endothelial cells. The occurrence of spinal epidural capillary hemangiomas is exceedingly rare. There are only 3 reported epidurally located cases of capillary hemangiomas in the spinal channel in literature. Lumbar spinal epidural capillary hemangioma in a patient has not been previously reported. METHODS: Radiologic features, pathology, and clinical course were documented. RESULTS: L4 hypoesthesia and back pain of the patient was caused by an epidurally located capillary hemangioma. The neurologic symptoms of the patient were markedly improved after surgery. CONCLUSION: We have reported for the first lumbar epidural capillary hemangioma patient in literature. These lesions are benign and surgical treatment is curative.

Brucella-related cerebral aneurysms/subarachnoidal hemorrhage: a short review featuring a case report.

Brucellosis is a multisystem disease that may present with a large spectrum of clinical manifestations. Only five cases of intracranial aneurysm formation and/or subarachnoidal hemorrhage associated with brucellosis have been reported. In this paper, we take the opportunity to review these reports and present a new case of basilar artery aneurysm and subarachnoidal hemorrhage due to brucellosis.

Multilevel cervical fusion without plates, screws or autogenous iliac crest bone graft.

OBJECTIVE: This prospective study was performed to evaluate the safety and efficacy of polyetheretherketone (PEEK) cages packed with demineralized bone matrix (DBM) mixed with autologous blood and curettage microchip material for treatment of multilevel cervical disc disease and spondylosis without the use of plates, screws or autogenous iliac crest bone graft. MATERIAL AND METHODS: Sixteen patients underwent multilevel anterior cervical discectomy and fusion (ACDF) for a total of 42 levels. Minimum follow-up was 18 months. Neurological outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scoring system; cervical lordosis and cervical fusion status was assessed on X-ray. Statistical analysis was performed to compare preoperative and postoperative scores using a dependent t-test (P<0.05). RESULTS: Eight patients underwent two-level, six underwent three-level and two underwent four-level operations. The fusion rate was 90.5% and non-fusion rate was 9.5%, but reoperation was not required for these patients in the follow-up period. Cervical lordosis was preserved and neurological status was improved. No cage migration or cage failure occured. CONCLUSION: ACDF using PEEK cages packed with DBM is a safe and efficient method for treatment of multilevel cervical disc disease and spondylosis. It preserves cervical lordosis and obviates the complications related to iliac crest graft harvest and screw-plate fixation.

Is there any relationship between proinflammatory mediator levels in disc material and myelopathy with cervical disc herniation and spondylosis? A non-randomized, prospective clinical study.

The proinflammatory mediator (PIM) levels were assessed in surgically removed samples of herniated cervical intervertebral discs. The objective of this study was to investigate if there is a correlation between the levels of PIMs in disc material and myelopathy associated with cervical intervertebral disc herniation and spondylosis. The role of proinflammatory mediators in the degeneration of intervertebral disc and the inflammatory effects of disc herniations on radicular pain has been previously published. However, the possible relationship between PIMs and myelopathy related to cervical disc herniation and spondylosis has not been investigated before. Thirty-two patients undergoing surgery for cervical disc herniation and spondylosis were investigated. Surgically obtained disc materials, stored at 70 degrees C, were classified into two groups: cervical disc herniation alone or with myelopathy. Biochemical preparation and solid phase enzyme amplified sensitivity immunoassay (ELISIA) analysis of the samples were performed to assess the concentration of mediators in the samples. Very similar values of interleukin-6 were found in both groups whereas the concentrations of mediators were significantly higher in myelopathy group. This study has demonstrated that PIMs are involved in cervical intervertebral disc degeneration with higher concentrations in the samples associated with myelopathy.

Cramp finding: can it be used as a new diagnostic and prognostic factor in lumbar disc surgery?

In this prospective study, the validity and the importance of a new finding (cramp finding) in the diagnosis and outcome after lumbar disc surgery were tested. The test is performed with the person in prone position. Against a forceful knee flexion, the examiner holds the leg with one hand and applies a force to overcome the knee flexion. The finding is positive if the examined person feels a disturbing cramp in the leg or thigh. The study was performed between October 1997 and December 1999. Besides the cramp finding, the classical disc herniation examination, including mechanical and neurological findings, magnetic resonance (MR) imaging tests, and laboratory findings were checked pre- and postoperatively. The positive cramp finding in the operated group was 72% (n=133) preoperatively and straight leg raising (SLR) test was positive in all of them. Cramp finding was positive in 70%, 52%, 34%, and 8% of patients postoperatively in the first, 3rd, 12th and 24th months, respectively. The presented finding appears to be as valuable as the SLR, and especially contralateral SLR, tests in lumbar disc surgery. Cramp finding is also important in outcome evaluation.