Fully endoscopic interlaminar and transforaminal lumbar discectomy: Analysis of 47 complications encountered in a series of 835 patients / Discectomía lumbar interlaminar y transforaminal completamente endoscópica: análisis de 47 complicaciones encontradas en una serie de 835 pacientes

Objective: To report perioperative complications in fully endoscopic lumbar discectomy (FELD). Methods: From September 2010 to November 2016, 835 patients underwent FELD. In total, 865 disc levels were operated on. Of the 835 patients, the transforaminal (TF) approach was used in 174 patients, while 691 patients were operated on using the interlaminar (IL) approach. Surgical complications occurred in 47 patients, which were retrospectively analyzed. Results: Neurological deficits occurred in six patients. In four of these six patients, deficits resolved spontaneously. In one patient, symptoms resolved after a laminectomy procedure. In only one case, the neurological deficit was permanent. Seven patients complained of dysesthesia, which resolved spontaneously with medical treatment in four patients. In the remaining two patients, dysesthesia symptoms improved after epidural and foraminal injections. Dural tears were encountered in 26 patients. Pudendal neuralgia occurred in three patients. Two cases showed wound infection. The other complications comprised one disc infection, one retroperitoneal hematoma and one wrong level surgery. Conclusion: The FELD procedure has a steep learning curve and it is a difficult procedure to master. Surgeons should be aware of complications that can occur with the FELD procedure, most of which resolve spontaneously

Objetivo: Informar las complicaciones perioperatorias en la discectomía lumbar completamente endoscópica (FELD). Métodos: De septiembre del 2010 a noviembre del 2016, 835 pacientes fueron sometidos a FELD. Se utilizó un total de 865 niveles de disco. De los 835 pacientes, 174 pacientes fueron operados utilizando el enfoque transforaminal (TF) y 691 pacientes fueron operados en el método interlaminar (IL). Las complicaciones quirúrgicas ocurrieron en 47 pacientes que fueron analizados retrospectivamente. Resultados: Se presentaron déficits neurológicos en seis pacientes. En 4 de 6 de estos pacientes los déficits se resolvieron espontáneamente. En un paciente, los síntomas se resolvieron después de un procedimiento de laminectomía. En un solo caso, el déficit neurológico fue permanente. Siete pacientes se quejaron de la disestesia, que se resolvió espontáneamente con la terapia médica en 4 pacientes. En los 2 pacientes restantes, los síntomas de la disestesia mejoraron después de las inyecciones epidurales y foraminales. Se encontraron lágrimas dural en 26 pacientes. La neuralgia de Pudendal ocurrió en 3 pacientes. Dos casos mostraron infección de la herida. Una infección a nivel de disco, un hematoma retroperitoneal y una cirugía de nivel incorrecto fueron las otras complicaciones. Conclusión: El procedimiento FELD tiene una curva de aprendizaje abrupta y es un procedimiento difícil de dominar. Los cirujanos deben ser conscientes de las complicaciones que pueden ocurrir con el procedimiento FELD, la mayoría de los cuales se resuelven espontáneamente

Fully endoscopic interlaminar and transforaminal lumbar discectomy: Analysis of 47 complications encountered in a series of 835 patients.

OBJECTIVE: To report perioperative complications in fully endoscopic lumbar discectomy (FELD). METHODS: From September 2010 to November 2016, 835 patients underwent FELD. In total, 865 disc levels were operated on. Of the 835 patients, the transforaminal (TF) approach was used in 174 patients, while 691 patients were operated on using the interlaminar (IL) approach. Surgical complications occurred in 47 patients, which were retrospectively analyzed. RESULTS: Neurological deficits occurred in six patients. In four of these six patients, deficits resolved spontaneously. In one patient, symptoms resolved after a laminectomy procedure. In only one case, the neurological deficit was permanent. Seven patients complained of dysesthesia, which resolved spontaneously with medical treatment in four patients. In the remaining two patients, dysesthesia symptoms improved after epidural and foraminal injections. Dural tears were encountered in 26 patients. Pudendal neuralgia occurred in three patients. Two cases showed wound infection. The other complications comprised one disc infection, one retroperitoneal hematoma and one wrong level surgery. CONCLUSION: The FELD procedure has a steep learning curve and it is a difficult procedure to master. Surgeons should be aware of complications that can occur with the FELD procedure, most of which resolve spontaneously.

Fully endoscopic interlaminar and transforaminal lumbar discectomy: short-term clinical results of 163 surgically treated patients.

OBJECTIVE: To evaluate the clinical outcomes of patients with lumbar disc disease undergoing fully endoscopic surgery at a single clinic. METHODS: Between August 2009 and January 2012, 163 patients (74 men and 89 women) underwent fully endoscopic lumbar discectomy. All patients were followed for 1 year after surgery. The Oswestry Disability Index and a visual analog scale were used to analyze outcomes. RESULTS: During the follow-up period, 114 (70%) patients had no complaints, 30 (18%) patients had occasional pain, and 19 (12%) patients had no improvement. During postoperative follow-up, 8 patients required repeat surgery for recurrence or residual fragments. Postoperatively, 4 patients experienced dysesthesia, which completely resolved in time. Neurologic deterioration occurred in 5 patients, 4 of whom recovered completely without any intervention. Dural tears occurred in 6 patients. CONCLUSIONS: Fully endoscopic interlaminar or transforaminal surgeries are safe and effective treatment modalities for lumbar disc herniations. Despite the difficulties of acquiring this new technique, good results can be achieved with sufficient experience.

Sorafenib and lithium chloride combination treatment shows promising synergistic effects in human glioblastoma multiforme cells in vitro but midkine is not implicated.

OBJECTIVES: The objectives of this study were to test the effects of the new combination treatment modality, sorafenib (SOR) and lithium chloride (LiCl) and to assess whether midkine (MK) protein has a role in any potential effects. METHODS: Monolayer and spheroid cultures of T98G human glioblastoma multiforme (GBM) cells were treated with LiCl and SOR (inhibition concentration 50 value  =  100 µM), or their combination, or were left untreated (control). Cell proliferation and apoptotic indices, the mechanism of action, and the levels of apoptotic and anti-apoptotic proteins were evaluated in monolayer cultures and ultrastructure was evaluated by transmission electron microscopy (TEM) in spheroid cultures after for 72 hours. RESULTS: All drug applications decreased cell numbers and increased the apoptotic index. The combination shows a synergistic effect. In the combination group, the decrease in cell numbers and the increase in the apoptotic index were significantly greater than with the individual drugs (P < 0.01). The combination treatment led to the greatest decreases in MRP-1 and p170 levels; but the greatest decreases in p-STAT-3, p-ERK (P < 0.05), p-AKT, p-GSK-3-beta (P < 0.01), EGFR (P < 0.01), NF-kappa-ß levels were with SOR alone, followed by the combination. The decreases in MK levels in the SOR and combination groups were similar (P  =  0.06). Severe ultrastructural damage was more frequently observed in the combination group compared with the other groups. CONCLUSIONS: These results suggest the possibility that the addition of LiCl to SOR could improve the prognosis in at least some patients who need both cancer and psychotherapy and indicate the need for further studies.

Functional outcomes after treatment of traumatic brachial plexus injuries: clinical study.

BACKGROUND: The aim of this study is to evaluate functional outcome and quality of life using statistically validated tools. METHODS: Participating patients were called and asked questions from the Short Form 36 (SF-36), the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, a pain scale and an additional question on their satisfaction with surgery. RESULTS: A total of 33 patients were operated by a single surgeon (MI) between 1997 and 2010 at the Neurosurgery Department of Istanbul School of Medicine. Three of these patients refused to participate and three other patients were excluded, leaving 27 patients, with an average follow-up of 79,6 months, for review. The most common cause of traumatic brachial plexus injuries (TBPI) was motor vehicle accidents. Fourteen patients had isolated supraclavicular injuries and three patients had infraclavicular injuries. The remaining 10 patients' injuries were both supra- and infraclavicular. Avulsion was encountered in three patients. The patients who were operated within the first six months after trauma represented significantly better scores in DASH, SF-36 and pain scale. CONCLUSION: Statistically validated tests like DASH and SF-36 questionnaires are valuable tools for evaluating TBPI patients. Centers specialized in treating TBPI with surgery may use these tests pre- and postoperatively which lead to objective personalized evaluation of patients' subjective symptoms.

Primary multiple cerebral hydatid disease: still symptomatic despite pathologically confirmed death of the cyst.

Hydatid disease is a life-threatening parasitic infestation caused by Echinococcus granulosus. Infection with E. granulosus typically results in the formation of hydatid cysts in liver, lungs, kidney and spleen. Majority of the intracranial cysts are secondary and solitary. Multiple primary cerebral cysts are uncommon. Surgical and medical management of a 14-year-old boy with multiple primary hydatid cysts are presented. 14 cysts, which were symptomatic due to their mass effect, were surgically removed, whereas a deep-seated asymptomatic cyst was followed-up with medical treatment. Despite proper antibiotic regimen the patient was admitted with epileptic seizures six months later. The deep-seated lesion was also surgically removed. Intraoperative observations and pathological examination demonstrated different characteristics, with pericystic gliosis, gel-like cyst content and death scolices within the cavity. In addition to the fact, that the presented case is an additional example for the rare primary multiple cerebral hydatid cysts, to our knowledge it is the first case of a dead cerebral hydatid cyst, causing symptoms despite effective medical treatment.

Analyses of clinical prognostic factors in operated traumatic acute subdural hematomas.

BACKGROUND: Traumatic acute subdural hematoma is the most lethal of all head injuries. METHODS: In this study, 113 patients with the diagnosis of posttraumatic acute subdural hematoma, who were operated between 1998 and 2006, were reviewed retrospectively. Statistical analysis was performed to detect any effects of the variables of age, Glasgow Coma Scale (GCS) score on admission, time interval between the trauma and operation, and abnormality in the pupil reaction on the disease mortality and morbidity. RESULTS: Results obtained in the study are discussed and compared with the related current literature. The overall mortality in 113 patients was 56.6%. CONCLUSION: According to the results, the most important determinants of the prognosis are GCS score of the patient on admission, abnormality in pupil reaction, timing of the operation, and the patient's age.

The effects of tibolone on the human primary glioblastoma multiforme cell culture and the rat C6 glioma model.

OBJECTIVES: In the light of recent advances in tumor biology and genetics, we hypothesized that tibolone, an estrogen receptor agonist, may have antiproliferative effects on primary human glioblastoma cells and rat C6 malignant glioma cell lines. We thought that tibolone should exert its antiproliferative effects by augmenting glial cell differentiation through the naive, nonhypermethylated estrogen receptors in the glioma cells. METHODS: Human primary glioblastoma multiforme (GBM) cells were acquired perioperatively from ten patients aged between 45 and 69 years, diagnosed clinically and radiologically with GBM. The diagnosis was confirmed using immunohistochemical assays. Human GBM and rat C6 malignant glioma cells were cultivated in vitro to obtain monolayer cell cultures. Tibolone was then applied to these cultures in wells, each containing 500,000 tumor cells. RESULTS: Tibolone significantly decreased the number of human GBM cells at the concentrations of 10 and 100 mg/ml. For tibolone, a strong dose-dependent correlation in tumor inhibition was found (p=0.001). This antiproliferative effect of tibolone in human GBM cells was not observed in rat C6 malignant glioma cells. Tibolone demonstrated differential effects on human GBM and rat C6 glioma cells. DISCUSSION: In vitro antiproliferative effects of tibolone on human GBM need to be investigated further in in vivo works.

[Epidemiological study in head injury patients]. / Kafa travmali hastalarda epidemiyolojik çalisma.

BACKGROUND: The aim of this study was to determine the hospital-based epidemiological data of the head injury patients who admitted to our Emergency Surgery Department. METHODS: The records of the patients (284 males [66%], 146 females [34%]; mean age 30+/-19) with head injury who admitted to our Emergency Surgery Department between 01.01.2006 - 31.12.2006 were analyzed retrospectively. RESULTS: Among the age groups, most head injuries occurred in children (22%) and young adults (30%). The most common trauma types were due to falls (40%) and motor vehicle accidents (37%). The mortality rate in head injury patients was 11%, serious morbidity was 2%, and the rate of deaths from head injury among all deaths in 2006 was 30%. CONCLUSION: According to these data, the most common causes of death in head-injured patients are falls (0-16 years of age) and outside vehicle traffic accidents and cranial gunshot wounds (16-35 years of age), especially for males. Admission Glasgow Coma Score is an important prognostic factor in head-injured patients. Primary precautions for head injury must be taken according to each age group. Further development of the diagnosis and treatment options will help to lower the mortality and morbidity of patients with traumatic brain injury.

Effect of magnesium, MK-801 and combination of magnesium and MK-801 on blood-brain barrier permeability and brain edema after experimental traumatic diffuse brain injury.

OBJECTIVE: Glutamate antagonists are very attractive drugs in laboratory works to protect neural tissue against ischemia. In this work, the effects of magnesium, MK-801 and combination of magnesium and MK-801 on blood-brain barrier (BBB) and brain edema after experimentally induced traumatic brain injury are evaluated. METHODS: A standard closed head injury was induced on the rats by a controlled impact device using a 450-g free falling mass from a height of 2 m onto a metallic disc fixed to the intact skull. One of the following was injected to animals intraperitoneally 30 minutes after injury: saline, magnesium, MK-801 and magnesium plus MK-801. To quantify the brain edema, the specific gravity of the brain tissue was determined. To demonstrate the alteration of the BBB permeability, Evans blue dye was used as a tracer. RESULTS: In all treatment groups, the specific gravity of brain tissue values was significantly higher compared with the control group. Evans blue dye content in the brain tissue was significantly reduced in all three treatment groups with respect to the control group. There was no significant difference of effect between the groups of magnesium alone and MK-801 alone when compared with each other and when compared with their combination. CONCLUSION: The present data demonstrate that treatment with magnesium, MK-801 and combination of magnesium and MK-801 can reduce formation of brain edema and can help restore BBB permeability after experimental diffuse brain injury.

Traumatic epidural hematomas of the posterior cranial fossa.

BACKGROUND: Traumatic EDHs of the posterior cranial fossa are rare and have a higher mortality than supratentorial localizations. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. Active use of cranial CT scanning has taken a major role in the diagnosis, surgical indication, close observation, and strategy planning. As a result, better prognosis is achieved. In this study, we represent our results and experiences in the management of TEHPCF. METHODS: Between 1993 and 2006, 65 patients with TEHPCF were treated in Istanbul University Faculty Of Medicine, Neurosurgery and Emergency Surgery Departments. The hospital records of these patients were analyzed retrospectively. RESULTS: Of 65 patients, whose diagnosis and management decisions were determined by cranial CT scans, 53 were treated through surgery and 12 by conservative methods. Of the 53 surgically treated patients, 2 (3%) patients died, and 2 (3%) other patients remained moderately disabled during their discharge. As a result, 61 (94%) of 65 patients had excellent recovery. CONCLUSION: When compared with the literature, our mortality rate was superior to other previously reported studies. In our opinion, this is a result of extensive use of the cranial CT scan together with aggressive surgery. Patients with occipital trauma should be evaluated using cranial CT scans, and those showing mass effect should be immediately treated surgically. The patients that have no mass effect on CT scans can be closely observed by planned serial control CT scans.

[Craniocerebral civilian gunshot wounds: one hospital's experience]. / Kranyoserebral atesli silah yaralanmalari: bir hastanenin deneyimi.

BACKGROUND: In this study we have discussed the factors that affect our surgical results according to our experience on patients who were admitted to our hospital's Emergency Surgery Department for civilian craniocerebral gunshot wounds between 1997 and 2006. METHODS: The clinical and radiological findings of 82 patients (74 males, 8 females) who were treated for civilian craniocerebral gunshot wounds were retrospectively recorded. Neurological and physical examination, cranial computerized tomography (CCT) findings, trauma types, treatment modalities, prognosis, complications, morbidity and mortality rates were analyzed. RESULTS: Seventy-four (90%) of the patients were male, the mean age was 29.2 year. The Glasgow Coma Scores (GCS) during admission were as following respectively: 3-5 in 35 patients, 6-8 in 9 patients, 9-12 in 19 patients and 13-15 in 19 patients. According to their radiological findings, most commonly subdural hematoma, intracerebral hematoma, multiple contusion, depressed fracture and subarachnoidal hematoma were encountered. Operation or debridement was performed in 51 patients totally. Forty-one patients died and the mortality rate of 82 patients was calculated as 50%. CONCLUSION: The mortality rate of craniocerebral gunshot wound is high. The patients with GCS higher than 8 and with unihemispheric lesions during admission have better prognosis. We concluded that all patients must undergo debridement and the patients that have mass effect must be operated as soon as possible.

[Longitudinal clival fractures: a report of three cases]. / Longitüdinal klivus kirigi: Uç olgu sunumu.

Fractures of the clivus are often associated with severe head trauma and have high mortality rates due to coexisting injury of the adjacent vessels, brain stem and lower cranial nerves. An early diagnosis is often not possible because of adherent problems, high mortality rate and inadequacy of emergency imaging. Diagnosis has recently become easier with high resolution bone window computed tomography studies. In this study, radiological and clinical findings of three patients with longitudinal clival fractures and severe head trauma have been presented and associated injuries and prognostic issues are discussed with reference to the limited number of similar cases in the English literature.

Quadrigeminal cistern arachnoid cyst in a patient with Kabuki syndrome.

Kabuki syndrome is a rare dysmorphic disorder characterized by peculiar facial appearance, developmental delay, skeletal abnormalities, mental retardation, and dermatoglyphic abnormalities. Neurologic anomalies are frequently observed. This report presents a 2-year-old male with Kabuki syndrome who had a quadrigeminal cistern arachnoid cyst: the second case of such an association to be reported in the literature.

Destructive stereotactic surgery for treatment of dystonia.

BACKGROUND: This study is a retrospective review of the results of stereotactic destructive surgery in selected cases of drug-resistant dystonia. METHODS: Fifty-eight patients with drug-resistant dystonia were treated with stereotactic surgery between 1991 and 1999 in our institution. These patients' charts were retrospectively analyzed. The timing of the conducted evaluations was as follows: preoperatively, postoperatively, in the postoperative 1st week, 6th month, 12th month, and also thereafter every year. RESULTS: Symptoms of dystonia occurred before the age of 10 years in 30 patients (51.8%) and after the age of 10 years in 28 patients (48.2%). Generalized dystonia was detected in 41 patients, whereas 11 patients had hemidystonia, 5 patients had focal dystonia, and 1 patient had segmental dystonia. The most common etiologic factor was CP (n = 34). A total of 103 ablative lesions were created in 86 surgical sessions. Thalamotomy, pallidotomy, subthalamotomy, and the region of Forel lesions were performed either separately or in combination. In this series, the mean follow-up time was 102.2 months. Except for 2 cases of temporary hemiparesis, no other complications were observed. Minor improvement was obtained in 17 patients (19.7%), improvement of a medium degree was obtained in 17 patients (19.7%), high-degree improvement was obtained in 11 (12.8%), and very high degree improvement was obtained in 16 (18.6%) patients. A final evaluation revealed permanent improvement in 32 patients (55.2%). CONCLUSION: Production of stereotactic destructive lesions in certain specified targets is a safe method that improves quality of life and aids ambulation in patients with dystonia resistant to medical therapy.

[Trigeminal neuralgia and treatment options]. / Trigeminal nevralji ve tedavi seçenekleri.

Trigeminal neuralgia is a painful condition of the face characterized by paroxysmal lancinating, shock-like pain confined to the somatosensory distribution of the trigeminal nerve. The etiology of most cases of trigeminal neuralgia has been suggested to be vascular compression of the central axons of the trigeminal nerve at the level of pontocerebellar region, so called hyperactive dysfunctional syndrome. Trigeminal neuralgia is the one of the most known pain syndromes. Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal neuralgia and in this review, idiopathic trigeminal neuralgia was discussed in aspect of different surgical modalities.

Surgical results in pediatric Spetzler-Martin grades I-III intracranial arteriovenous malformations.

OBJECTS: The goal of cerebral arteriovenous malformation (AVM) therapy in pediatric patients should be complete resection or obliteration of the AVM to eliminate subsequent hemorrhage, because of high mortality and morbidity rates related to hemorrhage in addition to the longer life expectation. Despite advances in Gamma knife radiosurgery and in endovascular embolization, surgical resection is still the gold standard for treating cerebral AVMs. METHODS: Between 1986 and 2003, 20 children were surgically treated for cerebral AVMs. The AVMs were graded I, II, and III using the Spetzler-Martin (S-M) Grading Scale. Good recovery was achieved in 18 out of 20 patients (90%) and only 1 patient was moderately disabled (5%). There was one mortality (5%) related to the preoperative deep comatose state of the patient. The total obliteration rate was 89% (17 out of 19). CONCLUSION: For S-M grade I-III AVMs, surgical resection is the treatment of choice, considering its high cure rate and low morbidity and mortality rates.

Obsessive-compulsive disorder after epilepsy surgery.

It is a well-known fact that after epilepsy surgery (ES) preexisting psychopathology may deteriorate or de novo psychopathological syndromes, mainly of a depressive and psychotic nature, may appear. Previously, recovery of obsessive-compulsive disorder (OCD) after ES has been reported in patients who had comorbid OCD preoperatively; however, there have been no reports on the appearance of de novo OCD interfering with daily living activities post-ES. This is the first report of OCD after ES in patients with mesial temporal lobe epilepsy (MTLE). Five patients with MTLE were identified with obsessive personality traits before surgery. Within the first 2 months after ES, two of these MTLE patients fulfilled OCD diagnostic criteria. These OCD patients were not any different from the other three patients with respect to age, age of onset of epilepsy, seizure types, and seizure frequency. All patients stopped having seizures postoperatively, but the OCD patients had worse quality of life postoperatively than preoperatively. Our findings show that those patients with obsessive traits preoperatively should be carefully monitored after ES.

The effect of epidural free fat graft on the outcome of lumbar disc surgery.

Numerous materials have been used to prevent epidural scar tissue after lumbar disc surgery. Free fat grafts are common both experimentally and clinically, but there is some doubt about their protection against fibrosis, and some complications have been reported. In this prospective study, the usefulness of free fat grafts during lumbar disc surgery was evaluated. Ninety-nine patients who had undergone operation due to lumbar disc herniation were divided in two groups: those with implantation of free fat grafts (group A) and those without (group B). Outcome was evaluated at a mean of 2.6 years postoperatively according to the following criteria: visual analog scale for back and leg pain, Hannover Questionnaire on activities of daily living, reflex findings, sensory and motor deficits, consumption of analgesics, walking distance, straight leg raising test, and clinical examination. The outcome variables showed no significant differences between the two groups ( P>0.05). This study suggests that the use of free fat grafts during lumbar disc surgery was clinically ineffective.

The effect of low-dose external beam radiation on extraneural scarring after peripheral nerve surgery in rats.

OBJECTIVE: Scar tissue is an inevitable result of peripheral nerve surgery. A variety of substances have been used to prevent epineurial scarring. In this study, the effect of low-dose radiation therapy on epineurial scarring was investigated. METHODS: Seventy-eight male Sprague-Dawley rats were studied. A total of 60 rats were subjected to one of three types of surgical procedure on the sciatic nerve, as follows: Procedure 1, external neurolysis (n = 20); Procedure 2, abrasive injury (n = 20); and Procedure 3, anastomosis (n = 20). On the left sciatic nerves, 700 cGy external beam radiation was administered 24 hours after surgery, and the right sciatic nerves served as a control group (surgery only). Eighteen animals without surgical intervention were used to establish the fibrotic effect of radiotherapy on normal nerves. A neurological examination was performed weekly. Six weeks after surgery, the extent of extraneural scarring was examined by gross microdissection by means of a numerical grading scheme and histological analysis. Cellular density and surface measurements of scar tissue were also evaluated. RESULTS: The dissection around the nerve was easier in rats treated with low-dose radiation compared with the control group. Furthermore, grading scores in both nerve adherence and nerve separability were significantly lower in treated nerves than in the control group (P < or = 0.05). Low-dose radiotherapy decreased the scores of cellular density and surface measurement of scar tissue (P < or = 0.05). In normal nerves, radiotherapy did not produce any fibrotic effects and the density of fibroblasts/fibrocytes was also very low. CONCLUSION: In the case of surgery or local trauma to peripheral nerve, the use of low-dose radiation therapy may be a safe method of limiting postoperative epineurial scar formation.