Lumbosacral plexopathy secondary to discectomy and fixation.

Lumbosacral plexopathy (LSP) is a rare entity characterized by acute onset of pain followed by sensory and motor deficits, reflex changes and muscle atrophy. The diagnosis is based on clinical and EMG findings. LSP can result from pelvic tumors, infections, trauma, abdominopelvic or spinal surgery, radiation, intravenous drug abuse, diabetic neuropathy, vasculitis or maybe idiopathic. We present a case report of LSP following spinal surgery treated by pulse steroid and immunotherapy.

Posterior Fossa Epidural Hydatid Cyst in the Adult.

ABSTRACT: Hydatid cyst is an important parasitic disease especially in endemic regions. Hydatid cysts are most commonly found in the liver and lungs and only 1% to 2% of the cysts reach the brain. Intracranial hydatid cysts are usually supratentorial and majority of cases are children and young adults. In this case report, a 55-year-old woman who lives in rural area in Turkey, admitted to our clinic with severe headache, neck pain, gait disturbance, and vomiting. Her neurological examination revealed cerebellar ataxia and left dysmetria. Radiological findings were compatible with hydatid cyst. On the 3rd of antihelmintic therapy, the patient underwent suboccipital craniotomy and epidural cyst was excised using Dowling technique without rupture of the cyst wall. Patient's symptoms improved postoperatively. Although hydatid cyst in posterior fossa is a very rare entity, it should be kept in mind in patients with intracranial cystic lesions who live in endemic regions.

Light Microscopic Evaluation of Acute and Chronic Hypophyseal Endocrinopathy in a Kaolin-Induced Hydrocephalus Model.

AIM: To demonstrate progression of acute and chronic endocrinopathies in a kaolin-induced hydrocephalus model using light microscopy. MATERIAL AND METHODS: Adult male Sprague-Dawley rats (n = 48) were divided into six groups. Hydrocephalus was induced by intracisternal injection of kaolin solution in the acute and chronic kaolin groups, whereas an identical volume of sterile saline was injected into the sham groups. RESULTS: Somatotropic cell concentrations were lower in the kaolin groups compared with their controls, but there was no difference in somatotropic cell concentration between the acute and chronic kaolin groups. Corticotropic cell concentrations were higher in the acute kaolin and sham groups compared with acute controls. Thyrotropic cell numbers were higher in the acute sham and kaolin groups compared with their controls, and although thyrotropic cell concentations were higher in the acute kaolin group than the acute sham group. No differences were observed between the acute and chronic controls and sham and kaolin groups regarding mammotropicand gonadototropic cell concentations. CONCLUSION: Somatotropic cells are most affected by hydrocephalus that causes pituitary dysfunction, and this effect was more prominent under acute and chronic phases.

Severe hypertension and tachycardia during transforaminal endoscopic discectomy - Is indigocarmine to blame?

Endoscopic transforaminal discectomy is a minimally invasive technique used for the surgical treatment of herniated discs. Indigocarmine is a dye which is widely used to identify the ureteral orifice in urologic procedures. Hemodynamic effects such as hypotension and anaphylaxis in addition to hypertension, bradycardia and atrioventricular block have been reported in intravenous application of indigocarmine. The aim of this case report is to prepare anesthesiologists for such cases and make them consider invasive blood pressure monitorization. Both patients had radicular pain radiating to the leg and scheduled to undergo transforaminal endoscopic discectomy. Intraoperative vital signs were within normal limits, however severe hypertension and tachyarrhythmia developed following the injection. Hemodynamics in both patients returned to normal following lidocaine and nitroglycerine injection.

Effects of Topical Cova™, Tisseel® and Adcon® Gel Application on the Development of Spinal Peridural Fibrosis: An Experimental Study in Rats.

AIM: Leptomeningeal adhesions and fibrosis in the spinal peridural space are the most common causes of post-laminectomy syndrome. Fibrin sealant agents and membrane barriers are commonly used for hemostasis and sealing purposes in spinal surgery. Peridural fibrosis may be a risk of the usage of these topical agents. In this study, we aimed to compare the effects of Cova ™, Tisseel® and Adcon ® Gel on the development of spinal peridural fibrosis in the experimental rat model. MATERIAL AND METHODS: Thirty-two Sprague Dawley female rats were randomly divided into 4 groups. Groups were constituted as group 1; Cova™ group (laminectomy+Cova™), group 2; Tisseel® group (laminectomy+Tisseel®), group 3; Adcon®Gel group (laminectomy + Adcon®Gel), group 4; control group (laminectomy only). Six weeks after laminectomy, spinal columns were removed en bloc between L1 and L4 vertebrae. Peridural fibrosis was evaluated histologically and the results were compared statistically. RESULTS: Statistically significant reduction of peridural fibrosis was achieved in groups 1, 2, and 3 when compared with the control group (p < 0.05). Our data revealed a statistically significant difference between group 1 and group 3 (p < 0.05). When we compared with group 2 and 3, the fibrosis grades were not different between these two groups (p > 0.05). CONCLUSION: Fibrin sealant agent Tisseel® and membrane barrier Cova™ do not enhance peridural fibrosis following laminectomy. Cova™ and Tisseel® may be appropriate for hemostasis and leakage prevention during the spinal surgery and it is safe to leave these materials on the operation surface.

Neuroprotective Effects of Pregabalin Against Spinal Cord Ischemia-Reperfusion Injury in Rats.

AIM: To evaluate the effect of pregabalin pre-treatment on spinal cord ischemia-reperfusion (I/R) injury and compare with methylprednisolone (MP). MATERIAL AND METHODS: Thirty-two rats were randomly divided into four groups as follow: Group 1 (sham)(n=8), group 2 (ischemia only)(n=8), group 3 (30 mg/kg pregabalin)(n=8), and group 4 (30 mg/kg methylprednisolone)(n=8). Laparotomy was performed without aortic clamp in the sham group. All animals were sacrificed 24 hours after surgery. The spinal cord tissue samples were harvested and caspase-3 activity, tumor necrosis factor-alpha (TNF-α) and Interleukin-1 Beta (IL-1ß) levels, catalase (CAT) activity, glutathione peroxidase (GPx) activity, superoxide dismutase (SOD) levels malondialdehyde (MDA) levels and nitric oxide (NO) levels were analyzed to investigate the effects of different excitatory and inflammatory pathways in mechanism of I/R injury. Ultrastructural and histopathological examinations were carried out. Neurological recovery was measured by Basso, Beattie, Bresnahan (BBB) test and Inclined Plane Test. RESULTS: Decresead caspase-3 activity and decreased inflammatory markers like TNF-α, IL-1ß, and decresaed excitotatory pathways like CAT, GPx, MDA, NO and SOD were observed in both pregabalin pre-treatment and MP treatment groups. Pregabalin pre-treatment produced better ultrastructural results compared to MP treatment, as with histopathological examination. Pregabalin group showed better recovery compared to MP treament group according to BBB scoring system. CONCLUSION: Pregabalin pre-treatmet and MP treatment both has neuroprotective effect on I/R injury by decreasing caspase dependant apoptosis, and inflammatory and oxidative stress markers. In addition, pregabalin pre-treatment had better clinical effects compared to MP treatment.

The Use of Neuronavigation and Intraoperative Imaging in Spinal Stabilization Surgery.

AIM: Misplacement of pedicle screw is the serious complication of spinal surgeries. Intraoperative imaging techniques and navigation systems are currently in use for the prevention of this complication. The aim of this study was to document the results of our experience with the navigation and intraoperative imaging technique and to share our experience with our colleagues. MATERIAL AND METHODS: Between 2011 and 2014, one hundred and two patients underwent instrumented spinal surgery while using intraoperative computed tomography (iCT) and a navigation system. All patients had a CT scan performed no more than three days postoperatively to confirm adequate placement of the screws. The accuracy of pedicle screw placement was assessed by postoperative CT scan. Pedicle violations were graded according to an established classification system. RESULTS: In the 36-month period, a total of 610 screws in 102 patients were evaluated. Stabilization surgery was performed in the lumbosacral region in 51 (50%) patients, lumbar region in 35 (34.31%) patients, cervical region in 5 (4.9%) patients, thoracolumbar region in 7 (6.86%) patients and thoracic region in 4 (3.92%) patients. Of the 610 screws, 396 (64.91%) were placed in lumbar, 66 (10.81%) in thoracic, 106 (17.37%) in sacral and 42 (6.8%) in cervical vertebrae. Of the 610 screws, 599 screws (98.18%) were placed without a breach. Grade 1 breaches occurred in 8 screws (1.31%), Grade 2 breaches occurred in 2 screws (0.32%), and Grade 3 breaches in 1 screw (0.16%). No dural defect or neurological deficit occurred after the surgeries. CONCLUSION: The use of an iCT scan associated with a navigation system increases the accuracy of pedicle screw placement. This system protects the surgical team from fluoroscopic radiation exposure and the patient from the complications of screw misplacement and repeated surgeries.

Non-invasive detection and monitoring of experimental hydrocephalus with distortion product otoacoustic emissions.

OBJECTIVE: We aimed to find out the effects of short term and long term hydrocephalus and intracranial ventricular volume changes on cochlear functions by using distortion product otoacoustic emission (DPOAE) in experimental hydrocephalus rat models for the first time in literature. METHODS: This study was performed with 48 healthy, adult (8 weeks old), Sprague-Dawley rats which weighed between 200 and 240g. Six groups were formed in this study: short term control, short term sham, short term hydrocephalus, long term control, long term sham and long term hydrocephalus groups. Each group contained eight rats. Short term period was 4 weeks and long term period was 8 weeks after the study started. At the end of these periods, DPOAE measurements were performed and then rats were sacrificed to determine ventricular volumes. RESULTS: DPOAE values at all frequencies were significantly decreased in the short term hydrocephalus group when compared to the short term control and short term sham groups. DPOAE values at all frequencies were significantly decreased in the long term hydrocephalus group when compared to the long term control and long term sham groups. Besides, long term sham group which had higher ventricular volumes than long term control group also had lower DPOAE measurements. Significant associations were present between DPOAE measurements and ventricular volumes in hydrocephalus models. CONCLUSION: The functional disturbances in cochlear functions due to hydrocephalus have been demonstrated with DPOAE measurements in this study. DPOAE measurements may be thought as an easily applicable non-invasive method in detection and follow-up of patients with hydrocephalus. Our findings should be supported with clinical studies in humans.

A Rare and Serious Syndrome That Requires Attention in Emergency Service: Traumatic Asphyxia.

Traumatic asphyxia is a rare syndrome caused by blunt thoracoabdominal trauma and characterized by cyanosis, edema, and subconjunctival and petechial hemorrhage on the face, neck, upper extremities, and the upper parts of the thorax. Traumatic asphyxia is usually diagnosed by history and inspection; however, the patient should be monitored more closely due to probable complications of thoracoabdominal injuries. Treatment is conservative, but the prognosis depends on the severity of the associated injuries. Herein we present a traumatic asphyxia due to an elevator accident in a 32-year-old male patient and discuss the diagnosis, treatment, and prognosis by reviewing the relevant literature.

Neuroprotective effects of agmatine in experimental peripheral nerve injury in rats: a prospective randomized and placebo-controlled trial.

AIM: The purpose of this study was to demonstrate the activity of agmatine, an inducible nitric oxide synthase (iNOS) inhibitor and selective N-methyl-D-aspartate receptor (NMDAR) antagonist, on reducing tissue damage in distal part of traumatic nerve in an experimental rat peripheral nerve injury model. MATERIAL AND METHODS: Sciatic nerves of 30 Sprague Dawley male rats were used. Rats were divided into 5 groups; group 1 (n=6), control group; group 2 (n=6), axonotmesis + placebo group; group 3 (n=6), axonotmesis + 50 mg/kg agmatine treatment group; group 4 (n=6), neurotmesis + placebo group; group 5 (n=6), neurotmesis + 50 mg/kg agmatine treatment group. Axonolysis, axon degeneration, edema, hemorrhage, and inflammation were evaluated in histopathologic examinations of all the groups. RESULTS: When group 2 was compared with group 3 in histopathologic sections, axonolysis was less in group 3 (p=0.007), as was axon degeneration (p=0.022) and edema (p=0.018). When group 4 was compared with group 5, axonolysis was less in group 5 (p=0.009), as was axon degeneration (p=0.006) and edema (p=0.021). CONCLUSION: This study demonstrated agmatine to have antioxidant and antineurotoxic effects in an experimental rat peripheral nerve injury model.

Collapsed L4 vertebral body caused by brucellosis.

Brucellosis is caused by gram-negative, aerobic, non-motile, facultative, intracellular coccobacilli belonging to the genus Brucella. A 50-year-old man working as an employee was admitted to neurosurgery clinic with severe low back, radicular right leg pain and hypoesthesia in right L4-5 dermatomes for 2 months. Brucella tube agglutination (Wright) test was positive in serum sample of the patient with a titer of 1/640. Brucella melitensis was isolated from blood culture. X-ray and MRI of the lomber spine showed massive collapse of L4 vertebral body. Neural tissue was decompressed and then posterior L3-5 short segment transpedicular screw fixation and stabilization was performed. Brucella melitensis was isolated from microbiologic culture of pathologic specimen. Antibiotic therapy was given as doxycycline 200 mg/day and rifampicin 600 mg/day for 6 months. Brucellosis is a systemic zoonotic infection and still an important public health problem in many geographical parts of the world. Vertebral body collapse caused by brucellosis occurs very rarely but represents a neurosurgical emergency because of its potential for causing rapidly progressive spinal cord compression and permanent paralysis. Neurosurgeons, emergency department personnel as well as infectious disease specialists should always keep a high index of suspicion and include brucellosis in the differential diagnosis of vertebral body collapse.

The effect of copper on vasospastic femoral artery in rats.

AIM: The aim of this study was to investigate the effect of copper, which is the cofactor and regulator of the superoxide dysmutase enzyme, on preventing experimental peripheral vasospasm in rats through antioxidative mechanisms. MATERIAL AND METHODS: Twenty-four female Wistar-Albino rats were divided into 3 groups: group 1 (n=8), control group; group 2 (n=8), vasospasm group; and group 3 (n=8), vasospasm + copper treatment group. Morphometric measurements of wall thickness and lumen diameter of femoral arteries were performed. RESULTS: Statistical comparison of groups 1 and 2, regarding thickness of vascular walls, revealed a significant increase in group 2 (p=0.037) and regarding lumen diameters, revealed a significant decrease in group 2 (p=0.043). Comparison of diameters of the vascular lumen of groups 1 and 3 showed no significant difference (p=0.19), whereas the comparison of the thicknesses of the vascular walls displayed a significant increase in group 3 (p=0.028). Comparison of groups 2 and 3 regarding diameter of vascular lumens showed a significant decrease in group 2 (p=0.042), whereas group 3 displayed a significant decrease, in terms of thickness of the vascular walls (p=0.029). CONCLUSION: This study showed quantitatively that copper could prevent the development of experimental peripheral vasospasm in rats.

Hemangioblastoma of the filum terminale associated with von Hippel-Lindau disease: a case report.

We report a 41-year-old man who presented with low back pain, lower extremity paresthesia, urinary retention and constipation. Magnetic resonance imaging showed a vascular intradural-extramedullary lesion at the second lumbar vertebral level. His medical history revealed that he had undergone surgery for a cerebellar hemangioblastoma 5 years ago. The patient underwent a spinal operation and a vascular tumor was removed from filum terminale. Pathologic examination of the tumor revealed a hemangioblastoma. Hemangioblastomas may occur sporadically or in association with von Hippel-Lindau disease. In the second case, they are often multiple and accompanied by cerebellar and brainstem lesions. The hemangioblastomas reported in the conus medullaris or in the extramedullary compartment adjacent to the conus medullaris are rare, tumors of the cauda equina are uncommon, and lesions of the filum terminale are extremely rare. We report a patient with von Hippel-Lindau disease having filum terminale hemangioblastoma and discuss the diagnosis, pathogenesis and treatment of hemangioblastoma.

Mutation in MEOX1 gene causes a recessive Klippel-Feil syndrome subtype.

BACKGROUND: Klippel-Feil syndrome (KFS) is characterized by the developmental failure of the cervical spine and has two dominantly inherited subtypes. Affected individuals who are the children of a consanguineous marriage are extremely rare in the medical literature, but the gene responsible for this recessive trait subtype of KFS has recently been reported. RESULTS: We identified a family with the KFS phenotype in which their parents have a consanguineous marriage. Radiological examinations revealed that they carry fusion defects and numerical abnormalities in the cervical spine, scoliosis, malformations of the cranial base, and Sprengel's deformity. We applied whole genome linkage and whole-exome sequencing analysis to identify the chromosomal locus and gene mutated in this family. Whole genome linkage analysis revealed a significant linkage to chromosome 17q12-q33 with a LOD score of 4.2. Exome sequencing identified the G > A p.Q84X mutation in the MEOX1 gene, which is segregated based on pedigree status. Homozygous MEOX1 mutations have reportedly caused a similar phenotype in knockout mice. CONCLUSIONS: Here, we report a truncating mutation in the MEOX1 gene in a KFS family with an autosomal recessive trait. Together with another recently reported study and the knockout mouse model, our results suggest that mutations in MEOX1 cause a recessive KFS phenotype in humans.

Bilateral thoracic ganglion cyst : a rare case report.

Ganglion cysts usually arise from the tissues around the facet joints. It is usually associated with degenerative cahanges in facet joints. Bilateral thoracic ganglion cysts are very rare and there is no previous case that located in bilateral intervertebral foramen compressing the L1 nerve root associated with severe radiculopathy. We report a 53 years old woman who presented with bilateral groin pain and severe numbness. Magnetic resonance imaging revealed bilateral cystic mass in the intervertebral foramen between 12th thoracal and 1st lumbar vertebrae. The cystic lesions were removed after bilateral exposure of Th12-L1 foramens. The result of hystopathology confirmed the diagnosis as ganglion cyst. The ganglion cyst may compromise lumbar dorsal ganglion when it located in the intervertebral foramen. The surgeon should keep this rare entity in their mind for differential diagnosis.

Intracranial sewing needles in an adult patient.

A 37-year-old patient is reported with intracranial sewing needles, which were located in the right frontal lobe. Both clinical and radiological findings suggested that these needles must have been introduced in infancy before the closure of anterior fontanelle during an unsuccessful homicide. Usually intracranial foreign objects are placed due to penetrating trauma or surgical procedures. Child abuse has been known for centuries. Many types of physical traumas have been reported, especially in Western countries. In Iran, insertion of sewing needles into the brain aiming to kill the infant have been seen in a lot of cases. This situation takes part in a lot of Persian stories. We reported a 37-year-old man who had 2 intracranial sewing needles with unknown etiology.

Diagnosis and treatment of ossified cephalhematoma.

Ossified cephalhematoma is a rare clinical entity. Even though cephalhematoma is frequently encountered, ossified cephalhematoma occurs only sporadically. We report a 13-week-old boy who was admitted to neurosurgery clinic with deformity of the skull. A plain skull radiograph showed radiolucent areas in the right parietal region. CT scan of the head showed thickened right parietal bone and a low-density lesion between bony layers. 3D CT of the skull showed bony protrusion of the right parietal bone. A cosmetic surgical procedure was performed for the patient, and biopsy of the bony lesion confirmed ossified cephalhematoma. We discuss diagnosis, pathogenesis, and treatment of ossified cephalhematoma.

Unilateral hyperplasia of lamina and spinous process of C6 vertebra: case report.

We report a 20-year-old male patient who was admitted to our emergency clinic after a traffic accident and who suffered from neck pain. Radiographic examination of the cervical spine showed hypertrophy of the left lamina and hypertrophy and elongation of the left spinous process of the sixth cervical vertebra (C6). A computed tomography scan revealed the associated schisis of the spinous process at the same level. Magnetic resonance imaging scan demonstrated no abnormality of the neural elements. The patient underwent a surgical operation due to persistent neck pain and the local aesthetic abnormality.

Subdural hematomas and emergency management in infancy and childhood: a single institution's experience.

OBJECTIVE: We aimed to identify the incidence, clinical features, management, and outcome of subdural hematomas (SHs) in infancy and childhood. METHODS: Twenty-one children younger than 11 years with SH were analyzed. Clinical features and possible child abuse were considered in each case. RESULTS: Eight children experienced minor injuries due to hitting of solid items on their head. Five of these children also had coagulation disorders. Three of the children suffered from child abuse, only one of the children had head trauma due to car accident. Nine of the patients experienced SH due to fall down. Nine patients have acute SH, 7 had subacute SH, 4 had chronic SH, and 1 had acute and subacute SH together. Clinical presentation varied greatly. Most of them presented with vomiting and seizure. The outcome patterns were different among the patients. Deep coma on admission was associated with an unfavorable outcome. CONCLUSIONS: Subdural hematoma is common in infancy and childhood and carries a poor prognosis. Most of the cases are due to head trauma, coagulation disorders, and child abuse. We believe that clinical investigation of such children should be carried out in a multidisciplinary approach with the collaboration of pediatricians, social workers, and neurosurgeons.