Abdulfettah Tumturk

Different etiologies of acquired torticollis in childhood

IntroductionTorticollis can be congenital or may be acquired in childhood. Acquired torticollis occurs because of another problem and usually presents in previously normal children. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders.ObjectiveWe performed this study to evaluate the underlying causes of torticollis in childhood.Material and methodsTen children presented with complaints of torticollis between April 2007 and April 2012 were enrolled in this study. The additional findings of physical examination included neck pain, twisted neck, walking disorder, imbalance, and vomiting The identified etiologies of the enrolled children was acute disseminated encephalomyelitis in a 2.5-year-old boy, posterior fossa tumor in a 10-month-old boy, spontaneous spinal epidural hematoma in a 5-year-old hemophiliac boy, cervical osteoblastoma in a 3-year-old boy, arachnoid cyst located at posterior fossa in a 16-month-old boy, aneurysm of the anterior communicating artery in a 6-year-old girl, pontine glioma in a 10-year-old girl, and a psychogenic torticollis in a 7-year-old boy were presented.ConclusionThere is a wide differential diagnosis for a patient with torticollis, not just neurological in etiology which should be considered in any patient with acquired torticollis. Moreover, early diagnosis of etiological disease will reduce mortality and morbidity. Therefore, clinicians managing children with torticollis must be vigilant about underlying neurological complications.

The Management of Blood Loss in Non-Syndromic Craniosynostosis Patients Undergoing Barrel Stave Osteotomy

AIM Barrel stave osteotomy is a widely used procedure in neurosurgery for the majority of craniosynostosis patients. Both in the intraoperative and postoperative periods, there is inevitable leakage type bleeding from the bones undergoing osteotomy. A number of studies have been performed in order to prevent this complication but a concise procedure is still lacking. MATERIAL AND METHODS Synostectomy and parietotemporal barrel stave osteotomy were applied to 143 patients who were operated on with a diagnosis of craniosynostosis between the years 2005-2013. At the beginning to osteotomy, 5 ml/kg erythrocyte suspension (ES) was given for probable blood loss. Whole blood count was performed at the postoperative 1st and 6th hours and cases with hemoglobin levels below 10 or with hematocrit levels which had decreased more than 5% between the 1st and 6th hours were administered erythrocyte transfusion. RESULTS Of the patients, 100 were boys and 43 were girls. Of these, 98 had metopic, 30 had sagittal, 9 had metopic+sagittal, 4 had unilateral, 2 had bilateral and 6 had coronal synostosis. All the cases were administered intraoperative erythrocyte suspension. The preoperative amount of administered mean erythrocyte was 8.61 ml/kg. In the postoperative period, 92 patients were administered erythrocyte suspension. The postoperative amount of administered mean erythrocyte suspension was 7.98 ml/kg. CONCLUSION For an operated infant with craniosynostosis who is operated on in the first year of life, undergoing osteotomy and inevitable bone-borne blood losses are very important and these have to be replaced immediately.

SURGICAL STRATEGIES IN SPONDYLODISCITIS DUE TO LUMBAR DISC SURGERY.

AIM Despite different surgical treatment protocols at different centers for spondylodiscitis due to lumbar surgery, there is no consensus on its surgical indications. In this study, we aimed to clarify the steps to be followed in the management and treatment of postoperative spondylodiscitis. MATERIAL AND METHODS The data of 20 cases with postoperative spondylodiscitis were evaluated. C-reactive protein (CRP) was used for diagnosis and follow-up. According to culture results of the infected material obtained from the operated cases, appropriate antibiotic treatment was initiated. In non-operated cases, parenteral empirical antibiotic treatment was implemented. Surgical treatment was planned for cases with clinical and radiological instability, abscess on imaging and those who were nonrespondent to empirical antibiotic treatment. For the cases that clinically recovered and had normal CRP levels, oral antibiotic treatment was continued after parenteral antibiotic treatment. RESULTS Of the cases; 13 were male (65%) and 7 were femals (35%). The mean age was 56.3 years (32-74). The most prevalent complaints in referral were waist and leg pain. Except one, all cases had increased CRP levels. All patients had spondylodiscitis on magnetic resonance imaging. Seven had radiological and clinical instability and 3 had epidural abscess. The most commonly growing microorganism in culture was Staphylococcus aureus. Surgical treatment was applied to seven cases and medical treatment to 13 cases. CONCLUSION In cases with waist pain in the postoperative period, the first potential diagnosis to be considered is spondylodiscitis. Surgical treatment should be implemented for cases resistant to empirical antibiotic treatment, with abscess on imaging, or with lumbar instability.

Brain abscesses in children: results of 24 children from a reference center in Central Anatolia, Turkey.

Childhood brain abscesses are a rare and potentially life-threatening condition requiring urgent diagnosis and treatment. This retrospective study analyzed the clinical and radiologic findings of 24 (7 girl, 17 boys) cases with brain abscess. Mean age was 92.98 ± 68.04 months. The most common presenting symptoms were nausea-vomiting (45.8%) and headache (41.7%). Brain abscess was most commonly located in the frontal region. Diffusion restriction was determined in 78.4% of lesions. The mean apparent diffusion coefficient value in these lesions was 0.511 ± 0.23 × 10–3 mm2/s. Cultures were sterile in 40% of cases. Antimicrobial therapy was given to only 16.7% of cases. Predisposing factors were identified in 91.6% of cases (congenital heart disease in 20.8% and immunosuppression in 20.8%). Mortality level was 12.5%. In conclusion, immunocompromised states, and congenital heart disease have become an important predisposing factor for brain abscesses. Effective and prompt management should ensure better outcome in childhood.

Short Segment Stabilization by Protecting the Alar Ligaments in a Case of Eosinophilic Granuloma Involving the C2 Spine.

BACKGROUND The craniocervical junction is a complex anatomic location that contains the occipital bone, atlas, axis, and important complex ligamentous structures. The stability of this region is ensured only with the help of ligaments. CASE DESCRIPTION A 6-year-old boy was admitted to our clinic for neck pain. Computed tomography and magnetic resonance imaging revealed a lytic bone lesion involving the C2 vertebral body and pedicle without odontoid tip. The tumor was resected using an anterior retropharyngeal approach and a wide marginal resection method. The odontoid tip and alar ligaments were protected, and the costal autografts were located between the C1-odontoid tip and the C3 body. The costal graft was stabilized in the C3 body with a miniplate. Then, C1-C3 posterior fixation with fusion was performed. The craniocervical junction was not considered unstable because the occipital bone was not involved in the fusion. Histologic examination confirmed the diagnosis of eosinophilic granuloma. Fusion was detected on a 1-year postoperative cervical computed tomography scan. CONCLUSIONS The occiput should not be involved in the fusion area when the alar ligaments are preserved during surgery for a C2 lesion.

En bloc cervical laminoplasty with preserving posterior structure and arcocristectomy in cervical spondylotic myelopathy.

AIM To evaluate the clinical success of the en bloc laminoplasty and impact of the arcocristectomy on postoperative axial pain of the patients with cervical spondylotic myelopathy (CSM). MATERIAL AND METHODS A retrospective review of 81 patients with CSM who underwent en bloc cervical laminoplasty while preserving posterior structure of the cervical spine during the period from 2007 to 2014 was performed. Arcocristectomy was performed if the C6-7 level was included in the surgery. The posterior spinal elements and muscles attached to the spinous process of C2 and C7 were preserved. Thus, postoperative deformity of the cervical spine could be avoided. The neurological status of the patients was assessed using the modified Japanese Orthopedic Association (JOA) scale. The neurological recovery rate was calculated according to the Hirabayashi method. RESULTS The mean modified JOA scale score was 11.4±2.4 preoperatively and 15.0±3.9 postoperatively. The neurological recovery rate was 68.6%. C7 arcocristectomy was performed in 19 patients. No axial pain was noted in the first 2 postoperative months. Keyhole foraminotomies were performed in 11 patients and radicular pain completely resolved after surgery. Temporary C5 nerve root palsy was observed in 3 patients. Mean cervical spine lordosis was 10.6o±10.5o preoperatively and 8.6o±9.5o postoperatively. No postoperative spinal instability or kyphotic deformity was noted. CONCLUSION En bloc cervical laminoplasty while preserving posterior structure is useful in preventing postoperative spinal malalignment and axial pain. Arcocristectomy is an effective technique for the prevention of postoperative axial pain in patients with C6-7 spinal stenosis.

Television Tip Overs and Head Traumas in Childhood: Results of 36 Children from a Reference Center in Central Anatolia, Turkey.

AIM Television tip overs and head traumas in children showed an increase in the recent years in Turkey and throughout the world. In this study, the injury types, the surgical interventions and the children exposed to head trauma due to an accident caused by a falling television were investigated retrospectively. Some cautions were suggested in order to prevent these injuries. MATERIAL AND METHODS The gender, age, Pediatric Glasgow Coma Scale (PGCS) score, radiologic findings, the need for intensive care unit, the time period spent in the hospital, the applied surgical treatments, the accompanied treatment and pathology of 36 children who were treated in the department of neurosurgery at Erciyes University School of Medicine were evaluated. RESULTS Eighteen of the patients were male and 18 were female. The number of cases younger than 3 years was 21 while the number of cases over the age of 3 years was 15. Thirty-two of the cases had full head trauma. Three female patients died. The mean PGCS score at admission was 12.7. While surgical treatment was applied to four of the patients in our department, facial nerve exploration was performed in the Ear Nose and Throat Department to the patient who suffered facial nerve damage. CONCLUSION Each year, many children are injured or even die due to this trauma that can be easily prevented. The parents, television producers, doctors, health personnel, academic institutions, governments, legislators, national and international organizations are responsible for this trauma.

Intratumoral Ethyl Alcohol Injection for Devascularization of Hypervascular Intracranial Tumors.

AIM Hypervascular intracranial tumors may cause serious bleeding in surgery. Though pre-operative endovascular embolization of tumor is a widely accepted method, sometimes despite embolization, an effective and safer intraoperative hemostatic technique is needed to prevent or at least decrease the massive bleeding from the tumors. The aim of this study was to investigate the effect of the ethyl alcohol (EA) injection in hypervascular tumors and find out whether it is likely to be an alternative method to prevent massive bleeding from tumor. MATERIAL AND METHODS Fifty-five cases that had hypervascular intracranial tumor and underwent EA injections into their tumors were included in the study. A small amount (0.1-0.2 ml) of EA was used in every injection. Total EA amount differed from 1.2 to 18 ml for each patient. RESULTS Most of the tumors were removed with less bleeding, because bleedings stopped or decreased during resection after EA injections. No serious complication that might be related to EA was observed. CONCLUSION EA injection into the tumor is an easy, cheap and less invasive method to obtain effective and safe tumor devascularization. It may be an alternative method for tumor devascularization when preoperative embolization cannot be performed due to any reason or severe bleeding despite embolization.

Evaluation of Aggressive Behavior and Invasive Features of Pituitary Adenomas Using Radiological, Surgical, Clinical and Histopathological Markers.

AIM Total surgical resection of pituitary macroadenomas is difficult due to the location of the adenoma and the propensity to invade surrounding tissues. The purpose of this study was to evaluate the risk factors for invasive and aggressive pituitary macroadenomas using radiological, hormonal, clinical, and immunohistochemical markers. MATERIAL AND METHODS Seventy cases of pituitary macroadenoma were examined. Age, gender, symptoms, the presence of fibrosis within the adenoma, hormonal levels, radiological findings, pathological results and immunohistochemical staining of the patients were evaluated using statistical methods. RESULTS We observed that the patients with macroadenomas in our study most frequently presented during their 5th decade. The most frequent pituitary adenomas were non-functional, GH-secreting and PRL-secreting macroadenomas. The most frequent complaint was vision loss, headache and acral growth. Based on Magnetic Resonance Imaging (MRI) results, it was observed that the degree of invasion into surrounding tissues increased as the size of the macroadenoma increased. Macroadenomas that had invaded into the cavernous sinus invasion or that had a fibrotic tumor structure had a low probability of being resectable. There were no significant relationships between invasive behavior and p53, telomerase, ghrelin and CD46. CONCLUSION It is not possible to identify only one factor that affects the prognosis of patients with pituitary macroadenomas. The contribution of the experience of surgeon to the treatment is surely beyond dispute. Fibrotic tumor structure, the surgical technique, the type of hormone, and cavernous sinus invasion affect the ability to perform a total resection and the overall prognosis.

The Results of the Surgical Treatment of Spontaneous Rhinorrhea via Craniotomy and the Contribution of CT Cisternography to the Detection of Exact Leakage Side of CSF.

AIM To share the results of conventional surgery in rhinorrhea and the contribution of computerized tomography (CT) cisternography to determination of the site of cerebrospinal fluid (CSF) leak. MATERIAL AND METHODS Twelve cases treated for spontaneous rhinorrhea were included in this study. All the cases underwent cranial CT and magnetic resonance imaging (MRI). CT cisternography was performed in four patients whose bone defect or leakage site could not be detected by CT and MRI. In order to repair the defect, either the galea or galea together with collagen matrix was used and the procedure was supported with fibrin glue. RESULTS In the cases, postoperative rhinorrhea was seen in neither the early nor the late follow up period. We observed no complications related to CT cisternography or craniotomy. The leakage area was successfully detected with CT cisternography when the other methods failed. CONCLUSION Bone defect can usually be shown by means of CT. However, when bone-defect cannot be shown or the dura in the defective area is intact, CT cisternography is useful to show the CSF leak. Conventional surgery was very succesful in the treatment of spontaneous rhinorrhea but it was cosmetically problematic. In the patients both treated with galea and galea together with collagen matrix, the repair of the defect was successful.