Ali Cetin Sarioglu

Microneurosurgical Treatment of Intracranial Dermoid and Epidermoid Tumors

Forty-three patients with intracranial, intradural dermoid (8) and epidermoid (35) tumors underwent radical surgical resection utilizing strict microneurosurgical technique. The average age was 37.3 years for the patients with epidermoid tumors and 36.2 years for the patients with dermoid tumors. The male to female ratio was 3:2 for the epidermoid group and 3:1 for the dermoid group. Common clinical presentations included cerebellar dysfunction, cranial nerve impairment, and seizures. Typically, computed tomography scans revealed the epidermoid tumors (30 cases studied) as nonhomogeneous hypodense lesions with irregular borders and without contrast enhancement. The dermoid tumors (7 cases studied) had a similar appearance, but with a wider range of attenuation values. Magnetic resonance imaging findings for the epidermoid tumors (6 cases studied) consisted of increased T1 and increased T2 relaxation times. Supratentorial tumors were excised by the pterional (frontosphenotemporal) approach, mesencephalic tumors by either a supratentorial posterior interhemispheric transtentorial approach or an infratentorial/supracerebellar method, and posterior fossa tumors by either a medially or laterally positioned suboccipital osteoplastic craniotomy. One epidermoid tumor and one dermoid tumor were considered to be subtotally resected because of dense adherences left attached to vital structures; the remaining 41 tumors were completely excised. The most frequent complications were aseptic/chemical meningitis and transient cranial nerve palsies. There were no perioperative deaths. Mean follow-up was 5.2 years. Eighty-six percent of patients reported good to excellent results. No patient had experienced symptomatic or radiographic evidence of recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery.

OBJECTIVE: Postoperative fibrosis is one of the most important causes of failed back surgery syndrome after lumbar disc surgery. Numerous natural and synthetic materials have been investigated as means to prevent or reduce postoperative scarring after these operations. Preservation of the ligamentum flavum for this purpose has not been studied in depth. A prospective, randomized, controlled clinical study was conducted. The aim was to present a new technique for preserving the ligamentum flavum during lumbar discectomy, and to evaluate whether this helps prevent or diminish postoperative fibrosis. METHODS: Twenty patients with unilateral L5–S1 disc herniation were randomly divided into two equal groups. Group A patients underwent classic microlumbar discectomy, and Group B patients underwent the same procedure but with preservation of the ligamentum flavum. Visual analog pain scale (VAPS) scores, Oswestry scale scores, and straight-leg raising angles were recorded preoperatively and at 6 months postoperatively. Differences between the pre-operative and postoperative findings for each group were statistically compared using the Wilcoxon test. Magnetic resonance imaging was also done at 6 months to assess the extent of postoperative fibrosis, and a scarring grade was recorded for each patient. The group findings for this were analyzed with Levene’s test. RESULTS: Both groups’ clinical parameters were significantly improved at 6 months postsurgery. In Group A, the mean pre- and postoperative VAPS scores were 9.2 and 3.2, respectively (P < 0.05); the corresponding mean Oswestry scale scores were 88 and 28.2, respectively (P < 0.05); and the corresponding mean straight-leg raising angles were 290 and 630, respectively (P < 0.05). In Group B, the mean pre- and postoperative VAPS scores were 9.2 and 2.6, respectively (P < 0.05); the corresponding mean Oswestry scores were 85.2 and 22.2, respectively (P < 0.05); and the corresponding mean straight-leg raising scores were 260 and 710, respectively (P < 0.05). The mean scarring grades in Groups A and B were 1.8 and 1.0, respectively (P < 0.05). CONCLUSION: The groups both showed satisfactory clinical outcomes and the improvements were comparable; however, the group with preserved ligamentum flavum showed significantly less local fibrosis at 6 months postoperatively. The authors speculate that this surgical technique provides a physical protective barrier that can reduce or even eliminate fibrosis-related complications after lumbar disc surgery.

Idiopathic spinal cord herniation: case report and review of the literature.

Abstract Background: Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive myelopathy frequently present in Brown-Séquard syndrome. Preoperative diagnosis can be made with magnetic resonance imaging (MRI). Many surgical techniques have been applied by various authors and are usually reversible by surgical treatment. Methods: Case report and review of the literature. Findings: A 45-year-old woman with Brown-Sequard syndrome underwent thoracic MRI, which revealed transdural spinal cord herniation at T8 vertebral body level. During surgery the spinal cord was reduced and the ventral dural defect was restorated primarily and reinforced with a thin layer of subdermal fat. The dural defect was then closed with interrupted stitches. Results: Although neurologic status improved postoperatively, postsurgical MRI demonstrated swelling and abnormal T2-signal intensity in the reduced spinal cord. Review of the English language literature revealed 100 ISCH cases. Conclusions: ISCH is a rare clinical entity that should be considered in differential diagnosis of Brown-Séquard syndrome, especially among women in their fifth decade of life. Outcome for patients who initially had Brown-Séquard syndrome was significantly better than for patients who presented with spastic paralysis. Although progression of neurologic deficits can be very slow, reduction of the spinal cord and repair of the defect are crucial in stopping or reversing the deterioration.

Anterior cervical microdiscectomy with or without fusion.

Background Anterior cervical microdiscectomy (ACD) is commonly applied in the surgical treatment of cervical disc herniation. However, following discectomy procedure to perform a fusion process is still controversial. Therefore, a controlled, multicentric, prospective, randomized study was designed. Material and Method Totally 20 patients were operated. Eleven patients were operated with applying simple anterior microdiscectomy technique. Nine patients were operated via ACD and fusion with a semirigid plate technique. Preoperative and postoperative [immediate; postoperative first day and postoperative 1u2009y (mean 13.95u2009mo)] computed tomography studies and plain x-rays were obtained. The cervical disc and bilateral neural foramen heights of the operated level and adjacent segments were calculated. Pain assessment was performed using visual analog pain scale. Mann-Whitney statistical analysis method was applied to compare the outcomes for both groups. Results Satisfactory result was achieved in both groups. The pain scores for major complaint (arm pain) were decreased significantly in all patients after surgery regardless of the type of technique applied. The improvement in neck pain scores was significant only in patients who were treated with fusion procedure. There were no significant changes in disc height and neural foramen height measurements for both groups in adjacent levels in immediate and 1-year postoperative periods. The patients who were operated with simple ACD technique showed no significant decrease at postoperative first day in disc height and neural foramen height. However, the 1-year postoperative radiologic studies showed a significant decrease in disc height and neural foramen dimensions compared with preoperative values. The patients who were treated with fusion process showed a significant increase in disc height and nonsignificant increase in neural foramen heights at immediate postoperative study. However, with time, all dimensions showed significant decrease compared with preoperative values. Conclusions ACD technique offers satisfactory outcome regardless of whether fusion process is applied or not. Fusion with semirigid plate offers an advantage at operated level in immediate postoperative period in regard of disc height and neural foramen height. However, semirigid anterior plates by definition do not stop subsidence and the advantage that is offered by this technique is not persistent. On the other hand, to apply fusion process with semirigid plate system offers significantly less narrowing in disc height compared with simple ACD technique.

The Results of ??-tricalcium Phosphate Coated Hydroxyapatite (??-TCP/HA) Grafts for Interbody Fusion After Anterior Cervical Discectomy

Study Design The efficacy of tricalcium phosphate and hydroxyapatite (β-TCP/HA) grafts was studied after anterior cervical discectomy (ACD). Objective This study presents our observations about the efficacy of β-TCP/HA grafts after ACD. Summary of Background Data Especially in the last 2 decades, fusion materials such as autograft and allograft, as well as different kind of cages were used to maintain fusion after ACD. Methods β-TCP/HA grafts after ACD were used in 17 patients. The cervical and radicular pain was evaluated via visual analog scale (VAS) score preoperatively, at postoperative third week, and after 20 months (range: 18 to 24u2009mo) after the operation. The radiologic evaluations were done preoperatively, at postoperative first day and at the latest follow-up. The VAS, intervertebral space ratio, height of intervertebral disc space and neural foramen, and cervical and segmental lordosis angles were recorded preoperatively and during the postoperative follow-up period. The presence of fusion was controlled in computed tomography scans taken at the latest follow-up. Results Both clinical and radiologic evaluations yielded satisfactory results. VAS scores decreased significantly in all patients. The intervertebral space and neural foramen and intervertebral disc heights increased at postoperative day 1 but were found to be decreased at the latest follow-up (P<0.05). On the contrary the cervical and segmental lordosis angles decreased at postoperative day 1 but were found to be increased at the latest follow-up (P<0.05). There was a solid fusion in 16 out of 17 patients (94.11%). Conclusions Although there was a loss of the initially obtained neural foraminal and disc height, the application of β-TCP/HA graft after ACD resulted in a high rate of fusion and patient satisfaction. Additionally, the cervical and segmental lordosis was preserved. We concluded that it is a good alternative to current methods to maintain cervical alignment and fusion after ACD.

Long-term follow-up after open-window corpectomy in patients with advanced cervical spondylosis and/or ossification of the posterior longitudinal ligament.

Study Design Prospective study was performed in case with cervical spondylosis and ossification of the posterior longitudinal ligament (OPLL). Objective A novel anterior approach was defined and some patients were operated in this study. The late results of open-window corpectomy (OWC) were documented in a group of patients. Summary of Background Data The aim of this study was to assess long-term clinical and radiologic outcomes after OWC in patients with advanced cervical spondylosis and/or OPLL. Methods Data were collected from 15 patients at 3 time points: preoperatively and at 15 months and 92 months postoperatively. The clinical parameters were pain (assessed by visual analog scale) and upper extremity function (assessed by Japanese Orthopedics Association) score. The radiologic parameters recorded from magnetic resonance imaging and computed tomography were lordosis angles (cervical and segmental) and cervical spinal canal diameter. Group means were calculated and findings at the 3 time points were statistically compared. Adjacent-segment degeneration was also evaluated at 92 months. Results Concerning visual analog scale and Japanese Orthopedics Association results, the 2 postoperative mean scores were both significantly better than the preoperative mean but were not statistically different. The postoperative mean results for cervical and segmental lordosis angles and spinal canal diameter were all significantly better than the respective preoperative means for these parameters. Comparisons of postoperative means revealed no significant change in cervical lordosis, segmental lordosis, or cervical spinal canal diameter from short-term to long-term follow-ups. Five patients showed mild degeneration at adjacent segments in long-term follow-up. Conclusions Long-term follow-up indicates that OWC yields satisfactory clinical and radiologic outcomes in patients with anterior compressive cervical spondylosis and/or OPLL. OWC technique creates a more stable construct with 3-point fixation and offers better load sharing among implants and healthy vertebrae. Our observations suggest that OWC is a good surgical option for this patient group.

Spontaneous pyogenic spinal epidural abscess.

AIMnSpontaneous pyogenic spinal epidural abscess (SEA) is a rare condition but might be devastating and fatal. Traditional treatment is surgical decompression and antibiotics. A retrospective study was designed to assess the eff ect of clinical findings and treatment methods on the outcome.nnnMATERIAL AND METHODSn14 patients were reviewed (10 male, 4 female, mean age 59.14). Six dorsal, seven ventral and one dorsal with ventral SEA were observed. SEA found in thoracal (5), lumbar (4), cervical (3) regions. One patient showed both cervical and thoracal and one patient showed cervical, thoracal and lumbar involvement. All patients received minimum 3 weeks of I.V., followed by minimum 3 weeks of oral antibiotics. All patients complained of spinal pain. Ten patients presented with fever. Neurological deficit was observed in 9 cases.nnnRESULTSnA total of 22 interventions was performed. Instrumentation was applied in 5 cases. Full recovery was achieved in 7 patients, significant improvement was observed in 5 patients. The neurological findings did not change in one patient. One mortality and one morbidity were observed.nnnCONCLUSIONnSpontaneous SEA is a rare disease but might result in catastrophic neurological deficits and fatal even with prompt treatment. Therefore, one should always keep SEA in mind if a patient presents with fever, vague and spinal pain.

Thoracoscopic surgical approaches for treating various thoracic spinal region diseases.

AIMnMinimally invasive surgery is currently a goal for surgical intervention in the spine. The effectiveness of endoscopic thoracic spine surgery and technological improvements are two factors that are always under consideration in the practice of spinal surgery.nnnMATERIAL AND METHODSnWe present twenty-five patients whose thoracoscopic spinal surgeries were performed between 2002 and 2008 for the treatment of various spinal diseases. Eleven patients with thoracic disc herniation, five patients with traumatic thoracic spinal compressive fracture, six patients with metastatic thoracic spinal tumors and three patients with tubercular spondylitis underwent thoracoscopic spine surgery. Clinical evaluations were performed at 3, 6,12 and 24 months post-surgery. The Oswestry disability questionnaire and linear visual analog scale (VAS) were used for the evaluation of pain.nnnRESULTSnPostoperatively, two patients had lung contusions, one patient had pneumonia and one patient had instability. There were significant initial improvements in both the Oswestry score and the VAS pain score up to 6 months (p<0.05). The average relative difference in pain scores in all groups was not significant at 12 and 24 months (p>0.05).nnnCONCLUSIONnThe favorable results of thoracoscopic spinal surgery encourage its application to situations in which a conventional thoracic approach is indicated. Thoracoscopic spine surgery is applicable to all patients with various spinal diseases.