Atilla Yilmaz

Being a neighbor to Syria: A retrospective analysis of patients brought to our clinic for cranial gunshot wounds in the Syrian civil war

OBJECTIVE Toward the end of 2010, the Arab spring, the waves of revolutionary demonstrations and protests influenced also Syria, where violent clashes turned into a civil war. Hundreds of thousands of people became refugees. The use of excessive force unfortunately culminated in numerous deaths and injuries in many cities. Being the closest city to Aleppo, Damascus and Homs, the biggest cities of Syria, Antioch/Hatay has been the city where initial emergency treatments were performed. For this reason, we examined and retrospectively analyzed the medical records of the patients treated in the clinics of our hospital due to cranial gunshot wounds during the war. MATERIAL AND METHODS The medical records of 186 patients who were injured in the Syrian War and brought to, followed up and treated in the Neurosurgery Clinic of Mustafa Kemal University, Faculty of Medicine in Hatay, a Turkish city on the Syrian border, between April 2011 and June 2013. RESULTS A total of 186 patients were evaluated in a period of more than 2 years. Of all 91.4% of the patients were adults (male/female: 152/18) and 8.6% of them were pediatric patients (male/female: 14/2). The average age of the patients was 31 years, with an age range of between 2 months and 67 years. According to Glasgow coma score (GCS) of the patients at the time of admission, GCS was 3 in 32 patients (17.2%), between 4 and 7 in 70 patients (37.6%), and between 8 and 15 in 84 patients (45.1%). We observed that the patients with GCS of 4-7 had a significantly lower mortality among the 56 patients treated surgically compared with the 14 patients treated medically. DISCUSSION Cranial gunshot wounds are responsible for high mortality and morbidity. A multiplicity of factors plays a role on morbidity and mortality. These are the duration of transport, the injury pattern, the velocities of the weapons used, and the Glasgow Coma Scales of the patients at the time of admission. CONCLUSION The authors recommend that the patients with cranial gunshot wounds who has GCS of 4-7 should be aggressively treated including surgery as well. We do not recommend surgical treatment for patients with GCS of 3. All our experiences show that treatment of gunshot wounds will continue to be a matter of debate, about which there is more to learn. The data presented in this study will once again demonstrate the seriousness of the event, and will, perhaps, contribute to the peace negotiations to end the war.

Protective effects of minocycline on experimental spinal cord injury in rats.

BACKGROUND The effects of minocycline on neuronal injury after spinal cord injury (SCI) are limited and controversial. Therefore we aimed to investigate the protective effects of minocycline on tissue and on serum concentrations of malondialdehyde (MDA) levels, superoxide dismutase (SOD) activity, glutathione peroxidase (GSH-Px) activity, tissue total antioxidant and oxidant status (TAS and TOS, respectively), and AST and LDH levels in rats with SCI. METHODS This study was performed on 7-8 weeks 38 male Wistar albino rats. The animals were randomly divided into five groups: group 1, Sham (n=8); group 2, SCI (spinal cord injury)/control (n=8); group 3, SCI+minocycline3 (n=7); group 4, SCI+minocycline30 (n=8) and group 5 SCI+minocycline90 (n=7). Blood and tissue samples were analysed for MDA, SOD, GSH-Px, TAS, TOS, AST and LDH levels. RESULTS The MDA levels were significantly higher in SCI group compared to sham group (p<0.001), and MDA levels were also significantly higher in SCI group compared to SCI+M3, SCI+M30, SCI+M90 (p<0.05). SOD levels were significantly higher in SCI+M30 when compared to SCI and SCI+M3 groups (p<0.05). GSH-Px levels decreased significantly in SCI and SCI+M3 groups compared to sham (p<0.05). SCI+M3 group showed significantly decreased levels of TAS and TOS compared to SCI group (p<0.05). TAS and TOS levels significantly increased in SCI+M90 group compared to SCI+M3 and SCI+M30 groups (p<0.05). CONCLUSIONS The present study demonstrates the dose-dependent antioxidant activity of minocycline against spinal cord injury in rats. Minocycline administration increased antioxidant enzyme levels and improved total antioxidant status.

Serum nesfatin-1 levels: a potential new biomarker in patients with subarachnoid hemorrhage*

Background: Acute subarachnoid hemorrhage (SAH) is a neurological emergency with significant potential for long-term morbidity and mortality. Nesfatin-1 is a polypeptide which is found in various regions of the brain that play role in the feeding and metabolic regulation. Objective: So this study aimed to investigate if nesfatin-1 levels in patients with SAH, could be used as a marker for the severity and prognosis. Method: Forty-eight consecutive patients (except those excluded) admitted to the emergency service of our hospital and hospitalized at our clinic with the diagnosis of aneurysmal SAH between 2011 and 2013 were included in the study and followed up for six months for outcome. The control group consisted of 48 healthy individuals of similar age and gender. Results: During the 6-month follow-up, 7 of 48 patients died and 16 (33.3%) patients had poor Glasgow Outcome Score (GOS) scores. In the study group, the mean nesfatin-1 level was significantly higher than the control group (7.36 ± 2.5 pg/ml and 4.29 ± 2.02 pg/ml, respectively; p < 0.01). The mean nesfatin-1 level was 11.58 ± 0.87 pg/ml in the non-survival group and 6.64 ± 1.89 pg/ml in the survival group. Furthermore, it was 10.22 ± 1.42 pg/ml in patients with poor outcome in terms of GOS and 5.93 ± 1.46 pg/ml in those with good outcome. The nesfatin-1 levels significantly increased with worsening of GOS, the World Federation of Neurological Surgeons grading system, and Fisher scores and increasing plasma C-reactive protein levels (p < 0.01 for all). Conclusion: The present study is the first that shows the mortality/poor outcome of the SAH with assessing serum nesfatin-1 levels. So levels of nesfatin-1 might be useful in SAH management.

Disc Rehydration after Dynamic Stabilization: A Report of 59 Cases

Study Design A retrospective study investigating decrease in the nucleus pulposus signal intensity or disc height on magnetic resonance imaging (MRI) and disc degeneration. Purpose Although a degenerated disc cannot self-regenerate, distraction or stabilization may provide suitable conditions for rehydration and possible regeneration. This study aimed to evaluate clinical outcomes and disc regeneration via MRI in a series of patients with degenerative disc disease (DDD) who underwent lumbar stabilization with a dynamic stabilization system (DSS). Overview of Literature A dynamic system provides rehydration during early DDD. Methods Fifty-nine patients (mean age, 46.5 years) who undedwent stabilization with DSS for segmental instability (painful black disc) between 2004 and 2014 were retrospectively evaluated. All patients underwent MRI preoperatively and 12 months postoperatively. Intervertebral disc (IVD) degeneration grades at the implanted segment were categorized using the Pfirrmann classification system. Patients were followed for a mean of 6.4 years, and clinical outcomes were based on visual analog scale (VAS) and Oswestry disability index (ODI) scores. Results Significant improvements in back pain VAS and ODI scores from before surgery (7 and 68%, respectively) were reported at 6 (2.85 and 27.4%, respectively) and 12 months postoperatively (1.8 and 16.3%, respectively). Postoperative IVD changes were observed in 28 patients. Improvement was observed in 20 patients (34%), whereas progressive degeneration was observed in eight patients (13.5%). Thirty-one patients (52.5%) exhibited neither improvement nor progression. Single Pfirrmann grade improvements were observed in 29% of the patients and two-grade improvements were observed in 5%. Conclusions Our observations support the theory that physiological movement and a balanced load distribution are necessary for disc regeneration. We conclude that DSS may decelerate the degeneration process and appears to facilitate regeneration.

High Infection Rates in Patients with Long-Segment Dynesys System

BACKGROUND Infection follow-up in patients stabilized with the Dynesys system. Infection rates were determined in patients who had ≥5 segments stabilized with the Dynesys system. METHODS Eighty-three patients with various etiologies were stabilized with the Dynesys system. Long-level stabilization patients were separated from the main group as a result of their high rates of infection. RESULTS Long-level stabilizations were performed in 8 of 83 patients. Five patients were determined to have infections including 4 deep infections and 1 superficial infection. In patients with deep infections, 3 of them exhibited chronic infections that lasted for approximately 2 years and the system was removed. A deep infection in 1 patient and a superficial infection in 1 patient were diagnosed after 1 month. The early-diagnosed deep infection patient was treated with wound irrigation and antibiotics. The system was not removed, and the wound was closed with daily dressing after 45 days. One superficial infection patient was only treated with daily dressing, and the infection healed within 2 weeks. The infectious agent was determined in 2 patients. Three patients in the chronic infection group underwent a surgical procedure to remove the system. Specific antibiotic treatments were administered to patients whose infectious agents were identified. The remaining patients were treated with wide-spectrum antibiotics. CONCLUSIONS We report that long-level stabilization with the Dynesys system results in a high infection rate.

Suspension of the spinal dura mater to the corpectomy cage with tack-up sutures for bleeding control and prevention of epidural hematoma: operative technique

Case s tudy: A 70-year-old male patient was admitted with paresis on the right arm. MRI showed protrusion and grade 2 spondylolisthesis at C3–C4, obliteration of anterior cerebrospinal fluid column caused by osteophytes at C4–C5–C6, and loss of intervertebral disc height and degenerative fusion at the same level. C4–C5 anterior corpectomy and instrumentation was performed. Two hours after surgery, neurologic deficits developed and an epidural hematoma was detected on MRI. The patient underwent a revision surgery and hemostasis was achieved by the suspension technique. Neurologic deficits recovered postoperatively. Postoperative MRI showed the suspension of dura like a tent and no hematoma in the epidural space.

Is emergent cervical radiological evaluation mandatory in isolated cranial gunshot injury

Aim: The aim of this study was to evaluate the accompanied cervical injuries of the patients presenting to the emergency department (ED) because of penetrating, perforating or tangential cranial gunshot injuries (CGI). Material and Methods: The retrospective study included 137 patients that presented to the EDs at Mustafa Kemal and Adiyaman University due to penetrating, perforating or tangential CGI between 2014 and 2018. Patients younger than 12 years old and had insufficient radiological records were excluded from the study and thus 115 patients were included in the study. Results: 115 patients included 105 (91%) men and 10 (9%) women with a mean age of 27 (range, 12-65) years. Of the 115 injuries, 84 (73%) were high-velocity and 31 (27%) were low-velocity gunshot injuries. The injuries included 92 (80%) penetrating or perforating and 23 (20%) tangential injuries. No cervical dislocation injury was accompanied by CGI in any patient. Unilateral lamina fracture of the cervical vertebra was observed in one patient. Conclusion: Our results support the opinion that isolated penetrating, perforating or tangential CGI did not cause to cervical spinal injuries, the intubation or tracheostomy procedures should not be postponed after radiological evaluation of cervical spinal stability.

Complications of 2-level dynamic stabilization

AIM A retrospective chart and a radiographic review. Evaluation of postoperative complications, clinical improvements and radiological parameters in patients who underwent surgery using a dynamic system for 2-level lumbar stabilization. We aimed to investigate the postoperative complications, such as screw loosening, screw breakage and ASD, in patients who underwent surgery with 2-level dynamic stabilization systems. MATERIALS AND METHODS Dynamic lumbar systems enable the stabilization of unstable degenerative spines, while preventing fusion-related complications, such as adjacent segment disease(ASD) and pseudarthrosis. In our study a total of 103 patients with lumbar degenerative spinal instability underwent 2-level dynamic stabilization. Clinical findings were reviewed at a 2-year follow-up. Screw breakage and loosening were evaluated during this duration together with clinical findings. RESULTS Visual analog scale(VAS) and Oswestry Disability Index(ODI) scores significantly decreased at the four-month evaluation, and they were also decreased at the 1-year follow up and at the 24th postoperative month. Adjacent segment disease was diagnosed in twelve (8 females, 4 males) of the 103 patients in the follow-up radiological and clinical controls. There were 9 screw breakages and 4 screw loosening. The complication rate of 2-level of dynamic stabilization was high in this study. CONCLUSIONS Our results showed that complications (screw loosening or breakage and adjacent segment disease) are not rare after using the 2-level dynamic stabilization system, unlike the acceptable results with the single-level dynamic system. The most probable explanation is that the instrument system behaves more rigidly with every additional segment.

Use of programmable versus nonprogrammable shunts in the management of normal pressure hydrocephalus: A multicenter retrospective study with cost–benefit analysis in Turkey

Abstract Ventriculoperitoneal shunt systems that are used in the treatment of normal pressure hydrocephalus are often associated with drainage problems. Adjustable shunt systems can prevent or treat these problems, but they may be expensive. The aim of our study is to compare the complications and total cost of several shunt systems. Patients with normal pressure hydrocephalus who underwent ventriculoperitoneal shunting between 2011 and 2016 were included in the study. The study involves patient consent and the informed consent was given. Complications and the average cost per person were compared between patients with adjustable and nonadjustable shunts. Shunt prices, surgical complications, and revision costs were taken into account to calculate the average cost. Of the 110 patients who were evaluated, 80 had a nonadjustable shunt and 30 had an adjustable shunt. In the group with adjustable shunts, the rates of subdural effusion and hematoma were 19.73% and 3.29%, respectively. In the group with nonadjustable shunts, these rates were 22.75% and 13.75%, respectively. One patient in the adjustable group underwent surgery for subdural hematoma, while 8 patients in the nonadjustable group underwent the same surgery. Ten patients required surgical intervention for subdural effusion and existing shunt systems in these patients were replaced by an adjustable shunt system. When these additional costs were factored into the analysis, the difference in cost between the shunt systems was reduced from 600 United States dollars (USD) to 111 USD. When the complications and additional costs that arise during surgical treatment of normal pressure hydrocephalus were considered, the price difference between adjustable and nonadjustable shunt systems was estimated to be much lower.

A rare complication of subdural-peritoneal shunt: Migration of catheter components through the pelvic inlet into the subdural space

Subdural-peritoneal (SP) shunting is a simple procedure to treat subdural hygromas; however, several rare complications such as shunt migration exist. A 15-year-old boy presented with headache, nausea, and vomiting , and underwent SP shunting for left frontoparietal chronic subdural effusion. Six weeks later, radiographic examinations revealed total migration of the shunt through the pelvic inlet. The migrated shunt was replaced with a new SP shunt. Four weeks later, radiographic examinations revealed shunt migration into the subdural space. The shunt catheter was removed and the subdural effusion was evacuated. Shunt migration may result from pressure differences between the abdomen and the cranium or from head movement, and insufficient fixation and/or large burr holes can facilitate shunt migration. Double firm anchoring and small-sized burr holes can prevent this complication. SP shunt is a simple procedure, and its assumed complications can be prevented through precaution.