Ercan Özer

Inverse laminoplasty for the treatment of lumbar spinal stenosis.

Study Design. Fifteen patients with lumbar spinal stenosis were treated by a new technique, inverse laminoplasty, and the results were evaluated clinically and radiologically. Objective. To present the advantages of inverse laminoplasty over laminectomy for the treatment of lumbar spinal stenosis. Summary and Background data. Laminectomy has been used widely in the treatment of lumbar spinal stenosis. Destruction of the spinal bony structure, instability, and peridural scar formation are the main problems with this procedure. To overcome these disadvantages, a practical technique is presented here. Material and Methods. In a prospective study, 15 patients who underwent surgery with the inverse laminoplasty technique were evaluated clinically and radiologically. The Oswestry Disability Index was used for clinical assessment. L4–L5 spinal stenosis was detected in all patients. As the operative technique, the L4 lamina was elevated en bloc using a high-speed drill and rongeur. After removal of the ligamentum flavum, the roof of the foramina, and/or disc , the lamina was rotated 180 degrees, rested on facets, and reattached by use of a titanium miniplate. Results. All patients improved clinically and neurologically after this procedure. The mean Oswestry Disability Score was 38.33 preoperatively and 7.0 postoperatively. The mean follow-up time was 17.3 months. Spinal canal diameters were calculated by preoperative and postoperative computed tomography, and the mean enlargement was 77.8%. No complications were observed. Conclusion. With this technique, the important integrity of the spinal osseous structures is preserved, and a significant enlargement of the spinal canal area is achieved. This technique prevents peridural scar formation after laminectomy caused by a mechanical barrier effect. Long-term follow-up is needed to evaluate spinal stability in these patients.

Parenchymal Brain Metastasis of a Spinal Myxopapillary Ependymoma after Extradural Manipulation

A 54-year-old male patient was admitted to a neurosurgical clinic with the complaint of low back pain one month before admission to our clinic. The patient was operated, upon with the diagnosis of spinal stenosis as shown on computed tomography. An L4, L5 laminectomy and L4±5 and L5-S1 cage application was performed in that neurosurgical clinic. After the operation, the patients neurological status deteriorated and progressive paraparesis developed. He was referred to our clinic. Lumbar magnetic resonance imaging (MRI) showed intradural, multiple, well circumscribed, nodular and enhancing mass lesions of the cauda equina and ®lum terminale (Fig. 1a). Thereafter, left 3., 7., 9., and 10th cranial nerve palsies developed within a few days, and cranial MRI revealed intra-axial mass lesions of the infratentorial and supratentorial regions (Fig. 1b, c). The patient was operated on and two of the nodular mass lesions on the ®lum terminale were removed by en-bloc excision. No neurological progression was observed after the operation. Histopathological examination of the specimens showed: prominent papillary growth pattern of neoplastic ependymal cells, columnar cells with round monomorphic nuclei and inconspicuous nucleoli, perivascular pseudorosettes, and accumulation of mucin in the cytoplasm of some neoplastic cells (Fig. 1d, e). Immunohistochemically, tumour cells showed strong immunoreactivity for glial ®brillary acidic protein (GFAP) and vimentin. So the patient was diagnosed as myxopapillary ependymoma. He was treated with cranial and spinal radiotherapy however he died three months after the diagnosis because of the unusually aggressive character of the tumour. Discussion

Microanatomical characteristics of the petrosphenoidal ligament of Gruber.

AIM The petrosphenoidal ligament (PSL, or Grubers ligament) is located between the petrous apex (PA) and posterior clinoid process (PCP). Details of its anatomy are conflicting in the few studies that exist in the literature. We performed this study to describe in detail the microanatomical characteristics of Grubers ligament. MATERIAL AND METHODS 20 human cadaveric heads (40 specimens) were used to make morphometric measurements and qualitative evaluations of the microanatomy of the petrosphenoidal ligament. RESULTS The anatomy of the PSL was predominately butterfly (78%) in shape, with the remaining being triangular (22%). The structure of the PSL was complete in 52% of cases and incomplete (fragmented or hypoplastic) in 38%. A second, smaller ligament was seen in 10% of cases. Mean length of the PSL was 13.4+/-3.2 mm, mean width was 6.1+/-3.2 mm at the PCP and 4.2+/-1.6 mm at the petrous apex. Butterfly-shaped ligaments were narrowest in the middle (mean 2.0+/-0.9 mm), while triangle-shaped ligaments were narrowest (mean 2.8+/-2.3 mm) at its end, at its insertion on the PA or PCP. CONCLUSION The PSL (Gruber‘s ligament) is an important structure in the petroclival region. In this study, microanatomical characteristics were described in detail, along with new descriptions of its shape.

Kyphosis one level above the cervical disc disease: is the kyphosis cause or effect?

If present, kyphotic angulation is generally at the level of the cervical disc disease (CDD) in the neck, but sometimes occurs at one level above the CDD. We name this situation as kyphosis one level above (KOLA). KOLA CDD has not been studied previously. In this study, we present 18 patients who had KOLA among 147 patients operated for CDD over a 5-year period. Seven of these 18 patients also received surgery for their KOLA. As new, surgical treatment of kyphotic level was performed with plating and without bony fusion in 5 patients. Clinical outcomes (according to Odoms criteria) and kyphotic corrections of KOLA patients receiving and not receiving surgery for their kyphosis during were compared. The 7 KOLA patients having surgery to correct the kyphosis had a mean 20.14±3.13 degrees correction in their kyphosis (from mean 12.85 to −7.28 degrees), whereas the 11 patients undergoing surgery only for CDD showed only a mean 3.00±2.52 degrees correction (from mean 7.45 to 4.45 degrees). When kyphotic corrections were compared, statistically significant difference was found between 2 groups (P<0.01). Clinical outcome scores showed a trend towards improvement in the patients operated upon for kyphosis correction. KOLA may be a factor in the development of cervical disc herniation and spondylosis, and should be treated if more than 11 degrees. In cervical region, upper adjacent level disease may be an extension of KOLA. Larger studies can further define the relationship between KOLA and CDD, and indications for surgical correction of KOLA.

Pin site metastasis of meningioma.

Metastasis of meningiomas due to iatrogenic implantation of tumour cells is extremely rare and only four cases have been reported to date. In this study, we report a 45-year-old female patient who presented with meningioma metastasis at the pin site of head holder applied in the original operation.

Lumbar Disc Herniation Associated with Contralateral Neurological Deficit: Can Venous Congestion Be the Cause?

Lumbar disc herniation (LDH) associated with a contralateral neurological deficit is sometimes encountered by surgeons. Compression against the opposite pedicle in case of a large discal herniation and prominent stenotic changes of contralateral side are held responsible for contralateral symptoms and findings. In this study, we report a case of LDH associated with a painless contralateral neurological deficit. Prominent venous engorgement and congestion at the contralateral side of discal herniation were detected during the operation. Its treatment with bipolar coagulation and significant improvement was seen after the operation.

Histopathologic effects of discitis on neural tissues: An experimental study

To determine the cause of neurologic symptoms and signs seen in discitis, the neural histopathologic effects of discitis were investigated in an experimental study carried out on rats. Groups of seven rats each had their intervertebral discs inoculated with either Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, or a control solution. Histopathologic examinations of the spinal cord and nerve roots were performed after 3 weeks. On histopathologic examination, vacuolar myelopathy in the spinal cord and vacuolar neuropathy within the nerve roots near the junction with the spinal cord were found. The severity and form of vacuolar myelopathy varied according to the bacteria used for inoculation. The myelopathy and neuropathy seen in this rat model of bacterial discitis might be the result of an immunologic mechanism and could be responsible for the neurologic signs and symptoms of discitis in patients.

Filling of a sacral bone defect from a perineurial cyst by cementation.

In this study we present a case of Tarlovs cyst that is treated operatively. The operation involved partial excision and oversewing of the cyst wall with connection to the dural sac and methylmethacrylate filling of the sacral bone defect that is formed by the cyst to prevent cyst recurrence. In symptomatic cases Tarlovs cyst can be treated operatively with a favorable outcome.

Imaging findings of an epidermoid cyst with malignant transformation to squamous cell carcinoma.

We report imaging findings of a 64-year-old male patient with a ruptured epidermoid cyst (EC) known to be constant over the 23-year follow-up and showing malignant transformation to squamous cell carcinoma (SCC). Computed tomography (CT) and magnetic resonance imaging (MRI) findings including diffusion weighted imaging (DWI), 1H+MR spectroscopy (MRS), dynamic susceptibility contrast perfusion (DSC) MRI of EC, and its rare complications are presented together with a review of the literature. Fluid-lowattenuated- inversion-recovery (FLAIR) and T1-weighted images with gadolinium are the best sequences together with DWI to show the relationship of the EC, the SCC and the border between. Primary brain SCC enhances mostly ring-like or peripherally, but diffuse enhancement is also possible. To our knowledge, no MRS and DSC findings have been reported in the literature yet.

Temporary anterior cervical plating in a child with traumatic cervical ligamentous instability.

Application of anterior cervical plates in children is problematic because of the growing spine, and thus has been reported only rarely in the medical literature. In this case report, a 7-year-old with traumatic C2–3 and C3–4 ligamentous instability was treated surgically by limited-duration anterior cervical plating. The plate was removed in a second operation, as the osseous union occurred 1 year after the primary operation. Limited-duration anterior cervical plating is an alternative for stabilization operations of the growing cervical spine in children.