Ferhat Harman

Management of Thoracal and Lumbar Schwannomas Using a Unilateral Approach without Instability: An Analysis of 15 Cases

Study Design Retrospective case series. Purpose The objectives of this study were to determine and discuss the surgical planning of patients who underwent operations following diagnoses of thoracal and lumbar spinal schwannomas. We also aimed to discuss the application of unilateral hemilaminectomy for the microsurgery of schwannomas. Overview of Literature Schwannomas are located in different regions and sites. These differences require several surgical approaches. Unilateral laminectomy without stabilization of the spine provides a more minimally invasive removal of the tumor. Methods In this retrospective study, 15 patients with spinal schwannomas were evaluated with regards to age, sex, onset history, neurological findings, tumor locations, McCormick scale, surgical procedure, and operational results. The lateral approach provides exposure of intradural structures and posterior paraspinal regions. Extensions of tumors cause problem for the surgeon in terms of approach, resectability of the tumor, and stability of the spine. Gross total resection was achieved in all cases, and none of the patients necessary required a fusion procedure. Results Five patients were males and 10 were females. The age interval was 29-65 years. The tumor was located in the lumbar region in 9 patients, in the thoracic region in 2 patients, and in the thoracolumbar junction in 4 patients. The intradural lesions were removed by laminectomy and the extradural lesions were resected with hemilaminectomy. The paramedian route was used to explore the extraspinal part of the tumor. Costotransversectomy was for the thoracic region. Subtotal resection was performed in 1 patient. Patient symptoms recovered gradually in the postoperative period. Conclusions Resection of giant schwannomas is challenging and usually requires a different approach. We describe the complete resection of complex dumbbell or paraspinal schwannomas of the thoracic and lumbar spine by unilateral hemilaminectomy.

Neuroprotective effect of magnesium sulfate and dexamethasone on intrauterine ischemia in the fetal rat brain: ultrastructural evaluation.

AIM The aim of this study was to investigate the neuroprotective effect of magnesium sulfate and dexamethasone on oxidative damage in intrauterine ischemia. MATERIAL AND METHODS In this study, 19-day pregnant rats were divided into five groups. Fetal brain ischemia was achieved in the ischemia/ reperfusion (I/R) group by bilaterally closing the utero-ovarian artery with aneurysm clips for 30 min and subsequently removing the aneurysm clips for 60 min for reperfusion. Mg (600 mg/kg) and dexamethasone (0.25 mg/kg) were administered 20 min before the I/R insult. The lipid peroxidation in the brain tissue was determined by the concentration of thiobarbituric acid reactive substances (TBARS). The mitochondrial score was calculated after an evaluation with electron microscopy. RESULTS Both the electron microscope and TBARS data showed a significant difference between the control and I/R groups. The Mg and dexamethasone treatment groups exhibited significantly lower TBARS values compared to the IR group. Similarly, the mitochondrial scores in the Mg and dexamethasone treatment groups were significantly lower than those in the I/R group. CONCLUSION Result showed that magnesium sulfate and dexamethasone prevent lipid peroxidation and reduce mitochondrial injury thus suggests neuroprotective effects in fetal rat brain in intrauterine ischemia-reperfusion (I/R) injury.

Open-door laminoplasty with preservation of muscle attachments of c2 and c7 for cervical spondylotic myelopathy, retrospective study

AIM Some restriction and complications, such as progression of kyphosis, incidence of axial neck pain and decrease of postoperative cervical range of motion are concern. We designed this retrospective clinical study to evaluate the effect of laminoplasty by preserving the muscle attachments of C2 and C7 spinous processes on range of motion (ROM), axial neck pain and cervical lordosis. MATERIAL AND METHODS Twenty-seven cases with cervical spondylotic myelopathy underwent open-door laminoplasty with the protection of muscle attachments to the C2 and C7 spinous process and laminae between 2007 and 2013. At the end of the followup, cases were evaluated with preoperative and postoperative modified Japanese Orthopedic Association (mJOA) scores, recovery rate, ROM, lordosis angle and visual analogue scale (VAS). Also, patients were divided into two groups and evaluated according to the magnetic resonance imaging (MRI) findings, with or without T2 signal change. RESULTS The mean age of the patients was 66 years. The mean follow-up duration was 25 months. The postoperative mJOA scores were significantly higher than the preoperative mJOA scores (p < 0.001). The recovery rate was 57.4%. Although the postoperative VAS score was higher than the preoperative VAS score and the mean postoperative ROM was lower than the preoperative ROM there was no significant difference between preoperative and postoperative VAS score and ROM (p > 0.05). The postoperative lordosis angle was significantly lower than the preoperative lordosis angle (p < 0.05). There were no significant differences regarding the postoperative lordosis angle, ROM and mJOA scores with or without T2 signal change on MRI. CONCLUSION Protection of the anatomic structures around the cervical spine such as the muscles and ligaments provides us better results regarding ROM and cervical axial pain.

Esophageal perforation after anterior cervical surgery: a review of the literature for over half a century with a demonstrative case and a proposed novel algorithm.

PurposeTo review relevant data for the management of esophageal perforation after anterior cervical surgery.MethodsA case of delayed esophageal perforation after anterior cervical surgery has been presented and the relevant literature between 1958 and 2014 was reviewed. A total of 57 papers regarding esophageal perforation following anterior cervical surgery were found and utilized in this review.ResultsThe treatment options for esophageal perforation after anterior cervical surgery were discussed and a novel management algorithm was proposed.ConclusionFollowing anterior cervical surgery, patients should be closely followed up in the postoperative period for risk of esophageal perforation. Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury. Review of the literature revealed that conservative treatment is advocated for early and small esophageal perforations. Surgical treatment may be considered for large esophageal defects.

Painful Lumbosacral Plexopathy Due To Ganglion Cyst: Magnetic Resonance Image Findings and Treatment

Background Lumbosacral plexopathies are rare and may develop as a result of various pathologies. The most common causes of lumbosacral plexopathy include infiltrative infections such as herpes zoster, parturition, tumors, postoperative complications of abdominopelvic surgery, and ischemic vascular injury resulting from intramuscular injections. Treatment is based on the etiology and the severity of the pain. Findings We describe herein the evaluation and treatment of a 37-year-old female patient who was admitted with complaints of pain in her left hip and sciatic nerve traces. Conclusions Pain resulting from lumbosacral plexopathy is a difficult diagnosis. Keys to the diagnosis include a clinical picture disproportional to lumbar–sacral magnetic resonance image findings. Treatment is determined by the etiology.

Acute cerebellar ischemia after lumbar spinal surgery : a rare clinical entity

To the Editor: We present a case of cerebellar ischemia following a lumbar spinal surgery with prolonged prone position. Acute cerebellar ischemia after lumbar surgery is extremely rare, and its exact cause is not well known [1, 2]. Compression of vertebral arteries as a result of the prone position and unusual neck rotation with prolonged surgery have been demonstrated as the causes of cerebellar hypoperfusion leading to ischemia [2, 3]. Our patient was an ASA physical status II, 69-year-old man with degenerative lumbar stenosis at L2–L3–L4 levels. The patient had small ischemic areas on his previous cranial magnetic resonance imaging (MRI), and a left vertebral artery occlusion was detected on his previous computed tomography (CT) angiography performed 2 years ago; with no neurological symptoms or signs relevant to those lesions. Clopidogrel and acetyl salicylic acid administered previously were discontinued 7 days before the operation to avoid the risk of intraoperative bleeding. Compression stockings were applied to the patient to prevent the thromboembolic events of both cardiovascular and central nervous system. The patient was turned into prone position with his head semiflexed and mildly turned to his right side on a donut cushion, not exceeding his normal range of motion. Neutral position could not be achieved because of his short neck. Parallel chest foams were placed because of lack of a spine frame. Total laminectomy and fusion by transpedicular screw stabilization was performed at L2 to L5 levels, and the duration of the operation was 6 h. Throughout the surgery, mean arterial pressure was kept at 65–70 mmHg levels for the majority of the operation. The patient had altering levels of consciousness, dysarthria, and dizziness 2 h after the surgery. Brain CT scan demonstrated an acute cerebellar ischemia with surrounding edema in both hemispheres, more marked on the left side (Fig. 1). The patient was discharged from the hospital 4 weeks later with satisfying recovery of consciousness and dizziness, although his dysarthria improved very slowly. The position of our patient might have compromised the blood flow of right vertebral artery. Also, our patient had a prior left vertebral arterial occlusion. Both the position and the prior left vertebral arterial occlusion might have contributed to the ischemia involving both sides of the cerebellum. Our preventive measures were the application of compression stockings and avoiding hypotension and extensive neck rotation. Additionally, a low molecular heparin prophylaxis could have been considered to prevent possible contribution of thromboembolic complication. Further, aspirin should have not been discontinued, as suggested in a most recent review [4]. We conclude that preference of neutral alignment of the neck, maintenance of mean arterial pressure in normal range, and F. Harman M. Yaman E. Kaptanoglu Department of Neurosurgery, Near East University Faculty of Medicine, Lefkosa, Mersin 10, Turkey

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.

Ventriculoperitoneal shunt infection after an insect sting

Ventriculoperitoneal (VP) shunt transfers cerebrospinal fluid from the lateral ventricles of the brain to the peritoneum via subcutaneous tubing. VP shunt implantation is the most widely used treatment for the management of hydrocephalus [2]. Although VP shunting reduces the mortality and morbidity of hydrocephalus, there are potential shunt complications such as infection, obstruction, mechanical disconnection, and breakage. These complications may cause shunt failure and reoperations [22]. The long-term studies show that 45% to 59% of all patients require surgical revisions [5]. VP shunt infections are serious complications. Infections of the catheter may spread into the abdomen by ascending direction or into the brain ventricles by descending direction and may threaten life. The incidence of shunt infection ranges from 1% to 29% [3, 20]. Therapeutic modalities for the treatment of shunt infections vary from only antibiotic treatment to IV antibiotics with removal of the infected shunt. We herein report a case of shunt infection after an insect sting. Although an insect sting can cause local and inflammatory reactions, to the best our knowledge, this is the first report of a shunt infection after a single insect sting in English literature.