Hamit Selim Karabekir

Procalcitonin Levels as an Early Marker in Patients with Multiple Trauma under Intensive Care

This prospective study investigated the levels of procalcitonin (PCT) and C-reactive protein (CRP) in patients with various types and severity of multiple trauma, and their relationship to trauma-related complications. Adult multiple-trauma patients (n = 113) admitted to the intensive care unit (ICU) in the first 24 h after trauma were included. The Injury Severity Scores (ISS), and PCT and CRP levels were measured in the first 24 h (day 1), on day 7 and on the final day of their ICU stay. Survival at 30 days was recorded. Mean PCT and CRP levels were both significantly higher on day 7 compared with day 1 and the final assessment day in patients with an ISS > 20. Levels of PCT were significantly higher in cases with sepsis, severe sepsis or septic shock compared with cases who developed systemic inflammatory response syndrome (SIRS), however levels of CRP were significantly higher only in cases with severe sepsis or septic shock, but not in cases with sepsis alone. These data support the view that PCT levels may be a better indicator than CRP levels in the early diagnosis of septic complications in patients with multiple trauma.

Evaluation of Lumbar Vertebral Body and Disc: A Stereological Morphometric Study

El acceso anterior a las vertebras L1-L5 y espacios entre los discos puede ser tecnicamente dificil, con frecuencia requiere la participacion de un cirujano para una exposicion adecuada. La tecnica se utiliza para la extirpacion de la lesion, corpectomia, la reconstruccion del cuerpo vertebral con jaulas, realineamiento y / o placas o tornillos. Para un enfoque exitoso anterior y un diseno adecuado instrumental a traves de tornillo, un acabado conocimiento sobre la morfometria del cuerpo de las vertebras lumbares y de los espacios entre los discos y la evaluacion volumetrica son necesarias para el neurocirujano. El objetivo fue la evaluacion morfometrica y volumetrica de los cuerpos lumbares y los discos, para contribuir al abordaje seguro durante la cirugia. Se evaluo en 25 sujetos adultos, diestros, sin antecedentes de fracturas vertebrales y de enfermedad degenerativa espinal, el cuerpo vertebral y la morfometria del disco mediante estereologia con RM. La forma de las vertebras, el indice de concavidad y la definicion de las medidas volumetricas de los cuerpos L1-L5. Ademas, se midieron los parametros morfometricos como longitud, altura, ancho del cuerpo vertebral. Se efectuo un analisis morfometrico y volumetrico de loss cortes axiales y sagitales de los discos entre L1 y L5. Como era de esperar, las dimensiones promedio de las vertebras en los hombres fueron mayores que en las mujeres, pero la mayoria de ellos no son estadisticamente significativas. Solo tres dimensiones, la diferencia promedio entre la altura anterior y central de las vertebras L3, L4 y L5 mostraron diferencias estadisticamente significativas, indicando menor altura central tanto en los hombres como en las mujeres. Los diametros transversal y anteroposterior del cuerpo vertebral, la altura del disco intervertebral y el volumen no mostraron dimorfismo sexual (p>0,05). Sin embargo, aumentaron la altura del disco intervertebral y el volumen de L1 a L5 (p<0,01). Los indices de concavidad, de todas las vertebras lumbares, para ambos sexos, no diferian estadisticamente. El metodo es importante para el neurocirujano, para estimar el tamano y cantidad del implante y su aplicacion en las cirugias de descompresion.

Lumbar vertebra morphometry and stereological assesment of intervertebral space volumetry: a methodological study.

The use of technology in the treatment of degenerative spinal diseases has undergone rapid clinical and scientific development. It has been extensively studied in combination with various techniques for spinal stabilization from both the anterior and posterior approach. Minimally invasive and instrumental approach via posterior fixation is increasingly being used for the treatment of adult degenerative disc disease, stenosis, and deformity of the lumbar vertebrae. Posterior access to the lumbar disc spaces for posterolateral fusion scan has been technically challenging, frequently requiring the use of an approach surgery for adequate exposure. For successful surgery and suitable instrumental design, adequate anatomical knowledge of the lumbar vertebra is also needed. Anatomic features of lumbar vertebrae are of importance for posterior screw fixation technique. The morphometry of L1-L5 has been studied to facilitate the safe application of pedicle screws. Thus, we aimed to evaluate the morphometric landmarks of lumbar vertebrae such as pedicle, vertebral body, vertebral foramen, intervertebral space height and volume for safe surgical intervention using a posterior fixation approach to offer anatomical supports for lumbar discectomy, stenosis and cases of deformity. The features of the L1-L5 vertebral body, the detailed morphometric parameters of lumbar vertebrae and the intervertebral space were analyzed using computerized tomography scan, magnetic resonance imaging and also dry lumbar vertebrae. Additionally, intervertebral space volumes were measured using stereological methods to ensure safe surgical intervention.

Evaluation of Cerebellar and Cerebral Volume in Migraine with Aura: A Stereological Study

Migraine is associated with an increased risk of deep white matter lesions and subclinical posterior circulation infarcts. A significant association between deep white matter hyperintensities and cerebral atrophy is true for various neurological diseases; it was not specifically proven in migraine. The aim of this study was to evaluate the cerebellar and cerebral volume and volume ratios for cerebellum using the Cavalieri principle. We also aimed to examine whether migraine with aura causes cerebellar and cerebral atrophy. Twenty three right-handed patients with migraine with aura diagnosed by means of the International Headache Society criteria and 24 age-matched subjects whose only health problem was headache due to rhinosinusitis and tension type headache were included in the study. Measurements of the cerebellar and cerebral volumes as well as cerebellar/cerebral volume ratios were made using Cavalieri’s principle by utilizing the point-counting methods. There were no significant differences between the volumes of cerebrum, cerebellum, and the ratio of cerebellum to cerebrum for males (p = 0.05, p = 0.10, and p = 0.64, respectively) and for females (p = 0.18, p = 0.89, and p = 0.24, respectively). Our results suggest that patients with migraine with aura do not have a significant difference in cerebellar and cerebral volumes and cerebellar/cerebral volume ratios compared to the non-migraine group.

Evaluation of Cerebellar Asymmetry in Alzheimer's Disease: A Stereological Study

Objectives: Alzheimer’s disease (AD) is the most common cause of dementia and, as previous studies have indicated, degenerative changes in the cerebellum occur in AD. It is well known that the cerebellum does not have a symmetric morphology and some pathological disorders, such as schizophrenia, epilepsy, autism and alcoholism, can cause asymmetrical changes in the cerebellum. In this study, we aimed to evaluate whether or not patients with AD show cerebellar asymmetry. We also intended to depict the probable volumetric asymmetry by using a stereological technique. Materials and Methods: The study evaluated the volu- metric measurements of each cerebellar hemisphere by applying a stereological method to MR images. This age- and gender-matched study was composed of 15 patients with probable AD and 14 healthy subjects (controls). MR images were analyzed by using the point-counting approach, holding to Cavalieri’s principle. Results: Although there was significant cerebellar atrophy in AD patients, the study showed no statistically significant cerebellar asymmetry according to age and gender, both in the study and control groups (p > 0.05). Conclusions: There was no difference in cerebellar asymmetry associated with age and gender between the AD patients and control subjects. The stereological evaluation of cerebellar asymmetry correlating with gender is of importance to both clinicians and anatomists. The technique is simple, inexpensive, reliable and unbiased.

Residue bone wax simulating spinal tumour: a case report.

Bone wax is primarily used in case of bleeding of the diploic vessels of the bones in surgical procedures. It is useful in neurosurgical procedures because of its inert, nonreactive characteristics. Bone wax is safe material and its use rarely leads to complications but there may be complications of over use. It can cause direct pressure of neural tissue as a mass, simulating tumour with the symptoms and on MRI. In the present case the authors evaluated the signs and symptoms, diagnosis, surgical treatment, and outcome in a patient with an unusual sequestered mass simulating a spinal tumour or another space-occupying lesion on preoperative MR imaging. A 64-year-old was woman admitted to the Neurosurgery Clinic with a 10 year history of low back pain, 1-year history of gait disorder, leg weakness, paraparesis, and 1-month history of urinary incontinence and weight loss. T1- weighted sagittal MRI showed the L3 hemilaminectomy, discectomy defect, heterogeneous hyperintense extradural mass and spinal stenosis extending from L2. A hypointense mass relative to the spinal structures was detected in T2- weighted axial MR images.The provisional diagnosis of a cauda equina syndrome and intra- or extradural spinal tumour was made. The patient underwent an L2 total laminectomy. In our case the fragment was seen in the epidural space, under the lamina of L2. The histopathology showed granulation tissue, inflammatory cells, macrophages and multinuclear giant cells. Postoperatively the patients neurological findings recovered quickly and she began to walk more comfortably.

Effect of ligamenta flava hypertrophy on lumbar disc herniation with contralateral symptoms and signs: a clinical and morphometric study

Introduction The purpose of this study was to determine whether ligamentum flavum hypertrophy among disc herniated patients causes contralateral pain symptoms. For this reason we measured the thickness of the ligament in disc herniated patients with ipsilateral or contralateral symptoms. Material and methods Two hundred disc herniated patients with ipsilateral symptoms as group I were compared with five disc herniated patients with only contralateral symptoms as group II. Ligamenta flava thicknesses and spinal canal diameters of both groups were measured on magnetic resonance imaging (MRI) with a micro-caliper. Results Both groups underwent surgery only on the disc herniated side. The total thicknesses of the ligamenta flava in group II was thicker than in group I. There was no spinal stenosis in either group and no significance difference between the groups. Statistically significant differences were found for both ipsilateral and contralateral thickness of the ligament flava in both groups. We also compared thickness of the ligamenta flava for each level of disc herniation in group I; ligamenta flava hypertrophy was more common at L3-L4 and L4-L5 levels of vertebrae in females. Conclusions Aetiology of contralateral sciatica among disc herniated patients may be related to hypertrophy of the ligamenta flava, especially on the opposite side. Surgical approaches of the disc herniated side alone may be sufficient for a good outcome.

Determining entropy values equivalent to the bispectral index values during sevoflurane anaesthesia.

Introduction We aimed to identify the entropy levels that would be equivalent to the bispectral index (BIS) levels in sevoflurane anaesthesia in patients who are to undergo elective lumbar disc surgery. Material and methods Thirty cases in ASA groups I-II who underwent lumbar disc surgery under general anaesthesia were included in our study after obtaining the consent of the patients and Ethics Committee of our medical school between January 1, 2005 and October 30, 2006. BIS and entropy electrodes were applied at the same time in 30 cases in the study group. The depth of the anaesthesia was regulated so that 10 min after beginning the general anaesthesia the BIS values were between 40 and 60. At the same time equivalent entropy values corresponding to BIS values were obtained. Results At the end of the study, entropy values corresponding to general anaesthesia BIS values were identified. General anaesthesia BIS and RE/SE values at 10 min were lower than the values of the control, which was statistically significant (p < 0.05). Equivalent entropy values were obtained lower than the BIS values during general anaesthesia and these values were found to be statistically significant (p < 0.05). The blood pressure (BP) values obtained were very low at equivalent BIS values and when these BP values were compared with the initial BP values they were found to be statistically significant (p < 0.05). Conclusions Based on this observation, we think that general anaesthetic agents that might cause severe hypotension could be more safely administered under entropy monitoring.

Comparison of Entropy and Bispectral Index during Propofol and Fentanyl Sedation in Monitored Anaesthesia Care

Comparison of entropy (state entropy [SE] and response entropy [RE]) with the bispectral index (BIS) during propofol sedation in monitored anaesthesia care (MAC) was carried out in patients undergoing hand surgery. Thirty candidates for elective hand surgery were pre-medicated with midazolam 0.06 mg/kg and atropine 0.01 mg/kg. Sedation was induced with intravenous propofol and fentanyl was also administered. The Modified Observers Assessment of Alertness/Sedation Scale (MOAA/S) was used to determine sedation level and pain was maintained at < 4 on a 0-10 verbal rating scale. The BIS, entropy, MOAA/S and pain values were recorded before initiation of sedation (control), during initiation of sedation, during surgery, and for 30 min after the end of surgery and anaesthesia. On initiation of sedation, entropy decreased more rapidly than BIS. At 10 min after initiation of sedation, the mean ± SD values for MOAA/S, BIS, RE and SE were 3.00 ± 0.36, 85.45 ± 0.15, 74.00 ± 0.60 and 72.02 ± 0.12, respectively. During recovery, BIS and RE and SE increased in parallel with MOAA/S. It is concluded that entropy monitoring is as reliable as BIS monitoring in MAC.

Intraradicular lumbar disc herniation: report of two cases

Study Design:A case report.Objectives:To report two cases of intraradicular disc herniation.Setting:Kocatepe University Faculty of Medicine, Department of Neurosurgery, Afyon, Turkey, Vakif Gureba Training Hospital, Department of Neurosurgery, Istanbul, Turkey and Yeditepe University Faculty of Medicine, Department of Neurosurgery, Istanbul, Turkey.Methods:Two cases with intraradicular disc herniation at L2–3 level in one, and at L5–S1 level in the other were presented. Both patients were admitted with complaints of severe leg pain and motor weakness. In both cases, intradicular disc herniation was diagnosed during surgery.Results:The patients had uneventful recovery. They had no complaints or neurological deficits 6 and 3 months after surgery, respectively.Conclusions:The possibility of an intradural disc herniation should be kept in mind for the success of the management of lumbar disc herniation. In some patients who did not benefit from surgery, intraradicular or intradural disc herniations may be the cause of failure.