Hidayet Sarı

Computed tomographic evaluation of lumbar spinal structures during traction.

In the previous studies, it is reported that traction diminishes the compressive load on intervertebral discs, reduces herniation, stretches lumbar spinal muscle and ligaments, decreases muscle spasm, and widens intervertebral foramina. The aim of this study was to evaluate the effects of horizontal motorized static traction on spinal anatomic structures (herniated area, spinal canal area, intervertebral disc heights, neural foraminal diameter, and m.psoas diameter) by quantitative measures in patients with lumbar disc herniation (LDH). At the same time the effect of traction in different localizations (median and posterolateral herniation) and at different levels (L4-L5 and L5-S1) was assessed. Thirty two patients with acute LDH participated in the study. A special traction system was used to apply horizontally-motorized static lumbar traction. Before and during traction a CT- scan was made to observe the changes in the area of spinal canal and herniated disc material, in the width of neural foramina, intervertebral disc heights, and in the thickness of psoas muscle. During traction, the area of protruded disc area, and the thickness of psoas muscle decreased 24.5% (p = 0.0001), and 5.7% (p = 0.0001), respectively. The area of the spinal canal and the width of the neural foramen increased 21.6% (p = 0.0001) and 26.7% (p = 0.0001), respectively. The anterior intervertebral disc height remained unchanged with traction however the posterior intervertebral disc height was significantly expanded. This study is the first to evaluated in detail and quantitatively the effect of motorized horizontal lumbar spinal traction on spinal structures and herniated area. According to detailed measures it was concluded that during traction of individuals with acute LDH there was a reduction of the size of the herniation, increased space within the spinal canal, widening of the neural foramina, and decreased thickness of the psoas muscle.

De Quervain’s syndrome associated with osteopoikilosis: a case report and review of the literature

Osteopoikilosis is a rare, usually asymptomatic, autosomal-dominant bone disorder, which is generally diagnosed incidentally on X-ray. De Quervain’s syndrome is a disorder characterized by pain on the radial (thumb) side of the wrist, impairment of thumb function and thickening of the ligamentous structure covering the tendons in the first dorsal compartment of the wrist. In this case report, we present a young woman with De Quervain’s syndrome associated with osteopoikilosis.

Evaluation of Effects of Cervical Traction on Spinal Structures by Computerized Tomography

The aim of this study was to evaluate the biomechanical efficacy of cervical spinal traction on spinal structures in cervical disc herniation patients. Thirteen patients diagnosed with acute cervical disc herniation by computerized tomography (CT) and clinical findings were treated by a special traction system consisting of a traction device placed on a traction board fitted on the CT table. Spinal structures were evaluated before and after 20 min of traction. The herniated disc level was C5-C6 in eight of the patients. Changes following traction were: regression of herniated disc area, increase in spinal canal area (11.21 mm2), spinal column elongation between C2 and C7 (l.39 mm) and intervertebral discal space widening at the C5-C6 level. Cervical traction has a significant biomechanical effect on spinal structures, which can be demonstrated by CT evaluation before and after traction.

Regression of a symptomatic thoracic disc herniation with a calcified intervertebral disc component

There were only a few cases describing spontaneous regression of calcified thoracic disc herniation in the literature. We present a 38-year-old male office worker who had left paramedian-foraminal extruded disc at T7–T8 with calcifications of the T7–T8 and T8–T9 intervertebral discs. This case was unique in that the non-calcified extruded disc material regressed almost completely in 5 months while the calcified intervertebral discs remained the same during the process of regression. This report stresses that regression of the herniated material of the thoracic discs with subsidence of the symptoms is still possible even if the disc material is calcified.

Multilevel thoracic disk herniations in a young woman.

A 34-yr-old woman with back pain, right chest pain, and difficulty walking that started 15 days earlier while doing housework was evaluated. She reported that her household duties frequently including pushing and lifting heavy objects. Her physical examination revealed spasm of the thoracic and lumbar paravertebral muscles, hypalgesia below the T8 dermatome and decreased lower-limb muscle strength (Medical Research Council Grade 4/5). She had hyperactive reflexes at the knees and ankles, a positive Babinski sign, ankle clonus, and grade 2 spasticity (modified Ashworth scale), with no pathological findings in the upper limbs. She also reported urge incontinence. Magnetic resonance imaging showed an extruded disk at T2Y3, protruded disks at T3Y4, T4Y5, and T5Y6 with mild spinal cord compression, and extruded disks at T7Y8, T8Y9, T9Y10, and T10Y11 with severe spinal cord compression (Fig. 1). Symptomatic multilevel thoracic disk herniations with myelopathy was diagnosed. Disk herniations were seen at eight of the 12 thoracic levels, and the extruded disks at T7Y8 and T8Y9 were thought to be symptomatic. The patient was referred for surgical intervention but preferred conservative management. She was subsequently lost to follow-up. Thoracic disk herniation (TDH) occurs much less frequently than cervical or lumbar disk herniation, and multiple TDHs are rare. The symptoms and signs are usually slowly progressive and are not strongly associated with the herniated disk position, level, composition, or size. TDH accounts for only about 0.25%Y0.75% of all symptomatic herniated disks and about 0.15%Y1.8% of surgically treated disk herniations. Most TDHs are found in the lower thoracic spine, with more than 75% occurring below T8, mainly at T11Y12, probably related to weakness of the posterior longitudinal ligament and the hypermobility of the lower thoracic segment. In a study of 78 cases of TDH, 26% of the patients had herniations at multiple levels, and 12% had disk protrusions at noncontiguous levels. A history of trauma is present in almost half of the patients, although the role of trauma in the pathogenesis of herniation is still not clear. The clinical presentation can be extremely varied, from no symptoms to symptoms mimicking those of other conditions such as lumbar disk herniation and cardiac, abdominal, gastrointestinal, neoplastic, and demyelinating diseases. Band-like dermatomal sensory disturbance, girdle pain, low back pain, motor weakness, or even symptoms of myelopathy can occur. Although uncommon and often asymptomatic, multiple TDHs can easily be misdiagnosed and should not be overlooked.

Osteopoikilosis associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles

Osteopoikilosis is a sclerosing bone dysplasia, characterized by multiple oval spots of radiodensities within the trabecular bone. It occurs equally common among men and women. Prevalence is estimated to be as high as 1:50,000. Most reported cases have been found incidentally on roentgenograms taken for other purposes. We present a 58-year-old woman with OPK associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles.

The clinical importance of the thyroid nodules during anti-tumor necrosis factor therapy in patients with axial spondyloarthritis

The clinical importance of the thyroid nodules in patients with axial spondyloarthritis (ax-SpA) rests with the need to exclude thyroid malignancy. The aim of this study is to assess the risk of thyroid malignancy in ax-SpA patients receiving anti-TNF therapy. From September 2015 until December 2015, 70 patients diagnosed with ax-SpA were included in the research. Forty of the patients had received anti-TNF therapy, and 30 of the patients were anti-TNF naive. All cases were screened for the presence of nodules in the thyroid gland with ultrasound. Of the patients that received anti-TNF therapy, 15 (37.5%); and of the anti-TNF naive patients, 11 (36.7%) had thyroid nodule(s). Four patients from the anti-TNF group underwent fine needle aspiration biopsy of the nodules, and two of them were diagnosed with papillary thyroid carcinoma. None of the nodules in anti-TNF naive patients required biopsy. When compared to the normal population, the standardized incidence ratio (SIR) was found to be increased in both male (SIR 2.03, 95% CI 1.9 to 18) and female (SIR 2.7, 95% CI 2.6 to 24) cases. It is not yet established whether the development of cancer during the treatment process is the effect of the treatment or if it is a part of the natural course of the disease or if it is coincidental. We saw a mild increase in thyroid malignancies in ax-SpA patients who received anti-TNF therapy. Therefore, we believe that the thyroid gland should also be taken into consideration while screening for malignancy before anti-TNF therapy.

Cauda Equina Syndrome Caused by Lumbar Vertebral Fracture in an Elderly Patient with Ankylosing Spondylitis

Abstract Background: Cauda equina syndrome [CES] in patients with ankylosing spondylitis [AS] is an important neurological complication characterized by low back and leg pain, impotence, urinary incontinence, sensory deficits, and motor dysfunction. Vertebral fractures in the course of AS have been found most often in the cervical region, followed in prevalence by the thoracic region but only rarely in the lumbosacral region. Findings: We present an elderly patient with AS who developed spondylolisthesis at the L4–L5 level and CES following a low-energy fracture. Conclusion: Vertebral fractures in course of AS is especially more common in elderly patients with long-standing disease. Early diagnosis and treatment might improve the clinical outcome and might prevent complications.

Ethical issues in decision making by hospital health committee members in Turkey

Hospital health committees (HHC) in Turkey review medical reports from clinical practitioners and decide whether or not they are justified. As a rule, each HHC member is expected to observe and examine each patient and then evaluate the report. If the report from the patients doctor is approved, then the Social Security Administration, a state organisation, will meet all of the patients expenses covering treatment, medication and operations. Justification of health expenditure is crucial for the state because health resources have to be carefully allocated. Conflicts of obligation also generate ethical issues which have to be resolved as well. However, HHCs are not designed to make ethical decisions. An overall concept of organisational ethics needs to be developed.

Aggressive vertebral hemangioma as a rare cause of myelopathy

Vertebral hemangiomas (VHs) are common lesions in the adult population. They are usually asymptomatic and found incidentally on radiological imaging. New-onset back pain followed by subacute progression of thoracal myelopathy is the most common presentation in patients with neurological deficit. Differential diagnoses would include metastasis, multiple myeloma, lymphoma, Paget disease, osseous tumors such as Ewing sarcoma or hemangioblastoma and blood dyscrasia. We present a 41 year-old-male patient with thoracal VH causing myelopathy that completely improved after rehabilitation program with embolization and vertebroplasty procedures.