Kadir Tahta

Relationships between epidural fibrosis, pain, disability, and psychological factors after lumbar disc surgery

Abstract Failed back surgery syndrome (FBSS) is an important complication of lumbar disc surgery. Epidural fibrosis is one of the major causes of FBSS. However, most patients with epidural fibrosis do not develop symptomatic complaints from scarring. The purpose of this prospective study was to evaluate the relationships among the severity of epidural fibrosis, psychological factors, back pain and disability after lumbar disc surgery. Twenty-nine surgically managed patients (13 women, 16 men) were included in this study. In all patients, the presence and severity of epidural fibrosis was determined with contrast-enhanced magnetic resonance imaging (MRI). A pain visual analog scale (VAS) and Oswestry Disability Questionnaire (ODQ) were completed before and after surgery. Subjects were grouped by their type of herniation (protrusion, free fragment), MRI findings and results of the mini form of the Minnesota Multiphasic Personality Inventory (MMPI), and the groups were compared for their VAS and ODQ scores. Our results disclosed that neither the postoperative VAS scores nor the postoperative ODQ scores differed significantly among the epidural fibrosis severity groups. Moreover, postoperative VAS scores were positively correlated with the scores of the mini MMPI. These findings indicate that epidural fibrosis may be considered as a radiological entity independent of patients’ complaints. Furthermore, the mini MMPI should be included in the assessment and planning of the reoperations in FBSS patients, because of the importance of psychological factors in postoperative pain and disability.

Intramedullary spinal tuberculoma presenting as a conus tumor: a case report and review of the literature

Abstract Intramedullary spinal tuberculoma is a rare form of central nervous system tuberculosis. Although tuberculosis is unusual in the west, it is still prevalent in Asia and Africa. We report a case in which the diagnosis was made histologically without evidence of symptoms of systemic tuberculosis. The lesion, located in the conus medullaris, mimicked a conus tumor. The patient was a 20-year-old man who presented with a history of progressive leg weakness, urinary urgency, and impotence. There was no history of, or recent contact with, tuberculosis. A diagnosis of an intramedullary tumor in the conus medullaris was made by MRI. The patient underwent a T11-L1 laminectomy and total resection of the lesion with microsurgical technique. Histologic examination revealed a granulomatous lesion containing Langhans’ giant cells, inflammatory cells, and caseating necrosis. Antituberculous medication was instituted as soon as the diagnosis was made. Neurologic symptoms and signs slowly improved postoperatively. A combination of microsurgical resection and antituberculous chemotherapy should be the choice of treatment for intramedullary tuberculomas.

Intracerebellar granulocytic sarcoma complicating acute myelogenous leukemia: a case report and review of the literature.

Granulocytic sarcoma is a solid mass composed of premature precursors of granulocytic series cells in an extramedullary region. Intraparenchymal central nervous system localization without skull or meningeal invasion is extremely rare. Although different theories have been proposed to explain the mechanism of this unusual disorder, its exact mechanism is still unclear. Some degree of improvement can be achieved after surgery and radiotherapy but its prognosis is poor and most patients die within months. Nine cases of purely intraparenchymal granulocytic sarcomas have been reported in the literature. Here, we report the tenth case and review the current literature.

Spinal cord compression caused by vertebral hemangioma being symptomatic during pregnancy

BACKGROUND Hemangioma is one of the most common benign tumors of the spine, and it remains silent in the vast majority of subjects afflicted. Pregnancy is a known risk factor for symptomatic conversion of the previously silent vertebral hemangiomas. However, the occurrence is rare with only 26 cases reported in the English medical literature. CASE DESCRIPTION A 22-year-old woman in her 36th week of gestation presented with acute onset of upper back pain and progressive paraplegia. Imaging studies revealed a T4 vertebral hemangioma, which involved the vertebral body, pedincules, transverse, and spinous process with a focal extradural extension of soft tissue component. She underwent emergent cesarean delivery and endovascular embolization, respectively. Her symptoms and neurologic deficits improved quickly. Her complaints restarted 2 years after embolization. Surgical treatment which consists of intraoperative vertebraplasty and segmental fixation was performed. The patients postoperative recovery was excellent. CONCLUSION According to literature review and our patients outcome, pregnancy may induce neurologic symptoms and signs in silent spinal hemangiomas. The way of management is decided by whether the neurologic deficits depend on the deformity caused by hemangioma or some other factors including vascular insufficiency.

Whipple's Disease Confined to the Central Nervous System: Case Report and Review of the Literature

Whipples disease confined exclusively to the CNS without systemic involvement appears to be very rare, with only 8 cases reported in the literature. We present here a further case of primary cerebral Whipples disease in which the neurological symptoms were seen in the absence of systemic involvement and emphasize the importance of diagnosing this treatable disease.

Brain stem abscesses in childhood

BackgroundSolitary brain stem abscess is a rare condition with high mortality and morbidity. These lesions were considered to be invariably fatal before 1974 when advanced diagnostic tools were not available. Recently, the diagnosis and prognosis of brain stem abscesses have been modified by the introduction of modern radiological tools, and several patients with a favorable outcome have been reported since then. Because the pons is the most common site of the abscesses, involvement of the sixth and seventh nerves is frequent. The midbrain is the second most likely location, and medullary abscesses are distinctly rare. Treatment of a brain stem abscess includes medical therapy alone, open microsurgical intervention, or stereotactic aspiration.Case reportWe report a case of a 7-year-old girl with a solitary brain stem abscess. Her neurological examination revealed involvement of the cranial nerves and pyramidal tracts. Microsurgical exposure and aspiration of the abscess resulted in rapid improvement in her neurological condition and radiological resolution of the lesion. We discuss this uncommon case to draw attention to the importance of early diagnosis and adequate treatment, and we review the relevant literature.

Spinal extradural compression caused by granuloma of brucellosis

A rare case of extradural brucellosis granuloma in the thoracic region is presented. In spite of medical treatment, total paraplegia with sphincter disturbance developed. Delayed neurosurgical intervention resulted in significant clinical recovery. Magnetic resonance imaging was useful in obtaining detailed information and to decide on surgery.

Postoperative mutism after removal of an anterior falcine meningioma

Postoperative mutism is rare. We present a 65-year-old man who had transient mutism after resection of anterior falx meningioma. Mild left hemiparesis and palmomental reflex on the right were the only abnormal signs on neurological examination. CT scan and MRI demonstrated a mass at the anterior one-third portion of the falx just superior to the corpus callosum. The mass enhanced homogenously with administration of gadolinium DTPA. The patient underwent surgical resection of the lesion and adjacent falx cerebri. The operation was uneventful. On the second postoperative day he became mute. He could follow verbal commands, and write and read. Postoperative CT scan revealed a hypodense area in the right frontal lobe including a part of the anterior cingulate cortex and the anterior part of the corpus callosum. Histopathological examination revealed a mixed meningioma. Ten days postoperatively, he began to say simple words, and three weeks later he could talk normally. We consider that lesion of the supplementary motor area (SMA) may be responsible for postoperative mutism.

The influence of cervical spinal cord stimulation on induced epileptic discharges in rats

Spinal cord stimulation (SCS), also known as dorsal column stimulation, is a novel technique used widely in pain surgery. However, its effect on other pathologies such as epileptic disorders is unknown. The aim of this study is to evaluate the influence of electrical epidural stimulation of the upper cervical region on epileptic cortical discharges. The long term goal is to elucidate and evaluate a therapeutic central nervous system (CNS) electrical stimulation methodology to treat epilepsy. Twelve Wistar female rats were randomly divided into two groups. In group 1 (six rats under general anesthesia), C2-3 laminectomies were performed and epidural electrodes were placed to perform SCS. To induce epileptic discharges, 1 ml (200 IU) penicillin G was microinjected into the left somatomotor cortex via left stereotactic parietal craniotomies, 0.01 to 0.1 mA at 2 Hz was used to stimulate the spinal cord. In group 2 (the control group, six rats under general anesthesia), C2-3 laminectomies were performed without electrode placement and epileptic discharges were induced with penicillin G microinjections, as described above. Both groups were monitored with digital electroencencephalography (EEG) for 70 min in seven stages and recordings analyzed with power spectral analysis. Spinal cord stimulation decreased penicillin-induced median values of epileptic discharges. Epileptic wave frequencies decreased significantly with increasing intensities of SCS. The results of this study suggest that SCS used for drug resistant epilepsies may be a viable alternative treatment modal.

Neurosurgical procedures in pregnancy

PURPOSE: Over the past few decades maternal mortality has progressively declined because of improved management of the major obstetric problems of hemorrhage, infection, and toxemia. As a result, the relative incidence of deaths resulting from non obstetric causes has increased. Chief among nonobstetric causes are neurologic disorders. Those most common during pregnancy are low back pain, intracranial tumors, subarachnoid hemorrhage, and neurotrauma. The management of the neurosurgical pathologies during pregnancy needs some specifications for both the mother and the fetus. METHODS: We performed a retrospective study evaluating the clinical, radiological, and surgical characteristics of 9 patients who have cranial neuropathologies and have undergone neurosurgical intervention. RESULTS: Most of the patients in this study had vaginal delivery. Prominent neurosurgical disease related to cerebral damage. Every patient underwent a laboratory and radiological evaluation. All except one survived the neurosurgical pathology. Neither baby nor mother had significant problem during delivery and neurosurgical intervention. CONCLUSION: Pregnant women may face to every kind of neurosurgical pathology that nonpregnant women have faced. In addition, pregnancy itself, gives rise some metabolic changes in the women and those changes may cause some neurologic pathologies to be symptomatic or to aggravate the present symptomatology. Because of those reasons, close neurologic follow up of a pregnant woman is of vital importance. At the end of a pregnancy having experienced some neurologic interventions including diagnostic evaluation or surgical intervention does not necessitates the cesarean section for a neurologically intact infant and mother.