Kasım Zafer Yüksel

Ankylosing Spondylitis: Patterns of Spinal Injury and Treatment Outcomes

Study Design Retrospective review. Purpose We retrospectively reviewed our patients with ankylosing spondylitis (AS) to identify their patterns of spinal fractures to help clarify management strategies and the morbidity and mortality rates associated with this group of patients. Overview of Literature Because of the brittleness of bone and long autofused spinal segments in AS, spinal fractures are common even after minor trauma and often associated with overt instability. Methods Between January 1, 1998 and March 2011, 30 patients (23 males, 7 females; mean age, 70.43 years; range, 45 to 95 years) with the radiographic diagnosis of AS of the spinal column had 42 fractures. Eight patients presented with significant trauma, 17 after falls, and 5 after minor falls or no recorded trauma. Eleven patients presented with a neurological injury, ranging from mild sensory loss to quadriplegia. Results There were 16 compression and 10 transverse fractures, two Jeffersons fractures, one type II and two type III odontoid process fractures, and five fractures of the posterior spinal elements (including lamina and/or facet, three spinous process fractures, three transverse process fractures). Twenty-four fractures affected the craniocervical junction and/or cervical vertebrae, 17 were thoracic, and one involved the lumbar spine. The most affected vertebrae were C6 and T10. The mean follow-up was 29.9 months. One patient was lost to follow-up. Eighteen patients were treated conservatively with bed rest and bracing. Twelve patients underwent surgery for spinal stabilization either with an anterior, posterior or combined approach. Conclusions Nonsurgical treatment can be considered especially in the elderly patients with AS and spinal trauma but without instability or major neurological deficits. The nonfusion rate in conservatively treated patients is low. When treatment is selected for patients with spinal fractures and AS, the pattern of injury must be considered and the need for individualized treatment is paramount.

An Experimental Study on the Effects of Smoking in the Perinatal Period and During Lactation on the Intervertebral Disks of Newborns

OBJECTIVE To evaluate the histopathologic effects of smoking before, during, and after pregnancy on the intervertebral disk structure of newborns in an experimental rat model. METHODS Seven adult female Wistar albino rats were randomly allocated into 7 groups. Nicotine (2 mg/kg/d) was intraperitoneally introduced to these rats in 6 groups before, during, and after pregnancy, whereas the rat in the control group received isotonic saline intraperitoneally. Fourteen newborns delivered by each rat were euthanized at the end of 9 weeks after being breastfed for 3 weeks after birth. The vertebral columns of the euthanized rats were removed en bloc, and histopathologic evaluation was performed on the intervertebral disk specimens. Histopathologic alterations were noted and compared between groups. RESULTS Ratio of proteoglycan amount exhibited a significant difference between groups (P < 0.001). Subjects in the control group had a predominantly mild amount of proteoglycans, whereas smoking before and during pregnancy and smoking before/during pregnancy and lactation resulted in deposition of a severe amount of proteoglycans in intervertebral disk tissue. Similarly, there was a statistically significant difference between groups with respect to the amount of fibrosis (P < 0.001). In the control group, fibrosis was absent in most (78.6%) subjects. Fibrosis was mild in groups with smoking before pregnancy and during lactation. A moderate degree of fibrosis was detected in groups with smoking during pregnancy, before and during pregnancy, during pregnancy and lactation, and before/during pregnancy and lactation. CONCLUSIONS Results of this study imply that maternal smoking before and during pregnancy and in the lactation period may have deleterious effects on the intervertebral disk of the newborn. The duration of smoking and fertility period can influence the type and severity of these effects.

Lumbar herniated disc: spontaneous regression

Background Low back pain is a frequent condition that results in substantial disability and causes admission of patients to neurosurgery clinics. To evaluate and present the therapeutic outcomes in lumbar disc hernia (LDH) patients treated by means of a conservative approach, consisting of bed rest and medical therapy. Methods This retrospective cohort was carried out in the neurosurgery departments of hospitals in Kahramanmaraş city and 23 patients diagnosed with LDH at the levels of L3−L4, L4−L5 or L5−S1 were enrolled. Results The average age was 38.4 ± 8.0 and the chief complaint was low back pain and sciatica radiating to one or both lower extremities. Conservative treatment was administered. Neurological examination findings, durations of treatment and intervals until symptomatic recovery were recorded. Laségue tests and neurosensory examination revealed that mild neurological deficits existed in 16 of our patients. Previously, 5 patients had received physiotherapy and 7 patients had been on medical treatment. The number of patients with LDH at the level of L3−L4, L4−L5, and L5−S1 were 1, 13, and 9, respectively. All patients reported that they had benefit from medical treatment and bed rest, and radiologic improvement was observed simultaneously on MRI scans. The average duration until symptomatic recovery and/or regression of LDH symptoms was 13.6 ± 5.4 months (range: 5−22). Conclusions It should be kept in mind that lumbar disc hernias could regress with medical treatment and rest without surgery, and there should be an awareness that these patients could recover radiologically. This condition must be taken into account during decision making for surgical intervention in LDH patients devoid of indications for emergent surgery.

Impact of Position on Efficacy of Caudal Epidural Injection for Low Back Pain and Radicular Leg Pain Due to Central Spinal Stenosis and Lumbar Disc Hernia

Objective This study was performed to evaluate and compare the efficacies of caudal epidural injections performed at prone and lateral decubitus positions. Methods A total of 120 patients suffering from low back pain and radicular leg pain were included and patients were randomly distributed into 2 groups according to the position during injection. In Group 1 (n=60; 32 women, 28 men), caudal epidural injection was performed at prone position, whereas it was implemented at lateral decubitus position in Group 2 (n=60; 33 women, 27 men). Visual analogue scale, Oswestry Disability Index (ODI), walking tolerance (WT) and standing tolerance (ST) were compared in 2 groups before and after injection. Results In Group 1, ODI values were higher at 30th minute (p=0.007), 3rd week (p=0.043) and 6th month (p=0.013). In Group 1, ODI, VAS and ST values were improved significantly at all follow-up periods compared to initial values. In Group 1, WT scores were better than initial values at 30th minute, 3rd week and 3rd month. In Group 2, ODI scores at 30th minute, 3rd week, 3rd month and 6th month were improved while VAS and ST scores were improved at all periods after injection. WT scores were better at 30th minute, 3rd week and 3rd month compared to initial WT scores. Conclusion Our results indicated that application of injection procedure at lateral decubitus position allowing a more concentrated local distribution may provide better relief of pain.

Histopathological Analysis of Ligamentum Flavum in Lumbar Spinal Stenosis and Disc Herniation

Study Design Histopathological analyses were performed in ligamentum flavum (LF) hypertrophy patients with lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH). Purpose The aim of the present study was to evaluate histopathological changes in LF patients with LSS and LDH. Overview of Literature LSS is the most common spinal disorder in elderly patients. This condition causes lower back and leg pain and paresis, and occurs as a result of degenerative changes in the lumbar spine, including bulging of the intervertebral discs, bony proliferation of the facet joints, and LF thickening; among these, LF thickening is considered a major contributor to the development of LSS. Methods A total of 71 patients operated with the surgical indications of LSS and LDH were included. LF samples were obtained from 31 patients who underwent decompressive laminectomy for symptomatic degenerative LSS (stenotic group) and from 40 patients who underwent lumbar discectomy for LDH (discectomy group). LF materials were examined histopathologically, and other specimens were examined for collagen content, elastic fiber number and array, and presence of calcification. Results The stenotic and discectomy groups did not differ with regard to mean collagen concentration or mean elastic fiber number (p=0.430 and p=0.457, respectively). Mean elastic fiber alignment was 2.36±0.99 in the stenotic group and 1.38±0.54 in the discectomy group (p<0.001). Mean calcification was 0.39±0.50 in the stenotic group, whereas calcification was not detected (0.00±0.00) in the discectomy group; a statistically significant difference was detected (p<0.001) between groups. Conclusions LF hypertrophy in spinal stenosis may occur as a result of elastic fiber misalignment along with the development of calcification over time. Further studies determining the pathogenesis of LSS are needed.

An uncommon case mimicking cervical trauma: Os odontoideum

Os odontoideum is a separate odontoid process from the body of the axis. It is the most common anomaly of the odontoid process. Patients with this condition can be asymptomatic or present with a wide range of neurological dysfunctions. It may cause cervical instability, atlantoaxial dislocation and myelopathy. This anomaly can mimic Type I and II odontoid fractures. There is a role for conservative treatment of an asymptomatic incidentally found, radiologically stable and non-compressive os odontoideum. However, surgical treatment has a definitive role in symptomatic cases. In this study, the case is presented of a 31 year-old male patient with neck pain who was diagnosed with incidental os odontoideum. The diagnosis of acute odontoid fracture was discarded in this case as the radiological findings were of a characteristic cortex with smooth contours, and there was no history of recent trauma, sclerosis or hypertrophy of the anterior tubercle of the atlas.

A Patient Presenting with Paraplegia Secondary to Cranial Gunshot Injury: A Case Report

Ateşli silahla kranial yaralanmalar (ASKY) kafa travmalarında önemli bir yere sahip olup, ciddi oranda mortalite ve morbitide ile seyretmektedir. Çeşitli çalışmalarda, ölüm oranları %51-84 arasında bildirilmiş olup, olguların çoğunun olay anında veya erken dönemde öldüğü bilinmektedir. Kurşunun parankimde yaptığı hasar, hemoraji, ödem, ventrikül içi kanama, herniasyon, hasarın bihemisferik olması, hastanın nörolojik ve genel durumu, Glaskow Koma Skalası (GKS) ve tedavi yaklaşımı en önemli faktörler olarak bildirilmiştir. On dokuz yaşında, evinde tek başına ateşli silahla başından yaralanmış hâlde bulunan erkek hastanın acil serviste yapılan ilk muayenesinde şuuru kapalı, GKS 9 ağrılı uyaranla üst ekstremite hareket mevcutken her iki alt eksremitede parapleji mevcuttu. BBT’sinde sağ parietooksipital bölgede kurşun giriş deliği, parankimde kemik parçaları ve hematom, sol parietooksipital bölgede kurşun çıkış deliği, hematom ve subaraknoid kanama (SAK) mevcuttu. Hastanın biyokimya değerleri normaldi. Koagülopati ve kanama diatezi yoktu. Hastaya antiödem tedavisi ve geniş spektrumlu antibiyotik tedavisi başlanarak acil ameliyata alındı. Ameliyat sırasında nonfonksiyone nekroze beyin dokuları debride edildi, hematom boşaltıldı ve ulaşılabilen kemik parçaları çıkarıldı. Kraniektomi kemik sağ bacak yan kısma yerleştirildi. Kontrol BBT’sinde ödemin olmadığı, hematomun rezorbe olduğu görüldü. Paraplejisinin olması nedeniyle yapılan spinal manyetik rezonans görüntülemede (MRG) herhangi bir patolojik bulgu saptanmadı. Hastanın son kontrol nörolojik muayenesinde sol alt ekstremitede 4+/5 defisit dışında ek nörolojik defisiti yoktu. ASKY ile ilgili birçok çalışma yapılmış olup, parapleji ile gelen hasta ender bildirilmiştir. ASKY mortalitesi ve morbitesi yüksek seyreden önemli bir nöroşirürji sorunudur. Bu hastalara yaklaşımla ilgili net bir bilgi yoktur. Hastalara olay yerinden başlayan uygun ve etkin yaklaşım sağlandığında, anında multidisipline şekilde müdahele edildiğinde mortalite ve morbitenin azalacağına düşünülmektedir. Parapleji ile gelen ASKY hastalarda spinal MRG görüntülemeninde yapılması gerektiğine inanmaktayız.

Can Cervical Arthroplasty Impact Alignment? A Comparison of the Synergy Disc with Cervical Fusion

Background context: Synergy disc is a new cervical disc prosthesis that incorporates alignment restoration while providing full intervertebral disc kinematics.Purpose: This follow-up study with 40 Synergy Disc patients with 24-month follow-up compared cervical alignment changes with a retrospective cohort of 30 single level anterior cervical discectomy and fusion (ACDF) patients.Study design/setting: The pilot trial was a multi-center, prospective, consecutive patient enrollment study using the Synergy Disc for the treatment of single and two-level degenerative disc disease of the cervical spine.Patient sample: The procedure was performed on 43 patients (45 implants) with follow-up on 40 patients (42 implants). For the historical cohort ACDF arm, 30 patients with similar follow-up with single level anterior discectomy, fusion and plating were used for segmental lordosis measurements.Outcome measures: For the Synergy Disc group, the kinematic parameters included: range of motion (ROM), shell angle (SA), disc height (DH), sagittal plane translation and center of rotation (COR) in the X and Y direction. Standard assessments of clinical outcomes were also measured (Neck Disability Index, Visual Analog Scale). For the fusion arm, only functional spinal unit (FSU) angle was recorded using a single pre-operative and post-operative standing lateral cervical radiograph.Methods: In the Synergy Disc group, static and dynamic radiological assessments were performed in 43 consecutive patients prior to the placement of the Synergy Disc. Forty patients were studied for the course of the study protocol (3 patients lost to follow-up). For the Synergy Disc group, all kinematic parameters were examined at a minimum of 24 months follow-up. Neck Disability Index and Visual Analog Scale for arm and neck pain were collected and analyzed. For the fusion group, standing lateral radiographs were reviewed.Results: At a mean of 28 months with all patients having a minimum of 24-month follow-up (40 patients, 42 implants), the average SA of the Synergy Disc was maintained at 6 ± 2.7˚ of lordosis. There was significant improvement in all clinical outcome measures. In the fusion group, with a similar follow-up period, there was a 4˚ increase in lordosis of the FSU.Conclusion: The Synergy Disc had an endplate angle of 6 ± 2.7˚ at 2 years following surgery. This was comparable to the lordotic correction provided by an anterior cervical discectomy with interbody fusion and plating.

Changes in Sagittal Alignment after Cervical Disc Arthroplasty: Results ofa Pilot Study

Background context: For cervical disc replacements to be comparable to the gold standard of cervical discectomy and fusion (ACDF), proper cervical alignment after disc replacement is imperative in preventing accelerated facet degeneration, excessive wear debris and axial neck pain. Purpose: This study evaluated whether the Synergy Disc (artificial cervical disc replacement) could provide preservation and/or restoration of cervical alignment while normalizing kinematics and providing acceptable clinical outcomes. Study design/setting: Prospective clinical study for an alignment correcting cervical disc replacement. Patient sample: The Synergy group was comprised of 37 consecutive patients (42 implants) with a minimum follow-up of 1 year (range 12-26 months) on 34 patients (39 implants). Outcome measures: Quantitative motion analysis (QMA) software was used for kinematic outcome parameters: range of motion (ROM), horizontal translation, center of rotation (COR-X, Y), disc height (DH), disc and shell angle (DA and SA, respectively). Neck Disability Index (NDI) and Visual Analog Scale (VAS) were also assessed. Methods: The Synergy Disc patients underwent 204 lateral cervical radiographs (34 patients – 39 implants). Static and dynamic radiological assessments were performed prior to surgery and at last follow-up (mean 18 months, range 12-26 months). Results: At 18 months post-surgery, the average SA of the Synergy Disc was 6 ± 3° of lordosis. Pre-operative ROM, translation and COR X did not change significantly post-surgery. Conclusions: The Synergy Disc provided segmental lordosis at the surgical level, while maintaining pre-operative ROM, translation and COR X. There was a superior shift of COR Y following insertion of the device. The lordosis of 6 ± 3° provided by the Synergy Disc was comparable to the lordotic correction provided by an ACDF