Mehmet Daneyemez

Ochronosis and lumbar disc herniation.

SummaryAlkaptonuria is a rare, autosomal recessive metabolic disorder in which the homogentisic acid oxidase activity is absent. Its incidence is as low as 0.001%. Ochronosis is the pigmentation of connective tissues and this pigmentation leads to degenerative changes in alkaptonuric patients.Alkaptonuria most prominently involves the lumbar region, but lumbar disc herniation as the presenting feature of alkaptonuria is not common. Only a few patients required surgical intervention.Herewith we report an alkaptonuric patient, who was operated on for lumbar disc herniation. His discectomy material was black and the metabolic disorder was diagnosed retrospectively.This metabolic disease is often recognized on physical re-examination after the black disc material was seen during the operation. Therefore urinalysis for homogentisic acid should be performed in all patients with degenerative changes of the vertebral column. The results of disc surgery in this patient group is successful.

Evaluation of spinal missile injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention: a new guideline.

Study Design. Analysis of the patients with spinal missile injury (SMI). Objective. Choosing the optimum treatment for SMI with respect to bullet trajectory, evaluation of surgical indications, and timing of surgical intervention. Summary of Background Data. A few guidelines were reported for the management of SMI. But there is still no consensus about the indication and timing of the surgery. The relationship between the surgery and bullet trajectory was not reported previously. Methods. One hundred twenty-nine patients with spinal missile injury were admitted to our department from 1994 to 2006 and 122 of them could be functionally monitored. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Surgical indications were discussed. The injuries were classified with respect to the bullet’s trajectory. Seventy-four patients were treated surgically, of whom 60 (81%) had incomplete injuries. All 17 patients whose vertebral column was injured with side-to-side trajectory were operated on because of instability. Results. In the surgical group, 33 (56.9%) showed improvement, 20 (34.5%) showed no change, and 5 (8.6%) worsened. The best results were obtained by the patients who received operations because of rapid neurologic decline, compression, and instability in the spinal canal (P < 0.0001). Twenty-three (31%) complications and associated injuries were seen in the surgically treated patients and 18 (34.6%) were seen in the conservatively treated patients. Conclusion. Anteroposterior and oblique trajectories [Gulhane Military Medical Academy (GATA)-SMI I and GATA-SMI II] of SMI must be recognized as highly infective in the lumbar region. A side-to-side trajectory (GATA-SMI III) missile causing spinal cord injury is unstable and needs further stabilization. The spinal cord is not injured by the GATA-SMI IV trajectory, and thus, the best approach in this case is conservative. The best results from neurosurgical interventions may be achieved after rapid neurologic deteriorations because of spinal compression and/or instability.

Spinal Hydatid Cyst Mimicking Arachnoid Cyst on Magnetic Resonance Imaging

Abstract Background: Primary spinal hydatid cysts are uncommon and account for 1% of all cases of hydatid disease. Echinococcus granulosus is most often responsible for the cyst hydatid. Intradural, extramedullary involvement is rare. When the cysts do not demonstrate typical magnetic resonance imaging findings, the differential diagnosis is more complex. Method: Case report. Findings: An isolated primary hydatid cyst of the spine in a 35-year-old man that appeared to be an arachnoid cyst on preoperative radiographic examination. Conclusion: Hydatid cysts that lack the typical radiographic appearance may be mistaken for arachnoid cysts. Misdiagnosis has serious implications for surgical intervention and long-term care.

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

Background The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries. Methods Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions. Results The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis. Conclusion Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.

Surgical management strategies of intracranial arachnoid cysts: a single institution experience of 75 cases.

AIM Arachnoid cysts are benign intra-arachnoid cystic lesions filled with cerebrospinal fluid. With advent of modern treatment techniques, debate continues regarding which surgical treatment is most effective. MATERIAL and METHODS A consecutive series of 75 patients with arachnoid cysts that were surgically treated between January 1992 and December 2009 are reported. Included in the study were 54 male and 21 female patients, ranging in age from 2 months to 45 years (mean age 20.02 years) at the time of surgery. Symptoms at presentation, location on the cysts, and treatment modalities were evaluated. RESULTS Headache was controlled in 92.5% of adult cases. Hydrocephalus, cognitive decline weakness and gait disturbances were controlled 100% after overall treatment methods. Follow-up CT scans showed significant reduction in cyst size in supratentorial arachnoid cysts. No significant changes in cyst size were found in infratentorial cysts but symptomatic improvements were noted. CONCLUSION Patients with symptomatic arachnoid cysts regardless of age and cyst location should be treated. We think that avoiding shunt dependence should be one of the principle treatment goals. Proper patient selection results in good outcomes.

Desmoplastic fibroma of the cervical spine

There have been only a few cases of desmoplastic fibroma of the spine in the literature and only one of them was purely located on the cervical spine. We report a new patient with the diagnosis of desmoplastic fibroma of the fourth cervical spine. The patient had the complaints of left arm and neck pain. After his radiological evaluation, a mass lesion was found on the left lamina of the fourth cervical spine. Surgical treatment was performed, and the histopathological examination revealed the diagnosis of desmoplastic fibroma. Patients with desmoplastic fibroma of the cervical spine may present with the arm and neck pain mimicking cervical disc disease. Higher index of suspicion by the clinicians must be practiced to make the appropriate diagnosis. Successful surgical outcome may be achieved in these patients.

Analysis of proximal radial nerve injury in the arm

BACKGROUND Radial nerve is the most frequently injured major nerve in the upper extremity. Proximal part of the radial nerve involvement can result from a humerus fracture, direct nerve trauma, compression and rarely from tumors. OBJECTIVES The aim of the study is to determine the clinical characteristics and electrodiagnostic findings in patients with proximal radial nerve injuries, and also the outcome of surgical treatment. MATERIALS AND METHODS The study subjects included 46 patients with radial nerve injuries seen between June 2000 and June 2008 at our hospital. The analysis included demographics, clinical features, etiology, pre-and postoperative EMNG (Electromyoneurography) findings. RESULTS Surgical decompression resulted in neurological improvement in patients with radial entrapment neuropathies. Good neurological recovery was observed from decompression of callus of old humeral fracture. The worst results were observed in the direct missile injuries of the radial nerve. CONCLUSIONS A detailed clinical and electrodiagnostic evaluation is of importance in patients with radial nerve injury to ensure an appropriate treatment. The choice of treatment, conservative or surgical, depends on the clinical presentation and the type of injury.

The Surgical Anatomy of the Brachial Plexus

AIM The brachial plexus (BP) has a complex structure and risky relations with its neighborhoods. This study was designed to investigate and overcome the morphometric features of the BP and the difficulties regarding surgery of BP lesions. MATERIAL AND METHOD Twelve BP of six adult cadavers were dissected and neural structures, branches, and variations were evaluated. Morphometric measurements were done and surgical approaches were discussed. RESULTS The length of anterior (ventral) rami of C5-T1 are in decreasing order such as C5 > C6 > C7 > C8 > T1 and the width of them is in decreasing order such as C7 > C8 > C6 > T1 > C5. The length of upper trunk (UT) , middle trunk (MT) and lower trunk (LT) are approximately similar (UT approximately MT approximately LT) , but the width is in decreasing order as LT > UT > MT. The length of the cords are in decreasing order as posterior cord (PC) > lateral cord (LC) > medial cord (MC), whereas their widths are PC > LC > MC . CONCLUSION From the ventral rami to the cords, BP has a complex and variable anatomic structure. The selection of surgical procedure to the BP needs to be mastered by having the best knowledge of the relevant anatomy.

Endoscope-Assisted Microsurgical Removal of an Intraventricular Ependymal Cyst That Manifested with Tremor

BACKGROUND Intraventricular ependymal cysts (ECs) are rare, histologically benign neuroepithelial cysts. Most of these cysts are clinically silent and discovered incidentally. Rarely, they become symptomatic, leading to obstruction of the cerebrospinal fluid circulation. ECs located inside the ventricles may manifest with signs of increased intracranial pressure. CASE DESCRIPTION A 32-year-old woman presented with a 6-year history of tremor affecting her left hand. In the last month, she had been experiencing headache as well, and the tremor of the left hand was affecting her quality of life. The patient demonstrated a fine resting and intention tremor of the left hand and a voice tremor. Magnetic resonance imaging revealed a large cystic, nonenhancing lesion within the right lateral ventricle. The fluid within the cyst was isointense to cerebrospinal fluid on all sequences. Because of the rapid progression of her symptoms and no response to medication, surgical decompression of the cyst was considered. The cyst was removed by an endoscope-assisted microsurgical technique. Her postoperative course was uneventful. A marked reduction in her tremor was noted in the immediate postoperative period. Histopathologic diagnosis was of an EC. During the follow-up period, the patients tremor, although still present, had improved dramatically. At 6 months postoperatively, she could hold a drinking glass without spilling. CONCLUSIONS This is a unique case of an intraventricular EC that manifested with tremor, which improved by endoscope-assisted microsurgical removal of the cyst. This case also supports the important role of endoscopic surgery in the treatment of intraventricular cystic lesions.

Fully Endoscopic Resection of Intra-Axial Brain Lesions Using Neuronavigated Pediatric Anoscope.

AIM To present a new simple disposable tubular retractor which provides fully endoscopic resections of the intraaxial brain lesions. MATERIAL AND METHODS A total of 13 patients underwent surgical resection of an intraaxial brain lesion larger than 3 cm with a fully endoscopic approach using the navigation-guided pediatric anoscope. The anoscope was adapted to serve as a tubular retractor. All lesions were resected under endoscopic visualization and navigation guidance. There were 7 men and 6 women with a mean age of 49.6 years (range, 19-76 years). Lesion location was as follows: frontal (n=4), parietal (n=1), frontoparietal (n=2), temporal (n=2), and intraventricular (n=4). RESULTS With the use of this technique, preoperative goals of surgery were met in all patients. Gross total resection of the lesions was achieved in 7 of 13 patients (53.8%), near-total resection in 3 patients (23.1%) and subtotal resection in 3 (23.1%) patients. The histological diagnosis included 2 metastases, 5 (38.5%) glioblastomas, 3 meningiomas, 2 low grade gliomas and one oligodendroglioma. There were no complications related to the surgical procedure. Duration of surgery ranged from 60 to 110 minutes, with an average 90 minutes. The average postoperative hospital stay was 2.7 days. CONCLUSION Endoscopic resection of deep-seated brain lesions with the neuronavigated tubular retractor is a safe and an effective technique and may be a feasible alternative to conventional microsurgical or endoscope-assisted methods in selected patients. The modified transparent plastic pediatric anoscope can be used as a tubular retractor and it is easy to apply, simple, lightweight, inexpensive and effective.