Mehmet Zileli

Spinal hydatid disease

Vertebral hydatid cysts are rare and found in less than 1% of all the cases of hydatidosis. Neural compression is common in vertebral hydatidosis. The prognosis is generally regarded as very poor. This paper examines the natural history and complications which may arise during the treatment of vertebral hydatid cyst, and discusses their treatment. Thirteen cases of hydatid disease affecting the vertebrae are presented. The patients were admitted with symptoms of spinal cord compression. Twelve were treated by laminectomy and one by costotransversectomy. Low back pain radiating to the legs and lower extremity weakness were the predominant symptoms. Different degrees of pareses were present in 12 patients. Nine patients had impaired sensation in lower extremities. In 13 patients, 27 operations were performed. The major complication of surgery was the death of one patient due to the formaline irrigation. The surgical goal should be an extensive removal of the cysts and affected bone. The surgical area needs to be irrigated with hypertonic saline. Mebendazole or albendazole therapy seems to retard the recurrences and control the disease.

Unilateral pallidal stimulation in cervical dystonia.

Cervical dystonia (spasmodic torticollis) is a focal dystonia of the cervical region. Various treatment modalities have been performed with variable success rates. We present a 42-year-old woman complaining of involuntary head rotation for the last 3 years. Different medical treatments had been used for 3 years. Botulinum toxin injections resulted in temporary and moderate improvement for periods of 3–4 months. Pallidal stimulation was performed using a quadripolar electrode and a battery-operated programmable pulse generator. We conclude that a unilateral pallidal lesion or stimulation is an effective method of treatment in focal dystonia. The target must be the pallidum contralateral to the contracted sternocloidomastoid muscle. Deep brain stimulation is superior to lesioning because of the capability of manipulating the stimulation parameters which can modify the pallidotomy effect.

A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multicenter AOSpine international study on 479 patients.

Study Design. Prospective, multicenter international cohort. Objective. To evaluate outcomes of surgical decompression for cervical spondylotic myelopathy (CSM) at a global level. Summary of Background Data. CSM is a degenerative spine disease and the most common cause of spinal cord dysfunction worldwide. Surgery is increasingly recommended as the preferred treatment strategy for CSM to improve neurological and functional status and quality of life. The outcomes of surgical intervention for CSM have never been evaluated at an international level. Methods. Between October 2007 and January 2011, 479 symptomatic patients with image evidence of CSM were enrolled in the prospective, multicenter AOSpine CSM-International study from 16 global sites. Preoperative and postoperative clinical status, functional impairment, and quality of life were evaluated using the modified Japanese Orthopaedic Assessment Scale, Nurick Scale, Neck Disability Index, and Short-Form-36v2. Preoperative and 12- and 24-month postoperative outcomes were compared using mixed-model analysis of covariance for repeated measurements. Results. The study cohort consisted of 310 males and 169 females, with a mean age of 56.37 ± 11.91 years. There were significant differences in age, etiology, and surgical approaches between the regions. At 24 months postoperatively, the mean modified Japanese Orthopaedic Assessment Scale score improved from 12.50 (95% confidence interval [CI], 12.24–12.76) to 14.90 (95% CI, 14.64–15.16); the Neck Disability Index improved from 36.38 (95% CI, 34.33–38.43) to 23.20 (95% CI, 21.24–25.15); and the SF36v2 Physical Component Score and Mental Composite Score improved from 34.28 (95% CI, 33.46–35.10) to 40.76 (95% CI, 39.71–41.81) and 39.45 (95% CI, 38.25–40.64) to 46.24 (95% CI, 44.94–47.55), respectively. The rate of neurological complications was 3.13%. Conclusion. Surgical decompression for CSM is safe and results in improved functional status and quality of life in patients around the world, irrespective of differences in medical systems and sociocultural determinants of health. Level of Evidence: 3

Combined anterior and posterior approach for managing basilar invagination associated with type I Chiari malformation.

Ventral brainstem compression is common in patients with basilar invagination associated with type I Chiari malformation. The aim of this study was to investigate the reliability of a combined one-session anterior–posterior surgical approach for these patients. Nine patients underwent transoral odontoidectomy, posterior foramen magnum decompression, occipitocervical fixation, and bone grafting. All but two patients had ventral and dorsal operations in one surgical sitting. One of these two individuals had previously undergone posterior decompressive surgery at another hospital, but his condition had deteriorated rapidly afterward. The mean follow-up time was 19 months (range, 14–30 months). There was no mortality and no significant morbidity in this series. All but one of the patients showed significant improvement in their symptoms. Chiari malformations have a surprisingly high association with basilar invagination, and patients may have symptoms in both conditions. If there is a marked anterior compression, anterior transoral and posterior decompression, fusion, and instrumentation is an optimal strategy for treating patients with basilar invagination associated with type I Chiari malformation.

Intradural spinal hydatid cysts

Abstract Spinal hydatid cysts are very rare and comprise only 1% of all bony involvement. Intradural hydatid cysts are extremely rare compared to other types of spinal hydatid cysts. We report the case of a 19-year-old man with lumbar intradural hydatid cysts. He complained of paraparesis and urinary hesitancy. Myelography revealed a block of the contrast medium at the L4 level and multiple round radiolucent lesions rostrally. At surgery, multiple hydatid intradural cysts were extirpated. The patient’s neurologic deficits improved postoperatively, but recurred 6 weeks later. Reoperation led to partial improvement of deficits. Primary intradural hydatid cysts are extremely rare. It is difficult to explain an isolated intradural location of multiple cysts. In our patient, the cysts were multiple and the patient’s cerebral CT scan was normal; he had undergone no previous lumbar puncture. So we can hypothesize that intradural spinal cysts may be primarily multiple.

Neuroanatomy of cervical sympathetic trunk: a cadaveric study.

To reduce the risk of iatrogenic injury to sympathetic chain during anterior and anterolateral approaches to the cervical spine, its location has to be well defined and known by surgeons. We analyzed the course of sympathetic chain and its ganglia from C7 up to its entry into the cranial base and its relationship mainly with the longus colli (LC). Formalin fixed 20 human cadavers were dissected under operating microscope. Measurement of the dimensions of the ganglia, distance of the trunk to the LC, and the angles identifying the course of the chain were performed. Superior and inferior cervical/cervicothoracic ganglion were observed in all specimens, the middle cervical ganglion was observed in 48% of the specimens. The middle ganglion consisted of two ganglia in 10% of the dissected sides. Forty percent of the inferior cervical/cervicothoracic ganglion was at the C7 level, 25% was at C7‐Th1 disc level, and 35% was at Th1 level. Vertebral ganglion was detected in only 8% of the specimens. The course of the sympathetic trunk converges medially descending from upper cervical levels to the lower levels. Anterior surgical approach to the cervical spine is a commonly used procedure. Although Horner syndrome due to sympathetic injury is not a common sequence of cervical operations, our findings support the current few reports on the subject and should be useful to any surgeon who operates in the cervical region to avoid this uncommon complication. Clin. Anat. 22:324–330, 2009.

The Effects of Melatonin on the Antioxidant Systems in Experimental Spinal Injury

Melatonin has been recently shown by various in-vivo and in-vitro studies to exert potent neutralising effects on hydroxyl radicals, stimulate glutathione peroxidase (GSH-Px) activity, and protect catalase (CAT) from the destructive activity of hydroxyl radicals in neural tissue. We aimed to investigate the possible effects of pharmacological dose of melatonin on some of the antioxidant defence systems in an in-vivo study of experimental spinal injury. Seven groups of adult male Sprague Dawley rats were used in the following scheme: Group I: Naïve (n = 6), Group II: Lesion (n = 8), Group III: Melatonin (n = 5), Group IV: Melatonin + Lesion (n = 8), Group V: Placebo + Lesion (n = 5), Group VI: Sham operation (n = 5), and Group VII: Placebo (n = 5). Experimental spinal injury was induced at level T7-T8 by 5 sec compression of the total cord with an aneurism clip on anaesthetised and laminectomized animals. The total 10mg/kg dose of melatonin (Sigma) dissolved in alcohol-water was administered i.p. four times in 2.5 mg/kg doses, at 20min pre-, at the time of and at 1h and 2h post-compression. At 24±2h post-injury, the rats were euthanized and the lesioned segments of cord were dissected and homogenised with special care taken to distribute equal amount of injured tissue in each sample for analysis of reduced glutathione (GSH), oxidised glutathione (GSSG), superoxide dismutase (SOD), and CAT activity. Compression injury decreased GSH/GSSG ratio significantly (p <. 0001). Melatonin, by itself, significantly decreased GSSG content (p <. 05) and increased CAT activity (p <. 05) in the naive rats. Melatonin treatment decreased GSSG activity, thus elevating GSH/GSSG ratio, and also increased SOD and CAT activity without reaching statistical significance in the lesioned animals. In conclusion, pharmacological dose of systemically applied melatonin seemed to support some features of the antioxidant defence systems in our hands.

Surgery of intramedullary spinal cord tumors

The diagnosis and management of intramedullary spinal cord tumors have been significantly influenced by new diagnostic and surgical tools such as MRI, ultrasonic aspiration, intraoperative ultrasound, and evoked potential monitoring. In this study we compared the surgical results of our earlier cases using conventional methods with more recent cases using these new methods. We report our experience based on 44 adult cases. Histologic diagnosis revealed ependymoma (20 cases), astrocytoma (15 cases), glioblastoma multiforme (1 case), and other histologic diagnoses (8 cases). We performed 20 gross total resections, 19 partial resections, and 5 biopsies. The mean follow-up period was 25.8 months (3 months-10 years). Surgical results were improvement in 11 patients (25%), stabilization in 24 (54%), and deterioration in 9 (20%). The first 28 cases (group A) were diagnosed using conventional ventional myelography and CT myelography. The more recent 16 cases (group B) were diagnosed with MRI and operated on using techniques such as ultrasonic aspiration, intraoperative monitoring and ultrasound imaging. Radical surgery (total excison) was performed in 36% (n=10) of group A, while it was possible in 62% (n=10) of group B. Deterioration after operation was noted in 28% (n=8) of group A, but only 6.2% (n=1) of group B. These results stress the importance of a preoperative MRI scan and the positive effects of intraoperative ultrasound imaging, ultrasonic aspiration, and evoked potential monitoring on surgical results. With the help of these tools, most intramedullary spinal cord tumors may be diagnosed and treated surgically with significantly decreased risk. Radical surgery was possible in as many as 62% of our more recent patients. Partial resection with radiotherapy should be confined to patients with high-grade astrocytomas.

Linezolid in the treatment of methicillin-resistant staphylococcal post-neurosurgical meningitis: A series of 17 cases

Abstract Background: Linezolid is a bacteriostatic antibiotic with good cerebrospinal fluid penetration. The aim of this study was to evaluate the efficacy of linezolid in methicillin-resistant staphylococcal (methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase-negative Staphylococcus (MRCoNS)) meningitis. Methods: We extracted data and outcomes for all adult patients (age > 18 y) with culture-proven MRSA or MRCoNS meningitis treated with linezolid between January 2006 and September 2010 in our hospital. Demographic, clinical, and laboratory data and predisposing factors, as well as information on response to treatment and outcome were obtained by regular visits. Results: A total of 17 cases (9 MRCoNS, 7 MRSA, and 1 MRCoNS and MRSA mixed) fulfilled the inclusion criteria. All patients had hospital-acquired meningitis and had undergone neurosurgery. Cumulative microbiological success on day 5 was 88%. There was 1 staphylococcal meningitis-related death. There were no severe adverse events. Conclusions: Our experience with linezolid suggests that it can be an alternative for the treatment of MRCoNS- and MRSA-related meningitis.

Gluteal artery pseudoaneurysm, a rare cause of sciatic pain: case report and literature review.

This article describes a very unusual case of sciatic pain and motor dysfunction resulting from gluteal artery pseudoaneurysm. A 36-year-old woman with primary infertility sustained an iatrogenic injury to her left gluteal artery during transvaginal ultrasound-guided follicle aspiration. Twenty-five days after the procedure she developed severe left sciatic pain and motor dysfunction. Pelvic computed tomography and magnetic resonance imaging revealed a huge pelvic hematoma. Angiography demonstrated a gluteal artery pseudoaneurysm. Because endovascular occlusion of the aneurysm did not relieve the pain, the patient underwent surgery for evacuation of the hematoma and release of the lumbosacral plexus. This eliminated all her sciatic pain and restored her motor dysfunction completely. The English literature details only five other cases of sciatic pain resulting from gluteal artery aneurysm, and these reports are also discussed.