Melih Cekinmez

The role of closed-suction drainage in preventing epidural fibrosis and its correlation with a new grading system of epidural fibrosis on the basis of MRI.

In this study we aimed to evaluate the role of closed-suction drainage on the extent of epidural fibrosis (EF) after lumbar disc surgery and to define a new grading system of epidural fibrosis in these patients, based on magnetic resonance imaging. Seventy-nine patients (34 women, 45 men) with a unilateral, single-level lumbar disc herniation were included in this study. Forty-one patients in whom closed-suction drainage was implanted were compared with 38 patients in whom the drain was not implanted. We have used a new grading system for the extent of epidural fibrosis, on the basis of follow-up magnetic resonance imaging findings. Pain intensity was evaluated by visual analog scale (VAS), and the patients’ function and working ability were measured according to the Prolo functional-economic scale. We conclude that, in patients operated on for unilateral, single-level lumbar disc hernias, implantation of closed-suction drainage into the operation site results in less formation of EF radiologically and yields better clinical outcome.

The effect of metoclopramide on gastric emptying in traumatic brain injury.

OBJECTIVE Gastric paresis in traumatic brain injury (TBI) hinders the effectiveness of enteral support in this patient group. In this study we have investigated the effect of metoclopramide on gastric emptying in TBI patients. METHOD In this prospective, randomized, controlled, double-blind study, 19 TBI patients with Glasgow Coma Scale scores of 3-11 were included. In all patients, enteral nutrition was commenced with a nasogastric feeding tube within 48 hours of trauma. Patients were randomized into two groups. In the metoclopramide (M) group, 10 mg metoclopramide was delivered intravenously three times daily for 5 days. In the control (C) group, an equal volume of saline was administered. Besides demographics, gastric emptying according to a paracetamol absorption test at days 0 and 5, time to reach target nutritional requirements, gastric residues, intolerance to feeding, nutritional complications, and clinical outcomes were recorded for each patient. RESULTS The gastric residue rates were 2.7+/-7.4 mL and 8.1+/-17.7 mL per 100 patient days for groups C and M respectively (p=0.408). Similarly, feeding intolerance and complication rates did not significantly differ between groups C and M, (respectively p=0.543 and 0.930). Gastric emptying parameters also were similar between the study groups. CONCLUSION We were unable to document any advantage to using metoclopramide in TBI patients. Simple intragastric enteral feeding with close monitoring of the possible complications seems to be sufficient with acceptable morbidity rates.

Systemic administration of phosphodiesterase V inhibitor, sildenafil citrate, for attenuation of cerebral vasospasm after experimental subarachnoid hemorrhage.

OBJECTIVEOne of the phosphodiesterase isoenzymes, Type V (PDE V), specifically hydrolyzes cyclic guanosine monophosphate to cause vasoconstriction. This study analyses the effect of PDE V inhibition with sildenafil citrate (SC) on cerebral vasospasm and its effect on apoptotic changes of the vascular endothelium. METHODSTwenty-four rabbits were divided into four groups. The first group was composed of sham-surgery animals. The second group was the subarachnoid hemorrhage (SAH) group, in which cerebral vasospasm was induced. In the third group, sham-surgery rabbits were treated with SC. In the fourth group, animals were treated with SC after SAH. SC was administered for 48 hours, 0.7 mg/kg, three times per day in Groups 3 and 4. Basilar artery lumen circumferences were measured in all groups by computerized image analysis. The terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) method was used to evaluate the rate of apoptosis between SAH and SC-treated SAH groups. Results were compared by analysis of variance and paired t tests, and P values less than 0.05 were considered significant. RESULTSBasilar artery circumferences between groups were significantly different(P < 0.001). SC (0.7 mg/kg, three times per d) significantly dilated the basilar arteries in both the sham-surgery group (2370 ± 233 μm; P = 0.039) and the SAH group(2142 ± 195 μm; P = 0.006) after 48 hours of treatment. The TUNEL method for apoptosis revealed that actual numbers of the apoptotic endothelial cells per cross section after SAH in the control (no treatment) (73 ± 2) and SC-treated (0.7 mg/kg) groups(76 ± 3) were not significantly different (P > 0.05). CONCLUSIONThe vasodilatory effect of SC was observed to be significant on normal cerebral vessels and after SAH-induced vasospasm. SC did not prevent apoptosis of the endothelium in our study, which suggests that prevention of apoptosis is not necessary in the treatment of cerebral vasospasm.

Brain abscess caused by Staphylococcus intermedius

A 4 year-old boy presented to our clinic with the complaints of headache, fever, nausea and vomiting. He was lethargic, right hemiparetic, and had Babinski’s sign on the right. Laboratory investigation revealed haemoglobin 10.8 g=dl, white blood cell count 21,100=mm, erythrocyte sedimentation rate 114 mm=hour, serum C-reactive protein 67.1 mg=L. All chest x-ray and echocardiography findings were normal. Cranial computerized tomography (CT) demonstrated an abscess of 3-cm diameter in the left basal ganglia (Fig. 1A). The patient was taken to surgery, and 40 mL of suppurative material was removed from the abscess by stereotaxic drainage. Gram staining of the pus revealed gram-positive cocci and vancomycin 40 mg=kg=day, ornidazole 30 mg=kg=day and cefotaxime 195 mg=kg=day was administered empirically. Fever resolved at the second day of treatment. Coagulase-positive staphylococci grew in the culture of the material. BBL Crystal System (Becton Dickinson Microbiology Systems, USA) identified the organism as S. intermedius. Sensitivity testing revealed that the isolate was resistant to penicillin, methicillin, clindamycin and sulbactam ampicillin. Thus, Ornidazole and cefotaxime was stopped. An 8-week

Infected Lumbar Dermoid Cyst Presenting With Tetraparesis Secondary to Holocord Central Lesion

We report an unusual case of a 6-year-old boy with a sinus tract terminating with an intramedullary dermoid cyst and holocord central lesion, presenting with tetraparesis secondary to intramedullary abscess. Total excision of dermal sinus tract, dermoid cyst, and the intramedullary abscess by means of a L2–S3 laminectomy, followed by antibiotic therapy resulted in good functional recovery. Strengths of the upper extremities have fully recovered, and a remarkable improvement was detected in the muscles of the lower extremities. Postoperative magnetic resonance imaging (MRI) of the spine showed complete removal of the dermoid cyst, decreased inflamed granulation tissue over the medullary conus, and disappearance of the holocord high intensity lesion. The pathomechanism of holocord central lesion is discussed herein.

Effect of melatonin on cerebral vasospasm following experimental subarachnoid hemorrhage

Abstract Object: The current study was undertaken to determine whether melatonin therapy reverses vasospasm and prevents apoptosis by inhibiting lipid peroxidation in an experimental subarachnoid hemorrhage (SAH) model. Materials and methods: The rabbits were divided into four groups as follows: Group 1, SAH + melatonin (5 mg/kg/i.p. BID) simultaneously with SAH (n = 6); Group 2, SAH + melatonin (5 mg/kg/i.p. BID) treated 2 hours after SAH (n = 6); Group 3, control group (n = 4); Group 4, SAH only (n = 6). Light microscopic examinations of the basilar arteries were performed to demonstrate the pathophysiological changes of the arterial wall with hematoxylin– eosin. Apoptosis: Immunohistology using the ApopTag Peroxidase In Situ Apoptosis Detection Kit was used to demonstrate apoptosis in a cross section of basilary arteries. Apoptotic index was calculated as the number of the immunoreactive nuclei per total number of endothelial cells, and expressed as a percentage. Results: The results of measurements of diameters of the vessels between groups were significantly different (p = 0.028). While basilar arteries of the SAH only group showed 57% constriction, Groups 1 and 2 were calculated as 33 and 26% constriction, respectively, compared with the control group (p < 0.05). And also Groups 1 and 2 showed significant protection of apoptosis compared with Group 4. The difference between the four groups was tested by Kruskal–Wallis test and the significance between the two groups was tested by Mann– Whitney U-test. Conclusion: Melatonin with its strong antioxidant effect can prevent SAH-induced vasospasm and apoptosis of endothelial cells of vessels.

Rapidly Calcifying and Ossifying Epidural Hematoma

Conservative treatment of an epidural hematoma is not always effective in children. We describe an 8-year-old boy who had been followed up conservatively for 10 days at a local hospital due to acute epidural hematoma. A new CT revealed an expansion of the former hematoma accompanied by a thick hyperdense layer. Because the patient presented with symptoms of elevated intracranial pressure, an immediate craniotomy was performed to evacuate the hematoma. The ossified layer, which was densely adhered to the dura mater, was also completely removed. Rapid ossification and/or calcification of an epidural hematoma appearing 10 days after a head injury have not been reported previously. Possible mechanisms of rapid ossification are also discussed in relation to the present report, and the relevant literature is reviewed.

Effects of methyl prednisolone acetate, fibrin glue and combination of methyl prednisolone acetate and fibrin glue in prevention of epidural fibrosis in a rat model

Abstract Objectives: Epidural fibrosis, which develops during the post-operative period in 6–20% of the patients who undergo lumbar spinal surgery, can cause persistent low-back pain and signs of root compression. Conservative treatment protocols or repeat operations performed for the symptoms of epidural fibrosis are long-term and costly treatments and impairs the patients quality of life. In this experimental study, we applied methyl prednisolone acetate mixed with fibrin glue to the surgical field and examined the effects on epidural fibrosis in the surgical field by delaying the absorption of methyl prednisolone acetate. Methods: One hundred Sprague–Dawley rats were divided into five groups, and animals underwent total laminectomy of L4 and L5. We applied 0·05 ml/kg fibrin glue, 0·05 ml/kg methyl prednisolone acetate, 0·05 ml/kg fibrin glue + methyl prednisolone acetate and 0·10 ml/kg fibrin glue + methyl prednisolone acetate topically to the operative sites. Normal saline was applied in the control group. Following the surgery, animals were killed at weeks 1, 2, 4 and 6, and laminectomy sites were examined histopathologically for fibrosis, acute inflammation, necrosis and abscess formation. Results: None of the options had a statistically significant transcendence over others in terms of preventing epidural fibrosis. Conclusion: Many biological and non-biological materials have been tried in a quest to prevent epidural fibrosis. However, inducing least amount of injury to the anatomy of the tissues and a very good hemostasis seem to be the most effective methods in the prevention of epidural fibrosis.

Attenuation of microtubule associated protein-2 degradation after mild head injury by mexiletine and calpain-2 inhibitor.

The objective of the study was to address the early effects of mild, closed, head injuries on neuronal stability and the prevention of microtubule-associated protein-2 (MAP-2) degradation by mexiletine and calpain-2 inhibitor. Twenty-four rats were divided into four groups: control group (1); trauma group without treatment (2); mexiletine-pretreated and subjected to trauma group (3); trauma subjected and then calpain-2 inhibitor received group (4). All animals were subjected to mild, closed, head trauma. Frontal lobes were removed and processed for staining and immunofluorescent labelling of MAP-2 cytoskeletal proteins, which were evaluated by confocal microscopy in serial optical sections showing the three dimensional cytoarchitecture of affected areas. MAP-2 decoration in almost all neurons obtained from traumatized brain regions drastically diminished, while minute filamentous and granular profiles in axons and/or dendrites were retained together implying a massive degradation/depolymerization of microtubules. In contrast, in mexiletine-pretreated animals, MAP-2 positivity in axonal and perikaryonal profiles was fairly retained, which clearly depicts the protective role of mexiletine after trauma. Compared with mexiletine-pretreated group, calpain-2 inhibitor treated group displayed a less well-preserved MAP-2 expression. Mexiletine can prevent cytoskeletal structure and protein degradation after mild head trauma. Calpain-2 inhibitor prevents protein degradation, but cytoskeletal organization is better preserved with mexiletine.

Delayed radiation myelopathy: Differential diagnosis with positron emission tomography/computed tomography examination

Myelopathy is a rare but serious complication of radiation therapy (RT). Radiation myelopathy is white matter damage to the spinal cord developed after a certain period of application of ionizing radiation. Factors such as radiation dose and time between applications affect the occurrence as well as the severity of myelopathy. In those patients, positron emission tomography/computed tomography examination has a very important role both in the diagnosis and in the differential diagnosis of lesions. In this case report, the case of progressive paraparesis, developed in a 52-year-old female patient operated with pulmonary mucinous cystadenocarcinoma diagnosis and who received chemotherapy and RT following surgery, has been reported.