Mesut Yilmaz

Clinical and radiographic results of balloon kyphoplasty for treatment of vertebral body metastases and multiple myelomas

Kyphoplasty is a minimally invasive procedure that is used to augment vertebral body strength. This technique has been commonly used to treat osteoporotic, vertebral body compression fractures. The technique was also used to augment painful metastatic vertebral fractures. The objective of this study was to review the clinical and radiological results after kyphoplasty in patients with vertebral body compression fractures due to spinal metastasis and multiple myeloma and to determine factors that may affect outcome. Thirty-one patients had 41 vertebral body fractures secondary to spinal metastasis or multiple myeloma. A kyphoplasty procedure was performed on 39 levels. The pain and neurological status were evaluated using the visual analogue scale (VAS) score and the American Spinal Injury Association classification scale scores, respectively. Radiological evaluations were used to measure vertebral body height loss (VBHL) and the segmental kyphosis angle before and after surgery. The major symptoms that patients presented with included pain (25 patients); and neurological deficit (four patients). Two patients presented with no symptoms because the metastases were found during cancer screening. The mean (+/-standard deviation [SD]) VAS score was 7.2+/-2.2 before surgery and 1.6+/-1.3 after surgery. The mean preoperative VBHL was 27.8+/-11.3% for the thoracic spine and 27.7+/-12.5% for the lumbar spine. VBHL values were reduced to 22.4+/-10.0% and 18.4+/-10.4% for the thoracic and lumbar spine after surgery, respectively. The segmental kyphosis angles decreased from 21.2+/-11.4 degrees to 17.0+/-9.8 degrees for the thoracic spine and from 15.3+/-8.8 degrees to 10.4+/-7.2 degrees for the lumbar spine after surgery. There was a correlation between the symptom duration and VBH restoration rate. There was no correlation between the amount of injected polymethylmethacrylate and pain relief. We concluded that kyphoplasty is a safe and effective procedure for treating painful vertebral body fractures caused by metastasis and multiple myeloma. It can restore VBH and correct the kyphosis angle. While the increased amount of the injected PMMA led to its leakage, it did not contribute to restoration of the VBH or kyphosis correction. Therefore, one should avoid injection of excessive amounts of PMMA.

MRI demonstration of intra-articular median nerve entrapment after elbow dislocation

We report a case of median nerve entrapment in the elbow joint diagnosed with MRI 14xa0months after closed reduction of a dislocated elbow joint.

“Skip” corpectomy in the treatment of multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament

OBJECTnThe authors reviewed the results of skip corpectomy in 29 patients with multilevel cervical spondylotic myelopathy (CSM) and ossified posterior longitudinal ligament (OPLL).nnnMETHODSnThe skip corpectomy technique, which is characterized by C-4 and C-6 corpectomy, C-5 osteophytectomy, and C-5 vertebral body preservation, was used for decompression in patients with multilevel CSM and OPLL. All patients underwent spinal fixation using C4-5 and C5-6 grafts, and anterior cervical plates were fixated at C-3, C-5, and C-7.nnnRESULTSnThe mean preoperative Japanese Orthopaedic Association score increased from 13.44 +/- 2.81 to 16.16 +/- 2.19 after surgery (p < 0.05). The cervical lordosis improved from 1.16 +/- 11.74 degrees to 14.36 +/- 7.85 degrees after surgery (p < 0.05). The complications included temporary hoarseness in 3 cases, dysphagia in 1 case, C-5 nerve palsy in 1 case, and C-7 screw pullout in 1 case. The mean follow-up was 23.2 months. The final plain radiographs showed improved cervical lordosis and fusion in all cases.nnnCONCLUSIONSnThe authors conclude that the preservation of the C-5 vertebral body provided an additional screw purchase and strengthened the construct. The results of the current study demonstrated effectiveness and safety of the skip corpectomy in patients with multilevel CSM and OPLL.

Assessment of sexual dysfunction before and after surgery for lumbar disc herniation.

Object Sexuality is an important aspect of human life. Sexual activity may be affected in lumbar disc herniation through different mechanisms. The aim of this study is to evaluate patients sexual problems and sexual behavior patterns before and after surgical treatment of lumbar disc herniation. Methods Forty-three patients were included in the study (mean age 41.4 years). A visual analog scale, the Oswestry Disability Index, the Hospital Anxiety and Depression Scale, and a sexuality assessment questionnaire developed for this study were administered to the patients to evaluate pain and sexual dysfunction. Results Fifty-five percent of the men and 84% of the women reported experiencing sexual problems after the onset of low-back pain. The most common sexual problems were decreased sexual desire (18%) and premature ejaculation together with erectile dysfunction (18%) for the male patients, and decreased sexual desire (47%) for the female patients. The frequency of sexual intercourse before the operation was reduced in 78% of cases compared with the pain-free period. Postoperatively, the patients first attempted sexual intercourse a mean of 26.5 days after surgery. The frequency of intercourse was found to have increased (p = 0.01), while description of any type of sexual problem had decreased (p = 0.005) significantly. Conclusions Lumbar disc herniation has negative effects on sexual life, and not enough attention is given to the patients sexual problems by the physicians. Decreased sexual desire and decreased sexual intercourse are the most commonly reported problems. Taking time during examination and giving simple recommendations may improve sexuality and life quality of the patients.

Surgical anatomy of the presacral area

ObjectiveL5–S1 instabilities can be fixated using minimally invasive presacral approach. The close relationship between the sacrum and neurovascular as well as intestinal structures may complicate the procedure during this approach. This requires knowledge regarding the normal anatomy of the presacral area to avoid the iatrogenic injuries. The aim of this study was to measure the distance between the sacrum and the structures anterior to it.Materials and methodsThe measurements were performed on ten cadavers fixed with formaldehyde and ten MR imaging studies on individuals without any pathology in the presacral area. The distances between the sacrum and the presacral structures (i.e., middle and lateral sacral arteries, sympathetic trunks, internal iliac arteries and veins, and colon/rectum) were measured.ResultsCadaver study showed that the middle sacral artery was located on the right side in 55.0%, on the left side in 31.7%, and on the midline in the 13.3% of cases. The distance between the sacral midline and middle sacral artery was found to be 8.0xa0±xa05.4, 9.0xa0±xa04.9, 8.7xa0±xa06.0, 8.6xa0±xa06.4, and 4.7xa0±xa05.0xa0mm at the levels of S1–2, S2–3, S3–4, S4–5, and S5–coccyx, respectively. The distance between the sacral midline and the sympathetic trunk ranged between 22.4xa0±xa05.8 and 9.5xa0±xa03.2xa0mm in different levels between S1 and coccygeal level. The study also showed that the distance between the posterior wall of the intestine (colon/rectum) and the ventral surface of the sacrum can be as close as 11.44xa0±xa07.69xa0mm on MR images.ConclusionThis study showed that there was close distance between the sacral midline and the structures anterior to it. The close relationships, as well as the potential for anatomical variations, require the use of sacral and presacral imaging before presacral approach.

Treatment Principles for Coccygodynia

AIMnAn evaluation of treatment methods and outcomes for coccygodynia cases that do not respond to conservative treatment.nnnMATERIAL AND METHODSnLocal anesthetic and steroid injections were applied in 32 coccygodynia cases that did not respond to conservative treatment (average of 15 months). Coccyx excision was performed as surgical treatment in 25 cases that had pain relief after the injections but later re-presented with complaints. The patients pain levels were assessed with VAS. Postacchini classification was used for patient classification based on plain radiography.nnnRESULTSn20 (62%) of the cases (the total including injection and surgery groups) had a trauma history. Majority of the cases treated with local steroid injection included patients with Type I, while the 25 cases that received surgical treatment predominantly included Type II patients. One case had post-operative skin infection, which was treated with antibiotics. It was observed by comparing pre-operative and post-operative pain scores that both methods provided significant pain relief in all patients.nnnCONCLUSIONnWhile local steroid injection is an effective method of treatment for Type I patients, the coccyx removal is an effective method for controlling the pain in patients with trauma history and in Type II, III and IV patients.

Surgical treatment in sacral fractures and traumatic spinopelvic instabilities.

AIMnSacral fractures are generally seen together with pelvic ring fractures. They can also develop in isolated form rarely. Instability is observed in these fractures in rates reaching 30%.nnnMATERIAL AND METHODSnSpinopelvic stabilization was applied to 10 cases with pelvic fractures together with sacral fractures and spinopelvic instability. Two cases were treated with adductive screws extending from the iliac wing to the sacrum, 5 cases with standard lumboiliac instruments and 3 cases were treated with iliac wing plates that are our own design. The cases were evaluated according demographic data, VAS, ASIA and Oswestry scores and the types of the trauma and fracture.nnnRESULTSnSix cases had unilateral sacroiliac instability while the instability was bilateral in 4 cases. Follow-up periods range between 6 and 91 months. Preoperative VAS was 8.4, Oswestry mean value was 91.2, postoperative late VAS was 2.2, and Oswestry was 24.4.nnnCONCLUSIONnSerious spinopelvic instability can be talked of in sacral fractures accompanied by pelvic fractures, particularly when the anterior and posterior integrity of the pelvic ring is interrupted together. An aggressive stabilization and fixation must be performed without delay.

The contribution of cervical dynamic magnetic resonance imaging to the surgical treatment of cervical spondylotic myelopathy.

AIMnCervical spine is the most kinetic segment of the whole vertebrae. The radiologic imaging methods concern with the morphologic changes but give no functional data. At flexion, spinal cord strains, anterior osteophytic compression increases. At extension, spinal canal gets narrower, cord shortens and gets thicker, compression of posterior ligament gets abberant and cord compression increases.nnnMATERIAL AND METHODSn258 cervical spondylotic myelopathy (CSM) cases were scanned by conventional magnetic resonance imaging (MRI) and additionally dynamic MRI. Contributions of dynamic cervical MRI to the surgical plans and results were evaluated.nnnRESULTSnWe had sagittal and axial T2W MR scans at flexion and extension, in addition to the neutral cervical MR imaging. We found that the AP diameter of spinal canal is increased 14.9 % in flexion and decreased 13.4 % in extension relative to the neutral MR imaging.nnnCONCLUSIONnThe changes of the cord compression and the transvers area of cord which is the most important prognostic indicator in spinal diseases and also the area of spinal cord and subarachnoid space can be detected via dynamic axial sections of MRI. Dynamic MR images may be helpfull in the decision making for the surgical treatment of CSM.

Supraclavicular surgical approach for thoracic outlet syndrome: 10 years of experience.

AIMnSymptoms of thoracic outlet syndrome (TOS) may be vascular, neurological or combined symptoms involving both. Treatment of TOS is generally conservative. Surgical treatment is required when radiological results indicate anatomical abnormality. This study aims to present the surgical outcomes of TOS patients treated with supraclavicular approach via microsurgery.nnnMATERIAL AND METHODSn41 patients with thoracic outlet syndrome were rewieved retrospectively. The pain was determined using both on visual analogue scale (VAS) and Oswestry score both in the preoperative and postoperative period. All patients underwent electromyography including brachial plexus, ulnar and median nerves. Computed Tomography (CT) angiographic examination was applied dynamically with required manoeuvres.nnnRESULTSnPost-op VAS scores were recorded as 0.8 for the arm, 0.6 for the shoulder and 0.5 for the neck, while pre-op VAS scores were 6.3 for the arm, 6.0 for the shoulder and 5.2 for the neck. Post-op Oswestry disability index (ODI) average was found as 14,2, while this figure was 67,4 during the pre-operative period.nnnCONCLUSIONnAccurate patient selection is imperative for increasing the success of TOS surgery. Microscopic TOS surgery yields satisfactory results with smaller incision, safer surgery and a lower rate of complication.

A new technique in the surgical treatment of Hangman's fractures: Neurospinal Academy (NSA) technique.

Context: Treatment of Hangmans fractures is still controversial. Hangmans fractures Type II and IIA are usually treated with surgical procedures. Aim: This study aims at describing the Neurospinal Academy (NSA) technique as an attempt to achieve an approximation of the fracture line to the axis body, which may be used for Type II and IIA patients with severe displacement and angulation. Settings and Design: NSA technique both pars or pedicle screws are placed bicortically to ensure that anterior surface of C2 vertebral body will be crossed 1-2 mm. A rod is prepared in suitable length and curve to connect the two screws. For placing the rod, sufficient amount of bone is resected from the C2 spinous process. C2 vertebral body is pulled back by means of the screws that crossed the anterior surface of C2 vertebral body. Materials and Methods: Hangman II and IIA patient are treated with NSA technique. Result: Angulated and tilted C2 vertebral body was pulled back and approximated to posterior elements. Conclusions: In Hangmans fractures Type II and IIA with severe vertebral body and pedicle displacement, NSA technique is an effective and reliable treatment alternative for the approximation of posterior elements to the C2 vertebral body, which is tilted, angulated, and dislocated.