Murat Sakir Eksi

Factors Associated With the Development of and Revision for Proximal Junctional Kyphosis in 440 Consecutive Adult Spinal Deformity Patients.

Study Design. Retrospective review of prospectively collected data. Objective. The aim of this study was to examine which radiographic parameters and surgical strategies are most closely associated with proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery, the need for revision surgery for PJK, and whether these differ based on the upper instrumented vertebra (UIV). Summary of Background Data. Multiple parameters are considered when planning correction of ASD. Determining which of these factors contribute to the development of and need for revision surgery for PJK presents a challenging problem. Methods. Consecutive patients undergoing long fusion to the pelvis with age >18 years, minimum 6-month follow-up, and adequate radiographs for analysis in a single institution between 2003 and 2011 were included. Along with chart review, measurement of proximal junctional angle (PJA), sagittal balance, and pelvic parameters was performed on preoperative, postoperative, and latest follow-up radiographs. Postoperative radiographs were also examined for signs of PJF. Results. A total of 440 patients with a mean follow-up of 34 months met inclusion criteria, 159 of whom developed PJK (36%), with 65 requiring revision surgery (41%). Higher preoperative pelvic tilt (PT) (P = 0.018) and postoperative thoracic kyphosis (TK) (P ⩽ 0.001) were predictive for development of PJK, whereas hooks at UIV were protective (odds ratio [OR] 0.049). In patients who developed PJK, revision was more frequent in younger patients (P = 0.005) with greater postoperative sagittal vertical axis and PJA (P = 0.029, P = 0.018). PJF with spondylolisthesis, fracture, or instrumentation failure at the UIV had the highest ORs for proceeding to a revision (5.1, 1.6, and 2.2, respectively). Conclusion. TK and PT are important indicators of overall rigidity and reference the ability of the spine to compensate for sagittal plane deformity. Special attention should be paid to these characteristics and to the choice of proximal instrumentation when attempting to prevent PJK. Prevention of radiographically evident PJF may hold the key to reducing the need for revision surgery. Level of Evidence: 3

Multiple hemorrhages in brain after spine surgery supra- and infra-tentorial components together.

Remote cerebellar hemorrhage after cranial and spinal surgeries is a well-documented entity, so far concomitant supra- and infra-tentorial hemorrhage after spine surgery has rarely been reported in the literature. A 57-year-old woman presented with intractable low back pain and severely impaired mobility. One year ago, she underwent lumbar laminectomy and fusion with posterior spinal instrumentation between L2 and S1. She developed adjacent segment disease at the upper level of the instrumented vertebra. She had a revision surgery and underwent posterior laminectomy and fusion with bilateral transpedicular instrumentation between T10 and S1. She had severe headache, somnolence, and left hemiparesia 48 h after the surgery. Her emergent head computed tomography depicted intra-parenchymal hemorrhage in the right parietal lobe accompanying with subarachnoid hemorrhage, bilateral symmetrical cerebellar hemorrhages and pneumocephalus. She was treated nonsurgically and she got better despite some residual deficits. Symptoms including constant headache, nausea, vomiting, impaired consciousness, new onset seizure, and focal neurological deficit after spine surgeries should raise suspicion for intracranial intra-parenchymal hemorrhage.

Isolated metastasis of breast cancer to the pituitary gland

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Migration of Rod into Retroperitoneal Region: A Case Report and Review of the Literature

Spinal stabilization with fusion is the widely used method for traumatic or pathologic fracture of spine, spinal stenosis, and spondylolisthesis. Complications may emerge during or after the operations. Infection, hematoma and neurological deficits are early noticed findings. Screw and/or rod fractures present in long-term after surgery. Rod migration in out of the spinal column is a rare entity. A 67-year-old woman was visited our clinic for right leg pain. She had a previous spinal instrumentation surgery for spondylolisthesis in another center 6 years before. After radiological work-up, a distally migrated rod piece was observed in the retroperitoneal portion. The patient was operated for degenerative change; old instruments were replaced and extended to the L2 level with posterior spinal fusion. After the operation, her right leg pain improved. The asymptomatic migrated rod piece has regularly been followed clinically and radiologically, since then. Although it has rarely been reported, migration of the instrumentation material should be kept in mind. Spinal fixation without fusion makes the mechanical system vulnerable to motion effects of spine, especially in a degenerative and osteoporotic background. Long-term, even life-long follow-up is necessary for late term complications.

Cervical digit: a rare developmental anomaly

A 62-year-old man was admitted to the emergency department presenting with post-traumatic neck pain. Lateral radiograph and computed tomography of the cervical spine demonstrated a phalanx-like osseous structure with a clear cortex and medulla (digit or rib) posterior to the spinous process of the C5 vertebra and degenerative osteoarthritis without significant traumatic bone or soft tissue pathology (Figs. 1 and 2). The patient was treated with nonsteroidal anti-inflammatory drug and was given a cervical collar. Cervical digit (also known as cervical rib or finger) is an extremely rare developmental anomaly. It is usually seen in the pelvic soft tissues and abdomen, or less commonly around the vertebral column as an incidental finding. It can be associated with one or more pseudoarticulation. It should be differentiated from other diseases, such as heterotopic ossification, osteochondroma, and traumatic avulsion injuries, to avoid any unnecessary investigations or interventions [1]. Reference

Trigeminal Neuralgia Caused by Cerebellopontine Angle Arteriovenous Malformation Treated With Gamma Knife Radiosurgery.

AbstractTrigeminal neuralgia is a facial pain syndrome characterized as sudden onset and lightening-like sensation over somatosensorial branch(es) of fifth cranial nerve. Rarely, some underlying diseases or disorders could be diagnosed, such as multiple sclerosis, brain tumors, and vascular malformations. The authors present a 47-year-old man with trigeminal neuralgia over left V2 and V3 dermatomes. He had a previous transarterial embolization and long use of carbamazepine with partial response to treatment. Gamma knife radiosurgery (GKR) was planned. A marginal dose of 15 Gy was given to 50% isodose line. His pain was relieved by GKR in 1.5 years. Treatment of posterior fossa arteriovenous malformations causing trigeminal neuralgia, with GKR has a very limited use in the literature. It, however, is obvious that success rate as pain relief, in a very challenging field of functional neurosurgery, is satisfactory. Large series, however, are in need to make a more comprehensive statement about efficacy and safety of the procedure in these pathologies.

Epidural anesthesia in elective lumbar microdiscectomy surgery: is it safe and effective?

AIM The aim of this study was to evaluate effectiveness and safety of epidural anesthesia in elective lumbar microdiscectomy surgery. MATERIAL AND METHODS Twenty-seven patients (78%, female), who were admitted for single level simple microdiscectomy surgery between May 2012 and December 2013 in single spine center of a university hospital, were enrolled into the study. Clinical evaluations with demographical and per-operative data were collected prospectively. RESULTS Mean age was 60.04 years. Mean weight, height, and BMI of the study population were 77.7 kg, 160.22 cm, 30.26; respectively. Mean operation duration was 45.56 minutes. Mean VAS score for pain was 0.78 at immediate post-op, 0.52 at 4th hour, and 0.35 at post-operative 24th hour. Ramsay sedation scale (RSS) scores steadily decreased from 2.07 in the immediate post-operative time to 1.93 at 4th hour and 1.88 at 24th hour. The only correlation seen between patient demographics and RSS was body weight seen in immediate post-operative period. Improvements for VAS scores for pain at 4th and 24th hours were 28% and 31%; respectively. Three patients had nausea, one of them vomited after the surgery. All patients were satisfied and would consider epidural anesthesia in future similar surgeries. CONCLUSION Epidural anesthesia provides a safe and effective method for elective lumbar microdiscectomy surgery.

Purely extradural spinal nerve root hemangioblastomas

Spinal nerve root hemangioblastomas present mostly as intradural-extradurally. Purely extradural spinal nerve root hemangioblastoma is a very rare entity. In this study, we aimed to analyze epidemiological perspectives of purely extradural spinal nerve root hemangioblastomas presented in English medical literature in addition to our own exemplary case. PubMed/MEDLINE was searched using the terms “hemangioblastoma,” “extradural,” “spinal,” and “nerve root.” Demographical variables of age, gender, concomitant presence of von Hippel–Lindau (VHL) disease; spinal imaging and/or intraoperative findings for tumor location were surveyed from retrieved articles. There are 38 patients with purely extradural spinal nerve root hemangioblastoma. The median age is 45 years (range = 24–72 years). Female:male ratio is 0.6. Spinal levels for purely extradural spinal nerve root hemangioblastomas, in order of decreasing frequency, are thoracic (48.6%), cervical (13.5%), lumbar (13.5%), lumbosacral (10.8%), sacral (8.1%), and thoracolumbar (5.4%). Concomitant presence of VHL disease is 45%. Purely extradural spinal nerve root hemangioblastomas are very rare and can be confused with other more common extradural spinal cord tumors. Concomitant presence of VHL disease is observed in less than half of the patients with purely extradural spinal nerve root hemangioblastomas. Surgery is the first-line treatment in these tumors.

Poster 139 Paraspinal Muscles and Sagittal Spinopelvic Alignment in Patients with Degenerative Spondylolisthesis

Case Description: The patient, a 74-year-old right hand dominant woman, presented for evaluation of left wrist pain and dorsal hand numbness. 3 months prior, she had been treated for left shoulder pain by an acupuncturist. During the treatment, a needle was placed subcutaneously in the anatomic snuff box of her left wrist (corresponding to the acupuncture point Yang Xi/Large Intestine 5). She immediately experienced intense pain, and the needle was removed. Since that time, the patient noted intermittent paresthesias and shooting pain along the dorsal left wrist and hand. She presented to an orthopedic hand surgery clinic, where x-rays of the wrist revealed no acute abnormalities and no retained foreign bodies. The patient was prescribed hand therapy, a wrist brace, and gabapentin; all provided minimal relief. She was then referred for electrodiagnostic testing. On the day of electrodiagnostic evaluation, physical examination of the patient was remarkable for allodynia along the radial aspect of the dorsum of the left wrist. Nerve conduction studies revealed absent left radial superficial sensory nerve action potential at the thumb and reduced left superficial sensory nerve action potential at the wrist. Corresponding evoked potentials on the right side were normal. Needle EMG examination of the left upper limb and cervical paraspinals was normal. Setting: Academic Medical Center Electrodiagnostic Laboratory. Results or Clinical Course: Electrophysiologic testing demonstrated evidence of a left superficial radial sensory neuropathy. The acute onset of neuropathic symptoms in a corresponding distribution during acupuncture treatment suggests iatrogenic superficial radial nerve injury. Discussion: There have been rare case reports of iatrogenic peripheral nerve injury from acupuncture. To our knowledge, this is the first reported case of injury to the superficial radial nerve. Physiatrists performing or prescribing acupuncture for pain management should be aware of this possible complication. Particular care should be taken when employing acupuncture points in close proximity to peripheral nerves. Conclusion: Iatrogenic nerve injury is a potential complication of acupuncture treatment.

Cervical myelopathy due to single level disc herniation presenting as intramedullary mass lesion: What to do first?

Cervical myelopathy (CM) is mostly a degenerative process ending in myelopathic and/or radiculopathic syndromes. On T2-weighted magnetic resonance imaging (MRI), CM appears as a hyperintense area near the spondylotic spine. This high intensity signal depends on the impact of outer forces and their duration. It also determines the prognosis of the surgical candidate. A 40-year-old male patient admitted to our clinic with right upper extremity weakness and hypoesthesia that had started 2 months earlier. On neurological examination there was 2/5 motor weakness of right biceps brachii, and hypoesthesia over right C6 dermatome. Right upper extremity deep tendon reflexes were hypoactive, but lower ones were hyperactive. After clinical and radiological work-up, preliminary diagnosis was directed to a spinal intramedullary tumor. Total resection of the herniated cervical disc fragment and the mass lesion was managed. Pathology of the mass lesion was compatible with subacute infarct tissue and inflammatory response. Final diagnosis was CM under effect of cervical disc herniation. Contrast-enhanced spinal cord myelopathic lesions are very rare and resemble much more tumors and inflammatory processes. However, the principal treatment approach totally differs depending on pathology. When there are both a disc herniation and a high clinical suspicion; biopsy should be delayed. The most probable solution will be surgery for the disc disease with thorough preoperative scanning of vascular malformations; clinical and radiological close follow-up after surgery. Biopsy or surgical resection can be performed if patient deteriorates despite the primary surgery.