Orhan Sen

Intradural disc mimicking: a spinal tumor lesion

Study design: A case report of intradural disc hernia mimicking an intradural extramedullary spinal tumor lesion in radiological evaluation.Objective: To describe a lumbar intradural disc herniation with atypical radiological appearance and point out the role of contrast magnetic resonance imaging (MRI) of the lumbar spine.Setting: Turkey.Case report: A 58-year-old man with suspected lumbar intradural mass and neurological involvement received L5 total laminectomy. L5 total laminectomy was performed, and on inspection dura was swollen and immobile. A longitudinal incision was made in the dura and an intradural-free disc fragment was removed. The patients postoperative period was uneventful and he had full recovery in 3 months.Conclusions: Lumbar intradural disc rupture must be considered in the differential diagnosis of mass lesions causing nerve root or cauda equina syndromes. Contrast-enhanced MRI scans are useful to differentiate a herniated disc from a disc space infection or tumor. This case demonstrates the role and the importance of contrast MRI in the diagnosis of intradural disc herniation.

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 mexiletine on the level of lipid peroxidation and apoptosis of endothelium following experimental subarachnoid hemorrhage

Abstract Objective: The role of apoptosis in etiopathogenesis of vasospasm is not clearly understood yet. It is widely accepted that protection of the endothelial cells from the process of apoptosis could have beneficial effects on cerebral vasospasm after subarachnoid hemorrhage (SAH). Mexiletine blocks sodium and calcium channels and activates ATP-sensitive K+ channels. Moreover, mexiletine is known to have potent antioxidant effects through inhibiting free-radical production. Methods: Twenty-one rabbits were allocated into three groups randomly. Group I was sham operated group (n=7). SAH occurred but no medication was given to the Group II rabbits (SAH only group) (n=7). Mexiletine (50 mg/kg, b.i.d., i.p.) was administered just before SAH and continued until 48 hours following SAH to the Group III rabbits (Mexiletine treated group) (n=7). The ApopTag peroxidase in situ apoptosis detection kit (Serologicals Corporation, former Intergen) was used to demonstrate apoptosis in a cross section of basillary arteries. Thiobarbituric acid reactive material was used to determine the lipid peroxidation levels. Results: There was a statistically significant difference between lipid peroxidation product levels of the control and SAH only groups (p<0.05). The level of lipid peroxidation production in Mexiletine treated group was significantly lower compared with SAH only group (p<0.05) but not significantly higher than the control group (p>0.05). Discussion: In the present study we investigated the antioxidant action of mexiletine on apoptosis of endothelium following a rabbit SAH model. This experimental study directly suggested that lipid peroxidation is an important step in development of apoptosis in endothelial cells and prevention of structural integrity of endothelial cell should play a beneficial role in attenuation of cerebral vasospasm. Mexiletine treatment prevented the increase in lipid peroxidation and cerebral vasospasm. Examination of endothelial cells by staining specific for apoptosis demonstrated significant protection of cell integrity in the treated group.

Primary primitive neuroectodermal tumor within the spinal epidural space: report of a case and review of the literature

Abstract Primary intraspinal primitive neuroectodermal tumors (PNETs) are rare tumors and a have poor prognosis. In reviews of the literature, it is seen that primary intraspinal PNETs may arise at all levels of the spine and may be intramedullary, intradural-extramedullary, or epidural. Spinal epidural location of PNET is extremely rare and out of 22 cases of primary spinal PNETs reported to date, only two were epidural. Tumors within the epidural space of the spinal canal are most often metastatic neoplasms from different primary sites. Here we report a case of primary extradural PNET located in the thoracic spine in a 16-year-old boy and review the relevant literature.

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.

Prefabricated galeal flap based on superficial temporal and posterior auricular vessels

Scalp layers are widely used in reconstructive procedures. The authors used prefabricated galeal flaps based on the superficial temporal or postauricular vessels for ear, cheek, mandible, and cranium reconstructions in three cases. In case 1, synchronous beard and ear reconstructions were accomplished by using the temporoparietal and retroauricular flaps. In case 2, a buccomandibular defect was reconstructed by transposing the supra-auricular and retroauricular galea with prefabricated bone and skin. In case 3, an epidural hematoma in the left frontoparietal area was evacuated after a circular craniectomy. The harvested bone was not put back on the defect area but buried between the periosteal and galeal layers because of brain edema. These layers were raised as an osteogaleoperiosteal flap and transposed onto the defect area after 7 weeks. When used with a prefabrication method, scalp layers offer versatile options for repairing composite defects of the head region. A galeal flap based on the posterior auricular vessels is practical and reliable in reconstructive procedures. The authors suggest that this flap is an option in cases in which the temporoparietal fascia artery or the superficial temporal artery is not available. Prefabrication of the harvested cranial bone inside the adjacent tissues offers several advantages in that a viable bone is provided at the end of the procedure, intervention at a distant area is avoided, the graft is placed on osteogenic tissue (periosteum) that is also transposed onto the defect, and sophisticated procedures such as microsurgical techniques are not needed.

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.

Giant cell tumour of the sixth cervical vertebrae with close relationship to the vertebral artery

Giant cell tumours of the vertebral column are rare and cervical vertebrae involvement is even less common. As these lesions may be closely related to the vertebral artery, therapeutic decision-making may be complex. Reviewing the literature, we found that there was no consensus on treatment or outcome assessment for these rare and difficult lesions. We present a case of a giant cell tumour of the sixth cervical vertebrae involving the posterior elements, neural foramina and transverse foramina and closely related to the vertebral artery. Radiological evaluation and therapeutic solutions are also discussed.

Osteogaleal flaps in pediatric cranioplasty.

Reconstruction of cranial defects larger than 2 to 3 cm in diameter and frontal defects of any size is indicated for mechanical protection and cosmetic reasons. The authors used osteogaleal flaps for cranioplasty in 2 pediatric patients with the aim of decreasing infection risk and maximizing bone healing. In the first patient, bone was harvested from the diploë. Children’s cranial bones are thin, and in the second patient the authors used full-thickness grafts of adjacent bone, splitting this into three pieces to cover the recipient and donor sites. The postoperative period was uneventful for both children. Scintigraphic studies performed the first week after surgery revealed uptake in the flaps. Computed tomography demonstrated rapid bone healing with good contouring. The scintigraphic findings and rapid bone healing suggest that the bone component of the osteogaleal flap nourishes the graft site with blood from the galea and the periosteum. These flaps are an ideal choice for reconstruction of cranial defects because of their membranous origin, ease of harvest, applicability to any part of the calvarium, and reliable vascularity.