Saim Kazan

Complications of closed continuous lumbar drainage of cerebrospinal fluid.

Summary. Sixty three patients who had a lumbar subarachnoid catheter placed for closed continuous cerebrospinal fluid drainage and the complications are presented. The drain was successful in achieving the desired goal in 59 patients (93,6%). The complications are mainly divided into 3 groups; A – complications related to alterations in CSF drainage rate, B – complications due to mechanical failure of the catheter, C – infection. The overall complication rate is found to be 44,4%. Overdrainage, pneumocephalus and meningitis are found to be the most severe complications, but most of these complications are reversible with early recognition. Unfortunately one patient died following meningitis and hepatic failure. Lumbar subarachnoid drainage is a safe method unless the development of any neurological findings should prompt rapid discontinuation of lumbar drainage and immediate radiographic evaluation.

The effect of condylectomy on extreme lateral transcondylar approach to the anterior foramen magnum

SummaryThe dorsolateral, suboccipital, transcondylar technique was used in this cadaveric study. The angle and distance measurements in the corridors were taken intradurally both superior and inferior of the foramen magnum level. In the first stage of this study, the findings which were gained from the standard lateral suboccipital approach were compared with the findings after condyle and lateral atlantal mass removal. After condylectomy, the approach to anterior foramen magnum via both corridors was found to be shorter and the lateral angle of the exposure of the anterior foramen magnum was found to be wider. The considerable shortening of the distances to the anterior foramen magnum, especially in the superior corridor, emphasises the necessity of combining standard approaches with condylectomy. In addition, it was found that after condylectomy, considerable widening of both transverse and longitudinal planes in the inferior corridor allows the surgeon greater access to work on lesions. Furthermore, the freed space between the superior corridor and the inferior corridor, which was gained by condylectomy, shows that condylectomy provides a combined approach to the inferior and superior parts of the foramen magnum anteriorly.

Anatomical evaluation of the groove for the vertebral artery in the axis vertebrae for atlanto-axial transarticular screw fixation technique

Anatomical measurements were studied on 40 dry axis vertebrae to determine the suitability of the groove for the vertebral artery for atlanto‐axial transarticular screw fixation technique. We measured 13 parameters including three angular and 10 linear dimensions related to the groove of the vertebral artery, pedicle, and pars interarticularis and evaluated 80 measurements for each parameter. All measurements were done after placing a Kischner guide wire through the pedicle. We found that differences between measurements on the left and right sides of each vertebra were nonsignificant. In spite of the variability in measurements such as height, width, and median angle of the pedicle, the decline angle for instrumentation, the depth of the groove for the vertebral artery, and the internal height of the pars interarticularis, all of these had good symmetry. However, there were statistically significant differences between the sides in measurements for both the width (P=0.05) and the angle (P<0.02) of the pedicle allowing instrumentation and they did not show good symmetry. The risk of vertebral artery injury was found to be 22.5% per specimen, or 16.25% per screw inserted because the internal height of the pars interarticularis at point of fixation was ≤ 2.1 mm. In addition, we found that the pedicle width allowing instrumentation was not suitable in 12.5% of screws inserted because their values were ≤ 6 mm. When the width of the pedicle for instrumentation and the internal height of the pars interarticularis were both evaluated together, we also found that this technique would be extremely dangerous in 7.5% of specimens. In conclusion, the internal height of the pars interarticularis and the width of the pedicle for instrumentation should be evaluated together in thin CT sections preoperatively, because of the risk of vertebral artery injury in patients upon which atlanto‐axial transarticular screw fixation is to be performed. Clin. Anat. 13:237–243, 2000.

Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury.

AIM Debate continues as to whether decompressive craniectomy (DC) is an effective treatment for severe traumatic brain injury (STBI). DC is mostly used as a second tier treatment option. The aim of this study was determined whether early bilateral DC is effective as a first tier treatment option in patients with STBI. MATERIAL AND METHODS The study compared two groups. Group 1 comprised 36 STBI patients for whom control of intracranial pressure (ICP) was not achieved with conservative treatment methods according to radiological and neurological findings. These patients underwent bilateral or unilateral DC as a second tier treatment. Group 2 comprised 40 STBI patients who underwent early bilateral DC as a first tier treatment. RESULTS Group 2 patients had a mean better outcome than Group 1 patients especially for patients with a GCS 6-8. Postoperative ICP was lower in Group 2 patients than Group 1 patients. CONCLUSION This study indicates that early bilateral DC can be effective for controlling ICP in STBI patients. It is likely the favorable outcome results for Group 2 patients reflects the relatively short time between trauma and surgery. Therefore, these data indicate early bilateral DC can be considered as a first tier treatment in STBI patients.

Post-traumatic bilateral diffuse cerebral swelling

SummaryThis study confirms that bilateral diffuse cerebral swelling with or without parenchymal haemorrhages (< 15 cc) is a more common occurrence in the paediatric patients with severe head injury as compared with adults, since the analysed sample represented 42.55% and 20.43% of all paediatric and adult patients with severe head injury recorded in our clinic at the time of the study, respectively. The incidence of patients with diffuse cerebral swelling without parenchymal haemorrhages was found to be 27.65% of paediatric patients and 5.37% of adult patients with severe head injury. Secondary neurological deterioration occurred only in 5 (12.5%) paediatric patients and in 4 (10.5%) adult patients with diffuse cerebral swelling and was not to be found associated with parenchymal haemorrhages. A better outcome was seen in paediatric patients. Mortality rates were 12.5% in paediatric patients and 34.21% in adult patients. Our data also suggest that the mortality rate between paediatric and adult patients with diffuse cerebral swelling without parenchymal haemorrhages was similar (15.38% and 20% in paediatric and adult group, respectively), while the adult patients with diffuse cerebral swelling associated with small intraparenchymal haemorrhages have a worse prognosis than paediatric patients.

Conservative Management of Extradural Haematomas: Effects of Skull Fractures on Resorption Rate

SummaryIn conservative management of extradural haematomas (EDH), several mechanisms were described to explain the resorption of the haematoma. One of these was the transfer of the clot into the epicranial space through the skull fracture. In this study, the effects of skull fracture and associated intracranial lesions in the conservative management of EDH were investigated. Skull fracture and associated intracranial lesions were found in 71.11% and 51.1% of the patients, respectively.Resorption rate was calculated using an original formula and it was 0.548±0.227 in patients with skull fracture and 0.507±0.170 in patients with both skull fractures and additional intracranial lesions. These rates were found to be significantly higher than in the patients without fracture.In conclusion, in the patients with EDH planned to be managed conservatively, skull fracture and additional intracranial lesions must not be thought as risk factors, on the contrary, resorption of the clot might be earlier than in the others.

Conservative management of epidural haematomas. Prospective study of 15 cases.

SummaryConservative management of epidural haematoma (EDH) depends on a balance between expansion and resorption rate of the clot.15 patients with EDH whose CT scans demonstrated a small EDH and were asymptomatic or with minor symptoms or with a delayed diagnosis were treated conservatively. The thickness of haematoma ranged between 4.9–40.8 mm. In two patients, the haematoma extended from the posterior fossa to the supratentorial region. In 7 patients, additional intracranial pathology was detected. None of the patients had neurological deterioration on follow up. The second CT was performed on second day at the earliest, in fourth week at the latest.We conclude that the patients with EDH who are neurologically stable during the first 24 hours after trauma, with small EDH and with minor or no symptoms or signs, might be candidates for conservative management. An absolute precondition for conservative management is close supervision of the patient.

Outcomes of intrathecal baclofen (ITB) therapy in spacticity.

AIM Spasticity is associated with various neurological conditions. Intrathecal baclofen (ITB) is one of the popular treatments for severe spasticity. In this paper we present our experience in treating 30 patients with both spinal and supraspinal spasticity with chronic infusion of Baclofen to evaluate the long term efficacy of this treatment on spasticity, disability and pain, and to evaluate the side effects of intrathecal Baclofen. MATERIAL AND METHODS The medical records of 30 patients who underwent baclofen pump placement from 2000 to 2010 under Department of Neurosurgery at the University of Akdeniz at Antalya/Turkey, were reviewed. All study subjects had diffuse chronic, severe, and generalized spasticity (Ashworth score ≥ 3), and had shown inadequate response to various oral antispastic drugs including baclofen. All patients were evaluated by means of the Ashworth score, spasm frequency, Barthel index, Rankin scales and VAS. RESULTS Spasticity and spasm frequency and pain scores were clinically and statistically decreased in all patients. CONCLUSION ITB therapy increases the quality of lifestyle and functional independence by reducing not only cerebral but also spinal related spasticity in appropriately selected cases.

Percutaneous Anterior Odontoid Screw Fixation Technique

Summary We describe a new instrument and a percutaneous technique for closed anterior fixation of odontoid fracture. The instrument which we developed consists of a telescopic tube system. This new instrument and closed fixation technique was used in six cadavers with type II odontoid fractures and to two cadavers with an intact odontoid process. Each cadaver underwent satisfactory placement of the screw to the odontoid with this technique under biplanar scopy control. After this procedure, no serious injury was found in the parapharyngeal and neurovascular areas of the necks of the cadavers, in which anatomical dissection along the track of this instrument was performed. The instrumentation and the technique as a whole is seen as reliably applicable for odontoid fracture fixation. Also, we expect to reduce operating time and hospital costs because this system is simple, easily applicable and minimally invasive.

Effects of the Temporary Clipping in Aneurysm Surgery on the Remnant

Summary. The residual aneurysm rate is reported between 3,8% and 21% in the cases followed after intracranial aneurysm surgery. In the formation of the residual aneurysm, the risk factors include such structural characteristics as the size and lobulation of the aneurysm, posterior circulation, para-ophtalmic localisation and intra-operative rupture. The rates and causes of postoperative residual aneurysms were analyzed in 186 intracranial aneurysm of 160 patients, including the possible effects of temporary clipping on the residual rates. The entire series demostrated a residual rate of 7%. It was found higher in the large lobulating aneurysms and intra-operative rupture. The residual rate considerably decreased to 4,2% in the aneurysms with temporary clipping. The determination of residual aneurysms, identification of any risk factors and elimination of recoverable factors would allow improvement of surgical results in the treatment of the intracranial aneurysms in the future. Moreover we believe that these will be useful in development of the indications for alternative treatment methods.