Salih Gulsen

Lumbar Microdiscectomy With Spinal Anesthesia : Comparison of Prone and Knee-Chest Positions in Means of Hemodynamic and Respiratory Function

Study Design. Prospective clinical study to compare the physiologic changes in lumbar disc surgery regarding to positions. Objective. To compare the perioperative hemodynamic and respiratory functions between prone and knee-chest positions for lumbar disc surgery under spinal anesthesia. Summary of Background Data. Spinal anesthesia is a safe but rarely used alternative to general anesthesia for lumbar disc surgery. It reduces blood loss, avoid pressure necrosis, and nerve injuries, and it provides a more comfortable postoperative period. Prone and knee-chest positions are mostly used positions in lumbar discectomy; hemodynamic and respiratory effects of spinal anesthesia and the differences between these 2 positions in spinal anesthesia were evaluated in this study, which only been evaluated in general anesthesia. Methods. Forty-five patients were randomized for lumbar microdiscectomy with spinal anesthesia under either prone position (group 1 n = 22) or knee-chest position (group 2 n = 23). All patients were classified as physical status 1 or 2 according to the American Association of Anesthesiology. Spinal anesthesia was performed with hyperbaric bupivacaine. Perioperative continuous hemodynamics and respiratory function test results were recorded after the spinal anesthesia was performed. Results. Immediately after the spinal anesthesia was performed, both the systolic and diastolic arterial blood pressure values were significantly decreased and heart rates were significantly increased in both groups. Both positions showed significant decrease in forced vital capacity (P = 0.002) and forced expiratory volume in 1 second (P = 0.0015) during the surgery respect to preoperative values. The decrease in peak expiratory flow (P = 0.011) and forced expiratory flow at the 25% of the pulmonary volume (P = 0.011) was significant in knee-chest position respect to prone position. Conclusion. In conclusion, spinal anesthesia is appropriate for lumbar disc surgery with respect to the hemodynamic parameters in both prone and knee-chest posi tions, however, in terms of pulmonary functions, the knee-chest position can cause a restrictive effect. Therefore this position should be used cautiously in higher-risk patients.

Identification of Promoter Region Methylation Patterns of MGMT, CDKN2A, GSTP1, and THBS1 Genes in Intracranial Meningioma Patients

BACKGROUND Cytogenetic, molecular and epigenetic changes are all known to take place in the pathogenesis of meningiomas. In this study, we aimed at investing methylation of MGMT (DNA repair), CDKN2A (cell cycle control), GSTP1 (detoxification), and THBS1 (angiogenesis inhibitor) genes, which are known to be unmethylated in normal tissue, in meningioma samples. MATERIALS AND METHODS Methylation specific polymerase chain reaction was used to study promoter regions methylation of genes in 36 patient samples. RESULTS Methylation in promoter regions of MGMT, CDKN2A, GSTP1, and THBS1 genes were found in 11.1%, 8.3%, 2.8%, and 0% of the cases, respectively. About 19.4% of cases revealed promoter methylation of at least a single gene, whereas only 2.8% of cases revealed methylation of more than one gene. Based on their World Health Organization 2007 grade; 6.3% of grade I cases, 35.3% of grade II cases, and 33.3% of grade III cases showed hypermethylation in the promoter regions of the genes studied. No statistically significant relation was found between promoter zone methylation and factors such as age, sex, histopathology, grade, or recurrence. CONCLUSIONS Further research on promoter zone methylation will help expose the methylation profile and pathogenesis of meningiomas, which will consequently guide to a deeper understanding of the pathogenesis of the disease, thus ensuring a better understanding of the prognosis and considering novel treatment options.

The retrospective analysis of the effect of balloon kyphoplasty to the adjacent-segment fracture in 171 patients.

Study Design: Analysis of the adjacent-segment fractures in 171 balloon kyphoplasty (BK)-performed patients. Objective: The purpose of this study was to investigate the risk factors for new symptomatic vertebral compression fractures (VCF) after BK. Summary of Background Data: Although there are many studies about the incidence and possible risk factors for occurrence of adjacent-level fractures, there is no consensus on the increased risk of adjacent-level fractures after BK. Methods: We performed a retrospective analysis of 171 patients treated with percutaneous kyphoplasty. The follow-up period was 41.04±21.78 months. The occurrence of new symptomatic VCF was recorded after the procedure. We evaluated the variables of patient age and sex, the amount of injected cement, the initial kyphotic angle (KA) of VCF, the change of the KA after BK, the severity of osteoporosis, and the percentage of height restoration of the vertebral body. Furthermore, possible risk factors were reported for new symptomatic VCFs. Results: The only 2 factors identified as being significantly associated with adjacent-level fractures were the sex (P=0.001) of the patient and the preoperative KA (P=0.013). The patients with new symptomatic compression fracture had higher initial KA than those without fractures. The female group had higher risk than the male group in occurrence of the new vertebra fractures. The severity of the osteoporosis (low bone mineral density) was not a determinant in occurrence of the new VCF after BK. Conclusions: If the patients experience severe or mild back pain with higher preoperative KA, especially in the first 2 months, then they deserve detailed radiologic examination. To avoid subsequent fracture in the same or adjacent level, vertebral body should be filled adequately and sagittal balance should be obtained with KA correction. BK alone did not influence the incidence of subsequent VCF.

Rare Lesions of the Cerebellopontine Angle

Vestibular schwannomas, meningiomas and epidermoids account for a vast majority of the lesions occurring in the cerebellopontine angle (CPA). Neoplastic and non-neoplastic pathologies other than these tumors constitute 1% of all lesions located in the CPA. The aim of this study was to reveal our experience in the treatment of the rare lesions of the CPA. We have retrospectively reviewed the medical files and radiological data of all patients who underwent surgery involving any kind of pathology in the CPA. We have excluded those patients with a histopathological diagnosis of meningioma, schwannoma and epidermoids. Our research revealed a case of craniopharyngioma, a case of chloroma, a case of solitary fibrous tumor, a case of pinealoblastoma, a case of atypical teratoid rhabdoid tumor, a case of an aneurysm, a case of hemorrhage and a case of abscess.

Intracavernous granular cell tumor

BACKGROUND Granular cell tumors in the central nervous system are quite rare. To date, only 6 cases of granular cell tumor arising from cranial nerves have been reported in the literature. To the best of our knowledge, we present the first case of a predominant intracavernous granular-cell tumor arising from oculomotor nerve. CASE PRESENTATION A 42-year-old man presented with third-nerve paresis and decreased visual acuity on the left side. Magnetic resonance imaging showed a mainly intracavernous mass partially extending to the superior orbital fissure and entrance of the optic canal. Using a pterional craniotomy, the tumor was removed from within the cavernous sinus via combined superior and lateral intradural approach, and optic nerve was also decompressed. Histologically, the tumor was diagnosed as a granular cell tumor. CONCLUSIONS Although it is quite rare, granular cell tumor should be included into the differential diagnosis of intracavernous masses because surgical treatment is curative.

Radiofrequency facet joint neurotomy in treatment of facet syndrome.

Study Design Retrospective analyses of 50 patients with lumbar facet syndrome treated with lumbar facet joint neurotomy. Objective To establish the efficacy of lumbar facet joint neurotomy under optimum conditions in selected patients. Summary of Background Data With the realization of the significance of facet joints in the etiology of chronic low back pain over the last decade, many studies were conducted about various methods of treating the facet joint syndrome. Methods Fifty patients with lumbar facet syndrome with at least 80% pain relief by controlled, diagnostic medial branch blocks underwent lumbar facet joint neurotomy. Before surgery, all were examined carefully both clinically and radiologically and evaluated by visual analog scale (VAS) and descriptive system of health-related quality of life state (EQ5D) measures of pain, disability, and treatment satisfaction. All outcome measures were repeated postoperatively and at 12 months after surgery. Results Of the 50 patients 35 were females and 15 were males with a mean age of 51.82±16.99 years. One level was treated in 26 patients, 2 levels in 14, 3 levels in 8, and 4 levels were treated in 2 patients. Symptom duration was ranging between 2 and 24 months with a mean of 7.64±5.98 months. Mean preoperative, postoperative, and at the 12th month VAS were 75.2±11.29, 23.8±10.28, and 24.6±11.817, respectively. Forty-eight percent of patients obtained a relative reduction of at least 70% in VAS, and 86% obtained a reduction of at least 60% at the 12th month. Health-related quality of life state was improved in all patients. When the VAS scores were evaluated with respect to the ages of patients, level numbers, and preoperative symptom duration, no significant differences were found, [0.106, 0.635 and 0.526 (preoperative VAS); 0.033, 0.555, and 0.235 (postoperative VAS); 0.701, 0.978, and 0.155 (follow-up VAS), respectively]. Conclusions The most important factors determining success of this procedure is strict patient selection criteria and technique of the procedure.

Ulnar nerve entrapment in Guyon's canal due to recurrent carpal tunnel syndrome: case report.

Guyons canal syndrome is a compression neuropathy of the ulnar nerve entrapment at the wrist. Compression of the ulnar nerve at the wrist by a ganglion, lipomas, diseases of the ulnar artery, fractures of the hamate and trauma are common etiologcal factors. Unlike Guyons canal syndrome, carpal tunnel syndrome (CTS) is the most common nerve entrapment of the upper extremity. Although, open (OCTR) or endoscopic carpal tunnel release (ECTR) is highly effective in relieving pain, failure with carpal tunnel release is seldom seen. In this paper, we presented a patient with ulnar nerve entrapment associated with recurrent CTS and discussed the possible pathomechanism with a review of current literature.

Tuberculoma in the medulla oblongata and medulla spinalis: two case reports.

BACKGROUND Central nervous system tuberculosis remains a prevalent problem in developing countries. Also, this disease has been an important problem in developed countries due to the increased incidence of acquired immunodeficiency syndrome. Tuberculosis of the central nervous system is seen in 10% of immunocompetent patients with primary tuberculosis. CASE REPORT We report two patients with tuberculoma in the central nervous system. The first case had a lesion located in the medulla oblongata, and the second case had a lesion in the medulla spinalis between the 5th cervical and 1st thoracic vertebral level. Both of these patients underwent surgery. CONCLUSION CNS tuberculomas may not always show typical magnetic resonance imaging (MRI) signs, but when a neurosurgeon encounters a brown-yellow rubber-like lesion that is easily extirpated from the glial tissue, tuberculoma should be considered; anti-tuberculous and corticosteroid therapy should be initiated as soon as possible to prevent meningitis and the immune-mediated destructive effects of tuberculosis on the CNS. Whether or not anti-tuberculous therapy is continued can be decided upon by following definitive pathologic diagnosis.

Placement of three-pin head holders in the Concorde position.

AIM To reevaluate the Concorde position with different surgical interventions to the posterior fossa and cervical pathology and to improve patient comfort in the Concorde position through obtuse angle placement of the three-pin holder while the patient is in the supine position. MATERIAL AND METHODS Twenty-nine patients with posterior fossa pathology or cervical pathology were included in this study. All patients were operated in the Concorde position. The three-pin holder was placed with an obtuse angle while the patient was in the supine position as shown in figure 1a. The angle between the handle of the three-pin holder and the floor was measured in the supine and prone positions as shown in Figure 1A,B. RESULTS The average angle between the floor and the handle of the three-pin holder in the supine position and the Concorde position was 135 degrees (SD +/- 5.45) and 95 degrees (SD +/- 3.26) respectively (Figure 4) All the patients body including the shoulders was within the borders of the operation table. CONCLUSION The placement of three-pin holders with an obtuse angle in the supine position provides three advantages: easier manipulation during neck flexion especially for cervical vertebral pathology, much less body weight loading on the three-pin holders during surgery, and less flexion of the neck to expose pathology located in the cervical or posterior fossa region.

Brain Computed Tomography and Magnetic Resonance Imaging in Neurological Complications of Liver and Kidney Transplantation

Introduction Certain neurological complications may be seen before liver and renal transplantation and are diagnosed by brain CT and MRI. After organ transplantation most of them may disappear, some of them insist or new complications may arise, mostly due to immunosuppressive therapy. Prompt diagnosis of neurological complications are important to plan the appropriate treatment. Brain Computed Tomography (CT) which is the primary imaging modality is not sufficient in most of the cases. Brain Magnetic Resonance Imaging (MRI) and diffusion-weighted imaging should be done in such cases. Our aim is to show examples of CT and MRI findings of neurological complications after liver and kidney transplantation. Materials and Methods We retrospectively evaluated patients who had neurological complications after liver or kidney transplantation. Brain CT and MRI studies are retrieved from the Picture Archiving and Communication System (PACS). Neuroradiological findings can be classified in three groups; as complications due to primary parenchymal disease, due to transplantation or as incidental findings. Results Symptoms of patients were seizures, altered mental status, confusion, unconsciousness, headache, visual hallucinations, motor deficit, nausea and vomiting. Diffuse vasogenic brain edema, acute stroke, intracranial hemorrhage and posterior reversible encephalopathy syndrome (PRES) are commonly seen short-term neurological complications. Vasogenic brain edema and intracranial hemorrhage can be diagnosed on brain CT. Acute stroke can be diagnosed on diffusion-weighted imaging. PRES, which is seen commonly after transplantation is caused by immunosuppression or hypertension. Vasogenic edema is seen mostly within the bilateral parietal and occipital regions. Aspergillosis, rhinocerebral mucormycosis, toxoplasmosis, tuberculosis, bacterial abscess, viral encephalitis are the opportunistic infections which can be seen after transplantation. Aspergillus brain abscesses are seen as solitary or multiple ring enhancing lesions in gray white matter junction with central diffusion restriction on brain MRI. Aspergillus spondylodiscitis which is rare in transplant patients, can be seen as discitis, epidural abscess and subchondral T2 hypointense band on lumbar MRI. Also because of immunosuppression, posttransplant brain tumor risk increases 3-4 times more than the normal population. Posttranplant lymphoproliferative disorder may be seen after solid organ transplantation. Conclusion Neurological complications are not rare after liver and kidney transplantation. Brain CT is the primary imaging modality to rule out intracranial hemorrhage. Brain MRI with diffusion-weighted imaging should be done if brain CT is insufficient and in the presence of serious symptoms. Prompt imaging is very important to establish the certain diagnosis and for achievement in treatment.