Tevfik Yılmaz

Current and future medical therapeutic strategies for the functional repair of spinal cord injury

Spinal cord injury (SCI) leads to social and psychological problems in patients and requires costly treatment and care. In recent years, various pharmacological agents have been tested for acute SCI. Large scale, prospective, randomized, controlled clinical trials have failed to demonstrate marked neurological benefit in contrast to their success in the laboratory. Today, the most important problem is ineffectiveness of nonsurgical treatment choices in human SCI that showed neuroprotective effects in animal studies. Recently, attempted cellular therapy and transplantations are promising. A better understanding of the pathophysiology of SCI started in the early 1980s. Research had been looking at neuroprotection in the 1980s and the first half of 1990s and regeneration studies started in the second half of the 1990s. A number of studies on surgical timing suggest that early surgical intervention is safe and feasible, can improve clinical and neurological outcomes and reduce health care costs, and minimize the secondary damage caused by compression of the spinal cord after trauma. This article reviews current evidence for early surgical decompression and nonsurgical treatment options, including pharmacological and cellular therapy, as the treatment choices for SCI.

Posterior Epidural Migration of a Sequestered Lumbar İntervertebral Disc Fragment.

AIM Posterior epidural migration of a sequestered lumbar intervertebral disc fragment (PEMSLIDF) is an extremely rare condition published so far only as case reports or small case series (ranging between 2 to 8 cases). Diagnosing this condition is often challenging and the diagnosis is usually made intraoperatively. The affected patients usually suffer cauda equina syndrome (CES). In the present study, we aimed to discuss the clinical and radiological findings, types and features of surgical therapies, and outcomes of 9 patients with PEMSLIDF. MATERIAL AND METHODS This study included 9 (0.36%) patients with PEMSLIDF among 2470 patients who underwent lumbar disc hernia surgery between August 2002 and September 2012. The preoperative clinical and radiological properties of the patients were evaluated. The postoperative outcomes were assessed using neurological examination, radiological imaging, visual analog scale (VAS) and modified Odom criteria. RESULTS As far as we know, this study is the largest case series examining the characteristics of PEMSLIDF. Seven (77.8%) of our patients were male and 2 (22.2%) were female and they had a mean age of 49.5 years (range 28-70 years). The mean duration from symptom onset to hospital admission was 7.4 days. Seven patients had CES. All patients underwent sequestrectomy and discectomy via posterior microsurgery. The patient outcomes were evaluated by the Modified Odom criteria and the outcome was excellent in two (22.2%) patients, good in 4 (44.5%), fair in 2 (22.2%), and poor in 1 (11.1%). CONCLUSION The entire free fragment can usually be excised via the posterior microsurgery technique. Early surgical treatment is of great importance to prevent more serious neurological deficits.

Evaluation of spatial memory and locomotor activity during hypercortisolism induced by the administration of dexamethasone in adult male rats.

In neurosurgery practice glucocorticoids are commonly used. Steroids may have central nervous system side effects affecting whole body, including steroid-induced mental agitation and psychosis. In experimental and clinical studies conducted by using dexamethasone (DEX), it has been reported that DEX adversely affects learning and memory skills. Unfortunately, there are yet no clinically accepted clinical approaches to prevent DEX-induced cognitive dysfunction. In this experimental study it was aimed to investigate the effect of chronic DEX administration on learning-memory and locomotor behaviors in adult male Sprague Dawley rats. In addition, it was also aimed to explore the potential favorable contribution of melatonin (MEL) and vitamin C (Vit C) having antioxidant and neuroprotective properties to the effects of DEX on learning-memory and locomotor behaviors. For this purpose, rats were injected 10mg/kg DEX intraperitoneally, both alone and in combination with MEL (40 mg/kg) and Vit C (100mg/kg), for 9 days, and the animals were tested using the radial arm maze and open field apparatus. The test results revealed that DEX caused a significant decrease in spatial memory and locomotor activities and MEL and Vit C failed to reverse losses in these activities. Furthermore, DEX led to a gradual weight loss that reached 30% of the initial weight at 9th day of the injection. DEX administration causes a generalized loss of behavioral activity of rats. Experimental studies devised to investigate effects of DEX should take into account this DEX-induced generalized behavioral loss when assessing the effects of DEX on learning and memory skills. This article is part of a Special Issue entitled SI: Brain and Memory.

Co-occurrence of lumbar spondylolysis and lumbar disc herniation with lumbosacral nerve root anomaly

Lumbosacral nerve root anomalies are the leading cause of lumbar surgery failures. Although co-occurrence of lumbar spondylolysis and disc herniation is common, it is very rare to observe that a nerve root anomaly accompanies these lesions. A 49-year-old male patient presented with sudden-onset right leg pain. Examinations revealed L5/S1 lumbar spondylolysis and disc herniation. At preoperative period, he was also diagnosed with lumbosacral root anomaly. Following discectomy and root decompression, stabilization was performed. The complaints of the patient diagnosed with lumbosacral root anomaly at intraoperative period were improved at postoperative period. It should be remembered that in patients with lumbar disc herniation and spondylolysis, lumbar root anomalies may coexist when clinical and neurological picture is severe. Preoperative and perioperative assessments should be made meticulously to prevent neurological injury.

Omurilik yaralanmaların patofizyolojisi

Correspondence: Tevfik Yılmaz, Department of Neurosurgery, Faculty of Medicine, Dicle University, Diyarbakır, TURKEY Email: kartaltevfik@hotmail.com Received: 27.08.2013, Accepted: 01.12.2013 Copyright

Efficacy of dexamethasone on penicillin-induced epileptiform activity in rats: An electrophysiological study

Corticosteroids are extensively used in treatment of many diseases. In neurosurgery practice, dexamethasone (DEX) is commonly used particularly in cerebral edema secondary to brain tumors, head trauma, and central nervous system infections. There are some uncertainties surrounding the secure use of DEX in patients with epilepsy or seizures induced by diseases of the central nervous system such as head trauma and brain tumors. Despite its extensive use, the effect of DEX on epileptiform activity is unclear. In this study the effect of DEX on epileptiform activity was investigated in rats. The effects of 1, 3, and 10mg/kg DEX on epileptiform activity was compared with effects of antiepileptic drugs commonly employed in treatment of epilepsy, namely phenytoin (PHT) 50mg/kg and levetiracetam (LEV) 50mg/kg that were administered intraperitoneally for 1 week. All groups were administered intracortical penicillin (500IU) to induce epileptiform activity. DEX at the doses of 3mg/kg and 10mg/kg significantly reduced spike frequencies compared to the initial values. In conclusion, we think that DEX can effectively decrease the epileptiform activity.

Lumbosacral stabilization using iliac wings: a new surgical technique.

Study Design. Case reports. Objective. A novel spinopelvic instrumentation system is introduced. Summary of Background Data. Spinopelvic stabilization is a problematic area of the spine. A mobile segment (spine) is fixed onto a stabile construction (pelvis). Another problem is the spinal anatomy because L5 vertebrae are affected by shear forces due to lomber lordosis so that stabilization needs extra power and 360° fusion of L5–S1 level. Long instrumentation is preferred to decrease the stress on the screws and the rods. We designed iliac plates to support lumbopelvic instrumentation laterally. Four cases of spinopelvic pathology were treated in this way manner. The short-term results are good. Methods. Four adult cases that had spinopelvic instability were treated with a novel spinopelvic instrument. All cases were evaluated with visual analog scale (VAS), Oswestry and radiologic studies pre- and postsurgery at 6 and 12 months. Results. All the patients benefited from the stabilization. Preoperative mean VAS scores of all patients decreased from 7.75 to 1.75 and preoperative Oswestry disability index scores decreased from 83.50 to 24.50 at the 12 months postoperative evaluation. Conclusion. In this study, we define four cases and report that iliac wings can be used to augment stabilization. We review the literature and discuss our knowledge and experiences in these cases.

Three-dimensional analysis of foramen magnum and its adjacent structures.

AbstractThe goal of this effort is to evaluate the anatomy of the foramen magnum (FM) using 3-dimensional computed tomography (3D CT), and determine whether or not the anatomical features of vascular structures and condylar foramen (CF) affect the types of FM.The CT angiography records of 101 patients (44 men and 57 women) were retrospectively examined in this study. Details of the FM, CF, and the vertebral and basilar arteries were examined using maximum intensity projection and 3D rendering images. The average age of the 101 patients was 45.28 ± 16.3 years. The 8 types of FM, in order of their frequency of occurrence, are as follows: round (19 cases; 18.8%), 2 semicircles (18; 17.8%), egg-shaped (15; 14.9%), hexagonal (14; 13.9%), tetragonal (11; 10.9%), oval (11; 10.9%), pentagonal (9; 8.9%), and irregular (4; 4%). There was no statistically significant relationship between the anatomical features of the vertebral and basilar arteries and the CF with the different types of FM (P ≥ 0.05). In our study, the diameter of the anteroposterior (AP) FM was 34.7 ± 3.6 mm, and the transverse (T) diameter was 29.5 ± 2.5 mm. The AP and T diameters were significantly higher in men than in women (P = 0.006 and P ⩽ 0.001, respectively).Our study revealed that 3D CT is a safe and easy method for visualizing the anatomical structure of the FM and neighboring structures. Furthermore, this study was the first to demonstrate that there is no correlation between the 8 types of FM and the vertebral artery, basilar artery, and CF.

Surgical therapy of a vertebral artery aneurysm with saccular and fusiform segments.

Abstract Vertebral artery aneurysms form a group of aneurysms having high rates of rebleeding, morbidity, and mortality, poor treatment outcomes, as well as low rate of surgical treatment. Examinations for subarachnoid bleeding revealed a vertebral artery aneurysm with a diameter of 12 mm in a 67-year-old man who presented with headache. The vertebral artery aneurysm with saccular and fusiform segments was shrunk and clipped via lateral left suboccipital approach. No neurologic deficit was present at the postoperative period. Control digital subtraction angiography showed complete shrinkage of aneurysm with continued blood flow and no residue. Clinical findings, treatments, and surgical approaches of VA aneurysms are different from anterior and posterior circulation aneurysms. Microneurosurgical clipping is the most effective treatment of vertebral artery aneurysms in suitable cases. Although endovascular intervention is commonly applied as therapeutic modality for patients with vertebral artery aneurysm, researchers have also emphasized that saccular vertebral aneurysms with fusiform extension can also be surgically treated in suitable cases.

Recurrent gliosarcoma in pregnancy.

Gliosarcoma is a rare tumor of the central nervous system and it constitutes about 1 to 8% of all malignant gliomas. In this report we are presenting a recurrent gliosarcoma case during a pregnancy in a 30-year-old woman. This is the first report presenting gliosarcoma in the pregnancy.