Tufan Cansever

Pyogenic brain abscess

Brain abscesses have been one of the most challenging lesions, both for surgeons and internists. From the beginning of the computed tomography (CT) era, the diagnosis and treatment of these entities have become easier and less invasive. The outcomes have become better with the improvement of diagnostic techniques, neurosurgery, and broad-spectrum antibiotics. Atypical bacterial abscesses are more often due to chemotherapy usage in oncology, long life expectancy in patients with human immunodeficiency virus (HIV) infection, and immunosuppression in conjunction with organ transplantation. Surgical treatment options showed no significant difference with respect to mortality levels, but lower morbidity rates were achieved with stereotactically guided aspiration. Decompression with stereotactically guided aspiration, antibiotic therapy based on results of pus culture, and repeated aspirations if indicated from results of periodic CT follow-up scans seem to be the most appropriate treatment modality for brain abscesses. Immunosuppression and comorbidities, initial neurological status, and intraventricular rupture were significant factors influencing the outcomes of patients. The pitfalls and evolution in the diagnosis and treatment of brain abscesses are discussed in this study.

The evaluation of surgical treatment options in the Chiari Malformation Type I.

AIM There have been several treatment modalities to reduce the volume of the syringomyelic cavity and the pressure on the brainstem in Chiari Malformation Type I (CM-I). Foramen magnum decompression with and without duroplasty were compared in this retrospective study. MATERIAL AND METHODS From 2003 to 2006, 27 patients suffering from CMI were operated on at our institute. The following were measured: the ratio of the syringomyelic cavity to the spinal cord; pre-operative tonsillar herniation from the foramen magnum; pre- and postoperative tonsillo-dural distance; and spinoposterior fossa dural angle. RESULTS 83.3 % of the patients in the non-duroplasty and 73.3% of the patients in the duroplasty group were symptom free. The ratio of syrinx regression was 28+/-10% in the non-duroplasty and 36+/-33% in the duroplasty group. The tonsillodural distance was 3.1+/-1.8 mm in the non-duroplasty and 4.6+/-2.1 mm in the duroplasty group (p>0.05). The spino-posterior fossa dural angle was 133.6+/-9.44 degrees preoperatively and 136.7+/-9.78 degrees postoperatively in the non-duroplasty (p=0.376); 123.7+/-11.7 degrees preoperatively and 129.8+/-11.1 degrees postoperatively in the duroplasty group (p=0.885); no significant difference was found postoperatively (p=0.55, z=1.92), respectively. One patient was re-operated in the non-duroplasty group and thereafter duroplasty was performed. CONCLUSION Almost the same clinical outcomes can be achieved with and without duroplasty. There might be an option to perform duroplasty if simple procedure fails.

Surgical Results of Large and Giant Pituitary Adenomas with Special Consideration of Ophthalmologic Outcomes

OBJECTIVE To analyze functioning and nonfunctioning pituitary adenomas (PAs)>3 cm, with special emphasis on preoperative and postoperative visual functions. METHODS The cases consisted of 49 women and 54 men with mean age of 43.2 years (range 19-66 years). All cases had a macroadenoma >3 cm in diameter. The transsphenoidal approach was performed in 117 procedures, and the transcranial approach was performed in 8 procedures. Radical tumor excision was achieved in 50 of 103 patients. Postoperative evaluation was done in 88 patients. Preoperative and postoperative visual acuity, visual field, and ocular fundi and their relationship with the pattern and duration of the symptoms and the size of the tumor were evaluated. RESULTS Normalization of visual acuity was obtained in 71.5% of patients, improvement occurred in 13.6%, symptoms persisted in 13.6%, and symptoms worsened in 1%. Postoperative improvement of visual field defects (VFDs) was observed in 74.1% of patients, and visual impairment score improved postoperatively in 92% of patients. Patients operated on <6 months before the onset of vision loss had better and more sustained visual improvement. One patient died, and 15.5% of patients experienced surgery-related complications. CONCLUSIONS This study shows that patients with severe visual impairment may have remarkable improvement if surgical decompression is done early. The transsphenoidal approach should be performed to correct the patients visual impairment and to relieve the pressure on the optic apparatus caused by macroadenoma of any size.

Evaluation of spinal missile injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention: a new guideline.

Study Design. Analysis of the patients with spinal missile injury (SMI). Objective. Choosing the optimum treatment for SMI with respect to bullet trajectory, evaluation of surgical indications, and timing of surgical intervention. Summary of Background Data. A few guidelines were reported for the management of SMI. But there is still no consensus about the indication and timing of the surgery. The relationship between the surgery and bullet trajectory was not reported previously. Methods. One hundred twenty-nine patients with spinal missile injury were admitted to our department from 1994 to 2006 and 122 of them could be functionally monitored. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Surgical indications were discussed. The injuries were classified with respect to the bullet’s trajectory. Seventy-four patients were treated surgically, of whom 60 (81%) had incomplete injuries. All 17 patients whose vertebral column was injured with side-to-side trajectory were operated on because of instability. Results. In the surgical group, 33 (56.9%) showed improvement, 20 (34.5%) showed no change, and 5 (8.6%) worsened. The best results were obtained by the patients who received operations because of rapid neurologic decline, compression, and instability in the spinal canal (P < 0.0001). Twenty-three (31%) complications and associated injuries were seen in the surgically treated patients and 18 (34.6%) were seen in the conservatively treated patients. Conclusion. Anteroposterior and oblique trajectories [Gulhane Military Medical Academy (GATA)-SMI I and GATA-SMI II] of SMI must be recognized as highly infective in the lumbar region. A side-to-side trajectory (GATA-SMI III) missile causing spinal cord injury is unstable and needs further stabilization. The spinal cord is not injured by the GATA-SMI IV trajectory, and thus, the best approach in this case is conservative. The best results from neurosurgical interventions may be achieved after rapid neurologic deteriorations because of spinal compression and/or instability.

Radiofrequency thermocoagulation of ganglion impar in the management of coccydynia: preliminary results.

AIM Coccydynia is a painful condition affecting quality of life. The majority of patients can be successfully treated by non-surgical means. Chemical neurolysis, cryoablation and radiofrequency thermocoagulation (RFT) of ganglion impar are also used in the treatment of visceral pelvic pain. We analyzed the efficacy of RFT of ganglion impar in patients with chronic coccydynia. MATERIAL AND METHODS We retrospectively analyzed the collected data of 10 patients with chronic coccydynia (pain>6 months) who were treated by RFT of the ganglion. RESULTS The mean age of the patients was 49.2+/-14.4 (range 27-77) with 8 females (80%) and 2 males (20%). The average follow-up duration was 9.1+/-1.2 months. Statistically significant differences were observed between the preprocedure and post-procedure VNSs (p<0.01). Improvements in VNS scores were correlated with improvements in the EQ-5D scores. Midterm evaluation after the treatment (6 months) revealed that 90% of the patients had a successful outcome and 10% were deemed failures. CONCLUSION Our data suggest that RFT destruction of ganglion impar in patients with chronic coccydynia has an effective outcome and patients responding to RFT have significantly lower post-RFT pain scores. The most important factors determining success of this procedure is strict patient selection criteria and the technique of the procedure.

Transforaminal epidural steroid injection via a preganglionic approach for lumbar spinal stenosis and lumbar discogenic pain with radiculopathy

BACKGROUND Epidural steroid injection (ESIs) is one of the treatment modalities for chronic low back pain (CLBP) with various degrees of success. AIM We analyzed the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESIs) via a preganglionic approach in patients with foraminal stenosis due to lumbar spinal stenosis and lumbar discogenic pain with radiculopathy. MATERIALS AND METHODS We analyzed the data of 40 patients (February 2008 and April 2009) with the diagnosis of CLBP and treated by fluoroscopically guided TFESIs via a preganglionic approach. Patients were followed-up at one month (short term), six months (midterm) and one year (long term) after injections. Follow-up data collection included the Visual Numeric Pain Scale (VNS) and North American Spine Society (NASS) patient satisfaction scores. RESULTS The mean age of the patients was 59.87 +/- 15.06 years (range 30 - 89 years, 25 women). Average follow-up period was 9.22 +/- 3.56 months. Statistically significant differences were observed between the pre-procedure and post-procedure VNSs (P < 0.01, Pearson Correlation Test). Improvements in VNS scores were correlated with improvements in the NASS scores. When the VNS scores were evaluated with respect to the age of patient, level numbers, gender, pre-procedure symptom duration and pre-procedure VNS, no significant differences were found (P < 0.05, linear regression test). At short term evaluation in post treatment (one month), 77.78 % of patients were found to have a successful outcome and 22.22 % were deemed failures. Overall patient satisfaction was 67.23 % in the midterm period. Additionally, 54.83 % of patients (N/n: 15/8) had a successful long-term outcome at a follow-up of one year. CONCLUSION Our data suggest that fluoroscopically guided TFESIs via a preganglionic approach, in patients with foraminal stenosis due to lumbar spinal stenosis and lumbar discogenic pain with radiculopathy, has effective outcome and patients responding to injection have significantly lower post-injection pain scores.

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.

Effects of Clotrimazole on Experimental Spinal Cord Ischemia/Reperfusion Injury in Rats

Objective. The effect of clotrimazole was examined using a spinal cord ischemia/reperfusion model. Methods. Twenty albino Wistar rats weighing 234 ± 12.3 g were used in this study. Rats were anesthetized intraperitoneally with 50 mg/kg ketamine HCl. All animals underwent laparotomy under aseptic conditions. Abdominal aortas of the animals in all but the sham group were exposed. After opening the retroperitoneum, the infrarenal abdominal aorta was clipped for 45 minutes to produce ischemia/reperfusion injury. Polyethylene glycol (PEG, 1 mL) was administrated to the vehicle group. PEG (1 mL) and clotrimazole (30 mg/kg) were administered intraperitoneally in the clotrimazole group. Total laminectomy of T8–T12 was performed on all rats under a microscope. Spinal cords were excised for a length of 2-cm rostrally and 1-cm caudally to the injury site and deep frozen at −76°C for biochemical studies. The levels of malondialdehyde, glutathione-peroxidase, superoxide dismutase, and catalase were measured as an indicator of ischemia level. The most cranial part of the specimens was evaluated morphologically. Results. Treatment with clotrimazole significantly decreased malondialdehyde, glutathione-peroxidase, superoxide dismutase, and catalase levels in comparison with other groups (P = 0.008). Morphologic evaluation revealed that clotrimazole protected the axons and their myelin sheaths from ischemic damage. Conclusion. This study showed the neuroprotective effects of clotrimazole on spinal cord ischemia/reperfusion injury.

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.

An anatomical variation of the third common digital nerve and recurrent motor branch of the median nerve

Carpal tunnel syndrome (CTS) is an entrapment neuropathy where the median nerve is compressed in the carpal canal. There are many variations of the distal branches of the median nerve at the wrist. Anatomical variations of this nerve have fundamental clinical importance to prevent injuries, especially during limited open or endoscopic surgical procedures. A case is presented of an anomalous course of the recurrent motor branch of the median nerve and high division of the third common digital nerve seen in a limited open carpal tunnel release.