New Laminoplasty Technique for Preserving Paravertebral Muscles: Technical Note

AIM

To develop a new laminoplasty technique for preserving paravertebral muscles.

MATERIAL AND METHODS

In this technique, semispinalis and splenius muscles are cut approximately 1 cm laterally to the muscle insertion point to the spinous process at the laminotomy side. Then, multifidus and rotatory muscles are dissected subperiosteally and retracted laterally. The posterior part of the spinous process is cut horizontally below the insertion point of the semispinalis and splenius muscles. At this point, all the contralateral paravertebral muscles with the cut head of the spinous process are dissected subperiosteally and retracted laterally in the same manner as the laminotomy side. After the open-door laminoplasty for reconstruction of the anatomical formation, we fixed the head of the spinous process on the opening side laminae close to the inferior part of the spinous process with a titanium wire.

RESULTS

This technique is unique in that it reconstructs the spine similar to its normal anatomical form by preserving the posterior paravertebral muscles' attachments to the bones and tension ligaments.

CONCLUSION

This technique can reduce the risk of axial pain and kyphotic deformity, and prevent the reduction of ROM.

Open-door Laminoplasty with Preservation of Muscle Attachments of C2 and C7 for Cervical Spondylotic Myelopathy: Retrospective Study

AIM

Some restriction and complications, such as progression of kyphosis, incidence of axial neck pain and decrease of postoperative cervical range of motion are concern. We designed this retrospective clinical study to evaluate the effect of laminoplasty by preserving the muscle attachments of C2 and C7 spinous processes on range of motion (ROM), axial neck pain and cervical lordosis.

MATERIAL AND METHODS

Twenty-seven cases with cervical spondylotic myelopathy underwent open-door laminoplasty with the protection of muscle attachments to the C2 and C7 spinous process and laminae between 2007 and 2013. At the end of the followup, cases were evaluated with preoperative and postoperative modified Japanese Orthopedic Association (mJOA) scores, recovery rate, ROM, lordosis angle and visual analogue scale (VAS). Also, patients were divided into two groups and evaluated according to the magnetic resonance imaging (MRI) findings, with or without T2 signal change.

RESULTS

The mean age of the patients was 66 years. The mean follow-up duration was 25 months. The postoperative mJOA scores were significantly higher than the preoperative mJOA scores (p < 0.001). The recovery rate was 57.4%. Although the postoperative VAS score was higher than the preoperative VAS score and the mean postoperative ROM was lower than the preoperative ROM there was no significant difference between preoperative and postoperative VAS score and ROM (p > 0.05). The postoperative lordosis angle was significantly lower than the preoperative lordosis angle (p < 0.05). There were no significant differences regarding the postoperative lordosis angle, ROM and mJOA scores with or without T2 signal change on MRI.

CONCLUSION

Protection of the anatomic structures around the cervical spine such as the muscles and ligaments provides us better results regarding ROM and cervical axial pain.

Meta-analyses of intracerebral hematoma treatment

AIM

The aim of this study is to define the position of surgery preference in the treatment choice for spontaneous intracerebral hematoma (ICH) and to compare the efficacy of surgery with the medical treatment based on data from 18 previously reported randomized prospective studies on this topic.

MATERIAL AND METHODS

Literature databases and articles were searched from 1960 to 2010. Eighteen randomized studies on this topic were evaluated.

RESULTS

Among these 18 studies, 7 (38.9%) were multicenter and 11 (61.1%) were single center. Totally 204 centers were involved. 1769 patients were treated surgically and 3200 medically. Craniotomy was the most preferred method (n = 14; 77.8%). Follow-up time was mostly 6 months. In general, the effect of surgical versus medical treatment on outcome (mortality/morbidity) after a supratentorial spontaneous ICH do not differ significantly. In individual analysis, the mortality was found to be significantly lower in the operated group than the nonoperated group in only two studies (Kurtsoy's and Miller's studies). Meta-analysis of subgroup analysis revealed surgical treatment results were significantly better for hematoma volume > 40 ml, early surgery (before 24 hours), and Glasgow Coma Scale (GCS)≥ 6.

CONCLUSION

Surgical treatment results were found to be superior to medical treatment in cases with hematoma volume > 40 ml, and GCS ≥ 6. The studies are not adequate to analyze the best type of surgery.

Diffuse cerebral arteriovenous malformation

Diffuse cerebral arteriovenous malformation (AVM) is a rare disorder of the brain and defined as diffuse infiltration of brain by complex vascular structures. It is usually associated with hereditary syndromes and presented with hemorrhage or seizure. We report a 20-year-old male patient who presented with drooping of the left eyelid. He had no skin lesion. The ophthalmological examination was within normal limits except periorbital bruit on oscultation. Radiological examination revealed a diffuse AVM comprising multiple arteriovenous shunts, draining bihemispherically through numerous dilated veins but without a typical arteriovenous malformation nidus. No hereditary disorder was detected. No treatment was performed and the patient is still under follow-up.

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 outcomes of the brachial plexus lesions caused by gunshot wounds in adults

BACKGROUND

The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries.

METHODS

Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions.

RESULTS

The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis.

CONCLUSION

Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.

Central neurocytoma: proton MR spectroscopy and diffusion weighted MR imaging findings

PURPOSE

To present proton magnetic resonance spectroscopy and diffusion-weighted imaging (DWI) findings of central neurocytoma (CN).

METHODS AND MATERIALS

Imaging findings of seven patients with the histopathological diagnosis of CN (five male and two female; age range, 21-28 years of age) were evaluated retrospectively. In addition to conventional magnetic resonance imaging features, we also assessed the metabolite ratios and tumor normalized apparent diffusion coefficient (NADC), which was calculated by dividing the tumor apparent diffusion coefficient (ADC) values by normal ADC. Approval from our institutional review board was obtained for this review.

RESULTS

The tumor choline/creatine ratios were 5.17+/-2.38, while N-acetyl aspartate/choline and N-acetyl aspartate/creatine ratios were 0.33+/-0.15 and 1.84+/-1.38, respectively. On DWI, tumors had heterogeneous hyperintense appearances when compared with the contralateral parietal lobe white matter and tumor NADC values were 0.63+/-0.05.

CONCLUSION

Significantly increased choline/creatine and decreased N-acetyl aspartate/choline ratios with lower NADC values in CN resemble high-grade gliomas and complicate the diagnosis. Familiarity its physiologic features would help to presurgical diagnosis of ventricular and exraventricular CNs.

Surgical management and outcome of large orbitocranial osteomas

Object

The goal of this study is to review the surgical management and outcome of patients who were treated for large orbitocranial osteomas at Gulhane Military Medical Academy over a period of 7 years.

Methods

Twenty-one patients with large orbitocranial osteomas were evaluated retrospectively. All patients were male and between 19 and 25 years old. Surgery was performed in all patients. The main surgical procedure was resection of the osteoma using orbitotomy and/or craniotomy followed by orbital reconstruction and cranioplasty. Cranioplasty was performed in 16 patients, using methyl methacrylate in 5 patients (31%) and porous polyethylene in 11 patients (69%). Thin, flexible, porous polyethylene was preferred for orbital reconstruction in 10 patients. The cranioplasty materials were attached to the intact bone using miniplates.

Results

There were no severe postoperative complications. Mild transient periorbital ecchymosis was noted in 19 patients. The mean follow-up period was 11.7 months (range 9–24 months) after surgery. No tumor regrowth was observed in any patient at the end of the follow-up period.

Conclusions

Large osteomas of the orbitocranial region must be resected for cosmetic and functional reasons. Selection and planning of the surgical technique should be based on the direction of the tumor growth and on the size of the tumor and the structures that are compressed by the tumor.

Endoscopic endonasal resection of a midline intradural frontobasal dermoid tumour

Dermoid and epidermoid cysts are congenital, slowly growing tumours that usually become symptomatic when patients reach the middle of their third decade. An otherwise healthy 20-year-old man presented with an epileptic attack. Imaging studies including computed tomography and magnetic resonance imaging revealed an intradural cystic lesion located in the anterior subfrontal region. Choices of traditional approaches for such a lesion are a bicoronal craniotomy or a transfacial procedure. Taking the advantage of the endoscope, the authors decided to remove the lesion via an endonasal route. After a fully endoscopic endonasal operation, gross total resection of the dermoid tumour was achieved. We have not observed cerebrospinal fluid leakage or any infectious complication after the operation. In this report the technique of operation and reconstruction method are described. The endoscopic endonasal approach offers a good option for lesions located in the anterior skull base. Carefully piecemeal resection of the tumour while preserving the underlying neural and vascular structures should be the main strategy of the operation. Reconstruction is very important after the surgery and a carefully planned pedicled graft technique may help in the prevention of cerebrospinal fluid leakage.

Comparison of the efficacies of antibiotic-impregnated and silver-impregnated ventricular catheters on the prevention of infections. An in vitro laboratory study

BACKGROUND AND OBJECTIVE

Infection of the cerebrospinal fluid is a life-threatening condition which is usually treated with systemic antibiotics and continued ventricular drainage in children. The aim of this study was to analyze the antimicrobial activities of two antimicrobial-agent-impregnated ventricular catheters and to compare their efficacies on the bacterial cultures.

METHODS

Antibiotic-impregnated (clindamycin and rifampicin), silver-impregnated, and standard ventricular catheters were used in this study. The experiment was performed in 2 steps. In the first step, small pieces of the catheters were cut and incubated. Then, they were washed and placed in agar medium. Finally, the number of colonies was counted. In the second step, the pieces of catheters were placed on agar plates containing Staphylococcus aureus,Staphylococcus epidermidis, and Pseudomonas aeruginosa. The plates were incubated, and then, the inhibition zone for each catheter was measured.

RESULTS

An inhibition zone was observed only in the plates for antibiotic-impregnated catheters. In the other plates, no inhibition zone was detected. The number of colonies was lowest in the plate with the silver-impregnated catheter, followed by the antibiotic-impregnated and standard catheters.

CONCLUSION

The antibiotic-impregnated catheter seems more effective for antimicrobial treatment. Although no inhibition zone was found in the plates for silver-impregnated catheters, these catheters allow the lowest bacterial colonization in agar.

Tethered cord syndrome in adulthood

OBJECTIVE/BACKGROUND

The standard treatment for tethered cord syndrome (operative vs nonoperative management) that presents in adulthood remains controversial. A comparative study of tethered cord syndrome in adulthood is needed.

DESIGN

A retrospective chart-based analysis.

METHODS

Patients admitted to Gulhane Military Medical Academy Department of Neurosurgery for management of caudal spinal cord tethering from June 1999 through December 2006 (N = 22).

RESULTS

Conus level was normal in 1 patient with split cord malformation and dermal sinus. Tight terminal filum was found in 21 patients, including postrepair myelomeningocele tethered cord in 4, lipomyelomeningocele/meningocele in 8, split cord malformation in 3, dermal sinus in 7, and syringomyelia in 3. The most common complaints were back pain (15 patients, 68.1%), bladder dysfunction (8, 36.3%), fecal incontinence (2, 9.09%), and leg pain (7, 31.8%). One patient had hydrocephalus (4.5%). Ten of 22 patients underwent surgery; 8 of 10 patients had detethering; and 12 patients refused surgery. Postoperative cerebrospinal fluid leakage requiring reinforcement sutures occurred in 1 patient. There were no infectious complications. Neurologic status and outcomes were compared with preoperative findings.

CONCLUSIONS

Some patients refuse surgery despite severe neurologic disturbances. Neurosurgeons should fully explain the risks and benefits of surgery for tethered cord to the patient and family. A much larger and prospective randomized series is needed to determine the effects of operative vs nonoperative management of tethered cord syndrome in adulthood.

Spinal hydatid cyst mimicking arachnoid cyst on magnetic resonance imaging

BACKGROUND

Primary spinal hydatid cysts are uncommon and account for 1% of all cases of hydatid disease. Echinococcus granulosus is most often responsible for the cyst hydatid. Intradural, extramedullary involvement is rare. When the cysts do not demonstrate typical magnetic resonance imaging findings, the differential diagnosis is more complex.

METHOD

Case report.

FINDINGS

An isolated primary hydatid cyst of the spine in a 35-year-old man that appeared to be an arachnoid cyst on preoperative radiographic examination.

CONCLUSION

Hydatid cysts that lack the typical radiographic appearance may be mistaken for arachnoid cysts. Misdiagnosis has serious implications for surgical intervention and long-term care.

Aplasia cutis congenita: a rare cutaneous sign of split cord malformations

BACKGROUND

Aplasia cutis congenita (ACC) is characterized by the absence of a portion of skin in a localized or widespread area at birth. It manifests usually as a solitary defect on the scalp, but sometimes may occur on the face, trunk, or limbs. ACC is most often a benign isolated defect, but can be associated with other physical anomalies or malformation syndromes. A few cases have been reported in which patients with split cord malformation (SCM) have presented with ACC.

METHODS

Two patients with SCM are reported.

RESULTS

Both patients presented with ACC and abnormal hair growth on their backs. Type II SCM was detected in the first patient and Type I SCM in the second. No surgical treatment was performed because the patients were neurologically intact.

CONCLUSIONS

ACC may seldom manifest as a skin marker of SCM. Our patients are unique examples of SCM presenting with ACC, but not requiring surgery. It is important to recognize ACC as a cutaneous sign of SCM, and to refer these patients to radiologic evaluation as soon as possible.

Simultaneously occurring vestibular schwannoma and meningioma in the cerebellopontine angle: case report and literature review

Simultaneously occurring multiple primary brain tumors of different histological types are rare, and the coexistence of schwannoma and meningioma in the same cerebellopontine angle (CPA) without neurofibromatosis is extremely rare. A 57-year-old female patient presented with headache, speech disturbance, left facial numbness and deafness in the left ear. Magnetic resonance imaging demonstrated two different tumors in the left CPA. These tumors were not in continuity. The tumors were totally removed through the left suboccipital approach. Histopathological examination revealed that the large tumor was a vestibular schwannoma and the smaller was a meningioma. Neurofibromatosis was not diagnosed in the patient. No recurrence was observed at the end of 9 years after the operation. The simultaneous occurrence of vestibular schwannoma and meningioma in the CPA appears coincidental. This association must be kept in mind if two different tumors are detected radiologically in the same CPA.

Surgical repair of ulnar nerve lesions caused by gunshot and shrapnel: results in 407 lesions

Object

Ulnar nerve lesions caused by gunshot wounds have rarely been reported in the current literature. The authors describe the outcome after surgical repair of such injuries, and the factors influencing the results of treatment.

Methods

This retrospective study includes 455 patients with 462 ulnar nerve injuries caused by gunshot wounds who were treated at Gulhane Military Medical Academy over a 40-year period. A total of 407 ulnar lesions were surgically repaired at that institution between 1966 and 2005; 237 patients were injured by shrapnel and 218 patients by gunshot. The authors evaluated the motor, sensory, and electrophysiological recovery in these patients, as well as the patients' judgment of the outcome. The authors also tested the effect of repair level, nerve graft length, time to operation, repair technique used, and the presence of coexisting damages in the nerve repair region. The final outcome in these patients was defined as poor, fair, or good on the basis of the British Medical Research Council scores.

Results

A good outcome was noted in 15.06% of patients who underwent high-level repair, 29.60% of patients who underwent intermediate-level repair, and 49.68% of patients after low-level repair. On average, patients with successful outcomes had a significantly shorter time to operation than those with unsuccessful outcomes. The critical period for surgery was within 6 months of injury. Although the optimal graft length was found to be 5 cm, this finding was not statistically significant.

Conclusions

The reported outcome of repairs to ulnar nerves damaged by gunshot has varied in the literature, but there is a consensus that the duration of the interval to surgery, the repair level, and the graft length used influence the outcome of surgical repair for ulnar nerve lesions.

Head injuries due to landmines

BACKGROUND

Landmine explosions cause most of the war injuries in the battlefield and pose a substantial public health risk. Although the lower limbs are usually affected, head injuries also occur. The aim of this study is to describe the types of head injuries caused by the explosion of landmines and the management of the victims.

PATIENTS AND METHOD

Fifteen patients who sustained a head injury due to a landmine explosion were treated in the Department of Neurosurgery between 2000 and 2006. The average age of the patients was 22.5 (range between 20 and 33). The Glasgow Coma Scale (GCS) score ranged between 3 and 15 and was 8 or less in 4. Shrapnel, stone and earth were the wounding agents. Four patients underwent neurosurgical treatment and 11, apart from simple scalp closure, had conservative treatment. Ten patients had associated lesions in the other parts of the body including thorax, upper and lower limbs, and the abdomen.

FINDINGS

Two patients died. At the time of admission, one had a GCS score of 3 and the other a score of 4. Infection was observed among 4 patients and a cerebrospinal fluid (CSF) fistula in 1 patient.

CONCLUSION

Landmines occasionally cause head injuries. Surgical intervention is seldom required and survival is likely unless the patient is in deep coma. Multidisciplinary approaches are required in case there are associated lesions in the other parts of the body.