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OBJECTIVEEnhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.METHODSThis study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods-during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II-V or if they were younger than 18 years or older than 65.Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.RESULTSThe ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.CONCLUSIONSERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.

Object Sexuality is an important aspect of human life. Sexual activity may be affected in lumbar disc herniation through different mechanisms. The aim of this study is to evaluate patients' sexual problems and sexual behavior patterns before and after surgical treatment of lumbar disc herniation. Methods Forty-three patients were included in the study (mean age 41.4 years). A visual analog scale, the Oswestry Disability Index, the Hospital Anxiety and Depression Scale, and a sexuality assessment questionnaire developed for this study were administered to the patients to evaluate pain and sexual dysfunction. Results Fifty-five percent of the men and 84% of the women reported experiencing sexual problems after the onset of low-back pain. The most common sexual problems were decreased sexual desire (18%) and premature ejaculation together with erectile dysfunction (18%) for the male patients, and decreased sexual desire (47%) for the female patients. The frequency of sexual intercourse before the operation was reduced in 78% of cases compared with the pain-free period. Postoperatively, the patients first attempted sexual intercourse a mean of 26.5 days after surgery. The frequency of intercourse was found to have increased (p = 0.01), while description of any type of sexual problem had decreased (p = 0.005) significantly. Conclusions Lumbar disc herniation has negative effects on sexual life, and not enough attention is given to the patients' sexual problems by the physicians. Decreased sexual desire and decreased sexual intercourse are the most commonly reported problems. Taking time during examination and giving simple recommendations may improve sexuality and life quality of the patients.

Object: The authors reviewed the results of "skip" corpectomy in 29 patients with multilevel cervical spondylotic myelopathy (CSM) and ossified posterior longitudinal ligament (OPLL)., Methods: The skip corpectomy technique, which is characterized by C-4 and C-6 corpectomy, C-5 osteophytectomy, and C-5 vertebral body preservation, was used for decompression in patients with multilevel CSM and OPLL. All patients underwent spinal fixation using C4-5 and C5-6 grafts, and anterior cervical plates were fixated at C-3, C-5, and C-7., Results: The mean preoperative Japanese Orthopaedic Association score increased from 13.44 +/- 2.81 to 16.16 +/- 2.19 after surgery (p < 0.05). The cervical lordosis improved from 1.16 +/- 11.74 degrees to 14.36 +/- 7.85 degrees after surgery (p < 0.05). The complications included temporary hoarseness in 3 cases, dysphagia in 1 case, C-5 nerve palsy in 1 case, and C-7 screw pullout in 1 case. The mean follow-up was 23.2 months. The final plain radiographs showed improved cervical lordosis and fusion in all cases., Conclusions: The authors conclude that the preservation of the C-5 vertebral body provided an additional screw purchase and strengthened the construct. The results of the current study demonstrated effectiveness and safety of the skip corpectomy in patients with multilevel CSM and OPLL.

A Chiari malformation Type I may remain asymptomatic until the patient has reached adulthood and acute presentation of symptoms occurs. In several clinical and experimental studies it has been shown that essential hypertension is associated with vascular compression of the brainstem, particularly of the rostral ventrolateral medulla oblongata. Nevertheless, two cases of Chiari malformation and neurogenic arterial hypertension have been reported. In this article the authors describe a patient with Chiari malformation Type I and neurogenic arterial hypertension. A simple suboccipital decompression not only provided neurological improvement, but also led to resolution of the hypertension. In cases of Chiari malformation and concomitant neurogenic arterial hypertension, careful preoperative clinical and neuroimaging assessments may reveal the cause of the arterial hypertension. Resolution of neurogenic arterial hypertension may be expected even in a case of simple suboccipital decompression.

Object: The C-2 pedicle plays an important role regarding screw purchase for spinal fixation. The aim of this study was to measure the C-2 pedicle-related linear and angular parameters., Methods: Seven parameters in 160 C-2 pedicles (80 dry vertebrae) were measured using a Vernier caliper (accurate to 0.1 mm) and goniometer. The Student t-test was used to determine statistical significance. The authors found that the C-2 isthmus (pars interarticularis) and the C-2 pedicle are distinct structures. The C-2 isthmus covers the pedicle. The isthmus is present between the superior and inferior articular processes, and the pedicle is the structure beneath the C-2 isthmus. It connects the lateral mass-inferior articular process to the body of the axis. The heights of the right and the left C-2 pediculoisthmic components (PICs) were 10.3 +/- 1.6 and 9.9 +/- 1.5 mm, respectively. The posterior part of the superior aspect of the PIC was wider than the anterior portion. The widths of the posterosuperior aspect of the PIC were 11.1 +/- 2 and 11 +/- 1.7 mm on the right and left sides, whereas the widths of the anterosuperior aspect of the PIC were 7.9 +/- 1.7 and 8.5 +/- 1.6 mm, respectively. The inferior widths of this component were 6.0 +/- 1.5 and 5.5 +/- 1.3 mm on the right and left side, respectively. The lengths of the component were 28.8 +/- 2.9 mm on the right and 28.8 +/- 3.4 mm on the left side. The PIC exhibits a lateral-to-medial and an inferior-to-superior angle. Its axial angles were 28.4 +/- 2.5 and 28.6 +/- 2.2 degrees on the right and left sides, respectively; its sagittal angles were 18.8 +/- 2.1 and 18.8 +/- 1.7 degrees, respectively., Conclusions: The C-2 pedicle can be seen in the inferior aspect of the vertebra, and it connects posterior vertebral elements (that is, the lateral mass and inferior articular process) to the axial body. The isthmus drapes the pedicle. The authors suggest that this be termed "the pediculoisthmic component."

The first reference to spinal cord injury is recorded in the Edwin Smith papyrus. Little was known of the function of the cord before Galen's experiments conducted in the second century AD. Galen described the protective coverings of the spinal cord: the bone, posterior longitudinal ligament, dura mater, and pia mater. He gave a detailed account of the gross anatomy of the spinal cord. During the medieval period (AD 700-1500) almost nothing of note was added to Galen's account of spinal cord structure. The first significant work on the spinal cord was that of Blasius in 1666. He was the first to differentiate the gray and white matter of the cord and demonstrated for the first time the origin of the anterior and posterior spinal nerve roots. The elucidation of the various tracts in the spinal cord actually began with demonstrations of pyramidal decussation by Mistichelli (1709) and Pourfoir du Petit (1710). Huber (1739) recorded the first detailed account of spinal roots and the denticulate ligaments. In 1809, Rolando described the substantia gelatinosa. The microtome, invented in 1824 by Stilling, proved to be one of the fundamental tools for the study of spinal cord anatomy. Stilling's technique involved slicing frozen or alcohol-hardened spinal cord into very thin sections and examining them unstained by using the naked eye or a microscope. With improvements in histological and experimental techniques, modern studies of spinal cord anatomy and function were initiated by Brown-Sequard. In 1846, he gave the first demonstration of the decussation of the sensory tracts. The location and direction of fiber tracts were uncovered by the experimental studies of Burdach (1826), Turck (1849), Clarke (1851), Lissauer (1855), Goll (1860), Flechsig (1876), and Gowers (1880). Bastian (1890) demonstrated that in complete transverse lesions of the spinal cord, reflexes below the level of the lesion are lost and muscle tone is abolished. Flatau (1894) observed the laminar nature of spinal pathways. The 20th century ushered in a new era in the evaluation of spinal cord function and localization; however, the total understanding of this remarkable organ remains elusive. Perhaps the next century will provide the answers to today's questions about spinal cord localization.

As a cause of revision spinal surgery, spinal epidural abscess after instrumentation-assisted fusion is rare in neurosurgical practice. Postoperative infections are frequently seen in the time period soon after surgery. The authors report on the case of a 45-year-old woman who had undergone posterior instrumentation-augmented fusion for L4-5 degenerative spondylolisthesis. Ten months after the operation she presented to the neurosurgery clinic with complaints of severe low-back pain and radicular right lower-extremity pain. She had undergone laparoscopic surgery for acute cholecystitis 1 month prior to readmission. Radiological study revealed a spinal epidural abscess in communication with a right psoas abscess at L4-5. The abscess was drained percutaneously with the aid of C-arm fluoroscopic guidance, and a 6-week course of parenteral antibiotic therapy was administered. Retrograde lymphatic bacterial translocation, hematopoietic spread, and the suitable characteristics in the host may facilitate the development of infection around the implant. Thus, distant surgery and infection may be a risk factor in cases in which spinal instrumentation is placed. In such cases a prolonged antibiotic therapy for distant infection after surgery is recommended.

Object: Lumbosacral spondylolisthesis (LSS) is a common disorder that often requires a stabilization and fusion procedure. The aim of this study was to determine the early neuroimaging-detected results of instrumentation-assisted (in situ) fusion with no attempt at surgical reduction of the deformity in patients with low-grade LSS. The neuroimaging results were evaluated to determine the extent of reduction and its correlation with different parameters., Methods: Thirty patients with low-grade LSS underwent short-segment transpedicular screw fixation; surgical reduction was not attempted. All patients underwent plain anteroposterior and lateral lumbar radiography, flexion-extension lateral lumbar radiography, and computerized tomography and magnetic resonance imaging of the lumbar spine before and after surgery. Postoperative measurements were determined on the late (9 to 12-month) postoperative radiographs. The findings were recorded and grouped. Correlation analysis was performed among the radiological findings, body mass index, age, and sex. Paired-sample t-tests were performed for each paired group to determine statistically significant differences. There was no significant difference in extent of deformity reduction in patients with different lordotic angles, sagittal-plane rotation angles, and intervertebral disc heights. The extent of reduction was statistically significant at the L4-5 level (p < 0.05), in patients younger than 50 years of age (p < 0.05), and in those in whom the facet joint angle was increased (p < 0.05)., Conclusions: The authors found that in cases of low-grade LSS, short-segment posterior stabilization (in situ fusion and fixation) does not require surgical reduction and in fact is associated with a measurable reduction when used as the sole treatment.

The history of spinal surgery represents an important aspect of spine-related sciences. The development of the treatment strategies of spine-related disorders has predominantly been recorded in the Western literature. In this paper, a Turkish physician, Serefeddin Sabuncuoğlu (1385-1468), and his treatise, Cerrahiyetül Haniye (Imperial Surgery), are presented. Three sections of this book regarding spinal disorders (spinal dislocations, sciatica, and back pain) are reviewed. The techniques described were used by Sabuncuoğlu in the 1400s. In conclusion, the language and illustrations of this treatise are unique. Compared with current approaches, there are no major differences in the principles of treating spinal traumas despite the passage of almost 500 years.

A variety of diseases may affect the craniovertebral junction and require a decompressive and fusion procedure. Craniovertebral junction instability is expected after a fusion procedure. The authors describe two patients with basilar invagination who underwent transoral odontoidectomy and occipitocervical fixation. Despite an uneventful immediate postoperative course, further cranial settling of the C-2 vertebral body (VB) was demonstrated. One patient experienced neurological deterioration and required a second decompressive procedure, whereas the second patient was asymptomatic and required no additional surgery. It was concluded that the odontoidectomy may have led to horizontal separation of the C-1 lateral masses, resulting in further cranial settling of the C-2 VB. Preservation of one aspect of the C-1 anterior arch minimizes C-1 lateral mass offset and, in turn, further cranial settling of the C-2 VB. In addition, a more rigid fixation of C-2 may minimize the possibility of horizontal separation of the C-1 lateral masses after transoral odontoidectomy.

Object: To demonstrate the safety and utility of one surgical approach, the authors reviewed their experience with the ventral surgical approach for decompression, reduction, and stabilization in 10 patients with either unilateral or bilateral cervical facet dislocation., Methods: Six patients presented with unilateral cervical facet dislocation and four patients with bilateral cervical facet dislocation. There were six male and four female patients who ranged in age from 17 to 72 years (average 37.1 years). The level of facet dislocation was C4-5 in one, C5-6 in four, and C6-7 in five patients. Three patients presented with a complete spinal cord injury (SCI), three patients with an incomplete SCI, three with radicular symptoms or myeloradiculopathy, and one patient was neurologically intact. All patients underwent plain radiography, magnetic resonance imaging, and computerized tomography evaluation of the cervical spine. All patients had sustained significant ligamentous injury with minimum or no bone disruption. All patients underwent ventral decompressive surgery, reduction of the dislocation, and stabilization of the cervical spine. Techniques for performing ventral reduction of unilateral or bilateral cervical facet dislocation are described. Decompression, reduction, and stabilization of the cervical spine via the ventral approach was accomplished in all but one patient. This patient underwent a ventral decompressive procedure and an attempt at ventral reduction and subsequent dorsal reduction and fusion in which a lateral mass screw plate fixation system was used; this was followed by ventral placement of instrumentation and fusion. There were no surgery-related complications. Postoperative neurological status was unchanged in four patients and improved in six patients. No patient experienced neurological deterioration after undergoing this surgical approach., Conclusions: The authors conclude that a ventral surgical decompression, reduction, and stabilization procedure provides a safe and effective alternative for the treatment of patients with unilateral or bilateral cervical facet dislocation without significant bone disruption.

The authors conducted a biomechancial study to determine whether C-1 ring integrity is important in maintaining normal occiput-C-2 separation, specifically when the anterior arch is transected to provide access to the dens during an odontoidectomy procedure. Six human cadaveric occiput-C3 specimens were loaded under axial compression, and the bilateral horizontal separation of the C-1 lateral masses and the vertical compression of the occiput relative to C-2 were recorded. Specimens were first studied after odontoidectomy without C-1 ring transection, then after C-1 anterior arch transection, and finally after C-1 lamina transection. With applied compressive load corresponding to three times the weight of the head, the C-1 ring spread horizontally 1.57 +/- 0.30 mm more when the anterior arch of C-1 was transected than when left intact, resulting in 0.74 +/- 0.44 mm collapse in the occiput-C-2 vertical separation. After laminar transection, the C-1 ring spread 6.55 +/- 2.29 mm more than when it was intact. The resultant vertical separation was a 3.37 +/- 1.89-mm collapse in the occiput-C-2. All changes in C-1 spreading and the occiput-C-2 collapse were statistically significant (p < 0.05, paired Student's t-tests). The C-1 ring continuity prevents horizontal spreading caused by the wedging of C-1 between the occiput and C-2 and thus prevents cranial settling. Therefore, to prevent the subsequent development of disease related to cranial settling, the authors recommend that the surgeon resect part of C-1 only if necessary during odontoidectomy.

Forty-four patients with cervical spondylotic myelopathy who underwent a ventral surgical approach were evaluated with respect to the results of surgery. The neurological status of the patients was categorized according to the modified Japanese Orthopedic Association scale (0-18). Three patients had a functional score of 8, one patient 9, five patients 10, five patients 11, seven patients 12, seven patients 13, seven patients 14, and nine patients had a functional score of 15, preoperatively. Twenty-three patients underwent a one-level corpectomy, 15 patients a two-level corpectomy, and six patients underwent a three-level corpectomy. Forty-one (93.1%) of the 44 patients underwent ventral cervical plate fixation. Complications among the 44 patients included graft- and instrumentation-related complications in seven cases, iliac crest donor-site infection in three cases, and respiratory complications in three cases. The follow-up periods ranged between 7 and 60 months (mean 42.3 months). Overall, the fusion rate was 97.72%. Three patients showed no functional change (6.8%), two patients were worse (4.5%), and 39 patients (88.6%) showed functional improvement in their score between +1 and +6 points (mean 2.16 points). There was no statistically significant difference in the functional improvement score in patients younger or older than 60 years old. The mean improvement in the functional score was found to be +2.857 +/- 1.352, +2.400 +/- 1.454, and +0.5000 +/- 1.871 following one-level corpectomy, two-level, and three-level corpectomies, respectively. There were statistically significant differences in the neurological improvement observed between patients with one-level corpectomy and three-level corpectomy (p < 0.01), as well as between those with two-level and three-level corpectomy (p < 0.05). There was no statistically significant difference in the neurological outcome between patients with one-level and two-level corpectomy (p > 0.05). The results of this study demonstrate a high rate of solid bone fusion and a high rate of functional (neurological) improvement. Five patients underwent reoperation, predominantly for instrumentation failure. The use of instrumentation dictates careful consideration of the risk/benefit ratio associated with its use in each case.

Cervical spondylotic myelopathy can produce a variety of clinical signs and symptoms secondary to neural compromise and biomechanical involvement of the spine. The surgical treatment of cervical spondylotic myelopathy remains a controversial issue after many years of study, evolution, and refinement. Several ventral, dorsal, or combined approaches have been defined. The complications associated with ventral approaches and the concerns about kyphosis following dorsal approaches led to the development of a variety of laminoplasty procedures. This paper reviews the biomechanical basis of cervical spondylotic myelopathy and its effect on choosing the appropriate surgical approach.