Search

Zafer Orkun Toktas,1,2 Baran Yilmaz,1 Murat Şakir Ekşi,1,3 Lei Wang,2,4 Akin Akakin,1 Yasin Yener,5 Murat Konakcı,6 Emre Ayan,7 Turker Kılıc,1 Deniz Konya,1,2 Yang D Teng2,4 1Department of Neurosurgery, Bahçeşehir University Medical Faculty, Istanbul, Turkey; 2Departments of Physical Medicine and Rehabilitation and Neurosurgery, Harvard Medical School, Boston, MA, USA; 3Department of Orthopedic Surgery, University of California at San Francisco, San Francisco, CA, USA; 4Division of Spinal Cord Injury Research, Veterans Affairs Healthcare System, Boston, MA, USA; 5Department of Anesthesiology, Göztepe Medikal Park Hospital, Istanbul, Turkey; 6Department of Anesthesiology, Bahçeşehir University Medical Faculty, Istanbul, Turkey; 7Department of Radiology, Göztepe Medical Park, Istanbul, Turkey Purpose: To date, application of intraoperative magnetic resonance imaging (ioMRI) to enhance surgical quality for spinal intramedullary neoplastic lesions has been rarely reported. Moreover, in developing countries or regions, ioMRI accessibility remains very limited. This report describes a technology design of high-field ioMRI accessible for multioperation rooms via a case presentation of an imaging-assisted surgical excision of human cervical spinal cord diffuse glioma.Patient and methods: The patient was a 44-year-old woman with symptomatic and progressive C2–5 intramedullary diffuse glioma (IDG). Our ioMRI system was designed and arranged with accessibility to multiple operation rooms, which was used to assure more complete spinal cord or brain tumor removal. The intraoperational diagnostic aspects and the system setup technical details are presented for future applications of the system in hospitals where a designated ioMRI suite is not available.Results: After a conventionally defined complete removal of C2–C5 IDG using a well-established surgical approach, ioMRI examination was able to detect residual tumor tissues that were indistinguishable under the surgical microscope. The IDG clusters were subsequently excised. The operation regimen resulted in a gross total elimination of the tumor, which enabled the patient to show very satisfactory postsurgery recovery and prognosis.Conclusion: ioMRI-assisted surgical removal of cervical spinal cord diffuse glioma should be systematically developed and applied to enhance therapeutic efficacy. The reported logistic flow of operating room tasks and imaging technical management are innovative for performing the tumor removal procedures in hospitals where designated ioMRI surgical suites do not exist. Critically, we emphasize implementation of stringent quality control measures for patient transportation safety and contamination prevention in establishing and maintaining such a system. Keywords: intraoperative imaging, spine, spinal cord, glioma, residual tumor, decompression

Aim: To analyze the demographic and clinical data of preterm or low birth weight newborns with periventricular hemorrhage., Material and Methods: This retrospective study analyzed patients admitted to the neonatal intensive care unit of a Bahcesehir University School of Medicine-Affiliated Hospital due to preterm birth or low birth weight between June 1, 2012, and April 30, 2021. Categorical values were evaluated by Pearson chi-square or Fisher's exact test. The Mann-Whitney U test compared continuous values between the groups. Logistic regression was used to evaluate the factors that affected permanent cerebrospinal fluid (CSF) diversion., Results: The study finally evaluated 180 newborns. Ninety-one newborns (50.5%) had grade I, 18 (10%) had grade II, 22 (12.2%) had grade III, and 49 (27.2%) had grade IV hemorrhage. One hundred and forty-nine patients (82.8%) were delivered by cesarean section, and 31 (17.2%) were delivered vaginally. All patients with low-grade hemorrhage who needed temporary CSF diversion eventually required permanent CSF diversion. For high-grade hemorrhage, 15 (grade III, 1; grade IV, 14) of 51 (29.4%) patients with ventricular access device (VAD) insertion required permanent CSF diversion. Fifteen (grade III, 6; grade IV, 9) of these 51 (29.4%) patients did not need permanent CSF diversion; thus, their VADs were removed., Conclusion: The permanent CSF diversion rate was significantly higher in the high-grade hemorrhage group, which had significantly lower weight and gestational age at birth. Moreover, only weight at VAD insertion had minimal effect on the need for permanent CSF diversion.

Objective: The aim of this study was to emphasize on the interaction of spatial and temporal gait parameters and analyse the gait asymmetry in the patients with lumbar disc herniation (LDH) before and after microdiscectomy., Methods: This was a prospective, observational study conducted on 59 cases of LDH planned for lumbar microdiscectomy, and healthy control group with 54 participants for analysis was performed prior to surgery and 15 days after surgery. The spatiotemporal gait parameters were measured using a "Win-Track" gait analysis platform system. All the participants walked barefoot for 10 times with their normal walking speed in the same day. The 3 flawless walking data were recorded and the arithmetic means were computed. The gait symmetry index was used to calculate the walking asymmetry. The pain intensity of the patients was recorded shortly before performing the analysis by a visual analogue scale., Results: In the postoperative assessment LDH patients had significantly shorter temporal parameters, longer spatial parameters, faster walking speed, and more cadence than the preoperative assessment (p < 0.05). There were improvements in the asymmetry values of the postoperative gait parameters compared to the preoperative values, but these differences were not significant (p > 0.05). In addition, there was a significant difference in all parameters in terms of gait asymmetry between the postoperative assessment and the healthy controls (p < 0.05)., Conclusion: These results can guide the patient-specific evaluating and implementation of gait rehabilitation programs, and design protocols before or after surgery in the LDH patients.

Background: Spinal meningiomas are benign, well-circumscribed and slowly-growing intradural tumors that compress the spinal cord. Hereby, a retrospective review of 61 spinal meningioma cases evaluated in terms of demographic, clinical, pathological and radiological features to predict the early postoperative functional outcomes., Methods: Patients' records and MRI images of all the histologically confirmed spinal meningioma cases that underwent surgical resection at two university hospitals from January 2005 to June 2016 were retrospectively reviewed. Demographic data, clinical findings, radiological features and pathology reports were reviewed. Univariate and multivariate logistic regression analyses were used to evaluate the impact of each factor on the early 3-month post-surgical functional outcome. A receiver operating characteristic (ROC) curve was used to predict the power of the model., Results: Sixty-one cases of spinal meningiomas were operated: 13 males (21%) and 48 females (79%). Mean age was 60.5 years and ranged from 24 to 92 years. Patients presented with back pain (57%), motor deficits (47.5%), sensory deficits (18%) and sphincteric dysfunction (11.5%). One case (1.6%) showed an additional extradural growth. There were 40 thoracic, nine cervical, five cervicothoracic, five thoracolumbar, and two lumbar cases. Only four cases (6.6%) showed atypical pathological features (WHO grade II). At 3-month follow-up, 46 patients (75.4%) had either functionally improved or remained stable. Fifteen patients (24.6%) had "worse" functional outcome. Three variables showed statistically significant odds ratio for improved outcomes (OR): pre-surgical motor deficit (OR=5; P=0.005); presurgical sensory disturbance (OR=3.5; P=0.026); pre-surgical myelopathy (OR=3.5; P=0.026). Multivariate analysis showed increased OR for cross-sectional ratio, pre-surgical myelopathy, pre-surgical radiculopathy and non-cervical location of tumor (1.59, 3.46, 3.2, 1.63/3.56, respectively). Although none has reached statistical significance (P>0.05), the receiver operating characteristic (ROC) curve showed an area under the curve (AUC) of 0.74., Conclusions: The independent predictors of the early postoperative functional outcomes of spinal meningioma resections may include pre-surgical motor deficit, sensory deficit and myelopathy.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly contagious life-threatening condition with unprecedented impacts for worldwide societies and health care systems. Since the first detection in China, it has spread rapidly worldwide. The increased burden has substantially affected neurosurgical practice and intensive modifications have been required in surgical scheduling, inpatient and outpatient clinics, management of emergency cases, and even in academic activities. In some systems, nonoverlapping teams have been created to minimize transmission among health care workers. In cases of a massive burden, neurosurgeons may need to be reassigned to COVID-19 wards, or teams from other regions may need to be sent to severely affected areas. Recommendations are as following. In outpatient practice, if possible, appointments should be undertaken via telemedicine. All staff assigned to the non-COVID treatment unit should be clothed in level 1 personal protective equipment. If possible, postponement is recommended for operations that do not require urgent or emergent intervention. All patients indicated for surgery must receive COVID-19 screening, including a nasopharyngeal swab and thorax computed tomography. Level 2 protection measures are appropriate during COVID-19-negative patients' operations. Operations of COVID-19-positive patients and emergency operations, in which screening cannot be obtained, should be performed after level 3 protective measures. During surgery, the use of high-speed drills and electrocautery should be reduced to minimize aerosol production. Screening is crucial in all patients because the surgical outcome is highly mortal in patients with COVID-19. All educational and academic conferences can be undertaken as virtual webinars., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Low back pain is the most common reason for physician visit in Western population. It's one of the factors that affect health-related quality of life. Intervertebral disc degeneration is one of the leading factors for low back pain and disc degeneration needs serious attention. In this article, we try to summarize biomechanical factors on the degenerative process., Methods: Patients with low back pain in Neurosurgery Department between January 2012 and June 2019 are searched for this study. The patients were gathered under 2 groups; surgical intervention and conservative treatment groups. Intervertebral disc degeneration was assessed by Pfirrmann grading system. All spinopelvic parameters were measured by using standardized lateral plain standing lumbar radiographs., Results: There were 165 patients in the surgical group (60 females, 105 males) and 84 patients in the conservative group (57 females, 27 males) after randomization. One hundred fifty patients had microdiscectomy and 15 patients had spinal instrumentation with transforaminal lumbar interbody fusion. There was not a statistically significant difference between surgical intervention and conservative treatment groups when comparing disc degeneration status. There was a statistically significant difference in parameters lumbar lordosis (LL), L4-S1, and pelvic incidence-LL (PI-LL) between the 2 treatment groups. In the surgical group when we further analyze the spinopelvic parameters in between the 2 different surgical techniques; L4-S1, pelvic tilt, and PI-LL showed a statistically significant difference., Conclusion: Degenerative disc disease is related with multiple factors which can be detailed under the mechanic components and the genetic components. Of these factors, spinopelvic parameters seem highly penetrating to patients' surgery needs with degenerative disc disease independently.

Aim: To assess spatiotemporal gait parameters in patients with lumbar disc herniation (LDH) and chronic mechanical low back pain (CMLBP), and compare with healthy control group., Material and Methods: A total of 70 patients was enrolled in this prospective, controlled cross-sectional study, of which 25 with LDH, 25 with CMLBP and 20 healthy individuals as the control group. Participants completed 10 passes on the "WIN-TRACK" Gait Analysis Platform at their self-selected walking speed. The arithmetic mean of the five flawless walking data was used for analysis. Pain intensity is assessed by the Visual Analog Scale (VAS)., Results: The spatiotemporal gait parameters were significantly decreased in LDH and CMLBP groups than the healthy control group, particularly in LDH groups (p≥0.001). It was found that pain intensity is negatively correlated to step and stride length, cadence and velocity (p < 0.001). Results of linear regression analysis showed that 10% of the changes in gait cycle duration of the left extremity and 74% of the changes in the velocity were associated with pain intensity., Conclusion: Pain intensity can affect the spatiotemporal gait parameters in patients with Low Back Pain (LBP). Rehabilitation programs with gait optimization should be considered in the management of patients with LDH and CMLBP.

Antidepressant drugs can be advantageous in treating psychiatric and non-psychiatric illnesses, including spinal disorders. However, spine surgeons remain unfamiliar with the advantages and disadvantages of the use of antidepressant drugs as a part of the medical management of diseases of the spine. Our review article describes a systematic method using the PubMed/Medline database with a specific set of keywords to identify such benefits and drawbacks based on 17 original relevant articles published between January 2000 and February 2018; this provides the community of spine surgeons with available cumulative evidence contained within two tables illustrating both observational (10 studies; three cross-sectional, three case-control, and four cohort studies) and interventional (seven randomized clinical trials) studies. While tricyclic antidepressants (e.g., amitriptyline) and duloxetine can be effective in the treatment of neuropathic pain caused by root compression, venlafaxine may be more appropriate for patients with spinal cord injury presenting with depression and/or nociceptive pain. Despite the potential associated consequences of a prolonged hospital stay, higher cost, and controversial reports regarding the lowering of bone mineral density in the elderly, antidepressants may improve patient satisfaction and quality of life following surgery, and reduce postoperative pain and risk of delirium. The preoperative treatment of preexisting psychiatric diseases, such as anxiety and depression, can improve outcomes for patients with spinal cord injury-related disabilities; however, a preoperative platelet function assay is advocated prior to major spine surgical procedures to protect against significant intraoperative blood loss, as serotonergic antidepressants (e.g., selective serotonin reuptake inhibitors) and bupropion can increase the likelihood of bleeding intraoperatively due to drug-induced platelet dysfunction. This comprehensive review of this evolving topic can assist spine surgeons in better understanding the benefits and risks of antidepressant drugs to optimize outcomes and avoid potential hazards in a spine surgical setting.

Cerebrospinal fluid rhinorrhea is described as cerebrospinal fluid flow through the nose due to the abnormal connection of the subarachnoid space and sinonasal cavity. Spontaneous idiopathic rhinorrhea is a rarely seen disease. Besides the patient's clinical presentation detailed radiological evaluation and other invasive procedures must be carried out to confirm the diagnosis. Its treatment is compelling due to high recurrence rates. In the treatment algorithm when conservative treatment modalities had been proven inadequate, surgical repair must follow in order. In this paper the authors present the details of 2 cases of spontaneous rhinorrhoea patients.

Background: The posterior cervical keyhole (KH) laminoforaminotomy has been described to involve the lateral portion of cervical laminae of the upper vertebra alone (small KH) or of both upper and lower vertebrae (large KH)., Objective: To microscopically compare the two keyhole techniques in terms of their ability to expose the corresponding cervical roots., Methods: Ten cadaveric specimens were operated bilaterally from C3-4 to C6-7 level to expose a total of 80 nerve roots. The large KH was applied to the left side, the small KH to the right side. The maximal length of exposed nerve roots was measured under microscope. The virtual optimal KH surface area was determined using digital software. Each root was inspected for exposure of its root and axilla., Results: The maximal exposed nerve root length on the large KH side was significantly larger than on the small KH side at C3-4, C5-6, and C6-7 levels (P = .031, P = .002, P = .003). No significance was reported for C4-5 (P = .06). We could expose right axillae in (3/40) and left axillae in (33/40; P < .001). Optimal keyhole surface areas were 37.9, 38.2, 38.7, and 46.2 mm2 in craniocaudal order., Conclusion: Large KH defects involving both upper and lower laminae and facets can expose the roots to greater extent than small KH defects at C3-4, C5-6, and C6-7 levels. Large KH defects may allow better exposure of nerve roots axillae than small KH defects., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Aim: To better understand the indications and the impact of antidepressant drugs on the field of neurosurgery in terms of risks and benefits in Turkey., Material and Methods: A national survey was conducted among neurosurgeons in current practice in Turkey to report routine prescription trends of antidepressant drugs. Gender, neurosurgical subspecialty, city, type of practice, years of experience, antidepressant agent, indications and reasons not to prescribe were ascertained. A brief review of literature was done to show clinical and research evidence., Results: A total of 336 neurosurgeons took the survey; 53% of them prescribe antidepressants routinely, whereas 47% of them do not. Of the 72% non-prescribers prefer to refer their patients to a psychiatrist and 22% of them believe that antidepressants have no role in neurosurgery. Vascular and pediatric neurosurgeons as well as neurosurgeons at research hospitals showed the lowest prescription proportion, while general and brain tumor neurosurgeons and ones in private practice showed the highest prescription proportion. Surgeons with more than 20 year-experience had the lowest prescription proportion (43%). Type of practice and years of experience showed a statistically significant association with the prescription of antidepressant drugs across (p=0.002 and p=0.025, respectively)., Conclusion: Type of practice and years of experience showed a statistically significant association with the proportion of antidepressants' prescribers in Turkish neurosurgery practice at the time of this survey. Non-prescriber neurosurgeons need to recognize the indications, whereas prescribers have to understand the risks of using antidepressants.

Background: The cervicothoracic junction is a challenging anatomic transition in spine surgery. It is commonly affected by different types of diseases that may significantly impair stability in this region. The seventh cervical vertebra (C7) is an atypical cervical vertebra with unique anatomic features compared to subaxial cervical spine (C3 to C6). C7 has relatively broader laminae, larger pedicles, smaller lateral masses, and a long nonbifid spinous process. These features allow a variety of surgical methods for performing posterior rigid instrumentation in the form of different types of screws, such as lateral mass screws, pedicle screws, transfacet screws, and intralaminar screws. Many biomechanical studies on cadavers have evaluated and compared different types of implants at C7., Methods: We reviewed PubMed/Medline by using specific combinations of keywords to summarize previously published articles that examined C7 posterior rigid instrumentation thoroughly in an experimental fashion on patients or cadavers with additional descriptive radiologic parameters for evaluation of the optimum surgical technique for each type., Results: A total of 44 articles were reported, including 22 articles that discussed anatomic considerations (entry points, sagittal and axial trajectories, and features of screws) and another 22 articles that discussed the relevant biomechanical testing at this transitional region if C7 was directly involved in terms of receiving posterior rigid implants., Conclusions: C7 can accommodate different types of screws, which can provide additional benefits and risks based on availability of bony purchase, awareness of surgical technique, biomechanics, and anatomic considerations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: 1) To provide neurosurgeons and radiologists with a new quantitative and anatomical method to describe spinal meningiomas (SM) consistently. 2) To provide a guide to the surgical approach needed and amount of bony resection required based on the proposed classification. 3) To report the distribution of our 58 cases of SM over different Stages and Subtypes in correlation to the surgical treatment needed for each case. 4) To briefly review the literature on the rare non-conventional surgical corridors to resect SM., Patients and Methods: We reviewed the literature to report on previously published cohorts and classifications used to describe the location of the tumor inside the spinal canal. We reviewed the cases that were published prior showing non-conventional surgical approaches to resect spinal meningiomas. We proposed our classification system composed of Staging based on maximal cross-sectional surface area of tumor inside canal, Typing based on number of quadrants occupied by tumor and Subtyping based on location of the tumor bulk to spinal cord. Extradural and extra-spinal growth were also covered by our classification. We then applied it retrospectively on our 58 cases., Results: 12 articles were published illustrating overlapping terms to describe spinal meningiomas. Another 7 articles were published reporting on 23 cases of anteriorly located spinal meningiomas treated with approaches other than laminectomies/laminoplasties. 4 Types, 9 Subtypes and 4 Stages were described in our Classification System. In our series of 58 patients, no midline anterior type was represented. Therefore, all our cases were treated by laminectomies or laminoplasties (with/without facetectomies) except a case with a paraspinal component where a costotransversectomy was needed., Conclusion: Spinal meningiomas can be radiologically described in a precise fashion. Selection of surgical corridor depends mainly on location of tumor bulk inside canal., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aim: National and international society meetings are suitable mediums at which diverse research topics from basic, clinical and translational sciences can be presented to an audience of peers. In this study, our purpose was to evaluate publication rates of presentations in the last recent four years" annual scientific meetings of Turkish Neurosurgical Society (TNS)., Material and Methods: Abstracts of both podium and poster presentations were retrieved from the congress booklets of TNS. Study timeline included TNS annual scientific meetings of 2011, 2012, 2013, and 2014. Abstract titles and author names of the abstracts were searched in Pubmed/MEDLINE and Google Scholar databases., Results: In total, 3105 presentations to an audience took place in the annual scientific meetings of TNS organized between 2011 and 2014. Acceptance rate of these studies by peer-reviewed scientific journals was 326 (10.5%). In sub-analysis, there were 2408 electronic posters (148 accepted, 6.1%), 195 poster presentations with discussion (44 accepted, 22.6%), and 502 podium presentations (134 accepted, 26.7%)., Conclusion: Acceptance rate of podium presentations in annual scientific meeting of TNS is at comparable levels with similar organizations on the world. However, the rate is lower for poster presentations.

Aim: Cadaveric studies have a great impact on neuroanatomy learning. Cadaver preparation may take a lot of effort, especially at the phase of intravascular color filling. The authors describe their silicone dye technique and a novel mixture which is self-curing, quick to prepare and easy to inject., Material and Methods: The first one of these processes is undoubtedly embalming and decapitation of the cadaver. If possible, the most appropriate time that should be preferred is immediately after the donor's death. Preparation for cadaveric dissection of the brain requires some fundamental steps that can be summarized into: a) Embalming and decapitation, b) Exposing, cannulization and irrigation of main vascular structures, c) Preparing colored silicone, d) Injection of colored silicone and staining the vascular tree, e) Sample maintenance, Results: Our method of preparation of silicone dye and injection enables neurosurgeons and anatomists to fill cerebral and dural vascular structures, and even diploic veins nicely in both fresh and aged cadaveric heads. Moreover, the main vascular structures and their branches in the lateral and third ventricles are painted remarkably beautifully., Conclusion: We tried to provide our experience about the preparation of head cadavers for anatomical dissection using a novel mixture of colored silicone that is very easy to prepare and inject with very satisfactory results.

Background: Diffusion tensor imaging (DTI) is a novel magnetic resonance imaging (MRI) technique potentially able to evaluate the microscopic structural organization of white matter fibers., Aim: This study aimed to compare fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values obtained by DTI in stenotic versus nonstenotic cervical spinal segments of patients with clinical and neurological evidence of cervical spondylotic myelopathy (CSM)., Materials and Methods: This prospective study included 21 patients with CSM but without T2 changes on conventional MRI. Diffusion tensor (DT) images from the stenotic and nonstenotic segments of the subjects were obtained. FA and ADC values were estimated and compared with stenotic versus nonstenotic segments., Statistical Analysis: Paired t-test was used [Statistical Package for the Social Sciences (SPSS) 12.0]., Results: In the most stenotic segments, the mean FA value was significantly lower (0.4228 ± 0.1090 vs 0.6884 ± 0.0075, P < 0.001) and the mean ADC value was significantly higher (1.312 ± 0.2405 vs 0.9183 ± 0.1477, P < 0.001) when compared to nonstenotic segments. In addition, there was a negative correlation between FA and ADC values (r = 0.63, P = 0.002)., Conclusions: DTI of the cervical spine seems to be a promising novel imaging modality in patients with CSM., Advances in Knowledge: DTI may offer increased diagnostic sensitivity as compared to standard MRI and enables earlier detection of the disease.

OBJECT Due to lack of construct stability of the current anterior cervical approaches, supplemental posterior cervical approaches are frequently employed. The use of an anterior-only approach with anterior transpedicular screws (ATPSs) has been proposed as a means of providing 3-column fixation. This study was designed to investigate the feasibility of anterior transpedicular screw (ATPS) fixation of cervical spine, to obtain the morphological measurements for technical prerequisites, and to evaluate the accuracy of the ATPS using fluoroscopy. METHODS The study included both radiological and anatomical investigations. The radiological investigations were based on data from cervical spine CT scans performed in 65 patients. Technical prerequisites of ATPS were calculated using OsiriX for Mac OS. In the anatomical part of the study, 30 pedicles (C3-7) from 6 formalin-preserved cadavers were manually instrumented. Measurements obtained included pedicle width (PW), pedicle height (PH), pedicle transverse angle (PTA), distance of the entry point from the midline (DEPM), and distance of the entry point from the superior endplate (DEPSEP). The authors also analyzed screw position in the manually instrumented vertebrae. RESULTS The mean PW and PH values showed a tendency to increase from C-3 to C-7 in both males and females. The means were significantly larger for both PW and PH in males than in females at all levels (p = 0.001). The overall mean PTA value was significantly lower at C-7 (p < 0.0001). The mean value for the distance of entry point from the midline (DEPM) represented a point at the contralateral side of the pedicle for every level except C-7. The mean DEPSEP values showed significant differences between all levels (p < 0.0001). Seven of the 30 screws were identified as breaching the pedicle (23.3%); these screw malplacements were seen at C-3 (3 screws), C-4 (2 screws), and C-5 (2 screws). CONCLUSIONS The morphological measurements of this study demonstrated that ATPS fixation is feasible in selected cases. They indicate that ATPS insertion using a fluoroscopy-assisted pedicle axis view is safe at the C-6 and C-7 levels, but the results at the other levels did not prove the safety of this technique.

Fibromatosis is a benign lesion, which originates from proliferating fibroblasts. Although fibromatosis is a benign tumor, it is locally aggressive and invasive. Spinal presentation of fibromatosis is very rare, and case reports are the only source of the clinical knowledge. Herein, we describe the oldest patient having spinal fibromatosis with de novo occurrence and aggressive nature. A 68-year-old female patient admitted to our outpatient clinic with low back pain and neurological claudication. On lumbar spine magnetic resonance imaging, she had spinal canal stenosis with a concomitant lesion in the left longissimus muscle. We did our best to resect the tumor, entirely. The pathology result was consistent with spindle cell lesion. The lesion recurred 6 months after the primary surgery. In the second surgery, we did en bloc resection. Pathology and immunohistochemical analysis results were consistent with fibromatosis. After the second surgery, she had adjuvant radiotherapy. There was nothing other than radionecrosis in the operation site, still after 2 years. In conclusion, radiological work-up is usually insufficient to make fibromatosis diagnosis and whole pathological specimen should be carefully evaluated to achieve the accurate diagnosis. Spinal fibromatosis is very rare and its treatment methods have not universally been conceptualized. However, adjuvant therapies are necessary after en bloc resection.

Aim: To determine the role of intraoperative ultrasonography (IOUSG) in the surgical management of patients with intradural spinal tumors., Material and Methods: Twenty-six patients with intradural spinal cord tumors were surgically treated under intraoperative ultrasonographic guidance between January 2007 and May 2011. Guidance with IOUSG was used in 26 patients, of which 14 fourteen had extramedullary and 12 had intramedullary tumors. Intraoperative ultrasound assistance was used to localize each tumor exactly before opening the dura. The extent of tumor resection was verified using axial and sagittal sonographic views. The extent of tumor resection achieved with IOUSG guidance was assessed on postoperative early control MRI sections., Results: Total tumor resection was achieved in 22 (84%) of 26 cases. All of the residual tumors were typically intramedullary and infiltrative. The sensitivity of IOUSG for the determination of the extent of resection was found to be 92%. Ultrasonography was found to be effective in identification of tumor boundaries and protection of spinal cord vessels. The average time spent for IOUSG assessment was 7 minutes., Conclusion: Intraoperative ultrasonography is practical, reliable and highly sensitive for spinal cord surgery. It not only enhances surgical orientation, but also reduces morbidity and helps to resect the tumor completely.

Background: Intracranial meningiomas constitute approximately one fourth of all primary intracranial tumors. The invention of cranial angiographic techniques has led to the recognition of the angiogenic potential of meningiomas, which has been the subject of extensive research., Objective: To test the relationship between the angiogenetic potential of intracranial meningiomas and clinical/prognostic features such as World Health Organization (WHO) grade, peritumoral edema, tumor border shape, and recurrence using rat corneal angiogenesis assay., Methods: Fifteen WHO grade I (typical), 10 WHO grade II (atypical), and 5 WHO grade III (malignant) meningioma samples were implanted in the micropockets formed on rat corneas, and the number of developed vessels were counted on days 5, 10, 15, and 20. Normal brain and glioblastoma multiforme tissues served as negative and positive controls, respectively. Patients were evaluated by magnetic resonance imaging preoperatively and every 6 months thereafter., Results: The angiogenic potential of WHO grade II tumors was significantly lower than that of grade III tumors and higher than that of grade I tumors throughout the experiment. Tumors with a smooth border shape and nonrecurrent tumors exhibited significantly lower angiogenic activity compared with the tumors with irregular border shape and recurrent tumors, respectively. No association was found between angiogenic activity and peritumoral edema. However, multivariate analysis identified WHO grade, recurrence, and peritumoral edema as significant predictors of a high angiogenic potential., Conclusion: Our findings, based on a dynamic in vivo model to examine angiogenesis, demonstrate that the angiogenic potential of meningiomas is correlated with WHO grade, recurrence, and possibly with tumor border shape and peritumoral edema. Angiogenesis seems to be an important factor in the natural course of meningiomas, suggesting that inhibition of angiogenesis may be an option, particularly in the treatment of meningiomas with an aggressive course.

We present the outcomes of 35 uveal melanoma patients treated with gamma knife stereotactic radiosurgery. All cases were previously untreated. During follow-up, regular MRI examinations were used to detect any changes in tumor size and estimate the local long-term tumor control rate. Treatment-related complications were also recorded. During follow-up, systemic dissemination was observed in two patients, one of whom died of metastases. The most frequent complication was retinal detachment (17.1%). Three patients required enucleation. Cumulative 1-year and 3-year local tumor growth control rates were 97% and 83%, respectively. The mean and median times to local tumor progression were 48.0 and 51.7 months, respectively. Gamma knife surgery may be a suitable alternative for the treatment of low-volume uveal tumors without intraocular complications, as the control rate and long-term outcomes compare favorably with those of surgical excision and brachytherapy., ((c) 2009 Elsevier Ltd. All rights reserved.)

The trigemino-cardiac reflex (TCR) is a well-known reflexive response in which bradycardia, hypotension, and gastric hypermotility are induced by stimulation of a peripheral or central portion of the trigeminal nerve. This reflex occurs during craniofacial surgery and other operations on or near the cerebellopontine angle, petrosal sinus, orbit and trigeminal ganglion. TCR is a well-known, although not well documented, phenomenon commonly observed during trans-sphenoidal surgery for resection of pituitary adenomas. We report a case in which asystole occurred during trans-sphenoidal surgery on a pituitary adenoma that was infiltrating the right cavernous sinus. When the anesthesiologist reported asystole, the team stopped manipulation and administered intravenous atropine. Intra-operative MRI showed a small tumour remnant in the right cavernous sinus. The operation was terminated but subsequent radiosurgery was planned for the residual tumor. Although TCR is rare and usually self-limiting, this case led us to change our treatment strategy. Surgeons who perform trans-sphenoidal surgery should be aware of this potential problem. Invasive pituitary adenomas should be removed gently and the risk of triggering TCR should be kept in mind.