Can facet joint infiltrative analgesia reduce postoperative pain in degenerative lumbar disc surgery?

OBJECTIVE

Perioperative analgesia effects the postoperative course of pain. The purpose of this study was to evaluate its possible relation with the consumption of dolantine and analgesics and the facet-induced pain and postoperative pain score in degenerative disc surgery.

METHODS

We employed perioperative intra- and perifacet bupivacaine infiltration technique to reduce the postoperative pain after lumbar disc surgery. The study was randomized and observer blinded enrolling 40 American Society of Anesthesiologists physical status class I-II patients scheduled for elective degenerative lumbar disc surgery. The patients were divided into two groups of 20 of which Group 1 underwent injection of bupivacaine into the subcutaneous and muscular layers around the incision site, while Group 2 underwent additional intra- and perifacetal joint infiltration. Postoperatively, the patients were provided with a programmed patient-controlled pump which was only activated on demand to infuse dolantine for the next 24 hours. In the postanesthesia care unit the delay for analgesia and the dose of dolantine used were recorded.

RESULTS

There was no statistical significance between these two groups regarding postoperative visual analoque scale scores. The time before the first analgesic request was significantly longer in facet group (p= 0,006). The cumulative dolantine dose was also significantly lower in the facet group (p= 0,001).

CONCLUSION

The results indicate that facet joint infiltrative analgesia may have an effect on the postoperative analgesic requirement and reduce the dolantine consumption.

Ganglioglioma with lytic skull lesions: A case report

Gangliogliomas represent only 0.4% of central nervous system neoplasms and 1.3% of brain tumors. They are benign neoplasms with low morbidity and mortality and the patients usually present with seizures, but there has been no adult ganglioglioma with lytic skull lesion. A 49-year-old right handed woman suffering from generalized epileptic seizures was admitted to our hospital. She had also left hemiparesis with 4/5 motor strength. Magnetic resonance imaging and immunohistochemical studies revealed WHO Grade II ganglioglioma. Skull X-ray showed the lytic skull lesions. We have to consider gangliogliomas in the differential diagnosis of lytic skull lesions.

VACTERL-H associated with central hypothyroidism: a case report

The VACTERL-H syndrome is a rare combination of vertebral anomalies, anal atresia, congenital heart defects, tracheo-esophageal fistula, abnormalities of kidneys and limb anomalies together with hydrocephalus. This condition is recognized as a hereditary entity with poor prognosis. We present a newborn weighing 3400 g, born by cesarean section to a 27 years old mother who had had an irregular antenatal follow-up. The patient had severe hydrocephalus, proximal esophageal atresia and distal tracheoesophageal fistula, gastric outlet obstruction, imperforated anus and recto-urethral fistula, patent ductus arterious, a bifid scrotum, a vertebral defect, sacral dimple and central hypothyroidism. The patient had no limb defects. The association of central hypothyroidism and VACTERL-H has previously not been reported.

Tracing the Dural Tail with Image-Guided Surgery

OBJECTIVE

The extent of dural resection is important for preventing recurrence in meningioma management. An image-guidance assisted technique is described to perform adequate dural resection.

METHODS

A universal instrument adapter system for image-guidance was used to track the dural extension of the meningioma accurately.

RESULTS

The universal instrument adapter offers the surgeon the possibility to image-guide nearly any rigid instrument via the computed calibration method. In this way a surgical marking pen was used to chase and adequately mark the "dural tail".

DISCUSSION

Image-guidance systems can be used to avoid incomplete resection of the affected dura that may be responsible for tumour recurrence.

Spontaneous regression of cervical disc herniations

The spontaneous regression of cervical disc herniations is a rare occurrence. Six herniated cervical discs that had regressed spontaneously are presented. All radiological disc regressions correlated well with clinical improvements. We want to underscore the potential for regression that should be considered in the evaluation and management of any patient with a herniated cervical disc.

Pott's puffy tumor of the vertex years after trauma in a diabetic patient: case report

Pott's puffy tumor is a rare clinical entity characterized by subperiosteal abscess associated with osteomyelitis. It is usually seen as a complication of frontal sinusitis or trauma. This is the unique report of a Pott's puffy tumor located over the vertex of a type 1 diabetic patient with an unusual latency of 14 years following injury. A 27-year old man presented with pain and a soft swelling on his vertex. Magnetic resonance imaging demonstrated subperiosteal abscess in the vertex region associated with dural thickening and perisinusal irregularities of epidural space. Further history revealed that he had a trauma to the same location when he was 13 years old. Considering possible complications due to proximity of the lesion to the sagittal sinus, we retrained from aggressive surgical interventions. We treated our patient with a simple surgical abscess drainage followed by prolonged use of antibiotics and achieved complete therapy. The cellular and humoral elements of the immune system may be disrupted in diabetic patients resulting in such atypical courses and complications of infections. We want to emphasize both importance of the prompt diagnosis of Pott's puffy tumor as intracranial invasion may cause severe neurologic problems, and importance of a surgical intervention tailored for the individual lesion.

Ceftriaxone-Induced Symptomatic Pseudolithiasis Mimicking ICP Elevation

In neurosurgery, ceftriaxone is a widely used, third generation cephalosporin for the treatment of CNS infections and perioperational prophylaxis. Recent studies have demonstrated that ceftriaxone induces reversible precipitates in the gallbladder. This complication is referred to as "biliary pseudolithiasis", and it has symptoms similar to the raised intracranial pressure (ICP) symptoms of the perioperative period. Symptomatic biliary pseudolithiasis should be kept in mind in all pediatric neurosurgery cases under ceftriaxone therapy in order to prevent unnecessary postoperative investigations and surgery.

Spontaneous resolution of "protruded" lumbar discs

Decreasing size of disc material that has herniated, whether "contained" or "protruded" has previously been described and sometimes this can be so complete that residual material is barely visible. In a retrospective clinical survey, from among almost 2180 consecutive patients admitted during 1994 - 2002 with low back pain; due to our low follow-up ratios and high price of the magnetic resonance imaging (MRI), only 42 patients with a lumbar disc protrusion could be found who had two MRI scans obtained at least five weeks apart. Among these, 4 patients were spotted with a totally resolved disc protrusion. T (2)-weighted MRI images were suggesting shrinkage due to dehydration and regression within the annulus of protruded disc fragments that had not fully migrated. Our patients are further examples for total resolution of the large "protruded" disc without any treatment; and since concomitant disc protrusions at other levels persisted, the resolution of these discs is supposed to be spontaneous.

Diagnostic value of bed-side ultrasonographic evaluation by anterior approach in spine disorders? A preliminary report

A preliminary investigation was planned so as to evaluate the effectiveness of ultrasonography for bed- side evaluation of patients with suspected spinal pathology. Its application by anterior approach in 37 cases showed that herniated disc material, bone, epidural fat, scar tissue, tumoral masses and their relation to the interspace and dural sac could be visualized. A short description of the sonographic appearance of normal and pathological structures was also given in comparison to Computed Tomography or Magnetic Resonance images. Ultrasonographic examination was inadequate in five of the patients due to obesity, meteorism or diminution of the intervertebral disc space. Advantages of this technique are the availability almost in every hospital, the ease of obtaining images at various angles, avoiding the use of x-rays and the low price. The disadvantages are its relatively poor definition as compared to Computed Tomography or Magnetic Resonance Imaging and its inability to see through bone.

Imaging problems and clinical findings in adolescent lumbar disc herniation: a retrospective study

OBJECTIVES

Disc degeneration probably begins in childhood although low back pain and radicular leg pain is not as common a complaint as in adults. However as yet no explanation exists for the appearance of advanced degenerative changes seen occasionally in patients in their twenties.

PATIENTS AND METHODS

We report 12 adolescents between the ages of 15 and 20 among a total of 1068 cases with radiologically demonstrated lumbar disc herniations treated between March 1991 and March 1996.

RESULTS

Most of their findings were in good agreement with earlier and more recent reports. The only different findings worth commenting upon were the common presence of multiple level disc herniations, and the occasional presence of a so called "fractured epiphysial plate".

CONCLUSION

Depending on magnetic resonance imaging findings coupled with computed tomographic images; we suppose that the so called "fractured bone fragments of the vertebral epiphysial rim impinging on the spinal canal at multiple levels" and "wedges of bone attached to the disc end plate and associated bony defects in the margins of the posterior vertebral bodies" reported to be demonstrated on computed tomographic (CT) images may in fact be false images. Inappropriately angled CT scan slices may cut partly through the epiphysial ring which has totally been distracted backwards together with the firmly attached avulsed disc annuli, designated as an "epiphysial avulsion"; giving rise to the mistaken interpretation as a "fractured epiphysial ring" appearance. Such a mechanism may also involve the posterior longitudinal ligament, which is firmly attached to the neighboring annuli, accounting for the common multilevel involvement.

Atrophic and regenerative changes in rabbit mimic muscles after lidocaine and bupivacaine application

Destruction and denervation atrophy in skeletal muscles caused by the injection of local anaesthetics was investigated by injecting lidocaine or bupivacaine around the rabbit facial nerve to produce facial paralysis. Animals were then sacrificed at 2, 4, 6, and 8 weeks post-injection, and changes in mimic muscle tissue were assessed at each stage by light microscopy and electron microscopy. Atrophic changes were observed at 2-6 weeks after injection, and regeneration started at 6-8 weeks. Compared to bupivacaine, lidocaine caused more dramatic atrophic changes and was associated with slower muscle regeneration.

Redundant ventriculomegaly associated with brain abscess

OBJECTIVE

The aim of this clinical retrospective review was to emphasize the recently observed high incidence of ventriculomegaly, a wellknown complication of brain abscesses.

MATERIALS AND METHODS

Among twelve brain abscess cases operated on in our institution during five years, the most common surgical procedure was burr-hole aspiration applied in ten of the cases, while in the remaining two a standard craniotomy and total excision was performed. Ventriculomegaly was assessed by the "Evans' Ratio" values calculated using the frontal ventricular horn measurements made on axial tomographic images.

RESULTS

The signs, symptoms, radiological findings and clinical features of the patients were in accordance to the pertinent literature. The only finding worth commenting on was the surprisingly high incidence of ventriculomegaly (5/12) and periventricular edema (4/12). Concerning the outcome, there was only one death.

CONCLUSIONS

The "Evans' Ratio" either worsened or remained the same in four out of five cases during the early postoperative period (ranging from one to three months) and it got better in one case in the late postoperative control (1.5 years). Furthermore, periventricular edema persisted just in the same manner in three of the four cases.

Long-term degeneration and regeneration of the rabbit facial nerve blocked with conventional lidocaine and bupivacaine solutions

The alterations due to the long-term degeneration and regeneration of the rabbit facial nerve were investigated. The facial nerve was blocked with conventional lidocaine and bupivacaine solutions. The rabbits were sacrificed and facial nerves were removed 2, 4, 6 and 8 weeks after the administration of normal saline, lidocaine and bupivacaine. The samples were then processed for electron microscopic observation. Degenerations were seen 2-4 weeks after the injection of normal saline, lidocaine and bupivacaine. In the normal saline group the regeneration process was observed after 6 weeks, whereas in the lidocaine and bupivacaine groups this process was first noticed after 8 weeks. In the lidocaine and bupivacaine groups, regeneration was not completed at the end of 8 weeks; however, it was faster in the bupivacaine group. Bupivacaine is therefore suggested as the drug of choice for neural blockade as it caused less damage and a faster regeneration.

The precise human bioclock, possibly imported

Contrary to what has long been suggested, the biological clock is not a poor timekeeper. In fact, it has been working in precision for millions of years as a genetically set clock, independent of environmental periodicity. However, as the Earth's rotation has gradually slowed, this internal clock has gone through a relative phase shift. Extrapolating of changes backwards through time shows that the clock was set when mammals first appeared on the planet. Interestingly, primates are the only beings that have a free-running cycle longer than 24 hours. This bioclock may be set by lunar entrainment, or may be set extraterrestrially?

Endoscopy in the 15th century

The aim of this study was to investigate the contributions of Serefeddin Sabuncuoğlu (1385-1468?)--who was born and practiced in Amasya in northern part of central Anatolia--to the field of endoscopy. He was a humble, curious and intelligent surgeon, and also a calligrapher and a miniature artist. This remarkable pioneer used the classification of the Andalusian surgeon, Abdul-Kasim Kalaf Ibni Abbas El Zahravi, known as Albucasis of Cordoba (936-1013); but improved it by adding many important and major new observations and chapters. He described "a thin and hollow tube of almost 35 cm, which was made of silver" and used it to inspect the interior of the bladder.

Effects of trauma and pain on the acute anterior pituitary hormonal response

The aim of this study was to compare the effects of trauma and pain on the pituitary gland so as to determine whether pain is a significant component in the general acute hormonal trauma response. Adenohypophysis of rabbits that have undergone either diffuse traumatic brain injury or pain were investigated using immunohistochemistry. The ACTH staining pattern of the pain-administered rabbits was not as strong as the head-trauma-administered group, whereas PRL staining pattern of the former group was not so weak as the later group. As a conclusion, since adrenocorticotrophic hormone and prolactin staining patterns were different in the trauma administered and pain induced groups; it may be postulated that pain alone may not be an important factor in the hormonal response to trauma.

A new coated bipolar coagulator: technical note

BACKGROUND

Sometimes charring or popping occurs and the bipolar blades get stuck to the vessel.

METHODS

The tips of one of the many commercially available bipolar forceps were coated in a striped manner with Teflon--50 micro in thickness.

RESULTS

The new bipolar coagulator coated with Teflon reduced the incidence of tissue sticking.

CONCLUSIONS

Experience with this instrument was still quite limited, but preliminary results were promising.

Clinical significance of acute traumatic intracranial pneumocephalus

Among 1142 patients with head injuries hospitalized in the Neurosurgery Department of Gazi University Medical School during the period between 1979 and 1992, 583 had initial CT scans. A retrospective analysis of these initial CT images revealed intracranial air on admission in only 21 cases. These were classified as acute traumatic intracranial pneumocephalus: a potentially serious complication of head injury. CT scans were re-evaluated so as to reveal whether air was situated in the epidural, subdural, or subarachnoid spaces or intracerebrally; whether associated space-occupying lesions were present and whether the air bubbles were single or multiple. Clinical data such as the presence of persistent rhinorrhea and/or otorrhea, tension pneumocephalus, severity and type of trauma, and outcome were were also assessed to determine the significance of this rare finding.

Antiischemic effect of ZK-118.182 in rabbits: a comparative study with iloprost

The effects of ZK-118.182, a stable analogue of PGD2, were evaluated in an endothelin-1-induced cerebral ischemia rabbit model. Ischemia was induced by endothelin-1 injection (0.25 ng bolus) into subcavian artery and ischemic changes were assessed histologically by the number of ischemic neurons in the brain stem. ZK-118.182 (2 micrograms/kg, bolus into subclavian artery) reduced the number of ischemic neurons when injected 20 min after endothelin-1 injection, Iloprost, a stable analogue of PGI2, was also effective in reducing the number of ischemic neurons in a dose of 0.5 microgram/kg (bolus into subclavian artery). The results suggested that ZK-118.182 has a potent antiischemic effect which is comparable to that of iloprost in rabbits.

Measurements of the carotid canal in skulls from Anatolia

Since widespread applications of microsurgery are being employed for aneurysms, clival tumors, etc., precise knowledge of the skull base measurements has become vital, and a study of 307 adult skulls--130 female and 177 male--has been undertaken. Measurements were made between the landmarks chosen in accordance with the study of Lang in 1983 and our average values were similar to his series, being closer to his female data. There was no significant difference between the right and left sides of the skull.

Early phase alterations in endothelium dependent vasorelaxation responses due to aneurysm clip application and related manipulations

Mechanically induced vasoconstriction observed throughout surgery and in the immediate postoperative period was investigated to assess the effects of various microsurgical manipulations. Factors such as the type of aneurysm clip, duration of temporary clipping and peri-adventitial tissue stripping were the variables in this study. Microsurgical clips were applied on guinea pig "cervical carotid arteries" in which peri-adventitia had been removed microsurgically. Arterial rings were removed immediately after surgery. Endothelium dependent relaxations were measured and morphological investigations were performed using light microscopy. It was observed that as the clip application period increased, relaxation responses decreased. Peri-adventitial tissue stripping caused a marked decrease in the relaxation responses in all types of the clips. Microvascular clips, in spite of their lower closing forces, had the greatest deleterious effect on relaxation responses of the vessel, in both normal and peri-adventitial tissue stripped. When the peri-adventitial tissue of the vessel had been stripped, convolutions of the lamina elastica interna were found to be lost in parallel with the decreased tonus of the artery. In the vessels subjected to clipping endothelial denudation and cracking took place. As a conclusion it can be stated that both peri-adventitial tissue stripping and microvascular clip application have deleterious effects in the early postoperative period. While choosing clips from minimal occlusion force tables, care must be taken to choose clips with less width; and while performing microvascular anastomosis, temporary clips with a lesser width must be used in place of microvascular clips. Adventitial stripping must not be unnecessarily generous during microvascular anastomosis.

Pharmacological and pathophysiological effects of periadventitial stripping on immediate and subacute postoperative vasoconstriction in guinea pigs

Mechanically induced vasospasm observed in the immediate post-operative period was investigated, and the effect of factors such as temporary clip applications and post-operative intervals were studied. Guinea pig "cervical internal carotid arteries" were used and temporary clips, chosen according to the diameter of the artery and systolic pressure, were applied for a standard period. The same procedure was applied on arteries in which periadventitial tissue had been removed using appropriate microsurgical techniques. On postoperative days 1, 5, and 10, arterial rings were removed while the animals were still alive and Endothelium Dependent Relaxations were measured using a bioassay system. Morphological investigations were also performed using light microscopy on the same arterial preparations. We observed no difference between perioperative and first day postoperative results. The relaxations were minimum. The most striking pathological changes were observed on postoperative day 5, and the relaxation responses began to rise on day 10 together with morphological improvement. It was also found that periadventitial tissue stripping could be used to prevent subacute post-operative vasoconstriction, since its effect was marked on postoperative day 5 and began to resolve on day 10.

Neurocranial morphology as determined by asymmetries of the skull base

The goal of the current study was to provide an easy to use criterion to diagnose neurocranial asymmetries. An anatomical survey of the external aspect of the skull base was planned to correlate with radiological studies. In a sample of 239 skulls, variations of the angular relationship between the structures seen on a basilar view of the cranium were analysed. An anterior and a posterior transverse line were plotted with respect to the midline. Departures from 90 degrees to the midline for either of the transverse lines were less than 5 degrees in normal skulls, between 5 degrees and 7 degrees in skulls classed by independent inspection as asymmetric, and more than 7 degrees in obviously malformed skulls.

Moderate head injuries in children as compared to other age groups, including the cases who had talked and deteriorated

Patients defined as having a moderate head injury on the basis of Glasgow Coma Scale scores within the ranges of 9 to 13 after acute nonsurgical procedures were selected. Almost 1600 cases were hospitalized in the Neurosurgery Department. The cases were admitted through the Emergency Unit of Gaz University Medical School, Ankara, Turkey during the period between 1979 and 1992. The group studied consisted of 231 selected patients assessed separately in paediatric, adult and elderly age groups. Possible risk factors such as: GCS score, anisocoria, unilateral or bilateral fixed pupils, impaired oculocephalic reflexes, presence of multiple systemic injuries, aetiology of head trauma, presence of linear or depressed skull fractures, space occupying mass on CT or operation was also assessed. Subarachnoid haemorrhage turned out to be the only independent significant risk factor in predicting mortality. The data about the patients who have "talked and deteriorated" were also reported so as to assisst physicians charged with the care of trauma victims.

Sella turcica fractures in a trauma series and their clinical significance

BACKGROUND

Fractures in the region of the sella turcica (ST) are usually associated with severe blunt head trauma and may produce many complications. The true incidence is difficult to assess since there have been only about 30 cases reported in the literature.

METHODS

A total of 470 computed tomography (CT) sections--with optimum bone window images of skull bone--of 1600 head trauma patients who were admitted between 1979 and 1992, inclusive, to the Neurosurgery Department of Gazi University Medical School were analyzed retrospectively.

RESULTS

There were a total of 17 patients with a fracture of the ST, constituting an incidence of 3.6%, and there was a preponderance of children.

CONCLUSIONS

Computed tomography was very helpful in assessing the extent of ST fractures. In our cases, these fractures were not associated with a high complication or death rate, although a cerebrospinal fluid fistula was present in 53%.

Head trauma and leucocytosis

A prospective analysis of 153 cases of head trauma was conducted with respect to their white blood cell counts. A white blood cell count exceeding 20 x 10(6)/l is associated with a poor clinical grade on admission and with a 96% mortality as opposed to that of a 23% mortality for those with slightly lower or slightly above normal white blood cell count. The sensitivity for this level is a mortality of 96% while the specificity is 77%.

Co-incidence of Guillain-Barré syndrome and spinal cord compression in non-Hodgkin lymphoma

Extradural, radicular and spinal cord compressions are severe neurological complications of lymphomas. Less frequently, involvement of the peripheral nervous system, polymyositis, myasthenia gravis and Guillain-Barré syndrome (GBS) occur. We report a patient with GBS along with a lymphoma of the spinal extradural space where at the beginning the features of GBS outweighed the symptomatology of the extradural spinal mass.

Autogenous bone grafts in cervical vertebrectomy and fusion practice for injuries

Among the patients with a cervical injury admitted to our clinic between 1980 and 1988, 18 cases underwent a ventral fusion operation (Cloward) and 8 of them needed additional vertebrectomy. The injury in all of these cases was due to falls and presented with major compression fractures. In each case the vertebral body was resected and replaced by a "T" shaped iliac bone graft. The graft was fixated by a screw or wire when necessary, than the patients were immobilized by a bed rest for 2 weeks duration. During the follow-up period, cervical alignment was found to be stable in all patients. The radiological characteristics of the lesions, intraoperative surgical modifications for specific aspects of the lesion, other technical availabilities and the results are discussed.

Observation of 95 patients with extradural hematoma and review of the literature

The authors review the cases of 95 patients with extradural hematoma managed at Gazi Hospital in the last 4 years. The common factors in craniocerebral traumas, the time interval between admittance and trauma, the interval between admittance and operation, and the location of hematomas are determined. The arterial origins demonstrated at operation in extradural hematomas are described. The interactions between all these factors and mortality are discussed. Availability of computed tomography scanning accounts for the present mortality rate of 9.4% when compared with the mortality rate of 33% for conventional diagnostic facilities.