Percutaneous endoscopic translaminar approach in a patient with pedicle screw malposition and cement leakage

We present a 79-year-old female patient who had L2-5 dynamic stabilization with cement (Polymethylmethacrylate) injection 6 weeks prior. Due to post-operative right radicular pain, a lumbar CT was scheduled in which a malposition of the right L4 screw and cement leakage was observed. Via a percutaneous translaminar endoscopic approach the leaked cement was removed and the portion of the screw in contact with the nerve root was drilled. With this minimal-invasive procedure, the patient was relieved of her radicular pain.

Temporary 6TH cranial nerve paralysis after accidental durotomy in endoscopic disc surgery

We present a unique case of 6th nerve palsy following accidental durotomy in endoscopic lumbar spine surgery, which has not been reported in the literature before. A 72- year-old female patient was admitted to our outpatient clinic complaining of right leg pain for 6 months. A 4/5 motor paresis was observed on her right toe with a positive Lasegue test at 45°. On her magnetic resonance imaging (MRI), a L5-S1 disc herniation was detected. The patient was planned for percutaneous endoscopic interlaminar disc surgery. The extruded disc was adherent to the dura. During removal, a dural tear was observed. She was relieved of her right leg pain immediately after surgery, but after 30 min postoperatively, she complained of double vision with left abducens nerve paralysis. On cranial MRI, no abnormality could be observed. Intravenous fluids were administered and the paralysis resolved on the postoperative 24th hour. The patient was discharged from the hospital and did not show any complaints on her follow-ups. A 6th nerve palsy can be caused due to alterations of intracranial pressure or mechanic injury. We believe that the durotomy following removing of the disc fragment caused a rapid drainage of CSF, leading to intracranial hypotension and injury of the abducens nerve. Intracranial pressure should be monitored perioperatively and brisk deteriorations has to result in immediate finishing of the surgery to avoid further secondary damage.

Comparison of the effects of buparvaquone and paromomycin on oocyst excretion and clinical parameters in diarrheal calves naturally infected with cryptosporidiosis

Cryptosporidium is an obligate intracellular parasite that infects a wide variety of hosts. Twenty calves with cryptosporidiosis were divided into two groups. A single dose of 2.5 mg/kg buparvaquone was administered intramuscularly to one group, while 100 mg/kg/day paromomycin was administered orally to the other group. The results obtained from the study in which oocyst shedding and clinical parameters of sucking reflex, mental status, oocyst scattering were observed in both groups offer an effective control option with this study, which provides results that support the application of a single dose of buparvaquone injection against the complex treatment methods applied to calves with cryptosporidiosis in the field. In this study, a significant decrease in oocyst shedding and rapid improvement in clinical findings were observed in calves.

Modified Kickstand Rod Technique for the Correction of Adult Idiopathic Scoliosis

Adult idiopathic scoliosis (ADIS) is the delayed form of adolescent idiopathic scoliosis (AIS) which is defined as a three-dimensional deformity with a lateral curvature of more than 10° in adults with prior history of AIS. Surgery is necessary for patients with symptoms of chronic pain, neuromotor deficits and cardiopulmonary problems with a Cobb angle exceeding 45°. In untreated patients, AIS may lead to ADIS which can cause serious problems like osteoarthritis, progressive deformity and spinal stenosis. In recent years, the kickstand rod technique has been introduced in addition to posterior transpedicular stabilization. A kickstand rod is an additional rod which is placed on a supporting iliac screw which is placed on the superior lateral edge of the ilium on the concave side of the deformity (or in other words on the ipsilateral side of the trunk shift) and is connected with a domino connector to the thoracolumbar junction. The rod is then distracted with the screw nuts locked on the contralateral side to achieve coronal correction. The classic kickstand works as a an additional aid to keep the spine in place during maneuvering. We established a modified kickstand rod technique where we put the rod on the concave side and apply compression between the rod on the screw heads and the kickstand to bring the concavity to the midline. The kickstand was used as a temporary tool like a lever to push the spine medially with compression. We believe that our technique can be a useful alternative for correction of coronal imbalance besides the classic one.

Kyphosis After Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations

Thoracolumbar fractures change the biomechanics of the spine. Load distribution causes kyphosis by the time. Treatment of posttraumatic kyphosis is still controversial. We reviewed the literature between 2010 and 2020 using a search with keywords “thoracolumbar fracture and kyphosis.” We removed osteoporotic fractures, ankylosing spondylitis fractures, non-English language papers, case reports, and low-quality case series. Up-to-date information on posttraumatic kyphosis management was reviewed to reach an agreement in a consensus meeting of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The first meeting was conducted in Peshawar in December 2019 with WFNS Spine Committee members’ presence and participation. The second meeting was a virtual meeting via the internet on June 12, 2020. We utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized 42 papers on posttraumatic kyphosis. Surgical treatment of thoracolumbar kyphosis due to unstable burst fractures can be done via a posterior only approach. Less blood loss and reduced surgery time are the main advantages of posterior surgery. Kyphosis angle for surgical decision and fusion levels are controversial. However, global sagittal balance should be taken into consideration for the segment that has to be included. Adding an intermediate screw at the fractured level strengthens the construct.

Comparison of direct costs of percutaneous full-endoscopic interlaminar lumbar discectomy and microdiscectomy: Results from Turkey

Background and purpose

Microdiscectomy (MD) is a stan-dard technique for the surgical treatment of lumbar disc herniation (LDH). Uniportal percutaneous full-endoscopic in-terlaminar lumbar discectomy (PELD) is another surgical op-tion that has become popular owing to reports of shorter hos-pitalization and earlier functional recovery. There are very few articles analyzing the total costs of these two techniques. The purpose of this study was to compare total hospital costs among microdiscectomy (MD) and uniportal percutaneous full-endoscopic interlaminar lumbar discectomy (PELD).

Methods

Forty patients aged between 22-70 years who underwent PELD or MD with different anesthesia techniques were divided into four groups: (i) PELD-local anesthesia (PELD-Local) (n=10), (ii) PELD-general anesthesia (PELD-General) (n=10), (iii) MD-spinal anesthesia (MD-Spinal) (n=10), (iv) MD-general anesthesia (MD-General) (n=10). Health care costs were defined as the sum of direct costs. Data were then analyzed based on anesthetic modality to produce a direct cost evaluation. Direct costs were compared statistically between MD and PELD groups.

Results

The sum of total costs was $1,249.50 in the PELD-Local group, $1,741.50 in the PELD-General group, $2,015.60 in the MD-Spinal group, and $2,348.70 in the MD-General group. The sum of total costs was higher in the MD-Spinal and MD-General groups than in the PELD-Local and PELD-General groups. The costs of surgical operation, surgical equipment, anesthesia (anesthetist's costs), hospital stay, anesthetic drugs and materials, laboratory wor-kup, nur-sing care, and two main groups (PELD-MD) me-dication diffe-red significantly among the two main groups (PELD-MD) (p<0.01).

Conclusion

This study demonstrated that PELD is less costly than MD.

Perineal anesthesia following interlaminar endoscopic disc surgery

Perineal anesthesia is defined as the loss of sensation to the area of buttocks, perianal space and thighs. It is often seen in cauda equina syndrome as a collection of acute symptoms mostly occurring secondary to a large disc herniations leading to neuropathy of multiple lumbar and sacral nerve roots. We present 30 years- old male patient who was admitted with sever left leg pain for over a month. On neurological examination a 3/5 plantarflexion paresis was observed on the left with hypoesthesia concordant to the S1 dermatome. A lumbar MRI showed a broad left L5-S1 disc herniation was detected. The patient underwent interlaminar endoscopic disc surgery and postoperatively, was relieved of his pain and a slightly improvement of his paresis was seen. On the first week follow-up he complained of anesthesia of his buttocks when sitting. On follow-up MRI, the disc was removed completely and no further pathologies could be seen. The patient continued physical therapy and on the 8th week postoperatively his paresis and perineal anesthesia resolved completely. Perineal anesthesia following endoscopic disc surgery was a complication we never have experienced at out clinic. Even when searching through medical databases we have not seen any reports in the literature in that way.

Radiological evaluation of the localization of sympathetic ganglia in the cervical region

PURPOSE

To determine local variations of cervical sympathetic ganglia (CSG) according to vertebral levels on preoperative neck magnetic resonance imaging (MRI) by designating carotid artery (CA) as the standard landmark at the center, in attempts to prevent injury to CSG in the anterior-anterolateral approaches performed in the cervical spinal region.

MATERIALS AND METHODS

The retrospective study reviewed neck MRI images of 281 patients, of which the images of 231 patients were excluded from the study based on the exclusion criteria. As a result, the MRI images of the remaining 50 patients were included in the study. The circumference of carotid artery (CA) was divided into eight equal zones with CA defined as the standard landmark at the center. High-risk zones were determined based on the anterior-anterolateral approaches.

RESULTS

At C1 level, a superior ganglion was located on the right side in 32 (64%) and on the left side in 30 (60%) patients. At this level, it was most commonly located in Zone 6. Middle ganglion was observed most frequently at C3 level, which was detected on the right side in 17 (34%) and on the left side in 17 (34%) patients. At this level, it was most commonly located in Zone 2.

CONCLUSION

Variations in the localizations of superior and middle cervical ganglia should be taken into consideration prior to surgical procedures planned for this region. This study sheds light on high-risk zones in the surgical site and could guide surgeons to better understand the location of cervical sympathetic ganglia before surgical planning.

Iodine Intoxication in Beef Cattle in Turkey - Clinical, Hematological and Biochemical Evaluation

Iodine is an essential trace element for humans and animals. The incidence of iodine poisoning in cattle is low. In the present study, we evaluated the clinical findings, serum glucose and cholesterol, thyroid hormone and urine iodine levels in cattle exposed to excess iodine. All of the clinical data were determined following the addition of potassium iodide to the drinking water. Inappetence, cough, and hyperthermia were notable clinical findings. We detected a very high iodine level (470 μg /L) in an analysis of the drinking water samples. A biochemical analysis revealed that the serum cholesterol levels in the affected cattle were significantly lower (p<0.05) than in healthy cattle. However, the serum glucose in the affected cattle was significantly higher (p<0.05) compared to healthy cattle. The iodine concentration in the urine of the affected animals was also significantly higher (p<0.05) than in the healthy animals. Importantly, a hematological analysis indicated leukocytosis with neutrophilia. Several clinical signs, including hyperthermia, tachycardia, alopecia, and a naso-oral discharge, based on suspected history can suggest iodine intoxication. In addition, biochemical parameters, such as urine iodine, serum glucose and cholesterol levels, were observed to be different between healthy and affected cattle. The thyroid function in affected cattle should also be studied.

Can Right-Handed Surgeons Insert Upper Thoracic Pedicle Screws in much Comfortable Position? Right-Handedness Problem on the Left Side

OBJECTIVE

Thoracic pedicles have special and specific properties. In particular, upper thoracic pedicles are positioned in craniocaudal plane. Therefore, manipulation of thoracic pedicle screws on the left side is difficult for right-handed surgeons. We recommend a new position to insert thoracic pedicle screw that will be much comfortable for spine surgeons.

METHODS

We retrospectively reviewed 33 patients who underwent upper thoracic pedicle screw instrumentation. In 15 patients, a total of 110 thoracic pedicle screws were inserted to the upper thoracic spine (T1-6) with classical position (anesthesiologist and monitor were placed near to patient's head. Surgeons were standing classically near to patient's body while patients were lying in prone position). In 18 patients, a total of 88 thoracic pedicle screws were inserted to the upper thoracic spine with the new standing position-surgeons stand by the head of the patient and the anesthesia monitor laterally and under patient's belt level. All the operations performed by the same senior spine surgeons with the help of C-arm. Postoperative computed tomography scans were obtained to assess the screw placement. The screw malposition and pedicle wall violations were divided and evaluated separately. Cortical penetration were measured and graded at either : 1-2 mm penetration, 2-4 mm penetration and >4 mm penetration.

RESULTS

Total 198 screws were inserted with two different standing positions. Of 198 screws 110 were in the classical positioning group and 88 were in the new positioning group. Incorrect screw placement was found in 33 screws (16.6%). The difference between total screw malposition by both standing positions were found to be statistically significant (p=0.011). The difference between total pedicle wall violations by both standing positions were found to be statistically significant (p=0.003).

CONCLUSION

Right-handedness is a problem during the upper thoracic pedicle screw placement on the left side. Changing the surgeon's position standing near to patient's head could provide a much comfortable position to orient the craniocaudal plane of the thoracic pedicles.

Classification of Radiological Changes in Burst Fractures

AIM

Burst fractures can occur with different radiological images after high energy. We aimed to simplify radiological staging of burst fractures.

METHODS

Eighty patients whom exposed spinal trauma and had burst fracture were evaluated concerning age, sex, fracture segment, neurological deficit, secondary organ injury and radiological changes that occurred.

RESULTS

We performed a new classification in burst fractures at radiological images.

CONCLUSIONS

According to this classification system, secondary organ injury and neurological deficit can be an indicator of energy exposure. If energy is high, the clinical status will be worse. Thus, we can get an idea about the likelihood of neurological deficit and secondary organ injuries. This classification has simplified the radiological staging of burst fractures and is a classification that gives a very accurate idea about the neurological condition.

Effect of Erythropoietin on Microvascular Anastomosis in Rat

Purpose: To investigate the re-endothelialization potential of erythropoietin (EPO) following microvascular anastomosis in rat femoral artery.Methods: Ninety-six male Sprague-Dawley rats weighing between 300 g and 320 g were allocated randomly into two groups (control and EPO, n = 48). Left femoral artery microvascular anastomosis was performed in the rats. The control group was given 0.5 mL of 0.09 % NaCl subcutaneously 48 h  postoperatively while the EPO group was given 150 U/kg recombinant human erythropoietin  subcutaneously 48 h post-operatively. Tissue was harvested from each group after 1, 3, 5, and 7 days. All of the rats were sacrificed for morphometric analysis. Each arterial segment was analyzed morphometrically using Clemex Image Analysis software by a single examiner. The cross-sectional area of the media and neointima was measured and the intima/media ratio was calculated. Hematocrit  measurement was carried out for all the rats.Results: The I/M ratio differed significantly (p < 0.05) between the control and erythropoietin groups, at all time-points. The hematocrit was significantly (p < 0.05) lower in the control group than in the erythropoietin groups on day 7, but not on the other days.Conclusion: This study demonstrates that erythropoietin markedly inhibits neointima formation with accelerated re-endothelialization in rat femoral arteries following microvascular anastomosis.Keywords: Erythropoietin, Microvascular anastomosis, Re-endothelialization, Hematocrit, Neointima/media ratio

The dome procedure: a new technique for the reconstruction of the umbilicus

PURPOSE

The absence of the umbilicus is, in essence, an aesthetic deformity of the abdominal wall. The goal of reconstructing the umbilicus is to obtain a natural, three-dimensional appearance. In this study, we present a new technique called the "dome procedure" for the reconstruction of the umbilicus.

METHODS

This procedure can be applied under local anaesthesia on an outpatient basis and the drawing of the design is simple. The technique was applied to six patients who presented with an absence of the umbilicus following repair of a large incisional and umbilical hernia.

RESULTS

No major or minor complications were encountered. Patient satisfaction was high after surgical intervention.

CONCLUSIONS

The dome procedure, which enables the umbilicus to have a natural appearance with sufficient depression and normal-appearing wrinkles, is simple, easy to perform, and safe.