Treatment Facilities of Neurosurgery
The incidence of primary brain tumors is 6 / 100,000 per year. It is thought that the metastatic brain tumor frequency is also at this level although it is not seen in a small number. The most common lung and breast cancers are brain metastases. About 1/12 of the primary brain tumors occur below 15 years of age. In adults, 85% of intracranial tumors are located in the supratentorial region. Gliomas, meningiomas and metastases are the most common types. In children, 60% of intracranial tumors are located in the infratentorial region, the most common types being medulloblastoma and cerebellar astrocytoma.
The main symptoms and findings of intracranial tumors are headache, nausea and vomiting, loss of consciousness, unconsciousness, papillary stasis in eye dick examination, eye-baby light reaction anomalies and generalized, partial or partial epileptic seizures that occur in 30-50% of patients.
Contrast-enhanced and contrast-enhanced CT and MRI examinations are essential. Depending on the tumor type, additional tests such as direct radiography, angiography, lumbar puncture may be required.
Başlıca intrakraniyal tümörler: Major intracranial tumors
ASTROCYTOMA and GLIOBLASTOMA
These tumors are caused by astrocytic cells of the brain and can be seen in all age groups. It is more common between the ages of 40-60. The male to female ratio is 2/1Histopathologically, there are 4 stages (Stages 1-4). Glioblastoma in the malignant stage (stage 4) constitutes 40% of all intracranial tumors. It is most commonly seen around 55 years old. It is a rapidly growing tumor that causes widespread infiltration and environmental edema in the neighboring brain.
They develop from arachnoid membrane cells, that is the second layer of brain membranes. They are usually located near the venous sinuses and in the parasagittal region, in the hemisphere convexity. Meningiomas cause compression in neighboring brain tissue. Though they infiltrate cranium from time to time, most are benign. It constitutes 20% of all intracranial tumors.
Intracranial metastases are seen in 25% of cancer patients. The most common tumors that initiate brain metastases are; bronchial carcinoma, breast carcinoma, kidney and thyroid tumors, stomach and prostate carcinoma, testicular tumors, and malignant melanoma. 50% of intracranial metastases are more than one.
VIII. Tumors arising from cranial nerve sheath cells are the most common infratentorial tumors. 5-10% of all intracranial tumors are formed. They are mostly seen in middle age (40-50) and are a little more frequent in women. It is a benign, slow-growing tumor that grows into a wedge-shaped region between the brainstem-cerebellum-petrous bone. With the development of the tumor, slowly progressive hearing loss, buzzing and tinnitus, facial paralysis, facial pain and numbness occur.
Benign tumors that arise from the anterior lobe of the pituitary gland (adenohypophysis), which constitute 15% of all intracranial tumors. Histopathologically and clinically, two main groups are distinguished: endocrine active (75%) and endocrine inactive (25%).
Clinical findings depend on the effect of the body on the pressure of the surrounding tissues in relation to changes in headache, visual field, visual acuity and hormonal activity. Unlike other intracranial tumors, sella spot X-ray, sella CT and dynamic contrast sella MRI, neuroendocrine profile, visual field and visual acuity are used. Endocrine active pituitary adenomas are the most common prolactinomas with 30%. Prolactin is a hormone that provides lactation (stimulating milk in the mammals). Excessive secretion can lead to infertility, amenorrhea, galactoremia, male impotence as well as galactorrhea. Other endocrine active pituitary adenomas are ACTH-secreting adenomas. As a result, the cause of Cushing's syndrome is a pituitary microadenoma or hyperplasia of 60%. Clinical findings include, but are not limited to, mental retardation, obesity, purple cracks in the skin, muscle weakness and weakness, bone erosion, diabetes mellitus, hypertension, acne, hair growth or baldness, Predisposition to infection, fat accumulation in the back (buffalo hovering).
Hypophyseal apoplexy which is a rare condition in pituitary adenomas bleeds into tumor tissue. Sudden and severe headache, rapid progressive loss of vision and paralysis of the eye muscles and severe hypophyseal insufficiency are observed. If it is not treated immediately (steroids, emergency surgery) it will result in death.
Cerebrovascular diseases (CBD) occur as a temporary or permanent lesion in a brain region caused by ischemia (nourishment) or bleeding.
Intracerebral hematoma (ICH) is the blood that enters the brain tissue. 70-80% of the patients have hypertension. Aneurysm and arteriovenous malformations (AVM) account for 25-30% of the cases. Sudden headache due to mass effect, sudden loss of consciousness, vomiting, unilateral force may be some of the clinical signs. In some cases, slow and progressive deterioration is seen within 24-48 hours in the level of consciousness. It shows the location of brain CT bleeding, size and other changes in brain tissue. Cerebral angiography shows the underlying cause (AVM, aneurysm).
Brain vessels are located at subarachnoidal distance. Subarachnoid hemorrhage (SH) occurs in these veins or in the blood of aneurysms on this vein. The frequency is around 9-12 / 100.000 per year. The severity of the symptoms depends on the severity of the bleeding. With sudden and severe headache, the patient can be torn down. This often follows a short or long-term loss of consciousness and / or an epileptic seizure. Nausea and vomiting are almost always seen.
The frequency of SAD due to intracranial aneurysm rupture is approximately 6-12 / 100,000 per year. The male / female ratio is 3/2 who are between 40 and 60 years old.
Arteriovenous malformation is the developmental anomalies of intracranial vessels. There is a direct and pathological relationship between the arterial and venous systems, depending on the absence of cerebral capillary development. Unilateral and pulsating headache may develop generalized and focal seizures either before or after bleeding. The risk of hemorrhage in Arteriovenous malformation is about 2-3% per annum, around the death rate in their hemorrhage.
Head trauma is a common occurrence in emergency services. Every year approximately 300 / 100,000 of the population are admitted to the hospital due to head trauma. 9 / 100,000 patients are dead for the same reason. According to these rates, at least 5500-6000 people per year die from head trauma in Turkey.
Head fractures that cause tears in the middle meningeal vessels are often caused by temporal or temporoparietal epidural hematoma. Occasionally it is resulted by sagittal and transverse sinus injury.
In some patients, bridging ligaments extending into the venous sinuses on the surface of the brain cortex cause a subdural hematoma by tearing the impact end.
It occurs with a hard, sharp object pulse. Since the damage is so small, there is usually no loss of consciousness in the patients. There is no risk of infection in incision or laceration on the scallop. Closed sulcus fractures exceeding a bone size are surgically treated for cosmetic reasons with the possibility of rupture of the dura, with the aim of correcting the cortical press. There is a scalloped incision in the open collapse. The skipping of the open collapse fractures together with the stump lead to severe complications such as meningitis, brain abscess.
CHRONIC SUBDURAL HEMATOMA
Chronic subdural hematoma is common in children and elderly people. The most common cause is a minor or old trauma that patient will remember. Cerebral atrophy, low CSF pressure, alcoholism, coagulation disorders, dehydration are facilitated in children.
Intracranial/spinal tumor rate is 6-9/1 in admission and 10/1 in child. Spinal tumors are divided into three groups according to their relation to spinal dura and spinal cord: Extradural, intradural extramedullary, intradural intramedullary. Most adnexal tumors are metastatic in admission. Intradural intramedullary tumors are predominant in the child. Since the spinal canal is a fixed and rigid structure, the space-occupying lesions in the canal cause symptoms and signs of spinal root and spinal cord compression. Such as pain, loss of strength, loss of sensation, reduction / disappearance of deep tendon reflexes. Bladder and anus sphincter disturbances are also added to the clinical picture in spinal cord and lumbosacral root pressures.
On direct vertebral radiography, pathologic collapse fracture in vertebral body, enlargement in intervertebral foramen, increase in paravertebral soft tissue density, indirect findings of spinal tumor. MRI is becoming increasingly common in the diagnosis of spinal tumors.
The movement of cartilage pillow-like cushions (discs) between the lumbar vertebrae into the spinal canal is called a spinal cord.
The herniated structure may extend into the spinal canal and press on the spinal cord and / or nerves leading to the legs. This situation leads to important indications such as Waist and leg pain, numbness in the legs, feeling chills and tingling, difficulty walking and loss of labor, urinary incontinence in advanced cases, forward weakness in the leg. Delay in the initiation of treatment can cause the problem to grow or become permanent. Your physician will inform you when surgery is necessary. Today, microsurgery and endoscopic methods (also known as closed surgery among the public) have made the herniated disc surgery very safe and practical. Patients can immediately get rid of their aches after surgery and walk on the same day. The length of stay in hospital is decreased to 1 day. After a few weeks of protection and rest, you can easily return to your old lives.
Cervical Disc Hernia
Similar mechanisms and problems in herniated disc are also valid for cervical disc hernia. Depressions in the discs between the neck vertebrae can cause severe pressure on the spinal cord and the nerves leading to the arms and herniation to the spinal canal over time. For this reason, pain, numbness, tingling, loss of power and awkwardness in the hands are encountered in the necks due to aches, frequent holdings, dizziness and short-term blurred attacks. If the spinal cord passing through the neck region has a control line leading to the whole body, spinal cord stiffness can be reduced in the arms and legs such as loss of power, balance defects, and is possible to be confronted with further problems.
Drug treatment, prevention, weight control, neck exercises, use of neck, if necessary, and physical therapy programs are important in situations where surgery is not needed and in advanced cases microsurgery and techniques are applied easily and safely nowadays, and patients see permanent benefits.
Modern methods of treatment remove herniated disc and cervical disc hernia from being a frightened issue. On the contrary, with modern endoscopic discectomy or microsurgery methods in appropriate cases patient comfort has reached to a satisfactory level of comfort.
LUMBAR SPINAL STENOSIS
Lumbar is a secondary contraction of the spinal canal due to congenital or facet joint hypertrophy. Symptoms and signs such as pain, sensory loss, and muscle weakness during neurogenic claudication occur after walking or standing for a while. Symptoms can be alleviated by sitting or lying down, arterial punctures are normal. Unlike disc herniation, sciatic nerve stretching tests are negative.
Spondylolisthesis is the anterior shift of a vertebra corpus (usually L4 or L5) on the underlying vertebra. The cause of the slipping is insufficiency or lamina fracture in the joints (congenital or degenerative). It is usually asymptomatic. However, narrowing of the spinal canal in the case of advanced listhesis may cause symptoms and signs of root pressure.
Approximately 2/100 000 patients per year of the population are admitted to the hospital for spinal trauma. Upper cervical (C1-4) trauma results in incomplete spinal cord fractures or shifts that are incompatible with life due to sudden respiratory arrest due to diaphragm and intercostal muscle paralysis. Spastic quadriparesis occurs in lesions of incomplete medulla spinalis in this area. The lesions of the lower cervical (C4-T1) region come to the vertebrae fractures and shear fractures. In these lesions, spastic quadriplegia / paresthesia patterns occur without respiratory paralysis. In spinal cord lesions over the C7 segment, the patient is often in need of care from others. Because the wrist movements can be performed in cases where the C7 segment is protected, the patient is independent to a degree.
The collapse of the thoracolumbar region is a paraplegia of spinal cord injury (paralyzed legs). These patients can survive an important independent lives with rehabilitation when upper limb strength is normal. The lesions on the T12-L1 vertebrae level may involve damage to the medullaris and cauda equina. A distal paraparesis / plegia develops with the findings of the first and second motor neurons. Typical cauda equina syndrome occurs in lesions under L1 vertebral level. The prognosis with the reason that the lumbosacral roots are more resistant to injuries in these traumas is more promising. At any level, after complete spinal lesions, there is a complete loss of motor and sensory function below the lesion level.
Hydrocephalus is defined as an increase in the amount of CSF (cerebrospinal fluid). Often the decrease in absorption occurs, rarely the result of excessive secretion. Inhibition of CSF flow or decreased absorption leads to expansion in the ventricles.
In infants and young children, the head circumference is larger than normal values, the anterior fontanel is stretched and broadly palpated, retraction of the upper eyelid, upward gaze, scaling of the scalp and enlargement of the scalp venules, unconsciousness, vomiting in a gushing manner are among the main findings of hydrocephalus. Mental retardation and developmental retardation may be the first signs of slow progressed cases.
Symptoms and signs in young and adults vary with the fixed size of cranium. Slow progressive hydrocephalus is a classic finding of sleepiness, gait disturbance, urinary incontinence. In these patients, CSF pressure may be normal (normal pressure hydrocephalus).
The spinal cord and roots move into a cystic cavity from the defect behind the spinal canal. This cavity may be covered with brain membranes and / or skin. In most patients, this cover is not complete or tears, spinal cord and roots are in contact with the external environment (myelosisis). Cerebrospinal Fluid (CSF) can leak from open lesion. Clinically, motor and sensory defect is detected on the lower extremity, mostly bladder atonic and enlargement, without anal reflex and tonus (paraplegia, paraparesis). Hydrocephalus, scoliosis, orthopedic foot deformities are detected in most cases.
The spinal cord is usually congenital in the lower thoracic and lumbar segments. A bone or cartilage protrusion generally extends between the two spinal cords in the anterior-posterior direction. In most cases, the medullaris are lower than the normal anatomical area. “tethered cord syndrome”. Because the development of the vertebral column is faster than the development of the spinal cord; spinal cord tension can lead to back and back pain, neurological findings.
Cranial bone sutures allow the cranium to expand as the brain develops during the normal development of the child. Early closure of one or more cranial papules removes suture expansion. In normally developing sutures, there is excessive development to compensate the other place. Cranial deformities eventually occur and brain development is prevented in advanced cases. Intracranial Pressure Increase Syndrome and optic nerve pressure occur. Sagittal synostosis is the most common type (50%).
Peripheral Nerve Diseases
CARPAL TUNNEL SYNDROME
The median nerve is trapped between the tendons of the transverse carpal ligament in the wrist. Carpal tunnel syndrome (CTS) is more common in women and in diabetics. Any pathology that causes increased connective tissue volume can lead to CTS; such as rheumatoid arthritis, acromegaly, hypothyroidism, amyload, pregnancy, excessive weight gain. The first symptoms are aching and pain in the forearm, hand numbness. Pain increases at nights and through doing work. In advanced cases; loss of median area sensation in the hand, loss of strength and melting in the muscles can be observed. ENMG helps in the diagnosis.
CUBITAL TUNNEL SYNDROME
The ulnar nerve can be compressed between the two heads at the starting point of the cubital tunnel at the elbow. The first symptoms are pain in the forearm and hand. In advanced cases, hand ulnar sensory loss, hand cervical hand deformity with melting in the muscles can be observed.