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34 Prophylactic Surgery forNeurosurgical Pathologies
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a
bcd
ef g
Fig. 34.16 SCM type I in an 11-year-old patient with
scoliosis and TCS.Radiological examinations show scoliosis on preoperative radiograph (a), extradural spur on
coronal, sagittal and axial CT examinations (b–d), interruption of the cord at the level of lumbar-1 on T1- and
T2-weighted sagittal and T2-weighted axial MRI views
(e–g). The patient was operated on under general anesthesia and in the prone position. Bone spur after laminectomy
34.14 Dermal Sinus Tract
was explored at the level of lumbar-1. After the bone spur
was excised, the double dura was exposed. The medial
parts of both sides were opened. Medial dura sections
were excised. Dura was planted to be one. Then, at the
L4–5 level, the thick lum was explored and cut. The
patient was very good after the operation. Subsequently,
3 months later, scoliosis surgery was performed by the
orthopedic clinic
place. In cranium, it is the occipital region. The
incidence rate is 1 in 2500–3000 live births.
Dermal sinus tract is an epithelial-lined canal
that leads to a potential union between the skin
surface and deep tissues. It is a pathology
showing congenital development. Cutaneous
portion of the tract is visible as a midline dimple. Lumbosacral region is the most common
MRI is essential to demonstrate both the extraspinal and intraspinal component of the dermal
sinus tract (Fig.34.17). If prophylactic surgery
is performed before infection, TCS or neural
compression, perfect results are obtained
[81–85].
414
ab
Fig. 34.17 Lumber
dermal sinus tract in
2-year-old girl. The
patient was admitted
with lumber purulent
pus. Neurological
examination was
normal. T1- and
T2-weighted sagittal (a,
b) MRIs show a dermal
sinus tract of lumber
midline. Dermal sinus
tract was excised
between skin and
intradural distance.
Postoperative period was
uneventful
from a failure of midline axial integration during
34.15 Spinal Lipomas
gastrulation. SCM is a rare form of spinal dysraphism [74]. Type I SCM is a split cord, in which
Lipomyelomeningoceles (spinal lipomas) are in
the occult spinal dysraphism group. It is responsible for primary tethered spinal cord syndrome.
The purpose of the treatment: It is the elimination
of the pathology that causes stretching by preventing the movement of the spinal cord in the
canal in the cranial direction. Thus, the spinal
cord is released. The best results can be obtained
with early preventive treatment surgeries
(Fig.34.18) [86–89].
each hemicord lies within a separate dural tube,
and a brous spur or a bony spur divides the spinal cord. Type II SCM refers to a split cord, in
which the two hemicords are contained within a
single dural tube, separated by a brous or cartilaginous tissue [90].
Many children with SCMs, especially when it
occurs as an isolated pathology, are born with normal or nearly normal neurologic function. The
most common skin nding is hypertrichosis.
Other skin ndings are hyperpigmentation, capillary hemangioma, dimple, dermal sinus tract,
34.16 Split Cord Malformation
lipoma. Open spinal dysraphism may accompany.
Orthopedic deformities, such as foot deformities,
Split cord malformation (SCM), also refered to
as either diastematomyelia, double cord malformation or diplomyelia, is believed to occur due to
a failure in gastrulation preceding neural tube
closure. Pang etal. [90] suggested that SCM is
caused by an ontogenetic error that occurs when
the primitive neurenteric channel is closed. Dias
and Walker [69] suggested that SCM developed
leg-length discrepancy, pes cavus, talipes equinovarus, pes planus, scoliosis, kyphoscoliosis, are
quite common. SCM is seen in approximately 5%
of patients with congenital scoliosis or kyphoscoliosis. Radiological procedures used for the diagnosis of SCM are spinal X-ray, ultrasound, CT
scan, myelo-CT and MRI (Fig.34.19). In addition
to scoliosis, spina bida, vertical laminar fusion,
N. Yüceer
ab
34 Prophylactic Surgery forNeurosurgical Pathologies
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Fig. 34.18 Lumber
lipomyelomeningocele
in a 25-year-old woman.
The patient presented
with low back pain.
Neurological
examination was
normal. Spinal T1- and
T2-weighted MRI
examinations showed
lumber intradural lipoma
(a, b). Spinal cord was
released by removing
the lipoma with
prophylactic surgery.
There was no problem
after the operation
415
fused vertebral bodies, split vertebral body, scoliosis, kyphoscoliosis, fused or deformed spinous
processes, bid lamina, block vertebra, buttery
vertebra and accessory lamina can be detected in
direct vertebral radiographs. Before MRI,
myelography and CT myelography were successfully used. Three-dimensional CT is especially
useful in imaging of type I malformation and
accompanying scoliosis. With the widespread use
of MRI, there has been an increase in SCM diag-
useful for follow-up periods. The most common
level of septum is lumbar and thoracolumbar vertebrae. It is rarely seen in the cervical region. It is
usually associated with Klippel-Feil syndrome.
The degree of scoliosis increases with advancing
age. Prophylactic surgical treatment is recommended before neurological symptoms, and signs
appear in patients with SCM.Prophylactic surgical treatment provides very good results. Surgical
complication is very low [91–103].
noses. While MRI provides detailed information
about SCM, it also provides detection in concomitant pathologies, such as hydromyelia.
34.17 Chiari Malformation
Ultrasonography helps diagnosis during intrauterine and newborn periods. In the preoperative
period, somatosensory-evoked potentials and urodynamic studies should be performed. This can be
Chiari malformations (CMs) represent a group of
anomalies characterized by descent of the cerebellar tonsils or vermis into the cervical spinal
416
ab c
N. Yüceer
def
Fig. 34.19 Scoliosis and syringomyelia in a 17-year-old
patient with SCM type I. Spinal sagittal and axial CT
scans (a–c) and three-dimensional (3D) CT examination
(d) demonstrate spinal fusion at the L1, L2, L3 levels (a),
bone spur at the L2 level of SCM type I (b, c), thoraco-
canal. Chiari type I malformation is a congenital
hindbrain anomaly characterized by downward
displacement of the cerebellar tonsils through the
foramen magnum. Chiari type I is the most common CM. It is estimated to occur in approximately every 1in 1000 births. This is an adult
type and tends to be diagnosed in the second or
third decade of life. The most common clinical
symptom is headache, especially localized in the
lumbar scoliosis (d). T2-weighted sagittal and axial MRIs
show syringomyelia at the thoracal-12 level (e), double
spinal canal of SCM type I (f). Prophylactic surgical intervention for type I SCM was performed. Postoperative
period had no problems
suboccipital region. The most accompanying
pathology of CM is syringomyelia (Fig.34.20).
Type II is an associated meningomyelocele. Type
III has the features of type II with an additional
herniation of the entire cerebellum through the
bony defect involving the foramen magnum,
forming an encephalocele. Type IV is a form a
cerebellar hypoplasia. The most valuable diagnostic methods for diagnosis are MRI and CSF
34 Prophylactic Surgery forNeurosurgical Pathologies
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417
Fig. 34.20 CM and
syringomyelia in a
6-year-old male. The
patient was admitted due
to headache.
Neurological
examination was
normal. Preoperative
T1- and T2-weighted
MRI examinations (a, b)
show Chiari type I
malformation associated
with cervical
syringomyelia.
Craniocervical
decompression and
duraplasty were
performed in the prone
position under general
anesthesia. He had no
problems after surgery
a b
ow MRI. The commonly used method in the
treatment is craniocervical decompression and
duraplasty. Preventive surgical treatment without
developing clinical ndings provides very good
results [104–108].
34.18 Arachnoid Cysts
Arachnoid cysts are the most common intracranial cysts and make up 1% of all intracranial
space-occupying lesions. We can divide arachnoid cysts into congenital and acquired arachnoid
cysts. Congenital (real) arachnoid cysts are
formed during the early embryonic formation of
the primitive arachnoid membrane. Acquired
arachnoid cysts develop as a result of trauma,
hemorrhage, chemical irritation, tumor or inammatory events after the cerebrospinal uid is
trapped in the arachnoid scar tissue. They can be
asymptomatic, as well as cause headache, vomiting, hydrocephalus ndings, endocrinological
disorders, focal neurological ndings, seizures
and cerebellar ndings in posterior fossa cysts.
Arachnoid cysts that tend to be symptomatic are
treated with prophylactic surgical treatment
methods [109–114] (Fig.34.21).
34.19 CyberKnife Radiosurgery
forBrain Tumors
CyberKnife radiosurgery can sometimes be applied
as an additional treatment option in both benign
and malign brain tumors. It can be preferred for
tumors with critical localization and less than 3cm
in size. Vestibular schwannomas, meningiomas,
pituitary adenomas, primary and metastatic malign
brain tumors are the most preferred brain tumors in
CyberKnife radiosurgery [115–131] (Fig.34.22).
In addition to brain tumors, CyberKnife radiosurgery is used as the primary or additional treatment
in the treatment of cerebral AVMs [132, 133].
34.20 Conclusion
The prophylactic surgical treatment results in neurosurgical diseases are usually good if appropriate
patient selection is made. The number of neurosurgical diseases that can be planned for prophylactic
surgery is many. Prophylactic surgical treatment
should be planned without delay after diagnosis in
cerebral aneurysms, tumors, hydrocephalus, congenital and degenerative diseases that have a
severe pressure effect on neural tissues.
418
gh
abc
N. Yüceer
Fig. 34.21 Left frontoparietal arachnoid cyst in an
11-year-old girl. The patient presented with a headache
complaint. Neurological examination was normal.
Preoperative CT scan (a) and T1-weighted axial MRI (b)
examinations demonstrate a arachnoid cyst in the left
a
bc d
ef
frontotemporal localization. A cystoperitoneal shunt was
placed in the patient under general anesthesia. The patient
was good after the operation. Arachnoid cyst was smaller
in the CT examination 3months later (c)
Fig. 34.22 Right vestibular schwannoma in a 60-yearold woman. The patient was admitted with hearing loss on
the right side for 4 years. T1- and T2-weighted axial
MRIs, and T1-weighted axial and coronal with contrast
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