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Introduction: Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is still controversial. We therefore analyzed the comatose patients diagnosed as having spontaneous SICH and treated by surgery. Materials and Methods: We retrospectively analyzed the collected data of 25 comatose patients with initial Glasgow Coma Scale (GCS) ≤ 8 diagnosed as having spontaneous SICH and they had been treated by surgical evacuation between 1996 and 2008. The outcome was assessed using Glasgow outcome scale (GOS). The side and location of the hematoma and ventricular extension of the hematoma were recorded. The hematoma volume was graded as mild (60 cc). Results: Age of the patients ranged from 25 to 78 years (mean: 59.6 ± 15.14 years). Among the 25 patients studied, 11 (44%) were females and 14 (56%) were males. GCS before surgery was P = 0.017). Income GCS (iGCS), however, did not affect GOS (P = 0.64). The volume of the hematoma also affected the outcome (P = 0.037). Ventricular extension of the hematoma did affect the oGCS and GOS (P = 0.002), but not the iGCS of the patients (P = 0.139). Conclusion: Our data suggest that being surgically oriented is very important to achieve successful outcomes in a select group of patients with SICH.

Scientific BACKGROUND: Paget’s disease is mostly asymptomatic. Neurological syndromes are uncommon but include headache, dementia, brain stem and cerebellar dysfunction, cranial neuropathies, myelopathy, cauda equina syndrome and radiculopathies. While she was in a symptomatic treatment by the diagnosis of cluster headache, our case was hospitalized to our clinic and reported after diagnosed cranial Paget’s disease according to the results of clinical, radiological and laboratory findings. OBJECTIVES: In our case of cluster headache, we aim to discuss the headaches that have different characters and the other properties due to Paget’s disease. RESULTS: While 61 year old female case was in the medical treatment of cluster headache, she was examined by the complaints of headache that was constant and localized on the right orbito-frontal region, tinnitus and hearing loss. On neurological examination, in addition to headache, she had mixed type hearing loss in the right ear, but sensorineural hearing loss in the left ear. Alcaline phosphatase levels were high in the serum and hydroxyprolin levels were high in the urine. In the cranial radiography, there was diffused osteoporosis, circumscripta, osteolytic areas, sclerosis in petrous bone, increasing diploe spaces in the skull base and diffuse cotton wool rough granular osteolytic spaces in the right lower part of frontal bone and basilar invagination. There was an appearance of bone-within-bone without any symptom in L2-L3 vertebrae. In her bone scintigraphy, other bones were normal but osteoblastic activity involvements in the head bones. After all the examinations of the headache, we thought that it was originated from two different causes like cluster headache and cranial Paget’s disease. CONCLUSION: In Paget’s disease, cranial headaches are intermittent in early stages and may be confused by the primary headaches. In late stages, it is violent and continuous. Cranial headaches are due to different causes as cluster headache associated with cranial Paget’s disease like our case. We wanted to emphasize the other etiologic causes to be considered in cranial headaches

Study Design: Analysis of the patients with spinal missile injury (SMI). Objective: Choosing the optimum treatment for SMI with respect to bullet trajectory, evaluation of surgical indications, and timing of surgical intervention. Summary Of Background Data: A few guidelines were reported for the management of SMI. But there is still no consensus about the indication and timing of the surgery. The relationship between the surgery and bullet trajectory was not reported previously. Methods: One hundred twenty-nine patients with spinal missile injury were admitted to our department from 1994 to 2006 and 122 of them could be functionally monitored. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Surgical indications were discussed. The injuries were classified with respect to the bullet's trajectory. Seventy-four patients were treated surgically, of whom 60 (81%) had incomplete injuries. All 17 patients whose vertebral column was injured with side-to-side trajectory were operated on because of instability. Results: In the surgical group, 33 (56.9%) showed improvement, 20 (34.5%) showed no change, and 5 (8.6%) worsened. The best results were obtained by the patients who received operations because of rapid neurologic decline, compression, and instability in the spinal canal (P < 0.0001). Twenty-three (31%) complications and associated injuries were seen in the surgically treated patients and 18 (34.6%) were seen in the conservatively treated patients. Conclusion: Anteroposterior and oblique trajectories [Gulhane Military Medical Academy (GATA)-SMI I and GATA-SMI II] of SMI must be recognized as highly infective in the lumbar region. A side-to-side trajectory (GATA-SMI III) missile causing spinal cord injury is unstable and needs further stabilization. The spinal cord is not injured by the GATA-SMI IV trajectory, and thus, the best approach in this case is conservative. The best results from neurosurgical interventions may be achieved after rapid neurologic deteriorations because of spinal compression and/or instability. [ABSTRACT FROM AUTHOR]

Background: Epidural steroid injection is widely used to treat the short and long-term symptoms of low back and radicular pain. To the best of our knowledge, the influence of transforaminal epidural steroid injection (TFSI) combined with caudal epidural steroid injection (CESI) on pain intensity, patient satisfaction, and quality of life in lumbar radiculopathy has not been examined., Aim: To evaluate the short and long-term efficacy of TFSI, and TFSI combined with CESI (TFSI + CESI) in patients with lumbar radiculopathy., Materials and Methods: We retrospectively examined the records of 104 patients with lumbar radicular pain and L4/5 and/or L5/S1 intervertebral disc disease who underwent TFSI or TFSI + CESI. We compared the pain intensity using a Visual Numeric Scale (VNS), North American Spine Society (NASS) pain satisfaction index, and EuroQol five dimensions (EQ-5D) quality of life scores before intervention, and after 1, 6 and 12 months., Results: In the TFSI group, the mean pre-treatment VNS score was 9.2, which improved to 4.9 after 1 month and to 7.2 after 12 months. In the TFSI + CESI group, the mean pre-treatment VNS score was 9.4, which improved to 2.6 and 4.6 after 1 and 12 months, respectively. Improvement in the VNS scores was significantly higher in the TFSI + CESI group (P < 0.0001 for each). Mean EQ-5D quality of life index in the TFSI group improved from 0.59 in the pre-treatment phase to 0.76 after 12 months of intervention, while it improved from 0.62 in the pre-treatment phase to 0.84 at 12 months of intervention in the TFSI + CESI group. The EQ-5D scores were significantly better in the TFSI + CESI group at 1, 6, and 12 months after the procedure (P = 0.004, 0.036, and 0.042, for 1, 6, and 12 months, respectively). The NASS scores were significantly better in the TFSI + CESI group at 6 and 12 months after the intervention (P = 0.025 and 0.001 for 6 months and 12 months, respectively)., Conclusion: In patients with lower lumbar radiculopathy, a combined TFSI + CESI technique offers superior short and long-term pain relief, quality of life, and long-term patient satisfaction, than when TFSI is performed alone.

Aim: Delayed ischemic neurological deficit (DIND) and cerebral vasospasm (CV) remain the most common and debilitating neurological complications following aneurysmal subarachnoidal hemorrhage (SAH). Many reports demonstrate the importance of proanthocyanidins (PR) on the vascular system, including endothelium-dependent relaxation of blood vessels. These effects of PR on the cerebral vascular system were examined in this study. < p < MATERIAL and METHODS: Fifty-two adult Sprague-Dawley male rats were used for the experimental double hemorrhage model. They were divided to control, sham, pre- and post-interventional treatment groups. 100 mg/kg PR was administered for the treatment for respect to groups. Basilar artery diameter (BAD) and arterial wall thickness were measured and the apoptosis ratio of the endothelial cells was calculated. Arterial walls were examined electron microscopically (EM)., Results: There were significant differences between the groups except control and pre-SAH (p=0.37) and post-SAH and pre- SAH groups (p=0.15) with respect to BAD. According to arterial wall thickness, apoptosis ratio, and grading, there were significant differences between the groups except control and pre-SAH (p=0.85, p=0.49 and p=0.18 respectively) and SAH and post-SAH (p=0.08, p=0.21 and p=0.24 respectively) groups. EM findings revealed that pro-apoptotic and pro-necrotic degenerated endothelial cells with seldom vacuolization in post-SAH treatment group which were more serious in SAH group., Conclusion: Pre-SAH administration of PR induces better vasodilatation and protection of basilar artery (BA) from vasospasm (VS), which could yield neuroprotective and vasodilatator effects. In addition, PR appears to be involved in relieving oxidative damage, with an antioxidant-antiapoptotic-antinecrotic effect that may contribute to vascular dilation.

Aim: Intervertebral disc degeneration can cause severe low back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption unresponsive to conservative medical care. We aimed to evaluate 12-month pain and functional outcomes and predictors of clinical success in patients with discogenic back pain treated with IDET with respect to the Dallas Discogram Scale (DDS)., Material and Methods: This was a retrospective analysis of patients undergoing IDET for low back pain from 2009 through 2014 at Baskent University, Department of Neurosurgery. A total number of 120 consecutive patients data were collected retrospectively. The degree of disc degeneration was graded using the DDS during discography, and the presence of a high intensity zone (HIZ) on magnetic resonance (MR) imaging was noted. The primary outcome measure was assessment of back pain severity based on the Visual Analogue Scale (VAS); function was assessed by the Oswestry Disability Index (ODI). Follow-up examinations for ODI and VAS scores were assessed at 1, 6, and 12 months post-treatment. Outcomes were discussed with respect to morphological changes in intervertebral discs on discogram., Results: There was an average 57.39% and 47.16% improvement in VAS and ODI scores, respectively, between pretreatment and 12 months follow-up (p < 0.0001 for both comparisons). Predictors of 12-month clinical success was depended on DDS (p < 0.0001), a HIZ on MR imaging (p < 0.0001)., Conclusion: Durable clinical improvements can be realized after IDET in select surgical candidates with mild disc degeneration and HIZ, discography, and low-grade DDS, with more effective treatment results.

Aim: Conjoined nerve roots (CNR) can be damaged during lumbar disc surgery and lead to neuropathic pain due to excessive retraction. The purpose of this study was to investigate the factors that facilitate the identification of CNRs that can lead to the loss of fragments in the secondary axilla, nerve root injury or unpleasant surprises during lumbar disc surgery. Accordingly, we aimed to measure the thicknesses and exit angles of the nerve roots close to the pedicle to obtain scientific data regarding rare double roots., Material and Methods: The data of 612 patients who were operated for lumbar disc disease in our hospital between 2012 and 2014 were reviewed retrospectively. Twenty one cases of CNR were detected in this series., Results: The mean nerve root thickness was 1.92 ± 0.45 mm for medially located roots and 3.33 ± 0.95 mm for laterally located roots. The comparison of medially located roots versus laterally located roots revealed a significant difference in mean values (p < 0.0001). The mean exit angle was 12.290± 4.890 for medially located roots, and 22.110 ± 5.420 for laterally located roots (p < 0.0001). In addition, the exit angles of the medially and laterally located roots increased as going down to caudal levels, (p=0.005, p=0.042)., Conclusion: CNRs are congenital anomalies that are usually diagnosed during the surgical procedure and affect the success of discectomy. The presence of a more medially located or thinner root during surgical exploration and the absence of the fragment in the axilla in extruded or sequestered discs usually indicate a conjoined nerve root closer to the pedicle.

Background: Though traumatic posterior fossa epidural hematoma (PFEDH) is rare, the associated rates of morbidity and mortality are higher than those of supratentorial epidural hematoma (SEDH). Signs and symptoms may be silent and slow, but rapid deterioration may set in, resulting in death. With the more frequent use of computed tomography (CT), early diagnosis can be achieved in patients with cranial fractures who have suffered traumatic injury to the posterior fossa. However, some hematomas appear insignificant or are absent on initial tomography scans, and can only be detected by serial CT scans. These are called delayed epidural hematomas (EDHs). The association of EDHs in the supratentorial-infratentorial compartments with linear fracture and delayed EDH (DEDH) was presently investigated., Methods: A total of 212 patients with SEDH and 22 with PFEDH diagnosed and treated in Göztepe Training and Research Hospital Neurosurgery Clinic between 1995 and 2005 were included. Of the PFEDH patients, 21 underwent surgery, and 1 was followed with conservative treatment. In this group, 4 patients underwent surgery for delayed posterior fossa epidural hematoma (DPFEDH)., Results: Mean age of patients with PFEDH was 12 years, and that of the patients with SEDH was 18 years. Classification made according to localization on cranial CT, in order of increasing frequency, revealed of EDHs that were parietal (27%), temporal (16%), and located in the posterior fossa regions (approximately 8%). Fracture line was detected on direct radiographs in 48% of SEDHs and 68% of PFEDHs. Incidence of DPFEDH in the infratentorial compartment was statistically significantly higher than incidence in the supratentorial compartment (p=0.007). Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p<0.05)., Conclusion: DPFEDH, combined with clinical deterioration, can be fatal. Accurate diagnosis and selection of surgery modality can be lifesaving. The high risk of EDH development in patients with a fracture line in the posterior fossa on direct radiographs should be kept in mind. These patients should be kept under close observation, and serial CT scans should be conducted when necessary.

The authors report a case of a 69-year-old woman who presented with a spontaneous spinal epidural hematoma (SSEH) 10 days after a total hip arthroplasty. The patient had been receiving 10 mg/d of rivaroxaban for 5 days for venous thromboembolism prophylaxis. She had a sudden onset of severe neck pain, followed by quadriplegia below C4. A dorsal SSEH was revealed by computed tomography. While preparing for the emergency evacuation of the SSEH, the neurological symptoms resolved spontaneously in 4 hours. The 1-month follow-up magnetic resonance imaging confirmed that the SSEH had completely resolved. The pathogenesis of SSEH is unclear, but anticoagulant therapy is a known risk factor. It is a relatively rare disorder. Only 1 case of SSEH has been reported, and that patient was receiving a nonsteroidal anti-inflammatory drug besides rivaroxaban, which is another known risk factor for bleeding disorders. [Orthopedics. 2016; 39(3):e558-e560.]., (Copyright 2016, SLACK Incorporated.)

Aim: Surgical anatomy concerning the posterior craniovertebral region in fresh human cadavers was studied to provide most accurate information for the surgical approach., Material and Methods: In thirty-two fresh human cadavers, the distance from the posterior tubercle to the sulcus of vertebral artery (VA), the thickness and length of the third segment of VA (V3), the distance of C1/C2 facet to V3, the length, height and shape of the C2 ganglion to the neighboring structures, the distance from medial border of C1 lateral mass to dura mater, the distance of the transverse process of atlas to mastoid tip, the thickness of C1 posterior arcus were measured., Results: There were variations of sulcus of VA in 14 of 32 cadavers (43.7%), the right VA was larger in 23 cadavers (71.8%). The ganglion was found over the C1 lateral mass screw entry point in 45 of 64 ganglions (70.31%) and below the screw entry point in 19 of 64 ganglions (29.69%). The distance of the medial border of the C1 lateral mass to dural tube was 3.81±0.55 mm at the right side and 3.91±0.59 mm at the left. The thickness of C1 posterior arch was 3.73±0.75 mm at the right side and 3.75±0.77 mm at the left. The mean distance from the transverse process of C1 to the mastoid tip was 15.82±4.49 mm at the right side and 15.46±4.38 mm at the left., Conclusion: This is the most comprehensive and only fresh cadaver study about this region in the literature.

Study Design: Analysis of the adjacent-segment fractures in 171 balloon kyphoplasty (BK)-performed patients., Objective: The purpose of this study was to investigate the risk factors for new symptomatic vertebral compression fractures (VCF) after BK., Summary of Background Data: Although there are many studies about the incidence and possible risk factors for occurrence of adjacent-level fractures, there is no consensus on the increased risk of adjacent-level fractures after BK., Methods: We performed a retrospective analysis of 171 patients treated with percutaneous kyphoplasty. The follow-up period was 41.04±21.78 months. The occurrence of new symptomatic VCF was recorded after the procedure. We evaluated the variables of patient age and sex, the amount of injected cement, the initial kyphotic angle (KA) of VCF, the change of the KA after BK, the severity of osteoporosis, and the percentage of height restoration of the vertebral body. Furthermore, possible risk factors were reported for new symptomatic VCFs., Results: The only 2 factors identified as being significantly associated with adjacent-level fractures were the sex (P=0.001) of the patient and the preoperative KA (P=0.013). The patients with new symptomatic compression fracture had higher initial KA than those without fractures. The female group had higher risk than the male group in occurrence of the new vertebra fractures. The severity of the osteoporosis (low bone mineral density) was not a determinant in occurrence of the new VCF after BK., Conclusions: If the patients experience severe or mild back pain with higher preoperative KA, especially in the first 2 months, then they deserve detailed radiologic examination. To avoid subsequent fracture in the same or adjacent level, vertebral body should be filled adequately and sagittal balance should be obtained with KA correction. BK alone did not influence the incidence of subsequent VCF.

Aim: This study was aimed to investigate the variations in the spinal nerve root compositions of musculocutaneous nerve and to confirm which spinal nerve root is the main ingredient in participating amount., Material and Methods: A total of 20 fresh cadavers were dissected. Brachial plexus and its branches were extracted. Musculocutaneous nerve stump was traced back to the roots to identify its fascicular origin. The number of fascicles originating from a particular nerve root and their axial location with in the nerve were noted., Results: The most frequent type of spinal nerve compositions of musculocutaneous nerve was C5, C6, and C7 with incidence of 60%. Musculocutaneous nerve had bundles from C5 root in all specimens, 90% of the specimens had contribution from C6 and only 70% of them had bundles from C7 root. There were a total of 46 (37.7%) bundles in C5 fascicles, 48 (39.3%) bundles in C6 fascicles, and 28 (22.9%) bundles in C7 fascicles., Conclusions: In electrophysiological studies it should be remembered that C7 or C6 lesions may not impair musculocutaneous nerve functions. The success of musculocutaneous nerve neurotization may be improved if care is taken to ensure whether or not C7 root is contributing to the musculocutaneous nerve.

Study Design: Clinical study., Purpose: The dimensions of the working zone for endoscopic lumbar discectomy should be evaluated by preoperative magnetic resonance images. The aim of this study was to analyze the angle of the roots, root area, and foraminal area., Overview of Literature: Few studies have reported on the triangular working zone during transforaminal endoscopic lumbar discectomy. Many risk factors and restrictions for this procedure have been proposed., Methods: Images of 39 patients were analyzed bilaterally at the levels of L3-L4 and L4-L5. Bilateral axial and coronal angles of the roots, root area, and foraminal area were calculated., Results: No significant difference was observed between the axial angle of the left and right L3 root. A significant difference was found between the axial angle of right and left L4 roots. A significant difference was observed when the coronal angle of the right and left L3 roots were compared, but no significant difference was found when the coronal angle of the right and left L4 roots were compared. No significant difference was observed when the foraminal area of the right and left L3 and L4 roots were compared, but a significant difference was observed when the root area of right and left L3 and L4 roots were compared., Conclusions: We suggest that these radiological measurements should be obtained for safety reasons before endoscopic discectomy surgery.

Risk factors for recurrent shunt-related cerebrospinal fluid (CSF) infections were analyzed. A total of 58 children were treated for initial shunt infections (ISI): all children were treated with antibiotics and CSF drainage, either by removal of the shunt system and insertion of an external ventricular drainage (EVD) catheter (44 children, 75.9%) or by externalization of the existing ventricular catheter (14 children, 24.1%). Recurrent shunt infections (RSI) were detected in 15 children: nine had been treated with shunt removal and insertion of a new EVD catheter and six had been treated with externalization of the existing ventricular catheter. There was a statistically significant increase in the number of RSI in children treated with externalization of the existing ventricular catheter. Thus, to reduce the risk of RSI, total shunt removal and insertion of a new EVD catheter is preferred., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Aim: To evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) for lumbar radiculopathy with respect to effect of injection levels, gender, and age group., Material and Methods: Hundred-fifty-three consecutive patients who underwent to lumbar TFESI were enrolled. The outcomes were measured by using a visual numeric scale (VNS), NASS and EQ-5D. The relationship between possible outcome predictors and the therapeutic effect were evaluated., Results: All the patients completed the 2nd year follow-up visits. Significant differences were observed between the pre-procedure and post-procedure VNSs, NASS patients' satisfactions scores and EQ-5D (P < 0.01) except 1st and 2nd year follow-up (P=0.12, P=0.27and P=0.19 respectively). Gender (higher in female patients) showed significant effect to pre-procedure VNS (P=0.04). An increase in the level number was significantly associated with an increase in the 6th month (P=0.005, P=0.004 respectively) and the 1st year (P=0.05, P=0.029 respectively) NASS and EQ-5D. No complication was occurred except discitis in two chronic renal failure patients., Conclusion: Especially in the patients with severe co-morbidities TFESI is an option to provide higher life quality. The clinical course of the success of the TFESI decreases in one year and becomes stable thereafter. In the patients with immune deficiency, the practitioners should always be aware for an infectious complication.

Aim: The study was conducted to compare the clinical effectiveness of FJ injections (FJI) and FJ radiofrequency (FJRF) denervation in patients with chronic low back pain., Material and Methods: This study included 100 patients; 50 in FJI 50 in FJRF group. VNS, NASS and EQ-5D were used to evaluate the outcomes. All outcome assessments were performed at baseline, 3 months, 6 months and 12 months., Results: FJI in early post-op but FJRF in 1st, 6th and 12th month VNS showed better results (p < 0.001). There was no significant difference in the 1st (p=1) and 6th month (p=0.13) but in 12th month (p=0.04) in NASS. Increase in level number showed positive effect in NASS in FJRF group (p=0.018) but no effect in FJI group (p=0.823) in the 12th month follow-up. There was no significant difference with respect to 1st month (p=0.17), 6th month (p=0.22) and 12th month (p=0.11) post-procedure follow-ups in EQ-5D. At the short term FJI was more effective than FJRF however in midterm follow-up FJRF had more satisfying results than FJRF., Conclusion: To our knowledge, the first choice should be the FJI and if pain reoccurs after a period of time or injection is not effective, RF procedure should be used for the treatment of chronic lumbar pain.

Object: The aim of this study was to evaluate the results and effectiveness of bilateral decompression via a unilateral approach in the treatment of lumbar degenerative spondylolisthesis (DS)., Methods: Operations were performed in 84 selected patients (mean age 62.1 ± 10 years) with lumbar DS between the years 2001 and 2008. The selection criteria included lower back pain with or without sciatica, neurogenic claudication that had not improved after at least 6 months of conservative treatment, and a radiological diagnosis of Grade I DS and lumbar stenosis. Decompression was performed at 3 levels in 15.5%, 2 levels in 54.8%, and 1 level in 29.7% of the patients with 1 level of spondylolisthesis. All patients were followed up for at least 24 months. For clinical evaluations, a visual analog scale, Oswestry Disability Index (ODI), and Neurogenic Claudication Outcome Score (NCOS) were used. Spinal canal size and (neutral and dynamic) slip percentages were measured both pre- and postoperatively., Results: Neutral and dynamic slip percentages did not significantly change after surgery (p = 0.67 and p = 0.63, respectively). Spinal canal size increased from 50.6 ± 5.9 to 102.8 ± 9.5 mm(2) (p < 0.001). The ODI decreased significantly in both the early and late follow-up evaluations, and good or excellent results were obtained in 64 cases (80%). The NCOS demonstrated significant improvement in the late follow-up results (p < 0.001). One patient (1.2%) required secondary fusion during the follow-up period., Conclusions: Postoperative clinical improvement and radiological findings clearly demonstrated that the unilateral approach for treating 1-level and multilevel lumbar spinal stenosis with DS is a safe, effective, and minimally invasive method in terms of reducing the need for stabilization.

Objective: To analyze functioning and nonfunctioning pituitary adenomas (PAs)>3 cm, with special emphasis on preoperative and postoperative visual functions., Methods: The cases consisted of 49 women and 54 men with mean age of 43.2 years (range 19-66 years). All cases had a macroadenoma >3 cm in diameter. The transsphenoidal approach was performed in 117 procedures, and the transcranial approach was performed in 8 procedures. Radical tumor excision was achieved in 50 of 103 patients. Postoperative evaluation was done in 88 patients. Preoperative and postoperative visual acuity, visual field, and ocular fundi and their relationship with the pattern and duration of the symptoms and the size of the tumor were evaluated., Results: Normalization of visual acuity was obtained in 71.5% of patients, improvement occurred in 13.6%, symptoms persisted in 13.6%, and symptoms worsened in 1%. Postoperative improvement of visual field defects (VFDs) was observed in 74.1% of patients, and visual impairment score improved postoperatively in 92% of patients. Patients operated on <6 months before the onset of vision loss had better and more sustained visual improvement. One patient died, and 15.5% of patients experienced surgery-related complications., Conclusions: This study shows that patients with severe visual impairment may have remarkable improvement if surgical decompression is done early. The transsphenoidal approach should be performed to correct the patient's visual impairment and to relieve the pressure on the optic apparatus caused by macroadenoma of any size., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To determine the suitability of the application of dynamic stabilization (DS) as a nonfusion technique to address dysfunctional segmental motion (DSM) in the lumbar spine., Methods: Over a 1-year period, 25 patients were treated with the same assessment and surgical protocol. Inclusion criteria were clinical presentation of DSM with or without stenosis. On preoperative and postoperative plain anteroposterior, lateral, and lateral flexion-extension radiographs, anterior and posterior disc height (DH); anteroposterior diameter of the disc; and global, segmental, apical segment, and below level lordotic angles (LAs) were measured., Results: The study included 9 women and 16 men with a mean age of 43.48 years ± 7.6. On average, patients had symptoms for 38.04 months ± 29.6, and mean follow-up was 12.36 months ± 3.46. The average height of anterior, posterior, and mean intervertebral discs increased significantly (P = 0.002, P = 0.003, and P < 0.0001). There were no significant differences between the preoperative and postoperative global, segmental, apical segment, and below segment LAs in flexion, extension, and neutral positions. At mid-term follow-up, no patients showed new signs of degeneration at the adjacent motion segment., Conclusions: Overall, the limited radiologic data advocate DS as a nonfusion technique in the treatment of DSM in the lumbar spine. Long-term follow-up is essential, however, to investigate the long-term efficacy of DS in the surgical treatment of DSM., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Object: The purpose of this study was to compare the methods of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in cases of isthmic Grades 1 and 2 lumbar spondylolisthesis, and to evaluate the clinical efficacy of the procedures., Methods: Operations were performed in 50 patients with lumbar spondylolisthesis in the authors' clinics between 2001 and 2007. Indications for surgery were low-back pain with or without sciatica and neurogenic claudication that had not improved after at least 6 months of conservative treatment. The study included 33 female and 17 male patients, with mean ages of 50.6 years in the PLIF group and 47.3 years in the PLF group. These patients were randomly allocated into 2 groups: decompression, posterior transpedicular instrumentation, and PLF (Group 1; 25 patients) and decompression, posterior transpedicular instrumentation, and PLIF (Group 2; 25 patients). In the PLIF group, titanium cages were used, and autograft material was obtained from the decompression. In the PLF group, bone fragments collected from the iliac crest were used as autografts. A minimum 18-month follow-up was available in all patients. For clinical evaluation, a visual analog scale, Oswestry Disability Index, and the 36-Item Short Form Health Survey were used. Improvements in pre- and postoperative spondylolisthesis, segmental angles, fusion ratios, and postoperative complications were evaluated radiologically., Results: The average follow-up period was 3.3 years. Based on the etiologies, isthmic spondylolisthesis was detected in all patients. The spondylolisthesis levels in the patients who underwent PLIF were located at L3-4 (5 patients, 20%); L4-5 (14, 56%); and L5-S1 (6, 24%), whereas the levels in the ones treated with PLF were located at L3-4 (4 patients, 16%); L4-5 (13, 52%); and L5-S1 (8, 32%). In the clinical evaluations, good or excellent results were obtained in 22 (88%) cases in the PLIF group and 19 (76%) cases in the PLF group. Fusion ratios were 100% in the PLIF group and 84% in the PLF group. Both lumbar lordosis and the segmental angle showed greater improvement in the PLIF group. There was no difference in the complication rates for each group., Conclusions: Based on early clinical outcomes and the fusion ratios of adult isthmic spondylolisthesis, the authors found PLIF to be superior to PLF.

Aim: The aim of this study was to determine the relationship between ischemic neurodegeneration, of the petrosal ganglion of the glossopharyngeal nerve, and BP fluctuations, after subarachnoid hemorrhage (SAH)., Material and Methods: Twenty-four rabbits had their blood pressure and heart rhythms studied daily over 20 days. Then, the histopathology of the petrosal ganglion was examined in all animals. Normal and apoptotic neuron density of the petrosal ganglion and blood pressure values were compared statistically., Results: Mean total volume of the petrosal ganglia was calculated as 0.9 ± 0.34/mm3. BP level of control group was 96.1 ± 2.1 mmHg; 116.5 ± 4 mmHg of mild hypertension (HT) group and 128.1 ± 3.6mmHg in the severe HT group. When the groups were compared to each other they were significantly different. The level of normal-apoptotic neuron in control group was 11,240 ± 802/mm³ -40 ± 6.3/mm³; 9730 ± 148.7/mm³ - 1560 ± 256.2/mm³ in the mild HT group and 6870 ± 378.8/mm³-4240 ± 628.2/mm³ in the severe HT group. When the groups were compared to each other there was significantly difference., Conclusion: Blood pressure variability observed in this study may be explained by ischemic neurodegeneration of petrosal ganglia caused by SAH. The results of this study suggest that petrosal ganglion ischemia has potential implications for the development of hypertension. These findings suggest that new treatment strategies should be considered for the treatment of SAH.

Aim: Cancers that metastasize to the cauda equina are uncommon. Only seventeen cases were reported. Those from pulmonary squamous cell carcinoma was never been published to our knowledge., Material and Methods: A 79-year-old male patient presented with low back pain since 1 year and severe sacral pain irradiating to the left leg, paraparesis, urinary dysfunction and leg weakness since one week., Results: Preoperative magnetic resonance images of the lumbar spine showed an intradural spinal mass in L2-3 with infiltration of the cauda equina; the lesion measured 13 mm craniocaudally and 11 mm anteroposteriorly, and thus occupied the majority of the intrathecal space at that level. The magnetic resonance images, surgical treatment, and related pathophysiology are reviewed., Conclusion: The majority of cauda equina tumors are primary tumors, and metastases are very rare. Especially old patients with intradural mass and rapidly progressive cauda equina syndrome should be evaluated for a primary malignancy to avoid an unnecessary spinal operation.

Carpal tunnel syndrome (CTS) is a common focal peripheral neuropathy. Increased pressure in the carpal tunnel results in median nerve compression and impaired nerve perfusion, leading to discomfort and paresthesia in the affected hand. Surgical division of the transverse carpal ligament is preferred in severe cases of CTS and should be considered when conservative measures fail. A through knowledge of the normal and variant anatomy of the median nerve in the wrist is fundamental in avoiding complications during carpal tunnel release. This paper aims to briefly review the anatomic variations of the median nerve in the carpal tunnel and its implications in carpal tunnel surgery.

Study Design: Retrospective analyses of 50 patients with lumbar facet syndrome treated with lumbar facet joint neurotomy., Objective: To establish the efficacy of lumbar facet joint neurotomy under optimum conditions in selected patients., Summary of Background Data: With the realization of the significance of facet joints in the etiology of chronic low back pain over the last decade, many studies were conducted about various methods of treating the facet joint syndrome., Methods: Fifty patients with lumbar facet syndrome with at least 80% pain relief by controlled, diagnostic medial branch blocks underwent lumbar facet joint neurotomy. Before surgery, all were examined carefully both clinically and radiologically and evaluated by visual analog scale (VAS) and descriptive system of health-related quality of life state (EQ5D) measures of pain, disability, and treatment satisfaction. All outcome measures were repeated postoperatively and at 12 months after surgery., Results: Of the 50 patients 35 were females and 15 were males with a mean age of 51.82±16.99 years. One level was treated in 26 patients, 2 levels in 14, 3 levels in 8, and 4 levels were treated in 2 patients. Symptom duration was ranging between 2 and 24 months with a mean of 7.64±5.98 months. Mean preoperative, postoperative, and at the 12th month VAS were 75.2±11.29, 23.8±10.28, and 24.6±11.817, respectively.Forty-eight percent of patients obtained a relative reduction of at least 70% in VAS, and 86% obtained a reduction of at least 60% at the 12th month. Health-related quality of life state was improved in all patients. When the VAS scores were evaluated with respect to the ages of patients, level numbers, and preoperative symptom duration, no significant differences were found, [0.106, 0.635 and 0.526 (preoperative VAS); 0.033, 0.555, and 0.235 (postoperative VAS); 0.701, 0.978, and 0.155 (follow-up VAS), respectively]., Conclusions: The most important factors determining success of this procedure is strict patient selection criteria and technique of the procedure.

Brucellosis is an infectious disease spread by consumption of non-pasteurized milk products or through contact with infected animals. Spinal involvement is one of the most important complications and the lumbar area is the most frequently affected site. Among the neurological consequences, nerve root compression can be a result of epidural abscess, granuloma or discitis secondary to vertebral body involvement. In this case report we present a 50-year-old male patient with brucellar discitis without spondylitis which caused lumbar disc herniation. We want to emphasize that discitis should also be considered in differential diagnosis of nerve root compression in suspected cases.

Aim: Coccydynia is a painful condition affecting quality of life. The majority of patients can be successfully treated by non-surgical means. Chemical neurolysis, cryoablation and radiofrequency thermocoagulation (RFT) of ganglion impar are also used in the treatment of visceral pelvic pain. We analyzed the efficacy of RFT of ganglion impar in patients with chronic coccydynia., Material and Methods: We retrospectively analyzed the collected data of 10 patients with chronic coccydynia (pain>6 months) who were treated by RFT of the ganglion., Results: The mean age of the patients was 49.2+/-14.4 (range 27-77) with 8 females (80%) and 2 males (20%). The average follow-up duration was 9.1+/-1.2 months. Statistically significant differences were observed between the preprocedure and post-procedure VNSs (p<0.01). Improvements in VNS scores were correlated with improvements in the EQ-5D scores. Midterm evaluation after the treatment (6 months) revealed that 90% of the patients had a successful outcome and 10% were deemed failures., Conclusion: Our data suggest that RFT destruction of ganglion impar in patients with chronic coccydynia has an effective outcome and patients responding to RFT have significantly lower post-RFT pain scores. The most important factors determining success of this procedure is strict patient selection criteria and the technique of the procedure.

Aim: There have been several treatment modalities to reduce the volume of the syringomyelic cavity and the pressure on the brainstem in Chiari Malformation Type I (CM-I). Foramen magnum decompression with and without duroplasty were compared in this retrospective study., Material and Methods: From 2003 to 2006, 27 patients suffering from CMI were operated on at our institute. The following were measured: the ratio of the syringomyelic cavity to the spinal cord; pre-operative tonsillar herniation from the foramen magnum; pre- and postoperative tonsillo-dural distance; and spinoposterior fossa dural angle., Results: 83.3 % of the patients in the non-duroplasty and 73.3% of the patients in the duroplasty group were symptom free. The ratio of syrinx regression was 28+/-10% in the non-duroplasty and 36+/-33% in the duroplasty group. The tonsillodural distance was 3.1+/-1.8 mm in the non-duroplasty and 4.6+/-2.1 mm in the duroplasty group (p>0.05). The spino-posterior fossa dural angle was 133.6+/-9.44 degrees preoperatively and 136.7+/-9.78 degrees postoperatively in the non-duroplasty (p=0.376); 123.7+/-11.7 degrees preoperatively and 129.8+/-11.1 degrees postoperatively in the duroplasty group (p=0.885); no significant difference was found postoperatively (p=0.55, z=1.92), respectively. One patient was re-operated in the non-duroplasty group and thereafter duroplasty was performed., Conclusion: Almost the same clinical outcomes can be achieved with and without duroplasty. There might be an option to perform duroplasty if simple procedure fails.

Background: Traumatic acute subdural hematoma is the most lethal of all head injuries., Methods: In this study, 113 patients with the diagnosis of posttraumatic acute subdural hematoma, who were operated between 1998 and 2006, were reviewed retrospectively. Statistical analysis was performed to detect any effects of the variables of age, Glasgow Coma Scale (GCS) score on admission, time interval between the trauma and operation, and abnormality in the pupil reaction on the disease mortality and morbidity., Results: Results obtained in the study are discussed and compared with the related current literature. The overall mortality in 113 patients was 56.6%., Conclusion: According to the results, the most important determinants of the prognosis are GCS score of the patient on admission, abnormality in pupil reaction, timing of the operation, and the patient's age.

Background: Epidural steroid injection (ESIs) is one of the treatment modalities for chronic low back pain (CLBP) with various degrees of success., Aim: We analyzed the efficacy of fluoroscopically guided transforaminal epidural steroid injections (TFESIs) via a preganglionic approach in patients with foraminal stenosis due to lumbar spinal stenosis and lumbar discogenic pain with radiculopathy., Materials and Methods: We analyzed the data of 40 patients (February 2008 and April 2009) with the diagnosis of CLBP and treated by fluoroscopically guided TFESIs via a preganglionic approach. Patients were followed-up at one month (short term), six months (midterm) and one year (long term) after injections. Follow-up data collection included the Visual Numeric Pain Scale (VNS) and North American Spine Society (NASS) patient satisfaction scores., Results: The mean age of the patients was 59.87 +/- 15.06 years (range 30 - 89 years, 25 women). Average follow-up period was 9.22 +/- 3.56 months. Statistically significant differences were observed between the pre-procedure and post-procedure VNSs (P < 0.01, Pearson Correlation Test). Improvements in VNS scores were correlated with improvements in the NASS scores. When the VNS scores were evaluated with respect to the age of patient, level numbers, gender, pre-procedure symptom duration and pre-procedure VNS, no significant differences were found (P < 0.05, linear regression test). At short term evaluation in post treatment (one month), 77.78 % of patients were found to have a successful outcome and 22.22 % were deemed failures. Overall patient satisfaction was 67.23 % in the midterm period. Additionally, 54.83 % of patients (N/n: 15/8) had a successful long-term outcome at a follow-up of one year., Conclusion: Our data suggest that fluoroscopically guided TFESIs via a preganglionic approach, in patients with foraminal stenosis due to lumbar spinal stenosis and lumbar discogenic pain with radiculopathy, has effective outcome and patients responding to injection have significantly lower post-injection pain scores.

Objective: The authors present the case of a dumbbell-shaped schwannoma of the upper cervical spine involving the ventral rami of C-2 sensory root and rising through the foramen magnum up to the pontobulbar junction. The 27-year-old male patient complaining of hoarseness, imbalance and experiencing cervical pain and cervical muscle contractions for 2 months was admitted to the hospital. The cervical T1 and T2- weighted magnetic resonance (MR) images revealed the presence of a slightly hyperintense left C1-2 intra-extradural lesion which had eroded the clivus and odontoid process and enlarged the intervertebral foramen and was rising up to ponto-bulbar junction. A posterior approach was used to perform a suboccipital craniectomy and C1- 2 laminectomy, including opening of the dura mater and gross-total removal of the lesion. The cerebrospinal MR image of the patient obtained at the early post-operative period revealed total removal of the lesion. The patient had hypoglossal nerve palsy and mild hemiparesis on the left side which had regressed almost totally at the 3-month follow-up. The far-lateral approach with the patient in the sitting position is very important and facilitates the total removal of the schwannoma. Simple suboccipital craniectomy provided enough exposure for total removal in this case.

A 26-year-old female patient under albendazole treatment because of multiple liver and lung hydatid cysts was admitted with headache and convulsions. Bilateral papilloedema and slight right hemiparesis were observed in neurological examination. Neuroradiological evaluation revealed a cystic lesion causing midline shift and oedema in the left frontal lobe. The cyst was removed unruptured using Dowling's technique and postoperative outcome was uneventful. Albendazole therapy was continued due to systemic infection. In her second month of follow-up, she suffered from severe headache and abundant haemoptysis. Control cranial magnetic resonance imaging (MRI) revealed a ring-shaped slightly contrast-enhancing lesion including heterogeneous fibrillary ingredient with surrounding oedema in the left frontal lobe. The further follow-up cranial MRI suggested brain abscess.We present a complicated case of brain hydatid cyst and its management with a successful outcome.

Aim: Previous studies demonstrated that mexiletine has some important features in the prevention of ischemic brain injury such as sodium and calcium canal blockage and free radical occurrence. Our aim was to investigate the effects of mexiletine on ischemic brain injury., Material and Methods: Experiments were performed on 30 adult male Sprague- Dawley rats (285-425 g). Left middle cerebral artery occlusion following microcraniectomy and simultaneous bilateral carotid artery occlusion were performed. Three different treatments were included in this study: (a) "naïve" control group (no drug applied; n = 10); (b) "sham surgery" control group (only saline was applied; n = 10); and a (c) "treatment group (n = 10) where mexiletine was applied. After 24 h from ischemic insult, all rats were decapitated and prepared for immunocytochemical and histopathological analyses. Cerebral infarct volumes were calculated and compared using ANOVA and a Post- Hoc Bonferroni test in each group statistically., Results: The results showed statistically significant differences between the treatment (81.98 +/- 12.58 mm?), control (121.57 +/- 11.41 mm?) and sham (116.08 +/- 12.36 mm?) groups (p < 0,0001), respectively., Conclusion: Mexiletine should be considered as an alternative medication for prevention and treatment of ischemic brain injury due to its multipotent effects.

Osteoid osteoma is a benign skeletal neoplasm composed of osteoid and woven bone. The majority of the lesions arise in the cortex of long bones. Osteoid osteoma of the spine is a rare primary spine tumor and those located at the thoracal spine are even rarer. The usual treatment involves complete resection, including the nidus, or alternatively radiofrequency percutaneous ablation is performed. The authors present a 32-year-old female with an unusual localization of the osteoid osteoma in the thoracal spine where imaging modalities were not conclusive for the diagnosis. The T1 vertebra lesion was successfully resected via a posterior approach with T1 laminectomy, including right side C7 and T1 foraminotomies, and vertebroplasty were performed. Histopathology reported the lesion as an osteoid osteoma.

Aim: This experimental biomechanical study was performed to determine the effects of multilevel anterior cervical discectomy and excision of posterior longitudinal ligament (PLL) to stabilize the cervical spine using an in vitro animal model., Materials and Methods: Fifty fresh cadaveric C3-C6 sheep spine specimens were divided into five experimental groups: Group A was the control group; Group B, one-level discectomy; Group C, two- level discectomy, Group D, three-level discectomy, and Group E, three-level discectomy and excision of PLL, respectively. The specimens were subjected to non-destructive loads cycled from zero to five Newton-meter for flexion, extension, right and left lateral bending, and axial rotation on an electrohydraulic test machine. Load displacement curves were obtained via collected data using strain gauges. The values were obtained for all five groups, statistical differences were determined respectively (P<0.05, ANOVA)., Results: One-level discectomy was less stable than the control group, two-level discectomy was less stable than one-level discectomy and three-level discectomy was less stable than two-level discectomy, respectively (P<0.05). Excision of PLL did not seem to affect stability (P>0.05)., Conclusion: Our data suggested that cervical discectomy decreases stability of sheep spine pieces.

Background: The hypoglossal canal (HC) is a region of the skull base whose involvement in many pathological entities is often ignored. Adequate knowledge of the anatomy of the HC and its related bony, neural, and vascular structures is essential for surgery of lesions involving this area., Methods: Ten adult human cadaver heads from a US source fixed by formalin (20 sides) and 20 dry human skulls from Indian sources (40 sides) were used in this study. Various aspects of the anatomy of this region including the size, course and variation of the hypoglossal nerve and its relationship to the adjacent and canalicular course were recorded., Results: The left HC was located at 10 o'clock and the right HC at the 2 o'clock position with respect to the foramen magnum. The canal was surrounded superiorly by the jugular tubercle, superolaterally by the jugular foramen, laterally by the sigmoid sinus and inferiorly by the occipital condyle. All dry skulls were drilled in the horizontal plane at an axis of about 45 degrees and directed slightly upwards., Conclusions: Detailed knowledge of the microsurgical anatomy of the region of the HC is crucial when performing surgery for lesions of the condylar region, the lower clivus, and ventral brain stem. This study provides the knowledge required to achieve accurate orientation and effective maneuvers during surgical procedures for treatment of the patient without injuring the vital neural and bony structures.

Background: Risks related to rebleeding of a ruptured intracranial aneurysm have decreased. However, ischemic neurologic deficits related to vasospasm are still the leading causes of mortality and morbidity. It is well known that vasospasm is a dynamic process affected by various factors. The severity of vasospasm in animal models and clinical observations differ from each other. This variability has not been completely explained by blood and blood degradation products. Therefore, metabolites released from the damaged vessel wall during the bleeding are thought to play an important role in vasospasm., Method: To test this hypothesis, we used 46 male Wistar rats that were divided into 7 groups and administered one of the following to cisterna magna: venous blood, arterial blood, arterial wall homogenate, venous wall homogenate, combined mixture of arterial blood and artery wall homogenate, or combined mixture of venous blood and venous wall homogenate. Brainstems of the rats were excised, and the basilar arteries were harvested for morphometric measurements., Result: There were significant differences between the degree of vasospasm caused by arterial and venous blood (P < .0001). The intraluminal area of the basilar artery was significantly narrower after application of arterial blood, artery wall homogenate, or their combination (49% +/- 1%) than after venous groups (30% +/- 1.9%) (P < .0001)., Conclusion: The results of this experiment demonstrated that metabolites from vessel walls play as important roles in the pathophysiology of vasospasm as blood and blood degradation products. Further investigation of these metabolites will improve our understanding of vasospasm, pathophysiology, and its treatment.

Carpal tunnel syndrome (CTS) is an entrapment neuropathy where the median nerve is compressed in the carpal canal. There are many variations of the distal branches of the median nerve at the wrist. Anatomical variations of this nerve have fundamental clinical importance to prevent injuries, especially during limited open or endoscopic surgical procedures. A case is presented of an anomalous course of the recurrent motor branch of the median nerve and high division of the third common digital nerve seen in a limited open carpal tunnel release.

Background: Colloid cysts are benign intracranial lesions but can show signs of severe obstructive hydrocephalus and present with sudden death. The approaches to colloid cysts have been described by many authors. The treatment modalities can be classified as endoscopic and microsurgical. Bilateral access through the foramen is commonly used with transcallosal surgery to reach the third ventricle but has never been described. Cystic lesions can be excised safely with both approaches but the excision of a solid lesion is still challenging despite advances in microsurgical techniques., Methods: After routine callosotomy, each foramen of Monroe can be identified with the landmarks of the lateral ventricle. The foramens can be widened with limited manipulation. The solid lesion can be excised with limited traction of the third ventricle and surrounding neural structures. Tumor control can be achieved with the biforaminal approach but the tumor excision should be performed from the right foramen due left side forniceal memory dominance., Results: The postoperative period was uneventful, and the patient was discharged without any memory deficit., Conclusion: Manipulation of both fornices increases the risk of significant memory system deficits. Safer and harmless excision can be achieved with the transbiforaminal approach if the tumor excision is performed from the right foramen.

Trigeminal neuralgia (TN) is a common pain syndrome and is characterized by recurrent episodes of intense lancinating pain in one or more divisions of the trigeminal nerve. Neurovascular compression (NVC) has been considered as the main cause of TN in the root entry zone (REZ) of the trigeminal nerve in the cerebellopontine angle cistern. Microvascular decompression (MVD) is the surgical procedure of choice for the treatment of medically refractory TN. MVD has also been shown to provide pain relief even in patients without visible neurovascular compression. Additionally, it has been accepted that MVD can provide the highest rate of long-term patient satisfaction with the lowest rate of pain recurrence. We did, systematic review of the subject and also our own experiences.

Background: The aim of this study was to determine the hospital-based epidemiological data of the head injury patients who admitted to our Emergency Surgery Department., Methods: The records of the patients (284 males [66%], 146 females [34%]; mean age 30+/-19) with head injury who admitted to our Emergency Surgery Department between 01.01.2006 - 31.12.2006 were analyzed retrospectively., Results: Among the age groups, most head injuries occurred in children (22%) and young adults (30%). The most common trauma types were due to falls (40%) and motor vehicle accidents (37%). The mortality rate in head injury patients was 11%, serious morbidity was 2%, and the rate of deaths from head injury among all deaths in 2006 was 30%., Conclusion: According to these data, the most common causes of death in head-injured patients are falls (0-16 years of age) and outside vehicle traffic accidents and cranial gunshot wounds (16-35 years of age), especially for males. Admission Glasgow Coma Score is an important prognostic factor in head-injured patients. Primary precautions for head injury must be taken according to each age group. Further development of the diagnosis and treatment options will help to lower the mortality and morbidity of patients with traumatic brain injury.

The sympathetic trunk is sometimes damaged during the anterior and anterolateral approach to the cervical spine, resulting in Horner's syndrome. No quantitative regional anatomy in fresh human cadavers describing the course and location of the cervical sympathetic trunk (CST) and its relation to the longus colli muscle (LCM) is available in the literature. The aims of this study are to clearly delineate the surgical anatomy and the anatomical variations of CST with respect to the structures around it and to develop a safer surgical method that will diminish the potential risk of CST injury. In this study, 30 cadavers from the Department of Forensic Medicine were dissected to observe the surgical anatomy of the CST. The cadavers used in this study were fresh cadavers chosen at 12-24 h postmortem. The levels of superior and intermediate ganglions of cervical sympathetic chain were determined. The distance of the sympathetic trunk from the medial border of LCM at C6, the diameter of the CST at C6 and the length and width of the superior and intermediate (middle) cervical ganglion were measured. Cervical sympathetic chain is located posteromedial to carotid sheath and just anterior to the longus muscles. It extends longitudinally from the longus capitis to the longus colli over the muscles and under the prevertebral fascia. The average distance between the CST and medial border of the LCM at C6 is 11.6 +/- 1.6 mm. The average diameter of the CST at C6 is 3.3 +/- 0.6 mm. Superior ganglion of CSC in all dissections was located at the level of C4 vertebra. The length and width of the superior cervical ganglion were 12.5 +/- 1.5 and 5.3 +/- 0.6 mm, respectively. The location of the intermediate (middle) ganglion of CST showed some variations. The length and width of the middle cervical ganglion were 10.5 +/- 1.3 and 6.3 +/- 0.6 mm, respectively. The CST's are at high risk when the LC muscle is cut transversely, or when dissection of the prevertebral fascia is performed. Awareness of the CST's regional anatomy may help the surgeon to identify and preserve it during anterior cervical surgeries.