The history of neurosurgery in the Turkish army is not long and complex. Neurosurgery was first practiced in the Ottoman army by Cemil Pasha, who was a general surgeon. After the fall of the Ottoman Empire, the Republic of Turkey was established and modern neurosurgical procedures were applied at the Gulhane Military Medical Academy (GMMA). Maj. Zinnur Rollas, M.D., was the founder of the Department of Neurosurgery at GMMA in 1957. A modern neurosurgical program and school was established in 1965 by Col. Hamit Ziya Gokalp, M.D., who completed his residency training in the US. Today, 26 military neurosurgeons are on active duty in 11 military hospitals in Turkey. All of these neurosurgeons work in modern clinics and operating theaters. In this paper, military neurosurgery in the Turkish army is reported in 3 parts: 1) the history of neurosurgery in the Turkish military, 2) the Department of Neurosurgery at the GMMA, and 3) the duties of a military neurosurgeon in the Turkish army.
Halil Ibrahim Secer, Engin Gonul and Yusuf Izci
The goal of this study is to review the surgical management and outcome of patients who were treated for large orbitocranial osteomas at Gulhane Military Medical Academy over a period of 7 years.
Twenty-one patients with large orbitocranial osteomas were evaluated retrospectively. All patients were male and between 19 and 25 years old. Surgery was performed in all patients. The main surgical procedure was resection of the osteoma using orbitotomy and/or craniotomy followed by orbital reconstruction and cranioplasty. Cranioplasty was performed in 16 patients, using methyl methacrylate in 5 patients (31%) and porous polyethylene in 11 patients (69%). Thin, flexible, porous polyethylene was preferred for orbital reconstruction in 10 patients. The cranioplasty materials were attached to the intact bone using miniplates.
There were no severe postoperative complications. Mild transient periorbital ecchymosis was noted in 19 patients. The mean follow-up period was 11.7 months (range 9–24 months) after surgery. No tumor regrowth was observed in any patient at the end of the follow-up period.
Large osteomas of the orbitocranial region must be resected for cosmetic and functional reasons. Selection and planning of the surgical technique should be based on the direction of the tumor growth and on the size of the tumor and the structures that are compressed by the tumor.
Yusuf Izci, Yusuf Tüzün, Halil Ibrahim Seçer and Engin Gönül
Hydatid cysts are rare, but most often they occur in the liver and lungs. Cerebral manifestation is very rare, and surgery is the main treatment. The goal of surgery is to remove the cysts in toto without rupture. The aim of this study was to investigate the surgical technique of removing cerebral hydatid cysts and to show the possible pitfalls of surgery.
This study included 17 patients who underwent surgery for an intracranial hydatid cyst. The Dowling technique was used in all patients. This technique is based on the large cranial opening, careful handling, meticulous cortical dissection, and removal of the cyst by hydrostatic assistance.
The hydatid cysts were removed unruptured in 88% of the cases. The cysts ruptured intraoperatively in 2 patients, and the ventricular system was opened in 1 of them. Anaphylactic reaction or chemical meningitis did not occur, but recurrence and spinal seeding were observed in the follow-up of these patients. The thin cyst wall, periventricular locations, and microadhesions to the surrounding brain tissue were the main surgical problems. None of the patients died after the surgery.
Although this technique seems safe and easy, there are some pitfalls concerning the cyst location and surgical approach. Successful management requires a flexible therapeutic strategy and meticulous dissection by an experienced surgeon.
Emrah Celtikci, Fatih Yakar, Pinar Celtikci and Yusuf Izci
The aim of this study was to investigate the relationship between lumbar spondylolysis and payload weight between different combat units of Turkish land forces (TLF).
The authors reviewed clinical and radiological data of the military personnel with low-back pain (LBP) admitted to their clinic between July 2017 and July 2018. Age, BMI, average payload weight, and military service unit were recorded. CT scans were evaluated for pars interarticularis fractures and spondylolisthesis, whereas MRI studies were evaluated for spondylolisthesis, Modic-type endplate changes, or signal loss on T2-weighted images compatible with disc degeneration.
Following exclusion, a total of 642 all-male military personnel were included. Of these personnel, 122 were commandos, 435 were infantry, and 85 were serving in the artillery units. Bilateral pars interarticularis fracture was noted in 42 commandos (34.42%) and 2 infantrymen (0.45%). There was no spondylolysis in the artillery units. There was no multiple-level spondylolysis and the most common level of spondylolysis was L5. Commandos had a significantly higher incidence of spondylolysis and more average payload weight (p < 0.001). Twelve patients (27.2%) with spondylolysis had accompanying MRI pathologies at the same level, whereas 32 patients (72.7%) had no accompanying MRI pathologies.
Increased payload weight in military personnel is associated with spondylolysis, and commandos in the TLF have significantly heavier payloads, which causes an increased rate of spondylolysis compared to other units. Additionally, spondylolysis without adjacent-level changes on MRI could be undiagnosed. LBP in active military personnel who have a history of carrying heavy payloads should be evaluated extensively with both MRI and CT scans.
Halil Ibrahim Secer, Mehmet Daneyemez, Engin Gonul and Yusuf Izci
Ulnar nerve lesions caused by gunshot wounds have rarely been reported in the current literature. The authors describe the outcome after surgical repair of such injuries, and the factors influencing the results of treatment.
This retrospective study includes 455 patients with 462 ulnar nerve injuries caused by gunshot wounds who were treated at Gulhane Military Medical Academy over a 40-year period. A total of 407 ulnar lesions were surgically repaired at that institution between 1966 and 2005; 237 patients were injured by shrapnel and 218 patients by gunshot. The authors evaluated the motor, sensory, and electrophysiological recovery in these patients, as well as the patients' judgment of the outcome. The authors also tested the effect of repair level, nerve graft length, time to operation, repair technique used, and the presence of coexisting damages in the nerve repair region. The final outcome in these patients was defined as poor, fair, or good on the basis of the British Medical Research Council scores.
A good outcome was noted in 15.06% of patients who underwent high-level repair, 29.60% of patients who underwent intermediate-level repair, and 49.68% of patients after low-level repair. On average, patients with successful outcomes had a significantly shorter time to operation than those with unsuccessful outcomes. The critical period for surgery was within 6 months of injury. Although the optimal graft length was found to be 5 cm, this finding was not statistically significant.
The reported outcome of repairs to ulnar nerves damaged by gunshot has varied in the literature, but there is a consensus that the duration of the interval to surgery, the repair level, and the graft length used influence the outcome of surgical repair for ulnar nerve lesions.
Kamil Melih Akay, Yusuf Izci, Alper Baysefer and Erdener Timurkaynak
✓The authors report on a child with a composite type of split cord malformation (SCM). The patient presented with symptoms of a common cold. The diagnosis of SCM was made based on computerized tomography and magnetic resonance (MR) imaging of whole spinal axis. The SCM was Type I at T-4 and T-5 and Type II at T-12, according to the classification developed by Pang. The child underwent resection of the splitting lesions and terminal filum release. No case of composite-type SCM reported to date contains documentation of such a malformation. Because of the possible neurological and urological problems, the authors recommend MR imaging of the whole spine be performed during an evaluation for SCM.
Cahit Kural, Sahin Kırmızıgoz, Mehmet Can Ezgu, Orhan Bedir, Murat Kutlay and Yusuf Izci
Intracranial infections are serious and life-threatening health problems. They may present as subdural empyemas or intracerebral abscesses. Surgical drainage and subsequent antibiotic treatment is the main technique for a satisfactory clinical outcome. The aims of this study were to present a 10-year intracranial infection series and discuss the surgical characteristics in the light of literature.
Fifty-two patients with intracranial infection underwent surgical treatment between 2008 and 2018. Eleven patients were female and 41 patients were male. The mean age was 40.46 years (range 10–75 years). Eighteen patients had intracerebral abscesses, and 34 had subdural empyemas. All patients underwent surgical treatment as well as an antibiotic regimen.
No etiological agent was isolated in 29 (56%) cases. Bacterial agents were detected in 20 cases, while fungi were observed in 3 cases. Staphylococci species were the most common agents and were isolated in 8 (15%) cases. Endoscopic aspiration was performed in 3 cases, while surgical drainage and capsule resection via craniotomy was performed in 49 cases. An associated intracranial tumor was diagnosed in 2 patients with brain abscesses. Four (8%) patients died despite surgical and medical treatments.
Surgical treatment via craniotomy is an older method, but it is still the best to treat the intracranial infections not only for decompression of the brain but also to attain an accurate diagnosis. The abscess wall should always be histologically examined after surgery to rule out any intracranial tumor.
Cahit Kural, Servet Guresci, Gulcin Guler Simsek, Erhan Arslan, Ozkan Tehli, Ilker Solmaz and Yusuf Izci
The structure of the filum terminale (FT) is important in the development of tethered cord syndrome (TCS) in children. Although many studies have been performed on the histological structure of the FT in adults, there has been no detailed investigation for those of fetuses. The aim of this study was to examine the histological structure of the FT in normal human fetuses and to compare the results with those of previous studies.
The histological examination of the FT was performed in 15 normal human fetuses; 11 of them were female and 4 were male. The gestational age of the fetuses ranged between 14 weeks and 35 weeks, and they weighed between 180 g and 1750 g. The FT of each fetus was cut and examined for adipose tissue, fibrous tissue, peripheral nerve, ganglion, ependymal cells, gliosis, elastic fibers, and collagen types (Types I and III).
Adipose tissue was observed in 2 specimens (13%), whereas fibrous tissue was found in 8 specimens. Peripheral nerve was detected in 11 (73%), ganglion in 6, ependymal cells in 5, and glial tissue in 7 FT samples. Type III collagen was present in 12 specimens (80%) with different concentrations, whereas Type I collagen and elastic fibers were not detected.
The normal structure of the FT in fetuses is different from its structure in adults. The FT has no elasticity during intrauterine life because of the lack of elastic fibers. More detailed studies are needed to understand the histological basis of TCS in children.
Emel Avcı, Erinç Aktüre, Hakan Seçkin, Kutluay Uluç, Andrew M. Bauer, Yusuf Izci, Jacques J. Morcos and Mustafa K. Başkaya
Although craniofacial approaches to the midline skull base have been defined and surgical results have been published, clear descriptions of these complex approaches in a step-wise manner are lacking. The objective of this study is to demonstrate the surgical technique of craniofacial approaches based on Barrow classification (Levels I–III) and to study the microsurgical anatomy pertinent to these complex craniofacial approaches.
Ten adult cadaveric heads perfused with colored silicone and 24 dry human skulls were used to study the microsurgical anatomy and to demonstrate craniofacial approaches in a step-wise manner. In addition to cadaveric studies, case illustrations of anterior skull base meningiomas were presented to demonstrate the clinical application of the first 3 (Levels I–III) approaches.
Cadaveric head dissection was performed in 10 heads using craniofacial approaches. Ethmoid and sphenoid sinuses, cribriform plate, orbit, planum sphenoidale, clivus, sellar, and parasellar regions were shown at Levels I, II, and III. In 24 human dry skulls (48 sides), a supraorbital notch (85.4%) was observed more frequently than the supraorbital foramen (14.6%). The mean distance between the supraorbital foramen notch to the midline was 21.9 mm on the right side and 21.8 mm on the left. By accepting the middle point of the nasofrontal suture as a landmark, the mean distances to the anterior ethmoidal foramen from the middle point of this suture were 32 mm on the right side and 34 mm on the left. The mean distance between the anterior and posterior ethmoidal foramina was 12.3 mm on both sides; the mean distance between the posterior ethmoidal foramen and distal opening of the optic canal was 7.1 mm on the right side and 7.3 mm on the left.
Barrow classification is a simple and stepwise system to better understand the surgical anatomy and refine the techniques in performing these complex craniofacial approaches. On the other hand, thorough anatomical knowledge of the midline skull base and variations of the neurovascular structures is crucial to perform successful craniofacial approaches.