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    Cervico-medullary compression ratio: A novel radiological parameter correlating with clinical severity in Chiari type 1 malformation
    (Elsevier Science Bv, 2018) Doruk, Ebru; Ozay, Rafet; Şekerci, Zeki; Durmaz, Hasan Ali; Güneş, Serra Özbal; Hanalıoğlu, Şahin; Sorar, Mehmet
    Objectives: Chiari malformation type 1 (CM-1) is associated with cough headache, intracranial hypertension, cerebellar and spinal cord symptoms/signs. Herniated cerebellar tonsil length (HCTL) is widely used radiological parameter to determine the severity of CM-1, but with limited utility due to its weak correlation with some clinico-radiological findings. In this study, we aimed to evaluate a novel, practical parameter (cervico-medullary compression ratio; "CMCR") for its relationship with clinico-radiological findings in CM-1. Patients and methods: Thirty-five adult patients (17 F, 18 M) with CM-1 were included in this retrospective study. Head CT and craniospinal MR images were assessed. CMCR was calculated as the ratio of herniated cerebellar tonsil surface area to foramen magnum surface area, and HCTL was measured. These two parameters were correlated with clinical and radiological findings. Results: The mean CMCR was 0.60 +/- 0.15 and mean HCTL was 8.91 +/- 3.4 mm with no significant difference between gender and age groups for both parameters. For cough headache (0.64 +/- 0.14 vs 0.52 +/- 0.15, p = 0.043) and syringomyelia (0.67 +/- 0.11 vs 0.56 +/- 0.16, p = 0.039), only CMCR; for intracranial hypertension (CMCR: 0.64 +/- 0.14 vs 0.55 +/- 0.16, p = 0.049; HCTL: 9.66 +/- 3.59 mm vs 7.79 +/- 3.03 mm; p = 0.045) and cerebellar symptoms (CMCR: 0.65 +/- 0.14 vs 0.54 +/- 0.16, p = 0.048; HCTL: 10.4 +/- 3.5 mm vs 7.4 +/- 2.8 mm, p = 0.041), both CMCR and HTCL were significantly different between patients with and without respective findings. However, neither CMCR nor HTCL was different between patients with and without spinal cord symptoms and hydrocephalus. Conclusion: CMCR is a superior numerical parameter than HCTL for the assessment of clinical severity in CM-1 cases and needs further validation with larger studies.
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    Revisiting ligament-sparing lumbar microdiscectomy: When to preserve ligamentum flavum and how to evaluate radiological results for epidural fibrosis
    (Elsevier Science Inc, 2018) Özay, Rafet; O?ur, Törel; Durmaz, Hasan Ali; Türkoğlu, Erhan; Çağlar, Yusuf Şükrü; Şekerci, Zeki; Sorar, Mehmet; Hanalioğlu, Şahin
    OBJECTIVE: Preserving the ligamentum flavum (LF) during lumbar spine surgery can help to limit the extent of postoperative epidural fibrosis (EF), which is a potential cause of persistent leg pain. We present a retrospective analysis of microdiscectomy with preservation of the LF to evaluate the effects of the two LF mobilizing techniques (reflecting inferiorly or medially vs. removing completely) on EF and clinical outcomes. METHODS: Microdiscectomy was performed through a unilateral laminotomy in 93 patients (52 male, 41 female; mean age, 46 years; range, 25-65 years) with L3-L4 (n = 3), L4-L5 (n = 40), and L5-S1 (n = 50) lumbar disc herniation. Patients whose LF was removed were assigned to group 1 (n = 42), and patients whose LF was preserved by mobilizing it medially (n = 31) or inferiorly (n = 20) were assigned to groups 2 and 3, respectively. Follow-up visual analog scale (VAS) scores and magnetic resonance images were evaluated. RESULTS: EF scores, particularly for the anterior quadrants, were significantly higher in group 1 than in groups 2 (P = 0.012) and 3 (P = 0.001). Likewise, postoperative VAS scores in group 1 were also significantly higher than in groups 2 (P = 0.009) and 3 (P = 0.044). CONCLUSIONS: Our results demonstrate that 1) preserving the LF during lumbar microdiscectomy reduces the formation of postoperative EF and improves clinical outcomes; 2) EF in the anterior, rather than the posterior epidural space, is correlated with clinical results; and 3) the ligament mobilizing technique used should be individually tailored on the basis of the features of disc herniation.