Introduction: In adults, brain stem lesions are varied in pathology and pre-operative radiological diagnosis, though improving with time, is still incorrect in at least 15 to 20% of cases [1, 2, 3, 8. 9]. Appropriate therapeutic measures to treat brain stem lesions require histological diagnosis. Patients and Methods: This is a prospective study to evaluate safety; diagnostic yield of brain stem biopsy using a frame-based computed tomography guided stereotactic procedures done between June 2004 and February 2007 . It included 66 stereotactic procedures in 65 cases diagnosed of brain stem lesions. Patients were categorized into adult and pediatric groups. All adult patients were biopsied while the patient is awake and physiologically monitored for any unwanted morbidity with subsequent change of the entry point.

Results: Among the study group there were 41 male (63%) and 24 female (37%). There were 9 (13.9%) pediatric patients and 56 (86.1%) adults. All cases but one had only single stereotactic procedure. We had only one procedure related mortality. Procedure related morbidity included 4 cases of hemifacial numbness required repositioning of the electrode, 2 cases of facial palsy, one recovered after few days and the other one improved in a month after steroid administration and one case of diplopia related to 6th nerve palsy improved after one week with steroid administration. Regarding the diagnostic yield we had positive pathological results in all cases but one (98.5%).

Conclusion: Brain stem stereotactic procedures are safe and reliable technique in both adults and children. Performing this technique in awake adult patient reduces the morbidity of this technique and adds to the safety of the procedure.

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Objective: Stereotactic radiosurgery is the principal alternative to microsurgical resection for vestibular schwannomas. The goals of radiosurgery are the long term prevention of tumor growth, maintenance of neurological function and prevention of new neurological deficits. In this study, the results of gamma knife radiosurgery (GKRS) for vestibular schwannomas were investigated. Method: Forty patients underwent stereotactic radiosurgery for vestibular schwannomas from 2001 till 2006, male to female ratio was 1:3 , initial symptoms were hearing deterioration in 72.5%, tinnitus in 35%, grade 1 facial function according to the House-Brackmann classification was present in 90% of the patients, 2.5% had grade 3, 5% showed grade 4, grade 5 in 2.5%. 27.5% of the patients had serviceable hearing and 60% had non-serviceable hearing according to the Gardner-Robertson scale while12.5% of the patients didn't comply with the repeated request to do an audiogram. As pre gamma knife modality, surgical tumor resections were done in 60% of the patients and V-P shunt in 35 % of the patients. Mean tumor volume was 5.03cm3and the mean dose delivered to the tumor was 16Gy, the maximal dose was 19.9Gy and the margin dose was 12Gy and kept behind the anterior border of the tumor to protect the facial nerve from excess radiation. Eighty % of these patients were followed up for radiological and clinical evaluation.

Results: Mean follow-up duration was 15.2 months and tumor control rate of 100 % was achieved i.e. 0%failure rate as none of these patients showed increase in tumor volume with serial radiological imaging or by the need for surgical intervention and 12.5 % of the patients showed decrease in size and serviceable hearing was maintained in 63.6% of the patients with Gardner Robertson class 1 or 2 hearing. None of the patients (0%) experienced facial neuropathy, while 12.5% experienced transient trigeminal neuropathy.

Conclusion: Stereotactic radiosurgery has become a common therapeutic choice for patients with acoustic tumors. Radiosurgery for acoustic neuroma performed using current procedures is associated with a continued high rate of tumor control and lower rates of post treatment morbidity.

Background: Cystic vestibular schwannoma (VS) is a unique entity of vestibular schwannomas. It differs from the solid variant clinically, radiologically, and even in outcome. The aim of this study is to discuss the impact of the presence of cysts on the surgical procedure and outcome in 13 cases. The pathogenesis of cyst formation is analyzed. Patients and methods: The study included 13 patients with cystic VS fulfilling radiological, operative and histopathological inclusion criteria for cystic VS. Radiologically, the cases were classified into three subtypes (A, B and C) according to Kameyama's classification. Retro-sigmoid approach was utilized to deal with the lesions. Operative records were analysed.

Results: The clinical symptoms were characterized by short duration in subtype A and C. Two patients had pre-operative facial paresis (subtype-A). The cystic component contained xanthochromic fluid while the solid part was very vascular. In multicystic (subtype-C), the cysts gave the tumour honey-combed appearance. Capsular dissection after cyst drainage and initial debulking was very difficult due to its adherence to the surroundings. The tumour was found to be adherent to the brainstem (69.2%), trigeminal nerve (61.5%), lower cranial nerves (46.1%) and the petrous dura and tentorium cerebelli (30.7%). Total removal was achieved in 53.91%. Conclusion: The presence of cysts was associated with rapid progression of symptoms and was important impact factor in the poor outcome due to difficulty of cyst wall dissection. The mechanism of cyst formation in cystic VS is not yet understood and all the previous studies were based upon limited number of cases; so further investigations and analysis of larger studies is required to get a complete view.

Introduction: There are many different modalities for the treatment of trigeminal neuralgia (TN). Pharmaceutical agents, microvascular decompression and percutaneous minimally invasive procedures are commonly applied for the treatment of trigeminal neuralgia.

Aim of study: Assessment of the technique and results of the treatment of trigeminal neuralgia by percutaneous radiofrequency rhizotomy (PRR) using straight tip electrode. Patients and methods: The present prospective study was carried out on 150 consecutive patients (63 males and 87 females) presented with primary trigeminal neuralgia at the department of Neurosurgery, Ain Shams University Hospitals, Egypt, from 2002 to 2006 and treated by PRR. Results: A mean age of 47.3 years and a female preponderance (58%) were noted. Right side pain was present in 59.3% of cases. V3 pain was the commonest single division affection (26.7%) while V2 and V3 was the commonest combination (46.7%). There was no mortality. As regard branch selectivity using straight electrode in this study, the results were comparable to studies using curved electrodes. Degree of sensory loss was anesthesia in 3.4%, analgesia in 26.6% and hypalgesia in 70%. Most patients (79.7%) tolerated facial numbness. Transient trigeminal motor weakness occurred in 5.3% while in one case (0.6%), it remained stationary but yet asymptomatic. Initial pain relief (within 1st day) occurred in 98.6% of cases. Pain recurrence after PRR occurred in 6.6%.

Conclusion: The end point of PRR, therefore, should be some degree of hypalgesia and not analgesia; so surgeons must contain their enthusiasm to ensure a cure by creating dense diffuse sensory deficits and instead accept the higher recurrence rate associated with less numbness in the face.

Introduction: Many kinds of minimally invasive surgeries for spine pathology have been developed over years. Microendoscopic discectomy (MED) is one of the minimally invasive techniques for lumbar disc surgery.

Aim of study: To discuss the steps of the microendoscopic discectomy (MED) and reporting difficulties, complications and outcome. The study was carried out at the Neurosurgery Department, Ain Shams University, Egypt, and the data was collected prospectively. Patients and methods: 30 patients with prolapsed lumbar intervertebral disc, who were prospectively collected between March 2003 and March 2006, were included in the study. The vertebroscope system (Zeppelin) was used to perform all the MED procedures in this study. The outcome assessment was done using the visual analogue score and the modified Macnab criteria.

Results: 30 patients (17 males and 13 females) underwent MED for prolapsed lumbar intervertebral disc. The follow-up was carried out from 2 to 36 months with a mean follow-up of 12.9 months. Twenty three patients had an excellent outcome, 5 patients had a good outcome, 2 patients had a fair outcome and no patients had a poor outcome.

Conclusion: Microendoscopic discectomy (MED) is a safe and effective technique for the treatment of prolapsed lumbar intervertebral disc.
Key words: Discectomy, Microendoscopy, MED.

Background: Over several decades, investigators have been trying to identify the painful degenerate disc. Their work included two main methods. The first was to set criteria on the radiological investigations, mainly the MRI scan, to describe the severity of the degenerative disc disease (DDD); and the second was to perform discographies. Neither of these two methods precluded the need for the other. Purpose: Using Pfirrmann's classification, we correlated the static MRI images, for the severity of disc degeneration, with the dynamic lumbar discography, aiming at improving the identification of painful 'discogenic' intervertebral segments. Study design: Prospective cohort study. Patient Sample and Method: 69 patients (45 females, 24 males). The average age was 38.9 years (range 20-56). All patients had DDD on lumbar MRI scans. The severity of DDD was graded using Pfirrmann's classification. A total of 162 discographies were performed using "miss the facet joint, double needle technique". Outcome Measures: During discography typical or concordant pain only was regarded as positive. Among each of the five Pfirrmann grades, the percentage of positive discographies was calculated. Significance and correlation were then investigated using the Chi-squared and Spearman's correlation tests.

Results: The percentages of positive provocative discography for concordant pain among the five Pfirrmann's grade were 0%, 9.1%, 71.4%, 100% and 100% respectively. Statistical analysis showed a high correlation between the severity of DDD on MRI scan and the result of the provocative discography. Conclusion: The higher the grade of segmental DDD, the more likely it will be painful on discography. All discs showing Pfirmann grade IV and V disease were painful on discography.

Objective: Tumors of the lateral ventricle can be approached through the transcallosal approach. In this study, the technique and outcome of the anterior transcallosal approach for lateral ventricular tumors will be discussed. Methods: An experience with 15 patients (8 females and 7 males) who had lateral ventricular tumors and were operated upon via the anterior transcallosal approach over a period of 3 years (2002 to 2005) was presented in a prospective study. The surgical technique, pitfalls and complications were discussed. The degree of resection was evaluated by gross total, subtotal resection, debulking and biopsy. The outcome was evaluated by Karnofsky performance status scale.

Results: There was no mortality in this study. The disconnection syndrome, the commonest complication, occurred in 6 patients (40%) and was transient. Hemiparesis occurred in 2 patients (13%) which improved over a period of one month to grade 4 power in both patients. Gross total resection was achieved in 3 patients (20%), subtotal resection in 8 patients (53.5%), debulking in 3 patients (20%) and biopsy in one patient (6.5%). As regard the outcome, 6 patients (40%) had an outcome of 90, 6 patients (40%) had an outcome of 80 and 3 patients (20%) had an outcome of 70.

Conclusion: The anterior transcallosal approach was found to be the more direct technique for lateral ventricular tumors with few complications and minor injury. Although the operation sacrifices a functionally significant part of the corpus callosum, the neurological sequlae have seemed to be acceptable.

Prediction of early response of brain gliomas after radiation therapy using MRI perfusion and spectroscopy may provide an opportunity to modify therapy plan in none responders. Our aim was to analyze these recent modalities, to evaluate its combined implication on the treatment plan and on initial grading. Forty-six patients with brain astrocytomas were examined prospectively before and after radiation therapy at regular intervals over a period of two years, using conventional MRI, MR-perfusion and 1H-Proton MR-spectroscopy. Findings were correlated with the histopathological grade and response to treatment. For patients who showed early poor response or resistance to radiation, chemotherapy was added in the form of Temozolomide 175mg/m2 for 5 days every consecutive 28 days, while patients with good response were just kept on regular follow-up. MR-perfusion (p-value=0.042)and MR-spectroscopy with its biomarkers Choline/Creatine, Choline/NAA showed statistically significant p-values of 0.001 and 0.004 respectively in differentiating between high grade (III,IV) and low grade (II)gliomas. Conventional MR-data were not statistically significant, except for the combination of necrosis, edema and mass effect (P=0.002). Biomarkers of spectroscopy were highly significant regarding Choline/Creatine, NAA/Creatine and Choline/NAA, with p-values of (0.005, 0.025, 0.01) respectively. MR-perfusion also showed a statistically significant p-value (0.004). Combined MR-perfusion and 1HMR-spectroscopy are important and promising new imaging modalities for diagnosis and early therapeutic evaluation of brain tumor response after radiation therapy, for proper selection of patients, in need of further chemotherapeutic supplement.

Objective: The author describe the results of performing a standard posterior craniovertebral decompression and duroplasty, with preservation of arachnoid layer, for the treatment of patients with symptomatic chiari I malformation with and without syringomyelia Patients and methods: This is a retrospectively analyzed series of ten patients with symptomatic chiari I malformation underwent surgical treatment from June 2003 to January 2007. Clinical, surgical and radiological findings, as well as data on patient history, were reviewed from medical charts and operative reports. MRI was done for all patients and the degree of descent of cerebellar tonsils was noticed. Craniovertebral decompression consisted of suboccipital craniectomy, a C-1 laminectomy and C2 laminectomy in some cases, and duroplasty to increase the cerebrospinal fluid space at the craniocervical junction. Serial post-operative complete neurological examination was done on follow-up clinic visit. Follow-up MRI was done in all patients, within 6 months to evaluate the degree of descent of cerebellar tonsils and size and extent of the syrinx.

Results: Between June 2003 and January 2007, ten patients surgically treated for chiari I malformation were followed. The average age was 34.3 years. Seven patients (70%) were female and three patients (30%) were male. The most common presenting symptoms were occipital headache in six patients (60%), neck pain in five cases (50%), paraesthesia in five patients (50%), motor deficit in four patients (40%) and cerebellar manifestations in five patients (50%). An excellent outcome was achieved in six patients (60%), a good result in three patients (30%) and a poor result in one patient (10%). There was no patient with worsened symptoms post-operatively. Conclusion: It could be concluded that posterior craniovertebral decompression and duroplasty, with preservation of arachnoid layer is very effective in the treatment of chiari I malformation. The outcomes were good with no mortality and minimal morbidity.

Objective: The authors reviewed factors related to the surgical techniques resulting in failure of the construct of the internal fixation of thoracolumbar fractures through transpedicular screw systems and how to be avoided. Patients and Methods: The authors reviewed 280 consecutive patients with traumatic thoracolumbar fractures who underwent spinal surgical fixation with short segment transpedicular screw instrumentation at three institutions, between January 1997 and June 2005. All patients in this series were due to high-energy trauma. Among this series, 30 patients had a construct failure attributed to surgical technique causes. Clinical evaluation of the patients was performed on admission and at post-operative period using ASIA scale. All patients were radiologically investigated by plain X-rays and computerized tomographic (CT) scan spine on admission and occasionally MRI and 3D CT scan of the spine when required. The patients were followed up as regard to clinical and radiological evidences of construct failure.

Results: Thirty patients out of 280 patients with post-traumatic thoracolumbar injuries had construct failures. Main clinical presentation of construct failure was severe pain and inability to walk at post-operative period. Radiologically there was progressive spinal deformity with implant failures. The locations of the fractures in order of frequency were as follows: L-1 in 18 cases, L-2 in 7 cases, T-12 in 5 cases. The construct failure was in the form of screws malposition in 13 patients, screws breakage in 10 patients, screw/rod dislodgement in 3 patients, disengaged screw's cup in 2 patients, and broken rods in 2 patients. Conclusion: Great attention must be directed to maintain the sagittal and coronal balances of the spine over the sacrum through reconstruction of comminuted anterior vertebral column, and appropriate distraction of the construct. In spite of routine use of pedicle screws, it has not been free of complications. The majority of construct failures is not actually device failures but instead is surgical technique causes.

Microendoscopic discectomy is a safe and effective procedure for intervertebral discs. Its results are comparable to standard open discectomy procedure. The microendoscopic system offers the benefits of a smaller incision than open discectomy and limited tissue trauma via sequential dilators. Microendoscopic discectomy has advantages over other minimally invasive surgical techniques because it can address lesions other wise unaccessible to percutaneous techniques on the other hand, the difficulties of the endoscopic procedure are evident because of the limited exposure and two dimensional video display. Materials and Methods: The study was conducted on 40 patients suffering from prolapsed lumbar disc they were admitted to Ain Shams University Hospitals department of Neurosurgery from the period between December 2004 till December 2006. 20 of them underwent open or conventional discectomy and 20 underwent microendoscopic discectomy. We selected the patients according to the strict inclusion/ exclusion criteria. The comparison between the two groups was conducted through the operation time, amount of bleeding, duration of hospitalization,, pre- and postoperative scores based on judgment criteria for treatment of lumbar spine disorders established by the Japanese Orthopaedic Association score, visual analog scales (VAS, 0 to 10) for back pain before surgery and at discharge, VAS for sciatica before surgery and at discharge, VAS for sciatica before surgery and at discharge, perioperative complications, and cases requiring further surgery.

Results: The microendoscopic discectomy has the advantages of smaller skin incision less tissue trauma, less time of hospitalization and less intraoperative blood loss in our own results, but also showed equivalent clinical results to those of standard open discectomy. Conclusions: Strict selection criteria could ensure optimal long-term outcome as microendoscopic discectomy is not suitable for all patients with lumbar disc herniation. The optimal indication for micorendoscopic discectomy is single level radiculopathy secondary to lumbar disc herniation. The advantages of microendoscopic disectomy over classic discectomy might be limited and they do not seem to last longer than the initial post operative period. And like other new minimally invasive techniques, microendoscopic discectomy has a learning curve which is related to surgery time, complications, conversion to the open procedure and recurrent disc herniation.

Standard open Discectomy is widely known as a common surgical procedure for lumbar disc herniation, while microdiscectomy in place of Caspar technique (the Caspar method) by a posterior approach is reported as less invasive surgical methods as a treatment modality. Nowadays "Minimal Invasive Surgery" is a trend setting catchword, but in the seventies the application of microsurgical techniques derived from intracranial procedures to the lumbar spine was a breakthrough. Caspar2 in 1976 and 1977, Yasargil14 in 1977, and Williams12 in 1978 independently reported microtechniques in the treatment of lumbar disc herniations. Materials and Methods: The objective of our study is to investigate the surgical outcomes of these two different modalities (The lumbar microdiscectomy and standard open lumbar discectomy) as surgical treatment of the disc prolapse. We evaluated 20 cases of microsurgical lumbar discectomy and 20 cases of standard discectomy performed at Ain shams university and Ain shams university specialized hospitals The target of our study was a group of 20 patients who underwent surgery by microdiscectomy in place of Caspar technique and a group of 20 patients who underwent surgery by standard open lumbar discectomy . The items investigated were the operation time, amount of bleeding, duration of hospitalization, amount of analgesic agent used after surgery, pre- and postoperative scores based on judgment criteria for treatment of lumbar spine disorders established by the Japanese Orthopaedic Association score, visual analog scales (VAS, 0 to 10) for back pain before surgery and at discharge, VAS for sciatica before surgery and at discharge, VAS for sciatica before surgery and at discharge, perioperative complications, and cases requiring further surgery.

Results: There were no significant differences between the 2 surgical procedures in the frequency of use of an analgesic agent after surgery, the pre- and postoperative Japanese Orthopaedic Association scores or postoperative VAS for sciatica. Statistically significant differences were observed in the operation time, amount of bleeding, duration of hospitalization, and post-operative VAS for lumbar pain, but the differences were not large, and may not have been clinically significant. Conclusions: For surgical excision of lumbar disc herniation, both microsurgical lumbar discectomy and standard open discectomy are appropriate, as long as surgeons have mastery of the procedures, and the technique of lumbar microsurgery needs longer learning curve and has to be learned, carried out properly, practiced often and not just occasionally

Low back pain affects millions of people worldwide each year. Many of these patients respond well to conservative treatment. The remaining patients undergo approximately 700,000 disc related surgical procedures annually including discectomy and spinal fusion. In the last decade Spine Arthrodesis became predominant choice of surgical procedure as an artificial disc whether as total replacement or subtotal replacement of the disc. Studies of disc replacement have been made sporadically in the past but have become increasingly active in recent years According to the theoretical concepts of the design of the Artificial disc prosthesis must provide (a) satisfactory pain relief, (b) adequate motion, and (c) stabilization1; sub total replacement of the disc has the potential to be an additional treatment option for patients who suffer from back pain caused by degenerative disc disease as It was intended to reduce low back pain, maintain or increase disc height at the operative level and maintain or improve range of motion of the affected level.

Study design: Our study is an evaluation of the subtotal replacement of the disc using the Prosthetic Disc Nucleus as a treatment modality in patients with degenerative disc disease fulfilling the theoretical target concepts of the design of the Artificial disc prosthesis that it must provide (a) satisfactory pain relief, (b) adequate motion, and (c) stabilization. Material and Methods: 20 patients were selected from the population of patients diagnosed with degenerative disc disease requiring surgical intervention at a single lumbar segment from L2 to S1 at Ain Shams university hospitals treated by discectomy and artificial disc nucleus device implantation starting from November 1998. The Oswestry Pain Evaluation Scale and VAS 11-Point Box pain assessment scale were to assess the satisfactory pain relief of the patients; The X-ray measurement of disc height, laboratory investigations of the patients and finally the electron microscope study of the device were to evaluate the adequate motion and stabilization of the implanted device.

Results: Our results after a minimum of one years follow-up showed that patients with implanted device as subtotal replacement of the disc had prolonged post operative back pain and slowly improved Oswestry scores, limitation in the motion and sever reaction in the end plates and vertebral bodies ending to fusion with change of the structural design of the device.

Conclusion: A normal, natural intervertebral disc has a deceptively simple appearance with an outer annulus fibrosus and an inner nucleus pulposus; however, it is extremely difficult to design an effective artificial disc replacement. The basic requirements of disc prosthesis include biocompatibility of the material, normal disc geometry, kinematics, dynamics, and motion constraints, endurance and good fixation to bone. In addition, it must be failsafe. Although the PDN device was a brilliant patent invention to replace the functions of the native nucleus pulposus in the form of subtotal replacement of the disc; the PDN device it fail to reach its goal.

Background: Meningiomas constitute about 26% of all primary intracranial tumors. They are known to recur frequently, and their long term management remains controversial. Previous studies evaluated the relation between estrogen (ER), progesterone (PR) receptors and proliferative activity. The correlation between the presence of these receptors and Ki 67 as proliferative marker on patients outcome is unclear. Aim: To evaluate the presence of estrogen and progesterone receptors, and their relation to proliferative marker Ki-67 in predicting the recurrence of non malignant meningiomas. Materials and Methods: Thirty cases of meningioma were examined immunohistchemically to detect ER, PR and Ki-67 status using monoclonal antibodies. Several parameters including recurrence, age, grade, sex, mitotic index and location of the tumor were analyzed. The correlation between ER, PR and Ki-67 immunoreactivity to these clinicopathological parameters were examined. Correlation between ER, PR and Ki-67 were also analyzed.

Results: Fifteen cases (50%) were ER negative immunostaining, 10 cases (33.3%) were weakly positive, 4 cases (13.4%) were moderately positive, while only 1 case (3.4%) was strongly positive for ER immunostaining. As regard to PR immunoreactivity, we detected 4 cases (13.4 %) were negative, 11 cases (36.6 %) were weakly positive, 11 cases(36.6%) were moderately positive, while only 4 cases (13.4%) were strongly positive for PR immunoreactivity. ER was proved to be related to increase age of the patients as moderate to strong ER positivity was detected in 5 cases with age range from 61-70 years. Benign meningioma demonstrated a generally low level of proliferative activity as measured by both mitoses count per 10 HPF and Ki 67 immunoreactivity. In cases of benign meningiomas, the mitotic count ranged from 0-3/10 HPF, while the 4 cases of atypical meningioma showed mitotic index 4-5/HPF. Regarding Ki-67 immunoreactivity, 10 cases were positive, the strong positivity was detected in all four atypical meningioma, including the two recurrent atypical cases. There was statistically inversed relationship between PR and Ki-67 immunoreactivity, as all negative cases of PR showed positive expression of Ki-67.

Conclusion: Progesterone receptor (PR) and Ki-67 immunostaining detection are essential in the evaluation of patients with intracranial meningiomas. They might have a role in the prediction of recurrence and proliferation. PR status in combination with the proliferative index can be a useful prognostic tool for benign meningiomas.

Background: Hydrocephalus is commonly characterized by ventriculomegaly (enlargement of the cranial ventricles) and changes in intracranial pressure. Endoscopic Third Ventriculostomy (ETV) has recently been accepted as an effective surgical treatment, but its outcome is still multifactorial. Different factors has been reported to affect the clinical outcome after ETV for hydrocephalic patients including-but not limited to-history of previous shunting or infection(4), cause of hydrocephalus(5), association of other neural congenital anomalies(5), and patients' age(6).

Objective: We hypothesize that the outcome of ETV is dependant on fenestration size and location, condition of the 3rd ventricular floor (thin Vs thick), and size of the third ventricle. Patients and Methods: We reviewed the records of all patients who had ETV as a treatment for hydrocephalus at the Cleveland Clinic Foundation during the period from 1995 to 2004. From all 200 ETV patients, only 115 patients were candidate for this study due to the availability of good quality endoscopic photographs. They were followed-up both clinically and radiologically with a follow-up period ranging from 1 week to 56 months. The outcome was classified into two categories clinical outcome and endoscopic outcome. In this study we used the endoscopic pictures obtained during the ETV procedures to assess the fenestration and third ventricular floor criteria (115 patients). In addition, we used the pre-operative anatomical MRI to make an estimate of the third ventricular sizes (59 patients).

Results: From all 200 ETV patients, only 115 patients were candidate for this study (43 Males and 72 Females). The patients' ages at time of surgery ranged from 6 months to 86 years (mean=34 years). The overall outcome of our 115 patients regardless fenestration size and location data showed that 77 patients (67%) had clinical success and 38 patients (33%) had clinical failure and required further surgery for CSF diversion. Clinical failure patients underwent a failure work-up including phase contrast cine PC-MRI, that resulted in 18 patients had patent flow pattern and underwent VP shunting without endoscopic exploration, whereas 20 patients had obstructed flow pattern and were re-explored endoscopically. At re-exploration, 7/20 patients showed a completely patent fenestration despite the obstructed cine flow pattern and were shunted, whereas the remaining 13 patients showed completely closed fenestration and were either shunted or re-fenestrated. So, only this group of patients (n=13/115) was expressed as closures or endoscopic failures (11%).The various relationships between the outcome and fenestration size and location, the condition of the 3rd ventricular floor, and the preoperative size of the 3rd ventricle were studied.

Conclusion: Third ventriculostomy patency is more likely to persist with a thin ventricular floor, but not significantly related either to size or location of the fenestration. Large third ventricle is associated with thin floor and large fenestration size, hence was related indirectly to the clinical success of ETV.

Background: Although neuroendoscopic third ventriculostomy has been used successfully in the treatment of obstructive hydrocephalus(8,11), failures occur as a result of external malabsorption or fenestration closure. Since ventricular size may change little after fenestration(11), postoperative follow-up may rely primarily on resolution of clinical symptoms. When a patient presents with residual or recurrent symptoms after a third ventriculostomy, it is important to differentiate fenestration closure from malabsorption, since the former may be explored for refenestration while the later requires shunting.

Objective: Our aim is to investigate whether Re-ETV is safe and worth trying again after an initial failed ETV, or do ventriculo-peritoneal (VP) shunt in addition to analysis of the RE-ETV and shunted patients and their outcomes. Patients and methods: The majority of this retrospective study was conducted in Cleveland clinic foundation, USA over a-3 year period between 2001and 2004. During the follow-up period of 189 ETV patients for obstructive hydrocephalus, 50 patients with symptom recurrence (failed cases) were candidate for this study. The failed cases were evaluated radiologically and failure work-up protocol was followed for them to determine the proper management. Furthermore, we evaluated the clinical outcome after Re-ETV or VP shunt to investigate its safety and usefulness in treating cases with recurrent symptoms.

Results: A work-up protocol was followed for the failed 50 patients. Cine phase contrast MRI showed the fenestration to be open in 30 patients and obstructed flow at the fenestration site in the remaining 20 patients. Of the twenty patients with obstructed flow pattern, only 16 were endoscopically re-explored and treated according to the condition of the fenestration (10 re-fenestration only due to simple membranous closure, 4 re-fenestration + shunt due to liability of further fenestration closure, and 2 shunt only due to opened fenestration). The remaining 4 were shunted without exploration due to unavailable principle surgeon. As a result, a total of 40 of the failed patients were shunted and 10 were endoscopically re-fenestrated. The clinical data of the Re-ETV patients as well as the shunted ones were verified. The overall outcome for shunting was success in 23/40 patients (58%) with a probability of success of 64% at 2 years follow-up. The mortality rate was 17/40 (42%) in the form of shunt infection, shunt obstruction, or over and under drainage. While, in the re-ETV patients the clinical success was encountered in 5/10 patients (50%) during a follow-up time of 4 -15 months with a probability of success of 60% at 2 years follow-up which is less than that of initial ETV "74% (139/189) at 2 years follow-up" and comparable with that of shunted patients (64%).There was no mortality at the Re-ETV. The surgeon did not observe any additional intra-operative difficulties and felt that the Re-ETV was technically similar to the initial ETV.

Conclusion: The majority (3/5) of initial ETV failures (n=30) were not due to fenestration closure (Cine MRI). Cine PC-MRI was helpful in evaluation of failed ETV by identifying 40% (n=20) of failed patients who were candidates for re-do ETV. Two thirds of closed fenestrations on MRI could be re-fenestrated on re-exploration. Re-ETV success was not as high as initial ETV but comparable to shunting with low morbidity and possibility of shunt avoidance. 144 patients [76%] (139 initial+5 Re-ETV) remained shunt free.

During a 5 year period, the authors performed instrumented transpedicular fusion with posterolateral fusion in cases with symptomatic adult degenerative spondylolisthesis with canal stenosis previously treated with decompression alone. There were 14 females and 11 males, with a mean age of 53 years. Twelve patients had Meyerding grade I and grade II in the remainder. All patients selected for surgery had failed conservative measures with symptoms including mainly back pain, leg pain and neurogenic claudication . All patients had neurological examination and radiological investigations including dynamic plain radiographs, CT scan and MRI with a clinical and radiographic follow up period for about 9.5 months. The surgical procedure was described in details, and lateral fusion was performed using bone graft harvested from the posterior part of the iliac crest. Fusion was performed at one level in 19, two levels in 5 and three levels in one patient.Operated segments included L45 level in all cases (100%), L34 in 4 cases (16%), L23 in one case (4%) and L5S1 in one case (4%).Excellent outcome was reported as regard leg pain and neurogenic claudication, (94%) and 90% respectively. Good result of back pain (84%) while fair outcome in leg numbness and weakness (50% and 40%).

To conclude, the ideal procedure for cases of canal stenosis with degenerative spondylolisthesis is decompression with istrumented lateral fusion via transpedicular screws. Even in patients who failed improvement after decompression alone, they can benefit markedly from instrumented lateral fusion.

Objectives: Intraventricular meningiomas (IVMs) are rare and formidable lesions. Herein, a report of 11 intraventricular meningiomas is reported with a special emphasis on the clinico-radiological appearance and surgical outcome. Methods: Eleven patients with histoliogically verified IVMs underwent a retrospective study. Surgery was performed via parieto-occipital route in six patients with trigonal meningiomas, infratentorial supracerebellar approach in two patients with posterior third ventricular meningioma, while telovelar approach was utilized in three patients with fourth ventricular meningiomas. A retrospective study was conducted by analyzing clinical data, neuro-imaging studies, and operative findings. The degree of tumor removal, clinical outcome, and post operative complications are described.

Results: Six of the 11 tumors were located in the trigone of the lateral ventricles (54. 5 %), three were in the fourth ventricle (27. 3 %), and two were in the posterior third ventricle (18. 2 %). There were seven females (63. 6 %), and four males (36. 4%). Repeated vomiting was a characteristic symptom with fourth ventricular meningiomas, while bilateral tinnitus was present with posterior third meningiomas. Raised intracranial pressure was the commonest presentation. Pre operative CSF diversion was carried for patients with third and fourth ventricular meningiomas. Total tumor removal was achieved in all trigonal meningiomas via parieto-occipital craniotomy. Post operative intraventricular drain was sufficient to drain bloody CSF and permanent CSF diversion was not needed. For the posterior third ventricular meningiomas (Two cases), subtotal removal was obtained via infra-tentorial supracerebellar approach. Subtotal removal was complicated by post operative hematoma, and two patients died after hematoma evacuation. In fourth ventricular meningioma, telovelar approach allowed panoramic view for the fourth ventricle with uneventful total tumor removal. The mortality rate was 18.2% (Two of 11 cases). Conclusions: Intraventricular meningiomas are rare tumors. In the trigonal IVMs there are no specific clinical features, and the tumors often grow slowly to a substantial size before they become symptomatic. Repeated vomiting is a characteristic symptom with fourth ventricular meningiomas, while bilateral tinnitus is a unique feature with posterior third meningiomas. Surgery for these lesions is a challenging, and requires planning to avoid eloquent area damage. After considerable internal debulking of the tumor, control of the vascular supply to the tumor is a crucial point. For lateral intraventricular meningiomas with trigonal location, the parieto-occipital route is a safe surgical approach, while for posterior third ventricular meningioma, infratentorial supracerebellar offers limited exposure whenever conservative surgical strategy is attempted. For fourth ventricular meningiomas, telovelar approach is a safe and effective approach.

The present study presents our experience with posterior fossa hemangioblastomas surgically treated at Cairo University hospitals. Methods: A retrospective review of a series of 11 consecutive patients with histopathologically verified posterior fossa hemangioblastomas operated upon in our institution along a period of 5 years.

Results: Among all 11 patients, 7 were males (63.6%) and 4 were females with a mean age of 27.3 years. The tumors were all newly diagnosed in 10 patients and only one case was recurrent. Tumors were predominantly cystic with a mural nodule in 8 patients (72.8%), entirely solid in 2 cases (18.2%) and mixed in one. In 8 patients (72.8%), the tumor was located in one of the cerebellar hemispheres, with extension of the cyst into the vermis in 2 of these. The Vermian-brainstem region was the site for 3 tumors (27.3%) . Six patients presented with hydrocephalus at the time of their initial diagnosis; of which 3 had a shunt inserted. Total excision of the tumor was achieved in 10 of all 11 cases (90.9%). Subtotal excision was done only in the case with the recurrent tumor. The clinical condition improved in 6 patients (54.5%), did not change in 3 (27.3%) and was worsened in one case (9.1%). One patient became severely disabled due to severe bulbar manifestations and died of fatal aspiration pneumonia.

Conclusion: Complete and safe microsurgical resection of posterior fossa hemangioblastomas can be achieved in most cases, although the treatment of complex solid masses, recurrent tumors, those in close proximity to the brain stem and/or part of VHL syndrome remain challenging to the neurosurgeon.

Objectives: Selecting patients for shunt insertion in idiopathic normal pressure hydrocephalus (NPH) remains controversial. The use of clinical criteria together with imaging studies has limited effectiveness in predicting shunt success. Other used tests included isotope csiternography, tap tests, resistance measures, and long term recording of intracranial pressure. The goal of this study is to assess the usefulness of external lumbar drainage (ELD) of cerebrospinal fluid (CSF) in determining which patients would most likely benefit from shunt insertion. Methods: Sixty-five patients were diagnosed as cases of idiopathic NPH according to a fixed management protocol. The clinical criteria included gait disturbance, incontinence and dementia, together with ventriculomegaly demonstrated on computerized tomography or magnetic resonance imaging studies. All patients were admitted to the hospital neurosurgical department for 3 days ELD of CFS. Full assessment of gait and neuropsychological testing was conducted before and after drainage. A Shunt procedure was then offered to patients who had experienced clinical improvement from ELD. Shunt outcome was assessed along one-year post surgery.
Conclusions: Data in this report confirm that ELD is the best prognostic indicator of a positive shunt outcome, with an accuracy of prediction 95% or more, with negligible complications.

Objective: Anterior single screw fixation is one of the surgical options providing sufficient immediate stabilization of the spine and preserving normal C1-2 motion. In this study the indications, the surgical technique, and outcome of patients who underwent this procedure were reviewed. Methods: Thirty consecutive patients (25 males and 5 females) who underwent anterior single screw fixation for recent Type II odontoid fractures at King Fahd Hospital, Al-Madina Al-Munawarah, in Saudi Arabia (SA) between January 2004 and December 2007 were included in this study. Data including clinical examination, imaging studies and operative technique were used to analyze the results of this surgical technique.

Results: The clinical and radiological results, in our series, were conclusive. The use of single screw for fixation of type II odontoid fracture was found easier and simpler than common method at which the double screws were used with the same advantages. The surgical technique resulted in immediate spinal stability and preserves normal rotation at C1-2 in all patients (100% of cases). Radiological evidence of bone union achieved in 22 patients (73% of cases); and nonunion in 8 patients (27% of cases). Complications related to surgical procedure and hardware failure were recorded in 4 patients (13% of cases). Conclusions: Direct anterior single screw fixation is an effective, simple, and safe method for treating type II odontoid fractures. It is associated with rapid patient mobilization, minimal postoperative pain, and shorter hospital stay. By this technique, the required anatomical and functional outcome can be obtained through immediate stability of the axis, preserves C1-2 rotatory motion, and achieved high union rate.

Objectives: The present study aimed to evaluate the outcome of early surgical management of Chiari malformation type I (CMI) as regards surgical feasibility and neurological outcome. Patients & Methods: The study included 15 patients; 9 females and 6 males with mean age of 30.5±9.1 years. Inclusion criteria included symptomatic manifestation and MRI findings of cerebellar herniation through the foramen magnum of at least 3 to 5 mm below it. Suboccipital headache was the main presenting symptom described by all patients in association with ocular disturbances in 11 patients, otoneurological disturbances in 10 patients, lower cranial nerve palsy manifestations or nystagmus in 5 patients, sensory disturbances in 13 patients, motor weakness 7 patients, pain in 6 patients and disturbances of spinal cord function in 14 patients in varied combinations. All patients underwent MRI and syringomyelia was reported in 10 patients. Preoperative MRI revealed the syrinx to be located off-center in 9 patients. In 7 patients the syrinxes were considered large. All patients were surgically treated by foramen magnum decompression (FMD) and 7 syringo-subarachnoid (SS) shunts were implanted. Patients were evaluated clinically in the immediate postoperative period, at 6 weeks, 6 months, and at least yearly thereafter and MRI scans of the syrinx were performed between 2 and 12 weeks postoperatively.

Results: Patients with brainstem compression had significantly shorter duration of preoperative symptoms compared to those with syringomyelia. Collectively, neurological improvement was reported in 12 patients (80%), while 2 patients (13.3%) showed no change and one patient (6.7%) became worse after surgery. However, all patients showed improvement of presenting symptoms but of variable presentation and postoperative evaluation showed statistically significant reduction of the frequency of symptoms determined preoperatively. There was only one FMD non-responder who developed mild subjective increase in long tract signs and MRI revealed no changes in the syrinx size, 2-months later a SS shunt was implanted and the patient started to improve. All the patients who had SS shunting showed decreases in size of the syrinxes; no patient showed deterioration after surgery but one patient (6.7%) developed mild post operative bacterial meningitis which was controlled conservatively. Conclusion: for clinically symptomatizing CMI patients early surgery gives good responce, the diagnosis and choice of surgical procedure must rely on MRI findings. Brain stem compression symptoms improve dramatically with decompression, whereas syrinx symptoms improve slightly or stabilize especially in small syrinxes. SS shunting for syringomyelia with CMI is a safe, effective, and is technically a simple procedure with effective outcome.

Background: The value of Steindler flexorplasty in restoring elbow flexion after failed brachial plexus surgery was investigated. Materials and Methods: 3 male adult traumatic brachial plexus patients ( 2 C5,6 lesions, 1 C5,6,7 lesion) were selected for surgery. 1 patient had recovered shoulder function, in the other 2 patients the shoulder had been arthrodesed; in 1 patient a tendon transfer had been carried out to restore wrist and finger extension. All patients were treated subsequently by Steindler flexorplasty. Functional improvement was scored using the criteria established by Alnot and Abols [2].

Results: C5,6 lesions (2 patients) were found to have a very good functional score, the C5,6,7 lesion ( 1 patient) was found to have a good functional score. Conclusions: Steindler flexorplasty is avaluable option to restore elbow flexion after failed brachial plexus surgery, especially in C5,6 lesions when the forearm flexors are powerful and there is no loss of elbow wrist or finger extension.

Background: In the modified Tsuge tendon transfer for radial nerve palsy, tendon bowstringing occurs after transferring the palmaris longus to the rerouted extensor pollicis longus leading to loss of thumb extension. Therefore, the effect of a split flexor carpi radialis transfer to restore extensor pollicis longus and extensor digitorum functions separately was investigated. Materials and Methods: 7 male patients suffering from late high radial nerve palsy were treated with the split flexor carpi radialis technique and followed up for 2 years. To achieve wrist extension, the tendon of pronator teres (PT) was transferred to the extensor carpi radialis brevis (ECRB) distally. Extension of the fingers and of the thumb were restored with a split flexor carpi radialis (FCR).

Results: Improvements were recorded in wrist extension (range: 50°) and flexion (range: 40°), finger extension (range: 30°), thumb extension (range: 65°), radial abduction (range: 36°), thumb abduction (range: 40°) A palmaris longus to abductor pollicis transfer was carried out in 2 patients, however. Grip strength improved to 63% of that of the contralateral hand. Conclusions: Pronator teres transfer to extensor carpi radialis brevis restores wrist extension efficiently; the split flexor carpi radialis transfer to extensor pollicis longus and extensor digitorum restores function separately to each muscle. No tendon bowstringing occurs. To enhance thumb abduction, the transfer may be augmented in certain cases with Palmaris longus to abductor pollicis longus transfer.

Objectives: This study aimed to determine the frequency of unintended dural tear (DT) during lumber spinal surgery and to evaluate the efficacy of a proposed DT management protocol. Patients & Methods: Among 2016 cases of lumbar spine surgery, 183 cases of unintended DT were reported with a frequency of 9.08%; 19 cases among 76 cases had revision spinal surgery (25%) and 164 cases had primary spinal surgery (8.45%). Management protocol insisted on preventive measures and urgent treatment once CSF is noticed by primary closure of DT using 4-0 vicryl. Anterior side DT was accessed through a posterior durotomy that was subsequently closed by 4-0 vicryl and a small muscle patch over it. If primary repair was impossible, alternatives included placement of muscle graft over the suspected leak site or the use of gelfoam. Non-suction wound drainage was used in few cases if there is some bleeding. Early mobilization 1-day after repair was practiced and carbonic anhydrase inhibitor in divided doses between 250-1000 mg -day and diuretics like frusimide 40 mg -day were used immediate postoperatively for 3 weeks.

Results: Dural thinning in cases of longstanding stenosis, adhesion of the dura to removed bone and dural retraction were the commonly encountered causes (23.5%, 22.4% and 17.5%) followed by perforation of the dura when it expands onto a surgically created spicule of bone or due to an obscured fold of dura caught in a rongeur or curette or slippage of an instrument (10.4%, 8.2% and 6.5%, respectively). DT due to adhesion to scar tissue was reported in 10.4% of cases had DT. All DT were repaired with a 4-0 vicryl suture; after this repair, a Valsalva maneuver showed that there was no CSF leakage from the repair site. Failure of primary closure was reported in 4 patients (2.18%) presented as persistent headache and clear fluid drainage from the drain after the procedure. However, conservative measures failed and these 4 patients underwent a second repair of the dural defect 4-weeks later.

Conclusion: DT was reported in 9.08% of cases had lumber spine surgery and was more frequent after revision surgeries. The applied policy of prompt identification and careful water-tight closure of the dural defect with early mobilization and administration of carbonic anhydrase inhibitor and diuretics provided successful outcome in 98.2% of cases with DT.