Purpose: To study the results of anterior cervical discectomy and fusion (ACDF) using PEEK cage packed with autologous iliac bone graft harvested by a minimally invasive technique.

Outcome measures: Visual pain analogue scale (VPAS) was used to assess the severity of radicular pain both pre and postoperatively. Odom's criteria were used to assess the postoperative functional level. Any residual pain or discomfort at the graft donor site was reported. Fusion was evaluated by plain radiography. Statistical comparison of the pre and postoperative VPAS was done using paired "t" test.

Results: 10 cases were graded excellent, 6 good, 4 fair and 2 poor. Radiular pain showed dramatic improvement postoperatively. The mean postoperative VPASs at 6 weeks, 3 months, 6 months and 12 months were 2.5, 1.5, 0.5 and 0 respectively. None of the patients reported any symptoms in relation to the graft donor site. Fusion was evident in 72.7 % of cases at 3 months and 90% at 6 months. All cases reviewed at 12 months (six cases) showed radiological evidence of fusion. Complications included: temporary dysphagia (9.1%), haematoma (4.5%) and temporary recurrenct laryngeal nerve palsy (4.5%).

Conclusion: ACDF using PEEK cage packed with autologous bone graft is a safe and effective method for treating degenerative cervical disc disease. The minimally invasive technique did not result in any graft donor site morbidity.

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Objective: The temporal lobe is a complex part of the brain which contains eloquent structures that perform many higher cerebral functions. Several pathologies can affect the temporal lobes and have different clinical presentations. Temporal lobe surgery includes several approaches with varying outcome results. The aim of this study was to identify common temporal lobe pathologies, evaluate their clinical presentations and postoperative outcome following different surgical approaches.

Methods: Fifty cases operated upon at the neurosurgery department, Alexandria University were reviewed. The different clinical and imaging features were analyzed, and outcome following different surgical approaches was addressed.

Results: Patients with temporal lobe lesions presented with manifestations of elevated intracranial pressure in 52%, focal neurological deficits in 28%, short-term epilepsy in 20%, and long-term medically intractable epilepsy in 28%. Lesionectomy either partial or complete was performed for 72% and anterior temporal lobectomy with extended mesial resection was performed for 28%. Following lesionectomy, headache and symptoms of elevated intracranial pressure improved in 70%, contralateral hemiparesis improved in 67%, and seizure control "on antiepileptic medications" for short-term epilepsy was complete in 80%. No patients achieved seizure cure i.e. off antiepileptic medications. Following anterior temporal lobectomy with extended mesial resection, complete seizure control "on antiepileptic medications" for long-term medically intractable epilepsy occurred in 78.5%, of whom 18% achieved seizure cure i.e. off antiepileptic medications.

Conclusion: Lesionectomy for temporal lobe lesions is beneficial to reduce elevated intracranial pressure and correct neurological deficits and provides good seizure control for short-term epilepsy however, seizure cure and withdrawal of antiepileptic medications is seldom achieved. Anterior temporal lobectomy with extended mesial resection provides good seizure control for long-term medically intractable epilepsy and may be beneficial to achieve seizure cure for short-term epilepsy.

Objectives: The current study aimed to compare the efficiency of epidural injection of methylprednisolone (M) with or without hyaluronidase (H) in treating patients with failed back surgery syndrome

Patients & Methods: The study included 60 patients with history of previous spine surgery and had persisting pain for >6 months with a leg pain severity of ?60 on pain visual analogue scale (VAS) and pronounced epidural fibrosis surrounding the nerve root as judged by MRI examination. Both back pain and leg pain were evaluated separately using 0-100 point pain VAS with zero= no pain and 100= worst intolerable pain. Impact of pain on daily life activities was evaluated using the modified Oswestry Disability Questionnaire (ODQ) with higher total score indicates worse function. All patients received epidural injection of 100?g fentanyl plus 120mg methylprednisolone solution (Solu-medrol) in 20ml saline in group M and 120mg methylprednisolone solution and 1500 units hyaluronidase in 20ml saline in group H+M. All patients were assigned to receive 2 injection-settings one-week apart of the same medications. Follow-up consisted of evaluation of back and leg pain scores, disability score and the need for analgesics at 1, 3, 6 and 12 months after the second injection-setting.

Conclusion: The obtained results confirm the benefits of percutaneous epidural adhesiolysis as part of an overall pain management strategy with a superior outcome with the use of hyaluronidase in combination with methylprednisolone

Objective: the aim of this study is to evaluate vertebroplasty as a minimally invasive technique in the management of vertebral compression fractures.

Patients and methods: A prospective study was carried out in the Department of Neurosurgery at Ain Shams University Hospitals from July 2004 to January 2006. 31 patients were treated for disabling back pain and / or impaired mobility secondary to vertebral compression fractures of variable etiology. Two outcome measurement tools were utilized, a Verbal Pain Scale and Roland-Morris Disability Questionnaire (RDQ). Only patients with moderate or severe disability according to the former classification were considered for vertebroplasty using polymethylmethacrylate (PMMA). Within the first week after vertebroplasty, the eleven point pain scale was reapplied to the patients, together with the (RDQ). Two follow up visits were scheduled, at (4-6) weeks, and at six months after the procedure, during which the patients were asked to complete the (RDQ) again.

Conclusion: the majority of patients who offered vertebroplasty noted significant pain relief after the procedure. Sever or permanent complications are rare. Selecting appropriate patients for vertebroplasty is of utmost importance.

Background: The incidence of brain metastases in breast cancer patients is 14-20%.(1) Whole brain radiotherapy (WBRT) is the most common treatment for brain metastases. Most of these patients have a poor survival prognosis. A short radiation program may be preferred, if it provides a similar outcome as longer program.(2) Purpose: Prospective randomized comparative study to assess the outcome of one week whole brain radiotherapy (WBRT), 20 Gy in five fractions versus the longer, more commonly used two weeks, 30 Gy in ten fractions, in breast cancer patients with brain metastases, regarding overall survival, objective clinical outcome, and early delayed toxicity, together with assessment of other clinical and biological prognostic factors.

Material & Methods: Patients underwent recording of their clinical and biological disease criteria and were randomized into two groups, group (A) to receive one week WBRT, 20 Gy in five fractions, versus group (B) who received two weeks WBRT, 30 Gy in 10 fractions.

Conclusion: In most breast cancer patients with brain metastases, a short one week whole cranial irradiation of 20 Gy in five fractions is more preferable to the more time consuming, laborious, and costly two weeks WBRT, being offering similar survival, clinical objective response rate and early-delayed toxicity profile. Breast cancer patients and brain metastases, with favorable prognostic criteria, of RPA class I or II could be the selected group who deserve trials of more innovative treatment aiming for improvement of survival.

The purpose of this study was to determine whether the anatomic position of a lumbar disc herniation has any significant effect on the clinical outcome of lumbar discectomy in relation to the approach used. Between January 2003 and June 2007, 80 patients with simple disc herniations underwent lumbar discectomy for herniated nucleus pulposus. We reviewed preoperative computed tomography scans and magnetic resonance imaging of the lumbar spine. Disc herniations were classified as central, paracentral, intraforaminal, extraforaminal protrusions or migrating type. We evaluated our patients postoperative by the Macnab evaluation scale, which divided patients into groups with excellent, good, fair and poor clinical outcome. The post-operative evaluation period ranged from 6 to 42 months.

The clinical outcome was then correlated with the different positions of herniations. We found a poorer clinical outcome that was statistically significant in patients with central herniations and intraforaminal. Most herniations occurred at the L4-L5 level (58.7%). However, the level of disc herniation was not found to be a predictor of clinical outcome. Types and anatomic positions of the lumbar disc herniation are of prognostic value for the outcome of lumbar discectomy. Further studies are required to confirm our preliminary results and eventually help improve surgical indications for lumbar discectomy.
Key Words: site of the herniated lumbar disc.

Objective: The objective was to determine the importance of the "sagittal shoulder sign" on magnetic resonance (MR) images for the diagnosis of conjoined Lumbosacral nerve roots (CLNR) that are compromised by herniated discs.

Materials and Methods: Magnetic resonance images of 11 patients (6 men and 5 women; age range, 25-71 years; average age, 48.7 years) with surgically proven CLNR, which was compromised by herniated discs, were retrospectively evaluated by two radiologists. MR images were evaluated for the presence or absence of the sagittal shoulder sign - a vertical structure connecting two nerve roots and overlying disc on the sagittal MR images. The radiologists noted the type of accompanying disc herniation and bony spinal canal changes, as well as other characteristic MR features of CLNR, the common passage of two consecutive nerve roots through the neural foramen on axial MR images.

Results: The sagittal shoulder sign was identified with a mean frequency of 90.9% by the two observers (in 10 of 11 patients, by observers 1 and 2, respectively). Good interobserver agreement for the sagittal shoulder sign was present (k = 0.621, p < 0.05).

Conclusion: Observation of the sagittal shoulder sign may prove helpful for diagnosing CLNR in patients with disc herniation. In particular, this sign appears to be useful when there is no evidence of CLNR on axial MR images.

Objective: Despite advances in cerebrospinal fluid (CSF) diversionary techniques, shunt failure due to infection or malfunction remains a persistent problem in hydrocephalus care. The aim of this study was to identify risk factors predisposing to repeated CSF shunt malfunction and to determine whether subsequent shunt failures are related to patient characteristics, and/or surgical details.

Patients and Methods: There were 195 shunt failures in 130 patients with hydrocephalus requiring CSF diversionary procedures were included in a prospective observational study during 9 years in Benha University Hospital. Patient characteristics were defined as age, gender, weight, head circumference, cause of hydrocephalus; and the shape of ventricular systems. Surgical details and procedures were studied to define any relation to the incidence of shunt failure.

Results: The patient's age at the time of initial shunt placement is important predictor of repeated shunt failures. There were significant association between the cause of hydrocephalus, and the shape of ventricular system; and shunt failure. Some surgical details and procedures were associated with an increased risk of failure included whether the procedure was performed on an emergency or non-emergency basis, manipulation of the shunt hardware; and the duration of surgical procedure.

Conclusion: The patient's age at the time of initial shunt placement as well as the cause of hydrocephalus and the shape of ventricular system are important predictors of shunt failures. Some surgical procedures were associated with an increased risk of shunt- related failure. Prevention and early identification and management of CSF shunt failures remain the main factors to assure the quality of the patient's long term outcome.

Objective: To assess patient outcomes and complication rates after minimally invasive lumbar microdiscectomy.

Patients and methods: A retrospective clinical review of 30 patients who underwent microsurgical discectomy for previously untreated single level lumbar disc herniation. All patients were clinically followed for at least one year and outcomes were evaluated by using pain intensity and presence of physical signs.

Results: Out of the 30 patients, 17 patients are males and 13 patients are females. The mean age of the patients in this study is 37 years (range from 21 to 52 years). Favorable clinical outcomes were obtained in 28 patients (93.3%). The overall complication rate was 6.6%. Two patients had recurrent disc herniations requiring reoperation.

Conclusion: Minimally invasive lumbar microdiscectomy is an effective and reliable treatment for lumbar herniated discs. The results and complications in this series were comparable with other publications. Careful preoperative evaluation correlating clinical symptoms and signs to neuroimaging abnormalities are essential for favorable outcome.

Background: Split Cord Malformation (SCM) is the most common underlying anatomical abnormality of occult spinal dysraphism.[2,3]. Split cord malformations (SCM) are increasingly being recognized as one of the causes of tethered cord syndrome. Renaming them as SCMs has reduced the conflict in terminology, like 'Diastematomyelia' (Olivier) 'Diplomyelia' (Bruce) with poor distinction. Pang et al. have proposed unified theory and recoined them as 'Split cord malformations'[12, 28, 29, 30]. With the advent of MRI, the diagnosis of SCM has become relatively frequent.

Objective: To study the clinical profiles, radiological findings and surgical outcome of patients having split cord malformation.

Patients and methods: This study was conducted in neurosurgery department, Assiut university hospital over a three-year period between January 2005 and December 2007. Of 90 patients with spinal dysraphism, 10 (11.1%) patients had symptoms and signs that raised the suspicion of occult spinal dysraphism, which was confirmed on neuro-imaging investigations to be split cord malformation and some associated anaomalies.

Conclusion: SCMs are rare complex forms of occult dysraphism. In type I the cord is anchored by an extra-dural bony spur and /or short, thick filum terminale. In type II tethering is caused by fibrous band, which anchors, hemicords to the anterior dura. MRI is the imaging of choice, but high resolution CT can be complimentary. Hypertrichosis is the commonest marker to the clinical diagnosis. Surgery and detethering should be considered prophylactically after diagnosis and in all symptomatic children. Rational decisions are necessary in children who are neurologically compromised and harbor complex anomalies. Outcome is very good in children with isolated split cord malformation without associated complex malformations.[26].