Objective: The goal of this study was to demonstrate the efficacy of a simple and reliable technique for anterior skull base reconstruction as single stage management after complete removal of extradural destructing lesions affecting the anterior skull base.

Method: All the cases treated surgically through frontal craniotomy and complete removal of the lesion with extirpation of sinus mucosa, and then acrylic cranioplasty which shaped to cover the deficit bone and to be in fixed in position to prevent pulsating eye, and taking the natural topographic features of anterior skull bases . Immediate successes of treatment of proptosis achieved after this reconstructive surgery, and follow up radiology proved the efficacy of this policy of management.

Conclusion: Single Stage Management after complete removal of extradural destructing lesions affecting the anterior skull base by using acrylic cranioplasty appear to be efficient in reconstruction of anterior skull base and without complications.

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Aim of the work: The present study was designed to study the factors that affect the prognosis of posterior fossa medulloblastoma in children as age, sex of the patient, location of the tumor, extent of surgical resection of the tumor, CSF cytology and histopathological factors as tumor subtype, apoptosis, cytological anaplasia, proliferative index, and the expression of p53.

Material and Methods: 30 cases of childhood medulloblastoma were studied retrospectively regarding their clinicopathological features in order to evaluate the impact of different factors on patients' survival. In addition, proliferative index (assessed by Ki67 expression) and p53 expression were evaluated in relation to each other as well as other clinicopathological factors.

Results: The present work was conducted on 30 children (< 12 years) with medulloblastoma: 12 cases (40%) were classic medulloblastoma, 12 cases (40%) were desmoplastic/nodular medulloblastoma and 6 cases (20%) were anaplastic medulloblastoma. The mean percentage of Ki67 was 33.67%. p53 was positive in 11 (36.67%) cases. Proliferative index was found to be significantly higher in patients presenting with metastatic disease at the time of diagnosis or brain stem infiltration and in anaplastic variant, tumors showing cytological anaplasia and diffuse or extensive apoptosis. p53 was significantly correlated with apoptosis, cytological anaplasia and radiotherapy. A statistically significant relation was found between the proliferative index and the expression of p53. Bivariate survival analysis showed that survival was significantly shorter in children < 7 years of age, male gender, anaplastic variant, brain stem infiltration, tumors positive for p53, tumors featuring cytological anaplasia and diffuse or extensive apoptosis and in patients who did not receive radiotherapy. Multivariate analysis showed that histopathological subtype was the only independent predictor of patients' survival. The estimated risk of death was highest among patients with anaplastic medulloblastoma.

Conclusion: The histopathological subtype was the only variable that showed influence on patients' survival rate and which might be considered as a potential prognostic factor in MB. We suggest that the histopathological subtype should be incorporated into the current clinical risk stratification of MB patients.

Objectives: A retrospective comparative study evaluating the results achieved using PMMA (polymethylmethacrylate) or cervical cage for disc replacement and fusion following single level anterior cervical discectomy (ACD).

Methods: A total of 40 patients, divided into two groups of 20 patients each, group I; having PMMA used for disc replacement and group II; having cervical cage placement after ACD. Results of both groups are evaluated regarding: 1) clinical outcome according to Odom's criteria and classified into, excellent, good, fair and poor, 2) radiological outcome and interbody fusion, 3) simplicity and postoperative morbidity of each procedure and 4) complications related to each technique. Patients were followed up for a mean period of 12 months. Group I presented excellent and good clinical outcome in 75% of patients immediately postoperative and 85% at 6 and 12 months, while fair and poor outcome in 15% of patients at 12 month interval. Radiological partial fusion (although not targeted) occurred in 40% of cases at 12 months postoperative interval. Graft extrusion occurred in 10% of cases which is partially related to surgical technique (careful placement and impaction of PMMA). No other graft related complications, progressive deformity or instability were reported. Group II achieved 90% excellent and good clinical outcome at 6 and 12 months respectively. Fusion rate of 80% at 12 months interval was achieved, cage migration in 5% (1 patient) into adjacent vertebral bodies which needed surgical removal after causing partial collapse of the disc space height. No other cage related complications were reported.

Conclusion: The use of both PMMA and cervical cage are safe, effective and simple techniques for disc replacement after ACD having few rate of morbidity and material related complications at 12 months interval. Cervical cage is preferred owing to the higher rate of fusion and relatively low complications.

Objective: Prospective randomized study evaluating preliminary results of performing posterior fossa decompression, intradural dissection of arachnoid adhesions, fenestration of Magendi's foramen and duroplasty in treatment of symptomatic Chiari type I malformation in adults.

Methods: Eighteen consecutive patients 7 males and 11 females (M:F=1:1.6), ranging from 18-56 yrs (mean age 36 yrs), were operated upon by the author at Cairo University Hospitals between January 2005 and December 2007. All patients were radiologically studied by preoperative MRI of the cranio-cervical junction, cervical and dorsal spine revealing Chiari type I malformation reaching C1 in 10 patients (56%) and C2 in 8 patients (44%) in addition to CT or MRI brain to exclude associated anomalies. Syringomyelia was detected in 10 patients (56%) 7 of them cervical and cervico-dorsal in 3 patients. Clinically, patients were presenting by predominently headache (100%) and neck pain (89%) in addition to other posterior fossa compression symptoms and cord dysfunction. Postoperative clinical outcome was assessed at 3,6 and 12 months intervals, revealing good outcome in 66%, 78% and 83% respectively, fair outcome in 17%, 11% and 15% while poor outcome was reported in 17%, 11% and 6% respectively. Radiological follow up was performed by 2nd day postoperative CT of the cranio-cervical junction with sagittal reconstruction demonstrating the bony work. Postoperative MRI was done at 6 and 12 months intervals revealing good tonsillar position in 89% while 11% had tonsillar level within 5 mm below foramen magnum. Syringomyelia showed marked improvement in 60% and 70% at 6 and 12 months respectively. No patients required resurgery, 2 patients (11%) had CSF leak and 1 patient (6%) had superficial wound infection. No cases of hematomas, neurological deterioration or instability were encountered.

Conclusion: Posterior fossa decompression, fenestration of foramen of Magendi and duroplasty is an effective modality among various postulated techniques for treatment of Chiari type I malformation with or without syringomyelia, achieving good clinical and radiological outcome and low complication rate.

Aim: The goal of this study is to examine the role of gamma knife radiosurgery (GKS) as part of a multimodal approach in the management of craniopharyngiomas. Method: This study included 23 patients who were treated by GKS, at the Nasser Institute, Cairo, between January 2002 and January 2008 and followed up for a minimum of one year. These patients underwent a total of 32 treatments by the gamma knife, as well as a combination of microsurgery, Ommaya catheter placement and intracystic Bleomycin therapy. The patients were then followed up by MRI, visual field examination and hormonal profile for a mean follow up of 34 months and a maximum of 72 months. The mean tumor volume was 7.1 cc (range 0.6-27 cc). The mean prescription dose was 8.7 Gy (range 6-15 Gy) with a mean tumor cover of 92% (range 81-98%).

Results: Fourteen patients showed growth control (61%) and 9 demonstrated tumor progression (39%) and those were all due to either cyst re-expansion or new cyst formation. There was a tumor progression tendency in younger age patients and tumors with cystic components. Further analysis revealed that a prescription dose of 9 Gy or more was specially a significant factor (p 0.03) towards tumor growth control. The solid portions of the tumors all showed growth control (stable in 8 and smaller in 7) with doses as low as 6 Gy. Regarding visual outcome, 9 patients showed improvement of their visual fields (in 3 patients this was attributed to cyst aspiration), in 11 it remained stable and in 3 it worsened (all due to cyst progression), with visual improvement sited more in the higher age group.

Conclusion: Because of the complex morphological nature of these tumors, a multimodality approach is necessary as it was found that no single treatment modality could achieve adequate long-term control. Minimal invasive treatments such as GKS, stereotactic Ommaya placement and Bleomycin therapy should be considered due to their minimal morbidity and mortality.

Introduction & Objective: Endoscopic third ventriculostomy has become an increasingly preferred alternative to ventricular shunts for noncommunicating hydrocephalus in adults. However, the criteria of evaluating its success or failure remains problematic. Few studies report purely adult series of ETV.

Methods: Thirty two hydrocephalic patients were included in this retrospective single-surgeon case series analysis. Eighteen cases were aqueductal stenosis and 14 cases of hydrocephalus due to mass lesions. Age ranged 18-62 with the mean of 38.4 years. The main criterion to evaluate ETV success was clinical improvement and shunt indepandence.

Results: One month after ETV an overall clinical improvement was observed in 26 (81%) patients. Three patients remained unchanged, and 3 deteriorted. At 6 months the ETV was successful in 22 (68.7%), 2 remained unchanged while 8 cases (25%) deteriorated. Radiologically ventricular size became smaller in 50% of cases after 1 month, compared to 68% of cases after 6 months. The overall success rate was higher for aqueduct stenosis cases (83%) compared to mass lesions (78%).

Conclusion: ETV is a valuable alternative to shunt in managing obstructive hydrocephalus patients especially in idiopathic aqueductal stenosis cases. Compared to postoperative clinical improvement, ventricular size remains an inadequate measure to judge for its success or failure.

The outcome of surgical treatment of secondary tethered cord syndrome varies according to the clinical presentation of the patients, the time of diagnosis and the surgical skills and experience of the surgeon.

Aim of the study: the aim of this work was to evaluate the outcome of patients after surgical correction of secondary tethered cord syndrome in pediatric and the factors that affect the prognosis.

Patients and methods: the study was conducted on 16 patients having secondary tethered cord syndrome admitted to the neurosurgery department of the main Alexandria University Hospital from January 2005 till 2009. The patients underwent untethering surgery for their lesions, the age of the patients ranged from 3-12 years, less than 5 years in groups A and more than 5 years in group B, most of the selected patients had neurological deficit as motor and sensory deficit, bladder and bowel dysfunction that was aggravated than their initial clinical status. All the patients had preoperative neurological and urine function evaluation, and then reevaluation after surgery for a period ranged from 6-18 months.

Results: bladder and bowel dysfunction was found in 85.7% of group A, and in 88.9% of group B. It is improved in 66.7% in group A and 50.0% in group B. Motor and sensory deficit was detected in 85.7% in group A and in 100% in group B. It is improved in 50.0% in group A and 44.4% in group B. Non dermatomal leg pain was present in 57.1% in group A and 88.9% in group B, that was improved in 100% in both groups. In general the improvement in group A was better than in group B.

Conclusion: the outcome of untethering operation for secondary tethered cord syndrome depends mainly on the clinical presentation of the patients, the time of surgical intervention and the surgical skills of the surgeon.

Background: A decompressive craniotomy can relieve critically increased intracranial pressure, so it was performed in the treatment of uncontrollable unilateral cerebral edema resulting from trauma and other conditions. In this prospectively collected data ,

Objective: to assess the postoperative clinical outcome and compare it with other series.
Methods: (a) patient selection : patients presented to the Neuroemergency unit in Kasr El-Eini Hospitals from January 2006 to December 2007 with traumatic brain injury and fulfilling the following criteria 1) clinical deterioration to Glasgow coma scale (GCS) 11 or presented to us with GCS (5-11 )and refractory to conservative treatment of increased intracranial tension, 2) age ranging from 20 to 60 years, 3) radiological criteria : unilateral brain swelling with midline shift .(b) procedure :decompressive hinge craniotomy.(c) Evaluation of postoperative clinical outcome by the Glasgow outcome scale (GOS) at the time of hospital discharge and at 6-months thereafter, then comparing the clinical outcomes with those of in other researches.

Results: The overall outcomes at 6-months follow up were good in 9 patients (45%), fair in 2 patients (10%), poor in 9 patients (45%).mortality in 6 cases (30%), vegetative state was seen in 3 cases (15%) . overall survival was 70% with favorable outcome in 65% of the survivors.

Conclusion: Age and initial posttraumatic GCS remain to be the most important factors in determining the postoperative clinical outcome. Decompressive hinge craniotomy provided favorable clinical results in nearly 45% of patients who were otherwise most likely to die.

Background: Ex preterms often develop hydrocephalic changes which may necessitate Ventriculo-peritoneal shunt insertion as early as possible to preserve cognitive functions. Surgery is often challenged by the preterm's bleeding tendency, susceptibility to infections in addition to anatomical differences.

Methodology: A case series of ex preterms with hydrocephalic changes were followed through their course and evaluated by comprehensive examination. Detailed history taking of their Neonatal Intensive course stay along with peri-operative evaluation and report of intra-operative or postoperative incidents were done. Results: Reported incidents included seizures (3/10), Jitteriness (2/10) and hypotension (1/10). Infection rate was 10 % and obstruction occurred in 10% rate. Developmental outcome was comparable to normal peers.

Conclusion: Despite being fraught with risks, early intervention for progressive hydrocephalus under meticulous peri-operative care and vigilant observation is advised.

Study design: A non-randomized prospective studt To compare results of anterior cervical discectomy with fusion (ACDF) and cervical disc prosthesis in treatment of cervical disc disease.
Background The use of cages in ACDF has been the treatment of cervical disc disease but fusion may lead to accelerated adjacent segment disease. The advantages of disc arthroplasty include maintenance of range of motion, avoidance of adjacent segment degeneration, reconstitution of disc height and spinal alignment, maintenance of mechanical characteristics, decreased surgical morbidity, avoidance of complications from instrumentation or postoperative immobilization, and allowing early return to function.

Methods: 20 patients with cervical disc disease were included. It was done with specific selection inclusion criteria: 10 patients had been operated upon by ACDF (group I) while another 10 patients had ACD with cervical disc prosthesis replacement (group II). All patients were assessed at discharge then at 3, 6, 12 and 18 months post-operatively by visual analogue scale. Motor power and Sphincteric troubles were also recorded.

Results: Pre-operative evaluation for group I showed that nine had neck pain and all suffered from brachialgia. All patients were ambulant except for one with spasticity. One patient had precipitancy of micturition. In group II, six complained of neck pain and all had brachialgia. All patients were ambulant except for one case of spasticity and one had precipitancy of micturition. Post-operative results are summarized in tables 2 and 3.

Conclusions: The long-term function of a cervical prosthesis is essential to its clinical utility as similar improvement in clinical parameters were observed in both groups, but with arthroplasty there was radio-graphic evidence of motion preservation. Cervical prosthesis demonstrates the potential to play a prominent role in the treatment of degenerative cervical disc disease in well-selected cases.

Objective: To assess the value of first postoperative day serum GH level as an indicator of the extent of tumor removal.

Methods: This is a prospective study of thirty four patients with GH secreting adenomas who were operated upon through a sublabial transseptal transsphenoid approach. First postoperative day evaluation of GH level was done to all patients and serial follow up levels were done regularly during the follow up period. Early postoperative contrast enhanced MR I and/or multi-slice CT scan brain was done for radiological evaluation of the extent of tumor resection.

Results: Preoperative Serum GH level ranged from 17 to 40 ng/ml. Early postoperative radiological evaluation revealed total adenoma removal in 25 patients (73.5%).In 21 out of these 25 patients (84 %) the early postoperative GH level was below 2 ng/ml and never increased during the follow up period which ranged from1 to 5years. In all nine patients with obvious tumor residue and four patients with total tumor removal early serum GH level was more than 10 ng/ml and remained at or higher than that level till adjuvant treatment was started.

Conclusion: First postoperative day serum GH level < 2 ng/ml is a reliable indicator of the radicality of tumor excision in patients with GH secreting adenomas. Early postoperative serum GH level above 2 ng/ml signifies that the patient has not achieved either chemical or both chemical and structural cure and hence allowing for very early planning of further management of the disease.

Objective: a prospective study conducted on 40 patients with multiple level cervical spondylosis to compared the result with the published results of posterior approach.

Methods: from January 2004 to December 2008 40 patients with multiple level cervical spondylosis We treated patients with myelopathy caused by cervical spondylosis with multilevel cervical laminectomy alone if the curve is lordotic or with immediate stabilization with lateral mass plates and screws if the curve is straight or there is evidence of instability, in Kasr El-Eini Hospitals the inclusion criteria are (1) The patients must have a straight or lordotic cervical spine,(2)Cervical spondylosis at three or more motion segments,(3)Clinical findings consistent with myelopathy.

Results: In our study the recovery rate was 80% while the remaining 20% showed no improvement. Twenty two out of twenty four patients of grade IImyelopathy pre-operatively improved to grade I (91.5%) while 75% of patient of grade III and 50% of patients of grade IV preoperatively improved to grade II and grade III respectively.

Conclusion: Multilevel laminectomy and instrumentation with lateral mass plates when indicated is associated with minimal morbidity, provides excellent decompression of the spinal cord, produces immediate stability of the cervical spine, prevents kyphotic deformity, and probably precludes further development of spondylosis at fused levels.

Objectives: this study aimed at evaluating the effectiveness of ventriculo-subgaleal (V/S) shunt in temporarily diverting CSF to the subgaleal space in cases of acute hydrocephalus secondary to intraventricular hemorrhage.

Methods: twenty-six patients with IVH and hydrocephalus were operated upon Cairo & Beni-Suif University Hospitals. Age ranged from 13 to 65 years. Eleven were males. In 24 patients spontaneous IVH was found, it was either pure or associated with ganglionic, cerebellar hematoma or aneurysmal SAH. On admission 15 patients had severely disturbed conscious level, 4 with moderate and 7 with mild conscious level disturbance.

Results: Out of the survived 16 patients (61.5%), twelve were discharged fully conscious (46.2%), three of them (11.5%) didn't require permanent shunt. Two cases had infection (7.7%) and one case (3.8%) required revision due to obstruction.

Conclusion: Cases with intraventricular hemorrhage have high mortality and morbidity, V/S shunt in cases associated with hydrocephalus offers a good, economic relatively safe and easy option for CSF temporary diversion for reduction of intracranial pressure.

Objective: To describe the clinical and radiological features, surgical management, complications, and final outcome of patients with tentorial meningiomas.

Material and Methods: This is a retrospective study of 24 patients treated microsurgically for tentorial meningiomas (TM). The clinical data of these patients were reviewed from the medical records. Preoperative diagnostic tools included head CT scan and MRI brain in all patients and in 16 patients, the diagnosis was completed with digital subtraction angiography (DSA). The operative approaches chosen were infratentorial in n =16 and supratentorial in n=8. Occasionally a combined supra- and infratentorial approach was chosen. Data regarding surgery, histopathology and post operative course were reviewed. Tumour resection was evaluated by means of Simpson's grade and final outcome according to Glasgow outcome score (GOS).

Results: Eighteen patients were female and 6 were male Average age was 51.5 years (41-70). The average duration of the presenting symptoms was 17 months. Headache was the most frequent presenting symptom. A classification of TMs into 5 subgroups according to the tumour location is followed on the basis of imaging studies. Complete surgical resection (simpson I-II) was achieved in 18 cases. Final outcome was good recovery in 20 cases, severe disability in 2 and death of two cases.

Conclusion: Surgery is the elective treatment for tentorial meningiomas. Despite the advances in neuro-radiology and microsurgery, these tumours represent a challenge for the neurosurgeons due in some cases to large tumour size and extension to critical areas. In most cases, complete surgical resection should be the objective in order to minimize the recurrence risk.

Background: Traumatic brain injury is an important cause of morbidity cause of morbidity and mortality, with an annual incidence higher than 200 cases per 100000 populations. TBI represents one of the commonest causes of death and disabilities. The socioeconomic impact of moderate and severe head injury is quite severe. It is also being recognized that even minor head injuries may lead to long term squeals, further consuming scarce rehabilitation resources.

Patients and Methods: This study was conducted on 40 patients, in the ICU of the neurosurgery emergency department; all of them were victims of road traffic accidents. 20 patients randomly cohort of them received Cerebrolysin in a dosage of 20 mg/day with the conventional treatment, and the other 20 patients randomly cohort also received only the conventional treatment.

Results: The GCS in group 1 on day 1 with mean of 8.7 ± 2.72 while on day 20 = 11.75 ± 3.28, in group 2 on day 1 = 9.6 ± 2.6 while on day 20 = 9.7 ± 3. Patients on cerebrolysin compared to the control group had no statistically significant difference as regards GCS-1, while there GCS-20 scores showed a significant difference between both groups as the p-value< 0.05.

Conclusion: The use of cerebrolysin for 20 days with group 1 made a statistically significant difference in the final GCS outcome. We recommend cerebrolysin in the early management of head trauma with no CT finding to improve the outcome.

Object: Comparing the outcomes of vertebroplasty and conservative measures in the treatment of osteoporotic vertebral fractures.

Methods: A total of 18 patients with single level vertebral compression fracture were included in the study, half of them underwent percutaneous vertebroplasty, while the other half was subjected to conservative measures.

Results: Early (One week) symptomatic improvement in cases underwent vertebroplasty was noticed in 8 out of 9 cases. The same result was also noticed in cases treated conservatively though as late as 4-6 weeks. The mean compression ratio in the vertebroplasty cases changed from 0.6 to o.7 (P = 0.081), while remained unchanged in the other group. Also, the mean Cobb's angle was maintained in the cases treated by vertebroplasty (16.3°), while showed significant deterioration (P < 0.0001) in the group treated conservatively. There was no significant difference in the mean compression ratio or the mean Cobb's angle between the two treatment groups after one year of follow- up.

Conclusion: Vertebroplasty improves the clinical outcome of old-aged patients in terms of early pain relief and early spinal mobility. Vertebroplasty improves the patient's clinical condition, lessens the chances of general complications and maintains the quality of life despite the fact it does not lead to either significant restoration of height or correction of kyphosis.

It has been well recognized that neurovascular compression can elicit T.N or H.S, so microvasculer decompressive surgery has become popular as a radical treatment of thees clinical symptoms. Another cause of T.N or H.S. is cerebellopontine angle epidermoid.

Objective: This study was designed to evaluate the need for MVD of the respective cranial nerves in addition to CPA epidermoid removal in patients presenting with hyperactive cranial nerve dysfunction.

Methods: A total of 12 patient harbored C.P.A. epidermoid cysts underwent posterior fossa exploration between 2005 till 2009 in our hospital.

Results: The patient population was 5 males and 7 females, with a mean age of 42.1 years, the epidermoid was confined to the C.P.A. in each of 10 patients and 1 case had supratentorial extension, another case had anterior extension infront of the brain stem. Anatomical relationships between the 5th & 7th cranial nerves and offending arteries or tumors were verified at surgery. Compression of the nerves by an artery located on the same side or the opposite side of the tumor was found in 7 cases. Total resection was achieved in 9 cases, near total removal in 2 cases and partial removal was accomplished in 1 case. In addition to tumor removal microvasculer decompression of the respective cranial nerves were achieved in all the 7 cases in which there were direct arterial compression. 6 out of 7 patients were relieved from their symptoms and signs except for one patient who still experience tic convulsive but at longer intervals.

Conclusion: Although complete removal is ideal in the surgical management of CPA epidermoid, proximity to cranial nerves and the brain stem may pose technical difficulties in complete resection. In addition to complete resection of the tumor, arterial compression at the root entry zone (REZ) of the trigeminal or facial nerve exit should be sought, and if found, a microvascular decompression (MVD) should be performed, thanks to the modern radiological tools and microsurgical techniques which had improved morbidity and mortality

Objective: The current study was carried out to present the clinical and neuroimaging characteristics, operative findings and surgical outcome of Split Cord Malformations (SCM), to evaluate and compare our surgical results with those of other studies and to propose new suggestions in the management plan with the aim to provide better medical care for patients affected with such rare anomaly.

Patients and Methods: A total of 18 patients with SCM were included in the study. Patient age and gender, presenting features and signs were reviewed. Magnetic resonance imaging of the whole spine was performed in all patients. All patients with SCM were operated upon, even if they were asymptomatic and neurologically intact. Operative findings, complications, and outcome were analyzed.

Results: There were 7 males (38.8%) and 11 females (61.1%). The mean age at presentation was 4.8 years (range 4 months-14 years). Neurological deficits were noted in 16 patients, and cutaneous markers were present in ten cases. Seven patients had skeletal deformities. Eleven (61.1%) patients had Type I SCM and 6 (33.3%) patients had Type II SCM and one case had composite SCM having both bony and fibrous septa at different levels. Out of the 19 septa, 12 septa (63.1%) were located in the lumbar levels, 5 (26.3%) septa in the lower thoracic levels (T7-T12) and finally 2 (10.5%) were located in the upper thoracic levels. Magnetic resonance imaging revealed an additional lesion in 5 (27.7%) patients. Four (22.2%) patients suffered transient early postoperative complications. Two (11.1%) cases had cerebrospinal fluid leak. One (5.5%) patient developed transient urinary retention for two days. Transient leg paresis was noted in 1 (5.5%) case. Out of the 12 patients with preoperative motor deficits, 5 (41.6%) patients improved in motor power and gait. Three out of five (60%) patients showed improvement of their sensory symptoms and 2 out of 4 patients claimed subjective improvement of the preoperative sphincteric dysfunction.

Conclusions: SCMs are relatively rare spinal cord anomalies. Early diagnosis and operative repair of the condition while the patient is still neurologically intact will result in the best long term outcome emphasizing the importance of awareness of the general practitioners of the significance of neurocutaneous stigmata as an indicator of occult spinal dysraphism. Adding 2D MR myelograghic series to the MRI examination (single shot turbo spin echo ssTSE) will clearly delineate the relation of the bony spur to the split cord thus helping in proper surgical planning. All patients with type II SCM should be operated upon even if MRI examination fails to demonstrate the fibrous septum. We believe that the filum terminale should be divided in every case as preoperative MRI evaluation of filum terminale thickness in cases with low lying conus is not so solid.

Extensive craniofacial remodeling techniques were needed when the skull base was involved. But, there was a second group of craniosynostosis in which the skull base involvement was minimum. The peninsula-shaped linear craniectomy of Erdincler was designed for this second group of patients. These patients commonly present signs and symptoms of increased intracranial pressure if multiple. The aim of the surgery in these patients is to reduce the intracranial pressure and/or to ameliorate the calvarial dysmorphology.

Patients and method: The technique was applied to ten cases of multiple suture craniosynostosis and four cases of scaphocephaly under 1 years of age. None of them had major cranial base involvement or marked facial deformity. There was no syndromic case of craniosynostosis included in this group. In this technique, a curvilinear parasagittal craniectomy was combined with coronal and lambdoid craniectomies bilaterally. These craniectomies were curved postero- and antero-inferiorly, respectively, in order to create bilateral 'peninsulashaped' parieto-temporal bones with their neck still attached to the temporal bone. A linear craniectomy, crossing the superior sagittal sinus and combining right and left curvilinear craniectomies was added.

Results: The average operation time was 1 hour (45-80 minutes), There was no mortality or postoperative morbidity. The patients were discharged from the hospital at least 3 days postoperatively. Correction of the skull shape was successful in all cases.

Conclusion: This technique is simple, effective and can be applied with minimum equipment. . But, it is only applicable to mild degrees of craniosynostosis, where there is no major cranial base involvement or marked facial deformity in the first year of life. Patient selection is the key to better results.

Background: Loculated hydrocephalus is relatively seen frequently in our local neurosurgical practice and even with the different therapeutic modalities available for its management; no single treatment has clearly been shown to be superior. Nowadays there is a growing interest in and advancement of the ventriculoscope to navigate through the ventricular cavities and provide a good treatment option for loculated hydrocephalus.

Aim of the work: Our aim is to evaluate the efficacy the ventriculposcopic cyst fenestration to control hydrocephalus, to simplify the previously inserted shunt systems, and to reduce the operative complications.

Material and Methods: During the period between March 2004 to May 2008 we treated 18 patients with symptomatic loculated hydrocephalus (10 uniloculated and 8 multiloculated) by endooscpic cyst fenestration using both rigid and steerable endoscopes.

Results: Shunt revision rate reduced from 6.2 per year prior to endoscopy to 0.36 per year after endoscopic cyst fenestration, during follow up period ranging from 4 to 62 months, mean 26 months. Repeated endoscopic procedures were required in 40% of previously shunted patient whenever all patients without shunts did not require any more endoscopic procedure. Endoscopic fenestration alone avoid shunt placement in six patients with uniloculated hydrocephalus. Complication of endoscopy in our patients included cerebrospinal fluid leakage in 2 cases, venticulities in one case and superficial wound infection in one case.

Conclusion: Ventriculoscope is a successful and minimal invasive technique that should be considered as an initial alternative for the treatment of loculated hydrocephalus.

Objective: The aim of this study was to determine the incidence of screw misplacement and complications in patients who will undergo pedicle screw fixation in the thoracolumbar spine with conventional open technique and intraoperative fluoroscopy and to compare our results with published date.

Methods: This is a prospective study that has been conducted on all patients who underwent pedicle screw fixation of thoracolumbar region (T10-L3) at King Fahd Hospital at Al Baha, Saudi Arabia during a period of 3 years. 52 patients were included in this study. All patients underwent the same technique by the same surgeon using the same implant and all results were assessed both clinically and radiologically by means of specific CT protocol . A total of 248 screws have been assessed. The screw position was assessed by the author and independent radiologist. For the evaluation of pedicle violations, screw position was classified as "optimum" if the screw was completely surrounded by the pedicle cortex, as "possible violation" if the pedicle cortex could not be visualized due to screw encroachment, and as "evident violation" if the screw was located outside the pedicle. Evident violation was further divided into "grade 1" when the edge of the screw thread was less than 2 mm outside the pedicle cortex, "grade 2" when it was 2-4 mm, and "grade 3" when it was more than 4 mm outside the pedicle cortex. Other intraoperative or postoperative complications whether they are related to screws placement or not were also reported.

Results: The rate of questionable or "possible violation" was 4.8% and the rate of "evident violation" was 13%. Among the evident pedicle violation there were 14 (5.6%) medial, 10 (4%) lateral, 2 (0.8%) inferior, 4 (1.6%) superior and 2 (0.8%) anterior vertebral body penetrations. Among the evident violation, 14 screws were classified as grade1 violation, 10 screws as grade 2, and 8 screws as grade 3. Two patients (3.8%) developed postoperative radicular pain without neurological deficit that improved on conservative measures. One patient (1.9%) developed CSF leakage that stopped with conservative treatment. Two patients (3.8%) underwent additional surgery: one for persistent deep wound infection that required wound debridement and hardware removal, and the second for late hardware migration due to medially misplaced screw at L3. There was no associated neurological, vascular or visceral injury in our patients.

Conclusion: Our rates of screw misplacement and complications compare favorably with the reasonable rates of the series in which conventional technique was used. The conventional technique still remains an accurate, reliable and safe method for thoracolumbar fixation. Careful preoperative surgical planning, detailed knowledge of the anatomic landmarks, and strict adherence to the surgical steps are the most important factors to achieve accurate and safe pedicle screw placement.

Study Design: A retrospective study of 17 patients who underwent unilateral pedicle screw ?xation.

Objectives: To determine whether unilateral pedicle screw ?xation is effective in short segment lumbar spinal fusion or not.

Methods: This retrospective study was done in the last two years (2008-2010) in which 17 cases with unilateral metal fusion (transpedicular screws and rod) and bilateral bony fusion done. There was 12 females and 5 males age ranging from 38 to 56 years.

Results: According to the modified Stauffer-Coventry's criteria, 9 patients had an excellent result, 4 good, one fair and, 3 poor as regarding back pain but improved sciatica. Three patients still complaining of back pain while improved sciatica, two of them show sacroiliac joint affection and subjected to medical conservative treatment and physiotherapy. Two cases with mild wound infection responds to medical conservative treatment and improved.

Conclusions: Unilateral pedicle screw ?xation was as effective as bilateral pedicle screw ?xation in lumbar spinal fusion independent of the number of fusion segments (one or two segments) or pedicle screw systems. Based on the results of this study, unilateral ?xation could be used in one or two segment lumbar spinal fusion.