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:: E.J.N.S. Vol. 25 No. 1, Jan 2010 :: |
Background and purpose: Although the standard treatment for lumbar disc
herniation is with lumbar microdiscectomy, nucleoplasty offers a new technique
with encouraging results in well-selected cases. Nucleoplasty is a minimally
invasive technique that manages intradiscal herniation through energy-based
removal of part of the nucleus pulposus. The purpose of this study is
to assess the safety and clinical outcome of nucleoplasty procedure in
well-selected cases.
Methods: Coblation technology was used study in 50 cases who had radicular leg pain due to contained disc herniation or focal protrusion from 2005 to 2008. Clinical outcome was assessed through Visual analogue scale (VAS) and Oswestry Disability Index Questionaire (ODI). Reduction in analgesic treatment was also recorded. The procedure was performed under local anesthesia.
Results: The mean VAS score reduced from 8.2 to 1.3 at 1 year evaluation (P=0.001). ODI decreased from 62.2 to 9.6 at 1 year follow-up (P=0.001). Analgesic consumption was reduced or stopped in 90% at after 1 year. There was complete resolution of symptoms in 40 patients after 1 year. There were 4 patients who underwent conventional microdiscectomy. Five cases had post-operative discitis which cleared clinically and radiologically in 2 months without sequelae in 4 of them. One patient had to undergo operative instrumental fusion at the affected level.
Conclusion: Nucleoplasty does not require general anesthesia, offers less morbidity and shortens recovery time. Contained herniated disc or focal protrusion are the most important inclusion criteria. Studying the outcome, this technique is a promising tool in well-selected cases.
Objective: Spondylolisthesis refers to the forward displacement of one
vertebra relative to another, our objective is to study the value of fusion
in cases of degenerative spondylolithesis as a treatment option in comparison
to decompression without fusion.
Methods: 63 patients (20 men and 43 women; mean age 51 years) of lumbar degenerative spondylolithesis. Between January 2006 and December 2007. The mean follow-up period was 18 months (range 12-24 months).
Results: 49 cases were treated by decompression+ instrumented fusion (Group A), while 14 cases were treated by decompression only (Group B). An evaluation of the 2 groups and their comparison was concluded. profession and body weight. The non fusion group (B) has significant higher % of smokers 36% than does the fusion group (A) 12% (P<0.05). And the fusion group (A) has non significant higher % of laborers 61% than does the non fusion group (B) 43% (P>0.05).
Conclusion: decompression and fusion with pedicle fixation are reasonable in active, healthy, young patients with spinal stenosis associated with degenerative spondylolithesis who have relatively few degenerative changes promoting stability at the level of the slip. Elderly and active patients with degenerative changes usually benefit from decompression with non-instrumented fusion. fusion has non-significant better outcome in improvement rate than decompression only and significantly more hospital stay.
Objective: The World Health Organization (WHO) reclassified atypical meningiomas in 2000, creating a more clear and broadly accepted definition. We evaluated the pathological and clinical for atypical meningiomas patients according to the new WHO grading system at cairo university hospital.
Methods: A total of 30 atypical meningiomas occurring in 30 patients between 2005 and 2007 were prospectively reviewed to determine diagnosis, postoperative treatment trends, and early outcomes.
Results: In the 3-year period, 371 meningiomas were operated on at cairo university Hospitals; of these, 320 (86.5%) were benign, 30 (8%) atypical, and 21 (5.6%) malignant.
Conclusions: The histological parameters permit
an accurate identification of atypical and malignant meningiomas with
high growth potential and recurrence rates that far exceed that of benign
meningiomas. We hope that the use of these relatively simple histological
criteria will help to further the understanding of the biology of this
important group of tumors.
Background: Traumatic brain injury is one of the causes of mortality and one of the major causes of persisting neurobehavioural disorders.
Objective:- To determine the value of measuring serum levels of neuron specific enolase in predicting extent of disease and short- and long-term outcome after acute brain injury.
Design: Prospective study.
Patients: Thirty patients who presented for acute head injury.
Main outcome measures: Using a solid-phase enzyme immunoassay, serum levels of neuron-specific enolase was measured on admission and on days 1, 4, and 15.
Results: Mean (standard deviation) serum neuron-specific enolase levels were significantly higher among patients with head injury than among controls (18.48 +16.61 ng/mL versus 9.00 +2.70 ng/mL; P<0.001). The neuron-specific enolase level was also higher in those with severe head injury than in those with mild head injury (33.54 +29.71 ng/mL versus 15.97 +5.91 ng/mL; P<0.01).
Conclusion: Serum neuron-specific enolase levels
after head injury may be a useful marker to predict extent of the brain
damage short and long term outcome in patients with head trauma.
Background: The decision for re-operation after lumbar disc surgery was and remains a critical decision. This is usually due to "how much benefit the patient will obtain after a repeated surgery?", and although, the optimal technique for treating recurrent disc herniation is a precious goal- however it is still controversial.
Purpose: The goal of this study was to evaluate and compare the results of recurrent disc surgery with and without postro-lateral fusion in cases of stable spine.
Study design: This study was carried out in the Neurosurgical department of Ain Shams University and the data were collected prospectively.
Patients and Methods: 30 patients in our department underwent reoperation following primary lumbar discectomy between March 2005 and March 2008, were included in this study. Data were collected prospectively. Out-come assessment was done using "the Japanese Orthopedic Association's" evaluation system for lower back pain syndrome" (JOA score), as well as assessing the neurological out-come and the radiographic follow up.
Results: 30 patients (17 males & 13 females) underwent a discectomy for recurrent lumbar disc herniation. 15 patients (10 males & 5 females) had a discectomy alone and 15 patients (9 males & 6 females) had a discectomy with postero-lateral fusion, follow up ranged from 12-36 months with a mean follow up of 22.9 months. 24 patients had a satisfactory (excellent or good) out-come (11 patients with a discectomy alone and 13 patients with postero-lateral fusion) 5 patients had a fair out-come (3 patients with discectomy alone & 2 patients with posterolateral fusion), and one patient had a poor out-come (with discectomy alone).
Conclusion: Repeat discectomy for true recurrent
lumbar disc with evident recurrent sciatica and low back pain (LBP) is
more effective with postero-lateral fusion than discectomy alone.
The endoscopic revolution has impacted virtually every surgical field. A procedure is considered to be appropriate when the medical benefit in terms of quality of life or life-span, reduction in pain and improved function are thought to exceed by a sufficiently wide margin, the medical risks of mortality, morbidity, and anxiety caused by the procedure(18).
Objective: To evaluate short term outcome, clinical results, safety and efficacy of microendoscopic discectomy (MED) for the treatment of lumbar disc herniation.
Methods: In this study, 40 patients were reviewed, including 28 male and 12 female, with an average age of 40.6 years. All the patients had only solitary lumbar disc herniation. 24 patients had L4-L5 P.L.D, while 15 patients had L5-S1 and only one patient had L3-L4 P.L.D. All the patients had unilateral sciatica, and no patients with bilateral sciatica. The Protrusion type of herniation occurred in 7 discs, while extruded type occurred in 28 discs, and the sequestrated type occurred in 5 discs. The paramedian type of lumbar disc herniation occurred in 12 patients and the mediolateral type of herniation occurred in the other 28 patients. All the patients were treated by hemilaminectomy, and discectomy using microendoscopic discectomy (MED) procedure and utilizing microendoscopic tubular retractor system (METR'x) technique.
Results: All the patients were followed up for an average of 2.2 years. According to lumbar and leg pain evaluation criteria of the Modified Mac Nab's, there were 90% of satisfaction scores and 10 % of un-satisfaction scores. Complication rate were (12.5%).
Conclusion: Appropriate control indications and skillful surgical techniques are the key points to decrease the complication and to improve the curative effect.
Background: the use of PEEK cage in fusion after anterior cervical discectomy has increased dramatically in the last few years. There are several reports of their use in anterior cervical fusion, but there are no focused reports on the complications associated with the use of these PEEK cages in anterior cervical discectomy and fusion.
Purpose: the goal of this study was to assess the complications associated with PEEK cages usage in anterior cervical discectomy and fusion.
Study design: This study was carried out at the department of neurosurgery of Ain Shams University and the data was collected prospectively.
Patient and Methods: Out of a total number of 127 patients with cervical degenerative disc disease, 12 patients with cage related complications after usage of PEEK cage in anterior cervical discectomy and fusion, whom were followed at Ain Shams University hospital (Cairo, Egypt) between 2005 and 2009, were included in this study. Data was collected prospectively. Outcome assessment was done using visual analogue score (VAS) for arm pain, neck pain; as well as assessing neurological outcome and radiographic follow-up with cervical X-rays.
Results: Twelve patients (7 males and 5 females) from a total of 127 patients who underwent anterior cervical discectomy and fusion using PEEK cages had cage related complications. Follow up ranged from 12-27 months with a mean follow up of 15 months. There were 5 cases of cage migration (3 with anterior migration, 1 with posterior migration and 1 with lateral migration); 3 cases with subsidence; 2 cases with adjacent level degeneration; one case with kyphotic deformity and one case with pseudo-arthrosis.
Conclusion: Use of PEEK cages in cervical fusion
after anterior cervical discectomy is widely used and provides satisfactory
results. Complications with PEEK cages use is relatively low and avoidable
through careful attention to technical steps in graft site preparation
and choosing an appropriate sized cage, along with careful follow-up for
fusion and adjacent segment disease.
Background: Endoscopic treatment of intracranial cystic lesions had been widely used in the last two decades despite the other alternative treatment strategies.
Objectives: Evaluation of safety and efficacy of endoscope and endoscope-assisted microsurgery in treating different types of cystic lesions.
Methods: Prospective study of 20 consecutive patients admitted to Cairo University Hospitals between January 2007 and June 2009 presenting with different types of intracranial cystic lesions: 7 cases of arachnoid cyst (35%), 5 cases of craniopharyngioma (25%), 4 cases of colloid cyst (20%), 2 cases of ependymal cyst (10%), 1 case of dermoid cyst (5%), and 1 case of choroid plexus cyst (5%). The patients' age ranged from 9 to 35 years (mean 17.5 years). Ten patients (50%) were treated purely by endoscopic procedures for fenestration, cauterization or excision (6 arachnoid, 2 ependymal, 1 colloid and 1 choroid cyst) while the other ten patients were treated by endoscopic-assisted microsurgical technique for cyst resection (except in a single case of sylvian arachnoid cyst, microscopic hemostasis was needed).
Results: Radiologically, gross total excision was achieved in all 9 cases aimed for resection (100%) while good cyst fenestration and shrinkage was performed in the remaining 11 cases. Clinically, marked improvement of different symptoms was achieved. Transient intraoperative or postoperative complications were encountered in 4 patients (20%), 1 patient (5%) suffered recollection of the cyst that necessitated cyst shunting.
Conclusion: Endoscopic and endoscope-assisted microsurgical
treatment of different types of intracranial cystic lesions is safe, minimally
invasive, and effective techniques with minimal morbidity and low complications
rate, however, proper patient selection, preoperative planning, location
and size of the lesion as well as surgeon's experience are important success-contributing
factors.
Objective: In this retrospective review of prospectively collected data , we report the clinical outcomes of patients with ruptured middle cerebral artery (MCA) aneurysms who presented and operated upon.
Methods: (a) Patient selection: patients presented to the Neuroemergency unit in Kasr El-Einy Hospital from January 2006 to December 2008 with ruptured MCA aneurysms. (b)Procedure: conventional operative clipping of the neck by the appropriate clip using proximal sylvian approach.(c)Evaluation of postoperative clinical outcome by the modified Rankin Scale at the time of hospital discharge and at 6-months thereafter, then comparing the clinical outcomes with those in other researches.
Results: The overall outcomes at the time of hospital discharge using the modified Rankin Scale were good in 20 patient (80 %), fair in 1 patients (4%), and poor in 4 patients (16%). At 6-months follow up, outcomes were good in 21 patients 84% as 1 patient was back to normal life among 20 patients who had previously worked , fair in 1 patients (4%), poor in 3 patients (12%).mortality was 2 cases. overall ,84%of patients returned to work after 5 months , 4% were mildly disabled.
Conclusion: Microsurgical clipping is an effective
treatment of MCA aneurysms because of their peripheral location, wide
necks, straightforward surgical anatomy and possibly minimal amount of
SAH with its consequences.
Objective: Tectal glioma is a topographical diagnosis including tumors of different histology, mainly low-grade astrocytomas. Clinical symptoms are usually associated with increased intracranial pressure.
Methods: This report discusses the management of atypically presenting tectal gliomas in children. Clinical charts of 9 children with tectal glioma treated in our department were retrospectively reviewed. The mean age at time of diagnosis was 8.4 years (range 4-14 years), with male to female ratio 2:1. First-line therapy was endoscopic third ventriculostomy in 5 cases and ventriculo-peritoneal shunting in 4 cases. All patients were operated up-on through a supracerebellar infratentorial approach in a sitting position aiming at total resection, all patients were followed up for a varying period ranging from 1.5-2 years.
Results: Histopathological diagnosis revealed a low grade fibrillary astrocytoma grade II in 7cases and Grade I in 2 cases. Complete tumor removal was achieved in 6 out of 9 cases (66.6%), biopsy was performed in one case, and subtotal resection in one case. All 8 cases had smooth post-operative recovery, with only one case dying after admission to the ICU.
Conclusion: Atypical tectal gliomas present radiologically
different from small confined typical ones, which should be diagnosed
and treated differently. Microsurgical resection of such lesions is the
best option with similar risks to endoscopic or stereotactic biopsy and
even with more accurate diagnosis.
Introduction: Residual and recurrent pituitary adenomas remain a challenge for the neurosurgeons. On doing a plan for its management, each case should be individualized taking into consideration the physiological, the biochemical and the anatomical behavior of this benign tumor.
Objective: The present work was designed to evaluate the different and multi- modalities of management, which can be used to maximize the functional outcome of these patients.
Patients and Methods: Thirty one patients (13 with residual, and 18 with recurrent) pituitary adenomas were underwent pre & postoperative imaging grading, and were followed up clinically, biochemically and radiologically for two years. Sixteen cases were non-functioning pituitary adenomas, eight cases prolactin (PRL)-secreting, six cases growth hormone (GH)-secreting and one case had combined PRL and GH-secreting tumor. Eighteen cases had invasive pituitary adenoma (Knosp grade III-IV), with maximum diameter range from 15 to 70 mm, and nine cases had giant adenoma (?4cm). Seven cases with (PRL)-secreting adenoma had medical treatment. Twelve were subjected to fractionated radiotherapy, nine were subjected to stereotactic radiosurgery. Forty approaches were performed; 31 had transsphenoidal and 9 had transcranial. Five patients had repeated transsphenoidal surgery and one case had repeated transcranial surgery.
Results: Six cases (19.3%) were re-operated, 21 cases (67.8%) fulfilled the criteria of cure without complications, and 2 cases (6.5%) of mortalities were occurred. Eight cases (25.8 %) of morbidities including; 2 cases (6.4%) of postoperative rhinorrhea, one case (3.2%) of postoperative left 6th nerve palsy, one case (3.2%) of postoperative diabetes insipidus, one case (3.2%) of post-irradiation optic neuritis , 2 cases (6.4%) of post-irradiation new anterior pituitary deficit, and one case (3.2%) of right 3rd nerve paresis after stereotactic radiosurgery were occurred.
Conclusion: Combinations of different modalities may be necessary in recurrent and residual pituitary adenomas, depending on the patient's age, the hormonal status of the adenoma, the presenting symptoms, co-morbid conditions, previous surgeries, previous radiation exposure, the volume of the tumor, its proximity to optical structures, and its response to medical management. This underlines the importance of having a coordinated multidisciplinary team that can optimally manage those cases and may guarantee better outcome for the patient.
Background: Resection of sinonasal tumors involving the anterior skull base usually combines transcranial and transfacial incisions and osteotomies. The success of endoscopic surgery in resection of pituitary tumors and in the management of lesions of the supra-paraseller region; together with recent advances in endoscopic equipment and instruments have encouraged many skull base surgeons to widen the scope of endoscopic skull base surgery to involve most of the regions of the central skull base whether anterior, middle or posterior.
Objectives: The aim of this work is to assess the feasibility of the endoscopic approach to the central anterior skull base and to measure the degree of exposure offered by this approach.
Methods: Six cadaver heads were used for performing en block endoscopic anterior skull base resection and measurements of the created defect in the skull base were undertaken.
Results: The procedure was found feasible and the measurements indicate that a reasonably large area can be exposed and remove by this technique.
Conclusions: En block endoscopic anterior skull base resection is a promising technique for removal of select sinonasal tumors encroaching upon the anterior skull base.
Objective: The aim of this study is to evaluate the biomechanical stability, fusion rate, clinical outcome, hardware failure as well as the incidence of the complications associated with cervical corpectomy reconstruction with titanium mesh cage and anterior plate and to suggest new modifications of the technique that might help to decrease the complications associated with such approach, and to stress on surgical technical points that might help to improve the results.
Methods: Twenty-seven patients who underwent cervical corpectomy and fusion using a titanium mesh cage and an anterior cervical plate were included in the study. Cervical cord compression was caused by multilevel cervical spondylosis in 21 cases, traumatic burst fracture in 3 cases, ruptured migrating disc in 2 cases and post-laminectomy kyphosis in one case. Exclusion criteria included vertebral body tumour and infection. The study included 16 males and 11 females, their ages ranged from 16 to 65 years with a mean age of 52.2 years. The visual analog scale score was used to evaluate upper limb pain and numbness before and after surgery. The neurosurgical cervical spine scale was used to assess the neurological status. Radiographic assessment included sagittal alignment, cage subsidence, coronal angle, sagittal angle and sagittal displacement and settling ratio to evaluate the biomechanical stability of the cage.
Results: The follow up period ranged from 9 to 36 months with a mean of 23 months. Nine patients underwent one level corpectomy (33.3%). Two level corpectomy was performed in 16 cases (59.3%) and three-level corpectomy was performed in 2 cases (7.4%). There were no major intra-operative complications. Four patients (14.8%) developed transient hoarseness and 3 patients (11.1%) had temporary dysphagia. The neurological status of 25 (92.6%) patients improved, and 2 (7.4%) patients remained the same postoperatively. The average clinical improvement rate based on the neurosurgical cervical spine scale was 55.4 %. The mean sagittal cobb angle was 10.4° (range -40 to 30°) on the immediate postoperative X-ray and 4.1° (range -55 to 22°) on the final follow up examination. TMC subsidence was noted in 25 (92.6%) patients. Only one patient (3.7%) had a change in the settling ratio more than 10% and another patient showed more than 10% change in the sagittal displacement ratio denoting instability of the cage in both cases. However, both patients showed progressive neurological improvement and achieved solid fusion. One case had mild screw pull-out that remained stationary on the follow-up radiographs. There was no case of plate loosening or pull-out. One patient had mal-placement of the cage in the coronal plane. No patient had construct failure. 2D reconstruction CT scan revealed solid fusion in all cases.
Conclusions: The results of the current study demonstrated that the use of TMC for reconstruction after cervical corpectomy can lead to satisfactory clinical outcome, biomechanical stability and fusion rate while avoiding the complications associated with strut autograft and allograft. Although biomechanical instability of the cage and hardware related complications were noted in a small proportion of the patients, yet this did not have a negative impact on the clinical outcome or the fusion status.
Objective: To evaluate the short and long-term efficacy and safety of vertebroplasty as a minimally invasive procedure for the management of vertebral compressive fractures in terms of pain reduction, and complications. Our results were evaluated and compared with those of previously published trials.
Methods: Between May 2005 and November 2008, 35 patients meeting our inclusion criteria were enrolled in the study. All patients had preoperative plain radiography and Magnetic resonance imaging of the spine. Percutaneous vertebroplasty (PVP) was performed under general anesthesia. Follow up visits were scheduled at 3, 6, 12, 24 months postoperatively. All adverse events were recorded. Back pain was assessed using visual analogue scale (VAS). Plain digital radiographs were performed 1-3 days after surgery, at 3, 6, 12 and 24 months follow-up.
Results: A total of 35 consecutive patients underwent a total of 49 PVP procedures. There were 6males and 29 females. The mean age of the patients was 63.3 years. Two-year follow up was available for 29 patients. The procedure took on average 30 min for each level, the mean amount of cement application being 5 ml (range 3.5-7.5) per vertebra. Our patients showed improvement in mean VAS pain (34 postoperative vs. 81 preoperative). Cement leakages were observed in 4 treated vertebral bodies (8.2 %). Five patients (14%) experienced an adjacent incident fracture.
Conclusion: Vertebroplasty is a minimally invasive procedure that has been shown to be safe and effective for the treatment of osteoporotic compression fractures, with most of the complications being minor or clinically insignificant and resulting from the cement used in the procedure rather than the placement of the cannula. In our study the complication rate was relatively low and there was no direct procedure or technique related complications and this was consistent with most of previous studies.
Background: Sphenoid wing meningioma en plaque is a special morphological subgroup of intracranial meningiomas,defined by a carpet-like, soft tissue component that infiltrates the dura and invades the sphenoid ridge and orbit associated with a significant hyperostosis due to actual invasion of such bony parts by the tumour cells.
Objective: To describe the clinical and radiological features, surgical management, complications and final outcome of patients with sphenoid wing meningioma en plaque.
Methods: This is a retrospective study of 30 patients undergoing transcranio-orbital approach from 2003 to 2008. Patients ages: 16 years to 67 years, (45.5 years in average).sex: 7 males, 23 females. Chief complaints were progressive proptosis and visual acuity deficits. All patients were operated on using a fronto-temporal approach with orbital decompression. The extent of tumor resection was evaluated by means of Simpson's grade and postoperative complications were investigated.The follow-up period ranged from 3-48 months.
Results: Simpson grade II resection was achieved in 19 patients, Simpson grade III in7 patients and Simpson grade IV in 4 patients. Pathological examination showed 22(73%) patients were meningothelial meningiomas. After surgery,proptosis improved in all patients, visual acuity improved in14patients (47%). Temporary ophthalmoplegia was found in 6 patients,cerebrospinal fluid leak was found in 1 patient. Tumor was recurred in 5 patients (16%) postoperatively (range of follow up (6-23months) and underwent second surgery. There were no operation-related deaths or other significant complications.
Conclusion: An exact analysis of tumour growth and its involvement of different structures is mandatory before performing surgery. Extensive tumor removal with bony decompression at the orbital apex can produce satisfactory cosmetic and functional outcome and removal of all the hyperostotic bone of the great wing of sphenoid bone helps to decrease the incidence of recurrence.
Craniosynostosis is the premature and abnormal fusion of 1 of the 6 suture lines that form the living skull and can occur as part of a syndrome or as an isolated defect (nonsyndromic). Early surgery is the best treatment choice. The aim of this study is to identify types of craniosynostosis in our region, compare our data with data published by other authors, assess outcome of early cranial remodeling and to review the experience of a multidisciplinary staff with the surgical treatment of craniosynostosis.
Method: This is a prospective study including all the craniosynostosis cases admitted to Mansoura University Hospital, Neurosurgical Department, and treated surgically from 2003 to 2009. The following variables were statistically analyzed: sex, age, weight, type of deformity, surgical technique, surgical time, blood loss, hospital admission time, and postoperative complications.
Results: Among 73 patients admitted to Mansoura University hospital only 48 were included in this study. The excluded 25 cases: 5 of them were syndromic, 6 were above 1year old, the other 14 had mild deformity, pansynstosis or they didn't have major cranial base involvement. There were 48 patients with non syndromic craniosynstosis (33 males and 15 females). The average age was 7.2 months. The average weight was 7.3 kg. The commonest types of deformities found were scaphocephaly (n = 23, 47.9%) followed by trigonocephaly (n = 11, 22.9%). The mean surgical time was 150 minutes and the median postoperative hospitalization time was 12 days. The mortality on this series was 4.2% (2patients). In the last 35 operated cases, an improvement in surgical time (90 to 180 minutes with median 120 minutes), blood loss and hospitalization time (6 to 12 days with a of 8 days) was observed, also there was no morbidity and mortality
Conclusion: A proper experience can minimize the risks and decrease the complications in the treatment of craniosynostosis, leading to a satisfactory outcome.
Introduction: Neurosurgeons are familiar with the challenges presented by craniopagus twins, but other types of conjoined twins may also have neurosurgical implications. We report a case of complex pygopagus conjoined twins managed successfully in Mansoura University Hospitals. Pygopagus conjoined twins are joined at the rump and have union of the gastrointestinal and genitourinary systems as well occasional involvement of neural elements.
Case report: We report a case where the terminal spinal cords were fused, despite which there was no motor deficit after separation. The preoperative and intraoperative findings are described and issues of postoperative follow-up discussed.
Discussion: Among 18 operative cases of pygopagus conjoined twins that are reported in the literature; only 8 of them, like the case reported here, have had some degree of neural fusion. Eight other cases reported in the literature with varying degrees of involvement of the spinal cord and cauda equina are reviewed
Fixation of C2 pedicular screws is a very reliable procedure to achieve good anatomical and functional results. The major obstacles, that prevent most surgeons from using C2 pedicular screw fixation, are the difficulty to the determine direction of the pedicle and the entry point for C2 screws. This difficulty can possibly lead to violation of the cortical bone and injury of the vertebral artery. Many surgeon use a lot of sophisticated equipment to place C2 screws properly. In this article the author is presenting a very simple method to introduce these screws along the axis of C2 pedicles. This method was used in treating 11 patients with different pathologies. No complications related to C2 screw placement were encountered.
Background and Objective: In a contribution to development of an experimental primate model of optic chiasm and pituitary stalk ischemia, aiming at better understanding of their pattern of blood supply, we studied the arterial blood supply of the optic chiasm and pituitary stalk in olive baboon (Babio cinocephalus anubis) and discussed it in comparison with the corresponding microvascular anatomy in human.
Material and Methods: This study has been conducted on twelve fresh baboon heads (24 hemispheres) at the Biological Research Laboratory and the Microsurgery Training Laboratory of the Department of Neurosurgery at the University of Illinois at Chicago. Following injection of the major vessels of the head according to the standard injection techniques used for microvascular studies, each specimen was prepared and dissected in such a way that allows optimum visualization and study of all vascular structures using the surgical microscope with different degrees of magnification.
Results: Apart from minor differences, the pattern of arterial supply of the olive baboon optic chiasm and pituitary stalk is similar to what have been described in humans. Two distinctive groups of arteries have been identified : a superior group and an inferior group. The superior group of vessels is derived from the two anterior cerebral arteries to supply the superior surface of the optic chiasm. Long branches from both ACA cross the central part of the optic chiasm, without supplying it, to meet with prechiasmal branches from both ophthalmic arteries anterior to the chiasm forming the "pre-chiasmal anastomosis". The inferior group of vessels form a peculiar vascular network known as the "circuminfundibular anastomosis". Through this network, the inferior surface of the optic chiasm and the pituitary stalk receive their blood supply from the superior hypophyseal arteries, infundibular arteries and branches from the prechiasmal anastomosis.
Conclusion: Our anatomical findings support the previous findings in human that suggested that the characteristic bitemporal field defect caused by pituitary adenomas is probably due to ischemia of the central decussating fibers that may result from compression of the inferior group of vessels and not due to neural compression. Also, our findings are similar, to a large extent, to what has been described in human. Due to this similarity, the olive baboon is thought to be a good experimental model to study the effects of optic chiasm and pituitary stalk ischemia.
Objectives: Preservation of facial nerve function during vestibular schwannoma surgery has been a matter of increasing interest since the development of microsurgical techniques. This retrospective study was conducted to identify different clinical, radiological and operative factors that may influence and predict postoperative facial nerve function outcome after vestibular schwannoma surgery.
Patients and Methods: 35 consecutive patients with surgically and pathologically verified vestibular schwannomas were included in this study. Various clinical, radiological and operative variables were retrospectively studied through careful review of patients' data. These included age, duration of clinical symptoms, hearing loss, preoperative FN status, size of the tumor, relation of nerve to tumor (site and adhesion), facial nerve infiltration, surgical techniques (point of start and mode of tumor dissection), MRI aspect of the tumor, and early postoperative facial nerve status.. There were 26 females and 9 males; their ages ranged between 18 and 55 years (mean age 36.5 years) Of the 35 VSs, 18 were on the right side and 16 were on the left. In one patient with neurofibromatosis type 2 (NF2); only one tumor was removed. Facial Nerve function was evaluated pre-and postoperatively according to the classification of House and Brackmann.
Results: Facial nerve dysfunction after vestibular schwannoma surgery was encountered in 17 % of cases. Several statistically significant variables have been identified to influence and predict facial nerve function outcome following vestibular schwannoma surgery. Tumor size, consistency, pattern of facial nerve involvement, preoperative facial nerve function, tumor dissection strategy and the early postoperative facial function were significant factors determining facial nerve outcome. These are detailed, analyzed and discussed in view of the pertinent literature.
Conclusion: Various clinical, radiological and operative factors can be predictive of the postoperative FN function after VS surgery. The significant variables in our study were duration of symptoms, tumor size, nerve infiltration and/or adhesions, cystic changes, mode of surgical dissection, and immediate postoperative FN condition.
Introduction: Dorsal spinal epidural abscess remains a challenge in its diagnosis and treatment. Staphylococcus aureus is the main causative organism. Several conditions predispose to dorsal spinal epidural abscess. Classical symptoms of dorsal spinal epidural abscess include; pain, fever and neurological deficits, however it is only present in 10-15%. Laboratory investigations are non specific. MRI is the imaging method of choice. Treatment includes a combination of medical and surgical interventions, but urgent laminectomy for drainage of the abscess is almost always required. The final neurological outcome correlates with the severity and duration of neurological deficits prior to surgery. Increased awareness and rapid recognition and intervention are crucial for better outcome.
Patients and Methods: In the period from June 2005 to December 2008, 9 patients with dorsal epidural abscess were admitted to Cairo University hospitals. Patients were operated upon with laminectomy and evacuation of the abscess.
Results: The study included 5 males (56%) and 4 females (44%) with a mean age of 46 years ranging from 23 to 76 years. The main presenting symptom was back pain - 7 patients (78%).Outcome was excellent in3 patients (34%) and good in 4 patients (44%) while 1patient (11%) had poor outcome and 1 patient (11%) died.
Conclusion: The management of dorsal epidural abscess should be multidisciplinary and urgent. The best suitable treatment option is surgical decompression and drainage. The final neurological outcome correlates with the severity and duration of neurological deficits.
The occipitocervical junction represents a unique and complex interface between the cranium and the rostral cervical spine. 11 patients (6 males (55%) and 5 females (45%) - mean age 39 years, range (23-61 years) with craniocervical instability were operated upon by craniocervical fusion using plates and screws. 9 patients (82%) had good outcome and one patient (9%) had bad outcome and one patient (9%) died. Bony fusion occurred in 9 cases (91%), while non fusion occurred in 2 cases (9%). Lateral mass plates and posterior screw fixation is a reliable and efficient option for surgical treatment of craniocervical instability. However, all currently used implants achieve high stability and fusion is achieved in most of the cases and is usually accompanied with clinical improvement.
Introduction: The transvermian approach was used for long time to access tumors in the fourth ventricle but cerebellomedullary fissure as a natural corridor to this region without splitting of the vermis has been widely used in many neurosurgical departments. Many studies reported additional advantage of this approach in the form of clear observation of boundary between the tumor and vital structures in the fourth ventricle .In this study, this approach was used aiming to confirm its efficiency in identification and preservation of brain stem and blood vessels.
Patient and Methods: this is a prospective study on fifteen children (1.5-13 year) suffering from large fourth ventricular tumors using the telovelar approach in Abo-Reish Pediatric Hospital from January 2006 to December 2008 with minimum 1.5y follow up.
Results: This approach provided adequate exposure but the angle of work was narrow which was compensated by changing the angle of microscope and table. In addition, the vermis can be incised for short distance when needed. The brain stem and PICA were preserved in all cases. Subtotal removal leaving 5-15 % was achieved in six cases (40%).This was due to infiltrative nature of these tumors.
Conclusion: Telovelar approach provide adequate
exposure with clear observation of the relation between the tumor and
vital structures in this region. The pathological nature of the tumor
and the degree of brain stem infiltration are the factors that determine
the degree of removal
Objective: Our goal was to assess the efficacy of endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea.
Methods: We conducted a retrospective review of all patients presenting to our institution over the past 5 years with CSF rhinorrhea.
Results: Twenty-one patients were included in the study. We had different etiologies: traumatic, iatrogenic and idiopathic. Transcranial approaches whether intradural or extradural, and transnasal endoscopic approaches were used successfully with initial success rate of 90.4% and of 100% with revision surgery.
Conclusion: precise localization of the site of the CSF fistula with proper selection of the repair technique often leads to successful fistulae closure.
Objective: This study was conducted to investigate the efficacy of treating upper lumbar discs levels, addressing how far fixation is needed in managing these cases.
Methods: Twenty consecutive patients with disc herniations of the upper lumbar levels underwent the posterior approach, with fixation in about 60% of cases, from January 2002 through January 2009. Their clinical and radiological data were collected and analyzed. The patients were assessed with standard examinations preoperatively and evaluated with lumbar x-rays, computed tomographic scans,and or magnetic resonance imaging, standard pain and disability measurements, the Oswestry disability index, and a patient functional outcome postoperatively.
Results: The average follow-up period was 35.1 months, with a maximum of 48 months. The Oswestry disability index, showed statistically significant improvement at the time of the last follow-up evaluation, compared with preoperative scores. There have been neither recurrent disc herniations nor spinal instability during the follow-up period.
Conclusion: In this study, 20 cases of disc herniations
at the upper lumbar levels, were successfully excised with the need of
fixation in about 60% of cases .Fixation was done in an attempts to minimize
failure and recurrence,and resulted in satisfactory clinical outcomes
with few complications and no recurrence .
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