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:: E.J.N.S. Vol. 25 No. 2, June 2010 :: |
Objectives: Prospective comparative study
of surgical and clinical outcome in microscopic and endoscopic endonasal
transsphenoidal adenomectomy.
Methods: Between June 2006 and December 2008, twenty four patients with pituitary adenomas are studied and classified into 2 groups; group A: 12 patients having microscopic surgeries and group B: 12 patients having endoscopic surgeries. Both groups are evaluated and compared regarding 1) extent of tumor resection, 2) improvement of symptoms, and 3) complications.
Results: Gross total resection was achieved in 84.4% in group A and 75% in group B. Clinically, visual field defects improved in 86% of group A and 75% of group B. Hormonal dysfunction improved in all patients at 3 months postoperative. Intraoperative CSF leak occurred in 25% of group A and 33.4% of group B while postoperative CSF leak was encountered in 16.6% of group A and 8.4% of group B. Postoperative diabetes insipidus was observed in 25% of group A and 16.6% of group B and was permanent in a single patient (4.1%). Rhinological complications were reported in 58.4% of group A and 25% of group B, all of which were temporary. No major complications or mortalities were encountered in all 24 patients.
Conclusion: Both microscopic and endoscopic endonasal transsphenoidal surgeries are surgically effective with no significant difference in outcome and complications. However, the choice of technique depends mainly on the surgeon's skills, preference and experience.
Objectives: Craniopharyngioma constitutes up to 6-10% of childhood brain
tumors. Craniopharyngioma is the third most common intracranial tumor
of childhood. The aim of this retrospective study is to evaluate the efficacy
of surgical management alone in such tumors in paediatric age group.
Methods: Between January 2008 and January 2010, 24 children (14 males, 10 females) aged between 6 months and 14 years (mean age 8 years) were diagnosed with craniopharyngioma. All patients underwent surgical excision few days after their first presentation. Data were retrospectively collected for all 24 patients to assess the efficacy and outcome of surgical treatment.
Results: 17 (70%) out of 24 patients underwent gross-total resection (GTR), confirmed by intra-operative impression and postoperative MRI studies. There was no operative death. Diabetes insipidus was observed in 11 cases postoperative. 12 cases required cortisol replacement postoperatively. Two patients (8%) had tumor recurrences within the first 6 months and were reoperated. Disease control was achieved surgically in 17 (70 %) patients and with surgery and Radiotherapy in 3 patient during the first 2 years follow-up. Visual affection occurred postoperatively in one patient on the ipsilateral side of the surgery, otherwise vision was preserved in all other patients as preoperatively. There was no other long-term neurological morbidity.
Conclusion: Gross total resection remains the first
choice for paediatric patients harbouring Craniopharyngiomas, with the
least morbidity and complications when aiming at preservation of the existing
hypothalamic function and vision. Surgery alone could provide long term
tumor control, and minimize neurotoxic effects from other treatment options.
Objective: Little attention has been focused on the serious and sometimes fatal upward transtentorial herniation and / or intratumoral hemorrhage that may occur as a result of pre-resectional ventricular shunting in patients with posterior fossa tumors. In this work, the author will present the incidence and the resultant morbidity and mortality of such complications, and will propose a surgical technique and pre and post shunting management guidelines that might help to avoid such life threatening complications.
Patients and Methods: A total of 137 patients who were admitted to Abul Reech Pediatric University Hospital with a diagnosis of posterior fossa tumor between January 2006 and April 2010 were retrospectively reviewed to evaluate the incidence, and the resultant morbidity and mortality of upward transtentorial herniation or Intra-tumoural hemorrhage following placement of pre-craniotomy ventricular shunt. There were 79 (57.6%) males and 58 (42.3%) females. The patients' age ranged from 11 months to16 years with a mean of 5.8 years. All medical records and imaging studies were reviewed and analyzed. A diagnosis of intratumoral hemorrhage was made when the patient developed deterioration of the neurological status following placement of the shunt and the CT scan brain showed acute hemorrhage within the tumor. Upward transtentorial herniation was diagnosed when the patient had a disturbance of the conscious level after shunt placement and the CT scan brain revealed obliteration of the quadrigeminal and ambient cisterns and there was no other new evident pathology. Final outcome of these complications upon discharge of the patient from hospital was evaluated.
Results: Radiologic features of hydrocephalus were noted in 121 (88.3%) patients. Out of the 121 patients with hydrocephalus, 96 (79.3%) patients underwent pre-resectional ventriculoperitoneal shunt placement. Three patients (3.1%) developed intratumoral hemorrhage, one died before any neurosurgical interference, one did not recover inspite of urgent resection of the tumor and the third regained consciousness after excision of the tumor. Two patients (2 %) had upward transtentorial herniation without intratumoral bleeding. One patient died 2 days following resection of the tumor, the other patient recovered but was severely disabled with left sided weakness.
Conclusions: Although upward transtentorial herniation and intra-tumoral hemorrhage are rare complication yet they carry a very bad prognosis in most of the cases and markedly increase the overall mortality rate in posterior fossa tumors. In this paper, management guidelines that might help to avoid such fatal complications are proposed. Surgical interference to treat such conditions is not always promising.
Objective: In this study, we report the Clinical
and radiological outcomes of patients with sacral masses.
Methods: 10 patients presented to neurosurgery department in Kasr El-Einy Hospitals from January 2006 to December 2008 with sacral masses. Surgical resection using posterior approach with or without spinopelvic fixation by using Modified Galveston Technique if the sacroiliac joints are involved more than 50% by the tumor.
Results: The pathological diagnosis was giant cell tumor in 2 cases, aneurysmal bone cyst in 3 cases, chordoma 3 cases and neurofibroma in 2 cases. Total resection was done in 9 cases (90%). Low back pain and leg pains recovered well in 8 cases while remained for about 5 months in the 2 cases with giant cell tumors in which there were instability and fixation was used but fusion did not happened except after 6 months. Sphincteric disturbance recovered after 3 months in 4 cases (40%), three of them were aneurysmal bone cyst and one case of neurofibroma.
Conclusions: The surgical management of sacral tumors requires partial or total sacrectomy and spinopelvic reconstruction. These lesions present a great surgical challenge, because most spine surgeons are unfamiliar with the techniques required for these procedures.
Background and Objective: Tuberculosis (TB)
still represents a serious worldwide public health problem, especially
in developing countries. CNS tuberculous involvement is not rare and it
usually presents as tuberculous meningitis or tuberculomas. The aim of
this study was to identify the diagnostic features and to analyze different
lines of management that have been applied in the management of intracranial
tuberculoma.
Patients and Methods: 62 patients with intracranial tuberculomas have been encountered and managed at King Khalid University Hospital, King Saud University during the last 15 years (1993-2008). Of those, full data could be retrieved for 45 patients who were included in this study. All patients' medical records, radiological investigations, operative notes and follow up results were retrospectively reviewed for details of clinical presentation, neuroradiological findings, line of management, operative details and outcome.
Results: 45 patients were included in this study. 27 out of them were histopathologically verified while 18 were diagnosed based on clinical and/or radiological findings. The MRI features were highly suggestive of the diagnosis. Three modalities of management have been applied: gross total surgical resection followed by anti-tuberculous treatment (ATT) in 15 patients, biopsy or partial resection followed by ATT in 12 patients and empirical ATT based on clinical or radiological findings in 18 patients. We noticed that the group of patients who underwent gross total surgical resection has the highest rate of clinical and radiological improvement. Our results will be detailed and discussed in view of the pertinent literature.
Conclusion: Diagnosis of intracranial tuberculomas needs a high index of suspicion particularly in endemic areas. The presence of characteristic MRI findings can help with preoperative diagnosis so that proper line of management can be planned. Clinical, laboratory and radiological findings are only suggestive to the diagnosis. So, when there is no evidence of active extracranial involvement, the intracranial lesion should be biopsied before starting ATT. Total surgical resection should be considered in patients with a solitary lesion that is surgically accessible and in non-eloquent brain regions.
Introduction: Although craniopharyngiomas is a benign lesion, yet paradoxically can display malignant behaviors. The tumor have a tendency to invade surrounding structures and recur even after total resection. The rarity of these tumors has limited both individual neurosurgeons and most institutions from developing experience and expertise in their management. The consensus of treatment of craniopharyngioma is surgical, nevertheless approaches differ depending on the size of the tumor and the degree to which it has impacted adjacent structures. Nowadays conservative surgical approaches to the cranial base provide a minimal access and a maximally aggressive alternative to traditional open cranial base approaches for craniopharyngioma.
Objectives: Different endoscopic surgical approaches to craniopharyngiomas has described in several small case series. In this series we present our early experience and outcome of both pure endoscopic endonasal and endoscopic assisted microsurgical resection of craniopharyngioma.
Patients and Methods: Between June 2005 and September 2009, twelve patients underwent either pure endoscopic transsphenoidal or endoscopic assisted microsurgical resection for newly diagnosed craniopharyngioma at neurosuregy department of Mansoura university hospital. A retrospective review of ophthalmological, endocraniological, rate of resection and complication was made.
Results: Eight patients 66.6% achieved gross total and near total (>90) resection of their tumors. Permanent diabetes insipidus occurred postoperatively in 4 patients (33.3%), 3 of them had preoperative diabetes insipidus (16.7%). Five (50%) of 10 patients who had a functioning hypothalamic pituitary axis preoperatively developed pan hypopituitarism after surgery. Visual improvement or normalization occurred in 70% of patients with preoperative visual field deficits. We had a case of postoperative CSF rhinorrhea after endoscopic endonasal surgery that needed resurgery .Also we had another case of postoperative visual deterioration.
Conclusion: The endoscopic endonasal and endoscopic assisted microsurgical
approaches provide minimally invasive access for the majority of craniopharyngiomas.
A high rate of gross and near total resection and reliable visual improvement
have been achieved with these approaches. Although some patients experienced
new endocrinopathies but major surgical complications were not encountered.
Methods: A retrospective study conducted at the department of Neurosurgery in, Mansoura University Hospitals in Egypt. Data were collected for all 17 patients diagnosed at our institution with SPNET between 1999 and 2008. Information collected included: presentation, duration of symptoms, metastasis at time of diagnosis, CT and MRI findings, extent of surgical resection, histopathologic diagnosis, postoperative chemotherapy/ radiotherapy and overall survival(date from time of diagnosis to death or to the last follow- up).
Results: There were 11males and 6 females and the mean age at diagnosis was 19.26(±10.68) months. The mean survival was 14.59±7.89 months. Eight children had total resection, 4 had subtotal resection and 5 had partial resection. Survival in young children less than 12 months was worse. Children who received chemotherapy and radiation therapy (10 patients) showed statistically significant longer survival than those received chemotherapy alone (p 0.001). There was a statistically significant better survival in children undergoing gross total or near total resection.
Conclusion: Based on our results and experience with such tumors, we recommend preoperative chemotherapy followed by multistage surgeries aiming at complete resection when indicated, then the children should receive postoperative chemotherapy and radiation therapy even in young children. focal radiation of 54 Gy. can be applied larger multi-institutional study is needed to evaluate neurocognitive and functional outcomes of the cases after the proposed treatment regimen.
Objectives: The present study aimed to evaluation of surgical feasibility and frequency of complications of anterolateral retroperitoneal exposure of thoracolumber spine and neurosurgical outcome of anterolateral lumber fusion in cases with single level traumatic spinal injuries.
Patients & Methods: The study included 23 patients; 18 males and 5 females with a mean age of 41.9±5.7 years had thoracolumber injury. The mean time lapse between occurrence of injury and surgical correction was 9.2±2.8; range: 4-15 days. Mean preoperative anterior height (AH) compression rate was 36.1±6.8% and the mean vertebral column kyphotic angle (KA) was 26.7±3.4 degrees. Fourteen cases underwent corpectomy and fixation with corpectomy cage and lateral fixation device, while 8 cases had decompression and lateral fixation device. The frequency of intraoperative events and surgery related postoperative (PO) complication was reported. Neurological assessment using the grading scale of Frankel classification of spinal cord injury was conducted preoperatively, immediate postoperative and at end of follow-up (FU). PO radiological assessment included evaluation of the fusion grade and the extent of improvement of KA and AH was determined.
Results: Only one patient had failed exposure because of the presence of adhesive peri-ureteritis that could endanger the ureter with a procedural failure rate of (4.3%). Intraoperative events and PO complications were reported in 12 patients with a total morbidity rate of 54.5%; however, all these complications were mild and did not affect the outcome of surgical intervention or induced risks to the patients. At 9-months after surgery, 18 patients (81.8%) had good fusion and by 12 months 20 patients (90.9%) had good fusion, only 2 patients (9.1%) had delayed achievement of good fusion till 15 months after surgery, with a mean duration of 6.2±2.6; 2-12 months till having good fusion. Both KA and AH determined immediate PO or at end of follow-up (FU) were significantly improved compared to preoperative measures. At end of FU; PO neurological assessment showed that 16 patients were neurologically intact (Frankel classification E), 3 patients were Frankel D, 2 patients were Frankel C and one patient was Frankel D. By end of FU, bladder function was improved in 7 of 8 patients had preoperative bladder dysfunction and 18 patients had no pain, while 4 patients had infrequent mild pain that responded to non-steroidal anti-inflammatory drugs (NSAID) in average dose.
Conclusion: Neurological outcome of patients treated using anterolateral retroperitoneal approach is satisfactory because of complete decompression of the spinal canal. Moreover, it yielded excellent long-term maintenance of kyphosis correction. Direct decompression of the spinal canal by anterolateral retroperitoneal approach using rigid lateral fixation system can be sufficient for large number of unstable single level thoracolumber fractures; however, when direct clearance and decompression of the spinal canal was necessary, corpectomy and replacement with corpectomy cage and bone grafting was preferable.
Patients & Methods: The study included 62 patients; 37 males and 25 females with a mean age of 52.2±9.3 years, 41 patients had radiculopathy, 12 patients had radicluo-myelopathy and 9 patients had myelopathy. C5-6 was the commonest level affected with a mean duration of symptoms of 10.5±4 months. PEEK cage were inserted in 23 (37.1%) patients (PEEK group) and titanium cage in 21 (33.9%) patients (Ti group), while in 18 cases, the vertebra was stabilized with a horseshoe-shaped autologous iliac bone graft harvested from the right iliac crest (BG group). Intra and postoperative complications, preoperative and postoperative (PO) patients' function and working ability were assessed using the Coopers' scale. Anterior vertebral height (AH), PO bony fusion and PO graft subsidence were assessed.
Results:6 patients developed immediate PO complications and 3 patients in BG group developed donor site hematoma, 2 wound infections and 2 patients had severe donor site pain; 3 cases had mild, one had moderate subsidence (collectively 4 cases in Ti group (19%)). Only one case (4.4%) in PEEK group showed moderate subsidence and one patient (5.6%) had BG fusion showed graft dislodgement. PO complications were significantly higher in BG group compared to PEEK and Ti groups. All patients showed functional and ability improvement with a mean improvement of Cooper scale by 43.9% compared to preoperative score and significant improvement in PEEK group compared both to Ti group. All patients showed improved cervical spine curvature; however, one patient in Ti group showed straight spine. In BG group two patients still had straighting of the spine with significant difference in favor of PEEK group. PO AH was significantly higher compared to preoperative AH in all studied groups with significantly higher AH in both PEEK and Ti groups compared to BG with significantly higher AH in Ti compared to BG group. At 12-m after surgery, the frequency of patients had good fusion in Ti group was still significantly lower compared to those included in PEEK group. It was non-significant compared to those included in BG group with non-significant difference between PEEK and BG groups.
Conclusion: ACDF for single level cervical disc disease degenerative
cervical spine diseases using either PEEK or titanium cage provided satisfactory
outcome with good fusion slash alignment of cervical spine and spared
PO donor site morbidities. However, these results were superior using
PEEK cage compared to titanium cage.
Methods: 68 consecutive cases of surgically and pathologically verified anterior skull base meningiomas were retrospectively studied. We compared patients criteria, tumor characteristics and surgical results in our material with those in other recent series. Significant variables for outcome in our material were: preoperative karnofsky perfacmance scale (KPS) score, co morbidity, cranial nerve palsy, tumor size, arachnoid plane around the tumor, peritumoral oedema, tumor vascularity, vessel encasement, pial blood supply, tumor consistency and the radicality of resection.
Results: Several statistically significant variables have been identified to influence the general outcome, extent of surgical resection and occurrence of perioperative complications. These are detailed, analyzed and discussed in view of the pertinent literature
Conclusion: The variables predicting the resectability of and outcome for anterior skull base meningiomas are too numerous. Moreover, some intraoperative variables like tumor consistency and its adherence to neurovascular structures can not be reliably predicted preoperatively so that resectability can not be established with certainty except only at the time of surgery. Each case is better to be evaluated individually taking into account all variables and not only the most influential ones.
Methods: In a group of 23 prospectively selected patients (15 males and 8 females) having (CIM) with and without syringomyelia (11 patients and 12 patients respectively) during a five years period from January, 2005 to January, 2010. Cranio-cervical bony decompression alone was done in 8 patients, Cranio-cervical bony decompression with duroplasty was done in 12 patients, and Cranio-cervical bony decompression with syringo-subarachnoid shunt was done in three patients. Outcome was defined as good, fair, or bad.
Results: During a mean follow-up period of 32 months, the overall outcome was good in 19 patients (83%), fair in 3 patients (13%), and bad in one patient (4%). No operative mortality or permanent post operative morbidity was encountered. Transient post operative morbidity was encountered in 6 patients (26%) namely mild temporary neurological deterioration, CSF leak, and mild wound sepsis. There were no statistically significant differences between the various decompressive approaches.
Conclusion: Decompression of the cranio-cervical junction through suboccipital craniectomy (SOC) with cervical laminectomy, duroplasty, or syringo-subarachnoid shunt is the recommended surgical management option for CIM±S. Further studies utilizing larger patient volumes are necessary to confirm our recommendation.
Objective: To asses the use of metrizimide intratumoral injection and intra operative imaging of tumor to detect tumor outline and extent of tumor to assess and assist complete resection.
Summary of Background Data: Transsphenoidal pituitary surgery permits effective treatment for the majority of these tumors. With large tumors with suprasellar extension, removal is more hazardous and the extent of resection more difficult to judge.
Methods: 16 patients were operated upon by Transsphenoidal pituitary surgery and metrizimide was injected intratumorally and intra operative imaging of tumor was done. The duration of surgery, extent of tumor removal, complications, the clinical and radiological results were evaluated.
Results: 10 females and 6 males with a mean age of 39.2, mainly presenting with headache (69%) and visual manifestations (63%). 75% had suprasellar extension. The mean follow up period was 19 .4 months. Improvement of symptoms occurred in 80 to 89% of cases. Recurrence rate within one year follow up was 6%.
Conclusion: The use of metrizimide intratumoral injection and intra operative imaging of tumor to detect tumor outline and extent of tumor to assess and assist in complete resection is an effective and cheap aid in total removal of large pituitary adenomas with suprsellar extension, reducing the need for reoperation.
Methods: The study was conducted on 47 patients with isolated head injury admitted to the neurosurgical intensive care unit. The results of the fibrin degradation products were compared with the admission Glasgow Coma Score and with the discharge Glasgow Outcome Score.
Results: The study included 33 males and 14 females, with a mean age of 23. 25 patients (53%) survived and were discharged from the department with good recovery in 19 patients (40%) and moderate disability in 6 patients (13%). On the other hand, 22 patients (47%) had a bad outcome; 6 patients (13%) were severely disabled, 5 patients (11%) were in the vegetative state and 11 patients (23%) died.
Conclusion: The higher the FDP score of the patient the worse the prognosis and outcome. FDP score had a good predictive value.
Methods: A total of 20 patients (group I) who had undergone revision discectomies for recurrent lumbar disc herniations were surveyed to assess their clinical outcomes. Patients were compared with a control group of 20 matched patients, who had undergone only a primary discectomy, using VAS (Visual Analogue Score) and JOA (Japanese Orthopaedic Association's evaluation system for low back pain syndrome) for low back pain and patient satisfaction as tools for assessment.
Results: The mean recovery rate of the 15 point of the JOA was 71.2 % (36.3-91.6) for group I and for group II was 72%. Patient satisfaction was slightly greater in group II, 97% compared to 90% in group I. Male gender, history of smoking and history of trauma may be implicated as risk factors for recurrent herniation. The rate of complications was less in group II (5%) compared with group I (10%).
Conclusions: Outcome of revision discectomy for treating recurrent lumbar
herniation is comparable with that of primary discectomy. Based on the
results of this study, revision discectomy can be recommended for the
management of recurrent lumbar disc herniation with the expectation of
satisfactory results.
Patients and Methods: 53 patients were surgically treated from brain abscess. 52 were operated through craniotomy and craniectomy. Only one patient was operated through trans- nasal trans-sphenoidal approach.
Results: Surgical decompression was achieved in all cases followed by 6- to 8-week course of parentral antibiotics, plus regular follow-up computed tomography scans for at least 3 months to evaluate the therapeutic response is also recommended.
Conclusion: The most common etiological causes were post-traumatic head injuries, post-neurosurgical procedures and post-infectious. The surgical treatment chosen depends on the patient's clinical status, the neuro-radiographic characteristics of the abscess, and the experience of the surgeon who will be carrying out the procedure.
Patient and Methods: Eleven patients with lesions related to the atrium of the lateral ventricle were operated upon adopting the transparietal approach whether posterior parietal (in the dominant hemisphere or small tumors in the non dominant side)or parietotemporal junction (large tumors stretching the cortex in non dominant side) and the results were analyzed.
Results: This approach provides short and simple pathway but with limited exposure that compensated by changing the angle of microscope. Four cases (36%) with thalamic tumors were subtotally removed due to the tumor nature. All cases had smooth recovery and there was single mortality in the study due to bleeding in the residual tumor by the second day postoperatively. Two cases had visual field defect, two cases had transient hemiparesis and one case had convulsion controlled by medical antiepileptic medication, without any case in this study with language or permanent motor deficit.
Conclusion: In spite of limited exposure, the transparietal approach
whether posterior parietal or parietotemporal junction can be used efficiently
for removal of tumors related to the atrium with minimal risk to the language,
motor area and optic radiation especially when compared with other approaches.
Methods: Patients with Glasgow coma scale (GCS) > 8, without focal neurological deficits, with EDH < 30 cc in volume and < 15 mm in thickness, with midline shift (MLS) < 5mm on their initial computed tomography (CT) were managed conservatively. Close monitoring of conscious level as well as regular follow up CTs were performed in all patients. Time interval between onset of trauma and time of initial CT, as well as intervals between subsequent CTs were documented. Hospital stay for at least 6 days after trauma was mandatory.
Results: None of our seventy patients showed clinical deterioration in the follow up period. Seven patients had increase in size (more than 30cc volume and/or 15 mm thickness) in their follow up CTs thus requiring surgical evacuation in all but one patient who refused surgery. The increase in size was detected in the first follow up CT in six patients, and in a later CT in one patient.
Conclusion: Conservative management of EDH can be adopted safely in patients
fulfilling the inclusion criteria, with close monitoring of conscious
level and regular follow up CTs. A group of these patients will need surgical
evacuation mostly in the first 24 hours following trauma, however delayed
asymptomatic increase in volume may uncommonly occur.
Objective: To study the effectiveness of supraclavicular approach in decompression of thoracic outlet.
Materials and Methods: From 2003 to 2010 twenty patients with TOS, the age range from 25 to 42 years, duration of symptoms range from 4 - 36 months. There were 18 females and 2 males. All cases were treated surgically through supraclavicular approach after failure of conservative treatment which include physiotherapy and medications.
Results: The outcome of our patients was complete response in 14 cases, partial response in 4 cases and no response in 2 cases. Skin infection occurs only in 1 patient treated with antibiotic and improved, subclavian artery injury was encountered in 2 patients and repair was done with postoperative anticoagulant to avoid thrombosis.
Conclusion: Supraclavicular exploration of the brachial plexus enables precise evaluation of the thoracic inlet and safe identification and release of all abnormal anatomical structures.
Objectives: Evaluation of effectiveness of middle turbinate flap in reconstruction of sellar floor after transsphenoidal surgery.
Material and Methods: A retrospective study of 30 patients with pituitary adenoma from 2008-2010 were treated surgically through transsphenoidal approach (age range 25-55 years). There were 20 females and 10 males, 10 microadenomas and 20 macrcoadenomas suitable for transsphenoidal approach. All patients are surgically treated with transsphenoidal approach with reconstruction of the sellar floor using middle turbinate flap. There were only 6 cases with intraoperative CSF leakage and in the rest of cases the arachnoid was intact.
Results: twenty-five patient had no CSF leakage immediately and after 3 months of follow up. Only five patients show CSF leakage after surgery. All of them subjected to conservative treatment in the form of head elevation and prophylactic antibiotics as well as repeated lumbar puncture and dehydrating measures. Three of them respond to conservative treatment and CSF leakage stopped after 10 days, only 2 cases underwent endoscopic repair using fat graft and leakage stopped.
Conclusion: Middle turbinate flap for the reconstruction of the sellar floor after transsphenoidal surgery is an effective method with less complication compared with either fat graft or foreign materials.
Objective: This study aims at evaluating the effectiveness and privileges of unilateral approach (lamintomy) as a minimally invasive technique in adequate bilateral decompression of clinically and radiologically significant stenotic canals of the lumbar spine.
Patients & Methods: A prospective study of 32 patients with clinically manifesting ligamentous lumbar canal stenosis without instability. Those patients were operated with unilateral microscopic laminotomy for bilateral decompression. Single level decompression was done in 21 patients, 2 levels were decompressed in 6 patients, while in 5 patients three levels were decompressed.
Results: Thirty two patients were operated for clinical and radiological
evidence of LCS without instability with total 48 levels. Adequate decompression
was obtained in all patients. Complications included dural tear, missed
level that was corrected intraoperatively, postoperative transient radicular
pain and superficial wound infection. Each complication occurred in one
different patient, otherwise, all patients improved following surgrey.
Postoperative hospital stay was less than 48 hours.
Conclusion: Unilateral microscopic laminotomy can be adequate for central, bilateral lateral recess and foraminal decompression of lumbar canal stenosis with low morbidity but with little longer operative time that was shortened with mastering the technique.
Objective: In this retrospective study, we report the clinical outcome and follow up of 113. Patients with chronic subdural hematoma who presented and operated by burr hole evacuation with negative pressure subgalial drainage.
Methods: (A) Patient selection: Patients presented to the Neuroemergency unit in Kasr El-Einy Hospital from January 2006 to December 2009 with chronic unilateral and bilateral subdural hematoma. (B) Procedure: Evacuation of the hematoma by making double burr holes at the sites of maximum hematoma thickness and washing the hematoma cavity with warm saline solution. A closed suction drain size 16 was then inserted under the galia leaving the draining holes over both burr holes and leaving it under medium suction for 3-5 days. (C)Evaluation: Clinical and radiological evaluation was routinely performed on the third day postoperatively to assess the brain expansion, another follow up CT scan was done one month postoperatively. Patients were prospectively followed up clinically using Glasgow outcome scale score at the time of hospital discharge and at 3-months thereafter, then comparing the clinical and radiological outcome with those of the other procedures in the literature.
Results: At 3-months follow up, the Glasgow outcome scale score (GOS) was 5 in 84 patients (74.3%), 4 in 21 patients (18.6%), 3 in 5 patients (4.4%), 2 in 1 patient (0.9%), and 1 in 2 patients (1.8%). Recurrence was confirmed in 5 patients (4.4%).
Conclusion: Evacuation of the chronic SDH combined with a subgalial suction drain is an effective, safe, technically easy treatment strategy. This procedure has much lower complications rates and recurrence rate than any other procedure as the suction drain helps complete and progressive evacuation of fluid and residual subdural blood.
Endoscopic trans-nasal repair is considered the
technique of choice for repair of the anterior cranial fossa CSF leaks
not only denovo but also in recurrent cases. Recurrence of CSF rhinorrhea
may be attributed to the presence of undiagnosed and untreated high pressure
hydrocephalus.
The Aim: evaluating the role of implanting a lumbo-peritoneal shunt in the same sitting for those patients undergoing trans-nasal endoscopic repair of their skull base defects for recurrence of their CSF rhinorrhea.
Patient material & Method: 16 cases (11 F: 5 M) aged 16 to 53 (mean 29.4 y), with recurrent CSF rhinorrhea underwent trans-nasal endoscopic repair of their anterior skull base defects using a variety of materials including fascia lata and abdominal fat either alone or with histoacryl blau or fibrin glue, and had a lumbo-peritoneal shunt inserted prior to repair in the same sitting. The cause of primary CSF rhinorrhea was post-traumatic in 5 cases (31%), post-operative in 7 (44%) & spontaneous in 4 (25%). All cases had their primary repair done at intervals more than 2 months after the occurrence of the CSF rhinorrhea.
Result: the leakage stopped in 14 cases (87.5%) of them, with a mean follow up period of 28 months. Only two cases failed and required removal of the shunt and transcranial repair. The shunt was removed in 3 other patients who experienced manifestations of intracranial hypotension which improved post-operatively. There were no major complications related to neither the shunt nor the endoscopic procedure.
Conclusion: The implantation of a lumbo-peritoneal shunt in the same sitting for patients undergoing trans-nasal endoscopic repair for recurrent CSF rhinorrhea is a safe and beneficial procedure, especially if an underlying undiagnosed untreated high pressure hydrocephalus is suspected to be the cause for recurrence and may facilitate healing of the sealing material at the leakage site.
Purpose: Central neurocytoma is a rare intraventricular
brain tumor that affects young adults and presents with increased intracranial
pressure secondary to obstructive hydrocephalus. Typically, it has a favorable
prognosis after adequate surgical intervention, but in some cases the
clinical course is more aggressive. In this report, we describe the diagnosis
and treatment of central neurocytoma in a series of patients at our institution.
Patients and Methods: fourteen patients with ventricular tumors showed typical radiological, histologic and immunohistochemical features of central neurocytoma. Most patients received craniotomy with removal of the tumor through transcallosal or transcortical approach. The surgical and histopathologic data of these patients were reviewed and analyzed.
Results: fourteen patients, 5:2 female: male ratio. 15 procedures, 13 transcortical and two transcallosal. Thirteen total and one subtotal excision. Twelve patients needed permanent csf diversion and we had one case of infection.
Conclusion: the best treatment for central neurocytoma is total excision which, if achieved needs no adjuvant treatment. A thorough histopathological diagnosis is crucial to differentiate it from oligodendroglioma. Transcortical approach is a safe and effective approach even in big tumors.
Objective: this study demonstrates the surgical
management of patients with multiple intracranial aneurysms (MIA) in neuroemergency
unit at Cairo University hospitals. Evaluating the accessibility and outcome
of clipping of all aneurysms during single surgery was stressed.
Methods: patients with subarachnoid hemorrhage (SAH) presenting to neuroemergency unit were investigated using conventional angiography and/or computed tomography angiography (CTA), and those with MIA were included in this study. Single session clipping of all aneurysms was planned whenever possible, otherwise staged management was adopted. Assessment of clinical outcome was based on patients' Glasgow outcome scale (GOS) on discharge from hospital.
Results: sixteen patients with 35 aneurysms were operated upon by surgical clipping in Cairo University hospitals. Successful clipping of all aneurysms during single surgery was achieved in 10 patients. Clipping of the ruptured aneurysm (in addition to accessible aneurysms) in the initial surgery, postponing the management of other aneurysms was performed in 6 patients. On discharge there were 9 patients with GOS 5, 3 patients with GOS 4, 2 patients with GOS 3, and 2 patients died.
Conclusion: clipping of multiple aneurysms via a single craniotomy during same surgery protects the patient from rebleeding with no added morbidity or mortality. It is an optimum option as long as these aneurysms can be safely approached and clipped through single access. Clipping of the ruptured aneurysm in the initial surgery and consequent management of other aneurysms is a valuable option in other cases.
Aim: To evaluate dysfunctional sacroillitis occurring following lumbar
spine surgery and evaluate the efficacy of CT guided injection as a diagnostic
and therapeutic tool.
Material and Methods: Twenty eight patients suffering back pain and/or lower extremity pain with recent history of spinal operation are included having pain clinically suspicious of being of sacroiliac origin and with recent history of spinal operation.
Results: 12 patients were males and 16 patients were females. The age of patients ranged from 22 years to 65 years with a mean of 43 years. previous operation done included 15 patients undergoing single level discectomy, 10 patients undergoing spinal instrumentation 4 patients with 4-5 fixation, 6 patients with 5-S1 fixation. Three patients had laminectomy for canal stenosis. Post injection response classified to Negative responders: 3 and Positive responders: 25 patients. The duration of improvement in positive responder group lasted from 14 days to 6 months with an average of 73 days.
Conclusion: A painful SIJ should be more considered as a differential diagnosis in patients with low back pain and leg pain in patients with prior lumbar surgery. The use of accurate diagnostic, therapeutic injections helps both diagnosis and pain relief.
Frame-based stereotaxis (FB) is a well-established technique for performing
three-dimensional point stereotactic needle procedures. Nowadays with
the advent of neuronavigations (FL), with this era of modern neurosurgical
practice, some surgeons question the validity of frame-based stereotactic
procedures .We give our experience in using both tools in managing supratentorial
structural brain lesions, during more than twelve years in order to speculate
the role of both in management of these lesions. We can conclude that
both techniques have evolving role in both biopsy and resection guided
procedures while FB offers diagnostic accuracy in deep seated and very
small non-enhanced lesions, FL gives us the opportunity to deal with most
of other lesions especially if general anesthesia is warranted. Regarding
stereotactic guided resection while the FL gain the biggest share ,FB
sill have a role in some instances specially in awake craniotomy.
Arteriovenous malformations AVM are important entity of cerebrovasculer
malformation although not common in our country, it constitutes an important
cause of morbidity and mortality not specific for certain age groups.
It gain much of its interest in its unresolved dilemma in all its aspects.
There is great interest and also great debate and conflict in studying
the natural history, risk factors, predictors of hemorrhage and other
important aspects regarding these lesions. Trying to solve this dilemma
needs much more studies .We give our experience in the surgical management
of a group of 27 patients during a period of twelve years, although small
in number, it's our begging step on our way for better management of these
lesions and most important its gives a good idea about the presentation,
characters, and management strategy for AVM in our country.
Study Design: We reviewed our surgical experience and results in 24 patients
operated upon by multiple oblique corpectomy without fusion for cervical
spondylotic myelopathy. Objective To review the safety, efficacy and surgical
experience of multiple oblique corpectomy in carefully selected 24 patients,
through anterolateral corridor to the cervical spine without the need
for vertebral fusion or stabilization.
Methods: Between March 2007 and April 2010, 24 patients have been treated with multiple oblique corpectomy technique for cervical spondylotic myelopathy. The functional status was assessed using the Modified Japanese Orthopedic Association Score preoperatively and at 1,6,12 months postoperatively. Radiological Assessment was done preoperatively with MRI, CT scan and plain X-ray dynamic films, and postoperatively on the following 1,6,12 months after surgery and routinely prior to discharge.
Results: Among the 24 patients (16 males and 8 females) with a mean preoperative duration of symptoms for of 11.7 months, satisfactory significant recovery occurred in 17 patients, 4 patients had no clinical improvement and 3 patients had variable degrees of clinical deterioration. Only one patient showed an evidence of spinal instability postoperatively.
Conclusion: The multiple oblique corpectomy is a safe and effective technique in removal of the anterior compressing spurs to the spinal cord. No fusion is required regardless the number of the levels. The short recovery period, few complications rate with satisfactory significant outcome make this technique a better surgical option for cervical spondylotic myelopathy in selected patients.
Background: the burst fractures of the fifth lumbar vertebra are very
rare, due to different anatomical and biomechanical characters, with little
reports discussing it. Objective: to asses the results of conservative
management by external orthodesis for 4-6 months in the burst fractures
of the fifth lumbar vertebra without or with mild neurological deficits.
Methods: Ten patients with burst fracture of the fifth lumbar vertebra were managed by conservative management, three of them had mild neurological deficits, they were diagnosed by x-ray, CT lumbosacral and followed by x-ray to follow the wedge index and lordotic angle, with follow up to the pain and the mild neurological deficits, then classification of patients into excellent, good, fair or poor outcome
Results: Axial compression was the main cause, 60% of patients had associated injuries, 100%had back pain, 30%had mild neurological deficits, canal narrowing was less than 50%, average of wedge index changed from83 to 80, lordotic angle changed from average 30 to 28 degree.
Conclusion: The conservative management is the
first line of management for the burst fractures of the fifth lumbar vertebra
specially in cases without or with mild neurological deficits.
Rationale: improper application of basic principles of primary repair
of myelomeningocele leading to recurrent tethering.
Patients: twelve patients were included in this article with myelomeningocele primarily repaired during their first two months after birth, with failure to gain neurological development of lower back, lower limbs, and bladder and bowel control, their MRI pictures showing failure of untethering and/or recurrent tethering of the myelomeningocele, and failure of spinal cord ascent.
Results: this article includes 12 patients, their age ranges from 2.5years old to 5years old, 7females, 5males, with 9cases were shunted, primarily repaired for their myelomeningoceles within 1st two months of their life, presented by inability to gain walking in all cases, bladder and bowel dysfunction in8cases, inability to sit in4, foot deformity in 4, previous orthopedic corrections in 3, kyphosis in 2, the level of affection were at L4/5 in7, L5/S1 in5, operative findings were small skin incision 12, intact upper two normal cranial laminae above the defect 12, no duroplasty 12, placode without closure 12, residual large lipomas 2, intact filum terminale 10, two cases complicated by, one superficial wound infection, and the other with CSF leakage needing secondary sutures, outcome of this cases one year after correction were, ability to walk 4, walking with support 3, sitting 2, bladder and bowel improvement 7, no improvement 3.
Conclusion: for prevention of recurrent tethering
of myelomeningocele repair, this rules should be followed, large skin
incision, laminectomies of the 1st upper two laminae, pial-arachnoidal
closure of the neural placode, sectioning of the filum terminale, extensive
duroplasty by thoracolumbar fascial flap, and good skin closure with non
absorbable NYLON sutures.
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