Two different surgical techniques were used to treat contagious two-level cervical spine disc diseases.

Methods: Forty two consecutive cases of contagious two-level cervical spine diseases were operated on. Patients were randomized into two groups: Group A (23 patients) underwent anterior cervical discectomy and cage fusion, and Group B (19 patients) underwent anterior cervical discectomy, autogenous iliac crest graft fusion and plate fixation. Cervical X-ray was taken every 3 months until fusion is completed, functional and working status was evaluated. Blood loss and operative time were recorded.

Results: Radiculopathy improved after surgery in all the cases, and so mylopathy. The fusion rates were the same in Group A and B. Cage interbody fusion was better than plating in total complications. Cervical lordosis was restored in twenty two of the twenty three patients, operated in group A, in whom it was lost preoperative.

Conclusion: Both cage and plating are good surgical methods for interbody fusion in contagious two-level cervical degenerative disease. They increased spinal lordosis and graft fusion rate. However, the cage has least amount of blood loss and fewest rates of complications.

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Materials and Methods: From 2008 to 2010, 7 cases of aneurysmal bone cyst were treated surgically, the average age was 20-35 years, the duration of symptoms ranging from 4 months to 1.5 year, there were 6 females and one male. In 4 (57.2%) cases the lesion was in the lumbar vertebra and in 3 (42.8%) cases in the dorsal vertebra. The lesion was in the posterior element of the vertebra in 3 (42.8%) cases, vertebral body in 2 (28.5%) cases and in 2 (28.5%) cases anterior and posterior element affection.

Results: Complete excision was done in 4 (57.2%) cases and partial excision in 3 (42.8%) cases. Fixation using rods and screws was done in 3 (42.8%) cases in which extensive excision was done, Intraoperative bleeding was excessive in 6 cases which needs blood transfusion (500-3500 cc).

Conclusion: Complete surgical excision with or without spinal decompression offers the best line of treatment for cases with aneurysmal bone cysts.

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Objectives: The goal of this study was to determine the incidence of screw misplacement and complications in 70 patients who underwent transpedicular screw fixation in lumbar spine with conventional open technique and intraoperative fluoroscopy using postoperative CT scan.

Patients and Methods: 70 patients (55 dorsolumbar fracture and 15 lumbar fractures) with traumatic dorsolumbar and lumbosacral spine fractures underwent posterior transpedicular fixation and reduction. A 500 pedicle screws (55 x 8 + 15 x 4) were inserted under fluoroscopic control. Screws position was assessed postoperatively by computed tomography. Screws position was classified as (correct) when the screw was completely surrounded by pedicle cortex, as "cortical encroachment" questionable violation if the pedicle cortex could not be visualized, and as "frank penetration" when the screw was outside the pedicular boundaries. Frank penetration was further subdivided into minor (when the edge of the screw was up to 2.0 mm outside the pedicle cortex, moderate between 2.1 mm - 4.mm) and severe (>4 mm).

Conclusions: The conventional open technique using intraoperative C-arm fluoroscopy for transpedicular screw insertion is still safe and effective method for fixation. Our rates of screw misplacement and complications was reasonable in comparison with other series in which conventional technique was used namely intraoperative C-arm fluoroscopy. The risk of malpositioning of the screws and other intraoperative complications may be reduced with careful surgical planning and increasing surgical experience. Computed tomography is more superior than plain x-ray in determining the accuracy of pedicle screw placement.

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Objective: In this study, we retrospectively analyze the post operative clinical outcomes of 14 patients operated upon for ruptured intracranial arteriovenous malformations (AVMs).

Methodology: Patient selection: patients with ruptured supratentorial intracranial arteriovenous Malformations. Operation: evacuation of the hematoma and excision of arteriovenous malformation.

Results: Outcomes at last follow up at six months post operative were excellent in 8 patient (57.1 %), good in 4 patients (28.7%), Poor in 1 patient (7.1%) and one case mortality.

Conclusion: Surgery on ruptured AVMs is much easier than the unruptured AVMs due to the Plane of dissection created by the hematoma, good surgical outcome can be achieved by rapid surgical intervention and aggressive treatment of the increased intracranial pressure.

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Background: Endoscope procedures have become the preferred treatment for obstructive hydrocephalus. The purpose of this paper is to present our experience with endoscopic procedures.

Methods: fifty cases underwent endoscopic procedures, third ventriculostomy, for the treatment of obstructive hydrocephalus in forty five patients, in addition to five cases for endoscopic excision of colloid cyst between January 2007 and January 2010. The follow-up period was 36 months. The obstructive hydrocephalus was caused by space-occupying lesions in twenty patients (posterior fossa tumor), aqueductal stenosis in twenty five patients, and third ventricular colloid cyst in five cases.

Results: there was success rate of endoscopic third ventriculostomy for aqueduct stenosis (88%) ,( 85%) for posterior fossa lesions ,and (100%) among cases of third intraventricular tumors. the procedure failed in three patients (15%) in posterior fossa tumor within one month post tumor excision and in three cases in aqueduct stenosis . There was no permanent morbidity after ventriculostomy in our patients.

Conclusion: third ventriculostomy is an effective treatment in cases of obstructive hydrocephalus that is caused by aqueduct stenosis and space-occupying lesions. This procedure is worthy for controlling hydrocephalus instead of shunt and its complications. Early clinical picture after the operation plays an important role in predicting patient's outcome after endoscopic third ventriculostomy.

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Objective: To analyze the association of cerebellar tonsillar descent and syringomyelia in patients with posterior fossa arachnoid cysts.

Methods: This is a retrospective study of ten patients (7 males and 3 females with mean age 31; range, 22-47 years) diagnosed with posterior fossa arachnoid cyst and tonsillar descent. Symptoms evolved over a mean of 12 months (range, 6 months to 3 years). Syringomyelia was present in 6 cases.Six patients underwent a suboccipital craniectomy, 3 cases underwent an additional C1 laminectomy, and a further case had a limited craniectomy and tonsillar reduction. Two patients were also treated for hydrocephalus: one with a ventriculoperitoneal shunt and one with endoscopic third ventriculostomy. Three patients had conservative treatment. The posterior fossa arachnoid cysts were located at the vermis-cisterna magna (n=4), the cerebellar hemispheres (n=2), the cerebellopontine angle (n=3), and the quadrigeminal cistern (n=1).

Results: After a mean follow-up of 2 years (range, 3 months to 5 years), 4 patients showed resolution of their neurological symptoms, and two exhibited persisting ocular findings. Headaches and neck pain improved in 4 cases and persisted in four. Syringomyelia was resolved in four patients and improved in one and unchanged in one.

Conclusion: Patients harboring a posterior fossa arachnoid cyst may be associated with acquired Chiari malformation and syringomyelia. Initial management should be directed to decompressing the foramen magnum and should include the resection of the arachnoid cyst's walls. As a golden rule, hydrocephalus should be properly addressed before treating the arachnoid cyst.

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Objective: To evaluate the role of combined estimation of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) as a predictor of outcome of children with severe traumatic brain injury (TBI).

Patients & Methods: The study included 39 children with severe TBI; with a total mean age of 9.8±2.6 years and mean at admission Glasgow Coma Scale (GCS) of 4.8±1.6. All patients underwent radiological workup and patients had intracranial hematoma underwent surgical evacuation and insertion of the intraventicular ICP sensor at the end of surgery, while in patients free of hematoma ICP sensor was inserted through Kocher's pathway. Both ICP and cerebral perfusion pressure (CPP) were monitored throughout ICU stay. The frequency of difficult catheter insertion or occurrence of complications was recorded. Glasgow outcome Score (GOS) was determined at time of hospital discharge and 6 months thereafter and patients were divided as to have favorable and unfavorable outcome.

Results: Eighteen patients had intraoperative catheter insertion after intracranial hematoma evacuation, while in the other patients catheter was applied through Kocher's pathway. Two patients had bleeding and 3 developed infection and catheter was removed. Six patients died, 25 of survivors had favorable, while 6 survivors had unfavorable outcome. At 6-months follow-up, 2 patients showed improved disability and increased favorable outcome rate among survivors to 87.1%. Survivors had significantly higher mean arterial pressure (MAP) and CPP with significantly lower ICP compared to non-survivors and among survivors, patients had favorable outcome had significantly higher MAP and CPP with significantly lower ICP compared to those had unfavorable outcome. Both survival and favorable outcome showed negative significant correlation with operative interference and mean ICP measure, while showed positive significant correlation with CPP. Operative interference and high ICP are significant negative sensitive predictor for both survival and outcome, while high CPP was found to be the significant specific predictor for all forms of outcome.

Conclusion: This study supports the role of combined monitoring of ICP and CPP as a relevant marker for prediction of the overall outcome of children with severe TBI.

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Objectives: To evaluate the surgical short-term outcome of endoscopic ulnar nerve release in patients with cubital tunnel syndrome (CTS) after at least 6-months postoperative (PO) follow-up.

Patients & Methods: The study included 17 patients; 10 males and 7 females with mean age of 31.9±5; years. The dominant hand was affected in 9 patients (52.9%) with a mean duration of the complaints of 15±5.5 months and mean duration of preoperative conservative treatment of 8.4±2.7 months. There were 2 patients (11.8%) Dellon's grade 1, 14 patients (82.3%) were Dellon's grade 2 and one patient (5.9%) was Dellon's grade 3. Preoperative nerve conduction studies, both sensory and motor were conducted to confirm ulnar nerve compression at elbow level. All patients underwent endoscopic release under general anesthesia and were followed up daily for one week, weekly for one month and then three monthly. Outcome was judged using Modified Bishop rating system.

Results: Proximal endoscopic advancement was failed in one case (5.9%) and nerve release was completed through an open incision. Fourteen patients (82.4%) reported significant improvement of symptoms within the first PO 24 hours, 2 patients (11.7%) reported similar improvement on the 2nd PO day, while the patient (5.9%) who had open completion reported improvement on the 6th PO day. Thirteen patients had full elbow motion within 72 hours after surgery and 4 patients within a week. After a mean follow-up duration of 12.5±2 months, 15 patients documented better improvement, 10 patients became asymptomatic, 11 patients regained their grip strength, 14 patients had improved sensibility and 15 patients returned to their preoperative job. Thus, according to modified Bishop Rating System, 12 patients (70.6%) had excellent outcome, 4 patients (23.5%) had good result and only one patient (5.9%) had fair result with a total mean score of 7.8±1.3; range: 4-9. All patients showed PO improvement of nerve conduction velocity compared to preoperative one. Four patients had PO minor complications that resolved spontaneously. No recurrence was reported.

Conclusion: Endoscopic cubital tunnel release of entrapped ulnar nerve is feasible, safe and easy procedure with procedural success rate of 94.1% and high successful outcome. Moreover, it provides small cosmetically acceptable wound with minimal PO complications and could be managed as one-day surgery.

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Purpose: evaluate our experience with patients suffering from lumbosacral lipoma and perform a review of the literature.

Materials and Methods: twenty one patients from 2006 to 2010. All patients had preoperative full examination, preoperative MRI, urodynamic study. Operated upon by unteathering. Postoperative assessment was conducted thgrough the period of follow up.

Results: all patients had undergone microsurgical reduction of the size of the intraspinal component of lipoma and widening the spinal canal to untether the cord. 66.6% improvent in pain, 40% improvent in weakness and 28.5% improvement in urological function.3 cases of CSF leak all stopped conservatevily, 2 temporary weakness and one permanent.

Conclusion: Lumbo sacral lipomas still represent a challenge regarding the management. So long the natural history is not clearly understood controversy will remain However, in review of our results particularly of the asymptomatic patients surgery can be offered safely to patients as neurological deterioration is unpredictable and may irreversible.

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Purpose: Assessment of the efficacy of the technique in reconstructing the skull base after transsphenoidal procedures to prevent CSF leakage.

Materials and Methods: Thirteen patients with intraoperative diagnoses of CSF leak after sellar and sinus procedures. The reconstruction includes en lay fat graft, nasal septal flap, fibrin glue and sterilized foley's catheter to hold the construct.

Results: ten cases were of the low flow leak and three cases of the high flow. The technique was successful in preventing postoperative CSF leak in 12 of the 13 cases. The remaining case was managed by ambulant lumber drain. There was 3 cases of diabetes insipidus, one patient of temporary hypocorisolism, no infection or mortality in the series. Conclusion: the multilayer reconstruction technique as described is highly effective in preventing both the low flow and high flow CSF leakage postoperatively.

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Objectives: The present study aimed to evaluate the applicability of at admission estimation of serum levels of S100B protein, neuron-specific enolase (NSE) and Glial Fibrillary Acidic Protein (GFAP), for the prediction of outcome during follow-up of patients had traumatic brain injury (TBI).

Patients & Methods: The study included 100 patients; 77 males and 23 females with mean age of 43.1±9 years with TBI. All patients had clinical evaluation using Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS); then all patients underwent radiological work-up including cranial CT (CCT) imaging. Patients proved to have intracranial lesion underwent surgical intervention, while other patients were managed conservatively. Patients and 20 volunteers (Control group) gave blood samples for estimation of serum levels of S100 protein, NSE and GFAP.

Results: 60 patients had mild TBI (20 had mild brain edema and 40 had free CCT), 25 patients had moderate TBI and all were managed conservatively, the other 15 patients had severe TBI and had immediate surgical interference. Mean serum levels of S100 protein were significantly higher in patients had moderate and severe CCT compared to those had mild TBI. Serum GFAP levels were significantly higher in patients with positive CCT compared to those had free CCT and in patients had severe TBI compared to those had mild or moderate TBI with significantly higher levels in patients had moderate TBI compared to those had mild TBI with edema. Postoperative mortality was 7% and morbidity was 17% and 4 patients required surgical interference. Non-survivors had significantly higher at admission serum S100 protein and GFAP levels compared to survivors, while only at admission serum GFAP levels were significantly higher in patients showed morbidities during follow-up. The ROC curve analysis, defined high GCS score as the highly sensitive parameter for the bad outcome during follow-up. At admission serum level of S100 protein and GFAP were the significant specific predictors for bad outcome than NSE.

Conclusion: At admission estimation of serum S100 protein and GFAP combined with determination of GCS could predict the presence of intracranial insult prior to CCT, the possibility for development of additional morbidities and mortality during follow-up, thus could help to differentiate patients predicted to have free CCT and for early designing of the management policy and could spare unnecessary CCT during follow-up.

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Objective: Thoracolumbar fractures commonly encountered following minor or major trauma. Controversy in management still exists, so comparing both lines of management conservative and surgical, to evaluate the best way of management.

Methods: Retrospective analysis of two groups of patients with thoracolumbar fractures ,one group treated conservatively and the other treated surgically to evaluate the effectiveness of both methods of management.

Conclusion: In spite of the increasing articles studying the various aspects of thoracolumbar fractures their management still carry a major controversy, but with increasing experience one can tailor the way of management according to every patient's parameters.

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Objective: chronic subdural haematoma (CSH) a condition of increasing incidence ,a wide variation in the method of management and there is still debate about the best surgical strategy .Recurrence is still a big problem and drainage is the most item detecting recreance. Evaluation of a new method of drainage using an under-water seal drains is carried out.

Method: A total of 50 cases were investigated between 2001and 2010 .of these cases eleven had bilateral subdural haematomas. Fifteen of all cases were operated with postoperative new adopted method using an underwater seal drains, on the bases of reducing postoperative subdural air collection and thus helping more brain expansion and less haematoma recurrence .comparing of the two methods of drainage and review of literature for the value of each type is carried on.

Conclusion: drainage after CSH surgery is very effective method that should be routinely done .In addition to this the new adopted underwater seal drainage is very effective method for drainage that prevents recurrence and minimize morbidity and mortality.

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Background: Many patients with spinal arachnoid cysts complain of symptoms suggesting spinal cord compression, and are often initially evaluated by their primary physicians. However,these cysts are often discovered incidentally. Intradural arachnoid cysts are more common than extradural cysts.

Objective: To describe intra-dural arachnoid cysts as the cause of compress-ive myelopathy.

Material and Methods: This is a retrospective study of eight patients harbouring intra-dural arachnoid cysts (7 males and 1 female with mean age 24;range, 6-34 years). A detailed description of symptomatology, radiological findings, surgical approach, techniques and outcome is discussed. Microsurgical excision was performed in all patients and the excised cyst wall sent to histopathological examination.

Results: Good long-term results were achieved in all 8 patients, after surgical intervention with only one recurrence. Conclusion: Rarely, intradural, extramedullary lesions like arachnoid cysts may lead to compressive myelopathy causing spastic paraparesis. Although uncommon, but intradural arachnoid cysts are important cause of compressive myelopathy and should be considered in the differential diagnosis. These lesions are curative, if excised surgically with precision.

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Aim: To evaluate the efficacy of endoscopic resection of colloid cysts of the third ventricle.

Material and Methods: 9 patients having colloid cysts were treated endoscopically through a kocher Burr hole.

Results: The preoperative CT scan showed the lesion hyperdense in 8 cases (88.9 %), isodense in 1 case (11.1%). The diameter of the cyst was measured on MRI and was found between 13 mm and 21 mm (mean 16 mm). Hydrocephalus was present in all cases. Total excision of the cyst was achieved in 6 cases (66.7%). Subtotal excision (cyst evacuation and wall coagulation) in 2 cases (22.2%). Abortion of procedure in one patient and transformation to open transcortical craniotomy. Complications included two cases (22.2%) of transient memory deficit that improved spontaneously over few weeks.

Conclusion: Endoscopic treatment of third ventricular colloid cysts is a minimally invasive safe and effective technique for managing these lesions.

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Background: Lateral ventricular tumors are challenge regarding the optimal surgical management, they may be primary or secondary, with variable clinical picture and different surgical approaches.

Objective: Review of 30 patients with lateral ventricular tumors and assessment main presentations, approaches, surgical and postoperative complications, pathology and adjuvant therapy. Methods: 30 patient with lateral ventricular tumor were assessed and diagnosed by CT and MRI brain, underwent full general and neurological examinations, comparing the presentation to the site of the tumor, transcortical and transcallosal approaches were selected, with exclusion of transplenial or parasplenial approaches, insertion of external ventricular drain( EVD) for all patients, follow-up for the patients clinically from time of surgery to 12-60 months, to define the surgical and postoperative complications, recurrence of the tumor, mortality and morbidity cases.

Results: high intracranial pressure (HICP) (67.7%), headache (50%) and mental disturbance (50%) were the most common presentations, transcortical approaches (68.75%) used more than transcallosal approaches (31.25%), complications of the first approach were seizure (18.2%), subdural hygroma (10%) and intracerebral haematoma( ICH) (10%), complications of the second approach were disconnection syndrome (50%), with no cases of venous injury. Meningitis (33.3%) was the most common postoperative complication and most common cause of mortality (50%) of meningitic cases, most common pathology was glioma.

Conclusion: Transcortical approach was more familiar than transcallosal approach, closed drainage system for cerebrospinal fluid (CSF) should be used to decrease the risk of meningitis, subtotal excision is accepted when the tumor was attached or difficulty dissected from important structures, also as the most common pathology was glioma then ependymoma which is good radiosensitive tumor, the shorter the time of EVD, the less risk of meningitis and less resistance to treatment.

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Background: Convexity and pterional meningiomas are commonly associated with hyperostosis.

Objective: this study was designed to indentify the cause of hyperostosis, whether it was due to true meningioma cells invasion to the adjacent skull bone or it was just due to secondary changes.

Methods: This retrospective study included 20 patients (16 females and 4 males) with convexity and pterional meningiomas were operated between May 2000 and September 2009. Patients were classified into 3 groups: Group 1; where the inner table was affected without diffuse thickening of the skull and they are treated by diathermy cautery. Group 2; where the inner table was affected with diffuse thickening of the skull and not causing disfigurement, they were treated by autoclaving of the affected bone. Group 3; where the outer table was affected or causing cosmetic trouble, the hyperostotic bone was removed and cranioplasty was performed. Biopsies of the hyperostotic bone were examined pathological in 17 cases.

Results: Tumor invasion of the affected bone was present in 88%. All cases of hyperostosis were sclerotic. Diathermy cautery was done in 40%, autoclaving in 35% and cranioplasty in 25% of cases. The pathology of the meningiomas was: 30% meningiothelial, 25% fibroblastic, 20% transitional and 25% atypical. Recurrence rate was 5% in an average follow up period 4.5 years.

Conclusion: Hyperostosis associated with convexity and pterional meningiomas is usually due to true bone invasion by tumor cells. However, bone invasion is not a sign of malignant transformation of a meningioma.

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Methods: In 32 patients, 33 intracranial aneurysms ruptured during surgery. Data were retrospectively collected regarding the timing of rupture (before or during dissection of the aneurysm or during its clipping), the intraoperative situation (aneurysm location, size, shape, proximal and distal vessel control), causes, difficulties, the management done and the suggestions for avoidance or better dealing with rupture if it occurs.

Results: All of the ruptures occurred after dural opening. Bleeding occurred before obtaining proximal arterial control in 4 cases, after proximal control (during dissection around the aneurysm) in 15 cases (16 aneurysms), and during the clipping procedure in 9 cases. Minor leak occurred in 6 patients out of the previous 28. In 3 cases bleeding occurred from sources other than the aneurysm, and in one case the aneurysm was intentionally opened.

Conclusion: Proper and safe clipping should be the aim and the possibility of intraoperative rupture should be considered in every case. Every case is unique. Several factors predispose to rupture and affect the way of its handling like aneurysm location, configuration (especially wide neck), timing of intervention, anatomy of the surrounding vascular and neurological structure that affects the way of its attack. Surgical experience may not reduce the incidence of rupture but significantly makes difference in its management. Predissection rupture is rare and can be minimized. It is important to identify the bleeding source. If adequate neck dissection was accomplished direct clipping of the aneurysm with a permanent or even temporary clip may be justified. The use of temporary clipping in advance needs further study.

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Objective: The aim of this study was to demonstrate our experience regarding the surgical management and outcome of patients with juvenile nasopharyngeal angiofibroma (JNA) with intracranial extension, with particular attention to the surgical approaches, the extent of excision, and the rate of recurrence.

Patients and Methods: The study included 22 patients with JNA with intracranial extension. All patients were examined by an otorhinolaryngologist and a neurosurgeon. Computed tomography (CT) of the paranasal sinuses, magnetic resonance imaging (MRI) of the brain, and carotid angiography were done for all patients. Preoperative emboliazation was performed 2 days before surgery. All patients were operated upon by either combined craniofacial approaches, or cranial approaches combined with endoscopic endonasal approach. Clinical outcome, extent of excision, and rate of recurrence were assessed.

Results: Total excision was achieved in 21 patients. There was no mortality. Complications included injury to the internal carotid artery with massive bleeding, anosmia, injury to frontal branch of facial nerve, transient cranial nerves palsy, unaesthetic facial scar, and facial parasthesia. Extracranial recurrence occurred in 3 cases, and reoperation was performed. There was no intracranial recurrence.

Conclusion: Combined craniofacial approaches are effective in management of JNA with intracranial extension allowing for radical excision with minimal morbidity. Combining endoscopic endonasal approach with transcranial approaches is a less invasive alternative to craniofacial approaches.

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Methods: Patients with anterior and anterolateral FMMs were operated upon through a posterior midline approach. Drilling of the occipital condyle was performed as needed, and was limited to the posterior third of the condyle. Patients were examined immediate postoperative, on discharge from hospital, and on follow up visits scheduled based on patients clinical condition on discharge. Assessment of extent of resection was based on postoperative magnetic resonance imaging (MRI) with contrast performed 3 months postoperatively.

Results: Out of 12 patients included in this study, we achieved gross total excision in 9 patients. Incomplete excision was due to vertebral artery involvement in the remaining cases. Postoperative radiosurgery was given to two patients with residual tumors. There was a single mortality, and postoperative cranial nerves affection developed in two patients. Complications were related to the tumor dissection and excision rather than the approach.

Conclusion: Posterior midline approach is a safe and familiar approach that allows good access to anterior and anterolateral FMMs. Incomplete excision is related to tumor adhesion to the vertebral artery rather than the choice of surgical approach.

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