Case Of Cerebrospinal Fluid Leak Research Articles

Supraorbital keyhole approaches in the first 3 years of practice: outcomes and lessons learned. Patient series.

Supraorbital keyhole approaches (SKAs) have garnered criticism for a limited surgical exposure, restrictive surgical freedom, blind spots, and the learning curve. This retrospective study of patients who underwent SKA aims to explore the outcomes, technical nuances, and the learning curve reflected in a single surgeon's experience in the initial 3 years of practice. A total of 20 SKA operations were performed in 19 patients. Gross- or near-total resection was achieved in 14 of 17 tumor cases. The mean blood loss was 80.5 mL, the mean duration of surgery was 5 hours, and the median stay was 3 days. Endoscopic augmentation was used in 11 cases in which additional tumor removal occurred in 8 of the 11 cases. There were no cases of cerebrospinal fluid leakage or wound infection. A 30-day readmission and typical narcotics after discharge were seen in one patient each. When comparing two halves of a neurosurgery practice over 3 years, the duration of surgery was significantly longer in the later year, which is likely due to operating on a larger tumor size as the years progressed. No cases required static retractors or conversion to larger craniotomies. Careful case selection and respecting the learning curve allows the safe incorporation of SKA in the early stages of neurosurgical practice.

Evaluation of Treatment Strategies for Male Prolactin-Secreting Pituitary Neuroendocrine Tumors.

Prolactin-secreting pituitary neuroendocrine tumors (PitNETs) are more common in women. Male patients may also have few symptoms and have macroadenomas extending outside the sella turcica. This study aimed to report the results of cabergoline treatment in male patients with prolactin-secreting PitNET. The study included nine male patients aged 26-65 years (median, 46 years) diagnosed with prolactin-secreting PitNETs. The age at onset, prolactin values, tumor size, symptoms, and treatment were assessed. The mean prolactin value at the initial presentation was 2734.6 ng/mL, and the mean maximum tumor diameter was 40.4 mm. Visual field disturbance was the most common symptom (44.4%), followed by headaches (33.3%), asymptomatic symptoms (11.1%), and galactorrhea (11.1%). Eight patients responded to cabergoline treatment with normalization of prolactin levels and tumor shrinkage. One patient did not respond to the cabergoline treatment and required surgical intervention. There were no cases of cerebrospinal fluid leakage. Cabergoline was found to be an effective treatment for male prolactin-secreting PitNETs.

Oncological Skull Base Reconstruction with Microvascular Tissue Transplantation in Advanced Relapsed Cases

Introduction: Tumors involving the skull base are real challenges to reconstructive surgeons. Many articles have been published about these reconstructions, especially in primary cases. In tumor relapses after previous surgeries or irradiation, the surgical options for reconstruction are extremely narrowed and is our opinion that microvascular autologous tissue transplantation is specially indicated in those patients, even though it requires a technically demanding procedure. Materials and Methods: We analyzed retrospectively all patients treated at our institution between March 2014 and December 2018 and that met all the inclusion criteria: 1) oncological surgery for a tumor involving the skull base; 2) previous surgical treatment for that tumor; 3) cranial base bone resection; 4) dural exposure or defect; 5) reconstruction done with a free flap. The patient's age, comorbidities, number of previous surgeries and/or irradiation, oncological excisional procedures, type of defect, type of reconstruction, postoperative complications and mortality were reviewed. Results: Fifteen flaps were used in the 14 patients that met all the inclusion criteria. The used flaps were: Anterolateral Thigh (ALT) perforator or chimeric ALT/Vastus Lateralis (VL) (n=6), profunda artery perforator (n=3), muscular Rectus Abdominis (n=2), Vertical Rectus Abdominis Myocutaneous (VRAM) (n=2), chimeric osteomuscular scapular tip/Latissimus Dorsi (LD) (n=1) and radial forearm (n=1). Dural defects were reconstructed with Pericranial or fascia Lata grafts in 7 patients. No total flap failures or vascular thrombotic events were noted and just one case of partial flap necrosis was registered (treated conservatively). There was one case of cerebrospinal fluid leakage, one diffuse cerebral edema and one donor site wound dehiscence, all successfully treated with conservative measures. The only complication that required a second operation was a cranioplasty prosthetic exposure that required a second free flap. One patient had a tracheostomy bleeding followed by a pneumothorax and died 8 weeks postoperatively with a nosocomial pneumonia. In the follow-up period, one patient died 19 months postoperatively with a local relapse and another with a metastatic disease (at month 15). Conclusion: Secondary or multiple relapsed cases in the skull base require reconstructions that are technically demanding and the defects are often extensive. The surgical options are extremely reduced by previous treatments and if the basic concepts of cranial base reconstruction were strictly respected, the microsurgical free flaps can offer the best chance to avoid severe complications. However, it is not without some postoperative complications and mortality can be significant in the follow-up because of the advanced stage of the oncologic disease.

The Endoscopic Lateral Transorbital Approach for the Removal of Select Sphenoid Wing and Middle Fossa Meningiomas. Surgical Technique and Short-Term Outcomes.

The endoscopic lateral transorbital approach (eLTOA) is a relatively new approach to the skull base that has only recently been applied in vivo in the management of complex skull base pathology. Most meningiomas removed with this approach have been in the spheno-orbital location. We present a series of select purely sphenoid wing and middle fossa meningiomas removed through eLTOA. The objective here was to describe the selection criteria and results of eLTOA for a subset of sphenoid wing and middle fossa meningiomas. This is a retrospective study based on a prospectively maintained database of consecutive cases of eLTOA operated on at our institution by the lead author. The cohort's clinical and radiographic characteristics and outcome are presented. Five patients underwent eLTOA to remove 3 sphenoid wing and 2 middle fossa meningiomas. The mean tumor volume was 11.9 cm 3 . Gross total resection was achieved in all cases. There were no intraoperative complications. Postoperatively, there was one case of subretinal hemorrhage, which was corrected by open vitrectomy repair, and one case of cerebrospinal fluid leak, which resolved with lumbar drainage. Three patients presented with visual impairment, 1 improved, 1 remained stable, and 1 worsened, but returned to stable after vitrectomy repair. All patients have been free of disease at a median follow-up of 8.9 months. eLTOA provides a direct minimal access corridor to certain well-selected sphenoid wing and middle fossa meningiomas. eLTOA minimizes brain retraction and provides a high rate of gross total resection. Meningiomas appropriately selected based on size, type, and location of dural attachment, and the eLTOA is a safe, rapid, and highly effective procedure with acceptable morbidity.

Posterior paramedian approach combined with a novel inverted V-shaped surgical access for intraspinal schwannomas: a retrospective case series study

ObjectiveTo explore the efficacy and safety of the posterior paramedian approach combined with a novel inverted V-shaped surgical access for the treatment of intraspinal schwannomas.MethodsThis study retrospectively reviewed consecutive patients who underwent surgical resection of the intraspinal schwannomas via the inverted V-shaped approach at our center between January 2016 and May 2021. Changes between the preoperative and postoperative visual analog scale (VAS) scores and neurological function Japan Orthopaedic Association (JOA) scores were assessed. Secondary outcomes such as success rate of tumor resection, operation time, blood loss, spinal stability, and disruption degree of intervertebral joints. Postoperative complications were also investigated.ResultsOf these 36 consecutive patients, there were 6 cases in the cervical spine, 2 cases at the cervical-thoracic junction, 11 cases in the thoracic spine, 4 cases at the thoracic-lumbar junction and 13 cases in the lumbar spine. The average operation time was 99 min, and the average blood loss was 95.4 mL. The tumor removal rate was 100%. Postoperative CT re-examination showed that the spinous processes were intact in all cases, the facet joint surfaces were intact in 32 cases. At the time of last follow-up, the median JOA score was 25 (9–27), which was significantly improved compared to the preoperative median JOA score of 15 (10–22) (P < 0.01). The overall excellent and good rate were 88.9 %. The median VAS score at post-surgery was 0 (0–2), which was significantly improved compared to the preoperative median VAS score of 4 (2–8) (P < 0.01). As for complications, there were no cases of cerebrospinal fluid leakage or spinal instability. Three patients who had a postoperative fever finally recovered after lumbar cistern drainage.ConclusionThe inverted V-shaped surgical access via the posterior paramedian approach is an effective and safe method for the treatment of intraspinal schwannomas.

Meningoencephalitis Secondary To Cerebrospinal Fluid Leakage From Nasopharyngeal COVID-19 Swab (P6-10.006)

<h3>Objective:</h3> NA <h3>Background:</h3> The WHO regarded the novel coronavirus as an outbreak on January 2020. The preferable initial testing to detect SARS-CoV-2 RNA was from the upper respiratory tract using nucleic acid amplification testing (NAAT) through nasopharyngeal, oropharyngeal, nasal mid-turbinate, or anterior nasal specimen. Although specimen collection is considered safe and adverse events are rare, some reported cases of cerebrospinal fluid leakage were attributed to pharyngeal swab procedures. Therefore, increased awareness of nasal and pharyngeal swab complications is necessary. <h3>Design/Methods:</h3> A 36 years old female known to have chronic idiopathic intracranial hypertension brought to the emergency department with a history of fever, altered level of consciousness, and generalized tonic-clonic seizure. She had unilateral rhinorrhea for three months following a nasopharyngeal COVID-19 swab as part of an in-vitro fertilization workup. Upon assessment in the ED, she was stuporous due to sedation effect. There was no clear rhinorrhea, no papilledema on the fundus exam, and the remaining cranial nerves examination was unremarkable. She had positive meningeal signs. A cloudy cerebrospinal fluid analysis revealed findings of bacterial meningitis with high WBC and protein. She was started on empirical antimeningeal coverage. MRI brain showed a small CSF containing space at the left inferior frontal in the olfactory groove, which is continuous with the adjacent sulci concerning for the CSF leak site. Beta-transferrin was requested by the otolaryngology team and came back positive. After fourteen days of antibiotics, she regained her baseline cognitive and functional status then was discharged in stable condition with close follow-up with neurology, otolaryngology, and MRI cisternography. <h3>Results:</h3> NA <h3>Conclusions:</h3> Our case emphasizes that awareness of potential adverse events related to nasopharyngeal swabs that became part of daily clinical practice and hospital policies must be improved. It also supports existing scattered evidence that an existing idiopathic intracranial hypertension can be associated with cerebrospinal fluid leakage. <b>Disclosure:</b> Dr. Alnafisah has nothing to disclose. Dr. Altowairqi has nothing to disclose.

Gorham-Stout disease affecting the spine with cerebrospinal fluid leakage and Chiari-like tonsillar herniation: a rare case report and review of literature

BackgroundGorham-Stout disease (GSD) is a very rare disorder characterized by massive osteolysis of poorly understood aetiology. The association between GSD involving the skull base and cerebrospinal fluid (CSF) leakage has been reported in the literature. However, few cases of CSF leakage and Chiari-like tonsillar herniation in GSD involving the spine have been reported.Case presentationWe present the case of a 20-year-old man with GSD involving the thoracic and lumbar spine, which caused CSF leakage and Chiari-like tonsillar herniation. The patient underwent four spinal surgeries for osteolytic lesions of the spine over a 10-year period. Here, we discuss the possible aetiology of the development of CSF leakage. Epidural blood patch (EBP) was performed at the T11-T12 level to repair the CSF leakage. After EBP treatment, rebound intracranial hypertension (RIH) developed, and tonsillar herniation disappeared 2 months later.ConclusionsGSD involving the spine with CSF leakage and Chiari-like tonsillar herniation is relatively rare. For patients who have undergone multiple spinal surgeries, minimally invasive treatment is an alternative treatment for CSF leakage. EBP can repair CSF leakage secondary to GSD and improve chronic brain sagging, with reversibility of Chiari-like malformations.

Ликворея как следствие перенесенной новой коронавирусной инфекции COVID-19

The article presents a clinical case of cerebrospinal fluid leak after suffering COVID-19. The clinical picture of the disease was dominated by obvious nasal liquorrhea that occurred without previous injuries. The patient’s condition was stable. Nasal liquorrhea was diagnosed clinically and according to MRI of the head.

Efficacy of one-stage total spondylectomy and circumferential reconstruction for axial tumors through a combined anterior retropharyngeal-posterior approach

Objective: To elucidate the safety and efficacy of one-stage total spondylectomy and circumferential reconstruction through a combined anterior retropharyngeal-posterior approach for axial tumors. Methods: A total of 20 patients with axial tumor who received total spondylectomy through a combined anterior retropharyngeal-posterior approach in Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology from February 2006 to December 2018 were retrospectively analyzed. Anterior reconstruction was performed with a special-shaped titanium mesh or three-dimensional printed (3DP) implants. The degree of local pain and neurological function was assessed by the visual analogue scale (VAS) and Frankel classification systems, respectively. Status of internal fixation and local recurrence was analyzed by radiological examination during follow-up. Results: Among the 20 patients, 12 were male and 8 were female with a mean age of (59.1±11.0) years (31 to 72 years). The mean operation time was (605.0±60.1) minutes (430 to 700 minutes) with a mean intraoperative blood loss of (1 250±347) ml (800 to 2 400 ml). The mean postoperative hospital stay was (13.2±2.8) days (8 to 20 days), and mean follow-up duration was (37.2±14.2) months(14 to 66 months). Anterior reconstructions were performed with a special-shaped titanium mesh in 14 patients and with 3DP implants in another 6 patients. Posterior occipital-cervical fixation was performed in 5 patients, while cervical fixation only in another 15 patients. The mean VAS score of pain at the last follow-up decreased significantly when compared with that before operation (1.6±0.6 vs 7.1±1.1, P<0.001). Nine patients with neurological deficits indicated significant improvement by at least 1 level at the last follow-up; among them, 2 cases of Frankel B improved to Frankel C and D, respectively; 3 cases of Frankel C all improved to Frankel D, and 4 cases of Frankel D improved to Frankel E. The perioperative complications included: 2 cases of vertebral artery injury, 2 cases of dysphagia, 3 cases of hoarseness and cough, 2 cases of cerebrospinal fluid leakage, and 1 case of greater occipital neuralgia. At the last follow-up, 5 patients died and 3 patients relapsed. Only 1 case suffered fixation failure due to local recurrence at the last follow up. Conclusions: One-stage total spondylectomy and circumferential reconstruction through a combined anterior retropharyngeal-posterior approach is safe and effective for axial tumors with favorable clinical outcomes and minor complications. Circumferential reconstruction with special-shaped titanium mesh or 3DP implant and posterior fixation can effectively reconstruct mechanical stability.

Endoscopic endonasal transsphenoidal approach during COVID-19 pandemic in Brazil.

Endoscopic endonasal transsphenoidal approach (EETA) is a well-established technique for sellar tumor resection. However, this route causes aerosol dispersion from the nasal cavity. In the context of the coronavirus (COVID-19) pandemic, new measures were taken aiming at the safety and protection of patients and health-care professionals. Herein, we present a Brazilian experience with EETA during COVID-19 pandemic. This study was based on the review of medical records and observation in the operating room of the patients undergoing endoscopic surgery in the period from May 2020 to July 2022. All patients were tested by real-time polymerase chain reaction (RT-PCR) COVID-19 before and after surgery. Since September 2021, it has been mandatory to present vaccination cards for adults (over 18 years old). This case series included 28 patients and 35 surgical procedures using the EETA, who presented of nonfunctioning macroadenomas (19 cases - 67.8%), GH-secreting tumor (three cases - 10.8%), ACTH-secreting tumor (three cases - 10.8%), meningiomas (two cases - 7.1%), and Rathke's cleft cyst (one case - 3.5%). There were eight cases of diabetes insipidus (28.5%), five cases of cerebrospinal fluid leak (17.8%), and one case of meningitis (3.5%). Three patients died due to meningitis (one case), carotid occlusion (one case), and COVID-19 complications (one case). A simple protocol was established to perform EETA during the COVID-19 pandemic. The pituitary surgeries were maintained to treat critical cases. To date, the protocol should be continually updated to improve the procedure's safety.

Analysis of the surgical strategy and postoperative clinical effect of thoracic ossification of ligament flavum with dural ossification.

PurposeOur research was designed to analyse the postoperative clinical results of patients suffering from single-segment thoracic ossification of the ligamentum flavum (TOLF) combined with dural ossification (DO) who underwent posterior laminar decompression and internal fixation.MethodsThis retrospective research included thirty-two patients who underwent surgery for ossifying the ligamentum flavum in the thoracic spine between January 2016 and January 2020. Patients were fallen into one group included patients with evidence of DO during surgery, and the other group included patients without evidence of DO. We assessed and compared general clinical characteristics and health-related outcomes before surgery and during follow-up.ResultsThe DO group had a longer operation duration, more blood loss, and longer hospital stay (operation time: 94.75 ± 6.78 min vs. 80.00 ± 10.13 min, p < 0.001; blood loss: 331.67 ± 50.06 ml vs. 253.00 ± 48.24 ml, p < 0.001; length of hospital stay: 13.83 ± 2.76 days vs. 10.05 ± 2.33 days, p < 0.001).ComplicationsThere were 12 cases of cerebrospinal fluid leakage and 1 case of superficial wound infection in the DO group. However, the neurological recovery and health-associated quality of life (HRQOL) scores showed no statistically significant changes between the DO and non-DO groups (p > 0.05).ConclusionsPosterior laminectomy and internal fixation combined with intraoperative resection of the ossified ligamentum flavum and dura is an efficient and relatively safe method for treating TOLF with DO, which can provide satisfactory results. Moreover, DO had no significant effect on postoperative neurological recovery and health-related quality of life scores.

The surgical management of benign tumors of the lateral skull base with intracranial invasion: experience from a single centre over ten years

Objective: To investigate the clinical features, pathological types, imaging features, and surgical strategies of lateral skull base benign tumors with intracranial invasion. Methods: From January 2011 to March 2021, 36 patients of lateral skull base benign tumors with intracranial invasion were included in this retrospective study. Among the 36 patients, 14 cases were male, 22 cases were female, the aged range from 20-67, with the median age of 48. The clinical manifestations, characteristic imaging findings, pathological types, surgical approach selection, and prognosis were analyzed. Results: 36 cases of lateral skull base tumors with intracranial invasion were all accepted surgeries. 23 cases were neurogenic tumors, facial nerve tumors (n=8), neurogenic tumors in jugular foramen with unknown origin(n=6), hypoglossal schwannoma (n=3), transotic intralabyrinthine schwannoma (n=3), vestibular schwannoma involving the middle ear(n=2), vagal nerve schwannoma(n=1). Other types of tumors included meningioma (n=10) and paraganglioma (Di 1 or 2,n=3). Different pathological types of tumors had different clinical manifestations and imaging manifestations. Sixteen cases were subjected to primary resection, while, other 20 cases underwent staged operation. Among the patients with staged operation, 10 patients had completed the second stage operation, five patients were waiting for the second stage operation, the other five patient's residual intracranial tumor were significantly reduced and the space between tumor and brain tissues widened after the first stage operation, so, the following up with "wait and scan"policy was suggested. The total resection rate of tumors was related to the pathological nature, in which neurogenic tumors were 15/17, and meningiomas were 5/8. The main postoperative complications were cerebrospinal fluid leakage and infection in the operation area. There were two cases of postoperative intracranial infection, and three cases of cerebrospinal fluid leakage occurred in non staged operation cases. Conclusions: Lateral skull base tumors with intracranial invasion are rare. The most common pathological type is schwannoma, followed by meningioma and paraganglioma. For this type of tumor, if there is infection in the operation area and neck invasion is large, it is suggested to choose staged surgery, which can reduce the risk of intracranial infection and the incidence of cerebrospinal fluid leakage. Staged surgery strategy can also reduce the difficulty of second stage surgery, so the operation is much safer than non staged surgery.

Surgical Effects of Resecting Skull Base Tumors Using Pre-operative Multimodal Image Fusion Technology: A Retrospective Study.

ObjectivesTo analyze the surgical effects of resecting skull base tumors using multimodal three-dimensional (3D) image fusion technology in the neurosurgery department and present some typical cases.MethodsFrom October 2019 to October 2021, we included 47 consecutive patients with skull base tumors in the Neurosurgery Department at Zhuhai People's Hospital in this study. Pre-operative head computed tomography and magnetic resonance imaging data acquisition was performed using the GE AW workstation software for registration fusion, image fusion, and 3D reconstruction. The surgical approach and surgical plan were designed based on the multimodal 3D image, and the resection rate, complication rate, and operative time of the surgery using the multimodal image fusion technique were analyzed.ResultsThe reconstructed multimodal 3D images precisely demonstrated the size, location, and shape of the tumor along with the anatomical relationship between the tumor and surrounding structures, which is consistent with the intraoperative findings. Among 47 patients, 39 patients (78.7%) underwent total resection, 5 (14.9%) underwent subtotal resection, and 3 (6.4%) underwent partial resection. The mean operative time was 4.42 ± 1.32 h. No patient died during the inpatient period. Post-operative complications included 6 cases of cerebrospinal fluid leakage (14.9%), 3 cases of intracranial infection (6.4%), 6 cases of facial paralysis (12.8%), 2 cases of dysphagia (4.3%), and 1 case of diplopia (2.1%), all of which were improved after symptomatic treatment. The application value of pre-operative 3D image fusion technology was evaluated as outstanding in 40 cases (85.1%) and valuable in 7 cases (14.9%).ConclusionsPre-operative multimodal image fusion technology can provide valuable visual information in skull base tumor surgery and help neurosurgeons design the surgical incision, choose a more rational surgical approach, and precisely resect the tumor. The multimodal image fusion technique should be strongly recommended for skull base tumor surgery.

Clinical Efficacy of Endoscopic-Assisted Resection of Single-Segment Ossification of the Posterior Longitudinal Ligament in the Treatment of Thoracic Spinal Stenosis.

ObjectiveTo explore the clinical efficacy, characteristics and safety of endoscopic-assisted resection of single-segment posterior longitudinal ligament ossification in the treatment of thoracic spinal stenosis (TSS).MethodFifteen TSS patients, including 6 males and 9 females aged 43–70 years treated with endoscopic-assisted resection of single-segment posterior longitudinal ligament ossification through the transfacet joint approach by our team from November 2016 to June 2020 were retrospectively analyzed. The operation time, intraoperative blood loss, and postoperative complications were recorded. The VAS score, ODI and JOA score (full score, 11 points) were recorded before the operation, after the operation and at the last follow-up to evaluate the clinical efficacy and calculate the improvement rate.ResultsThe ventral side of the spinal cord was decompressed in all patients, providing improvements in neurological symptoms and significant pain relief. The mean follow-up time was 20.27 ± 3.87 months. Mean operation time, intraoperative blood loss, and hospitalization time were found to be 84.80 ± 13.23 min, 36.33 ± 7.41 mL, 5.13 ± 1.02 days; respectively.The JOA score at the last follow-up was 8.6 ± 1.25, which was significantly better than the preoperative (5.53 ± 1.20) and postoperative (6.87 ± 1.31) scores (p < 0.05). The mean JOA score improvement rate was 56.5 ± 18.00%. The JOA score improvement rate classification at the last follow-up was excellent in 3 cases, good in 8 cases, effective in 3 cases, and no change in 1 case; for an effective rate of 93.33%. The VAS score significantly decreased from 6.67 ± 1.01 preoperatively to 3.47 ± 0.88 postoperatively and 1.73 ± 0.67 at the last follow-up (p < 0.05). The ODI significantly decreased from 72.07 ± 6.08 preoperatively to 45.93 ± 5.01 postoperatively and 12.53 ± 2.33 at the last follow-up (p < 0.05). Dural rupture occurred in 2 patients during the operation; 1 patient experienced neck discomfort during the operation, which was considered to be caused by high fluid pressure and was relieved by massage and by lowering the height of the irrigation fluid. No cases of cerebrospinal fluid leakage, wound infection or other complications occurred.ConclusionEndoscopic-assisted resection of posterior longitudinal ligament ossification through the facet joint approach is a safe and effective method for the treatment of TSS.

Long-term outcome following surgical treatment of posttraumatic tethered cord syndrome: a retrospective population-based cohort study

Study designRetrospective population-based cohort study.ObjectiveTo investigate the long-term outcome following surgery for posttraumatic spinal cord tethering (PSCT).SettingPublicly funded tertiary care center.MethodsPatients surgically treated for PSCT between 2005–2020 were identified and included. No patients were excluded or lost to follow-up. Medical records and imaging data were retrospectively reviewed.ResultsSeventeen patients were included. Median age was 52 (23–69) years and 7 (41%) were female. PSCT was diagnosed at a median of 5.0 (0.6–27) years after the initial trauma. Motor deficit was the most common neurological manifestation (71%), followed by sensory deficit (53%), spasticity (53%), pain (41%) and gait disturbance (24%). Median follow-up time was 5.1 (0.7–13) years. Fifteen patients (88%) showed satisfactory results following untethering, defined as improvement or halted progression of one or more of the presenting symptoms. Treatment goals were met for motor symptoms in 92%, sensory loss in 100%, spasticity in 100%, gait disturbance in 100% and pain in 86%. Statistically, a significant improvement in motor deficit (p = 0.031) and syrinx decrease (p = 0.004) was also seen. A postoperative complication occurred in four patients: three cases of cerebrospinal fluid leakage and one postoperative hematoma. Two patients showed a negative surgical outcome: 1 with increased neck pain and 1 with left arm weakness following the postoperative hematoma.ConclusionSurgical treatment of PSCT results in improved neurological function or halted neurological deterioration in the vast majority of patients.

Surgical treatment of delayed spinal cord injury caused by atypical compression of old thoracolumbar fractures

To explore the clinical characteristics and surgical treatment strategies of delayed spinal cord injury (SCI) caused by atypical compression of old thoracolumbar fracture. Between January 2011 and June 2018, 32 patients with delayed SCI caused by atypical compression of old thoracolumbar fracture who met the inclusion criteria were admitted and divided into group A (20 cases, underwent anterior subtotal vertebral body resection+titanium mesh reconstruction+screw rod internal fixation) and group B (12 cases, underwent posterior 270° ring decompression of vertebral canal+titanium mesh reconstruction+screw rod internal fixation) according to the different operation approaches. There was no significant difference between the two groups in age, gender, cause of injury, fracture segment, disease duration, preoperative American Spinal Injury Association (ASIA) classification, and preoperative back pain visual analogue scale (VAS) score, lumbar Japanese Orthopaedic Association (JOA) score, kyphosis angle, and vertebral canal occupational ratio ( P>0.05). The incision length, operation time, intraoperative blood loss, complications, and bone fusion time of reconstructed vertebrae were recorded and compared between the two groups; the kyphosis angle, back pain VAS score, and lumbar JOA score were used to evaluate the effectiveness. Except that the incision length in group A was significantly shorter than that in group B ( t=-4.865, P=0.000), there was no significant difference in intraoperative blood loss and operation time between the two groups ( P>0.05). There was no deaths or postoperative paraplegia cases in the two groups, and no deep infection or skin infection occurred. There was 1 case of cerebrospinal fluid leakage, 1 case of inferior vena cava injury, and 1 case of chyle leakage in group A. No serious complications occurred in group B. There was no significant difference in the incidence of complications between the two groups ( P=0.274). All 32 patients were followed up 12-61 months, with an average of 20.8 months. The follow-up time for groups A and B were (19.35±5.30) months and (23.25±12.20) months respectively, and the difference was not significant ( t=-1.255, P=0.219). The reconstructed vertebrae in all cases obtained bony fusion postoperatively. The fusion time of groups A and B were (8.85±2.27) months and (8.50±2.50) months respectively, and the difference was not significant ( t=0.406, P=0.688). The kyphosis angle, back pain VAS score, and lumbar JOA score of the two groups at each time point after operation and last follow-up were significantly improved when compared with preoperatively ( P<0.05); the lumbar JOA score was further improved with time postoperatively ( P<0.05), while the kyphosis angle and the VAS score of back pain remained similarly ( P>0.05). Comparison of kyphosis angle, back pain VAS score, and lumbar JOA score between the two groups at various time points postoperatively showed no significant difference ( P>0.05). At last follow-up, the JOA score improvement rate in groups A and B were 83.87%±0.20% and 84.50%±0.14%, respectively, and the difference was not significant ( t=-0.109, P=0.914); the surgical treatment effects of the two groups were judged to be significant. In the later stage of treatment of old thoracolumbar fractures, even mild kyphosis and spinal canal occupying may induce delayed SCI. Surgical correction and decompression can significantly promote the recovery of damaged spinal cord function. Compared with anterior approach surgery, posterior approach surgery has the advantages of less trauma, convenient operation, and fewer complications, so it can be preferred.

Surgical pathway proposal for severe paralytic scoliosis in adolescents with myelomeningocele.

The increased life expectancy of patients with myelomeningocele led to the necessity of new management for addressing complex spine deformities with severe pelvic obliquity. Tethered cord release (TCR) and spinal fusion were described as treatment options. However, nowadays, the surgical strategy is not well defined and high rates of mechanical failures and complications are reported. Our aim was to propose a new two-stage surgical pathway to treat a selected group of severe myelomeningocele scoliosis. This is a retrospective series of myelomeningocele scoliosis in paralytic adolescent patients treated with concurrent TCR and posterior spinal fusion (PSF), followed by delayed anterior fusion (ASF) through minimally invasive lateral approach. Inclusion criteria were as follows: evolutive scoliosis in tethered cord syndrome and paraplegia, main curve >70°, pelvic obliquity >20°, and age between 10 and 18 years. Clinical, surgical, and radiographic parameters were evaluated preoperatively and at a mean follow-up (FU) of 2.8 years. Six patients out of 58 met the inclusion criteria and were included in the study (mean age 12.3 years old). The mean curve and pelvic obliquity correction were 68.8% and 82%, respectively. No loss of correction was recorded at FU. One case of cerebrospinal fluid leakage requiring revision surgery was recorded. To the best of our knowledge, this is the first study proposing a two-stage surgical pathway for severe MMC spinopelvic deformity treatment. Concurrent TCR and PSF with delayed minimally invasive ASF permitted to minimize complications providing good fusion rates without loss of correction and implant failure.

Novel Surgical Treatment of Recurrent CSF Leak by Temporoparietal Temporalis Myofascial Flap: A Series of 6 Cases

With the advent of modern endoscopes and a better anatomic understanding of the skull base, the indications of endonasal approaches are increasing. These procedures may be complicated by high rates of postoperative cerebrospinal fluid (CSF) leak, and reconstruction of the defect remains challenging. In the anterior skull base, vascularized grafts have been reported as superior in preventing CSF leakage and infection. The Hadad-Bassagasteguy flap, being a pedicled flap, is our first line flap to reconstruct the skull base. When we were not successful with this flap, we resorted to different flaps. We modified the originally described temporoparietal fascial flap by Fortes etal and applied clinically. The objective of this paper is to briefly describe the modification of the flap and to review the clinical outcome. From 2014 to 2018, in 6 cases of CSF leak with the appropriate indication, we used the temporoparietal myofascial flap repair that is a modification of the temporoparietal fascial flap by Fortes etal. We took all the 6 patients in our study and followed them up. All of the 6 repairs were successful, and no CSF leak was found just after the operation in 6- to 48-month follow-up. We recommend our modified novel temporoparietal myofascial flap as a very good option in case of failed cases of postoperative CSF leak.

Resistant Temporal Lobe Epilepsy: Initial Steps into a Bigger Epilepsy Surgery Program.

Background Among the patients of drug-resistant epilepsy, a subset which has focal impaired seizures localizes to the temporal lobe region (TLE). A majority of these cases are surgically amenable with anterior-medial temporal lobe resection or “lesionectomy.” Objective In India, there is scarcity of “specialized centers” providing “comprehensive epilepsy care” and this dearth is further worse in populous states. In this article, we share our single center, observational, and retrospective experience of TLE in background of limited resources and utmost requirement. Methodology Our study is a retrospective analysis medically refractory epilepsy patients (2016–2019). Patients with medically refractory epilepsy were selected based upon our noninvasive protocol (clinical semiology, interictal scalp electroencephalography (EEG), long-term video EEG monitoring data, and magnetic resonance injury [MRI]). The follow-up was noted from the last out-patient visit record or through telephonic conversation (International League Against Epilepsy score). Results Of 23 cases of TLE ( n = 7, mesial temporal sclerosis; n = 16 temporal lobe like cavernomas, tumors, or arterio-venous malformations). Single photon emission computed tomography/positron emission tomography (SPECT/PET) was performed in five cases (three cases of ictal/interictal SPECT and two cases of PET scan) where there was discordance between EEG/clinical and MRI. The median follow-up was of 19 months with 18 cases being seizure free. Five cases were fully off the antiepileptic drug (AEDs) while in 15 cases, the AEDs dosages or the number were reduced. Average number of AEDs reduced from 2.9 in preoperative period to 1.2 postoperatively. Two cases had quadrantanopia and one case of cerebrospinal fluid leak. Conclusion A multidisciplinary and holistic approach is required for best patient care. The results of our initial surgical experience are encouraging.

Pituitary adenoma with posterior area invasion of cavernous sinus: surgical anatomy, approach, and outcomes

We found a series of Knosp grade 3A-4 pituitary adenomas in the posterior areas of the cavernous sinus (CS), a triangular-like structure on axial MRI. In this study, we dissected the surrounding neurovascular structure, discussed the surgical approach, and analyzed outcomes for patients with this invasion into this area. Eight embalmed adult cadaveric specimens were prepared for this study to demonstrate in detail the surgical anatomy related to this triangular-like structure. We used the "two points and one line" method to determine the surgical approach, and 35 cases with this area invasion were retrospectively reviewed. According to the endoscopic and microsurgical anatomy, the triangular-like structure appearing on the axial MRI is correlated with a square-based pyramid structure in the CS, and the upper surface is the posterior portion of the oculomotor triangle. A total of 37 posterior areas of the CS were involved in 35 patients. The accuracy of the "two points and one line" method in predicting the surgical approach is 86.5% (32/37). All three patients with Knosp 3A underwent gross total resection (GTR). Twenty (62.5%) patients with Knosp 4 underwent GTR, 9 (28.1%) patients underwent subtotal resection, and 3 (9.4%) patients underwent partial resection. Preoperative symptoms were alleviated to varying degrees, and no worsening occurred. Postoperative complications included two (5.7%) cases of cerebrospinal fluid leakage, one (2.9%) case of meningitis, two (5.7%) cases of permanent diabetes insipidus, and three (8.6%) cases of transient cranial nerve palsy. The "two points and one line" method is of great value in predicting the surgical approach of pituitary adenomas with CS invasion. The anatomic description of this particular square-based pyramid structure in the CS refines the understanding of pituitary adenomas with CS invasion.