Surgical management of transcervical gunshot injury presented with CSF leak and progressive left upper extremity paresis: a case report and literature review.

INTRODUCTION: Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality. RESEARCH QUESTION: There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients. METHODS AND MATERIALS: An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness. RESULTS: The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up. CONCLUSION: Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects.

Transforaminal Endoscopic Lumbar Diskectomy versus Open Microdiskectomy for Symptomatic Lumbar Disk Herniation: A Comparative Cohort Study on Costs and Long-Term Outcomes.

BACKGROUND: Transforaminal endoscopic lumbar diskectomy (TELD) is considered an effective treatment for lumbar disk herniation (LDH). There is a paucity of studies comparing in detail the costs and long-term clinical outcomes of TELD and open microdiskectomy (MD), especially in developing countries. Thus, we sought to provide a multidimensional insight into this matter by comparing the direct costs and long-term outcomes of TELD with those of MD. METHODS: The electronic health records of 434 patients with LDH who underwent either TELD or MD were collected from February 2011 to October 2014. Within a 7-year follow-up period, 412 patients, comprising 203 patients treated with TELD and 209 patients treated with MD, were fully evaluated. Patient characteristics, operative time, intraoperative blood loss (IBL), postoperative hospital stay, time to return to work (RTW), perioperative complications, and direct costs were collected. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria. RESULTS: The postoperative ODI and VAS scores improved significantly in both groups (p < 0.001). In accordance with the modified MacNab criteria, the rate of excellent and good outcomes was 88.67 and 88.03% in the TELD and MD groups, respectively. There were no significant differences between the groups in the clinical outcomes and perioperative complications. However, IBL, hospital stay, and RTW were significantly reduced in the TELD group (p < 0.05). Twenty-one cases in the TELD group and nine in the MD group underwent reoperation due to recurrence (p < 0.05). Total inpatient cost per patient was $1,596 in the TELD group and $1,990 in the MD group (p < 0.05). CONCLUSION: TELD for the treatment of symptomatic LDH could be an affordable strategy, providing certain advantages of minimally invasive procedures such as shorter hospital stay and earlier recovery along with comparable clinical outcomes to the conventional surgical method.

Clinicoradiological Outcomes and Complication Profiles of Bilateral Dual Sacral-Alar-Iliac Screws versus Bilateral Single Sacral-Alar-Iliac Screws in Patients with Spinal Deformity Who Underwent Grade 3 or 4 Spinal Osteotomies: A Retrospective Comparative Study.

OBJECTIVE: To compare short-term clinical and radiological outcomes and complication profiles between bilateral dual sacral-2-alar-iliac (S2AI) screw and bilateral single S2AI screw fixation techniques in patients who underwent grade 3 or 4 spinal osteotomies. METHODS: A retrospective review of 83 patients treated with bilateral dual S2AI screws and 32 patients treated with bilateral single S2AI screws was conducted between 2018 and 2020 with a minimum 1-year follow-up. Clinical and radiological outcomes of patients and incidence of perioperative complications, including rod breakage, screw dislodgment, proximal junctional kyphosis, proximal junctional failure, need for reoperation, and systemic adverse effects, were collected and statistically compared between the groups. RESULTS: With a mean follow-up of 18.2 months, rod fracture (6.0% vs. 18.7%, P = 0.03), screw dislodgment (0 vs. 12.5%, P < 0.01), and S2AI screw loosening (1.2% vs. 18.7%, P < 0.01) were significantly lower in the dual S2AI screws group than in the single S2AI screws group. However, the reoperation rate was similar between the 2 groups (24.1% vs. 34.3%, P = 0.26). No significant differences in clinical and radiological outcomes as well as proximal junctional kyphosis (10.8% vs. 18.7%, P = 0.25) and proximal junctional failure (9.6% vs. 18.7%, P = 0.18) were identified between the 2 groups. CONCLUSIONS: The dual S2AI screw fixation technique showed more advantages over the single S2AI screw fixation technique with reduced incidence of screw dislodgment, rod fractures, and sacral-alar-iliac screw loosening.

Translation, cross-cultural adaptation and validation of the Persian version of selected PROMIS measures for use in lumbar canal stenosis patients.

BACKGROUND: The National Institutes of Health (NIH) developed a new measurement system called the Patient-Reported Outcomes Measurement Information System (PROMIS) which can be used for multiple health conditions. The 29-item short form (PROMIS-29) with seven domains was more often used by clinical researchers to measure the physical function, mood and sleeping status of patients with low back pain (LBP). Translation of the PROMIS into multiple languages and adaptation of its application in different cultural diversities can help to further standardize clinical research studies and make them comparable to each other. This study aimed to cross-culturally adapt the PROMIS-29 into Persian (P-PROMIS-29) and evaluate the construct validity and reliability of the translated questionnaire among patients with lumbar canal stenosis. MATERIALS AND METHODS: The translation was conducted by using the multilingual translation methodology guideline. Construct validity, internal consistency, and test-retest reliability at a two-week interval for the P-PROMIS-29 were calculated. Construct validity was assessed by calculating correlations between the P-PROMIS-29 with Oswestry Disability Index (ODI) and Roland-Morris results. RESULTS: The study sample included 70 participants with lumbar canal stenosis. Internal consistencies were moderate to good with Cronbach's alpha ranging from 0.2 to 0.94. The test-retest reliability evaluation was excellent with intraclass correlation coefficients (ICCs) ranging from 0.885 to 0.986. Construct validity of different domains of P-PROMIS-29 were moderate to good, with Pearson's correlation coefficient results ranging from 0.223 to 0.749. CONCLUSION: Our results showed that P-PROMIS-29 is a valid and reliable measurement tool for evaluation of patients with lumbar canal stenosis.

The Impact of Rigid Cervical Collars on Outcome of Patients Who Underwent Posterior Cervical Laminectomy and Fusion: A Retrospective Comparative Study.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aimed to investigate the cervical collar impact on the functional outcomes of patients after posterior cervical laminectomy and lateral mass screw fixation (PCLF) surgery. OVERVIEW OF LITERATURE: The safety and possible benefits of implementing rigid cervical collars subsequent to PCLF are insufficiently investigated. METHODS: Patients who underwent PCLF and received postoperative cervical collars from 2018 to 2020 were included in this retrospective cohort study. Their data were compared with an age- and sex-matched group of subjects who did not receive collars after PCLF during the same period. Pain intensity (using the Visual Analog Scale), Neck Disability Index, and quality of life (using 36-item Short Form Health Survey) of the patients were compared at baseline, 1, 3, 6, and 12 months postoperatively. RESULTS: A total of 36 patients who received cervical collars after surgery and 40 controls were included. At baseline and 1-month follow-up, there were no differences in pain intensity, functional status, and quality of life between the groups. However, at 3 months postoperatively, the quality of life of the subjects with no orthosis was higher than those who received cervical collars (p =0.01). At 6- and 12-month follow-up, there were no differences between the groups in pain intensity, functional status, and quality of life. CONCLUSIONS: No difference in the pain intensity and functional status of patients who used cervical collars and controls was shown in our study. Patients who did not wear cervical collars had a higher quality of life during the 3-month postoperative evaluation. Future prospective, well-controlled studies with longer follow-ups are needed to further investigate the effects of cervical orthosis on the clinical outcome of patients after PCLF.

Effect of Topical Administration of Tranexamic Acid on Intraoperative and Postoperative Blood Loss during Posterior Cervical Laminectomy and Fusion Surgery: A Retrospective Study.

AIM: To assess the role of topical administration of tranexamic acid (TXA) on intraoperative and postoperative blood loss of patients undergoing posterior cervical laminectomy and lateral mass screw ?xation (PCLF) compared to a control group. MATERIAL AND METHODS: The data of 88 patients that underwent PCLF surgery, including 41 females and 47 males, were included in this retrospective study. Data elements including intraoperative blood loss (IBL), postoperative blood loss (PBL), amount of blood transfusion, surgical time, use of hemostatic agents, length of hospital stay, and time to return to work were extracted from medical records and compared between those who received topical TXA during surgery (irrigation of the surgical field with a solution of 3 g TXA in 100 ml normal saline) and an age- and sex-matched control group. RESULTS: There were 48 patients in the TXA group and 40 patients in the control group. There were no significant differences in the baseline measurements and the level of operation between the two groups. The results showed that IBL and PBL were significantly lower in the TXA group compared to the control group (p=0.03 and p < 0.01, respectively). There were no significant differences in the need for blood transfusion, surgical time, and hospital stay between the two groups (p > 0.05). Moreover, the use of hemostatic materials during surgery and the time to return to work were significantly lower in the topical TXA group (p=0.04 and p < 0.01, respectively). CONCLUSION: Topical TXA efficiently reduces intraoperative and postoperative bleeding in patients undergoing posterior cervical laminectomy and PCLF surgery. These results need further investigation in future studies to draw a definite conclusion.

The Impact of Single-Level Anterior Cervical Discectomy and Fusion on Cervical Sagittal Parameters and Its Correlation With Pain and Functional Outcome of Patients With Neck Pain.

BACKGROUND: This study examines the changes in segmental and global cervical sagittal parameters after single-level anterior cervical discectomy and fusion (ACDF) in patients with cervical radiculopathy or myelopathy. We also investigate whether these changes have any relation with postoperative pain and functional outcome of the patients. METHODS: Sixty patients (37 females and 23 males) with a mean age of 45.9 ± 9.5 years who were candidates of single-level ACDF due to cervical myelopathy or radiculopathy participated in the study. At baseline, 1 month, and 6 months after ACDF, outcomes of the study including sagittal balance parameters, pain intensity, and Neck Disability Index (NDI) were measured among the patients. Intensity of pain and neck disability were measured using the visual analog scale (VAS) and validated version of NDI, respectively. Using a standard lateral cervical radiography, the Cobb angle for occiput-C2, C1-C2, and C2-C7 as well as operation-level angle (OA; Cobb's angle at the level of discopathy), the thoracic inlet angle, and C7 and T1 slope angles were measured. RESULTS: The intensity of pain and neck disability of patients improved significantly during the follow up of the study comparing with baseline measurements (P < .001). There was a significant correlation between the increase of C2-C7 angle, C1-C2 angle, and OA and improvement in neck pain and NDI at 1- and 6-month follow ups. CONCLUSIONS: We found that changes at C2-C7 angle, C1-C2 angle, and OA have positive significant correlation with clinical outcome including pain improvement and decrease of disability in patients who undergo ACDF. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: The results of this study might be beneficial in selection of cervical cages with appropriate size during ACDF surgery, as our findinds showed that larger cages could lead to better functional outcome in patients.

Evolutionary model of brain tumor circulating cells: Cellular galaxy.

BACKGROUND: Although circulating tumor cells (CTCs) have been the focus of consideration for a decade, a categorized cell-based diagnostic strategy is unavailable. The personalized management and complementary/analytical-strategy of data require an alphabetic guide. Therefore, we aimed to determine the behavior of CTCs in tumor and blood in order to provide the hypothetical-based agenda in the brain neoplasms. Exploring the protein expression (PE) using a single cell-based method would clarify the heterogeneity and diversity in tumor and blood, which are key events in the evolution in brain tumors. In fact, heterogeneity, diversity, and evolution are required for cancer initiation and progression. AIM: To explore CTCs in brain tumors and blood cells and to assay intensity of PE through personalized insight. METHODS: The focal population included 14 patients with meningioma, and four patients with metastatic brain tumors (T). PE was assayed by immunofluorescence in tumors cells and CTCs in 18 patients with brain tumors. Ratio test was applied between the T cells and CTCs in tumor tissue and in vascular system. T/CTC ratio-based classification of PE in macrophage chemoattractant chemokine ligand 2 (CCL2), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), CD133, cyclin E, neurofilament marker, cytokeratin 19, and leukocyte common antigen (CD45) were investigated. RESULTS: Total analyzed cells ranged between 10794-92283 for tumor cells and between 117-2870 for CTCs. Characteristics of histopathologic and status of an ataxia-telangiectasia mutated polymorphism (D1853N) in 18 patients affected with brain tumors were also provided. The course of evolution and metastatic event relied on the elevated protein expression in CTCs, which could be considered as a prognostic value. Diverse protein expression of the migrated cells into the blood stream and the tumor was indicative of the occurrence of evolution. Besides, the harmonic co-expression between CCL2/EGF and CCL2/VEGF could facilitate the tumor progression including the metastatic event. Expression of these proteins in the migrated vasculature and into the buccal tissue offered a non-invasive follow-up detection in neoplastic disorders. PE-exploration of neurofilament marker/CD133/VEGF of the CTCs in meningioma and cytokeratin 19/CD45/ cyclin E in the patients with metastatic brain tumor would clarify the tumor biology of the brain neoplastic disorders. CONCLUSION: The alphabetical base of the evolutionary mechanisms relies on dual-, triple-, and multi-models with diverse intensity of expression. In fact, cross-talk between initiative and the complementary channels defines the evolutionary insight in cancer. A diverse-model of protein expression, including low, medium, and high intensity, is the key requirement for the completed model. The cluster of cells with diverse expression and remarkable co-expression between CCL2/EGF/VEGF and NM/CD133/VEGF in CTCs may be indicative of probable invasiveness of the tumor. Furthermore, the mode of cytokeratin-19+/CD45- can be traced in the metastatic patients.

Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma.

Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

Correction to: Comparison of cervical sagittal parameters among patients with neck pain and healthy controls: a comparative cross-sectional study.

Unfortunately, the affiliation of the second author (Jean Charles Le Huec) was incorrectly published in the original publication.

Comparison of cervical sagittal parameters among patients with neck pain and healthy controls: a comparative cross-sectional study.

INTRODUCTION: Previous studies have shown poor health-related outcomes among patients with spinal sagittal malalignment of the thoracolumbar or spinopelvic region, and less interest has been paid to the relationship between cervical sagittal balance and functional outcome of the patients. This study aims to compare the cervical sagittal parameters between patients with non-specific neck pain and asymptomatic controls. METHOD: Twenty-five patients (21 females/4 males) with non-specific neck pain and 25 age-, sex- and BMI-matched controls (18 females/7 males) participated in the study. Using a standard lateral cervical radiography, the Cobb angle between occiput-C2, C1-C2, C1-C7 and C2-C7 as well as the thoracic inlet angle (TIA) and C7 and T1 slope angles was measured. Also the spine cranial angle (SCA) and the C2-SVA (sacral vertical axis) and C1-SVA were measured. The primary outcome measure of the study was comparison of the sagittal balance variables between the patients and the healthy controls. Secondary outcome measures were correlation between pain intensity of the patients in neck pain group and their demographic and radiographic findings. Data analysis was performed using independent sample T test and Pearson's correlation for primary and secondary outcome measurements, respectively. RESULTS: There was no difference in cervical lordosis curvature (measured by C2-C7 and C1-C7 lordosis angle) between patients with non-specific NP and healthy controls (P value = 0.45 and 0.37, respectively). We found that T1 slope angle was significantly (P value = 0.02) lower in patients with neck pain. CONCLUSION: Our findings showed that the slope of the upper endplate of T1 vertebrae body (T1 slope) is significantly lower among patients with non-specific neck pain compared to controls. A compensatory mechanism to bring the center of head gravity back to the spinal axis might be the possible explanation for this difference. These slides can be retrieved under Electronic Supplementary Material.

Controlled Trial to Compare Therapeutic Efficacy of Endoscopic Third Ventriculostomy Plus Choroid Plexus Cauterization with Ventriculoperitoneal Shunt in Infants with Obstructive Hydrocephalus.

CONTEXT: Ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are the established surgical treatments for obstructive hydrocephalus (HCP). Powerful evidence regarding the best therapeutic approach for infants with obstructive HCP is lacked. AIMS: Comparison of the therapeutic efficacy of VP shunt and ETV/choroid plexus cauterization (CPC) in infants with obstructive HCP. SETTINGS AND DESIGN: This was a randomized, active control, unblind, single-center, clinical trial. METHODS: Infants with obstructive HCP were randomly allocated to each intervention group (ETV/CPC or VP shunt). They were monitored for at least 6 months for any sign of raised intracranial pressure (rICP). The recurrence of rICP signs requiring surgical intervention was considered as intervention failure. STATISTICAL ANALYSIS: The association between intervention group and outcome was tested with Chi-square test, and P = 0.05 or less was considered statistically significant. RESULTS: Of the total fifty patients entering the study, 49 were included in the final analysis, 27 of them were in VP shunt and 22 in ETV/CPC group. Seventeen patients (34%) were female and 33 (66%) were male with mean age of 3.74 ± 3.1 months (range = 10 days - 11 months). Thirty-nine (79.6%) were under 6 months of age and the remaining were 6 months or older. The overall success rate in 36-month follow-up was 88.5% and 68.2% for VP shunt and ETV/CPC, respectively, with the difference being not statistically significant. CONCLUSION: The current study determined no inferiority of ETV/CPC compared to VP shunt, and therefore, it may become an efficient treatment for obstructive HCP in infants.

Endoscopic Management of a Fourth Ventricular Cyst.

We report a case of a 12-year-old boy with previously shunted congenital hydrocephalus, presenting with a progressive headache, nausea, vomiting, and lethargy. In the brain magnetic resonance imaging, a large cyst was seen in the superior recess of the fourth ventricle extending through the cerebral aqueduct toward the third ventricle. Endoscopic dual fenestration of the cyst was performed successfully using the posterior suboccipital approach through the foramen of Magendie, which resulted in the relief of symptoms without any complications, and the patient was symptom-free in the subsequent follow-up visits for 4 years.

Pial arteriovenous fistula with giant varices: report of two cases with good surgical outcome.

Pial arteriovenous fistulas (pAVF) are rare vascular lesions consisting of one or more arterial connections to a single venous channel without any intervening nidus of vessels or capillaries. Case 1: A 65-year-old woman with a complaint of headache and left hand paresthesia was referred to us. Magnetic resonance imaging showed a large saccular lesion with signal void in the posterior part of the right sylvian fissure and catheter angiography showed a giant venous aneurysm fed by one branch of the middle cerebral artery (MCA) and draining into the vein of Trolard. Case 2: A 12-year-old boy was transferred to our hospital with a history of sudden loss of consciousness and hemiplegia. Brain computed tomography revealed a massive hemorrhagic mass in the right hemisphere and cerebral angiography showed a pAVF with a large aneurysmal varix, which was fed by multiple branches of the right MCA and draining into the superior sagittal sinus. Both patients underwent craniotomy and after ligation of vascular connections, aneurysmal varices were removed completely. Surgical resection can be a safe method for treatment of pAVFs, particularly in those with large varices.

Lumbar vertebral hemangioma with extradural extension, causing neurogenic claudication: a case report.

The authors present a rare case of lumbar vertebral hemangioma extending to the epidural space with a bisected appearance and impinging on thecal sac. This 52-year-old lady presented with one year history of low back pain and bilateral leg radiation. Plain radiography showed vertical linear streaks at L2 vertebral body and axial computed tomography (CT) scan revealed small "polka dot" appearance within the vertebral body. Magnetic resonance imaging (MRI) showed low signal intensity on T1-weighted images in L2 vertebral body which was not characteristic for hemangioma. The patient underwent an L2 laminectomy, spinal canal decompression and posterior spinal instrumentation. This study indicates that lumbar vertebral hemangioma can extend to the epidural space and cause neurologic symptoms. Magnetic resonance imaging may not show diagnostic features, especially in active lesions and plain radiography and CT scan may be helpful.