Cystic vestibular schwannoma - a subgroup analysis from a comparative study between radiosurgery and microsurgery.

Some vestibular schwannoma (VS) show cystic morphology. It is known that these cystic VS bear different risk profiles compared to solid VS in surgical treatment. Still, there has not been a direct comparative study comparing both SRS and SURGERY effectiveness in cystic VS. This retrospective bi-center cohort study aims to analyze the management of cystic VS compared to solid VS in a dual center study with both microsurgery (SURGERY) and stereotactic radiosurgery (SRS). Cystic morphology was defined as presence of any T2-hyperintense and Gadolinium-contrast-negative cyst of any size in the pre-interventional MRI. A matched subgroup analysis was carried out by determining a subgroup of matched SURGERY-treated solid VS and SRS-treated solid VS. Functional status, and post-interventional tumor volume size was then compared. From 2005 to 2011, N = 901 patients with primary and solitary VS were treated in both study sites. Of these, 6% showed cystic morphology. The incidence of cystic VS increased with tumor size: 1.75% in Koos I, 4.07% in Koos II, 4.84% in Koos III, and the highest incidence with 15.43% in Koos IV. Shunt-Dependency was significantly more often in cystic VS compared to solid VS (p = 0.024) and patients with cystic VS presented with significantly worse Charlson Comorbidity Index (CCI) compared to solid VS (p < 0.001). The rate of GTR was 87% in cystic VS and therefore significantly lower, compared to 96% in solid VS (p = 0.037). The incidence of dynamic volume change (decrease and increase) after SRS was significantly more common in cystic VS compared to the matched solid VS (p = 0.042). The incidence of tumor progression with SRS in cystic VS was 25%. When comparing EOR in the SURGERY-treated cystic to solid VS, the rate for tumor recurrence was significantly lower in GTR with 4% compared to STR with 50% (p = 0.042). Tumor control in cystic VS is superior in SURGERY, when treated with a high extent of resection grade, compared to SRS. Therapeutic response of SRS was worse in cystic compared to solid VS. However, when cystic VS was treated surgically, the rate of GTR is lower compared to the overall, and solid VS cohort. The significantly higher number of patients with relevant post-operative facial palsy in cystic VS is accredited to the increased tumor size not its sole cystic morphology. Cystic VS should be surgically treated in specialized centers.

Differentiating radiation necrosis from tumor recurrence: a systematic review and diagnostic meta-analysis comparing imaging modalities.

PURPSOSE: Cerebral radiation necrosis (RN) is often a delayed phenomenon occurring several months to years after the completion of radiation treatment. Differentiating RN from tumor recurrence presents a diagnostic challenge on standard MRI. To date, no evidence-based guidelines exist regarding imaging modalities best suited for this purpose. We aim to review the current literature and perform a diagnostic meta-analysis comparing various imaging modalities that have been studied to differentiate tumor recurrence and RN. METHODS: A systematic search adherent to PRISMA guidelines was performed using Scopus, PubMed/MEDLINE, and Embase. Pooled sensitivities and specificities were determined using a random-effects or fixed-effects proportional meta-analysis based on heterogeneity. Using diagnostic odds ratios, a diagnostic frequentist random-effects network meta-analysis was performed, and studies were ranked using P-score hierarchical ranking. RESULTS: The analysis included 127 studies with a total of 220 imaging datasets, including the following imaging modalities: MRI (n = 10), MR Spectroscopy (MRS) (n = 28), dynamic contrast-enhanced MRI (n = 7), dynamic susceptibility contrast MRI (n = 36), MR arterial spin labeling (n = 5), diffusion-weighted imaging (n = 13), diffusion tensor imaging (DTI) (n = 2), PET (n = 89), and single photon emission computed tomography (SPECT) (n = 30). MRS had the highest pooled sensitivity (90.7%). DTI had the highest pooled specificity (90.5%). Our hierarchical ranking ranked SPECT and MRS as most preferable, and MRI was ranked as least preferable. CONCLUSION: These findings suggest SPECT and MRS carry greater utility than standard MRI in distinguishing RN from tumor recurrence.

Assessment Of Endometrial Integrin Beta 5 In Women With Unexplained Recurrent Pregnancy Loss.

Objectives: To examine the relationship between endometrial integrin beta 5 level and risk of recurrent pregnancy loss. Method: The descriptive, prospective, observational, case-controlstudy was conducted at the Kafrelsheikh University Hospital, Egypt, from January to May 2022, and comprised women aged up to 35 years with at least 1 live birth delivery beyond 20-week gestation with normal thyroid and prolactin levels. Age-matched normal fertile women were enrolled as controls. All the participants were subjected to detailed history and complete clinical examination. Endometrial integrin beta 5 was assessed using an antibody sandwich enzyme-linked immunosorbent assay. Data was analysed using SPSS 20. RESULTS: Of the 50 subjects, 25(50%) were cases with a mean age of 26.72±2.64 years, and 25(50%) were controls with a mean age of 25.36±2.16 years. The integrin beta 5 level was significantly lower among the cases than the controls (p<0.05). The best cut-off level of serum integrin beta 5 was ≤2.5765 with area under curve 0.886, sensitivity 88%, specificity 76%, positive predictive value 78.6%, negative predictive value 86.4%, and accuracy 82%. CONCLUSIONS: Therewas an inverse correlationbetween endometrial integrinbeta 5 andthe risk ofrecurrentpregnancy loss.

Egg production, fertility, hatchability and immune responses of some chicken strains under high ambient temperatures.

This experiment was designed to investigate and compare the egg production, fertility, hatchability and immune responses of some local developed Egyptian chicken strains under high ambient temperatures. A total of 108 (26 weeks old) laying hens of Matrouh, Silver Montazah, Mandarah and Inshas (9 hens × 3 replicates × 4 strains) were used to evaluate the impact of thermal stress (24-34ºC) during summer season (June, July and August) on egg production, fertility, hatchability and immune responses. The obtained results revealed that final body weight (FBW/g) and body weight change (BWC/g) among different chicken strains were not affected. The daily feed consumption (FC/g) and feed conversion ratio (FCR) for Silver Montazah and Inshas strains were significantly (p ≤ .05) higher than those of Matrouh and Mandarah strains. The mean egg production (EP/%) and egg mass (EM) for Silver Montazah and Inshas strains were significantly (p ≤ .05) higher than those of Matrouh and Mandarah strains. The highest percentages of hatchability of total eggs (HTE) and fertile eggs (HFE) were recorded in Inshas chickens, while the lowest value was recorded in Mandarah chickens. Also, the highest embryonic mortalities (p ≤ .05) and lowest chick weight at hatch (CWH/g) were recorded in Mandarah chickens compared with the other strains. The highest values for antibody titres against phytohemagglutinin-P (PHA-P) were recorded in Mandarah chickens, while the least values were recorded in Inshas chickens.

Transfixing Kirshner wires for fixation of intertrochanteric valgus osteotomies in management of pediatric coxa vara.

BACKGROUND: Coxa vara is a radiological term describing a decrease in the neck-shaft angle to 120° or less. Coxa vara is associated with pathomechanical changes that can manifest clinically. If left untreated, coxa vara can affect the normal development of the pediatric hip. Valgus osteotomy is the standard surgical treatment for coxa vara, but there is no consensus regarding the optimal osteotomy technique and fixation method. The work reported here aimed to highlight transfixing wires as a fixation method for valgus osteotomy applied as treatment for various types of pediatric coxa vara. MATERIALS AND METHODS: This study included 16 cases of pediatric coxa vara with different etiologies in 9 patients with a mean age of 39.9 ± 15.2 months. Radiological and clinical evaluations and scoring of the condition of each patient according to the Iowa Hip Score were performed pre- and postoperatively. Transfixing wires and a protective spica were used for the fixation of a V-shaped, laterally based, closing-wedge valgus osteotomy in all cases. The postoperative follow-up period ranged from 14 to 102 months, with a mean duration of 33.3 ± 27.7 months. RESULTS: The mean Hilgenreiner epiphyseal angle (HEA) was corrected from 81.7 ± 2.2° to 24.3 ± 3.5° and the mean femoral neck-shaft angle (FNSA) was improved from 86.9 ± 4.2° to 138.6 ± 3.5°. No recurrence of the deformity was observed during the follow-up periods considered here. The osteotomy site united after an average of 11.7 ± 2.2 weeks with no secondary displacement, and in cases of developmental coxa vara there was progressive ossification of the neck defect with no surgery-related complications. Clinical results were markedly improved by the osteotomy, with a mean postoperative Iowa Hip Score at last follow-up of 95.06 ± 2.6, compared to a mean preoperative score of 57.4 ± 3.6. CONCLUSIONS: Transfixing wires protected in a hip spica cast represent a simple, easy, and reliable fixation method for valgus osteotomies performed to correct pediatic coxa vara. It assures stable fixation and rapid healing of the osteotomy without loss of the achieved correction, it completely avoids the femoral neck affording marked protection to the growth plate. LEVEL OF EVIDENCE: IV.

Triceps-sparing approach for open reduction and internal fixation of neglected displaced supracondylar and distal humeral fractures in children.

BACKGROUND: Supracondylar humeral fractures are one of the most common skeletal injuries in children. In cases of displacement and instability, the standard procedure is early closed reduction and percutaneous Kirschner wire fixation. However, between 10 and 20 % of patients present late. According to the literature, patients with neglected fractures are those patients who presented for treatment after 14 days of injury. The delay is either due to lack of medical facilities or social and financial constraints. The neglected cases are often closed injuries with no vascular compromise. However, the elbow may still be tense and swollen with abrasions or crusts. In neglected cases, especially after early appearance of callus, there is no place for closed reduction and percutaneous pinning. Traditionally, distal humeral fractures have been managed with surgical approaches that disrupt the extensor mechanism with less satisfactory functional outcome due to triceps weakness and elbow stiffness. The aim of this study is to evaluate the outcome of delayed open reduction using the triceps-sparing approach and Kirschner wire fixation for treatment of neglected, displaced supracondylar and distal humeral fractures in children. MATERIALS AND METHODS: This prospective study included 15 children who had neglected displaced supracondylar and distal humeral fractures. All patients were completely evaluated clinically and radiologically before intervention, after surgery and during the follow-up. The follow-up period ranged from 8 to 49 months, with a mean period of 17 months. Functional outcome was evaluated according to the Mayo Elbow Performance Index (MEPI) and Mark functional criteria. RESULTS: All fractures united in a mean duration of 7.2 weeks (range 5-10 weeks) with no secondary displacement or mal-union. Excellent results were found at the last follow-up in 13 of the 15 patients studied (86.66 %), while good results were found in two patients (13.33 %) according to the MEPI scale. According to the Mark functional criteria, there was one patient with a fair result (6.66 %). CONCLUSION: The results were very satisfactory if compared with traditional operative techniques, with many advantages including anatomical reduction and fixation of the fractures, avoidance of ulnar nerve injury, preservation of the extensor mechanism, decrease in incidence of myositis ossificans around the elbow and decrease in post-operative stiffness. LEVEL OF EVIDENCE: IV.

Multiple arthroscopic debridement and graft retention in septic knee arthritis after ACL reconstruction: a prospective case-control study.

PURPOSE: This study was undertaken to prospectively analyse, at a mean five-year follow-up, the clinical, functional, and radiographic outcomes in patients who developed postoperative acute septic knee arthritis following anterior cruciate ligament (ACL) reconstruction using hamstring autograft. We also assessed the effect of multiple arthroscopic debridement and graft retention on the functional outcomes in comparison with the matched control group. METHODS: From a consecutive case series of 2,560 ACL-injured patients who were treated with arthroscopic ACL reconstruction, we report on 24 cases with postoperative septic knee arthritis. These patients were individually matched for age, sex, comorbidity, body mass index (BMI) and preinjury Tegner activity scale in a ratio of 1/1. Clinical, laboratory, synovial fluid analysis and culture were performed. Arthroscopic debridement and graft retention was done for all cases, in addition to antibiotic therapy i.v.. A detailed physical examination, KT1000 laxity testing, Lysholm knee score, Tegner activity level scale, International Knee Documentation Committee (IKDC), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed. RESULTS: In all cases, treatment of infection was successful after a median of three (range one to six) repeated arthroscopic graft debridement and retention, in addition to antibiotic therapy i.v.. At an average of five years follow-up, two patients had over five millimetres manual maximum side-to-side difference in laxity. There were no significant differences between groups regarding Lysholm score, IKDC and KOOS. Median final Tegner activity score was 5.5 versus 7 in the control group (p = 0.004). Complications included graft rupture in three patients, loss of range of motion in five, Sudeck's atrophy in one and moderate joint narrowing in two. There were no recurrences of septic arthritis or bone infection. CONCLUSION: Graft retention seems not only possible but appropriate in view of the experience presented in this article for postoperative septic knee arthritis using hamstring autograft. A potential residual complication is arthrofibrosis, which deserves maximum attention.

Does lateral extra-articular tenodesis affect knee stability in cases with isolated anterior cruciate ligament reconstruction?

Objective: The purpose of this randomised controlled trial was to assess the effect on knee function and stabilising effectiveness of lateral extra-articular tenodesis (LET) in anterior cruciate ligament (ACL) restoration. Methods: A prospective randomised clinical study that compared the functional outcomes of two groups-one undergoing anatomic single bundle ACL reconstruction (ASB-ACLR) with ilio-tibial band tenodesis (LET) for 20 patients, and the other undergoing ASB-ACLR-was carried out between February 2020 and August 2022. Results: By combining Lateral Extra-articular Tenodesis (LET) with intra-articular Anterior Cruciate Ligament Reconstruction (ACLR), our study observed a significant reduction in the occurrence of high-grade pivot-shift phenomena. Prior to surgery, both Groups A and B exhibited graded (D) pivot-shift test results. However, post-surgery, the pivot-shift test yielded negative results in 60% of patients in Group A and 90% of patients in Group B. The statistical analysis revealed a notable difference between the two groups, as indicated by a P-value of 0.003. Upon conducting a brief follow-up, we evaluated the Lysholm score, and anterior knee stability of ACLR with LET, finding no statistically significant difference compared to those of single ACLR. The Lachman tests also revealed no significant disparity between the two groups (p = 0.106). Analyzing the Lysholm scores in Group A and Group B, we observed an increase to 90.70% and 91.10%, respectively. Conclusion: Rotational stability is much improved when lateral extra-articular tenodesis (LET) utilizing the ilio-tibial band as an augmentation is used in ACL restoration. Especially useful for high-grade pivot-shift phenomena is this technique.

Impact of ß-glucan dietary supplementation on productive, reproductive performance and physiological response of laying hens under heat stress conditions.

The exploration for effective in-feed additives is growing owing to the global climatic change trend to alleviate the negative effects of heat stress in laying hens. This research assessed the potential of using B-glucan (G) as an antiheat stress agent in Matrouh laying hens subjected to early heat shock programs during the growing period. Factorial design (3 × 3) was used, including 3 levels of heat stress (control, heat shock at 3 d and at 3 d and 8 wk of age) and 3 levels of ß-glucan (0, 100, and 200 mg ß-glucan /kg diet). During the first 12 wk of egg production (EP), treatments were exposed to heat challenge. The results revealed that heat shock program applications at 3 d and 8 wk of age significantly decreased body weight at 36 wk of age (P < 0.05) and reduced (P < 0.05) feed intake (FI). While significantly (P < 0.05) improved feed conversion ratio (FCR), hemoglobin, RBCs, WBCs, immunoglobulin M (IgM), immunoglobulin G (IgG), and Heat shock protein (HSP70) of the Liver (P < 0.01) as compared with the control group. At the same time, there was a decrease in lymphocyte%, H/L ratio, cortisol, and T3 compared to the thermo-neutral control. When compared to the control group, hens fed a diet containing 200 mg of ßG significantly (P < 0.05) improved body weight at 16 wk and final weight at 36 wk, feed conversion (FCR) (g. feed/g. egg mass), hen-day egg production, and egg mass, as well as the digestibility coefficients of crude protein (CP), dry matter (DM), metabolizable energy (ME), and cortisol. The interactions between heat chock programs and ßG levels were nonsignificant for the most studied traits except daily feed intake. Therefore, the early heat shock exposure 2 times and supplementation of Β-glucan (ßG) at 200 mg/kg diet during the growth period for laying hens that are exposed to heat stress during the reproductive period could improve productive, reproductive performance, HSP70 level and enhance immunity responses.

Human dental pulp stem cells expressing transforming growth factor ß3 transgene for cartilage-like tissue engineering.

BACKGROUND AIMS: The aim of this study was to engineer sizable three-dimensional cartilage-like constructs using stem cells isolated from human dental pulp stem cells (DPSCs). METHODS: Human DPSCs were isolated from teeth extracted for orthodontic treatment and enriched further using immuno-magnetic bead selection for stem cell marker CD146. Chondrogenic lineage differentiation of DPSCs induced using recombinant transforming growth factor ß3 (TGFß3) was verified by pellet culture. Because the use of recombinant proteins is associated with rapid degradation and difficult in vivo administration, we constructed the recombinant adeno-associated viral vector encoding human TGFß3 and determined the best multiplicity of infection for DPSCs. Transduced DPSCs were seeded on poly-l-lactic acid/polyethylene glycol (PLLA/PEG) electrospun fiber scaffolds demonstrating proper attachment, proliferation and viability as shown by scanning electron microscopy micrographs and CCK-8 cell counting kit. Scaffolds seeded with DPSCs were implanted in the back of nude mice. RESULTS: Transduced DPSCs highly expressed human TGFß3 for up to 48 days and expressed chondrogenic markers collagen IIa1, Sox9 and aggrecan, as verified by immunohistochemistry and messenger RNA (mRNA). Immunohistochemistry for TGFß3/DPSC constructs (n = 5/group) showed cartilage-like matrix formation with glycosaminoglycans. In vivo constructs with TGFß3/DPSCs showed higher collagen type II and Sox9 mRNA expression relative to non-transduced DPSC constructs (n = 5/group). Western blot analysis confirmed this expression pattern on the protein level (n = 3/group). CONCLUSIONS: Immuno-selected DPSCs can be successfully differentiated toward chondrogenic lineage, while expressing the chondrogenic inducing factor. Seeded on PLLA/PEG electrospun scaffold, human DPSCs formed three-dimensional cartilage constructs that could prove useful in future treatment of cartilage defects.

A comparative study of microsurgery and gamma knife radiosurgery in vestibular schwannoma evaluating tumor control and functional outcome.

Background: Both stereotactic radiosurgery (SRS) and microsurgical resection (SURGERY) are available as treatment options for sporadic vestibular schwannoma (VS). There are very few direct comparative studies comparing both treatment modalities in large cohorts allowing detailed subgroup analysis. This present study aimed to compare the nuances in the treatment of VS by SURGERY and SRS in 2 highly specialized neurosurgical centers. Methods: This is a retrospective bicentric cohort study. Data from patients treated between 2005 and 2011 were collected retrospectively. Recurrence-free survival (RFS) was assessed radiographically by contrast-enhanced magnetic resonance imaging. Results: The study population included N = 901 patients with a mean follow-up of 7 years. Overall, the incidence of recurrence was 7% after SURGERY, and 11% after SRS with superior tumor control in SURGERY in the Kaplan-Meier-analysis (P = 0.031). In small tumors (Koos I and II), tumor control was equivalent in both treatment arms. In large VS (Koos III and IV), however, RFS was superior in SURGERY. The extent of resection correlated with RFS (P < .001). Facial and hearing deterioration was similar in both treatment arms in small VS, but more pronounced in SURGERY of large VS. Tinnitus, vertigo, imbalance, and trigeminal symptoms were more often improved by SURGERY than SRS. Conclusions: SRS can achieve similar tumor control compared to SURGERY in smaller VS (Koos I and II)-with similar postinterventional morbidities. In large VS (Koos III and IV), long-term tumor control of SRS is inferior to SURGERY. Based on these results, we suggest that if combination therapy is chosen, the residual tumor should not exceed the size of Koos II.

Modified anterior transarticular C1/2 fixation for odontoid fractures: An approach with high complication rate in geriatric population.

Background: In patients over 75 years of age, we applied a modified anterior transarticular C1/2 fixation with reduced pharyngeal mobilization versus the standard anterior triple/quadruple osteosynthesis procedures. Methods: From 2010 to 2018, 29 patients underwent a modified anterior transarticular C1/2 fixation utilizing single odontoid screw fixation through a right-sided Smith-Robinson - (i.e., short and steep screw trajectory for the right and long trajectory for the left side) approach. All the patients were 75 years of age or older (mean age 82.6) and had sustained odontoid Type II fractures. In addition, a subset exhibited further ligamentous injuries and/or atlas fractures. Their Mean Age-adjusted Charlson Comorbidity Index was 5.3 points (range 3-12), while mean American Society of Anesthesiologists scores averaged 2.9 (range 2-4). Results: The mean operating time was 55.8 min, there were no intraoperative complications, and there was minimal blood loss in all cases. The most common medical complications included aspiration pneumonia (24.1%, n = 7), altered mental status (17.2%, n = 5), and cardiac decompensation (6.9%, n = 2). One patient with delayed dysphagia and an infected implant resulting in loosening/dislocation required implant removal and long-term antibiotic therapy. The 30-day mortality rate was 13.8% (four patients) and the 1-year mortality rate was 27.6% (eight patients). Conclusion: Anterior transarticular C1/2/odontoid fixation with reduced pharyngeal mobilization and shorter operative times was associated with high morbidity/mortality rates. Dysphagia/aspiration was the major postoperative complications leading to some deaths especially in patients with dementia/Parkinsonism.

Unstable jefferson burst fractures (JBF): Intraoperative stability testing after posterior atlas ring osteosynthesis (C1-RO) allows determination of surgical procedure extent.

Introduction: Motion preserving atlas ring osteosynthesis (C1-RO) for unstable Jefferson burst fractures (JBF) with insufficiency of the transverse atlantal ligament (TAL) is under debate. There is controversy about when to apply C1-RO and when further stabilization is needed. Research question: Is intraoperative stability testing after C1-RO with restoration of secondary stabilizers feasible, and what are mid-to long-term results of posterior C1-RO vs. C1-C2 ORIF in unstable Jefferson burst fractures with Dickman type I or II transverse atlantal ligament lesions based on intraoperative decision using this stability testing? Material and methods: Five consecutive patients with unstable JBF were treated with posterior C1-RO or C1-C2 ORIF based on the findings after intraoperative reduction and posterior C1-RO and stability testing. This newly developed intraoperative stability test based on the findings of biomechanical studies is a fluoroscopically controlled manual C1-C2 test with a force of approximately 50 â€‹N posterior-anterior stress and a tilting maneuver after C1-RO with repositioning. Clinical and radiological results of the cases with C1-RO were analyzed 3.5-21 months postoperatively. Results: Posterior C1-RO was performed in four patients. One case required C1-C2 fixation due to significant instability. In cases of C1-RO, stable bony fusions of the atlas ring were observed within a year. In flexion-extension views, the anterior atlanto-dental interval (AADI) did not increase until the latest follow-up. No complications were observed. Discussion and conclusion: The described intraoperative stability test after posterior C1-RO in unstable JBF enables the determination if C1-RO is sufficient or C1-C2 ORIF is necessary for treatment.

Trans - 6R Portal Repair of Superficial TFCC Tears; A Modified Arthroscopic Outside-in Technique.

Different arthroscopic repair techniques have been described for various tear types. Several series have reported successful outcomes for arthroscopic repair of superficial tear of the triangular fibrocartilage complex (TFCC) tears using the outside-in technique. Described techniques entail usage of special instruments for passage of sutures and/or use of many incisions. We describe an arthroscopic technique for repair of superficial part of TFCC through the 6R portal by single hypodermic needle, with no additional skin incisions or special equipment.

Functional outcome after the nonsurgical treatment for adolescent spasmodic valgus foot.

BACKGROUND: Adolescent spasmodic valgus foot is usually associated with resistant pain and deformity. It shows controversy regarding its incidence, etiology, and treatment. Our study aimed to evaluate the functional outcome after the nonsurgical treatment for such condition. METHODS: This study included 50 planovalgus feet secondary to peroneal or peroneo-extensor spasm in 33 adolescents with a mean age of 14 ± 2.8 years. The procedure included foot manipulation under general anesthesia, sinus tarsi injection with corticosteroids, and a walking cast in the neutral position. Patients were evaluated functionally (using the American Orthopedic Foot and Ankle Society (AOFAS)) and radiologically before the procedure, after cast removal, and 3, 9, and 18 months later with special attention given for recurrence during the follow-up period with a mean duration of 22.5 ± 3.5 months. RESULTS: Once general anesthesia had been conducted, the deformity was corrected without any manipulation, and full passive inversion could be easily obtained in 26 feet, the deformity was corrected only after manipulation, and full passive inversion had been obtained in 14 feet, while 10 feet remained stiff even after manipulation. The mean AOFAS score was significantly improved ( p < 0.001) from 40.9 ± 3.5 at presentation to 73.56 ± 5.2 at the last follow-up in which 12 feet was painless and freely mobile and 24 feet had partial relapse, while 14 feet had complete relapse. CONCLUSION: The nonsurgical treatment for adolescent spasmodic valgus foot could be a simple and effective treatment. Apart from limited complete recurrence, the overall functional outcome was satisfactory. Level of evidence: type IV case series.

Chances of Improvement in Cases of Vestibular Schwannoma Presenting with Facial Nerve Weakness: Presentation of Two Cases and Literature Review.

Background and Study Aim Facial nerve (FN) weakness as a presenting feature in vestibular schwannoma (VS) is extremely rare. We are presenting two different cases of VS with significant facial weakness and reviewed the literature for similar cases. Methods and Results We are presenting two cases of VS with significant facial weakness. The first case was a 63-year-old male patient presented with 3 weeks' history of severe left-sided facial weakness (House-Brackmann [HB] grade V) and hearing loss. Magnetic resonance imaging (MRI) of the brain showed a tumor in the left internal auditory canal. Gross total removal with anatomical and physiological FN preservation was performed through a retrosigmoid approach under neurophysiological monitoring. FN function improved postoperatively to HB grade II after 16 months. The other case was 83-year-old male patient presented with sudden left-sided hearing loss and severe facial weakness (HB grade V). MRI of the brain 2.5 years before showed a left-sided (Class-T3A) cystic VS. The tumor was asymptomatic; wait-and-scan strategy was advised by the treating neurologist. Recent MRI of the brain showed approximately three times enlargement of the tumor with brain stem compression, extensive cystic changes, and suspected intratumoral hemorrhage. Surgery was performed; the tumor was subtotally removed through a retrosigmoid approach with intraoperative FN monitoring. The FN was anatomically preserved; however, physiological preservation was not possible. Severe facial weakness with incomplete lid closure persisted postoperatively. Conclusion Surgical treatment could be offered to cases of suspected VS presenting with facial weakness, as these cases may still have a chance for improvement especially in laterally located tumors.

Multiple Colloid Cysts: Case Report and Literature Review.

BACKGROUND AND STUDY AIM: Colloid cysts usually occur in the anterior third ventricle at the level of the foramina of Monro. Colloid cysts may extend from the third toward the lateral ventricle. We present a rare case of multiple intraventricular colloid cysts, two of which were in the third ventricle and one in the lateral ventricle. CLINICAL DESCRIPTION: A 40-year-old female patient presented with three intraventricular cystic lesions: one cyst in the typical localization in the anterior rostral third ventricle, another cyst behind it in the same (third) ventricle, and a larger bulging cyst in the right lateral ventricle. A bilateral ventriculoperitoneal shunt had been inserted 26 years before to treat hydrocephalus. All three cysts had different magnetic resonance imaging (MRI) signal characteristics. We removed the cysts through an endoscopically assisted right transcortical transventricular microsurgical approach, using the right ventricular catheter as a guide to the lateral ventricle. After removal of the lateral ventricular cyst, we observed that the foramen of Monro was greatly enlarged (most likely as a result of the large cyst), which allowed us to remove the cysts in the third ventricle. During surgery, the cysts were found to have different consistencies. MRI 2 years following surgery showed complete removal and no hydrocephalus. The patient had no symptoms, and the clinical examinations were normal. CONCLUSIONS: Colloid cysts may become large and extend to the lateral ventricle, especially in patients treated with ventriculoperitoneal shunts. Studying the relevant pathoanatomy of these cysts is very important for preoperative planning including the choice of surgical approach.

Predictors of Preoperative Tinnitus in Unilateral Sporadic Vestibular Schwannoma.

OBJECTIVE: Nearly two-thirds of patients with vestibular schwannoma (VS) are reporting a significantly impaired quality of life due to tinnitus. VS-associated tinnitus is attributed to an anatomical and physiological damage of the hearing nerve by displacing growth of the tumor. In contrast, the current pathophysiological concept of non-VS tinnitus hypothesizes a maladaptive neuroplasticity of the central nervous system to a (hidden) hearing impairment resulting in a subjective misperception. However, it is unclear whether this concept fits to VS-associated tinnitus. This study aims to determine the clinical predictors of VS-associated tinnitus to ascertain the compatibility of both pathophysiological concepts. METHODS: This retrospective study includes a group of 478 neurosurgical patients with unilateral sporadic VS evaluated preoperatively regarding the occurrence of ipsilateral tinnitus depending on different clinical factors, i.e., age, gender, tumor side, tumor size (T1-T4 according to the Hannover classification), and hearing impairment (Gardner-Robertson classification, GR1-5), using a binary logistic regression. RESULTS: 61.8% of patients complain about a preoperative tinnitus. The binary logistic regression analysis identified male gender [OR 1.90 (1.25-2.75); p = 0.002] and hearing impairment GR3 [OR 1.90 (1.08-3.35); p = 0.026] and GR4 [OR 8.21 (2.29-29.50); p = 0.001] as positive predictors. In contrast, patients with large T4 tumors [OR 0.33 (0.13-0.86); p = 0.024] and complete hearing loss GR5 [OR 0.36 (0.15-0.84); p = 0.017] were less likely to develop a tinnitus. Yet, 60% of the patients with good clinical hearing (GR1) and 25% of patients with complete hearing loss (GR5) suffered from tinnitus. CONCLUSION: These data are good accordance with literature about non-VS tinnitus indicating hearing impairment as main risk factor. In contrast, complete hearing loss appears a negative predictor for tinnitus. For the first time, these findings indicate a non-linear relationship between hearing impairment and tinnitus in unilateral sporadic VS. Our results suggest a similar pathophysiology in VS-associated and non-VS tinnitus.

Mid-Sole Release of the Plantar Fascia Combined With Percutaneous Drilling of the Calcaneus for Treatment of Resistant Heel Pain.

BACKGROUND: Heel pain with or without calcaneal spur is a challenging problem. Once conservative measures have failed, surgery may be indicated; there has been debate about the best surgical procedure. Two standard operative procedures have been either releasing the plantar fascia or removing the spur with drilling of the calcaneus. In this study, we evaluated the results of percutaneous drilling of the calcaneus combined with mid-sole release of the plantar fascia for treatment of resistant heel pain. METHODS: This study included 20 cases with resistant heel pain after failure of conservative measures for 6 months. Clinical, radiological evaluation and scoring patients' conditions according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scale was done preoperatively and postoperatively. Percutaneous drilling of the calcaneus combined with mid-sole release of the plantar fascia was done in all cases, and the functional results were evaluated through the follow-up period that extended from 9 to 16 months with a mean duration of 12 ± 2.3 months. RESULTS: There was statistically significant improvement in the mean AOFAS Ankle-Hindfoot scale score from 50.8 ± 7.5 preoperatively to 91.6 ± 7 postoperatively at the last follow-up. There were no surgery-related complications, and the mean time for full recovery was 8 ± 3.7 weeks with no recurrence of pain by the last follow-up. CONCLUSIONS: The results were very satisfactory with using this minimally invasive and simple technique for treatment for resistant heel pain. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Implications of Vestibular Schwannoma Consistency: Analysis of 140 Cases Regarding Radiologic and Clinical Features.

OBJECTIVE: To evaluate the effects of vestibular schwannoma (VS) consistency on internal auditory canal (IAC) widening, magnetic resonance imaging appearance, presenting symptoms, and facial nerve outcome. MATERIAL AND METHODS: We performed a retrospective analysis of 140 consecutive patients presenting with unilateral VS who underwent surgical treatment at the Department of Neurosurgery, Tuebingen University, Germany. Operative videos were analyzed, and the tumors were classified into soft and firm according to resectability with an ultrasonic aspirator at 40% power. IAC opening was measured in preoperative bone-window computed tomography on the pathologic and healthy sides, and the percentage of widening between both sides was calculated. Tumor signal intensity was assessed on T2-weighted magnetic resonance imaging scans. Preoperative and postoperative findings in the patient reports were documented. RESULTS: Widening of the IAC due to presence of the VS occurred in 118 patients (84.3%). The degree of IAC widening on the tumor side compared to the other side ranged from 0.1 to 10.1 mm (mean 2.6 mm). The mean widening of the IAC in relation to the healthy side was 1.9 mm in soft tumors and 3.6 mm in firm tumors. A significant correlation was found between tumor consistency and degree of widening of the IAC (P < 0.0001). No significant correlation was found between tumor intensity (on T2-weighted imaging) and tumor consistency. In the early postoperative course, patients with soft tumors had better facial nerve function than those having firm tumors. However, at the last examination no difference between both groups was found. CONCLUSION: The consistency of VS has an impact on the immediate postoperative outcome. Widening on bony computed tomography scan, but not T2 intensity on magnetic resonance imaging, predicts whether the tumor is soft or firm.