Revisiting the microsurgical anatomy of the sagittal stratum and surgical implications: fiber microdissection and tractography study.

OBJECTIVE: The term "sagittal stratum" was coined by Heinrich Sachs in 1892 to define a parasagittally oriented white matter layer at the temporo-occipital cortex. Although this term has been widely used for more than 100 years, the description, classification, borders, and involved fibers of the structure vary among authors and remain imprecise. Through fiber microdissection and tractography, the authors aimed to define the sagittal stratum and resolve the uncertainty by revealing the relationship of this structure to other cerebral white matter pathways and the orientation of fibers in it. METHODS: Twenty postmortem human cerebral hemispheres were prepared according to Klingler's method. Fiber dissections were performed under a surgical microscope and with microsurgical techniques. The results of dissection at each step were photographed with 2D and 3D imaging techniques, and 3D photogrammetry techniques were used to create a 360° model. Diffusion tensor imaging and 7T high-resolution MRI were used to confirm the findings. RESULTS: This study revisited the 3D organization of white matter tracts in the sagittal stratum through fiber microdissection and tractography. The microneuroanatomical structure of the sagittal stratum and its special organization with fibers from all three fiber systems are demonstrated. The authors' findings revealed that the sagittal stratum has two layers consisting of four different fiber tracts. Its external layer consists of a long association fiber and a commissural fiber, while its internal layer consists of intertwined projection fibers, including temporo-parieto-occipitopontine fibers and the posterior thalamic peduncle. Detailed microdissection also showed the location of the posterior thalamic peduncle in the most medial site of all posterior hemispheric projection fibers. CONCLUSIONS: The structure of the sagittal stratum is distinctive in that it contains all three main fiber systems: association, commissural, and projection. Because of its expansive location in the temporal and occipital lobes, it can be damaged by most neurosurgical pathologies and procedures. The authors emphasize the significance of preserving the sagittal stratum during surgical interventions while also challenging the notion of a "silent" brain, suggesting that the current inability to fully comprehend cerebral function contributes to this misconception. Detailed knowledge of the complex white matter anatomy of the sagittal stratum can guide neurosurgeons in surgical planning and the selection of appropriate surgical approaches with intraoperative orientation for safe surgery and less comorbidity.

The first case of glioma detected by an artificial intelligence algorithm running on real-time data in neurosurgery: illustrative case.

BACKGROUND: The aim of this paper is to report one of the significant applications of artificial intelligence (AI) and how it affects everyday clinical practice in neurosurgery. The authors present a case in which a patient was diagnosed via an AI algorithm during ongoing magnetic resonance imaging (MRI). According to this algorithm, the corresponding physicians were immediately warned, and the patient received prompt appropriate treatment. OBSERVATIONS: A 46-year-old female presenting with nonspecific headache was admitted to undergo MRI. Scanning revealed an intraparenchymal mass that was detected by an AI algorithm running on real-time patient data while the patient was still in the MRI scanner. The day after MRI, a stereotactic biopsy was performed. The pathology report confirmed an isocitrate dehydrogenase wild-type diffuse glioma. The patient was referred to the oncology department for evaluation and immediate treatment. LESSONS: This is the first report of a glioma diagnosed by an AI algorithm and a subsequent prompt operation in the literature-the first of many and an example of how AI will enhance clinical practice.

How did intraoperative neuromonitorization prevent tetraplegia?

PURPOSE: Patients with mucopolysaccharidosis type IVA (MPS IVA) have many risk factors for myelopathy and paresis. These are spinal cord compression, bone stenosis, and soft tissue thickening with ligament laxity, deformity, odontoid hypoplasia, and atlantoaxial instability. Although most patients with MPS IVA appear generally healthy at birth, patients often show skeletal deformities within a few years. Surgical indications are difficult to determine. Historically, many physicians have used prophylactic decompression and fusion in young, asymptomatic MPS IVA patients to prevent cord compression. Although spinal cord decompression is usually required at the craniocervical junction in patients with MPS IVA, decompression may be required at other spinal cord levels as well. There is a risk of developing neurological damage during surgery. The most common causes are ischemia secondary to cardiac output deteriorated in the prone position or due to artery damage, and local trauma due to neck movements or traction while bringing the patient to the prone position. Neurophysiological monitoring is very important during surgery to reduce the risk of neurological damage in spinal cord surgery. In this case report, a case with loss of lower extremity neuromonitorization motor evoked potential (MEP) responses in the early period of surgery without any intervention to the craniocervical junction after prone positioning will be presented.

Comparison of the Results of Suture and Resorbable Plate-Screw Fixation in Craniosynostosis.

BACKGROUND: Although many fixation methods are used alone or in combination for craniosynostosis, only few studies have compared the effectiveness and long-term results of these methods. METHOD: In this study, patients in whom suture or resorbable plate-screw system was used for fixation were evaluated in terms of postoperative results and complications. The data of patients who underwent surgery for craniosynostosis between 2002 and 2019 were retrospectively reviewed and evaluated. RESULTS: A total of 70 patients, 41 in the suture group and 29 in the resorbable plate-screw group, were included in the study. Whitaker classification was used for head shape evaluation, and anthropometric head circumference measurements were performed in all patients in the preoperative and postoperative periods. In the postoperative period, all patients were compared in terms of the operation time, transfusion requirement, discharge, follow-up period, and complications according to the chosen fixation method.The mean age, postoperative complication rates, anthropometric head circumference measurements, and Whitaker scores of both groups were found to be statistically similar. Although the resorbable plate-screw group had a longer follow-up period, the operation time was longer in the suture group. Furthermore, the suture group had lower transfusion requirement and earlier discharge from the hospital than the resorbable plate-screw group. CONCLUSIONS: If fixation with suture is chosen in suitable patients, in addition to the low patient cost, this method can be safely applied in centers with limited logistical possibilities, because of the results and complication rates being similar to fixation with resorbable plate-screws.

Sagittal spinopelvic alignment in tethered cord syndrome and split cord malformation.

PURPOSE: Sagittal imbalance is common in degenerative and congenital spinal diseases. Some studies have examined spinal deformities in the spina bifida. However, sagittal spinopelvic parameters in tethered cord syndrome (TCS) and split cord malformation (SCM) have been poorly evaluated in the literature. In this study, we investigated sagittal spinopelvic differences in TCS due to fatty filum terminale and SCM patients. MATERIAL AND METHODS: A total of 78 patients with spina bifida occulta (30 SCM and 48 TCS due to fatty filum terminale) were included in the study. Radiological images of these patients were retrospectively evaluated. We evaluated the pelvic incidence, pelvic tilt, sacral slope, sagittal vertical axis (SVA), T1 pelvic angle, lumbar lordosis (LL), thoracic kyphosis, thoracolumbar alignment, and change in those parameters with age. RESULTS: Correlation coefficients between age and LL, T1 pelvic angle, and the SVA in patients with TCS due to fatty filum terminale were statistically significant. In addition, correlation coefficients between age and LL and the SVA in patients with SCM were statistically significant. Notably, LL was increased at a statistically significant level with age in patients with TCS and SCM. CONCLUSION: Improved knowledge of spinal balance parameters in patients with TCS and SCM may be helpful in understanding the clinical course of these pathologies, and provide information regarding the success of surgery at the follow-up period.

Utilizing Deep Convolutional Generative Adversarial Networks for Automatic Segmentation of Gliomas: An Artificial Intelligence Study.

AIM: To describe a deep convolutional generative adversarial networks (DCGAN) model which learns normal brain MRI from normal subjects than finds distortions such as a glioma from a test subject while performing a segmentation at the same time. MATERIAL AND METHODS: MRIs of 300 healthy subjects were employed as training set. Additionally, test data were consisting anonymized T2-weigted MRIs of 27 healthy subjects and 27 HGG patients. Consecutive axial T2-weigted MRI slices of every subject were extracted and resized to 364x448 pixel resolution. The generative model produced random normal synthetic images and used these images for calculating residual loss to measure visual similarity between input MRIs and generated MRIs. RESULTS: The model correctly detected anomalies on 24 of 27 HGG patients? MRIs and marked them as abnormal. Besides, 25 of 27 healthy subjects? MRIs in the test dataset detected correctly as healthy MRI. The accuracy, precision, recall, and AUC were 0.907, 0.892, 0.923, and 0.907, respectively. CONCLUSION: Our proposed model demonstrates acceptable results can be achieved only by training with normal subject MRIs via using DCGAN model. This model is unique because it learns only from normal MRIs and it is able to find any abnormality which is different than the normal pattern.

Stereotactic radiosurgery for cerebral cavernous malformation: comparison of hemorrhage rates before and after stereotactic radiosurgery.

OBJECTIVE: Cerebral cavernous malformation (CM) is an angiographically occult vascular pathology. Although microsurgery is the gold standard treatment to control the symptoms of CM, resection carries high risk in some situations, especially eloquent areas. The objective was to evaluate annual hemorrhage rates (AHRs) before and after stereotactic radiosurgery (SRS) treatment of cerebral CM in different locations. METHODS: A total of 195 patients (119 women and 76 men) with CM treated at the Gazi University Gamma Knife Center between April 2005 and June 2017 were analyzed. The mean ± SD follow-up period was 67.4 ± 31.1 months (range 12 days to 170 months). AHR before SRS, AHR after SRS, morbidity associated with radiation, seizure control rate after SRS, lesion volume, coexistence with developmental venous anomaly, and SRS treatment parameters were analyzed, with evaluation of radiological data and clinical charts performed retrospectively. The seizure control rate was assessed using the Engel outcome scale. RESULTS: The AHR before SRS was 15.3%. Application of SRS to these patients significantly reduced the AHR rates to 2.6% during the first 2 years after treatment and to 1.4% thereafter. Favorable seizure control (Engel class I and II) after radiosurgery was achieved in 23 patients (88.5%) with epilepsy. Radiation-related temporary complications occurred in 15.4% of patients, and permanent morbidity occurred in 4.6%. CONCLUSIONS: SRS is a safe and effective treatment modality for reducing the hemorrhage risk of CM. The authors suggest that SRS should be considered for the treatment of patients with CM, high surgical risks, and hemorrhage history, instead of a using a wait-and-see policy.

Stereotactic Radiosurgery after Subtotal Resection of Critically-Located Grade I Meningioma: A Single-Center Experience and Review of Literature.

AIM: To analyze the results of stereotactic radiosurgery in 295 patients with residual Grade I meningiomas located at parasellar region, petroclival region, cerebellopontine angle and parasagittal region. MATERIAL AND METHODS: A total of 295 patients with Grade 1 residual Meningiomas (197 women, 98 men), who were treated by adjuvant radiosurgery in Gazi University Gamma Knife Center between 2004-2015 were analyzed. WHO Grade 2 and 3 meningiomas were not included in our study. Minimum radiological follow-up was 24 months. The median follow-up was 54 months. The tumor volume, location, treatment dose, morbidity, progression free survival and tumor control rate were analyzed. RESULTS: The median tumor volume was 5.2 cm3 (0.04-39.7), median age was 50 (20-80), median dose was 14 Gy and tumor control rate was 94.5% (stationary in 85.0%, volume reduction in 9.5%). Increase in tumor volume was seen in 16 patients (5.5%) and re-operation was performed in 5 of them (1.6%). Stereotactic radiosurgery was performed again for 8 patients (2.7%).The location of the tumors was as follows: 39.3% parasellar region, 20% cerebellopontine angle, 13.6% petroclival and 27.1% was parasagittal, falcine or convexity. Major morbidities were detected in 6 (2%) patients. Minor morbidities were detected in 18 (6.1%) patients. CONCLUSION: Stereotactic radiosurgery is an effective and safe treatment modality for residual Grade I meningiomas.

Iron homeostasis is altered in response to hypoxia and hypothermic preconditioning in brain glial cells

Background/aim: Altered iron metabolism is one of the pathophysiological mechanisms occurring during hypoxic injuries in the central nervous system. Proper homeostasis of cellular iron is regulated by iron import, storage, and export proteins that prevent excess iron overload or iron starvation in cells. Therapeutic hypothermia is an approved treatment for hypoxic ischemia in newborns, but the underlying molecular mechanism is still unknown. We studied the effects of hypoxia, preceded with preconditioning, on the iron homeostasis of glial cells, known as a major actor in the inflammatory process during perinatal brain injury. Materials and methods: Primary microglia and astrocytes in culture were exposed to 12 h of hypoxia with or without mild hypothermic preconditioning. The mRNA expression was assessed using qPCR. Iron accumulation was visualized via modified Perl's histochemistry. Cytokine levels in cell cultures were measured using ELISA. Results: Hypothermic preconditioning enhanced microglial viability, which previously was decreased in both cell types due to hypoxia. Hypoxia increased iron accumulation in the mixed glial cells and in ferritin expression in both microglia and astrocytes. Hypotermic preconditioning decreased the elevated ferritin-light chain expression significantly in microglia. Iron importer proteins, DMT1 and TfR1, both increased their mRNA expression after hypoxia, and hypothermic preconditioning continued to support the elevation of DMT1 in both glial cell types. Ferroportin expression increased as a survival factor of the glial cell following hypoxia. Hypothermic preconditioning supported this increase in both cell types and was especially significant in astrocytes. IL-10 levels were prominently increased in cell culture after hypothermic preconditioning. Conclusion: The data suggest that hypothermic preconditioning affects cellular iron homeostasis by regulating the storage and transfer proteins of iron. Regulation of the cellular iron traffic may prevent glial cells from experiencing the detrimental effects of hypoxia-related inflammation.

First report of tethered cord syndrome in a patient with Sotos syndrome.

BACKGROUND: Sotos syndrome is caused by a gene deletion with an autosomal dominant pattern of inheritance. The Sotos syndrome was first described by Juan Sotos. Cole and Hughes identified the clinical characteristics of this syndrome. This syndrome is characterized by macrocephaly, frontal bossing, ocular hypertelorism, overgrowth, subdural hygroma, ventricular dilatation, agenesis of the corpus callosum. This syndrome is associated with mutations in NSD 1 (nuclear receptor SET domain-containing protein 1) gene, protein insufficiency, and a 5q35 microdeletion. Sotos syndrome is reported to occur in approximately 1/10,000-15,000 births. CASE PRESENTATION: We present a patient with Sotos syndrome who is harboring a sacral lipoma and tethered cord syndrome and she had growth retardation, frontal bossing and hypertelorism. After a standard approach for tethered cord syndrome, the patient was discharged 3 days after without any additional neurodeficits. CONCLUSION: In the literature, sacral lipoma and tethered cord syndrome with Sotos syndrome have not been published yet.

Cerebral cavernous malformation presenting in childhood: a single-centered surgical experience of 29 cases.

OBJECTIVES: Cerebral cavernous malformations (CMs) are benign vascular hamartomas of central nervous system. Although they are mostly asymptomatic, they may occasionally result in life-threatening complications leading to surgical treatment. The main goal is to evaluate the surgical outcomes of operated pediatric cerebral CMs in our clinic and compare our results with the literature. PATIENTS AND METHODS: The data of 29 pediatric patients who were operated for cerebral CMs in our clinic between 2007 and 2016 were collected. RESULTS: Of 29 patients, 13 were girls and 16 were boys, and the mean age at operation was 11.4 years (range from 2 to 17 years). Main symptoms at presentation were seizures (15 patients, 51.7 %), headache (12 patients, 41.3 %), and focal neurological deficits (4 patients, 13.7 %). The frequency of hemorrhage in CMs was significantly higher in younger patients (p = 0.019). Total excision was achieved in all patients. The mean follow-up period was 27.3 months (range from 12 to 97 months). New neurological deficit following surgery occurred in 1 patient (3.4 %) who completely recovered after 3 months. After surgery, 1 patient (3.4 %) has become free of preoperative deficit; while the rest (27 patients) remained in preoperative neurological status. Of 15 patients presented with seizures preoperatively, 10 patients (66.6 %) were seizure free (Engel Class 1), 4 (26.6 %) were "almost seizure free" (Engel Class 2) and one (6.6 %) experienced "worthwhile improvement" (Engel Class 3) at the last follow up visit. There was no mortality in our series. CONCLUSION: Although management of cerebral CMs in childhood is controversial, total resection ensures good clinical outcome and seizure control. In addition, age can be a predisposing factor for hemorrhage.

A Novel Deep Learning Algorithm for the Automatic Detection of High-Grade Gliomas on T2-Weighted Magnetic Resonance Images: A Preliminary Machine Learning Study.

AIM: To propose a convolutional neural network (CNN) for the automatic detection of high-grade gliomas (HGGs) on T2-weighted magnetic resonance imaging (MRI) scans. MATERIAL AND METHODS: A total of 3580 images obtained from 179 individuals were used for training and validation. After random rotation and vertical flip, training data was augmented by factor of 10 in each iteration. In order to increase data processing time, every single image converted into a Jpeg image which has a resolution of 320x320. Accuracy, precision and recall rates were calculated after training of the algorithm. RESULTS: Following training, CNN achieved acceptable performance ratios of 0.854 to 0.944 for accuracy, 0.812 to 0.980 for precision and 0.738 to 0.907 for recall. Also, CNN was able to detect HGG cases even though there is no apparent mass lesion in the given image. CONCLUSION: Our preliminary findings demonstrate; currently proposed CNN model achieves acceptable performance results for the automatic detection of HGGs on T2-weighted images.

Fluorescein-guided excision of a pediatric intraparenchymal schwannoma presenting with seizure and neurogenic pulmonary edema.

Intraparenchymal schwannomas of the brain are very rare, accounting for < 1% of intracranial schwannomas. We present a case of an 11-year-old boy with a left frontotemporal lobe schwannoma presented with seizure and neurogenic pulmonary edema. To our knowledge, this is the first case of intracerebral schwannoma with neurogenic pulmonary edema published to date and is the first case of an intracerebral schwannoma operated with fluorescein guidance.

Hyperbaric oxygen therapy in the treatment of malign edema complication after arteriovenous malformation radiosurgery.

A 16-year-old female patient with headache was admitted to our hospital. Radiological examination showed a Spetzler-Martin Grade III arteriovenous malformation (AVM) located at the left frontal lobe. Volume-staged stereotactic radiosurgery (SRS) treatment performed in two fractions at three-month intervals and post-procedural period were uneventful. Eight months later the patient was admitted to our hospital with headache, vomiting, right-sided facial palsy and right upper extremity paresthesia. Radiological examination demonstrated severe vasogenic edema in the left centrum semiovale and temporal region. Due to severe and steroid-resistant malign edema, hyperbaric oxygen (HBO2) therapy was performed as an alternative treatment option. Neurological symptoms resolved completely after HBO2. Radiological examination demonstrated serious improvement of brain edema and mass effect.

Management of Neonatal Facial Paralysis due to Cerebellopontine Angle Arachnoid Cyst: A Case Report.

Arachnoid cysts are benign, cerebrospinal fluid-filled collections that can be located in the brain or spinal cord. Arachnoid cysts form approximately 1% of all intracranial lesions. They are accepted as arachnoid developmental anomaly and arise from membrane splitting or duplication. Generally, lesion growth causes symptoms because of mass effect or obstruction. Arachnoid cyst growing mechanisms are a largely controversial issue. We report the case of a neonatal female patient who presented with congenital facial paralysis. Magnetic resonance imaging showed a right cerebellopontine angle arachnoid cyst causing severe mass effect on the brain stem. Cyst fenestration and cystocisternal shunt was performed through retrosigmoid suboccipital craniotomy.

Clinical Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations in Pediatric Patients: Systematic Review and Meta-Analysis.

BACKGROUND: Arteriovenous malformations (AVMs) in pediatric patients exhibit remarkable differences in terms of management and outcomes. Owing to a paucity of relevant data pertaining to AVMs in pediatric patients, special interest and investigation are required for an improved understanding of the available evidence by clinicians. OBJECTIVE: To determine the clinical outcomes of single-session stereotactic radiosurgery (SRS) for AVMs in pediatric patients. METHODS: A systematic literature review was performed to identify studies that reported the outcomes of SRS for AVMs in pediatric patients. Data pertaining to variables such as obliteration rate, post-SRS new hemorrhage rate, post-SRS new neurological deficit rate, and mortality rate were extracted and analyzed using meta-analysis techniques. RESULTS: Based on pooled data from 20 studies with 1212 patients, single-session SRS resulted in complete obliteration in 65.9% (95% confidence interval [CI], 60.5%-71.1%; I2 = 66.5%) patients. Overall complication rate (including new hemorrhage, new neurodeficit, and mortality) was 8.0% (95% CI, 5.1%-11.5%; I2 = 66.4%). Post-SRS new neurological deficit rate was 3.1% (95% CI, 1.3%-5.4%; I2 = 59.7%), and post-SRS hemorrhage rate was 4.2% (95% CI, 2.5%-6.3%; I2 = 42.7%). There was no significant difference between studies disaggregated by treatment method (Gamma Knife [Elekta AB] vs other), treatment year (before year 2000 vs after year 2000), median AVM volume reported (≥3 vs <3 cm3), median dose reported (≥20 vs <20 Gy), or follow-up period (≥36 vs <36 mo). CONCLUSION: Single-SRS is a safe treatment alternative that achieves high obliteration rates and acceptable complication rates for AVMs in pediatric patients.

Investigation of the Effect of Alemtuzumab in an Experimental Spinal Cord Trauma Model in Rats.

OBJECTIVE: Spinal cord injuries generate the most negative response to medical treatment among all general body injuries. This important morbidity is thought to be caused by a complex secondary damage mechanism. In the present study, we examined the neuroprotective effects of alemtuzumab in a spinal cord trauma model. METHODS: We divided 24 Long-Evans male rats into 4 groups (n = 6 per group). Laminectomy was performed at T5-T8 in all groups. Trauma was applied using the Yasargil temporary aneurysm clip for 60 seconds at these spinal cord levels in all groups, except for group 1. Next, 1 mg/kg of alemtuzumab was administered to each rat in groups 3 and 4. A functional evaluation was performed on days 1, 3, and 5 in groups 1, 2, and 4, and the rats were then sacrificed. The rats in group 3 were sacrificed on the third postoperative day to observe the early effects of alemtuzumab. The biochemical examination findings of malondialdehyde and glutathione in plasma and tissue samples and histopathological findings of the spinal cord were evaluated and compared by statistical analysis. RESULTS: The inflammatory findings in the trauma group were not seen in either group treated with alemtuzumab. The clinical motor examination and inclined plane test results were also significantly better in these groups. CONCLUSION: Our results have shown that alemtuzumab might prevent spinal cord injury after trauma and is a histopathologically and biochemically strong anti-inflammatory, antioxidant, and neuroprotective agent.

Prophylactic Bevacizumab May Mitigate Radiation Injury: An Experimental Study.

BACKGROUND: Stereotactic radiosurgery (SRS) is widely used to treat brain pathologies alone or in concert with other treatment modalities. However, there are some side effects, such as radiation injury characterized by edema and necrosis in peripheral tissues, that must be managed. A new treatment agent against this side effect is bevacizumab, which targets increased vascular endothelial growth factor (VEGF) as a prominent etiologic factor in radiation injury. In this study, we created a rat experimental model to describe the effects of both radiation and the anti-VEGF monoclonal antibody bevacizumab following high-dose SRS, and to compare the effects of prophylactic and delayed-onset bevacizumab treatment. METHODS: Fifty-four adult male Wistar rats were allocated into 9 groups based on differing Gamma-knife surgery (GKS) doses and bevacizumab treatment protocols. After 12 weeks, the rats' right frontal lobes were examined with hematoxylin and eosin staining and immunohistochemistry analysis via VEGF and CD31 antibodies. RESULTS: Radiation necrosis occurred to varying degrees in all irradiated animals between 3 and 10 weeks post-SRS. Higher GKS dose (50% isodose of 100 Gy) led earlier necrosis and prophylaxis of bevacizumab at this dose was associated with delayed onset of necrosis. Moreover, prophylactic bevacizumab mitigated the effects of radiation necrosis following GKS at both doses, whereas this effect was not prominent with late initiation of bevacizumab (treatment protocol). CONCLUSIONS: Our findings show that the onset and degree of radiation injury are affected by the GKS dose and protocol of bevacizumab administration.

Clinical and surgical outcomes of upper lumbar disc herniations: a retrospective study

Background/aim: Upper lumbar disc herniation (LDH), generally involving L1?L2 and L2?L3 level herniation, is less common than lower LDH and, in this retrospective study, the clinical and radiological findings of patients who suffered from upper LDH and were operated on due to this pathology were reviewed. Materials and methods: Data regarding neurological and radiological findings of patients operated on between January 2005 and December 2013 were retrospectively collected. During this period, 3494 patients had surgery for LDH, and 129 of these patients had disc herniation at the upper levels. Seventy-eight patients with proper follow-up and data were included in the study. Results: There were 39 males and 39 females enrolled in the study. Twenty-one patients (0.6%) were operated on due to L1?L2 disc herniation and 45 (1.2%) had L2?L3 disc herniation. Twelve (0.3%) patients had disc pathologies at both levels. The mean age of the population was 59.9 years old, and this was significantly higher than lower LDH averages previously described in the literature (42 years old). Cauda equina signs and urinary disturbances were frequently seen, in addition to symptoms related to back and leg pain, neurologic claudication, and weakness in lower extremities. Conclusion: Upper LDHs requiring surgical therapy are extremely rare, more so than other LDHs. They are more frequent among older patients and are often present along with signs of cauda equina and urinary dysfunction.