Unilateral gamma knife thalamotomy for tremor safety and efficacy in multimodal assessment: a prospective case-control study with two-year follow-up.

INTRODUCTION: Unilateral gamma knife thalamotomy (GKT) is a treatment option for pharmacoresistant tremor of various aetiologies. There have been to date no randomised controlled trials performed to assess its safety and efficacy. Our aim was to summarise a two-year multimodal observation of patients with tremor caused by Parkinson's Disease (PD) or essential tremor (ET). MATERIAL AND METHODS: 23 patients with PD (n = 12) or ET (n = 11) were included. They underwent assessments before, V0 (n = 23), and 12 months, V12 (n = 23), and 24 months, V24 (n = 15), after unilateral GKT. Patients were assessed with psychological tests and acoustic voice analysis. Tremor assessment was performed with a digitising table using the Fahn-Tolosa-Marin rating scale (FTMRS). The Unified Parkinson's Disease rating scale part III (UPDRS-III) was also used in the PD group. Gait and balance was assessed using clinical tests, stabilometric platform, and treadmill. RESULTS: No side effects were observed in a two-year follow-up. There was no notable deterioration observed in the patients' psychological evaluation, speech, or assessment of gait and balance. The scores were significantly lower (p = 0.01) in parts A and B of FTMRS one year after GKT. In post hoc analysis, the scores did not differ significantly between V0 and V24. In FTMRS part C (activities of daily living), no significant change was observed. There was no significant difference in total UPDRS part III score or in score of UPDRS part III domains 3 and 4 ('tremor at rest' and 'action and postural tremor of hands') between measurements. CONCLUSIONS: UGKT may be a safe treatment modality if performed in an experienced centre. Tremor reduction may diminish over time, and UGKT did not lead to cognitive, gait or speech deterioration in a long-term observation.

Targeted sequencing of cancer-related genes reveals a recurrent TOP2A variant which affects DNA binding and coincides with global transcriptional changes in glioblastoma.

High-grade gliomas are aggressive, deadly primary brain tumors. Median survival of patients with glioblastoma (GBM, WHO grade 4) is 14 months and <10% of patients survive 2 years. Despite improved surgical strategies and forceful radiotherapy and chemotherapy, the prognosis of GBM patients is poor and did not improve over decades. We performed targeted next-generation sequencing with a custom panel of 664 cancer- and epigenetics-related genes, and searched for somatic and germline variants in 180 gliomas of different WHO grades. Herein, we focus on 135 GBM IDH-wild type samples. In parallel, mRNA sequencing was accomplished to detect transcriptomic abnormalities. We present the genomic alterations in high-grade gliomas and the associated transcriptomic patterns. Computational analyses and biochemical assays showed the influence of TOP2A variants on enzyme activities. In 4/135 IDH-wild type GBMs we found a novel, recurrent mutation in the TOP2A gene encoding topoisomerase 2A (allele frequency [AF] = 0.03, 4/135 samples). Biochemical assays with recombinant, wild type (WT) and variant proteins demonstrated stronger DNA binding and relaxation activity of the variant protein. GBM patients carrying the altered TOP2A had shorter overall survival (median OS 150 vs 500 days, P = .0018). In the GBMs with the TOP2A variant we found transcriptomic alterations consistent with splicing dysregulation. luA novel, recurrent TOP2A mutation, which was found exclusively in four GBMs, results in the TOP2A E948Q variant with altered DNA binding and relaxation activities. The deleterious TOP2A mutation resulting in transcription deregulation in GBMs may contribute to disease pathology.

Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas.

OBJECTIVE: According to the literature, gamma knife surgery (GKS) is a promising method for intracanalicular vestibular schwannoma (IVS) management, providing excellent tumor growth control rates (91%-100%) and good hearing preservation rates (41%-76%), but this evidence originates primarily from a small series of patients. The aim of this study was to present the outcomes of GKS in the largest group of patients with IVS studied to date, with particular emphasis on the long-term outcomes of treatment. METHODS: The study included 136 consecutive patients with unilateral IVS, who underwent GKS in 2011-2015. Mean age of the patients was 54 ± 12.6 years. All patients were operated on with a 192-source cobalt-60 gamma knife unit. All patients had complete follow-up documentation and the mean duration of the follow-up was 52 ± 13.8 months (6-83 months). Neurological status (facial and trigeminal nerve), hearing and instability/dizziness presence were determined prior to GKS, immediately after the procedure, and during the follow-up visits. RESULTS: Tumor growth control was obtained in 124/136 (~91.2%) patients. Hearing improvement was observed in 32/136 (23.5%) patients, and there was a distinct cluster of 9 patients (6.6%) regaining serviceable hearing after GKS, whereas in 36 patients (26.5%) was stable. Four patients developed facial nerve dysfunction, including 3 periodic hemifacial spasm and 1 partial paresis, which resolved spontaneously within 12 months of GKS. None of the operated patients showed new, debilitating neurological deficits, including trigeminal sensory disturbances or hydrocephalus. CONCLUSIONS: GKS is a highly effective treatment for IVS, associated with low morbidity and good tumor growth control.

Advancing gene therapies, methods, and technologies for Parkinson's Disease and other neurological disorders.

INTRODUCTION: Vector-based intracerebral gene therapies are being used to treat specific neurodegenerative conditions such as Parkinson's Disease (PD). This review presents a basis for central nervous system (CNS) gene therapy treatments of neurodegenerative diseases such as PD, as well as the need for novel skill sets and health delivery strategies within the clinical neurosciences (neurology and neurosurgery) to meet future demand for such therapies. STATE OF THE ART: Preclinical vector-based gene therapy approaches have been translated into clinical trials for PD and other neurodegenerative conditions. Unfortunately, such trials, and parallel efforts using other therapeutics, have yet to provide a breakthrough. Image-guided convection enhanced delivery (CED) optimises the parenchymal distribution of gene therapies applied within the CNS, and may ultimately provide such a breakthrough. CLINICAL IMPLICATIONS: Currently, image-guided CED and gene therapy are not part of training programmes for most neurosurgeons and neurologists. As a result, few medical centres and hospitals have sufficiently experienced teams to participate in gene transfer clinical trials for PD or other neurological conditions. If CNS gene therapies prove to be efficacious for PD and/or other conditions, the demand for such treatments will overwhelm the available number of experienced clinical neuroscience teams and treatment centres. FUTURE DIRECTIONS: Expanded indications and demand for CNS gene therapies will require a worldwide educational effort to supplement the training of clinical neuroscience practitioners. Initially, a limited number of Centres of Excellence will need to establish relevant educational training requirements and best practice for such therapeutic approaches. Advanced technologies, including robotics and artificial intelligence, are especially germane in this regard, and will expand the treatment team's capabilities while assisting in the safe and timely care of those afflicted.

Dual Anchor Internal Pulse Generator Technique May Lower Risk of Twiddler's Syndrome: A Case Series and Literature Review.

BACKGROUND: Twiddler's syndrome (TS) is described as a spontaneous rotation or intentional external manipulation of implanted internal pulse generator (IPG) for neurological or cardiac disorders. There have been identified some predisposing factors of the development of TS such as: loose subcutaneous tissue, older age of individuals undergoing deep brain stimulation (DBS) procedures, creation of too large pockets for IPG. Apart from these factors, the construction of IPG itself may predispose to the development of TS. OBJECTIVE: To report the clinical course of three patients with TS. Moreover, the purpose of this study is to present the change in fixation technique of IPG that can prevent the occurrence of TS in patients after DBS procedure. METHODS: A prospectively collected database of all hardware related complications for patients operated on for various movement disorders was analyzed. In a total number of 347 DBS systems implanted since 1999 we have identified three patients diagnosed with TS. All three patients with TS in our series were implanted with the IPG harboring a single anchoring hole. This complication has never occurred in patients with the IPG harboring two anchoring holes in our center. RESULTS: All three patients underwent revision surgery. During reoperations all connection cables were replaced and IPG sutured with one additional silk stich through the plastic housing to immobilize it properly in subcutaneous pocket. There were no recurrences of TS in our patients. CONCLUSIONS: Our case series suggests that a predisposing factor of TS may also be the construction of IPG itself (a single anchoring hole intended for fixation), which naturally represents less fixation of the IPG to the fascia or muscle in the subcutaneous pocket. In this preliminary report we present suggestions to lower the risk of TS, including using dual anchor capable IPGs, reducing pocket volume and using nonabsorbable suture.

Deep brain stimulation failure due to external cardioversion in a patient with Parkinson's disease.

We report a case of deep brain stimulation (DBS) hardware failure due to emergently performed subcutaneous coronary angioplasties complicated by cardioversion for rapid worsening of angina pectoris and some trouble shooting problems emerged after invasive cardiovascular procedures. The patient with prior implantation of permanent pacemaker due to vasovagal syndrome underwent successful left-sided unilateral electrode implantation into the subthalamic nucleus. During 21 months follow-up period the patient experienced 2 times episodes of aggravation of unstable angina pectoris 15 and 21 months respectively, which necessities emergent coronary angioplasties. After the first emergently performed coronary angioplasty with cardioversion the interrogation of DBS system revealed the depletion of an internal pulse generator (IPG). The secondly performed coronary angioplasty complicated by ventricular tachyarrhythmia with DBS system switched on during emergent cardioversion resulted in partial dysfunction of DBS electrode. Patients harboring cardiovascular implantable electronic devices (CIEDs) and DBS systems require special attention and good cooperation of neurosurgeons, interventional cardiologist, and neurologist. Some emergently performed invasive cardiovascular procedures which necessities cardioversion may cause DBS hardware failure with subsequent worsening of movement disorder symptoms.

Deep brain stimulation for intractable tardive dystonia: Literature overview.

BACKGROUND: Tardive dystonia (TD) represents a side effect of prolonged intake of dopamine receptor blocking compounds. TD can be a disabling movement disorder persisting despite available medical treatment. Deep brain stimulation (DBS) has been reported successful in this condition although the number of treated patients with TD is still limited to small clinical studies or case reports. The aim of this study was to present the systematical overview of the existing literature regarding DBS for intractable TD. METHODS AND RESULTS: A literature search was carried out in PudMed. Clinical case series or case reports describing the patients with TD after DBS treatment were included in the present overview. Literature search revealed 19 articles reporting 59 individuals operated for TD. GPi was the target in 55 patients, while subthalamic nucleus (STN) was the target in the remaining 4. In most studies the motor part of Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) was improved by more than 80% when compared to preoperative BFMDRS scores. CONCLUSIONS: The performed literature analysis indicates that bilateral GPi DBS is an effective treatment for disabling TD. The response of TD to bilateral GPi DBS may be very rapid and occurs within days/weeks after the procedure. The efficacy of bilateral GPi DBS in TD patients is comparable to results achieved in patients with primary generalized dystonia.

Deep brain stimulation of the internal globus pallidus for disabling haloperidol-induced tardive dystonia. Report of two cases.

AIM: Tardive dystonia (TD) represents a side effect of prolonged intake of neuroleptic drugs. TD can be a disabling movement disorder persisting despite available medical treatment. Deep brain stimulation (DBS) has been reported successful in this condition although the number of treated patients with TD is still limited to small clinical studies or case reports. In this study, we present 2 additional cases of patients after bilateral globus pallidus internus (GPi) stimulation. METHODS: The formal assessment included the Burke-Fahn-Dystonia Rating Scale (BFMDRS). The preoperative and postoperative functional and motor parts of this scale were compared in each patient. The postoperative assessments were done every 6 months. RESULTS: Both patients underwent successful bilateral GPi DBS for TD. The postoperative motor score improved by 78% at 24 months in patient 1 and 69% at 12 months in patient 2. There were no surgical or hardware-related complications over follow-up period. CONCLUSION: Our experience indicates that bilateral GPi DBS can be an effective treatment for disabling TD. The response of TD to bilateral GPi DBS is very rapid and occurs within days after the procedure.

Bilateral failure of cerebral autoregulation is related to unfavorable outcome after subarachnoid hemorrhage.

BACKROUND: The extent of hemodynamic disturbances following subarachnoid hemorrhage (SAH) varies. We aim to determine the prognostic implications of unilateral and bilateral autoregulatory failure on delayed cerebral ischemia (DCI) and outcome. METHODS: Ninety-eight patients with aneurysmal SAH were recruited. Autoregulation was assessed using systolic flow index-Sxa. Interhemispheric difference in autoregulation was calculated to assess the spatial distribution and symmetry of autoregulatory changes. Assessment of interhemispheric difference in autoregulation in combination with overall autoregulation was used to measure the extent of autoregulatory impairment. Patients were dichotomized by the presence of DCI and 3-month mRS. RESULTS: Higher flow velocity and worse autoregulation (p < 0.0000001, 95 % CI 10.7-21.3 and p = 0.00001, 95 % CI 0.03-0.07 for difference in FV and Sxa, respectively) were found ipsilateral to the ischemic hemisphere or location of aneurysm (if no ischemia detected). DCI group had a higher interhemispheric difference of autoregulation than non-DCI group (p = 0.035, 95 % CI 0.003-0.08). 16/18 patients with unfavorable outcome vs. 17/72 with favorable outcome had overall poor autoregulation with low interhemispheric differences (p = 0.0013, χ (2)). Unilateral autoregulatory failure was seen on a median day 3, bilateral on day 4, and vasospasm was detected on day 6. CONCLUSIONS: Unilateral autoregulation failure was seen in patients who developed DCI (worse ipsilateral to the ischemic hemisphere). Bilateral autoregulation failure was seen more frequently in patients with unfavorable outcome. Analysis of the temporal profile showed unilateral dysautoregulation as the primary event predisposing to DCI, which in selected cases led to bilateral failure and unfavorable outcomes.

Twiddler syndrome in a patient with tremor dominant Parkinson's disease. A case report and literature review.

Twiddler syndrome is described as a spontaneous rotation or intentional external manipulation of implanted cardiac or occasionally deep brain stimulation (DBS) devices. We report this hardware related complication in a patient with tremor dominant Parkinson's disease (PD), who underwent unilateral subthalamic nucleus (STN) DBS and subsequently developed twiddler syndrome. The clinical course of twiddler syndrome in this patient is described. Some surgical nuances which may prevent its occurrence are suggested. Our case report indicates that twiddler syndrome occurs in DBS patients. Impedance check of DBS hardware, plain chest X-ray, or palpation for a knobbly extension lead through the skin above the IPG allows the correct diagnosis and subsequently a prompt surgical revision. Our subsequent literature review revealed only 10 patients with twiddler syndrome in DBS patient population worldwide. This number may suggest that this syndrome may be unrecognized or underreported, given the number of patients with movement disorders implanted with DBS hardware worldwide.

The neurosurgical treatment of patients in dystonic state - overview of the literature.

Treatment options for patients in dystonic state include sedation, artificial ventilation, intrathecal baclofen infusions and stereotactic procedures. The main aim of this overview is the presentation and assessment of stereotactic procedures applied for treating patients in severe dystonic state. We performed literature overview starting from 1998 to 2012 with case reports regarding all patients treated by stereotactic procedures for dystonic state. We were able to find 15 articles describing 22 patients. Ablative procedures were described in 5 articles (3 thalamotomies, 3 pallidotomies) and were done in 6 patients. In the remaining 10 articles, globus pallidus internus stimulation was utilized in another 16 patients. We can conclude that bilateral pallidal deep brain stimulation seems to be the best stereotactic target for patients in dystonic state.

Pallidal deep brain stimulation in the treatment of Meige syndrome.

INTRODUCTION: Meige syndrome (MS) is characterized by blepharospasm, facial, oromandibular, and often cervical dystonia. The medical treatment of this condition is challenging and unsuccessful over long time. Recent case reports and small clinical series showed that bilateral deep brain stimulation (DBS) of globus pallidus pars interna (GPi) improves dystonic features of MS validated by Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). MATERIALS AND METHODS: We report on our experience in using bilateral GPi DBS in 3 cases of MS. We present short-term (3 months) follow-up as well long-term (from 8 months to 36 months) results. Preoperative and postoperative BFMDRS assessments were performed on each patient. The postoperative BFMDRS scores was done when both stimulators were switched on and compared to baseline scores. RESULTS: Bilateral GPi DBS reduced the BFMDRS total movement score by 66% at short-term follow-up, and by 75% at long-term follow-up when compared to baseline scores. The BFMDRS total disability score was reduced by 34% at short-term follow-up, and by 47% at long-term follow-up when compared to baseline scores. CONCLUSIONS: Our results showed that bilateral GPi DBS in MS is effective and safe, if conservative treatment options failed. The benefit is not only observed at short-term 3 months period but is maintained at long-term follow-up ranging from 8 to 36 months.

A meta-analysis of treatment of vestibular schwannoma using Gamma Knife radiosurgery.

AIM OF THE STUDY: One of the alternative methods of surgical treatment of vestibular schwannoma is Gamma Knife radiosurgery. The purpose of this metaanalysis was to analyze the progress in treatment of vestibular schwannoma using Gamma Knife radiosurgery based on data in the literature of the last five years. MATERIAL AND METHODS: In the collected English-language literature from the years 2007-2011, contained in 20 scientific journals, clinical articles of many years study at a single center were extracted and also review papers and case reports. The main criteria of our own analysis were: patient age, tumor size, the dose in Gy, the time from surgery to follow-up, the degree of tumor growth inhibition, and hearing preservation. For statistical calculations comparing series of studies we used nonparametric analysis of variance and tests at the significance level of p > 0.05. RESULTS: The 46 evaluated clinical articles show the results of studies over many years. A comparison of the results of the analysis made on the basis of papers published in the period 1998-2007 with the results of the current series from the period 2007-2011 allowed us to establish that the average dose applied to the periphery of the tumor was lower (12.4 Gy) than in the earlier series of 1998-2007 (14.2 Gy), and hearing preservation was higher (66.45% vs. 51.0%). CONCLUSIONS: Clinical findings widely documented in the literature over the past five years indicate the progress in treatment of vestibular schwannoma using Gamma Knife radiosurgery.

Polish cross-cultural adaptation of the Glasgow Benefit Inventory as an instrument for the post-intervention measurement of change after Gamma Knife treatment.

<b>Introduction:</b> The Glasgow Benefit Inventory (GBI) is one of questionnaires for the measurement of treatment success, which is widely used in patients after vestibular schwannoma treatment.<b>Aim:</b> This study aimed to adapt the GBI originally written in English to Polish conditions and to evaluate its psychometric properties.<b>Material and methods:</b> The Polish version of the GBI used in this study was prepared by a bilingual translator, and its accuracy was ensured by back-translation. To identify the structure of the Polish version of the GBI, exploratory factor analysis was performed. The reliability was determined using Cronbach's α. To verify the validity, correlation analysis was conducted between the domains of GBI and other questionnaires.<b>Results:</b> The results of confirmatory factor analysis indicated that the original 3-factor model is not a good fit for the data. The exploratory factor analysis was performed and identified 4 factors. The total variance of the 4-factor solution was 66.25%. The Cronbach's α calculated for the total GBI reached 0.91. Our analysis confirmed significant weak or moderate correlations between tools for the measurement of general QoL (AQoL-8D: r = 0.411; p = 0.000) and health-related QoL (PANQOL: r = 0.367; p = 0.000; a tool dedicated for patients with VS), well-being (WHO-5: r = 0.432; p = 0.000), hearing and tinnitus (STS: r = -0.217; p = 0.016).<b>Conclusions:</b> This study reports the first adaptation of the GBI for patients with VS to Polish conditions. The results demonstrated that the Polish version of the GBI is a reliable and valid questionnaire that can be used to measure treatment success.

Polish cross-cultural adaptation of a disease-specific quality-of-life instrument: The Penn Acoustic Neuroma Quality-of-Life Scale.

BACKGROUND: The medical community has shown a growing interest in developing methods for measuring and comparing objective patient outcomes coupled with subjective patient assessments. Questionnaires enable healthcare professionals to obtain the patient's perspective about their experienced vestibular schwannomas (VS) symptoms quickly. To date, in Poland, a cross-cultural adapted version of a disease-specific questionnaire for the measurement of quality of life (QoL) in patients with VS has not been produced. OBJECTIVES: This study aimed to adapt the questionnaire evaluating disease-specific QoL in patients with VS (Penn Acoustic Neuroma Quality-of-Life Scale; PANQOL) to Polish and evaluate its psychometric properties. MATERIAL AND METHODS: One-hundred twenty-four patients aged between 24 and 85 years (mean (M) = 60.17 ±standard deviation (SD) = 13.27) diagnosed with VS and treated with Gamma Knife were included in the study. We used a questionnaire translated from English into Polish by a bilingual professional, verified through a back-translation. The final version consisted of 26 items. The internal consistency of the Polish version of the PANQOL scale domains was measured using the Cronbach's alpha (α). To verify the validity of PANQOL subscales, a correlation analysis was conducted between the domains of PANQOL and other questionnaires, including the Assessment of Quality of Life (AQoL-8D), the Glasgow Benefit Inventory (GBI), the 5 Well-Being Index (WHO-5), the Skarzynski Tinnitus Scale (STS) for the presence of dizziness, and the Gardner-Robertson classes. RESULTS: The majority of PANQOL domains showed excellent or good internal consistency (for a PANQOL total of 0.934; for subscales in the range of 0.916-0.424). Our analysis showed strong correlations between the total PANQOL score and AQoL-8D utility score, as well as between the subscales. We observed weak to moderately significant relationships between GBI and PANQOL domains (r = 0.18-0.43), the WHO-5 (r = 0.18-0.56) and the STS scale (r = -0.40- -0.19). CONCLUSIONS: The results demonstrated that the POL-PANQOL is a reliable and valid questionnaire for measuring QoL.

Planned Subtotal Resection following Stereotactic Radiosurgery of Koos 3 and 4 Vestibular Schwannomas.

Background/Objectives: Surgical resection of medium to large vestibular schwannomas (VSs, Koos grade 3 and 4) is a widely used approach, although stereotactic radiosurgery (SRS) is increasingly proposed as initial treatment. The quality of life-centered approach is challenged in cases where tumor growth control cannot be achieved with SRS, thus necessitating salvage surgery. We present a series of eight consecutive patients who required surgery due to continued tumor growth after SRS. Methods: Of the 146 patients with VS grades 3 and 4 initially treated with SRS, only eight patients (mean age, 54 ± 7.2 years; range, 42-63 years) required subsequent surgery. Their mean tumor volume was 9.9 ± 3.2 cm3. The mean time from SRS to first tumor progression and planned subtotal resection was 23 ± 5.9 months and 45 ± 17.5 months, respectively. SRS was not performed after the surgery in favor of a "wait and rescan" approach. Tumor residue was monitored on follow-up magnetic resonance imaging. In all patients, tumor growth control after planned subtotal resection was maintained at 63 ± 19.8 months. Results: None of the 146 patients had serious complications after SRS. In the eight patients who required surgery, tumor growth between 22% and 212% (mean, 4 cm3) was reported within 26 to 84 months after SRS. Before salvage surgery, they scored 1 point on the House-Brackmann scale. Subtotal excision was performed, and VIIth nerve function was preserved in all patients. At 63 ± 19.8 months, 3 patients had a House-Brackmann score of 1, four patients had a score of 2, and one patient had a score of 3. Conclusions: Surgical excision of medium to large VS after SRS can be relatively safe, provided that a quality of life-centered approach of subtotal resection is used.

Subtotal resection of vestibular schwannoma with subsequent Gamma Knife irradiation - tumor growth control, facial and cochlear nerve outcome - preliminary results.

<b>Introduction:</b> The choice of treatment of vestibular schwannoma (VS) depends on several factors, including the tumor size, the patient's age and overall health, and the presence and severity of symptoms.<b>Aim:</b> The aim of the study was to assess the effectiveness of intentional subtotal resection (STR) of tumor followed by Gamma Knife surgery (GKS) in patients with larger VS (Koos 3 and 4).<b>Materials and methods:</b> The retrospective analysis was performed on 18 patients. Data of VS volumes measured in MRI, the facial nerve function assessed in the House-Brackmann scoring system (HB), and the results of audiological examination expressed on the Gardner-Robertson scale (GR) were collected preoperatively, postoperatively, and post-GKS.<b>Results:</b> Preoperatively, the main symptom was hearing loss observed in 13 out of 18 patients. The facial nerve function was assessed as HB 1 in 16, whereas HB 2 in 2 patients. The mean volume of the tumor in the initial MRI amounted to 16.81 cm³ . Postoperatively, the facial nerve was assessed as HB 1 or 2 in 16, whereas HB 3 in 2 patients. Serviceable hearing was presented by only 4 persons. The Mean diameter of the tumor after subtotal surgery amounted to 3.16 cm³ , 1.83 cm³ after GKS, and 1.58 cm³ at the last follow-up. The facial nerve function and hearing level remained the same as before GKS in all patients.<b>Conclusions:</b> STR followed by GKS can be a safe and effective method of treatment of large VS concerning the functional outcome of the facial nerve and the tumor volume growth control.

Fracture of the Lumbar Spine Associated with Ureteral Injury Mimicking Spondylodiscitis Followed by Cervical Spine Fracture in Patient with Ankylosing Hyperostosis.

The purpose of this case report is to describe the case of a patient with ankylosing spinal hyperostosis (ASH) and lumbar spine fracture complicated by ureteral injury mimicking spondylodiscitis with osteomyelitis features and retroperitoneal abscess formation followed by the cervical spine fracture. A consecutive analysis and summary of the medical history, radiological documentation, operative procedure, complications, and outcomes were performed. A 59-year-old man presented with abdominal pain three weeks after sustaining a low-energy fall. The performed CT scans demonstrated a three-column fracture at the L3/L4 level and features of ASH. Additionally, MRI scans demonstrated hyperintense fluid collection within L3/L4 intervertebral space communicating with both psoas major muscles, mimicking spondylodiscitis with osteomyelitis features and retroperitoneal abscess formation. An in situ instrumented lumbar fusion at the L2-L3-L5-S1 levels with implantation vertebral body replacement implant at the L3/L4 level was performed. Postoperative CT imaging revealed evidence of post-traumatic right ureteral injury. Following urological treatment covering nephrectomy and ureter ligation, the patient was maintained at a 2-year follow-up. After this period, the patient presented again with tetraparesis after sustaining a low-energy fall. The performed CT scans demonstrated a three-column fracture at the C5/C6 level. The combined anterior and posterior osteosynthesis at the C4-C5-C6-C7 levels was performed. This case report presents the rare clinical constellation regarding the lumbar spine fracture complicated by ureteral injury followed by a cervical spine fracture regarding the same patient. The potential injury of retroperitoneal structures, including the ureter after hyperextensive lumbar spine fracture, should be considered in ASH patients. In this case, one should be aware of the atypical clinical presentation regarding the observed spondylodiscitis- and osteomyelitis-like features.