Can we improve the prediction of complications and outcome in aneurysmal subarachnoid hemorrhage? The clinical implications of serum proteomics.

Aneurysmal subarachnoid hemorrhage is a devastating condition, often leading to a debilitating outcome. Delayed ischemic neurological deficits are considered the feared sequelae. Proteomics is a large-scale study of proteins incorporating structural and functional properties in complex biological fluids. Analysis of proteomes has led to identifying relevant complex proteins related to specific pathophysiological processes reflecting the severity and extent of diseases. Proteomics has evolved in the past few years; more biomarkers are deemed clinically relevant to diagnose, monitor, and define prognosis in patients with aneurysmal subarachnoid hemorrhage. Despite the absence of candidate biomarkers in the clinical routine, many have shown promising results. The complexity of proteins implicated in aneurysmal subarachnoid hemorrhage rendered these biomarkers' clinical use paved with various pitfalls and technical difficulties, especially when data about the perfect timing and values are lacking. We review the latest literature concerning serum proteomics and their clinical utility regarding the prediction of cerebral vasospasm and other complications of aneurysmal subarachnoid hemorrhage, as well as the clinical outcome. Future prospective studies will allow changing the disease's course, label patients according to their prognosis to provide earlier and better management and improve outcomes.

Minimally invasive costotransversectomy for the resection of large thoracic dumbbell tumors.

BACKGROUND: Due to their important size and complex localization, the management of thoracic dumbbell tumors is challenging, frequently requiring the need for an anterior approach. Our study aims to first report the feasibility and safety of a single-stage posterior minimally invasive procedure in achieving complete resection of voluminous thoracic dumbbell tumors. METHODS: We retrospectively reviewed the medical records of five consecutive patients, who underwent the minimally invasive resection of a type III thoracic dumbbell tumor in our institution between March 2007 and March 2012. There were two men and three women, with a mean age at diagnosis of 57 years (range 41-68 years). After the placement of a non-expandable tubular retractor under fluoroscopic control, a costotransversectomy was achieved. By moving the retractor in all directions, the tumor was largely exposed and resected with the cavitron ultrasonic surgical aspirator. Clinical and radiological monitoring was performed before discharge, at 6 months, 1 year and 2 years. RESULTS: No major intraoperative complication was reported. Gross total resection was achieved in four patients. The mean operative time was 219 mins (range 75-540 mins) and the mean estimated blood loss was 230 ml (range 50-500 ml). No postoperative complication was reported. The mean length of hospital stay was 3.6 days (range 2-6 days) and all patients were discharged home. Histological analysis confirmed the diagnosis of grade 1 schwannoma in four patients and revealed a hemangiopericytoma in one patient. No tumor recurrence was noted with a mean follow up period of 46 months (range 32-54 months). CONCLUSION: Thoracic dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure. The costotransversectomy can be performed through a non-expandable retractor allowing sufficient access to all parts of the tumor.

Single-Stage Posterior Approach for the En Bloc Resection and Spinal Reconstruction of T4 Pancoast Tumors Invading the Spine.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aimed to evaluate the outcomes of patients who had T4 Pancoast tumors invading the spine and underwent en bloc resection and spinal stabilization through a single-stage posterior approach. OVERVIEW OF LITERATURE: Surgical resection for Pancoast tumors affecting the spine has been successfully performed in two stages involving spinal reconstruction and tumor resection. However, reports have rarely presented the results of en bloc resection combined with spinal stabilization for T4 Pancoast tumors invading the spine through a single-stage posterior approach. METHODS: Patients who had T4N0M0 Pancoast tumors invading the spine and underwent a single-stage posterior approach were retrospectively recruited. The following data were obtained and examined: demographics, tumor histology, preoperative and postoperative therapy, complications, spinal reconstruction technique, tumor resection extent, survival time, and disease recurrence. RESULTS: Eighteen patients were included. The mean population age was 61±17 years, and the most common pathological type was adenocarcinoma (61.1%). Complete resection (R0) was obtained in 15 patients (83.3%), positive surgical margins (R1) were found in three patients (16.7%), and the 90-day mortality rate was 0%. Postoperative major complications were detected in 12 patients (66.7%), who required reoperation. The mean survival time was 67±24 months, but the median survival time was not reached. Among the patients, 10 (55.6%) are still alive at the end of the study. The 2- and 5-year actual survival rates were 59% (95% confidence interval [CI], 35.7%-82.3%) and 52.5% (95% CI, 28.4%-76.6%), respectively. CONCLUSIONS: En bloc resection and spinal stabilization through a single-stage posterior approach might be effective for T4 Pancoast tumors invading the spine.

Minimally Invasive Resection of an S3 Osteoid Osteoma Using an Intraoperative O-Arm: A Technical Note.

Osteoid osteomas are benign primary bone tumors that typically arise in posterior vertebrae of the spine. For patients with severe pain or those poorly controlled with non-steroidal anti-inflammatory drugs, surgical management is the mainstay of treatment. The recommended surgical treatment option is complete open excision, although minimally invasive CT-guided percutaneous excision and CT-guided radiofrequency ablation have been reported. Open resection can result in prolonged hospital stays, activity restrictions, and possible spinal destabilization. We sought to utilize a lateral minimally invasive approach. We highlight the importance of aggressive surgical resection and the utility of using fluoroscopy and O-arm guidance to optimize the extent of resection. We report a pediatric case of a 12-year-old male who presented with an S3 osteoid osteoma. The patient underwent a minimally invasive resection with complete resection and confirmation of the histopathologic diagnosis. Postoperative imaging showed complete resection of the tumor. The patient went home five hours after surgery with return to daily activities; his symptoms resolved completely. However, the patient had symptomatic recurrence and underwent a second more aggressive minimally invasive resection using O-arm guidance. At the current three-month follow-up, the patient is symptom- and tumor-free. The minimally invasive resection of a pediatric sacral osteoid osteoma is a valid alternative to standard open resection and is associated with a decreased blood loss, decreased length of stay in the hospital, and decreased time to full functional recovery. The pitfalls are learning curve and risk of incomplete resection that can be counterbalanced with an intraoperative O-arm to guide resection and confirm complete excision.

A Bibliometric Analysis of Neurosurgery Research Productivity in Arab Countries Between 2005 and 2019.

BACKGROUND: The Arab world is lagging behind in the world of publications and research, especially in the biomedical-related field. This is a bibliometric analysis that aims to assess the neurosurgical research productivity across different Arab countries. METHODS: PubMed was used to quantify the number of neurosurgery-related articles published by each Arab country, by several journals, investigating specific topics between 2005 and 2019. Numbers were normalized with respect to each country's average population and average gross domestic product (GDP). RESULTS: Arab countries contributed 0.53% of total neurosurgery publications. Egypt had the highest number of neurosurgery-related publications (362), ahead of Saudi Arabia (238) and Lebanon (133). In terms of publications per million persons, Lebanon was first with 21.6 publications per million persons. In terms of GDP, Egypt ranked first with 18.85 publications per million $. There was an insignificant correlation between the number of publications on one hand and the average GDP (P = 0.09) on the other hand, whereas the average population explains around 50% of the neurosurgery-related publications (R squared = 0.49, P < 0.01). Neoplasms were the dominating area of research, and the WORLD NEUROSURGERY journal had the highest number of publications. CONCLUSIONS: The results reached by this study reflect an undoubtable need for more research on neurosurgery by Arab countries. This goes back to the different obstacles facing Arab countries every day, affecting the economic, educational, and health care systems.

A case of Bertolotti's syndrome as a cause of sciatica.

BACKGROUND: Bertolotti's syndrome (i.e., varying extent of fusion between the last lumbar vertebra and the first sacral segment) or lumbosacral transitional vertebrae is a rare cause of back pain. Notably, this syndrome is one of the differential diagnoses for patients with refractory back pain/sciatica. CASE DESCRIPTION: A 71-year-old male presented with low back pain of 3 years duration that radiated into the right lower extremity resulting in numbness in the L5 distribution. He then underwent a minimally invasive approach to resect the L5 "wide" transverse process following the CT diagnosis of Bertolotti's syndrome. Prior to surgery, patient reported pain that was exacerbated by ambulation that resolved post-operative. CONCLUSION: Bertolotti's syndrome is one of the rare causes of sciatica that often goes undiagnosed. Nevertheless, it should be ruled out for patients with back pain without disc herniations or other focal pathology diagnosed on lumbar MR scans.

Quality of life among men with spinal cord injury in Lebanon: A case control study.

BACKGROUND: Spinal cord injury (SCI) is a permanent disability which negatively affects individuals' health and particularly their quality of life. OBJECTIVE: To assess the quality of life (QoL) among Lebanese men with spinal cord injury and to compare it to a healthy control group. METHODS: A case control study was conducted. Fifty-one Lebanese patients with spinal cord injury and 51 age- sex-matched healthy persons were included in the study. RESULTS: Compared to healthy controls, the mean scores of eight domains of SF-36 were significantly lower in SCI group: physical functioning (PF) (26.5 vs 87; p value <0.0001), role limitations due to physical (RP) (57.8 vs 93.6; p value <0.0001), bodily pain (BP) (60.5 vs 90.7; p value, 0.0001), general health (GH) (49.5 vs 76.6; p value <0.0001), vitality (VT) (51.2 vs 71.3; p value <0.0001), social functioning (SF) (68.9 vs 91.2; p value <0.0001), role limitations due to emotional problems (RE) (71.2 vs 91.5; p value 0.003) and mental health (MH) (62.9 vs 79; p value <0.0001). Concerning PCS and MCS scores, SCI patients reported significantly lower scores than control group (p value <0.0001). CONCLUSION: Participants with SCI reported reduced QoL in comparison with normal individuals.

Minimally invasive resection of large dumbbell tumors of the lumbar spine: Advantages and pitfalls.

OBJECTIVES: The surgical management of dumbbell tumors of the lumbar spine remains controversial, because of their large volume and complex location, involving both the spinal canal and the retro peritoneum. While sporadically reported, our study aims to confirm the value of minimally invasive posterior access for the complete resection of large lumbar dumbbell tumors. PATIENTS AND METHODS: In this prospective study, we included all consecutive patients who underwent the resection of a voluminous dumbbell tumor at the lumbar spine through a minimally invasive approach, between March 2015 and August 2017. There were 4 men and 4 women, with a mean age at diagnosis of 40.6 years (range 29-58 years). The resection was performed through a trans muscular tubular retractor by the same surgical team. Operative parameters and initial postoperative course were systematically reported. Clinical and radiological monitoring was scheduled at 3 months, 1 year and 2 years. RESULTS: The mean operative time was 144 min (range 58-300 minutes) and the mean estimated blood loss was 250 ml (range 100-500 ml). Gross total resection was achieved in all patients. No major complication was reported. The mean length of hospital stay was 3.1 days (range 2 to 6 days). Histological analysis confirmed the diagnosis of grade 1 schwannoma in all patients. The mean follow up period was 14.9 months (range 6 to 26 months), and 5 patients completed at least 1-year follow-up. At 6 months the Macnab was excellent in 6 patients, good in one patient and fair in one patient because of residual neuropathic pain requiring the maintenance of a long-term treatment. No tumor recurrence was noted to date. CONCLUSION: Lumbar dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure, in a trained team.

Diffuse Idiopathic Hyperostosis Manifesting as Dysphagia and Bilateral Cord Paralysis: A Case Report and Literature Review.

BACKGROUND: Diffuse idiopathic hyperostosis (DISH) is characterized by calcifications affecting mainly the spinal anterior longitudinal ligament. This disease is mainly asymptomatic but cervical osteophytes can sometimes cause dysphagia (DISHphagia), hoarseness, and even dyspnea. CASE DESCRIPTION: We report, for the first time in the medical literature, a case of a 76-year-old patient with DISH causing an important dysphagia as well as bilateral vocal cord paralysis causing critical dyspnea. The patient was surgically treated by anterior resection of the osteophytes and application of bone wax, with significant clinical improvement and no radiologic recurrence after 2 years of follow-up. DISCUSSION AND CONCLUSION: A thorough literature review didn't yield any article reporting on bilateral vocal cord paralysis caused by DISH. Management of this condition is typically multidisciplinary, and treatment of cervical osteophyte-associated dysphagia or respiratory compromise is primarily medical, after performing necessary tests to rule out other causes of dysphagia. Surgical intervention is warranted when medical treatment fails, when there is weight loss, a significant airway compromise or sleeping alterations. A treatment algorithm is proposed in the end of this review for symptomatic anterior osteophytes caused by DISH in the mobile cervical spine.

Single Posterior Approach for En-Bloc Resection and Stabilization for Locally Advanced Pancoast Tumors Involving the Spine: Single Centre Experience.

STUDY DESIGN: Monocentric prospective study. PURPOSE: To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors. OVERVIEW OF LITERATURE: In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach. METHODS: We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation. RESULTS: Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment. CONCLUSIONS: The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Successful management of a giant anterior sacral meningocele with an endoscopic cutting stapler: case report.

Anterior sacral meningoceles (ASMs) are rare defects in the sacrum with thecal sac herniations and symptoms that commonly include constipation, dysmenorrhea, and urinary disturbances. An ASM causing hydronephrosis and acute renal failure from compression of the lower portion of the urinary tract is a rare clinical entity. Only one other case has been reported. The authors present the case of a 37-year-old man admitted for obstructive renal failure and hydronephrosis due to a giant ASM that measured 25 × 12 × 18 cm and compressed the ureters and bladder. The ASM was successfully treated via an anterior transabdominal approach in which the authors used a novel technique for watertight closure of the meningocele pedicle with an endoscopic cutting stapler. The authors review the literature and discuss the surgical options for the treatment of ASMs, specifically the management of ASMs in the context of obstructive renal failure and hydronephrosis.