First incidence of extrarenal wilms tumor within the spinal canal in the adult population: a novel case report and literature review.

BACKGROUND: Wilms tumor (WT), also known as nephroblastoma, is rare in adults, accounting for merely 3% of all nephroblastomas or 0.2 cases per million individuals. Extrarenal Wilms tumor (ERWT) emerges outside the renal boundaries and comprises 0.5 to 1% of all WT cases, with even rarer incidences in adults. Oncogenic mutations associated with ectopic nephrogenic rests (NR) may contribute to ERWT development. Diagnosis involves surgical resection and pathology examination. Due to scarce cases, adults often rely on pediatric guidelines. We thoroughly searched PubMed, Scopus, and Web of Science databases to establish our case's uniqueness. To the best of our knowledge, this is the first documented incidence of extrarenal Wilms tumor within the spinal canal in the adult population. CASE PRESENTATION: A 22-year-old woman with a history of congenital lipo-myelomeningocele surgery as an infant presented with a 6-month history of back pain. This pain gradually resulted in limb weakness, paraparesis, and loss of bladder and bowel control. An MRI showed a 6 × 5 × 3 cm spinal canal mass at the L4-S1 level. Consequently, a laminectomy was performed at the L4-L5 level to remove the intramedullary tumor. Post-surgery histopathology and immunohistochemistry confirmed the tumor as ERWT with favorable histology without any teratomatous component. CONCLUSION: This report underscores the rarity of extrarenal Wilms tumor (ERWT) in adults, challenging conventional assumptions about its typical age of occurrence. It emphasizes the importance of clinical awareness regarding such uncommon cases. Moreover, the co-occurrence of spinal ERWTs and a history of spinal anomalies warrants further investigation.

Intradural intramedullary epidermoid cyst in a 17-year-old male: An exceptionally rare case report and review of the literature.

INTRODUCTION: Spinal epidermoid tumors are exceptionally rare, comprising less than 1 % of all spinal tumors. True intramedullary epidermoid cysts (IECs) are even more infrequent, constituting only 0.8 % of all spinal epidermoid tumors, with a notable cranial preference. Due to their gradual growth, the clinical presentation varies widely based on factors such as size, location, and the patient's age. CASE PRESENTATION: A 17-year-old male patient was admitted after experiencing an eight-month-long gradual weakening of both lower limbs. Initially, he experienced paresthesia in the right lower extremities, which progressed to gait disturbances, impacting balance and coordination. Clinical examination indicated bilateral lower limb weakness, reduced vibration sense, and proprioception with a positive clonus sign and extensor plantar responses. Magnetic resonance imaging (MRI) revealed an intramedullary lesion at the T3-T4 level, appearing hypointense on T1-weighted and hyperintense on T2-weighted images. Subsequently, the patient underwent laminectomy of the T2-T5 vertebrae and microsurgical resection of the intramedullary lesion. Histopathological analysis confirmed the diagnosis of an epidermoid cyst. Following two months of physiotherapy, there was progressive improvement in the lower limb coordination and mobility. CLINICAL DISCUSSION: Progressive neurological deficits emphasize the importance of comprehensive neurological evaluation. Diagnosis involves clinical manifestations, imaging, and histopathological examination. Patients often exhibit gradual motor weakness, sensory alterations, and varying degrees of pain. Advanced neuroimaging such as MRI aids diagnosis. Surgical resection is the primary treatment with potential complications. CONCLUSION: A multidisciplinary approach is imperative for timely diagnosis and patient management, ensuring favorable outcomes while minimizing complications.

Role of brain metabolites during acute phase of mild traumatic brain injury in prognosis of post-concussion syndrome: A 1H-MRS study.

This study has investigated the potency and accuracy of early magnetic resonance spectroscopy (MRS) to predict post-concussion syndrome (PCS) in adult patients with a single mild traumatic brain injury (mTBI) without abnormality on a routine brain scan. A total of 48 eligible mTBI patients and 24 volunteers in the control group participated in this project. Brain MRS over regions of interest (ROI) and signal stop task (SST) were done within the first 72 hours of TBI onset. After six months, PCS appearance and severity were determined. In non-PCS patients, N-acetyl aspartate (NAA) levels significantly increased in the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC) relative to the control group, however, this increase of NAA levels were recorded in all ROI versus PCS subjects. There were dramatic declines in creatinine (Cr) levels of all ROI and a decrease in choline levels of corpus callosum (CC) in the PCS group versus control and non-PCS ones. NAA and NAA/Cho values in ACC were the main predictors of PCS appearance. The Cho/Cr level in ACC was the first predictor of PCS severity. Predicting accuracy was higher in ACC than in other regions. This study suggested the significance of neuro-markers in ACC for optimal prediction of PCS and rendered a new insight into the biological mechanism of mTBI that underpins PCS.

Endoscopic Endonasal Approach to the Craniovertebral Junction Lesions: A Case Series of 18 Patients.

Introduction Odontoid pathologies constitute a special category because they may lead to instability. Instability is defined by abnormal spinal alignment under physiologic conditions (loads) such as standing, walking, bending, or lifting. Since instability poses a risk of cord damage, surgical interventions may be required for durable long-term stabilization. This study demonstrates operative technique and results of endoscopic endonasal approach to the odontoid pathologies. Methods We conducted a retrospective study involving 18 patients who underwent endoscopic endonasal odontoidectomy (EEO) due to craniovertebral pathologies. Demographic data, clinical features of the patients, risk factors, and intraoperative and postoperative complications were reported in this series. Results Satisfactory outcomes achieved in 16 patients based on comparing the modified Rankin scale before and after the surgery ( p = 0.0001). The mean duration for EEO was 232.6 ± 18.8 minutes. The mean blood loss during surgery was 386.67 ± 153.04 mL. The mean duration of hospital stay was 7 days. All patients were extubated within a few hours after surgery. Despite of successful anterior decompression in the aforementioned cases, intraoperative cerebrospinal fluid (CSF) leakage, postoperative meningitis, and pulmonary thromboembolism occurred as complications. However, two intraoperative CSF leakages were managed by direct dural repair and fat graft; two patients died due to postoperative meningitis and pulmonary thromboembolism at 7 and 4 days after the second surgery. Conclusion In conclusion, EEO can be effectively used for anterior decompression of the odontoid pathologies, despite the risk of complications.

Hyper-selective neurectomy for knee flexion spasticity: anatomic bases and surgical technique.

PURPOSE: Spasticity may result from damage to neurons of the corticospinal tracts and loss of inhibitory supraspinal influences following head trauma. Traditionally, peripheral nerve surgeries for spasticity in lower limbs were limited to selective neurectomies. Here we used hyper-selective neurectomy (HSN) to release hamstring spasticity at the muscle spindle level. METHODS: This study describes anatomic bases and surgical technique of HSN and its results in treating spastic knee flexion in a 23-year-old male who developed severe spasticity following severe brain injury. The spasticity was prominent in the left knee. The surgical technique including resection of over one centimeter of three-quarters of the overstimulated nerve rami at the entry point of the nerve into the muscle is shown in the video 1. RESULTS: After the surgery Visual Analog Scale and Modified Ashworth Score reduced from 7 to 3 and 4 to 1, respectively. Popliteal angle improved from 118° to 73° at the second months after the surgery. CONCLUSION: Hyper-selective neurectomy is a safe and reliable therapeutic option for the treatment of permanent trauma induced spasticity in the lower limb.

Clinical Efficacy of Intraventricular rt-PA (Actilyse®) in the Outcome of Patients with Spontaneous Intraventricular Hemorrhage.

AIM: To evaluate the effectiveness of intraventricular injection of rt-PA (Actilyse®) in patients with spontaneous intraventricular hemorrhage (IVH) who had undergone external ventricular drainage (EVD). MATERIAL AND METHODS: This randomized clinical trial recruited 60 patients with spontaneous IVH who had undergone EVD due to the signs of hydrocephalus. The patients were randomly divided into two groups, including a group receiving intraventricular injection of rt-PA and the other normal saline. RESULTS: Both groups receiving rt-PA Actilyse® (n=28) or placebo (n=32) were male by majority (58.33%). We found no difference in the prevalence of meningitis and brain infection (35.7% vs. 37.5%, p=0.665). Changes in hematoma volume at the end of the fourth day compared to the first day after EVD differed significantly between the two groups (p=0.004). The majority (64.29%) showed a decrease in the rt-PA group, but in the placebo group, the majority (53.13%) remained constant. As a result, changes in the rt-PA group were significantly higher than those in the placebo group. Improvements in the level of consciousness (GCS) at the end of the fourth day compared to the first day after EVD implantation was 1.07 units in the Actilyse® group and -1.91 in the placebo group. As shown, the fourth day showed significant differences between the two groups (p < 0.001). Improvements in the Glasgow Coma Scale (GCS) were observed at the end of the period. CONCLUSION: It can be concluded that intraventricular injection of rt-PA (Actilyse®) can effectively reduce the volume of hematoma and improve the level of consciousness (GCS) during treatment. Intraventricular injection of 2-mg rt-PA is safe for patients and does not cause any acute complications such as cerebral hematoma expansion.

The Sagittal Balance of the Cervical Spine: Radiographic Analysis of Interdependence between the Occipitocervical and Spinopelvic Alignment.

STUDY DESIGN: This was a prospective clinical study. PURPOSE: Previous studies have indicated that cervical lordosis is a parameter influenced by segmental and global spinal sagittal balance parameters. However, this correlation still remains unclear. Therefore, a better understanding of the normal values and interdependencies between inter-segmental alignment parameters is needed. This is a preliminary analysis that helps to understand these factors. OVERVIEW OF LITERATURE: Change in global sagittal alignment is associated with poor health-related quality of life. Questions regarding which parameters play the primary roles in the progression of spinal sagittal imbalance and which might be compensatory factors remain unanswered. METHODS: Prospectively, 420 adults (105 asymptomatic, 105 cervical symptomatic, 105 lumbar symptomatic, and 105 post-surgical) were selected. Whole-spine standing lateral radiographs were taken, and spinopelvic, thoracic, and cervical parameters were measured. Then, the data were analyzed using correlation coefficient test and multiple regression analysis. RESULTS: All the parameters showed a normal distribution. The mean values of the cervical parameters are as follows: C1C2 Cobb angle, -27.07°±4.3°; C2C7 Cobb angle, -16.4°±5.6°; OCC2 Cobb angle, -14.5°±3.8°; OCC7 Cobb angle, -29.8°±5.6°; C2C7 Harrison angle, 20.4°±4.3°; and C7 slope, -25.4°±5.6°. The analysis of these parameters revealed no statistically significant difference between asymptomatic, symptomatic, and post-surgical patients. C7 sagittal vertical axis (SVA) correlated with the C2C7 Cobb angle (r =0.7) in all groups. No significant correlation was noted between cervical and spinopelvic parameters in asymptomatic patients. However, C1C2 Cobb angle correlated significantly with pelvic incidence (PI, r =-0.2), lumbar lordosis (LL, r =0.2), and pelvic tilt (PT, r =-0.2) in cervical symptomatic patients. Irrespective of the patient symptom sub-group (n=420), C1C2 Cobb angle correlated with LL (r =0.1) and C2C7 Harrison angle correlated with PI and PT (r =0.1). CONCLUSIONS: Our results indicate significant interdependence between the spinopelvic and cervical alignment, especially in cervical symptomatic patients. In addition, strong correlation was found between the C7 SVA and C2C7 Cobb angle. Overall, the results of this study could help to better understand the cervical sagittal alignment and serve as preliminary data for planning surgical reconstruction procedures.

Spontaneous Cervical Epidural Hematoma with Stroke Manifestations.

Spontaneous cervical epidural hematoma (SCEH), which is a rare disease, is manifested as by a sudden quadriplegia or paraplegia and other neurological deficits. SCEH can compress the spinal cord resulting in its clinical manifestations. The reported etiological risk factors are anticoagulants, coagulopathies, vascular malformations, infections, and herniated discs. Here, we report a 77-year-old woman with a presenting chief complaint of left hemiparesis and a history of hypertension. The medical drugs in use were aspirin and antihypertensives. The initiating presentations were hemiparesis, in favor of ischemic stroke, so the patient admitted to neurology ward and received anticoagulant therapy with the initial diagnosis of stroke. Although clinical manifestations and examinations are important in these patients due to mimicking stroke picture, imaging evaluation is paramount for a definite diagnosis, which in our case showed a SCEH, who was suspected to have an ischemic stroke during the initial assessment because its initial demonstration mimicked ischemic stroke. This patient underwent laminectomy after 3 days and showed a clinical recovery the day after. Her muscle strength improved gradually, and neurological symptoms were diminished after physiotherapy.

Anatomical Variations of Brachial Plexus in Adult Cadavers; A Descriptive Study.

BACKGROUND: Variations of the brachial plexus are common and a better awareness of the variations is of crucial importance to achieve successful results in its surgical procedures. The aim of the present study was to evaluate the anatomical variations of the brachial plexus in adult cadavers. METHODS: Bilateral upper limbs of 32 fresh cadavers (21 males and 11 females) consecutively referred to Guilan legal medicine organization from November 2011 to September 2014, were dissected and the trunks, cords and terminal nerves were evaluated. RESULTS: Six plexuses were prefixed in origin. The long thoracic nerve pierced the middle scalene muscle in 6 cases in the supra clavicular zone. The suprascapular nerve in 7 plexuses was formed from posterior division of the superior trunk. Five cadavers showed anastomosis between medial brachial cutaneous nerve and T1 root in the infra clavicular zone. Terminal branches variations were the highest wherein the ulnar nerve received a communicating branch from the lateral cord in 3 cases. The median nerve was formed by 2 lateral roots from lateral cord and 1 medial root from the medial cord in 6 cadavers. Some fibers from C7 root came to the musculocutaneous nerve in 8 cadavers. CONCLUSION: The correlation analysis between the variations and the demographic features was impossible due to the small sample size. The findings of the present study suggest a meta-analysis to assess the whole reported variations to obtain a proper approach for neurosurgeons.

Posttraumatic Temporal Bone Meningocele Presenting as a Cystic Mass in the External Auditory Canal.

INTRODUCTION: Temporal bone meningoencephalic herniation may occur in head trauma. It is a rare condition with potentially dangerous complications. Several different routes for temporal bone meningoencephalocele have been proposed. CLINICAL REPORT: An11-year-old boy with history of head trauma initially presented with a 9-months history of progressive right-sided hearing loss and facial weakness. The other complaint was formation of a cystic mass in the right external auditory canal. The patient underwent surgery via a mini middle cranial fossa craniotomy associated with a transmastoid approach. CONCLUSION: Although presenting symptoms can be subtle, early suspicion and confirmatory imaging aid in establishing the diagnosis. The combination of computed tomography and magnetic resonance imaging will help in proper preoperative diagnosis. The operation includes transmastoid, middle cranial fossa repair, or combination of both. The multilayer closure of bony defect is very important to avoid cerebrospinal fluid leak. Clinical manifestations, diagnosis, and surgical approaches for posttraumatic meningoencephaloceles arising in the head and neck region are briefly discussed.

Long-term clinical outcomes of spinal accessory nerve transfer to the suprascapular nerve in patients with brachial plexus palsy.

BACKGROUND: For the reconstruction of brachial plexus lesions, restoration of elbow flexion and shoulder function is fundamental and is achieved by dual nerve transfers. Shoulder stabilization and movement are crucial in freedom of motion of the upper extremity. In patients with C5-C6 brachial plexus injury, spinal accessory nerve transfer to the suprascapular nerve and a fascicle of ulnar nerve to musculocutaneous nerve (dual nerve transfer) are carried out for restoration of shoulder abduction and elbow flexion, respectively. In the present study, we evaluated the long-term clinical outcomes of spinal accessory nerve transfer to the suprascapular nerve for restoration of shoulder abduction in patients with brachial plexus palsy undergoing a dual nerve transfer. PATIENTS AND METHODS: In the present retrospective review, 22 consecutive subjects with upper brachial plexus palsy were assessed. All of the subjects underwent spinal accessory nerve transfer to the suprascapular nerve and a dual nerve transfer from the ulnar nerve to the biceps branch and from the median nerve to the brachialis branch of the musculocutaneous nerve simultaneously. All of the subjects were followed up for 18 to 24 months (average, 21.7 months) for assessing the recovery of the shoulder abduction and motor function. RESULTS: Spinal accessory nerve transfer to the suprascapular nerve showed a motor function recovery of M3 and M4 in 13.6 and 63.6% of the subjects, respectively. However, 22.7 % of the subjects remained with a motor function of M2. The mean of shoulder abduction reached 55.55 ± 9.95° (range, 40-72°). Altogether, good functional results regained in 17 out of 22 the subjects (77.2 %). Linear regression analysis showed that advanced age was a predictor of low motor functional grade. CONCLUSIONS: The evidence from the present study suggests that transferring spinal accessory nerve to the suprascapular nerve for restoring shoulder abduction is an effective and reliable treatment with high success rate in patients with brachial plexus palsy, especially in young patients.

The role of early posttraumatic neuropsychological outcomes in the appearance of latter psychiatric disorders in adults with brain trauma.

BACKGROUND: The objective was to determine the predictors of posttraumatic psychiatric disorders (PTPD) during the first 6 months following traumatic brain injury (TBI) focusing on neuroimaging, clinical and neuropsychological appraisements during acute and discharge phase of TBI. MATERIALS AND METHODS: We designed a prospective, longitudinal study in which 150 eligible TBI patients were entered. Postresuscitation brain injury severity and discharged functional outcome were evaluated by standard clinical scales. First neuroimaging was done at a maximum of 24 h after head trauma. Early posttraumatic (PT) neuropsychological outcomes were assessed using Persian neuropsychological tasks at discharge. The standardized psychiatric assessments were carefully implemented 6 months postinjury. A total of 133 patients returned for follow-up assessment at 6 months. They were divided into two groups according to the presence of PTPD. RESULTS: Apparently, aggression was the most prevalent type of PTPD (31.48%). There was no significant difference between groups regarding functional outcome at discharge. Diffuse axonal injury (12.96%) and hemorrhages (40.74%) within the cortex (42.59%) and sub-cortex (33.33) significantly occurred more prevalent in PTPD group than non-PTPD ones. Primary postresuscitation TBI severity, early PT lingual deficit and subcortical lesion on first scan were able to predict PTPD at 6 months follow-up. CONCLUSION: Almost certainly, the expansive dissociation risk of cortical and subcortical pathways related to linguistic deficits due to severe intracranial lesions over a period of time can augment possibility of subsequent conscious cognitive-emotional processing deficit, which probably contributes to latter PTPD. Hence, early combined therapeutic supplies including neuroprotective pharmacotherapy and neurofeedback for neural function reorganization can dampen the lesion expansion and latter PTPD.

Posterior lumbar interbody fusion and posterolateral fusion: Analogous procedures in decreasing the index of disability in patients with spondylolisthesis.

OBJECTIVE: The purpose of this study was to evaluate the disability in patients with spondylolisthesis who assigned either to posterolateral fusion (PLF) or posterior lumbar interbody fusion (PLIF) and to compare it between two groups. METHODS: In a prospective observational study, 102 surgical candidates with low-grade degenerative and isthmic spondylolisthesis enrolled from 2012 to 2014, and randomly assigned into two groups: PLF and PLIF. Evaluation of disability has been done by a questionnaire using Oswestry Disability Index (ODI). The questionnaire was completed by all patients before the surgery, the day after surgery, after 6 months and after 1-year. RESULTS: There were no statistically significant differences in terms of age and sex distribution and pre-operation ODI between groups (P > 0.05). Comparison of the mean ODI scores of two groups over the whole study period showed no significant statistical difference (P = 0.074). ODIs also showed no significant differences between two groups the day after surgery, 6(th) months and 1-year after surgery (P = 0.385, P = 0.093, P = 0.122 and P = 433) respectively. Analyzing the course of ODI over the study period, showed a significant descending pattern for either of groups (P < 0.0001). CONCLUSION: Both surgical fusion techniques (PLF and PLIF) were efficient to lessen the disability of patients with spondylolisthesis, and none of the fusion techniques were related to a better outcome in terms of disability.

Leptomeningeal dissemination of pilocytic astrocytoma in a 17-year-old boy.

Pilocytic astrocytoma with leptomeningeal dissemination is a rare phenomenon and can be associated with obstructive hydrocephalus and an unfavorable prognosis. Herein, we report a seventeen-year-old boy with a history of ventriculo-peritoneal shunt insertion due to severe hydrocephalus who presented with progressive headache and vomiting together with ocular and cerebellar signs and symptoms. Neuroimaging confirmed the presence of multiple intracranial masses in the cerebellum and thalamus. Intracranial dissemination of tumor to the the leptomeninges was seen during neuroendoscopy. Simultaneous biopsy and endoscopic third ventriculostomy were performed and the diagnosis of low-grade pilocytic astrocytoma with leptomeningeal dissemination was made by histological examination. The patient underwent chemotherapy in combination with radiotherapy to reduce the risk of reoccurrence of the primary tumor and was followed for one year.

Primary intracranial leiomyosarcoma.

Primary intracranial leiomyosarcomas are rare tumors that arise from the mesenchymal cells of the dura mater or cerebral blood vessels Here we report the case of an extra axial leiomyosarcoma in the right parieto-occipital region of a 19-year-old male who had normal clinical and laboratory findings. Diagnostic imaging showed bony destruction, dural involvement and no parenchymal invasion. No primary site was found after metastasis work up. Specific serology tests were negative. The patient underwent a craniotomy, total tumor resection, duraplasty and skull reconstruction. He received radiotherapy and after 18 months of follow-up, no clinical and radiological signs of recurrence have been found.

Effect of clonidine premedication on blood loss in spine surgery.

BACKGROUND: Blood loss in spine surgery is an important issue, even though it has been understudied compared with hip and knee arthroplasty. OBJECTIVES: In this study, we evaluated the effect of oral clonidine as premedication on blood loss in lumbar spine fusion surgery under anesthesia with propofol and remifentanil. PATIENTS AND METHODS: In this double-blind, randomized clinical trial, 30 patients who were undergoing lumbar spine posterior fusion surgery due to traumatic fracture were allocated randomly into 2 groups. The study group (clonidine group) received a 200-µg oral clonidine tablet 60-90 minutes before anesthesia, and the control group received placebo at the same time. Induction and maintenance of anesthesia and the mean target arterial pressure for controlled hypotension with remifentanil were the same in the 2 groups. We compared the amount of intraoperative blood loss, dose of remifentanil/hour administered, need for nitroglycerine to reach the mean target arterial pressure when remifentanil was insufficient, duration of operation, and surgeon's satisfaction of a bloodless field between groups. RESULTS: There was no statistically significant difference between groups in age (P = 0.115), sex (P = 0.439), weight (P = 0.899), operation time (P = 0.2), or American Society of Anesthesiologists physical status score (P = 0.390). Intraoperative blood loss and remifentanil dose administered per hour in the clonidine group were significantly less than in the control group (P = 0.002 and P = 0.001, respectively), but there was no significant difference in surgeon's satisfaction between groups (P = 0.169). CONCLUSIONS: As an oral premedication, clonidine can reduce surgical blood loss in lumbar spine posterior fusion surgery, even at the same levels of mean arterial pressure (MAP) with the control group. Its use can be studied in more complicated spine surgeries, such as scoliosis and spinal deformity surgeries.