Successful surgical resection of a rare case of a giant sacral chordoma: a multidisciplinary feat.

We, here, report the case of a 72-year-old man who presented with a giant sacral chordoma without aggressive clinical and neurological course and confirmed with a CT guided biopsy. The patient underwent multidisciplinary, two-stage successful complete en bloc sacrectomy along with total gross tumour resection, followed by lumboiliac fusion and instrumentation in the second stage without any neurological deficit nor bladder or bowel-related complications.

Demographics and outcomes of meningioma patients treated at a tertiary care center in the Middle East.

OBJECTIVE: Meningioma is the most common intracranial primary brain tumor. Risk factors such as age and exposure to radiation as well as prognostic factors such as grade, location, and extent of surgical resection have been reported in the literature worldwide; however, to our knowledge, data from the Middle East is still warranted. In this study, we aim to identify the characteristics, risk factors and outcomes of meningioma patients treated at a multidisciplinary regional referral center in the Middle East. PATIENTS AND METHODS: This is a retrospective chart review with a prospective follow up of outcomes. It included patients diagnosed with meningioma between January 2005 and December 2015 at the American University of Beirut Medical Center. Patient's demographics, risk factors and outcomes were first retrospectively collected. Then, we conducted phone calls to all included alive patients to update their disease status and outcomes. RESULTS: One-hundred and ninety-five patients were included. 69 % had grade I tumors and around 31 % with grades II and III meningiomas. The means of the overall survival and progression free survival (PFS) were 198 and 126 months, respectively. The residence area (city vs. countryside), occupation, alcohol use, oral contraceptive use, family history of meningioma, previous head trauma, radiation exposure for head/brain imaging, cell phone use, and finally, the tumor Ki-67 protein level did not correlate with the survival outcomes. The meningioma grade and extent of resection were significant predictors of the PFS on the univariate analysis, whereas, in the multivariate analysis only previous radiotherapy was significant in prolonging PFS. CONCLUSION: In our study cohort, that included around 30 % grades II and III tumors, previous radiotherapy use was the only significant prognostic factor for longer PFS in patients diagnosed with meningioma. Future prospective studies should be conducted to evaluate genetic and molecular factors that could possibly be linked to meningioma grade and prognosis in our population of Middle Eastern patients.

Prognostic significance of O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation and isocitrate dehydrogenase-1 (IDH-1) mutation in glioblastoma multiforme patients: A single-center experience in the Middle East region.

OBJECTIVES: To determine the prevalence and prognostic value of MGMT promoter methylation and IDH1 mutation in glioblastoma multiforme (GBM) patients from the Middle East. PATIENTS AND METHODS: Records of patients diagnosed between 2003 and 2015 were reviewed. MGMT promoter methylation was measured using methylation-specific polymerase chain reaction and IDH-1 mutation was reported. The primary endpoint was overall survival (OS). RESULTS: A total of 110 patients were included. The median age was 51 years and 71 patients (64.5%) were males. The median diameter of GBM was 4.6 cm and 29 patients (26.4%) had multifocal disease. Gross total resection was achieved in 38 patients (24.9%). All patients received adjuvant radiation therapy, and 96 patients (91.4%) received concomitant temozolomide. At a median follow up of 13.6 months, the median OS was 17.2 months, and the OS at 1 and 2 years were 71.6% and 34.8%, respectively. On multivariate analysis, age at diagnosis (HR 1.019; P = 0.044) and multifocality (HR 2.373; P = 0.001) were the only independent prognostic variables. MGMT promoter methylation was found in 28.2% of patients but did not significantly correlate with survival (HR 1.160; P = 0.635). IDH-1 mutation was found in 10% of patients was associated with a non-significant trend for survival improvement (HR 0.502; P = 0.151). CONCLUSION: Patients with GBM from the Middle East have adequate survival outcomes when given the optimal treatment. In our patient population, MGMT promoter methylation did not seem to correlate with outcomes, but patients with IDH1 mutation had numerically higher survival outcomes.

Mobile lumbar spine ependymoma: case report and review of literature.

Migrating intra-spinal lesions are quite rare, and are most of the reported cases are schwannomas. Several theories have been proposed to explain the changing location of an intra-spinal tumor. We present a very rare case of migrating lumbar intra-spinal intra-dural lesion at the conus level, the pathology of which was an ependymoma, and review the possible etiologies of such a unique occurrence in view of the reported literature. We hypothesize loose connection to the tissue of origin, likely the filum, as the cause in our case. We thus highlight the importance of repeated imaging and careful planning before surgical intervention of intra-spinal intra-dural lesions, to avoid complications and wrong level surgery, especially when the lesions are in the cauda-equina area.

Spontaneous intracranial hypotension syndrome treated with fludrocortisone.

Spontaneous intracranial hypotension is a rare syndrome characterized by orthostatic headache not associated with trauma or dural puncture. In most cases, it is caused by a spontaneous spinal cerebrospinal fluid leakage as demonstrated by neuroradiological studies. The standard of care consists of conservative treatment including bed rest, hydration, and administration of caffeine or glucocorticoids. When such conservative therapy fails, an epidural blood patch is recommended. In this report, we describe the treatment of 2 patients with spontaneous intracranial hypotension who failed conservative treatment and went on to have complete and sustained resolution of their symptoms after the administration of oral fludrocortisone.

Pseudoaneurysm of the superficial temporal artery: a complication of botulinum toxin injection.

Pseudoaneurysms of the superficial temporal artery (STA) must be considered in the differential diagnosis of masses of the lateral forehead and temporal fossa. Although the first reported case of a temporal artery aneurysm was by Thomas Bartholin in 1740, this lesion receives scant mention in the plastic and maxillofacial surgical literature. A history of recent blunt trauma or surgery to the forehead combined with a pulsatile bruit should direct the physician to this diagnosis. A case of pseudoaneurysm arising from the frontal branch of the left STA 2 months after Botox injection is presented. The patient underwent embolization of the STA with Onnix. A similar case was previously reported once in the world literature.

Effect of age and lordotic angle on the level of lumbar disc herniation.

It has been previously suggested in the literature that with aging, degenerative changes as well as disc herniation start at the lower lumbar segments, with higher disc involvement observed in an ascending fashion in older age groups. We conducted a study to investigate this correlation between age and level of disc herniation, and to associate it with the magnitude of the Lumbar Lordotic Angle (LLA), as measured by Cobb's method. We followed retrospectively lumbosacral spine MRI's of 1419 patients with symptomatic disc herniation. Pearson's correlation was used in order to investigate the relationship between LLA, age, and level of disc herniation. Student's t-test was applied to assess gender differences. Young patients were found to have higher LLA (R = 0.44, P < 0.0001) and lower levels of disc herniation (R = 0.302, P < 0.0001), whereas older patients had higher level herniation in lower LLA group (mean LLA 28.6° and 25.4°) and lower level herniation in high LLA group (mean LLA 33.2°). We concluded that Lumbar lordotic Cobb's angle and age can be predictors of the level of lumbar disc herniation. This did not differ among men and women (R = 0.341, P < 0.0001).

Significance and cost-effectiveness of somatosensory evoked potential monitoring in cervical spine surgery.

BACKGROUND: Intraoperative somatosensory evoked potential (SSEP) monitoring during cervical spine surgery is not a universally accepted standard of care. Our retrospective study evaluated the efficacy and cost-effectiveness of intraoperative SSEP in a single surgeon's practice. MATERIALS AND METHODS: Intraoperative SSEP monitoring was performed on 210 consecutive patients who had cervical spine surgery: anterior cervical approach 140 and posterior approach 70. They were screened for degradation or loss of SSEP data. A cost analysis included annual medical costs for health and human services, durable goods and expendable commodities. RESULTS: Temporary loss of the electrical wave during cauterization resolved upon discontinuation of the cautery. We had no loss of cortical wave with preservation of the popliteal potential. A drop in the amplitude of the cortical wave was observed in three patients. This drop was resolved after hemodynamic stabilization in the first patient, readjusting the bone graft in the second patient, and interrupting the surgery in the third patient. The additional cost for SSEP monitoring was $835 per case and the total cost of the surgery was $13,835 per case. By spending $31,546 per year on SSEP, our institution is saving a total cost ranging from $64,074 to $102,192 per patient injured per year. CONCLUSION: Intraoperative SSEP monitoring is a reliable and cost-effective method for preventing postoperative neurological deficit by the early detection of vascular or mechanical compromise, and the immediate alteration of the anesthetic or surgical technique.

Non-pyogenic infections of the spine.

Subacute and chronic spondylodiscitis can be caused by a wide spectrum of infectious aetiologies including Mycobacterium tuberculosis, Brucella spp. and a variety of fungi including Aspergillus spp., Candida spp. and Cryptococcus neoformans. Knowledge of the local epidemiology and prior exposure might suggest the aetiology. Non-invasive diagnostic approaches, such as blood culture or antibody titres in the case of Brucella or antigen detection in the case of fungal infections, can be helpful in reaching the diagnosis. However, direct aspiration or tissue biopsy is usually necessary to identify the causative organism. Specimens are usually sent for pathology, special stains, cultures and, when indicated, molecular analysis. To minimise morbidity and mortality, antibiotic treatment should be initiated promptly directed against the suspected organism, and later adjusted according to the confirmed aetiology. Surgical treatment is reserved for recurrent infection, unstable spinal segment or marked kyphosis in the face of any neurological deficits and uncontrollable pain. Surgical approaches are dictated by the anatomic location of the offending lesion. Once medical treatment fails and surgery becomes warranted, we advocate the use of a two-stage surgical treatment for non-fixed kyphosis and a three-stage operation for fixed kyphosis.

Endoscopy in the management of intra-ventricular lesions: preliminary experience in the Middle East.

OBJECTIVES: The study is aimed at evaluating neuroendoscopic procedures in the management of various intra-cranial intra-ventricular lesions. METHODS: We retrospectively review 24 consecutive patients harboring various intra-ventricular lesions with or without associated hydrocephalus, operated and managed by the authors between December 2002 and December 2007. Depending on the preoperative imaging and working diagnosis, endoscopic biopsy or endoscopic resection/debulking, along with concomitant treatment of hydrocephalus via third ventriculostomy or fenestration of the septum pellucidum and ventriculo-peritoneal shunting, were done. RESULTS: The single endoscopic procedure was successful in most of the patients (22/24), where the goals of surgery in attaining a diagnostic biopsy or resection, and simultaneous treatment of hydrocephalus, were attained helping guide further therapy. The endoscopic procedure was the only procedure needed in most of the patients. CONCLUSIONS: The endoscopic procedures carried a high success rate in the management of intra-ventricular lesions, and were especially valuable in patients harboring chemo and/or radiosensitive deep seated tumors.

The advantages of submandibular gland resection in anterior retropharyngeal approach to the upper cervical spine.

Anterior surgery to the upper cervical spine, although rare, several successful approaches were described in the literature. To avoid the risks and limitations of transoral approach, the anterior retropharyngeal approach was developed. In this study, we describe our experience with anterior retropharyngeal approach to the upper cervical spine and discuss the significance of resecting the submandibular gland. From July 2001 to July 2004, we performed six anterior prevascular retropharyngeal approaches to the upper cervical spine. The series included five males and one female, ranging in age from 26 to 60 years (mean = 46). All six patients were intubated with nasotracheal cannula. The submandibular gland was mobilized and removed in all patients allowing adequate exposure of the arch of C1, C2, and C3 vertebral bodies. The anterior retropharyngeal approach permitted an adequate access to anteriorly situated lesions from C1 to C3 in all six patients, without the risks and limitations of transmucosal surgery. This approach allowed us to perform decompression of the spinal cord and reconstruction of the anterior column of the spine with bone graft and internal fixation. Careful removal of the submandibular gland provided better visualization of the arch of C1 and C2. No facial nerve palsy was seen in any of the six patients. Anterior retropharyngeal approach to the upper cervical spine combined with removal of the submandibular gland permits exposure of the anterior spine similar to that obtained by the transmucosal route, and provides a safe simultaneous arthrodesis and instrumentation during the primary surgical procedure without the potential contamination of the oropharyngeal cavity. Removal of the submandibular gland allows better exposure with less retraction and thus avoids severe injury to the mandibular branch of the facial nerve.

Baclofen pump pocket infection: a case report of successful salvage with muscle flap.

Programmable pump for continuous infusion of intrathecal baclofen, an agonist of the inhibitory neurotransmitter gamma-aminobutyric acid, is nowadays being widely used to control spasticity. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site which cannot be effectively treated without pump removal. We report a 37-year-old man who developed a baclofen pump pocket infection that did not respond to antibiotic therapy. Because the continuation of intrathecal baclofen administration was critical to the patient, and because the high cost of the pump precluded its prompt replacement, the pump was salvaged using the ipsilateral rectus abdominis muscle that was elevated on its inferior vascular pedicle and wrapped around the pump. Abdominal skin was then approximated, leaving a small portion of exposed muscle overlying the refill site that was covered by a split-thickness skin graft. Continuous intrathecal baclofen administration was never discontinued. Three months later, the pump's refill site could be easily identified manually for pump refill. There were no signs of recurrent infection during the 2-year follow-up period.

Aneurysmal bone cyst of the cervical spine in a child: case report and review of the surgical role.

BACKGROUND: Surgical treatment of aneurysmal bone cysts of the cervical spine, frequently affecting pediatric patients, is a challenge to operating surgeons. Complete tumor resection offers the best chance for cure. CASE DESCRIPTION: We present the case of a child with an expansile aneurysmal bone cyst of the cervical spine that involves all 3 spinal columns. The advantages of combining a posterolateral followed by anterior approach after a preoperative angiography and vertebral artery balloon occlusion testing provided the added safety to maximize the extent of tumor resection. Spinal stabilization was successfully achieved in both approaches. CONCLUSION: The challenge of surgically resecting aneurysmal bone cysts of the cervical spine in children enabled us to achieve a total resection with the help of preoperative angiography and vertebral artery balloon occlusion testing. Spinal instability should be addressed with reconstruction and stabilization techniques.

Clinical outcome of surgical treatment of failed back surgery syndrome.

BACKGROUND: Failed back surgery syndrome (FBSS) is a condition in which there is failure to improve satisfactorily after back surgery. It is characterized by intractable pain and various degrees of functional disability after lumbar spine surgery. It is estimated that this complication occurs in 5% to 10% of patients after spinal surgeries. The major causes of FBSS are fibrosis and adhesions, spinal instability, recurrent herniated disk, and inadequate decompression. The purpose of this study is to report on the postsurgical outcome after a redo spinal surgery. METHODS: We prospectively studied 50 patients with FBSS. The underlying pathology was identified and all the patients were treated surgically. Redo surgery was targeted at correcting the underlying pathology: removal of recurrent or residual disk, release of adhesions with neural decompression, and fusion with or without instrumentation. The postsurgical outcome was studied using the Oswestry Disability Questionnaire (ODQ). RESULTS: The average preoperative ODQ mean score was 80.8; the average postoperative ODQ mean score was 36.6 at 1 month and 24.2 at 1 year. Best scores were obtained at 3 months of follow-up in most cases. Successful outcome (>50% pain relief) could be achieved in 92% of the patients at 1 year. CONCLUSION: The current study shows that successful management of patients with FBSS could be achieved with proper patient selection, correct preoperative diagnosis, and adequate surgical procedure targeting the underlying pathology.

Thoracic splenosis mimicking thoracic schwannoma: case report and review of the literature.

BACKGROUND: Thoracic splenosis is a rare entity. It occurs sometime after splenic and diaphragmatic injury, and it is rarely symptomatic. CASE DESCRIPTION: We report a case of left upper thoracic paraspinal splenosis 25 years after a thoracoabdominal penetrating trauma that required a splenectomy. The pathology was suspected on a routine chest x-ray and it mimicked a schwannoma on magnetic resonance imaging. Less than 40 cases of thoracic splenosis were described in the literature, but few were misinterpreted as schwannoma. CONCLUSION: Alertness to the possibility of thoracic splenosis can lead to confirmation of the diagnosis with technetium Tc 99m-tagged red blood cell radionuclide scanning based on a previous history of traumatic splenectomy.