Valve-controlled chronic subdural hematoma drainage: A feasibility study.

Introduction: Pneumocephalus after chronic subdural hematoma (CSDH) evacuation is a potential predictor of hematoma recurrence. Research question: To study the feasibility and safety of a novel CSDH evacuation technique using a valve-controlled method to avoid pneumocephalus. Material and methods: In a retrospective case series, we evacuated CSDH using very low-pressure valve-controlled drains and recorded the neurological, radiological, and functional outcomes. Patients with primary CSDH, without previous neurosurgical intervention, and who did not receive antiplatelet or anticoagulant therapy the week prior to the index surgery, were included in the study. Exclusion criteria were the evacuation with other treatment techniques and incomplete data files. Patients were assessed according to the Bender grading system to record the neurological status. The hematoma volume was estimated using the formula for ellipsoid volumes. Results: Thirty-six patients with a mean age of 73 years (±9 years) fulfilled our eligibility criteria. Our technique was effective since it decreased the CSDH volume from 141 â€‹ml (IQR 97 â€‹ml) to 20.6 â€‹ml (IQR 26.59 â€‹ml; p â€‹< â€‹0.001) and improved the neurological status according to the Bender grading system from two (IQR 0.25) to 1 (IQR 0). However, pneumocephalus and hematoma recurrence occurred in one case each (2.8%). At six months, all patients returned to their previous status, except for two patients (5.6%) who died due to irrelevant pathologies. Conclusions: Valve-controlled CSDH evacuation aiming to decrease the postoperative pneumocephalus and hematoma recurrence constitutes an effective and safe alternative. However, larger randomized controlled studies are required to establish its role in CSDH management.

Bursitis of the coccyx in an adult with rheumatoid arthritis mimicking a sacrococcygeal meningocele.

BACKGROUND: Bursitis is a chronic inflammatory condition characterized by the deposition of cholesterol, macrophage infiltration, and bursal wall calcification. Bursitis is, however, rarely found in the sacrococcygeal region where it may present as a space-occupying mass. CASE DESCRIPTION: A 64-year-old male with rheumatoid arthritis presented with 3 years' duration of difficulty sitting and walking due to a soft-tissue mass involving the coccyx region. Once the patient's MR demonstrated a cystic lesion with erosion of the coccyx, the patient underwent gross total resection of the lesion that proved to be pathologically consistent with bursitis. Postoperatively, the patient's complaints fully resolved. CONCLUSION: Bursitis may present as a soft-tissue tumor-like lesion in the coccyx that favorably responds to gross total surgical excision.

Extreme lateral lumbar interbody fusion (XLIF) in the management of degenerative scoliosis: a retrospective case series.

BACKGROUND: Surgical treatment of adult degenerative scoliosis (DS) always remains a challenge and often necessitates complex multilevel surgery via traditional open approaches. However, the severity of the procedure, in association with the fact that many of these patients are at an advanced age with several comorbidities, results in high rate of complications. Therefore, during the last decade, minimally invasive procedures have gained a place in the treatment of this pathology. Our aim is to determine the safety and efficacy of extra lateral lumbar interbody fusion (XLIF) with or without supplemented instrumentation in the treatment of DS. METHODS: In a retrospective case series study, we reviewed the files of patients who underwent XLIF in our Hospital between 2008 and 2017. We recorded the patients' demographic characteristics, clinical parameters such as back-pain [visual analogue scale (VAS)] and back-related disability [Oswestry Disability Index (ODI)], as well as radiological parameters including the Cobb angle. Comparison of the before and after results were performed with the t-test and Chi-square test, where appropriate. RESULTS: Twelve patients fulfilled the eligibility criteria of our study. All patients were female, with a mean age of 64.5 years (SD =7.8 years) and 28 months (SD =13 months) follow-up. The XLIF decreased the pain intensity by 4.66 cm (SD =1.23 cm), and improved the back-related disability by 26% (SD =8.35%) in the ODI scale at the 6-month follow-up. Similarly, scoliosis improved by an average of 11.5° (SD =7°) and lordosis changed by an average of 13.5° (SD =10.86°). All changes were statistically significant. There were three complications, two patients presented meralgia paresthetica, which resolved spontaneously in 3 months, and in one patient occurred an intraoperative bowel perforation treated with bowel anastomosis. CONCLUSIONS: XLIF is a feasible and efficient alternative in the treatment of DS. It can be the treatment of choice in elderly patients in whom comorbidities increase the perioperative risk of complications.

Correlation of Clinical and Radiological Outcome After Anterior Cervical Discectomy and Fusion With a Polyetheretherketone Cage.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) with a polyetheretherketone (PEEK) cage is considered as the gold standard for patients with cervical disc disease. However, there are limited in vivo data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. The purpose of this study was to investigate the impact of altered cervical sagittal alignment (cervical lordosis) and sagittal range of motion (ROM) on patients' self-reported pain and functional disability, after ACDF with a PEEK cage. METHODS: We prospectively studied 74 patients, who underwent single-, or consecutive two-level ACDF with a PEEK interbody cage. The clinical outcomes were assessed by using the pain numeric rating scale (NRS) and the neck disability index (NDI). Radiological outcomes included cervical lordosis and C2-C7 sagittal ROM. The outcome measures were collected preoperatively, at the day of patients' hospital discharge, and also at 6 and 12 months postoperatively. RESULTS: There was a statistically significant reduction of the NRS and NDI scores postoperatively at each time point (P < 0.005). Cervical lordosis and also ROM significantly reduced until the last follow-up (P < 0.005). There was significant positive correlation between NRS and NDI preoperatively, as well as at 6 and 12 months postoperatively (P < 0.005). In regard to the ROM and the NDI scores, there was no correlation preoperatively (P = 0.199) or postoperatively (6 months, P = 0.322; 12 months, P = 0.476). Additionally, there was no preoperative (P = 0.134) or postoperative (6 months, P = 0.772; 12 months, P = 0.335) correlation between the NDI scores and cervical lordosis. CONCLUSIONS: In our study, reduction of cervical lordosis and sagittal ROM did not appear to significantly influence on patients' self-reported disability. Such findings further highlight the greater role of pain level over the mechanical limitations of ACDF with a PEEK cage on patients' own perceived recovery.

Multimodality treatment of intradural extramedullary Ewing's sarcomas. A systematic review.

Ewing's sarcoma (ES) is an aggressive bone and soft tissue sarcoma that usually affects adolescents and young adults. ES occasionally presents as an intradural-extramedullary lesion of the spine. Our aim was to study the role of the multimodality treatment on the survival (overall survival, recurrence-free survival, and metastasis-free survival) of patients with intradural-extramedullary Ewing's sarcoma. Pubmed, EMBASE, Scopus, Web of Science, Cochrane Reviews were searched up to January 2017, using as mesh terms "intradural extramedullary", "Ewing's sarcoma", AND "treatment". The multidisciplinary treatment was recorded in binary variables under the headings of "surgery", "chemotherapy" and "radiotherapy". We also recorded three time-to-event variables, including death, recurrence, and metastasis. We performed survival analysis for all potential combinations. Twenty articles with twenty-three patients were eligible for the current review. The survival curves of GTR did not differ from the equivalent of STR regarding survival (p=0.098), recurrence-free survival (p=0.318), and metastasis-free survival (p=0.089). Patients who received chemotherapy enjoyed longer survival regarding overall survival (p<0.05), recurrence-free survival (p<0.05), and metastasis-free survival (p<0.05), when compared to those who did not receive chemotherapy. Their overall survival of patients who had radiotherapy was marginally superior to those who did not receive (p=0.0653). However, their recurrence-free survival (p<0.05), and metastasis-free survival (p<0.05) were significantly improved in comparison to the latter. In conclusion, the multimodality treatment is mandatory for the management of patients with intradural extramedullary Ewing's sarcomas, with surgery assisting in the diagnosis and decompression the neural elements. However, it is chemotherapy that improves survival, recurrence-free survival, and metastasis-free survival. Radiotherapy is reserved as an adjuvant therapy in the local control, especially in cases with subtotal tumour resection.

Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study.

Idiopathic normal pressure hydrocephalus is a hydrodynamic disorder whose etiology remains unclear. The diagnosis is mainly clinical and the traditional treatment is cerebrospinal fluid shunt diversion. With the introduction of modern management strategies, endoscopic third ventriculostomy has become a viable alternative to shunting and constitutes a well-established method of treatment for obstructive hydrocephalus. The new hydrodynamic concept of hydrocephalus suggests that endoscopic third ventriculostomy (ETV) may be an effective treatment for communicative hydrocephalus. In our current review, the authors focus on the up-to-date knowledge regarding the consideration of endoscopic third ventriculostomy as a safe surgical option in the management of idiopathic normal pressure hydrocephalus.

A supratentorial primitive neuroectodermal tumor presenting with intracranial hemorrhage in a 42-year-old man: a case report and review of the literature.

INTRODUCTION: We report on a very rare case of a supratentorial primitive neuroectodermal tumor in an adult, which presented with intracerebral hemorrhage, and review the relevant medical literature. CASE PRESENTATION: A 42-year-old Caucasian man complained of a sudden headache and nausea-vomiting. The patient rapidly deteriorated to coma. An emergency computed tomography scan showed an extensive intraparenchymal hemorrhage that caused significant mass effect and tonsilar herniation. During surgery, an increased intracranial pressure was recorded and extensive bilateral decompressive craniectomies were performed. A cherry-like intraparenchymal lesion was found in his right frontal lobe and resected. The patient died in the intensive care unit after approximately 48 hours. The resected lesion was identified as a central nervous system primitive neuroectodermal tumor. CONCLUSION: Supratentorial primitive neuroectodermal tumors must be considered in the differential diagnosis of space-occupying lesions in adults. Spontaneous supratentorial hemorrhage due to primitive neuroectodermal tumors is an extremely rare but potentially lethal event.

Role of endoscopic third ventriculostomy in treatment of selected patients with normal pressure hydrocephalus.

OBJECTIVE: The purpose of our study was to evaluate the results of endoscopic third ventriculostomy (ETV) in the management of patients with idiopathic normal pressure hydrocephalus (INPH). METHODS: Our prospective study included seven patients (five men and two women; ages ranging between 68 and 78 years) with two or more typical NPH symptoms of short duration (<6 months), with no other morbidity factors, with a Mini-Mental State Examination (MMSE) score ≥18, aqueductal cerebrospinal fluid (CSF) stroke volume ≥42 µL, and positive lumbar drain test. The etiology of NPH was idiopathic in all of these cases. Their preoperative work-up included brain magnetic resonance imaging (MRI) and cine-MR, MMSE test, and CSF lumbar drain test, in all cases. The clinical status of all participants was graded using the Japanese intractable hydrocephalus system. An ETV was performed in all participants. Follow-up included periodic clinical evaluations, MMSE, and MRI with cine-MR studies. The follow-up time range was 12-72 months. RESULTS: The mean postoperative clinical grade was 3.1, while the preoperative was 6.1. Gait disturbance and urinary incontinence were the most responsive symptoms. The mean postoperative MMSE score was 23.6, while the preoperative score was 20.3. The mean postoperative aqueductal CSF stroke volume, 6 months after the procedure, was 31.6 µL, while the preoperative volume was 48.8 µL. CONCLUSIONS: ETV may be a safe alternative surgical option for a limited number of carefully selected INPH patients.

Acute Schmorl's Node during Strenuous Monofin Swimming: A Case Report and Review of the Literature.

Study Design This case report describes an acute Schmorl's node (SN) in an elite monofin athlete during exercise. The patient presented with severe back pain and leg numbness and was managed successfully with conservative treatment. Objective The aim of our communication was to describe a rare presentation of a common pathological condition during an intense sport. Background Swimming is not generally considered to be a sport activity that leads to spinal injuries. SNs are usually asymptomatic lesions, incidentally found on imaging studies. There is no correlation between swimming and symptomatic SN formation. Case Report A 16-year-old monofin elite athlete suffered from an acute nonradiating back pain during extreme exercise. His back pain was associated with a fracture of the superior L5 end plate and an acute SN at the L5 vertebral body with perilesional bone marrow edema. The pain resolved with nonsteroidal anti-inflammatory drugs and bed rest. The athlete had an excellent outcome and returned to his training activities 6 months after his incident. Conclusion SN should be considered in the differential diagnosis of severe back pain, especially in sport-related injuries. SNs present with characteristic imaging findings. Due to the benign nature of these lesions, surveillance-only management may be the best course of action.

Genetic basis of Parkinson disease.

Over the past few years, considerable progress has been made in understanding the molecular mechanisms of Parkinson disease (PD). Mutations in certain genes are found to cause monogenic forms of the disorder, with autosomal dominant or autosomal recessive inheritance. These genes include alpha-synuclein, parkin, PINK1, DJ-1, LRRK2, and ATP13A2. The monogenic variants are important tools in identifying cellular pathways that shed light on the pathogenesis of this disease. Certain common genetic variants are also likely to modulate the risk of PD. International collaborative studies and meta-analyses have identified common variants as genetic susceptibility risk/protective factors for sporadic PD.

Serum and cerebrospinal fluid C-reactive protein levels as predictors of vasospasm in aneurysmal subarachnoid hemorrhage. Clinical article.

OBJECT: Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. The C-reactive protein (CRP) constitutes a highly sensitive inflammatory marker. The association of elevated systemic CRP and coronary vasospasm has been well established. Additionally, elevation of the serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between elevated CRP levels in the serum and CSF and the development of vasospasm in patients with aSAH. METHODS: A total of 41 adult patients in whom aSAH was diagnosed were included in the study. Their demographics, the admitting Glasgow Coma Scale (GCS) score, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum and CSF CRP measurements were obtained on Days 0, 1, 2, 3, 5, 7, and 9. All patients underwent either surgical or endovascular treatment within 48 hours of their admission. The outcome was evaluated using the Glasgow Outcome Scale and the modified Rankin Scale. RESULTS: The CRP levels in serum and CSF peaked on the 3rd postadmission day, and the CRP levels in CSF were always higher than the serum levels. Patients with lower admission GCS scores and higher Hunt and Hess and Fisher grades had statistically significantly higher levels of CRP in serum and CSF. Patients with angiographic vasospasm had higher CRP measurements in serum and CSF, in a statistically significant fashion (p < 0.0001). Additionally, patients with higher CRP levels in serum and CSF had less favorable outcome in this cohort. CONCLUSIONS: Patients with aSAH who had high Hunt and Hess and Fisher grades and low GCS scores showed elevated CRP levels in their CSF and serum. Furthermore, patients developing angiographically proven vasospasm demonstrated significantly elevated CRP levels in serum and CSF, and increased CRP measurements were strongly associated with poor clinical outcome in this cohort.

Stereotactic amygdalotomy in the management of severe aggressive behavioral disorders.

OBJECT: Stereotactic amygdalotomy has been utilized as a surgical treatment for severe aggressive behavioral disorders. Several clinical studies have been reported since the first description of the procedure. In the current study, the authors reviewed the literature and evaluated the surgical results, neuropsychological outcome, and complication rate in patients who had undergone stereotactic amygdalotomy for severe aggressive behavioral disorders. METHODS: The PubMed database was searched using the following terms: "amygdalotomy," "amygdalectomy," "amygdaloidectomy," "psychosurgery," "aggressive disorder," and "behavioral disorder." Clinical series with more than 5 patients undergoing stereotactic amygdalotomy for aggressive or other behavioral disorders were included in this review. The surgical technique, anatomical target, improvement in psychiatric symptomatology, postoperative employment and social rehabilitation, postoperative neurocognitive function, procedure-related complications, and long-term follow-up were evaluated. RESULTS: Thirteen clinical studies met our inclusion criteria. Reported postoperative improvement in aggressive behavior varied between 33 and 100%. Procedure-related complication rates ranged from 0 to 42%, whereas the mortality rate was as high as 3.8%. In the majority of the reviewed clinical series, the performance of stereotactic amygdalotomy did not compromise a patient's learning, language, and intellectual capabilities. The long-term follow-up, although very limited, revealed that initially observed improvement was maintained in most cases. CONCLUSIONS: Stereotactic amygdalotomy can be considered a valid surgical treatment option for carefully selected patients with medically refractory aggressive behavioral disorders. Recent advances in imaging and stereotactic navigation can further improve outcome and minimize the complication rate associated with this psychosurgical procedure.

Primary spinal intradural extramedullary cysticercosis.

BACKGROUND: Spinal cysticercosis represents an uncommon localization of a common parasitic disease and, in most cases, is associated with intracranial involvement. Once confirmed, the entire neuraxis should be evaluated. CASE DESCRIPTION: We present an unusual case of a 60-year-old male patient with isolated localization of spinal intradural extramedullary cysticercosis. The patient was treated successfully with the combination of surgical excision and orally administered albendanzole. We discuss the treatment options, the diagnostic screening, and the possible route of dissemination. CONCLUSIONS: Because this is a rare but potentially life-threatening disease, clinicians should always take it into consideration in the differential diagnosis of spinal space-occupying lesions.

Cervical spinal cord intramedullary teratoma.

We present the case of a 62-year-old patient suffering from the presence of a cervical spinal cord intramedullary teratoma and treated operatively. The purpose of this case report is to describe the highly unusual localization of the intramedullary teratoma associated with other vertebral malformations. A review of the literature is also presented.

Retroclival epidural hematoma secondary to a longitudinal clivus fracture.

Retroclival epidural hematomas (RCEDH) make part of posterior fossa epidural hematomas (PFEDH) and represent an extremely rare entity not always easily diagnosed with computerized tomography (CT) due to beam hardening artifacts. The authors present a case of a child-to our knowledge-the first reported until now-featured the rare combination of a longitudinal clivus fracture associated with concomitant epidural hematoma treated conservatively with favorable outcome of the patient.