Full Endoscopic Anterior Cervical Discectomy vs Anterior Cervical Discectomy with Fusion. A Systematic Review.

AIM: To assess, and to compare the efficacy of anterior endoscopic cervical discectomy (AECD) and anterior cervical discectomy with fusion (ACDF). MATERIAL AND METHODS: Major databases, registries, and other relevant material were screened for prospective trials directly comparing AECD and ACDF. No restrictions were imposed. Meta-analysis was not conducted due to high heterogeneity. RESULTS: After screening a total of 1339 articles, 2 studies enrolling 225 patients were included. One of these is a randomizedcontrolled- trial, including 120 patients, with a 14% lost to follow-up, showing no statistically significant differences in clinical outcomes according to the visual analogue scale (VAS) of the neck/arm and the North American Spine Society criteria regarding pain/neurological status. Radiological follow-up showed no adjacent-segment disease, with both groups presenting a statistically non-significant progression of a pre-existing adjacent-disc degeneration, and no difference in kyphosis. Recurrence was registered in 7.4% and 6.1% of patients who underwent AECD and ACDF, respectively. No statistically apparent differences in complications were observed. The second is a cohort study, including 135 patients with a 14.8% lost to follow-up. No statistically significant difference was found in clinical outcomes assessed using the VAS of the neck/arm and the neck disability index. No radiological data were provided. Recurrence was reported in 4% and 2% of patients in the AECD and ACDF group, respectively. No remarkable differences in complications were reported. Both studies reported that the surgical time was statistically shorter in AECD. CONCLUSION: A definitive conclusion cannot be drawn. Single-level AECD seems to have results equivalent to ACDF, presenting even some benefits. Technical limitations combined with required surgical skills and experience should be considered. We recommend cautious employment in anticipation of future updates.

Cleaning Up the Chimney: Early Renal Stent Graft Thrombosis Following Endovascular Treatment of a Juxtarenal Aortic Aneurysm With the Chimney Technique.

The endovascular management of juxtarenal aortic aneurysms with the chimney technique (ch-EVAR) has gained popularity in recent years. It provides an alternative to open repair, allowing treatment of challenging anatomies with devices readily available in any vascular suite. The primary drawback persists as the occurrence of type-Ia endoleak from gutters and renal stent thrombosis. We present two cases of early renal stent graft thrombosis following chimney endovascular aneurysm repair. The first patient was an 80-year-old man who underwent single ch-EVAR and came back on the fifth post-op day with renal stent graft thrombosis. He was re-operated for recanalization and additional stenting of his chimney graft. The patient recovered well with no complications. The second case involved a 72-year-old man with a juxtarenal aneurysm, treated with ch-EVAR on both renal arteries. Unfortunately, on the 10th post-op day, he was referred to our department due to lumbar pain and acute renal failure due to chimney graft thrombosis bilaterally. The left renal chimney graft was recanalized by endovascular means. On the contrary, despite efforts of the endovascular and open approach, the right chimney graft and the right renal artery remained occluded. While ch-EVAR is a viable and off-the-shelf solution for urgent and complex juxtarenal aortic aneurysms, it should be performed with awareness of the potential for graft thrombosis and persistent endoleaks. Despite these complications, the chimney technique can still be a viable treatment option. A better understanding of the indications and advancements in the devices used can lead to better long-term results.

Microanatomic Morphometric Characteristics of the Third Ventricle Floor.

Background: Endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus. The in-depth understanding of microanatomy is essential for accurate diagnosis, treatment and complications prevention. The aim of this study is to supplement the knowledge gap regarding the microanatomical metrics and correlations for which the literature includes only scarce mentions at best. Methods: This is a descriptive microanatomical study including 25 cadaver brains. Specimens from donors with neurological, psychiatric disorders or alcohol abuse were excluded. Surgical loops were used for harvesting. High-precision tools were employed to dissect and measure the anatomical landmarks under a surgical microscope. Each measurement was performed in three consecutive attempts and outliers were rejected. RStudio was used for statistical analysis. Distribution was evaluated employing the Shapiro-Wilk test. Normally distributed values were presented as mean and standard deviation, and others as median and interquartile range. Results: The age of the donors was 61.72 (±10.08) years. The distance from the anterior aspect of the foramen of Monro to the anterior margin of the mamillary body was 16.83 (±1.04) mm, and to the posterior margin was 16.76 (±1.9) mm. The distance from the anterior mamillary body margin to the infundibulum was 6.39 (±1.9) mm, to the optic recess was 8.25 (±1.84) mm, and to the apex of the vertebral artery was 5.05 (±1.62) mm. The distance from the anterior commissure to the brain aqueduct was 22.46 (±2.29) mm, and to the infundibulum was 13.93 (±2.54) mm. The mamillary body diameter was 4.91 (±0.34) mm in the anteroposterior and 4.21 (±0.48) mm in the cranio-caudal plane. The intraventricular segment was protruding by 1.63 (±0.46) mm. The diameter of the hypothalamus on the anterior margin of mamillary bodies was 1.37 (±0.75) mm, of the Liliequist membrane was 0.19 (±0.07) mm and of the lamina terminalis was 0.35 (±0.32) mm. Conclusion: The presented microanatomical measurements and correlations are expected to contribute to the improvement of ETV safety.

Cerebrospinal Fluid Homeostasis and Hydrodynamics: A Review of Facts and Theories.

BACKGROUND AND PURPOSE: According to the classical hypothesis, the cerebrospinal fluid (CSF) is actively secreted inside the brain's ventricular system, predominantly by the choroid plexuses, before flowing unidirectionally in a cranio-caudal orientation toward the arachnoid granulations (AGs), where it is reabsorbed into the dural venous sinuses. This concept has been accepted as a doctrine for more than 100 years and was subjected only to minor modifications. Its inability to provide an adequate explanation to questions arising from the everyday clinical practice, in addition to the ever growing pool of experimental data contradicting it, has led to the identification of its limitations. Literature includes an increasing number of studies suggesting a more complex mechanism than that previously described. This review article summarizes the proposed mechanisms of CSF regulation, referring to the key clinical and experimental developments supporting or defying them. METHODS: A non-systematical literature search of the major databases was performed for studies on the mechanisms of CSF homeostasis. Gray literature was additionally assessed employing a hand-search technique. No restrictions were imposed regarding the time, language, or type of publication. CONCLUSION: CSF secretion and absorption are expected to take place throughout the entire brain's capillaries network under the regulation of hydrostatic and osmotic gradients. The unidirectional flow is defied, highlighting the possibility of its complete absence. The importance of AGs is brought into question, potentiating the significance of the lymphatic system as the primary site of reabsorption. However, the definition of hydrocephalus and its treatment strategies remain strongly associated with the classical hypothesis.

Cross-Cultural Adaptation and Validation of the Greek Version of the "Full Outline of Unresponsiveness Score": A Prospective Observational Clinimetric Study in Neurosurgical Patients.

BACKGROUND: The Full Outline of Unresponsiveness (FOUR) score is a clinical instrument for the assessment of consciousness which is gradually gaining ground in clinical practice, as it incorporates more complete neurological information than the Glasgow Coma Scale (GCS). The main objectives of the current study were the following: (1) translate and cross-culturally adapt the FOUR score into Greek; (2) evaluate its clinimetric properties, including interrater reliability, internal consistency, and construct validity; and (3) evaluate the reliability of assessments among health care professionals with different levels of experience and training. METHODS: The FOUR score was initially translated into Greek. Next, patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with the GCS and FOUR score within one hour by four raters who had different levels of experience and training (two board-certified neurosurgeons, a neurosurgery resident, and a registered nurse). Interrater reliability, internal consistency, and construct validity were evaluated for the scales using weighted Cohen's κ (κw) and intraclass correlation coefficients (ICC), Cronbach's α and Spearman's ρ values, respectively. RESULTS: A total of 408 assessments were performed for 99 patients. The interrater reliability was excellent for both the FOUR score (ICC = 0.941) and GCS (ICC = 0.936). The values of κw exceeded 0.90 for all pairs, suggesting that the FOUR score can be reliably applied by raters with varying experience. Among the scales' components, FOUR score's brainstem and respiratory items showed the lowest, yet high enough (κw > 0.60), level of agreement. The interrater reliability remained excellent (κw > 0.85, ICC > 0.90) for all diagnosis and age groups, with a trend toward higher FOUR score values in the most severe cases (ICC = 0.813 vs. 0.723). Both the FOUR score and GCS showed high internal consistency (Cronbach's α > 0.70 for all occasions). The FOUR score correlated strongly with GCS (Spearman's ρ > 0.90 for all raters), suggesting high construct validity. CONCLUSIONS: The Greek version of the FOUR score is a valid and reliable tool for the clinical assessment of patients with disorders of consciousness. It can be applied successfully by nurses, residents, and specialized physicians. Therefore, its use by medical practitioners with different levels of experience and training is strongly encouraged.

Long-term Outcome Following Three-Level Stand-Alone Anterior Cervical Discectomy and Fusion: Is Plating Necessary?

BACKGROUND: Anterior cervical discectomy with fusion (ACDF) is a proven method for the treatment of selected patients. The necessity of use of an anterior plate is controversial. The article aims to assess the fusion rates (FRs) and long-term outcomes following three-level ACDF. MATERIALS AND METHODS: Data were collected from the medical records of patients operated on due to degenerative cervical disease. All patients were treated with three-level ACDF employing polyether ether-ketone cages without anterior plating. Visual analog scale (VAS), neck disability index (NDI), and plain radiographs were used in the clinical and radiological postsurgery assessment. Fusion evaluation was performed according to the <1 mm motion between spinous processes rule. Subsidence was defined as a more than 2 mm decrease in the interbody height. RESULTS: A total of 234 treated levels on 78 patients were assessed. The mean presurgery NDI score was 23.07 ± 4.86, with a mean disability of 46.03% ± 9.64. The mean presurgery VAS score of the neck was 7.58 ± 0.85, while VAS score of the arm was 7.75 ± 1.008. Post surgery, NDI stated no disability, while VAS score of the neck and arm showed no presence of pain. The mean FR was 19.50 ± 21.71 levels per month, with a peak from 3rd to 6th month. Presurgery evaluation showed 12 (15.38%) patients with a high T2 sequence signal. Magnetic resonance imaging screening detected 31 (39.24%) patients with coexisting cervical and lumbar findings. Post surgery, transient dysphagia was reported by 1 patient (1.28%), while subsidence was registered in 15 (6.41%) levels, situated in 12 patients (15.38%), most often at C6-7 (66.6%). Clinical and radiological follow-up extended to 69.47 ± 11.45 months. CONCLUSION: Multilevel stand-alone ACDF is a safe, cost-effective procedure providing favorable clinical and radiological results with minimal complications. The incidence of subsidence is usually clinically insignificant and can be decreased with a careful surgical technique.

Infantile Atypical Teratoid Rhabdoid Tumor of the Spine Presenting with Acute Hydrocephalus.

INTRODUCTION: Central nervous system atypical teratoid rhabdoid tumors (ATRTs) are aggressive lesions usually presenting during the first 3 years of life. These tumors have a dismal prognosis with most patients dying within 1 year from presentation. Primary spinal location in infants is very rare. CASE PRESENTATION: We report a case of a 4-month-old boy who presented with a history of hypotonia, poor head control, and gradually reduced level of consciousness, over the past week. Computed tomography (CT) showed acute hydrocephalus with no underlying intracranial pathology. A ventriculoperitoneal shunt was inserted acutely. Postoperatively, ventilator weaning was unsuccessful. MRI of the brain and whole spine revealed an intraspinal extradural contrast-enhancing heterogenous mass in the subaxial cervical spine extending to the thoracic cavity. A biopsy was taken through a transthoracic approach, and histopathology confirmed the diagnosis of ATRT. Several cycles of radiation therapy and chemotherapy were given but the tumor progressed both locally and intracranially. Eventually, pupils became dilated and fixed. Brain CT scan showed widespread ischemic lesions and an extensive intracranial tumor extension with massive bleeding. The child eventually died 110 days after admission. CONCLUSIONS: In infants presenting with acute hydrocephalus where an obvious intracranial cause is not detected, the whole neuraxis should be screened. However, despite aggressive measures and advances in multimodality treatment, prognosis of ATRT remains dismal.

Retroperitoneal Liposarcoma Masquerading as an Impending Rupture of Inflammatory Abdominal Aortic Aneurysm.

BACKGROUND: We present a unique case scenario of a periaortic liposarcoma masquerading as an impending rupture of an inflammatory abdominal aortic aneurysm (AAA). METHODS AND RESULTS: A 57-year-old man was referred to our unit for an emergency endovascular repair of "an inflammatory AAA with computed tomography (CT) features of impending rupture." He underwent an uneventful endovascular repair with a bifurcated endograft (C3; Gore, Flagstaff, AZ). Seven weeks later, CT showed that the periaortic "mass" grew larger and asymmetric, and a CT-guided needle biopsy suggested the presence of a high-grade malignant mesenchymal tumor. He underwent laparotomy and excision of the retroperitoneal tumor en bloc with the anterior wall of the infrarenal aorta. The endograft acted as an excellent "safety net" providing adequate hemostatic control and obviating the need for aortic cross-clamping and repair of the aortic defect with a patch or tube graft. CONCLUSIONS: The learning point from the present case is that when faced with an inflammatory AAA and/or retroperitoneal fibrosis, the rare possibility of a retroperitoneal neoplasm should be kept in mind.

Pedicle screw placement accuracy impact and comparison between grading systems.

BACKGROUND: Pedicle screw instrumentation is widely used for spinal stabilization. However, the accuracy for free-hand screw placement ranges from 69% to 94%. This study assesses the value of the existing classification systems, and investigates their impact on the ability to assess the accuracy of free-hand screw placement. METHODS: Data were collected retrospectively from the medical records of 34 patients who received 224 pedicle screws placed utilizing a free-hand technique. Screw placement was evaluated employing the 2-mm increment and Zdichavsky et al. classification systems. Kappa coefficient and Landis and Koch interpretations were employed for statistical analysis. RESULTS: The 2-mm increment classification system resulted in a total of 18 (8.03%) misplaced screws. Lateral screw misplacement was observed in 13 (5.8%) instances, with medial pedicle wall penetration being noted in 5 (2.23%). Of the 18 misplaced screws, 4 (22.22%) were classified as minor (≤2 mm), 12 (66.67%) as moderate (2-4 mm), and 2 (11.11%) as severe (>4 mm) (K = 0.882). The Zdichavsky et al. grading system categorized 208 (92.84%) pedicle screws as Ia, 10 (4.46%) as Ib, 1 (0.45%) as IIa, 2 (0.90%) as IIb, 2 (0.90%) as IIIa, and 1 (0.45%) as IIIb grade; this resulted in a total of 16 (7.14%) misplaced screws (K = 0.980). One patient exhibited a new postoperative radiculopathy attributed to poor screw placement. There were no additional early or late postsurgical complications attributed to screw misplacement. CONCLUSION: The free-hand pedicle screw placement technique is both safe and effective. Postoperative computed tomography studies; however, are useful to confirm the accuracy of screw placement. Although, the available grading systems proved reliable, easy to use, and clearly reflected the individual surgeon's skills, they do not clearly document whether screws are safely placed.

Severe cervical spondylotic myelopathy with complete neurological and neuroradiological recovery within a month after surgery.

Cervical spondylotic myelopathy is a complex syndrome evolving in the presence of degenerative changes. The choice of care and prognostic factors are controversial. The use of appropriate surgical technique is very important. Posterior approach may be chosen when pathology is present dorsally and/or in the presence of neutral to lordotic alignment. Anterior approach is the golden standard in patients with kyphosis and/or stenosis due to ventral lesions, even with three or more affected levels. A 67-year-old man presented with progressive weakness and clumsiness (mJOA: 5; Nurick: 4). An anterior discectomy, osteophytectomy and bilateral foraminotomy of the C4-C5; C5-C6; C6-C7 were performed. Polyether-Ether-Ketone spacers and a titanium plate were placed. The patient was mobilized 3-hour post-surgery and was released the following day. Medicament therapy and a neck-conditioning program were prescribed. Clinical examinations were normal within a month. Magnetic resonance imaging showed no traces of the preoperatively registered intramedullary focal T2 hyper-intensity.

The miracle of the black leg: E astern neglect of Western addition to the hagiography of Saints Cosmas and Damian.

The Christian miracle tales strongly support the identification of Sts. Cosmas and Damian as doctors. The most famous of the saints' posthumous miracles, is that of the Black Leg. The main source of this story is the Golden Legend by Jacobus da Varagine, collection of fanciful hagiographies compiled in the 13th century. Saints Cosmas and Damian miraculously transplanted the black leg of the Ethiopian man onto the white body of the verger with "cancerous" leg. Saints appeared to the patient in a dream, amputated his diseased leg and replaced it with the leg of a recently died man. This dramatic cure was attractive for many western artists. The iconography of this miracle was depicted for the first time in a Florentine panel of ca.1370. The color of the leg later attracted special attention. Since the 1990's the Miracle of the Black Leg, presented in a (neo) Byzantine style, appeared in Greece. The miracle of Holy Unmercenaries has no proper historical foundation in the Books of the lives of the Saints in the Orthodox Churches. Action focused on replacement of the affected leg with one from cadaveric donor was unknown to the eastern Christianity. Exploration of available orthodox hagiographical sources related to the healing powers of Sts. Cosmas and Damian showed remarkable neglect of that miracle. Some contemporary Greek authors find appropriate to disregard it.