Comparative study between pedicular screws, interbody fusion cages and combined procedures in management of spondylolisthesis

Background and Objective: to evaluate surgical management of spondylolisthesis through posterior approach using different instrumentation including fixation by pedicular screws/rods with posterolateral arthrodesis, posterior interbody titanium threaded [stand alone] cages as PLIF or pedicular system and posterior different types of cages [titanium or carbon] to bold the bony interbody fusion

Patients and Methods: sixty patients with lumbar spondylolisthesis were classified into three groups: Group A [n=20] was fixed by pedicular-screws/rods fixation with posterolateral arthrodesis; group B [n=20] had posterior interbody titanium threaded [stand alone] cages as PLIF; and group C [n=20] was fixed by pedicular system and posterior different types of cages [titanium or carbon]. All patients underwent serial clinical evaluations at regular 3-month intervals between the 3rd and the 12th postoperative months. At the second year they were examined at 6-month intervals. Functional disability was measured by the Oswestry low back pain disability questionnaire. Radiological evaluation was done with 6 months interval for 2 years to evaluate: fusion status; hardware status [correct placement or failure]; anatomical correction [horizontal displacement, angular displacement; disc height]; and instability and degenerative . changes on adjacent levels. All surgical problems were recorded including intraopertaive, early and late postoperative ones

Results: excellent postoperative Brodsky scores of pain were reported by 50%, 55% and 60% in group A, B and C respectively, showing a significant difference to preoperative scores in each group. The success rates were 80%, 85% and 90% in group A, B and C respectively. Correction Rate [CR] of preoperative symptoms was 90% in group C, 85% in group B and 75% in group A. Obvious fusion was detected in 18 cases [90%] of group C, 16 cases [80%] of group B and 14 cases [70%] of group A, i.e. the fusion rate after circumferential fusion is higher and reliable than that in stand-alone procedure. Immediately after surgery, there was a significant reduction in horizontal displacement [HD], and angular displacement [AD], and a significant increase in disc height [DH] in all groups, which still significant after 2 years in group B and group C only. There was non significant difference in the rate of complications except the significant increase in-operative time > 4 hours in group C

Conclusion: in cases of spondylolithesis grade I. and II, fixation by pedicular system and posterior different types of cages [titanium or carbon] provide a more solid mechanical construct -when compared with the pedicle screws used alone or stand alone cages. All surgical procedures are effective, although combined procedure showed better clinical outcomes if quality of life, pain improvement, and functional recovery are considered

comparative study of surgical approaches to cerebello-pontine angle tumours

The present study included 66 patients with cerebello-pontine angle [CPA] tumours. Retro sigmoid approach was done in 53 patients with CPA tumours, 29 retrospective cases and 24 pospective. Trans labyrinthine approach was done in 13 patients with CPA tumours, 8 retrospective cases and 5 prospective. Out of the 66 patients with CPA tumours ,40 cases were vestibular schwannomas, 14 were meningioma's, two arachnoid cysts, two epidermoid and eight patients with other tumours. In sub occipital retrosigmoid cases total resection were done in 71.42% and subtotal in 28.58%. Mortality occurred in 3 cases, facial nerve affection in 21.46%, hearing loss in 21.46% and CSF leakage in 7.14%. In trans labyrinthine cases total radicality occurred in 76.9% and subtotal in 25.1%. No mortality was recorded, hearing loss in all, CSF leakage in 7. 7%. Follow-up of patients for one year showed good preservation of facial nerve function in 76.9%·with trans labyrinthine resection as measured by House and Brackmann system. Facial nerve preservation occurred in all cases with small tumours, 50% of medium sized and55.5% of large tumours. With retro sigmoid resection of schwannomas facial nerve preservation was found in 85.71%.Complete hearing loss occurred in all patients with trans labyrinthine approach. Follow up of retro sigmoid surgery showed hearing preservation with good serviceable haring in 75% of moderate sized acoustic neuromas and hearing loss occurred in 21.46% in whole group of schwannoma. The present study demonstrated that with unserviceable hearing, the trans labyrinthine approach, whatever the size ·of the tumour, is the approach of choice. Young patients with good preoperative hearing are candidates for retro sigmoid surgery. If there is doubt concerning residual tumour the labyrinth should be sacrificed. With patients with tumours smaller than 1.5cm in diameter and in patients with good hearing and no extension in internal auditory canal, retro sigmoid approach is used. Tumours -size larger than 1.5 cm can be accessed by retro sigmoid or trans labyrinthine approaches

C-T Metrizamid and surgical corelation in Spina Bifida Cystica

This work was conducted on 38 cases of spina bifida cystica with employment of C.T. mitrizamid as preliminary methods of investigation and treated by microsurgical technique. The work showed that the agreement of surgical verification with C.T. mitrizamid was in 32 cases with percentage of 84.21%. The disagreement was only in 15.79% of the cases [6 cases]. So, C.T. mitrizamid is trustful method of investigation as regard to study of both vertebral lipoma in wide anomalies. MRI can be use as confirmatory method if intraspinal lipoma in wide spinal canal suspected to give more delineation of the soft tissue contents

Stroke presentation of chronic subdural haematoma

This work was conducted on 803 cases presented to Neurosurgery and Neurology departments as stroke; 25 cases out of these 803 cases proved by brain C.T scan or MRI to be chronic subdural haematoma with percentage of 3.1% of the cases. This percentage is still questionable as there are no previous studies that estimate the stroke presentation of chronic subdural haematoma. Statistical studies of factors affecting final outcome of chronic subdural haematoma showed significant correlation between the onset-intervention interval and the final outcome. Chronic subdural haematoma with stroke presentation only was diagnosed by radiological investigation [brain C-T. scan or MRI]

Epidural fentanyl, intravenous morphine, and oral rofecoxib, analgesia for control of post -laminectomy pain in case of lumbar canal stenosis

Fifty-four patients of lumber canal stenosis as proved clinically and radiologically treated by lumber laminectomy were randomly allocated to one of three groups, 18 cases each. The first group received epidural fentanyl infusion, the second group received intravenous morphine and the third group received oral rofecoxib in the early 48 hours postoperatively. Study of the analgesic effect for control post-laminectomy pain was done, which revealed a big difference in the analgesic effect of three used methods during the first 16 hours. The superior method was epidural fentanyl analgesia, and a satisfactory level of analgesia was obtained with the three methods by the end of first 16 hours and became stationary till the end of the 48 hours

Post-traumatic cerebrospinal fluid rhinorrhea [minimally invasive procedures reduce number of craniotomies]

In this study, 212 patients with post-traumatic cerebrospinal fluid [CSF] rhinorrhea were evaluated shortly [within few hours] after head trauma, they were arranged into two groups [A and B]. It was concluded that in post-traumatic CSF rhinorrhea whenever possible, the repair of the dura [during early surgical intervention for another emergency intracranial lesions] gives an excellent chance for clean healing of the dura-arachnoid tear with subsequently less incidence of complications and CSF leak. Otherwise, conservative management including minimally invasive procedures can achieve spontaneous sealing of the fistulae in a high percentage of patients. Trans- sphenoidal approach is another less invasive procedure that reduces the overall number of craniotomies for the treatment of persistent CSF rhinorrhea

Intraspinal epidermoid cysts

In this study, five patients with the rare epidermoid cyst of the intraspinal lumbosacral region were evaluated clinically and radiologically. All patients were presented by progressive neurological impairment of varying severity that m and ated surgical management for the removal of the cystic mass. Postoperative excellent improvement was obtained for four patients showing a restoration of normal muscle power with a return to normal daily activities. One patient got a residual neurologic deficit that did not improve during the follow up period, while another patient developed an asymptomatic leptomeningeal cyst that required no further management. Minor transient forms of meningismus occurred in two patients, in spite of the adequate hydrocortisone medication perioperatively. The pathology, etiology, epidemiology, clinical features, imaging characteristics and surgical treatment of such rare tumors were discussed. Magnetic resonance imaging [MRI] reduced the delay in the diagnosis of intraspinal tumors but it should be guided by the clinical judgment