Surgery for cervical spondylotic myelopathy: anterior versus posterior approaches

Surgical treatment of cervical spondylotic myelopathy [CSM] remains controversial. Several approaches have been advocated to treat cervical spondylotic myelopathy including anterior, posterior and combined approaches. The aim of this study was to review the clinical and imaging varieties of cervical spondylotic myelopathy and their influence on choosing the appropriate surgical approach. Fifty five cases with cervical spondylotic myelopathy operated upon at the neurosurgery department, Alexandria University were reviewed. The different clinical and imaging features were analyzed, and parameters for choice of surgical approach were addressed. Among all patients with CSM, neck pain was present in 49%, brachialgia in 67%, mild myelopathy in 44% and moderate myelopathy in 56%. Following cervical laminectomy, neck pain improved in 50% and remained stationary in 50%; brachialgia recovered in 33%, improved in 50% and remained stationary in 17%; mild myelopathy showed good outcome in 80% and fair outcome in 20%; whereas moderate myelopathy showed good outcome in 20%, fair outcome in 60% and poor outcome in 20%. Following anterior discectomy with fusion, neck pain recovered in 28.5%, improved in 38% and remained stationary in 28.5%; brachialgia recovered in 58.5%, improved in 31% and remained stationary in 10.5%; mild myelopathy showed excellent outcome in 17%, good outcome in 58% and fair outcome in 25%; whereas moderate myelopathy showed good outcome in 35%, fair outcome in 30% and poor outcome in 35%. Following cervical laminoplasty, neck pain improved in 100%; brachialgia remained stationary in 100%; mild myelopathy showed good outcome in 100%; whereas moderate myelopathy showed fair outcome in 50% and poor outcome in 50%. Early surgical intervention for CSM is associated with higher recovery rate. Selection of surgical approach depends on age, cord morphology, and spine geometry mostly spinal curve and canal diameter. The presense of cervical spine instability necessitates complementation of spine decompression with spine fixation

Tuberculum sellae meningiomas

This study was done to evaluate the importance of the size of the lesion and early identification of thesymptoms and their effect on the outcome in patients with tuberculum sellae meningiomas. Between 1999 and 2004, at the Department ofNeurosurgery, Alexandria University and other hospitals, 21patients with histopathologically identified tuberculum sellae meningiomas received surgical tumour removal. In thisstudy, the records and clinical data of these patients are retrospectively analyzed. All patients had preoperative plainX-ray, CTscan and MRI of the brain. Different surgical procedures were done. Unilateral subfrontal was done in 16patients. Bifrontal approach was used in one patient and pterional approach was done in 4 cases. Tuberculum sellae meningioma was most frequent in the fifth decade, with a clear predominance in women.Neurological and endocrine deficits were minimal, whereas ophthalmologic signs were always present. The duration ofsymptoms ranged from 3 months to 15 years, averaging 3.25 years. Tumor size ranged from 1.6 cm to 4.4 cm,averaging 3.4 cm. Sellae turcica was not enlarged in all cases. Computed tomography and MRI were the most reliablediagnostic tools. All patient underwent craniotomy using the operating microscope. Prognosis was evaluated accordingto the tumour size and duration of symptoms. Results showed the prognosis was favorably affected by a tumor size of 3cm or less and symptom duration of one year or less. In this series, patients with a tumor size of 3 cm or less and patients with a duration of symptoms for oneyear or less had a better visual outcome, higher total removal rates and lower recurrence rates

Management of adult tethered cord syndrome

This study was done to evaluate the surgical outcome of untethering of the cord in a consecutivec 10 adult patients suffering from tethered cord syndrome. This prospective study was carried out on consecutive 10 adult patients suffering from manifestations due to tethering of the cord. The patients were admitted to the Alexandria main university hospital over a period of 3 years starting from March 2002 to March 2005. The male to female ratio was 7 to 3 and their ages ranged from 25 till 57 years with mean age of 38.5. Most patients [9 patients] suffered from low back pain, while 7 patients showed signs of root affection and radiculopathy, sphincteric disturbances were present in all patients. Interestingly one patient had bilateral neuropathic ulcers at the site of the heel. All our patients developed signs and symptoms of tethered cord syndrome in adulthood. All patients were subjected to preoperative MRI of the lumbosacral spine, urodynamic study, and preoperative electrophysiological study of the lumbo-sacral plexuses. Intraoperative electrophysiological monitoring maneuvers using a bipolar stimulating electrode were used to identify functional neural tissue from the filum terminale and the response of lower limb muscles, and external anal sphincter were recorded either manually or by electromyography. Untethering of the cord using surgical microscope was done under general anesthesia without muscle relaxation. Dural graft was used in one case with secondary adhesions. Mean postoperative follow-up period was 15 months, including both clinical and MRI examination. The lower level of the conus was at lumbar vertebra L2 in one case, at L4 in 6 cases and at level from L5 to sacrum in 3 cases. The tethering lesions were tight filum terminale in 7 patients, lipoma in 2 patients, and secondary adhesions in one patient. Thickness of the filum was ranged from 1 to 7mm with a mean of 3.7mm. There was no operative mortality, and surgery did not provoke any permanent neurological aggravation of our cases. After surgery 2 patients [20%] were asymptomatic, 5 patients [50%] improved, and 3 patients [30%] stabilized, also all the patients were independent. The surgical outcome after tethered cord release in the adults is favorable, as most patients report improvement or stabilization of their symptoms. Safe surgical treatment with minimal complications and side effects can be achieved with the aid of intraoperative neurophysiological monitoring techniques. The success of surgery depends on early diagnosis and complete untethering of the spinal cord. It seems reasonable to recommend early surgical treatment in both symptomatic and asymptomatic adults

Surgical management of empty sella syndrome

This study was done to evaluate the clinical features, surgical management and outcome in a consecutive 10 cases with empty sella syndrome [ESS]. This prospective study was carried out on consecutive 10 adult patients suffering from manifestations due to empty sella syndrome. 6 patients [60%] had symptomatic primary empty sella syndrome and the rest 4 patients [40%] had manifestations due to secondary empty sella syndrome. The patients were admitted to Alexandria main university hospital or any of Alexander private hospitals over a period of 4 years starting from March 2000 to March 2004. The male to female ratio was 1 to 4 and their ages ranged from 21 till 50 years with a mean age of 38.5. Headache was the commonest symptom [70% of patients]. As regard the clinical presentation, manifestations of increase the intracranial pressure were found in 6 patients [60%], visual manifestations in 6 patients [60%], CSF rhinorrhea in 4 cases [40%], and endocrinological dysfunction in 3 patients [30%]. All patients had preoperative plain X-ray, CT scan and MRI of the brain. Different surgical procedures were done according to the mode of presentation and the radiological findings. Extradural transsphenoidal packing of the sella turcica was done in 8 cases while subfrontal craniotomy with intradural repair of the anterior cranial fossa with fascia was done in 2 of the 4 cases presented with CSF rhinorrhea then followed by application of thecoperitoneal shunt in the same 2 cases [after failure of intradural repair of the anterior cranial fossa with fascia to stop the CSF leak]. Mean postoperative follow-up period was 20 months, including both clinical and radiological examination. After surgery 4 patients [40%] were asymptomatic, 3 patients [30%] improved, and 3 patients [30%] stabilized, also all the patients were independent. Patients with preoperative complaint of headache respond well to surgery, with complete resolution in 85.3% of cases [6 cases out of 7]. On contrast only 50% of the patients with preoperative visual field defect improved [3 cases out of 6]. No patients with preoperative decreased visual acuity [2 cases] have improved after surgery. Postoperative MRI studies after transsphenoidal extradural packing revealed that the sellar contents appeared satisfactory elevated both on sagittal and coronal planes with upward lifting of suprasellar structures in all the 8 cases. The surgical outcome of cases with empty sella syndrome is favorable, as most patients report improvement or stabilization of their symptoms. Visual disturbances and CSF rhinorrhea are the main indications for surgery. The type of surgical approach depends on clinical presentation and radiological findings