A novel guide device for pedicle screw insertion using three-dimensional preoperative planning in open lumbar spinal surgery: a comparative retrospective study.

OBJECTIVE: Pedicle screw stabilization (PSS) surgeries for spinal instability are still the most effective treatment approach. The use of preoperative planning can minimize the complications related to transpedicular screw (TPS) misplacement. The study aimed to evaluate the surgical outcomes of a guide device developed to improve the accuracy of the free-hand technique using three-dimensional planning in PSS. PATIENTS AND METHODS: Patients with degenerative spinal diseases who underwent open PSS between 2019 and 2022 were evaluated retrospectively. FG group included patients who were operated on using the fluoroscopy alone with preoperative two-dimensional planning. AFG group included patients who were operated on using a guide advice-assisted technique with preoperative 3DP. Between-group comparisons were performed. RESULTS: A total of 143 patients with a mean age of 59.6 years were included in the study. 71 patients were assessed in the FG group and 72 patients in the AFG group. Between-group comparisons regarding demographics, etiologies, radiation exposure, and functional improvements showed no significant differences (p > 0.05). Although the accuracy of TPSs positioning was 94.2% and 96.5% in the 2DG and 3DG, the difference between the groups was not statistically significant. The statistically significant differences regarding the upper-level facet joint violation and pedicle breach rates were lower in the AFG group (p < 0.0001; X2 = 19.57) and (p < 0.0001; X2 = 25.3), respectively. CONCLUSION: Using a guide device associated with preoperative 3PD reduced the upper-level facet joint violation and pedicle breach rates in open PSS surgeries performed by free-hand technique for degenerative spinal diseases.

Comparing Three-dimensional and Two-dimensional Preoperative Planning for Lumbar Transpedicular Screw Placement: A Retrospective Study.

BACKGROUND: Transpedicular screw (TPS) misplacement is still a nightmare for spine surgeons. Preoperative planning is one of the methods that a surgeon could use to minimize this complication. This study aims to compare the efficacy of three-dimensional (3D) and two-dimensional (2D) preoperative planning in posterior lumbar TPSs placement performed using the freehand technique. PATIENTS AND METHODS: Patients who underwent posterior TPSs placement for degenerative lumbar spondylolisthesis or spinal stenosis using the freehand technique between November 2021 and October 2022 were evaluated retrospectively. In total, 33 and 30 patients who met the inclusion criteria were consecutively operated on with preoperative 2D and 3D planning, respectively. The patients were divided into the 2D preoperative planning group (2DG) and 3D preoperative planning group (3DG) and the two groups were compared. RESULTS: Sixty-three patients were operated during the study period. There was no significant difference between the groups regarding blood transfusion, operation time, and radiation exposure. Although the accuracy of TPSs positioning was 94.2 and 96.5% in the 2DG and 3DG, respectively, the difference between the groups was not statistically significant. The upper facet joint violation rate was 12.8% (n = 20) in the 2DG versus 3.5% (n = 5) in the 3DG (p = 0.006). All L4 TPSs were inserted with their standard entry points without any modification (p < 0.0001; relative/risk ratio = 0.64). The modification rate was higher in L1, L2, and L5 TPSs (p < 0.0001; χ 2 = 24.7). CONCLUSION: For patients with degenerative lumbar diseases, 3D preoperative planning in posterior lumbar instrumentation surgeries performed with the freehand technique decreased the upper facet joint violation rate.

Local Prophylactic Teicoplanin Effect on Spinal Fusion Surgery: A Comparative Retrospective Study.

BACKGROUND: Surgical site infection (SSI) is one of the severe complications of spinal fusion surgery that leads to increased morbidity and mortality rates. Prophylactic antibiotic usage is one of the methods that reduce the SSI possibility in this procedure. To determine the effect of local subfascial teicoplanin and compare it to vancomycin on surgical outcomes in patients who underwent decompression with posterior instrumentation (DPI) for lumbar spinal stenosis (LSS). PATIENTS AND METHODS: Medical charts of patients with LSS who received DPI and met the study criteria were divided into three groups: the teicoplanin group included patients who underwent DPI with local teicoplanin before closure, the vancomycin group, included patients who underwent DPI with local vancomycin, and the control group included patients who underwent DPI without any local prophylactic antibiotics. RESULTS: A total of 101 patients were included in the study. No significant differences were found among groups regarding demographics, follow-up, and clinical and functional outcomes. No significant differences were observed among groups regarding postoperative improvements in SF-36-MCS, SF-36-PCS, Oswestry disability index, and VAS (p>0.05). In the teicoplanin and vancomycin groups, the SSI rate was lower without statistical significance (2/35, 1/34, and 5/32, respectively, p=0.136); however, the postoperative fusion volume was significantly higher in the teicoplanin group when compared to other groups (3.35±1.08 cm3, 2.68±1.17 cm3, and 2.65±1.28 cm3, respectively, p=0.007). CONCLUSIONS: Although its cost is relatively higher, teicoplanin was a good alternative for vancomycin in preventing SSIs with a higher fusion rate, but no superiority was observed regarding other outcomes.

Surgical Outcome of Spinal Subdural Abscesses: A Report of Four Consecutive Patients and Brief Review of the Literature.

BACKGROUND AND STUDY AIMS: Spinal subdural abscesses (SSAs) are rare and have a poor prognosis, especially when they are diagnosed late. In the literature, most cases of SSAs have been reported as case reports and small case series. In this study, we aimed to evaluate the surgical outcomes of four consecutive SSA patients. MATERIAL AND METHODS: In this retrospective study, we reviewed the medical charts of four SSA patients who underwent surgical intervention at two neurosurgical centers from September 2012 to September 2019. RESULTS: Our series comprised four patients (three females and one male) with SSA (intradural-extramedullary) who were treated surgically. Holocord SSA was observed in two patients. The mean age was 15.1 ± 17.1 years. Unsteady gait and weakness of legs was the presenting symptom in all patients. The mean preoperative course was 5.3 ± 3.4 weeks. The causative pathogens were methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, and Mycobacterium tuberculosis. In the fourth case, the pathogen was non-M. tuberculosis. In the 44th postoperative month, the patient underwent surgery for an intramedullary abscess. The causative pathogen was E. coli. Except for one adolescent male who was paraplegic at presentation, improvement was observed in all patients at their last follow-up after 54.0 ± 35.9 months after surgery. CONCLUSION: Early diagnosis and urgent surgical intervention are essential for a good prognosis in SSA cases. We recommend drainage followed by appropriate antibiotics.

Oxidative Stress Level in Patients with Subarachnoid Hemorrhage.

BACKGROUND: One of the antioxidant mechanisms is the dynamic balance between thiol and disulfide, which, in subarachnoid hemorrhage and other chronic diseases, is disrupted in favor of the latter. The two most commonly used oxidative stress (OS) biochemical markers are the oxidative stress index (OSI) value, which indicates the total oxidant status (TOS) and total antioxidant status (TAS) balance, and the thiol-disulfide (TDS) value, which indicates the total thiol (TT) and native thiol (NT) balance. High OS levels require further investigations. We aimed to investigate the OS level in aneurysmal SAH (aSAH) patients. METHODS: In this clinical prospective study, blood samples were collected from 50 consecutively treated patients with aSAH and 50 volunteers. Serum TOS, TAS, TT, and NT levels were measured using Erel's method via a spectrophotometer. The Glasgow Coma Scale (GCS) scores, Fisher grades, length of hospital stay (LOS), and the Glasgow Outcome Scale (GOS) scores were recorded. Consequently, the OSI and TDS values were calculated in all participants. RESULTS: A statistically significant difference was observed in the TAS, TOS, OSI, and TDS values between the aSAH patients and the controls. The TT and NT values were significantly lower in aSAH patients than in the controls. A correlation was identified between the OSI values and the GCS scores. Although a correlation was observed between the TDS values and the LOS, no correlation was found between the OSI and the TDS values. CONCLUSION: The OSI and TDS, which are OS indicators, might serve as the additional objective nominal data to evaluate the treatment efficacy and follow-up for SAH patients. Moreover, decreasing the OSI values and increasing the TT values can be used as improvement indicators in the treated aSAH patients. If we can reduce the OS at the early stage of SAH, it could improve the prognosis by reducing both the morbidity and mortality rates. Further randomized investigations are required to prove the findings in this prospective study.

Effects of Methylprednisolone in the Treatment of Spinal Cord Injuries by Evaluation of microRNA-21: An Experimental Study.

BACKGROUND AND STUDY AIMS: Spinal cord injury (SCI) is one of the most complicated pathologies that affect active young males. miR-21 primarily regulates several cellular processes. We aimed to elucidate the regulatory role of miR-21 and test methylprednisolone as a disease-modifying agent on experimental SCI tissues. METHODS: A total of 36 8- to 10-week-old adult female Sprague-Dawley rats weighing 250 to 300 g were used. Animals were randomly divided into six groups. Except for groups 1 and 4, the spinal trauma model was applied to all animal groups using the clipping method. In groups 3 and 6, methylprednisolone was given. For real-time polymerase chain reaction (PCR) investigations, rats in groups 1, 2, and 3 were reoperated on after the first postoperative day, whereas those in groups 4, 5, and 6 were reoperated on after postoperative day 7 and spinal cord samples from the laminectomy area were removed for gene expression analysis. Relative gene expression of miR-21, Gfap, Vim, Stat3, Faslg, Pten, Bax, Bcl2, Cox2, and Il6 were determined with quantitative reverse transcription (qRT) PCR. RESULTS: In group 3, the miR-21 expression significantly increased compared with groups 1 and 2. When compared with group 3, a decrease in miR-21 expression was observed in group 6 (p < 0.05). When compared with group 4, group 6 had lower levels of Gfap, Pten, Stat3, and Bax (p < 0.05). CONCLUSIONS: miR-21 supports the beneficial aspects of the body's healing mechanisms following SCI. In the acute phase, the use of methylprednisolone increases miR-21 expression in the early period of trauma. Methylprednisolone increases some astrogliosis and inflammation biomarkers' levels; however, it did not affect the apoptotic biomarkers.

Management of Adult Chiari I Patients Based on CSF Flow Magnetic Resonance Imaging: Experience of Two Neurosurgical Centers.

BACKGROUND AND STUDY AIMS: Chiari malformation type 1 (CM1) is one of the most discussed neurosurgical disorders. No consensus exists how to manage adult CM1 patients. We aimed to evaluate all adult CM1 patients consecutively managed at our institutions and discuss our approach based on the phase-contrast (PC) magnetic resonance imaging (MRI). PATIENTS AND METHODS: The medical charts of adult patients diagnosed with CM1 at two referral neurosurgical centers between 2010 and 2017 were reviewed. The patients were either managed conservatively or surgically. We evaluated the patients clinically with the Chicago Chiari Outcome Scale (CCOS). The radiologic diagnosis was based on both craniocervical and PC-MRI. RESULTS: Ninety adult CM1 patients were managed conservatively. Conservative treatment failed in 5 of these 90 patients. Seventy-two patients (including those 5 patients who did not benefit from conservative treatment) underwent posterior fossa decompression with duraplasty. Eighty-five patients (94.4%) from the conservative group and 61 patients (84.7%) from the surgical group were treated successfully. An aqueductal stroke volume (ASV) value of 12 µL was found as the cutoff value for surgical candidates. A strong positive correlation between the increase in ASV values and clinical improvement was observed. CONCLUSIONS: PC-MRI can help in the management and follow-up of adult CM1 patients. Conservative management is possible in selected symptomatic CM1 patients with a high ASV (ASV > 15 µL). Surgery should be considered in patients with an ASV ≤ 12 µL. CM1 patients with ASV ≤12 to >15 µL require close follow-up. Long-standing symptoms, severe sleep apnea, symptoms influencing functionality, and syrinx are factors that affected outcomes negatively.

Association between subarachnoid hemorrhage-induced hydrocephalus and hydromyelia: pathophysiological changes developed in an experimental model.

BACKGROUND: Subarachnoid hemorrhage-induced hydrocephalus (SAIH) can affect the prognosis of subarachnoid hemorrhage (SAH). The relationship between hydromyelia and SAIH has been rarely investigated. This experimental model aimed to identify the pathophysiological changes developed in the SAH and elucidate the relationship between hydromyelia and SAIH. MATERIAL AND METHODS: 25 female rabbits were randomly divided into three groups. The SAH group (n = 15), sham group (n = 5), and control group (n = 5). In the former group, the injection of 0.5 mL/kg of autologous blood was carried out into the cisterna magna on days 0 and 2. All animals were decapitated 21 days thereafter. Histological examinations of the medulla spinalis and brain samples were performed. RESULTS: The mean volumes of the central channel were 1.054, 1.287, and 1.776 mm3 in the control, sham, and SAH groups, respectively (p = 0.028). The mean normal ependymal cell densities were 4.210, 3.602, and 2.923 cells/mm2 in the control, sham, and SAH groups, respectively (p = 0.002). The mean ventricular Evans' indices were 0.31, 0.34, and 0.41, in the control, sham, and SAH groups, respectively (p = 0.006). Basement membrane rupture, desquamated ependymal cells, and central channel occlusion were observed on histological examinations of the SAH group. CONCLUSIONS: Subependymal basement membrane destruction, blood cell accumulation on it, ependymal cell desquamation, increased cerebrospinal fluid (CSF) secretion, and increased ICP in the central channel that causes hydromyelia. When these pathological changes are chronically apparent, they may reflect on CSF pathways and cause permanent SAIH. Preventing long-time SAH-induced hydromyelia is believed to reduce the high rate of treatment-requiring SAIH.

Factors associated with the recurrence of lumbar disk herniation: non-biomechanical-radiological and intraoperative factors.

BACKGROUND: Recurrent lumbar disk herniation (RLDH) is one of the most undesirable complications following lumbar discectomy (LD). This study aimed to prospectively investigate the non-biomechanical-radiological and intraoperative factors affecting the recurrence after discectomy. PATIENTS AND METHODS: Data of 988 consecutive patients with Lumbar disk herniation (LDH) who underwent LD at our department for over 2 years (2014-2015) were prospectively collected. Patients who met our study criteria were included (n = 816). Patients were divided into the following groups; group 1 included patients with symptomatic RLDH within the first postoperative 2 years (PO24M), group 2 included patients with symptomatic RLDH after PO24M, and group 3 included patients without symptomatic RLDH/LDH. The preoperative non-biomechanical-radiological, surgical, and intraoperative characteristics were compared among the groups. RESULTS: A total of 842 LDHs in 816 (386 men and 430 women) patients received LD. The mean age was 46.9 years. The mean follow-up period was 72.8 months. The first recurrence rates within the first PO24M and after PO24M were 7.1% and 3.2%, respectively. Disks with Modic changes type-II and contained disks without fragments were associated with the short- and long-term RLDH [(p = 0.004; HR = 0.6); (p < 0.0001; HR = 0.14)] and [(p = 0.041; HR = 0.6); (p < 0.0001; HR = 0.16)], respectively. CONCLUSIONS: Several radiological, surgical, and intraoperative factors can play a critical role in RLDH; therefore, the selection criteria of patients with LDH should be carefully considered for surgical treatment to obtain acceptable outcomes. ABBREVIATIONS: ANOVA: A one-way analysis of variance, CIs: 95% confidence intervals, HR: Hazard ratio, LD: Lumbar discectomy, LDH: Lumbar disc herniation, LF: ligamentum flavum, MRI: Magnetic resonance imaging, MC-I: Modic changes type I, MC-II: Modic changes type II, MC-III: Modic changes type III, n: Number, ODI: Oswestry Disability Index, OR: Odds ratio, p-value: Probability value, PO: Postoperative, Pre: Preoperative, Pts: Patients, RLDH: Recurrent lumbar disc herniation, RR: Relative/risk ratio, SPSS: Statistical package for the social science, T1WIs: T1-weighted images, T2WIs: T2-weighted images, VAS: Visual analog scale.

An incidental diagnosis of an unusually located echinococcus alveolaris.

ABSTRACT: Hydatid cyst disease is a zoonotic infection caused by the genus Echinococcus. Hydatid cysts are usually located in the liver or lungs whereas the brain is an unusual location. A 45-year-old male patient was diagnosed with an intracranial mass suggesting a metastasis in the frontal region shown in the cranial computed tomography (CT) scan following a cranial trauma. The histological evaluation revealed an acellular laminated lesion surrounded with reactive changes, compatible with a cuticle. These findings were evaluated in favour of a hydatid cyst caused by Echinococcus multilocularis. Alveolar echinococcosis is a zoonotic disease caused by the genus Echinococcus multilocularis. Hydatid cyst is a common public health issue in the countries where livestock farming is common. Primary or metastatic tumours and abscesses should be considered in the differential diagnosis of hydatid cysts regardless of their location.

Factors Affecting Long-Term Surgical Outcomes of Spinal Extramedullary Ependymomas: A Retrospective Study.

BACKGROUND: Spinal intradural-extramedullary ependymomas (IEEs) most commonly affect the lumbosacral spine. Because of their neural axis dissemination and adherence to neural structures, managing IEEs is still a controversial neurosurgical challenge. The study aimed to investigate the potential prognostic factors that influence long-term surgical outcomes by evaluating consecutively operated patients with IEEs. METHODS: During the study period, medical records of all diagnosed patients with spinal tumors were reviewed retrospectively. This study included all patients with consecutive IEEs who underwent surgical intervention in 3 neurosurgical institutions in different periods (February 2004 to December 2020). RESULTS: In 3 neurosurgical institutions, 64 (28 women, 36 men) patients were operated upon for IEE. The mean age of the patients at diagnosis was 38.9 years. The mean preoperative symptom duration was 17.8 months. Radicular pain was the most common symptom, observed in 53 patients. Gross total resection was applied to 48 patients. 54 patients had good clinical outcomes at their last follow-up after 106.9 months on average. Myxopapillary ependymoma was the most common histopathological type (n = 43). The progression was observed in 5 patients. The presence of preoperative neurological deficits, IEEs extending >2 spinal levels, bone-eroded IEEs, surgical complication, capsule violation, and incomplete resection were associated with poor prognosis. CONCLUSIONS: Several clinical and surgical factors can affect the functional outcomes of the surgical treatment of IEEs. Some radiological features can make neurosurgeons aware of the prognosis of IEEs. In such cases, the neurosurgeons should plan to remove tumors without violating their integrities (capsules) to obtain satisfactory functional outcomes.

Long-Term Surgical Outcomes of Two Patients with Intracranial Extraskeletal Mesenchymal Chondrosarcoma and a Brief Literature Review.

Objective Intracranial extraskeletal mesenchymal chondrosarcomas (IEMCs) are malignant aggressive neoplasms. IEMCs originate from the meninges or parenchyma. In the current study, we aimed to figure out the importance of gross total resection (GTR) and adjuvant radiotherapy (RT) by evaluating all reported IEMCs through the literature that included our two patients. Methods and Methods We presented two IEMC patients who were treated at our institutions and followed up for a long duration. To understand the appropriate management for IEMC, we conducted a systematic literature review for previously reported series and cases of IEMCs. Results We surgically treated two young males with IEMC initially diagnosed at their age of 18 and 20 years. The patients were initially treated with GTR and GTR followed by RT, and followed-up for 218 and 73 months, respectively. Through both the patients, we obtained 83 reported IEMC patients from the literature. The mean age of the reported cases was 24.5 ± 16.0 years (2 months-71 years). Female predominance was 54.2%. The mean progression-free and overall survivals were 27.9 and 39.0 months, respectively. The progressiveness rate was 56%. The presence of progressiveness was a poor prognostic factor ( p = 0.0008). GTR was achieved in 53.0% of the patients. There was a significant difference between patients who received GTR compared with those who did not receive GTR ( p = 0.035). Conclusion Regarding their malignancy and progressiveness, we recommended the maximal surgical resection with wide margins followed by RT as appropriate management for IEMCs with close follow-up. The timely treatment provides high life quality and avoids life-threatening complications.

Early stage T1-weighted perfusion magnetic resonance imaging: a factor that predicts local control response in patients with meningioma who underwent gamma-knife radiosurgery.

BACKGROUND: Gamma-knife radiosurgery (GKRS) is an alternative treatment option for selected intracranial meningiomas. The study's aim is to demonstrate the advantages of T1-weighted perfusion magnetic resonance imaging (T1-PMRI) by measuring the volume transfer coefficient (Ktrans) values in the prediction of local response for patients with meningioma who have undergone GKRS consecutively. METHODS: The data of patients diagnosed radiologically with WHO grade 1 intracranial meningiomas was collected prospectively. The patients who were treated consecutively with GKRS at our institution (September 2017-September 2018) were included. After GKRS, the patients were followed up at the defined periods with routine contrast-enhanced MRI and T1-PMRI by measuring the Ktrans. The comparison between the pre-treatment and third-month post-treatment (PO3M) Ktrans was done using the Wilcoxon signed-rank test. RESULTS: Thirty-one patients with 36 tumors have undergone GKRS. Twenty-two patients were female. The mean age was 55.3 years. The mean pre-GKRS volume was 7.67 ccs. The mean 50% radiation isodose was 12.2 Gy. The local tumor control rate was 100%. Fourteen tumors were regressed fully at the last MRI. PO3M Ktrans decreased when compared with the pre-GKRS values (p < 0.0001). However, the numerical decrease in tumor volumes on contrast-enhanced MRI was not statistically significant (p = 0.117). CONCLUSION: Changes between Ktrans on PO3M and pre-GKRS T1-PMRI were more useful in determining the early response to GKRS in patients with meningioma than volumetric changes. Therefore, Ktrans should be taken as a reference to predict the early response to GKRS in follow-up imaging scans.

Management of myxopapillary ependymoma: a retrospective study from three institutions.

BACKGROUND: Myxopapillary ependymomas (MPEs) possess leptomeningeal, neural axis dissemination, seeding metastases, and extra-neural spread which are malignant characteristics, even they classified low-grade lesions as WHO grade II. Managing such lesions remains an arguable neurosurgical challenge. The study aimed to discuss the management of MPEs by evaluating the long-term surgical outcomes of consecutively treated MPEs in different 3 neurosurgical centers. METHODS: Medical records of all diagnosed patients with spinal tumors at our institutions were reviewed retrospectively. This study included all consecutive MPE who underwent surgical intervention in our institutions in different periods between February 2004 and December 2020. RESULTS: A total of 44 patients with MPE were treated surgically in three institutions. 28 (63.6%) patients were males. Six patients were pediatric patients (≤18 years). The mean age was 36.2 years. The preoperative course was 19.2 months. The most common symptom was leg pain, observed in 35 (79.5%) patients. Gross-total resection was performed in 35 (79.5%) patients. 39 (88.7%) patients had good functional outcomes with an average follow-up period of 106.2 months. The progression was observed in 5 (11.4%) patients. Extending >2 segments, unclear boundaries, bone-erosions were associated with poor prognosis and progression. Laminectomy and surgical complications were associated with poor functional outcomes. En bloc resection without violation of lesions' integrities reduced the progression. CONCLUSIONS: Radiological, intraoperative, and surgical factors can affect the functional outcomes and the progression of MPEs. Some precautions in the surgical interventions particularly in MPEs with defined radiological features can improve functional outcomes and reduce the progression risk.

Multiple recurrences of unknown primary tumor in a meningioma: A case report.

Metastasis of a systemic tumor into a primary brain tumor has been rarely reported in the literature. These metastases could be seen mostly in meningiomas and in less frequently in the other intracranial tumors. Carcinoma of an unknown primary site (CUP) metastasizing into an intracranial meningioma is not a common occasion. According to the best of our knowledge, in this report, we present the first case with multiple recurrent CUP, which metastasized to intracranial meningioma, reported in the literature. The whole body was investigated with FDG PET/CT and biomarkers of the most common carcinomas for primary cancer. However, these tests showed no primary affected region. Despite all adjuvant therapies, the tumor had multiple recurrences. Such cases are still a challenge to offer optimal management.

Conservative Treatment of Chiari Malformation Type I Based on the Phase-Contrast Magnetic Resonance Imaging: A Retrospective Study.

BACKGROUND: The use of phase-contrast magnetic resonance imaging is interestingly increased in the diagnosis and follow up of patients with Chiari type I malformation (CM1). The current study aimed to elaborate the benefits of conservative treatment by evaluating consecutively treated adult patients with CM1 who were selected on basis of phase-contrast magnetic resonance imaging. METHODS: Medical records of patients diagnosed with CM1 were retrospectively reviewed at 2 neurosurgical centers spanning 8 years (2010-2017). Adult patients with CM1, who were treated conservatively and met study criteria, were selected to be the core sample for this study. Between-group (benefited vs. nonbenefited) comparisons were performed to understand the factors that may affect the outcomes. RESULTS: Ninety adult patients (68 female and 22 male) received conservative treatment for CM1. The mean age was 40.6 years. Headaches and pinprick loss were the most commonly recorded symptoms and clinical findings, which were recorded in 58 (64.4%) and 31 (34.4%) patients, respectively. Eleven patients were presented with a syrinx. The mean aqueductal stroke volume (ASV) was 16.5 µL. Conservative treatment was ineffective in treating 5 (5.6%) patients, who underwent surgical intervention. The means of ASV in the benefited and nonbenefited groups were 16.7 and 13.2 µL, respectively (P = 0.004). CONCLUSIONS: Conservative approaches (prescriptive medications, physical therapy, Pilates, and swimming) can improve the life quality of nonsurgical candidate adult patients with CM1. Conservative treatment can be useful in selected patients with variably CM1 (ASV = 16.7 µL). Heavy sleep apnea or/and functional symptoms were prognostic factors that affected the conservative treatment negatively.

Factors associated with the recurrence of lumbar disk herniation: biomechanical-radiological and demographic factors.

Many risk factors associated with recurrent lumbar disk herniation (RLDH) following lumbar discectomy (LD) have been reported. This study aimed to elucidate the biomechanical-radiological, clinical, and demographic factors that affect symptomatic RLDH prospectively.We collected prospective data of 988 consecutive patients with LDH who underwent LD at our department from January 2014 to December 2015. Patients who met the study criteria and were followed up postoperatively for more than 5 years were included (n = 816). Patients were divided into 3 groups; group 1 included patients who experienced symptomatic RLDH within the first postoperative 24 months (PO24M), group 2 included patients with symptomatic RLDH after PO24M, and group 3 included the patients who hadn't experienced symptomatic RLDH/LDH. The preoperative biomechanical-radiological, clinical, and the patients' demographic characteristics were compared among the groups.A total of 816 patients with 842 LDH met our study criteria. The mean age at the first LD was 46.9 years. The mean follow-up period was 72.8 months. The preoperative trauma history, postoperative trauma history, and BMI > 24.5 kg/m2 were independent risk factors for RLDH. Large sROM at the L4-5 level and a higher intervertebral disk height index (IDH) were significantly higher in groups 1 and 2.Biomechanical-radiological and demographic factors can affect the incidence of symptomatic RLDH. To reduce the risk of RLDH, patients with these risk factors should receive more attention during surgical interventions. The patients should avoid gaining weight and potential traumatic accidents.

The factors affecting the outcomes of conservative and surgical treatment of chiari i adult patients: a comparative retrospective study.

BACKGROUND: The prognosis of the Chiari malformation type 1 (CM1) demonstrates a variant spectrum that varies from full recovery to complicated worse neurological disability. OBJECTIVE: To investigate the factors affecting the outcomes of conservative and surgical treatment for CM1 by evaluating adult patients consecutively managed at our institutions. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients diagnosed with CM1 at two reference neurosurgical centers for eight years (2010-2017). We selected all CM1 adult patients who managed conservatively or surgically as the core sample for this study. For clinical evaluation, we used a Chicago Chiari Outcome Scale (CCOS). For radiological assessment, we adopted both craniocervical and contrast-phase MRIs. We investigate factors such as age, sex, pretreatment symptoms, symptoms duration, and radiological findings in both groups. RESULTS: Ninety patients were treated conservatively. After a progression, five of them were treated surgically later and included in a total of 72 patients who underwent decompressive surgery. We successfully managed 85 patients (94.4%) of the conservative group and 64 patients (88.9%) of the surgical group. We found that patients with aqueductal stroke volume (ASV) of 12 µl are surgical candidates. We observed a strong positive correlation between clinical improvement and the increase in ASV values. CONCLUSIONS: ASV≤12 µl is a significant predictor for surgical intervention. The presence of heavy sleep apnea or/and functional symptoms, tonsillar herniation >13.4 mm on coronal images, low ASV, long symptom durations, and a syrinx are the independent prognostic factors that affected outcomes negatively.

Long-term surgical outcome of Chiari type-I malformation-related syringomyelia: an experience of tertiary referral hospital.

OBJECTIVE: Syringomyelia is a common condition seen in patients with Chiari type-I malformation (CM1). The purpose of this retrospective study was to evaluate the long-term clinical and radiological outcomes of posterior fossa decompression with duraplasty (PFDD) with coagulation of tonsillar ectopia in consecutive surgically treated adult patients with CM1-related syringomyelia (CRS). METHODS: Over 9 years' duration (1993-2001), medical charts of diagnosed patient with CM1 at our neurosurgical center were reviewed retrospectively. This study included adult patients with CM1 who had syringomyelia and underwent PFDD with coagulation of tonsillar ectopia surgery. The differences between the pre- and postoperative syrinx/cord ratio (S/C), the syrinx length, and the regression of herniated cerebellar tonsils on coronal and midsagittal MRIs were evaluated. RESULTS: A total of 87 surgical procedures (46 primary operations, 7 ventriculoperitoneal shunts, and 34 additional operations) for CRS were performed on 24 males and 22 females. The mean preoperative S/C was 0.59 ± 0.12. The means of regression in herniated cerebellar tonsils on mid-sagittal and coronal images were 11.8 ± 2.3 mm and 10.2 ± 2.2 mm (p < 0.0001), respectively. 35 (76.1%) patients were discharged after showing signs of recovery or improvement. Different complications occurred in 16 (34.8%) patients. Negative correlations were noticed between postoperative recovery/improvement and the long symptoms' duration, the herniated tonsils' extent, S/C, and the persistence of the herniated tonsils on the coronal images. CONCLUSION: Early diagnosis of patients with CRS can improve surgical outcomes. Due to its efficacy in resolving clinical symptoms and syrinx cavities, PFDD is still an optimal surgical approach for CRS.