Microsurgical treatment of ophthalmic artery aneurysm, a case series of 55 patients with long-term follow-up.

BACKGROUND: Ophthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes. METHODS: All the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant. RESULTS: Among 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores. CONCLUSION: OAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.

Lumbar sacralization and L4-L5 microdiscectomy, a prospective cohort study on radiologic and clinical outcomes.

Aim: To evaluate the role of lumbar sacralization (LS) on the surgical outcomes of L4-L5 microdiscectomy. Methods: This prospective cohort study was conducted in a university referral hospital. The patients with L4-L5 disc herniation and eligible for microdiscectomy were enrolled and allocated in G1 (with LS) and G2 (no LS). After the L4-L5 microdiscectomy patients were followed, clinical and radiological parameters were collected to investigate the influence on the outcomes. Recurrence, low back outcome score (LBOS), and the Oswestry disability index (ODI) were defined as main outcomes. Results: Two hundred and forty patients (n = 120, each), were reviewed in the final analysis. There was no difference between groups regarding baseline characteristics. Postoperative radicular and back pain was more severe in LS(P < 0.05). Univariate analysis showed recurrence was significantly higher in LS with a direct correlation with postoperative back pain persistence and low LBOS (p = 0.001). Age had a negative impact on G2 recurrence(p = 0.008). LS had a negative impact on LBOS and ODI scores. Postoperative radicular pain and higher lumbar lordosis were associated with a higher disability (ODI) index. Conclusion: L4-L5 microdiscectomy in patients with lumbar sacralization was associated with higher recurrence rates, worse ODI and LBOS scores, persistent postoperative axial back pain, and radicular pain. Postoperative axial back pain and poor LBOS results could effectively predict a higher recurrence rate following L4-L5 microdiscectomy in lumbar sacralization.

Treatment refractory acute necrotizing myelitis after COVID-19 vaccine injection: a case report.

Introduction and importance: Post-vaccination myelitis is a rare and debilitating clinical situation. There are few reports of post-COVID-19 infection and vaccination neurological sequela. Case presentation: A 69-year-old lady was admitted to the emergency department due to weakness and hypoesthesia in her hands 1 week after the Sinopharm vaccine injection. MRI showed a cervicothoracic cord haemorrhagic lesion that deteriorated within 48 h. The clinical course was refractory to conservative treatments. She underwent an emergency cervical laminectomy as a salvage treatment. Intraoperative samples were in favour of acute necrotizing myelitis. Discussion: In the review of the literature, the inflammatory storm, vasculitis, and many unknown etiologies are deemed to be the possible causes of encephalopathy and myelitis after COVID-19 infection and vaccination. There are few cases of post-COVID-19 myelitis and hematomyelia, but this case was the first report of post-vaccination necrotizing myelitis. Conclusion: Post-vaccination necrotizing myelitis is a lethal medical situation requiring intensive and emergent neurosurgical vigilance. Early clinical diagnosis in the beginning and full neurosurgical-neurological treatment armamentarium options are cornerstones of treatment paradigms. Salvage treatment options such as extensive laminectomy may play a life-saving role in treatment refractory cases of acute necrotizing myelitis.

SARS-CoV-2 and spinal cord ischemia: a systematic review on clinical presentations, diagnosis, treatment, and outcomes.

BACKGROUND CONTEXT: Spinal cord ischemia is a rare but ominous clinical situation with high levels of disability. There are emerging reports on COVID-19 and spinal cord ischemic events. PURPOSE: To investigate the cardinal manifestations of SARS-CoV-2 associated spinal cord ischemia, review treatment paradigms, and follow outcomes. STUDY DESIGN: A systematic review. METHODS: The current study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to February 12, 2023, on spinal cord ischemia and SARS-CoV-2 infection. Data on patient demographics, study methods, medical records, interventions, and outcomes were extracted from eligible articles. For each data set, the authors performed pooled estimates examining 3 factors of interest, which were (1) predisposing factors (2) treatment regimens, and (3) neurological rehabilitation outcomes. Neurological status was reported as the American Spinal Injury Association (ASIA) impairment scale reported by data sets. RESULTS: Six data sets were identified. The mean age of the study population was 50 years old, with 66.6% male predominance. Sixty-six percent of the patients had severe COVID-19. Five data sets reported preexisting coagulopathy. ASIA A and B were the most prevalent primary neurological status (80%). The mean interval between COVID-19 and the first neurological deficit was 13 days. Anterior spinal artery lesions were the most prevalent ischemic pattern. The most common treatment regimens were heparin and steroid therapy. Physical rehabilitation showed poor functional outcomes. CONCLUSIONS: SARS-CoV-2 is associated with spinal cord ischemia through multiple neuropathological mechanisms. Proper coagulation profile control and aggressive rehabilitation may play a promising role in the prevention and recovery of spinal cord infarction in SARS-CoV-2 patients.

Spontaneous spinal epidural haematoma following COVID-19 vaccination: a case report.

Introduction: COVID-19 vaccination side effects are rare but important medical situations. Spine-affecting side effects are amongst the rarest, but exceedingly important. Haemorrhagic spinal manifestations of COVID-19 and its vaccines are less reported with little knowledge about them. Case presentation: An 80-year-old male who received his first shot of the COVID-19 vaccine had developed COVID-19 pneumonia, weakness, and sensory problems in his legs followed by sphincter incontinence within 5 days period. MRI showed a spontaneous epidural spinal epidural haematoma (SSEDH) in T10-L1. He underwent laminectomy and haematoma evacuation. One month follow-up showed no clinical improvement. Discussion: To our knowledge, this was the first post-vaccination SSEDH and second in haemorrhagic spinal complications following COVID-19 vaccination. Considering the neuropathogenesis pathway of COVID-19 and its vaccines, there are common mechanisms of action that could potentially justify post-vaccination SSEDH such as seen in COVID-19 infection, itself. Early Neurosurgical intervention and better preoperative neurological status could be a beneficial modifier for favourable clinical outcomes. Conclusion: SSEDH and COVID-19 vaccine coincidence is a rare clinical event, still no solid association could be scientifically explained. Further studies are required for a reliable pathophysiologic association. Early diagnosis, interdisciplinary medical approach, and faster intervention are the cornerstone of the treatment paradigm.

Spondylodiscitis instrumented fusion, a prospective case series on a standardized neurosurgical protocol with long term follow up.

PURPOSE: To investigate the fusion construct properties, construct length, intervertebral prosthesis (IVP) selection, bone grafting methods, complications management, and follow-up outcomes of spondylodiscitis fusion. METHOD: This case series was conducted in Al-Zahra University referral hospital from March 2016 to November 2021. All the surgery-eligible patients were enrolled. Those who did not participate or failed the neurosurgical intervention were excluded. A unified neurosurgical protocol was defined. After operation and follow-up, all variables were documented. IBM SPSS v.26 was used for data analysis. P-value ≤ 0.05 was considered significant. RESULT: Ninety-two patients were reviewed in the final analysis with 65.2 % males. The mean age was 55.07 ± 14.22 years old. The most frequent level of pathology and surgery was the lumbar spine (48.9 %). Short and long constructs were almost equally used (57.6 and 42.4 %, respectively). Bone graft mixture was the dominant IVP (75 %). The most frequent persistent postoperative symptom was back pain (55.4 %), while the neurological deficits resolution rate was 76.7 %. The fusion rate was 92.3 %. Proximal junctional kyphosis incidence was 16.3 % and had a significant association with on-admission neurological symptoms, thoracic and thoracolumbar junction involvements (p < 0.05). Follow-up Oswestry disability index scores showed 44.6 % of the patients had mild or no functional disabilities. Advanced age, On-admission deficits, comorbidities, titanium cages, and poor fusion status were associated with poor functional outcomes and higher mortality rates (P < 0.05). CONCLUSION: The introduced neurosurgical protocol could effectively achieve acceptable SD treatment, spine stabilization, and fusion with low long-term surgical complications. Autologous bone graft mixture in comparison to titanium cages showed a higher fusion rate with a lower mortality rate. Patients with older age, neurological symptoms, and comorbidities are expected to experience less favorable clinical outcomes.

SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review.

The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including spontaneous spinal hemorrhage (SSH), are diverse. SSH is a detrimental neurosurgical event requiring immediate medical attention. We aimed to investigate the association between SARS-CoV-2 and SSH and delineate a rational clinical approach. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to January 25, 2023, on SSH and SARS-CoV-2 infection. For each dataset, the authors performed pooled estimates examining three outcomes of interest: (1) early post-intervention neurological status, (2) mortality, and (3) post-intervention neurological rehabilitation outcomes. After reviewing 1341 results, seven datasets were identified for the final analysis. Fifty-seven percent of patients were females. Twenty-eight percent of the patients experienced severe systemic infection. The mean interval between the SARS-CoV-2 infection and neurological presentation was 18 days. Pain and sensorimotor deficits were the most common (57%). Spinal epidural hematoma (EDH) was the most common presentation (71.4%). Three patients were treated conservatively, while 4 received neurosurgical intervention. Pain and sensorimotor deficits had the best treatment response (100%), while the sphincter had the worst response (0%). Long-term follow-up showed that 71% of patients had good recovery. SARS-CoV-2-associated SSH is a rare complication of infection, with an often insidious presentation that requires high clinical suspicion. Patients with SARS-CoV-2 infection and new neurological symptoms or disproportionate neck or back pain require a neuroaxis evaluation. Neurosurgical intervention and conservative management are both viable options to treat SSH following COVID-19. Still, a homogenous approach to the treatment paradigm of SSH cannot be obtained, but lesions with space-occupying effects are suitable for neurosurgical evacuation-decompression while more indolent lesions could be treated conservatively. These options should be tailored individually until larger studies provide a consensus.

Dorsal intradural spinal arteriovenous fistula associated with giant intradural spinal aneurysm, a case report.

Arteriovenous fistula and spinal aneurysms like other vascular malformations can mimic radiculopathy and low back pain. Precise imaging work combined with a hybrid endovascular-microsurgical approach is the key element for the best clinical outcome.

In-Fracture Pedicular Screw Placement During Ligamentotaxis Following Traumatic Spine Injuries, a Randomized Clinical Trial on Outcomes.

Objective: To investigate the efficacy and safety of two different techniques for spinal ligamentotaxis. Spine ligamentotaxis reduces the number of retropulsed bone fragments in the fractured vertebrae. Two different ligamentotaxis techniques require clinical evaluation. Methods: This was a randomized clinical trial. The case group was defined as one pedicular screw insertion into a fractured vertebra, and the control group as a no-pedicular screw in the index vertebra. Spine biomechanical values were defined as primary outcomes and complications as secondary outcomes. Results: A total of 105 patients were enrolled; 23 were excluded for multiple reasons, and the remaining were randomly allocated into the case (n=40) and control (n=42) groups. The patients were followed up and analyzed (n=56). The postoperative mid-sagittal diameter of the vertebral canal (MSD), kyphotic deformity correction, and restoration of the anterior height of the fractured vertebrae showed equal results in both groups. Postoperative retropulsion percentage and pain were significantly lower in the case group than in the control group (p=0.003 and p=0.004, respectively). There were no group preferences for early or long-term postoperative complications. Conclusions: Regarding clinical and imaging properties, inserting one extra pedicular screw in a fractured vertebra during ligamentotaxis results in better retropulsion reduction and lower postoperative pain.

Surgical outcomes of calvaria reconstruction in cranial pansynostosis associated with Arnold-Chiari type 1.5 malformation, a case report.

A 6-year-old girl with persistent headaches and the visual problem was diagnosed as a delayed onset cranial pansynostosis with concurrent type 1.5 Arnold-Chiari malformation. She underwent multi-sutural reconstructive surgery and followed. The headache was greatly decreased and tonsillar-brain stem herniation and syrinx were resolved.

Spontaneous intramedullary hematoma following COVID-19 vaccination: A case report.

A 67-year-old female was hospitalized due to right-sided hemiparesis and neck pain with rapid deterioration to a deep coma. She had received the Sinopharm vaccine 2 days earlier. MRI showed extensive cervicothoracic hematomyelia. She received intensive medical care for 2 months and was discharged. An 18-month follow-up showed significant neurological recovery.

Comparison between rivaroxaban versus enoxaparin for venous thromboembolism prophylaxis following spine surgeries, a randomized clinical trial.

BACKGROUND: Enoxaparin is currently used for VTE prophylaxis. Rivaroxaban is more cost-effective and is as potent as enoxaparin in VTE prophylaxis. METHODS: The study was held at Al-Zahra and Kashani university hospitals in Isfahan, Iran, from January 2019 to October 2020. Two hundred ninety-six patients requiring instrumented spine surgery were enrolled; 23 were excluded (lack of consent/interfering medical situations). They were randomized into the groups of rivaroxaban (case, n = 137) and enoxaparin receiving (control, n = 136). Medical data were recorded and 244 patients (case = 123, control = 121) were analyzed value < 0.05 was meaningful. RESULTS: 150 patients were males, and 94 were females. The mean age was 52.09 ± 12.6 years. Postoperative drain volume was higher in rivaroxaban received patients than in enoxaparin (p = 0.02). Post-operation epidural hematoma was detected in 3 patients in the case and 1 in the control group, which was not meaningful(p = 0.622). All of them were evacuated surgically. POH was associated with cervical canal stenosis surgery, existing comorbidities, and new medical events. New medical events were associated with postoperative wound dehiscence (p = 0.001). Short and long-term postoperative outcomes were similar in both groups. The mean follow-up duration was 25.8 ± 7.5 months. CONCLUSION: Rivaroxaban is as effective as enoxaparin in venous thromboembolic event prophylaxis. Regarding postoperative epidural hematoma, statistical analysis showed equal safety of both drugs. Still, the authors would like to recommend more discretion in rivaroxaban administration in cervical spine laminectomy until future studies are conducted.