An Insight into the Prospects and Drawbacks of Stem Cell Therapy for Spinal Cord Injuries: Ongoing Trials and Future Directions.

Spinal cord injury (SCI) is a devastating neurological disorder that has a substantial detrimental impact on a person's quality of life. The estimated global incidence of SCI is 40 to 80 cases per million people and around 90% of cases are traumatic. Various etiologies can be recognized for SCI, and post-traumatic SCI represents the most common of these. Patients worldwide with SCI suffer from a persistent loss of motor and sensory function, which affects every aspect of their personal and social lives. Given the lack of effective treatments, many efforts have been made to seek a cure for this condition. In recent years, thanks to their ability to regenerate tissue and repair lost or damaged cells, much attention has been directed toward the use of stem cells (embryonic, induced pluripotent, mesenchymal, hematopoietic), aimed at restoring the functional integrity of the damaged spinal cord and improving a functional recovery including sensory and motor function. In this paper, we offer an overview of the benefits and drawbacks of stem cell therapy for SCI based on clinical evidence. This report also addresses the characteristics of various stem cell treatments, as well as the field's likely future. Each cell type targets specific pathological characteristics associated with SCI and demonstrates therapeutic effects via cell replacement, nutritional support, scaffolds, and immunomodulation pathways. SCI accompanied by complex pathological processes cannot be resolved by single treatment measures. Stem cells are associated with the adjustment of the expression of neurotrophic factors that help to achieve better nutrition to damaged tissue. Single-cell treatments have been shown in some studies to provide very minor benefits for SCI in multiple preclinical studies and a growing number of clinical trials. However, SCI damage is complex, and many studies are increasingly recognizing a combination approach such as physical therapy, electrical stimulation, or medication therapy to treatment.

Pathogenesis, management strategies, and outcome of non-communicating extradural spinal arachnoid cyst (NEAC): a systematic review.

OBJECTIVE: Non-communicating extradural spinal arachnoid cysts (NEACs) are extremely rare aetiology of symptomatic spinal cord compression. The aim of this study was to address their pathogenesis, optimum management strategy and outcome through systematic review of existing published studies. MATERIALS AND METHOD: We have found 13 eligible publications by searching through PubMed, ScienceDirect, and Google Scholar databases, published from inception to December 2020. We have analysed the data of 21 patients extracted from those 13 publications by IBM SPSS version 23. RESULTS: According to our analysis congenital predisposition, trauma, and previous surgery history are the aetiology of NEAC. Clinical presentation of cyst depends upon the location and extent of compression or involvement of the neurovascular structures. Paraparesis with variable degree of sensory disturbance was seen among patients. Based on neuroimaging findings, NEACs are most commonly found at dorsal and dorsolumbar region. Magnetic resonance imaging (MRI) is the diagnostic modalities of choice and CT myelography can demonstrate the communication with the subarachnoid space. Recurrence rate of cyst after surgery is very low as only one out of twenty patients showed recurrence. If dural defect is not accurately addressed, the recurrence rate increased significantly. CONCLUSIONS: Our study has highlighted aetiology, treatment strategies, and neurological outcome of NEAC. These findings may help neurosurgeons to manage this rare surgical entity for favourable outcome.

Isolated fourth ventricle craniopharyngioma: Representative case illustration and review of literature.

Background: Sella and suprasellar areas are frequently affected by craniopharyngiomas. In this article, eight occurrences have been documented. One is new, and the remaining seven are from previously published articles. Their prevalence in the posterior fossa without expansion from the suprasellar area is unusual. Case Description: We present a case of a primary 4th ventricular craniopharyngioma of the posterior fossa in a 16-year-old male with no association with Gardner's syndrome. He presented with sudden deterioration of consciousness level and was diagnosed as having a homogeneously contrast enhancing lesion occupying the 4th ventricle with obstructive hydrocephalus. The patient underwent emergency placement of external ventricular drain followed by complete removal of the tumor on the next day by midline suboccipital craniotomy with telovelar approach. Histopathological features were consistent with the adamantinomatous variety of craniopharyngioma. He had complete neurological recovery and no evidence of tumor recurrence in 1-year follow-up. Conclusion: The craniopharyngioma in our case was distinct because it was a solid tumor with no cystic component, exhibited homogeneous contrast enhancement in neuroimaging, developed in the fourth ventricle, and reached the level of foramen magnum, features that had rarely been documented previously. We also reviewed the literature on reported cases of 4th ventricular craniopharyngioma to strengthen knowledge in this area and highlight the embryological basis of ectopic craniopharyngioma.

Adult-Onset Pilocytic Astrocytoma Predilecting Temporal Lobe: A Brief Review.

(1) Introduction: Adult-onset pilocytic astrocytoma (APA) accounts for only 1.5% of all brain tumors, and studies regarding APA are limited. This review is focused on the history, clinical course, cytogenetics, neuroimaging features, management, and outcome of APAs. (2) Methods: Using a systematic search protocol in Google Scholar, PubMed, and Science Direct databases, the authors extracted cases of APA predilecting the temporal lobe from inception to December 2020. Articles lacking necessary data were excluded from this study. Data were analyzed using IBM SPSS 23 statistical package software. (3) Results: A total of 32 patients, 14 (43.8%) males and 18 (56.2%) females, with a male/female ratio of 0.77/1, were grouped. The mean age of the patients was 34.22 ± 15.17 years, ranging from 19 to 75. The tumors were predominantly located in the left side. We have also discussed the clinical presentation, and headache was the most common complaint, followed by visual disturbance. Preoperative neuroimaging features demonstrated cystic lesions in 16 patients, with mural nodule in 5 patients; intracerebral hemorrhage was present in 1 patient, and solid enhancing mass was observed in 3 patients. Only our reported case presented as a solid calcified mass. Most of the patients (78.1%) underwent a gross total resection (GTR), only 5 (21.9%) underwent subtotal resection (STR). The outcome and prognosis history were excellent, and no recurrence was observed. (4) Conclusion: Most of the APAs of the temporal lobe follow benign clinical courses, but some patients exhibit aggressive clinical behavior. There was no history of recurrence after treatment at up to 27 years of follow-up.

Aspergillus spinal epidural abscess: A case report and review of the literature.

Aspergillus spinal epidural abscess (ASEA) is a rare entity that may mimic Pott's paraplegia as it commonly affects immunocompromised patients. We present one institutional case of ASEA with concomitant review of the literature. A 58-year-old female presented with intermittent low back pain for 10 years recently aggravated and with concurrent spastic paraparesis, fever, and weight loss. Emergent magnetic resonance imaging (MRI) showed T11-T12 epidural abscess with discitis and osteomyelitis. After empirical treatment with antibiotics, computed tomography-guided, percutaneous biopsy with drainage was performed, showing granulomatous tubercular-like collection. Antitubercular therapy was initiated, but after 1 month, the patient's condition deteriorated. Repeat MRI showed growth of the spinal epidural abscess with significant cord compression and vertebral osteomyelitis. T11-T12 laminectomy and tissue removal were performed with a posterior midline approach. Tissue histopathology showed necrotic debris colonies of Aspergillus spp. Antifungal therapy was started, and the patient rapidly improved. ASEA may mimic Pott's disease at imaging, leading to immediate start of antitubercular treatment without prior biopsy, leading to severe worsening of patients' clinical status. Cases of ASEA should be considered at pretreatment planning, opting for biopsy confirmation before treatment initiation so to prevent the occurrence of fatal infection-related complications.

Evaluation of Surgical Cleavage Plane by Preoperative Magnetic Resonance Imaging Findings in Adult Intracranial Meningiomas.

(1) Background: Meningiomas are usually benign encapsulated intracranial tumors with well-defined borders that offer a high chance of cure with complete removal. The aim of this study was to evaluate the association between preoperative MRI features and surgical plane of cleavage. (2) Materials and Methods: This was a cross-sectional observational study conducted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University. Data were recorded from 48 study participants with confirmed intracranial meningioma and analyzed by IBM SPSS (version 23). (3) Results: The highest incidence of intracranial meningioma was observed in the third decade of life of our study participants. The female to male ratio was 1.82:1. The most common location of meningiomas was convexity (29.16%), sphenoid wing (22.91%), parasagittal (20.83%), and falcine (14.58%). Most of the patients (68.8%) had medium-sized tumors, and 75.0% exhibited hyperintense signal change in the tumor parenchyma on T2-weighted imaging. One-third (33.3%) of patients were characterized as no edema, focal edema, and lobar/hemispheric edema. There was no statistically significant association between tumor size and types of surgical cleavage plane. Different signal intensities of tumor parenchyma, as well as types of peritumoral edema, showed no statistically significant association with surgical cleavage plane (p > 0.05). (4) Conclusion: There was no association among the size of the tumor, extent of peritumoral edema, the intensity of the tumor on T2-weighted images, and the types of surgical cleavage plane. Future studies with larger sample sizes are required to find out more precise findings.

Skull Base Approaches for Tuberculum Sellae Meningiomas: Institutional Experience in a Series of 34 Patients.

(1) Background: The aim of the present study was to evaluate our institutional outcome in tuberculum sellae meningioma (TSM) patients treated microsurgically using multiple skull base approaches, including a transcranial approach and an extended endonasal transsphenoidal approach. (2) Materials and Methods: This is a retrospective study that includes 34 patients with TSM. The study aimed to observe the efficacy of the different common approaches used by a single neurosurgeon. All the patients were evaluated preoperatively and during follow-up with campimetry, head CT scan, and post-contrast MRI. (3) Results: After a transcranial approach, visual acuity improved in 86.20%, was stable in 10.34%, and deteriorated in 3.45%. Through transsphenoidal surgery, vision improved in 80%, was static in 20%, and deteriorated in 0%. Transcranial approaches included pterional, mini-bifrontal basal, and supraciliary keyhole microscopic craniotomies. Gross total removal was performed in 58.82%, near total in 10.34%, and partial removal in 3.45%. The transcranial/supraciliary keyhole endoscopic-assisted approach showed a gross total removal rate of 80%, and near total in 20%. The transsphenoidal approach showed a gross total removal rate of 60%, near total in 20%, and partial removal in 20%. (4) Conclusion: Endoscopic-assisted keyhole supraciliary mini craniotomy for resection of tuberculum sellae meningioma offers low morbidity and good visual outcome. The endonasal route is preferred for the removal of TSM when they are small and midline placed. The major limitation of this approach is a narrow surgical corridor and the restriction on midline-placed lesions. Gross total removal was better achieved with mini-bifrontal basal and pterional craniotomies.

Primary Intraosseous Osteolytic Meningioma with Aggressive Clinical Behaviour: Clinico-Pathologic Correlation and Proposed New Clinical Classification.

(1) Introduction: Primary intraosseous osteolytic meningiomas (PIOM) are non-dural-based tumors predominantly presenting an osteolytic component with or without hyperostotic reactions. They are a subset of primary extradural meningiomas (PEM). In this study, we present a peculiar case with a systematic literature review and propose a new classification considering the limitations of previous classification systems. (2) Materials and Methods: Using a systematic search protocol in Google Scholar, PubMed, and Scopus databases, we extracted all case studies on PIOM published from inception to December 2020. A 46-year-old female patient form Dhaka, Bangladesh, was also described. The search protocol was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. (3) Results: Here, we present a 46-year-old female patient with PIOM who successfully underwent bifrontal craniotomy and gross total removal (GTR) of the tumor. At 6-month follow-up, no tumor recurrence was shown. Including our new case, 55 total cases from 47 articles were included in the analysis. PIOMs were in closer frequency among males (56.4%) and females (43.6%). The most common tumor location was the frontal and parietal calvarium, most commonly in the frontal bone (29.1%). Surgical resection was the predominant modality of treatment (87.3%); only 1.8% of patients were treated with radiotherapy, and 5.4% received a combination of surgery and radiotherapy. Gross total resection (GTR) was achieved in 80% of cases. Extracranial extension was reported in 41.8% of cases, dural invasion in 47.3%, and recurrence in 7.3%. Whole-body 68 Ga-DOTATOC PET/CT has also been reported as a useful tool both for differential diagnosis, radiotherapy contouring, and follow-up. Current treatments such as hydroxyurea and bevacizumab have variable success rates. We have also suggested a new classification which would provide a simple common ground for further research in this field. (4) Conclusions: Surgical resection, especially GTR, is the treatment of choice for PIOM, with a high GTR rate and low risk of complications and mortality. More research is needed on the differential diagnosis and specific treatment of PIOM.

Fusion versus nonfusion treatment for recurrent lumbar disc herniation.

BACKGROUND: Recurrent lumbar disc herniation (RLDH) is one of the major causes for failure of primary surgery. The optimal surgical treatment of RLDH remains controversial. AIM: Retrospectively, we evaluate 135 patients and compare the clinical outcomes between fusion and nonfusion treatment of RLDH. METHODS: Records of 75 men and 35 women aged 28-60 years for conventional revision discectomy alone (nonfusion) and 15 men and 10 women aged 30-65 years for revision discectomy with transforaminal lumbar interbody fusion (TLIF) and transpedicular screw fixation (fusion) were reviewed. Demographics, surgical data, and complications were collected and pre- and postoperative assessment were done by the Visual Analogue Scale (VAS) scale and Japanese Orthopaedic Association (JOA) score. The results after surgery were assessed according to the recovery rate as excellent, good, fair, and poor. RESULTS: The mean follow-up period was 28.8 and 24.6 months in Group A (nonfusion) and Group B (fusion group), respectively. The preoperative data between both the groups showed no statistically significant difference. The postoperative mean VAS and JAO scores, recovery rate, and satisfaction rate showed no statistically significant difference except postoperative low back pain and occasional radicular pain and neurological deficit in nonfusion group which was significantly higher than that of fusion group. In comparison to fusion group, nonfusion group required significantly less operative time, less intraoperative blood loss, less postoperative hospital stay, no blood transfusion, and less total cost of the procedure. Satisfaction rate was 80% and 88% in nonfusion and fusion groups, respectively. CONCLUSIONS: Both convention revision discectomy (nonfusion) and discectomy with instrumented fusion (TLIF) surgery are effective in patients with RLDH.

Lumbar revision microdiscectomy in patients with recurrent lumbar disc herniation: A single-center prospective series.

BACKGROUND: Recurrent lumbar disc herniation (RLDH) is a common complication following primary microdiscectomy. Notably, revision surgery for recurrent disc herniation typically warrants "aggressive discectomy (AD)" rather than microdiscectomy due to the marked changes in anatomy, including postoperative scar. Here, we prospectively evaluated clinical outcomes of 22 RLDH patients following secondary aggressive discectomy (AD). METHODS: Records of 15 males and seven females averaging 41.7 years of age (range 21-60) who developed RLDH following primary microdiscectomy at the L4-5 (n = 12) and L5-S1 (n = 10) levels were studied. All patients underwent secondary AD for recurrent lesions (2014-2019). Multiple clinical parameters were assessed for these 22 patients. Outcomes were evaluated an average of 28.8 months postoperatively and included assessment of visual analog scales (VASs) and Japanese Orthopedic Association (JOA) Scores. RESULTS: The VAS scores for back and radicular pain significantly improved, as did the JOA scores following surgery in all 22 patients after secondary AD. CONCLUSION: The authors concluded that secondary conventional revision discectomy (e.g., AD) effectively and safely managed RLDH.

Diagnosis and treatment of noncommunicating extradural spinal thoracolumbar arachnoid cyst.

BACKGROUND: Noncommunicating extradural spinal arachnoid cysts are extremely rare. They are believed to arise from congenital defects in the dura mater and become enlarged as a consequence of increased cerebro-spinal fluid (CSF) pressure within the subarachnoid space. Most retain a communicating pedicle through which the extradural cyst maintains connection with the subarachnoid space, and only rarely does this communication become sealed. The optimal treatment consists of complete surgical removal of the cyst with ligation of the communicating pedicle. CASE DESCRIPTION: A 29-year-old male presented with a progressive spastic paraparesis of 6 months' duration. The MRI showed a circumscribed intradural extramedullary cystic lesion located from D11-L2. Notably, peroperatively, the cyst appeared to be entirely extradural, without a communicating intradural pedicle. Further, no CSF leak was observed even after Valsalva maneuvers. Following surgical extirpation of the cyst, the patient sustained an uneventful recovery within 1 postoperative month. CONCLUSION: Noncommunicating extradural arachnoid cysts are extremely rare causes of spinal cord compression and should be fully excised.

Conservative versus operative management of postoperative lumbar discitis.

BACKGROUND: Treatment option of postoperative discitis (POD) is either conservative or operative, but till date, there are no established validated protocols of the treatment of postoperative lumbar discitis. AIM: The aim of this study was to assess the outcome of conservative versus operative management of POD following single-level lumbar discectomy. METHODS: We prospectively studied a total of 38 cases of POD. The patients were diagnosed clinically, radiologically, and by laboratory investigations and followed up with serial erythrocyte sedimentation rate (ESR), C-reactive protein, X-ray, computed tomography (CT), and magnetic resonance imaging. Demographic data, clinical variables, length of hospital stay, duration of antibiotic treatment, and posttreatment complications were collected, and pre- and postoperative assessment was done using the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) score. Functional outcome of the study was measured by the modified criteria of Kirkaldy-Willis. RESULTS: VAS score for pain was significantly decreased in both groups after treatment. However, posttreatment differences were not statistically significant. In posttreatment mean JOA score, differences were not statistically significant in both groups except the mean difference (-0.47) of restriction of daily activities, which was statistically significant (95% confidence interval: -0.88--0.07, P = 0.025, unpaired t-test). About 73.7% and 84.2% of the patients had a satisfactory functional outcome in conservative and operative management groups, respectively, at the end of 12-month follow-up. CONCLUSIONS: Operative management yielded better outcomes than traditional conservative treatment in terms of functional outcomes, length of hospital stays, and duration of antibiotic treatment as determined by both the pain and daily activity levels.

Primary sellar neuroblastoma mimicking invasive pituitary adenoma: a systematic review.

INTRODUCTION: To report an extremely rare case of sellar neuroblastoma, which mimicked invasive pituitary adenoma with supra- and parasellar extensions, treated through endoscopic endonasal approach. A systematic review of the literature on diagnosis and management of patients affected by sellar neuroblastomas has been performed. EVIDENCE ACQUIITION: A literature search according to the PRISMA statement was conducted using MEDLINE, Google Scholar, and EBSCO databases, searching for the following MeSH terms: (sellar OR parasellar OR suprasellar OR sphenoidal) AND (neuroblastoma OR extranasal esthesioneuroblastoma OR central neuroblastoma). EVIDENCE SYNTHESIS: Sixty-eight studies were identified. We included 16 papers in our systematic review, comprising a total of 16 patients, 37.5% males and 62.5% females, with a mean age of 47.2 years. Visual disturbances were found in 56.2% of them, hyperprolactinemia in 43.7%, panhypopituitarism in 12.5%, normal pituitary function in 6.25%, SIADH in 25%, but no data is available in 25% of cases. Brain computed tomography and magnetic resonance imaging showed suprasellar and parasellar extension in 31.2% of patients, isolated suprasellar extension in 50%, isolated parasellar extension only in 6.25%, while in 1 case involvement of the petrous apex was described. Transcranial surgery (TCS) was performed for the removal in 31.2% of patients, transsphenoidal surgery (TSS) in 43.7%, a combined approach in 12.5%, and in two cases surgery was not performed due to poor general patient conditions. Adjuvant treatment with conventional radiotherapy (CRT) was performed in 62.5% of cases, gamma knife surgery (GKS) in 18.7%; in 12.5% it was not carried out, while in one case there was no data available. Absence of recurrence was documented in 50% of patients, recurrence that required further treatments in 25%, while in 25% there was no data available. CONCLUSIONS: Primary sellar neuroblastoma is an extremely rare entity with high propensity to recur; whole body scintigraphy is recommended to search for extracranial locations, for optimum management of the disease. Special attention should be paid to endocrinological evaluation and management.

Huge Ventral Cervicomedullary Neurenteric Cyst: A Rare Entity with Good Surgical Outcome and Appraisal.

Neurenteric cysts are rare congenital lesions of benign nature that can be encountered at any level of the neuraxis, starting from the cranium down to coccyx. Rewarding outcome can be achieved with early diagnosis and complete removal of these benign lesions. Here, we report a case of a huge neurenteric cyst in an 11-year-old boy at the ventral craniocervical junction, a rarely reported entity with literature review. In this article, we focus on the clinical presentation, pathogenesis, radiological findings, surgery, and surgical outcome of this benign lesion, as we succeeded to have gratifying result following surgery in our instance.