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Background: Although controversial, endoscopic third ventriculostomy (ETV) in the management of Myelomeningocele and Chiari type II malformation-related hydrocephalous is gaining wider popularity and use. With variable success rates, it can be proposed as a first or second option after shunt malfunction. ETV in post-infectious hydrocephalus may also be considered as an alternative to shunting. With reported success rates of 50-60%, failure is attributed to anatomical reasons and/or to pathological subarachnoid space scarring that may result from infectious processes. Similarly, ETV in repeated shunt malfunctions is an acceptable option that may offer shunt independency. In all situations, case-by-case selection and discussion are to be considered. Case Description: A 5-year-old boy with a history of surgically treated lumbosacral myelomeningocele and ventriculoperitoneal shunting at six months of age is presented. During the course following the initial surgery, he experienced multiple shunt malfunctions, with two episodes of meningitis, leading to 7 shunt revision surgeries. Lately, the patient presented a large peritoneal cyst formation that needed regular evacuations. With a magnetic resonance imaging (MRI)-scan showing a large bi-ventricular hydrocephalus and a trapped third ventricle with multiple septations, surgical options included either ventriculoatrial shunting or third ventriculostomy. The latter option, offering shunt independency, was chosen after family consent and risk explanation. The expected success rate of the procedure was discussed and evaluated to 40-60% on the ETV success score. The video describes a step-by-step procedure with detailed radiological and correlated anatomical annotations of a completely distorted anatomy of a multifactorial hydrocephalous. No scarring at the prepontine cistern was observed. Shunt independency was achieved. However, the patient died from late postoperative status epilepticus and pulmonary complications. Whether these postoperative events are directly related to the procedure is unclear, although technically and clinically successful in the short term. Conclusion: We believe that ETV should be carefully indicated in selected patients with Chiari II, post-infectious hydrocephalus, by experienced hands, as the surgical anatomy can be extremely complex and misleading.
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Liagmentum flavum hematoma (LFH) is a rare cause of radiculopathy and low back pain, sharing similar symptomatology with disc herniation. It predominantly affects the lumbar thoracic spine. The underlying mechanism of LFH remains unclear; however, surgical removal of the hematoma has consistently demonstrated excellent outcomes. The objective of this case report is to emphasize the significance of diagnosing LFH. We present a surgically confirmed lumbar LFH case that mimicked a lumbar tumor, highlighting the challenges encountered during diagnosis and subsequent management.
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Before the advent of CT and MRI, and since the early 1920s, myelography has been used for the diagnosis of spinal cord lesions and lumbar disc herniations. We report a case of an 86-year-old man with a migration of lipiodol in the intracranial subarachnoid spaces. The patient had undergone a myelography in the early 1970s, 50 years earlier. Lipiodol, an iodized oil, was widely used as a contrast agent in conventional myelography for years and provided excellent radiographic visualization of the subarachnoid spaces. Although rare, images of its residues may still be encountered in modern radiographic imaging. Neurosurgeons and radiologists should be aware of this imaging appearance, and be able to differentiate it from possible pathologies.
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The objective of this study is to determine the accuracy and safety of trans-pedicular screws' insertion in the thoracolumbar spine using a fluoroscopy-assisted surgical technique. We retrospectively evaluated all patients who underwent a postoperative computed tomography scan to assess the location of the pedicular screws following thoracolumbar spinal surgery, at the Mohammed Vth Military Training Hospital-Rabat, from January 2020 to April 2022. We used Gertzbein's classification to grade pedicular cortex breaches. A screw penetration greater than 4 mm (grades D-E) was considered critical and one less than 4 mm was classified as noncritical (grades A-C). A total of 122 screws inserted in the T1 to L5 vertebrae were included from 25 patients. The average age was 46 years old. Pathologies included degenerative disorders (5 patients), tumors (8 patients), and trauma (12 patients). All screws were inserted using lateral and anteroposterior fluoroscopic guidance. A total of 11 transpedicular screws breaches were identified. The breaches incidence was significantly higher in thoracic pedicles (8 screws) than in lumbar pedicles (3 screws). Of these, three critical cases occurred in two patients and one of them required reintervention. The remaining eight exceedances were not critical and were closely monitored and followed up. Transpedicular screws fluoroscopy-assisted surgical fixation can be performed for the stabilization of the thoracolumbar spine with satisfactory safety and precision.
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Congenital spondyloytic spondylolisthesis (CSS) is characterized as a pars-interarticularis well-corticated cleft with antherolithesis. The presence of spina bifida and vertebral dysplastic changes corroborate the possibility of a congenital etiology. It is a rare condition, usually discovered incidentally, especially after a trauma and should be differentiated from traumatic spondylolysis, which requires aggressive treatments. The management is often conservative, with surgery being indicated for symptomatic or unstable lesions. We report the case of a sixth cervical vertebra Congenital Spondylolytic Spondylolisthesis (CCS), discovered fortuitously following a minor trauma, in a 19-year-old male patient, treated conservatively with a favorable evolution.
