Iranian Journal of Neurosurgery
Volume:8 Issue: 1, Winter 2022

Background and Importance: 

Mortality associated with post- coronavirus disease 2019 (COVID-19) rhino-orbito-cerebral mucormycosis (ROCM) is an evolving concern. Association of COVID-19, corticosteroid therapy and uncontrolled diabetes mellitus (DM) is considered as predisposing factors for ROCM. We present two cases of successful treatment leading to patient survival for post-COVID-19, stage 4c-ROCM.

Two middle-aged men with poorly controlled DM were referred to our hospital for post-COVID-19 ROCM. They had received intravenous antivirals and dexamethasone as treatment in a primary center. Both patients had unilateral oculofacial pain and swelling followed by acute visual loss, unilateral proptosis, facial palsy, and trigeminal hypoesthesia. Computed tomography scan revealed opacity as well as bony erosion of paranasal sinuses (PNS). Obtained specimens confirmed mucormycosis agent on histopathological examination. After failure of conservative treatments, retrobulbar injections of liposomal-amphotericin B, along with PNS debridement and orbital exenteration, both patients developed blurred consciousness owing to extension of the infection into the intracranial cavity. Brain magnetic resonance imaging revealed right frontal lobe abscess in case1, and left frontal sinus abscess and involvement in case2. Both underwent transcranial debridement and resection of necrotic tissue and drainage of abscess. At follow-up, the patients were in good condition and the fungal cultures were negative for mucormycosis agent.

ROCM may be a complication of COVID-19 in high-risk patients. Control of the patient's underlying systemic condition and prompt treatment with antifungal agents along with timely aggressive resection of cerebral abscess and necrotic paranasal tissues are the mainstays of management for ROCM.

Today, neuroendoscopic surgery is gaining popularity because of its minimal damage to normal structures, fewer complications, and excellent clinical results. Using an endoscope and related instruments, surgeons can perform complex surgeries through small incisions, especially for minimally invasive spinal and brain surgeries. Neuroendoscopic systems are currently costly and not portable. Our new video solution is portable at a lower cost and can display and record images in 4K resolution.

 We modified the GoPro Hero 6 camera to serve our purpose. By detaching the original camera lens and its front part and replacing the removed parts with a new design, we made a C-mount camera that can connect to a standard C-mount coupler and various common scopes. For color correction, we used an IR-cut filter in front of the camera sensor.

By changing some parts of the camera and connecting it to a C-mount coupler and a scope lens, we made a small, portable neuroendoscope that displays and records images in clear, sharp, high resolution, with a high frame rate.

The modified GoPro camera can be used as an alternative and unexpansive neuroendoscope system for education or treatment in medical centers in developing countries.

The viral agent in severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) is the cause of the novel coronavirus disease 2019 (COVID-19). It was first identified in December 2019 in the city of Wuhan, Hubei, China, and the World Health Organization declared it as an outbreak and a Public Health Emergency of International Concern on 30 January 2020, and a pandemic on 11 March 2020. Neurosurgeons are not prime in COVID-19 management but they continue for caring, visiting, and operating neurosurgical patients. In neurosurgical cases that need non-urgent operation, systematic SARS-CoV-2 testing of low-risk patients should be considered. In cases with positive SRAS-COV-2 testing, the procedures should be delayed until they are cured. The high-risk settings in the neurosurgical operation room are endotracheal intubation and extubation, operations in the vicinity of sinuses and/or mastoids, operations with accidental injury to respiratory or digestive tracts, and usage of aerosol-generating instruments on virioncontaminated tissues. The risk of SARS-COV-2 infection is decreased by delaying all nonemergent cases, replacing general anesthesia with other anesthesia methods, replacing neurosurgical approaches with alternative approaches that bypass the respiratory tract, and decreasing the usage of aerosol-generating instruments.

Methods and Materials/Patients: 

This is a narrative study about COVID-19 infection in neurosurgery. Using the keywords SARS-COV2, neurosurgery, and COVID-19, all the relevant articles (about 52) were retrieved from Google Scholar, Medline, and PubMed and reviewed and
critically analyzed.

Neurosurgeons can change neurosurgical routines in COVID-19 patients such as delaying all nonemergent cases, replacing general anesthesia with other anesthesia methods, replacing neurosurgical approaches with alternative approaches that bypass the respiratory tract, decreasing the usage of aerosol-generating instruments, and doing preoperative SRAS-COV-2 testing.

For decreasing the risk of COVID-19 transmission in neurosurgery, we can change routine neurosurgical protocols. Without the prevention of COVID-19 transmission, all neurosurgeons, personnel, and patients will contract COVID-19.

 Traumatic brain injury (TBI) is a globally-critical socioeconomic and public health problem. Introducing medications and strategies to treat and improve the prognosis of TBI is crucial. Current literature not only supports the key role of vitamin D on normal brain function, but also helps recovering from a myriad of pathologies. The present research was conducted to evaluate the neuroprotective effects of vitamin D on patients with TBI presenting to Imam Khomeini Hospital, Sari, Iran.

Methods and Materials/Patients: 

This randomized clinical trial assigned patients with vitamin D levels of over30 ng/ml to an intervention group (n=42) and a control group (n=42), who respectively received a single dose (150,000 units) of vitamin D and a placebo upon admission. The Glasgow Coma Score (GCS) and mortality were recorded at the beginning of the study and three months after the final prescription.

 The mean GCS score upon admission was obtained as 8.64±2.29 in the vitamin D group and 8.42±2.93 in the placebo group. This score was respectively obtained as 13.50±1.85 and 10.97±2.37 upon discharge, suggesting a significant difference as per the t-test (P=0.04).The mean Glasgow Outcome Score (GOS) upon discharge was obtained as 4.24±1.51 in the intervention group and 4.10±1.40in the controls. The t-test suggested insignificant differences in the GOS between the two groups upon admission (P=0.823). After three months, the GOS respectively reaching desirable levels in 49.7% and 62.8% of cases in the placebo and intervention groups revealed statistically significant differences among the two groups (P=0.03).

The present results showed the improving effects of vitamin D on level of consciousness and outcomes in patients with acute TBI. More studies are suggested to be performed to investigate the effects of other medications, including amantadine and methylphenidate with a larger sample size.

Background and Importance: 

Ventriculoperitoneal shunt surgery is a widely accepted treatment for hydrocephalus, but it is not free from complications. Of all the complications, bowel perforation represents only 0.01-0.07% and it often presents with asymptomatic anal protrusion of the distal end of the ventriculoperitoneal shunt. The mechanism causing shunt ejection is unknown, but the most widely accepted theory is that after intestinal perforation, the tubing of the shunt is propelled out by the peristaltic movements in the gut.

Case Presantation: 

A case of a 3.5-year-old boy with anal protrusion of the peritoneal end of ventriculoperitoneal shunt and multiple brain abscesses is reported. In surgery, the ventriculoperitoneal shunt was divided at the clavicular region, and the peritoneal end was gently pulled out of the anus while the ventricular end was exteriorized. Empirical antibiotics, antiepileptics, and steroids were given. The culture and sensitivity report revealed no microorganisms. The child improved over a period of two weeks and then a new ventriculoperitoneal shunt was inserted on the opposite side.

Suspicion for bowel perforation must be kept high in symptomatic ventriculoperitoneal shunt patients even though most of the patients present with asymptomatic anal protrusion of the peritoneal end of ventriculoperitoneal shunt. In order to avoid infectious and neurological consequences, early identification and then subsequent treatment are crucial. The extruded end can easily be removed from the migrated orifice without the need for extensive surgery.

Background and Importance: 

Movement disorders caused by meningiomas in the Cerebellopontine Angle (CPA) region are yet to be reported. This case report emphasizes the importance of careful imaging studies and examinations for patients presenting with movement disorders, even for benign tumors and less common etiologies.

A 45-year-old woman presented with irregular, involuntary, shortterm, transient, and unpredictable movements in the right upper and lower limbs since several months before, which conformed to the hemispheric pattern of the hemichoreahemiballismus type. Despite these issues, the main complaints of the patient were severe headaches, convulsions, blurred vision, and intermittent altered consciousness. Upon physical examination, abnormal movements of the right face and right upper and lower limbs were apparent. Dystonia was noted in the patient’s upper limbs. On brain MRI, a homogeneous mass 3.5 cm in diameter was found in the patient's right CPA, with compressive effects on the pons and medulla. The diagnosis of meningioma was made, and an excellent outcome was achieved following resection.

Although meningiomas are usually considered benign tumors, they can, as noted in this case report, exert mechanical mass effects on adjacent structures following gradual enlargement. This can lead to various movement disorders, even in unusual locations. Hence, all patients with movement disorders must be examined thoroughly, with the neurological examination being of utmost importance. The present case itself illustrates the variety of causes and manifestations of movement disorders, particularly dystonia and hemiballismus secondary to benign meningioma, even in less common site

Deep Brain Stimulation (DBS) surgery is increasingly performed to treat movement disorders. In these patients, a rechargeable or non-rechargeable battery is placed under their subcutaneous chest after implantation of an electrode in the basal ganglia of the brain, which has different battery life.

Methods and Materials/Patients:

 In this study, three databases, including PubMed, ScienceDirect, Scopus without time limit, and Google Scholar search engine were examined by two independent researchers.

In the initial search, a total of 338 data were found. Then, by reviewing the title and summary of articles, 17 articles were included in the study and then 13 articles were reviewed in full text. The results of the articles were divided into two subgroups of battery life related to the types or subtypes of movement disorders indicated by DBS and battery life related to the types of IPG models.

Battery life in Parkinson’s movement disorder and tremor is longer than in dystonia. Also, the battery life of Soletra model is longer than Kinetra and Kinetra model is longer than Activa, and any battery replacement surgery reduces battery life.

The COVID-19 has had several psychological and physical consequences, which have been more reported in people with chronic diseases, such as Parkinson’s Disease (PD). In this regard, this study reviewed all articles, which evaluated the mental health and quality of life of patients with PD during the COVID-19 epidemic.

Methods and Materials/Patients: 

In this study, the keywords Parkinson’s disease, PD, Coronavirus 2019, COVID-19, SARS-CoV-2, mental health, quality of life, depression, stress, and anxiety were searched in the abstract and title of articles published between 2020 (May) and 2022 (April) in reputable international scientific databases of EMBASE, Google Scholar, ScienceDirect, Scopus, and PsycINFO, PubMed, and Clarivate Analytics. The PRISMA checklist was used to review and control the quality of articles. Of the total 369 articles found, 21 articles were selected for review.

According to the studies, patients with PD had anxiety, depression, stress, poor sleep quality, death-related thoughts, fear, and cognitive, behavioral, and motor problems during the pandemic. Femininity, low level of education, and poverty were also among the factors exacerbating psychological disorders in PD patients. Decreased physical and social activity also reduced the quality of life in patients with PD. During home quarantine, many patients became concerned about access to medication and physicians, which exacerbated PD.

According to studies, the outbreak of COVID-19 reduced the mental health and quality of life of patients with PD. Since having high mental health has an important role in increasing the immune system against various diseases, identifying and treating vulnerable groups can increase life expectancy in patients.

Background and Importance: 

Distant extracranial metastasis of meningioma is rare, and the pathophysiology of metastasis in meningioma remains a topic of debate. This study aimed to describe a patient who suffered from multiple pulmonary metastases of meningioma.

This report introduced a rare case of a 47-year-old female who presented with right hemiparesis. Cranial Computed Tomography (CT) demonstrated a homogeneously enhanced tumor in the left temporal lobe. The patient underwent tumor resection; the pathological result was found to be World Health Organization (WHO) grade I meningothelial meningioma. Recurrence of the tumor transpired after two years and a second operation was performed. WHO grade II atypical meningioma was diagnosed.Subsequently, the patient developed a chronic cough and her chest x-ray showed multiple lung masses. CT-guided biopsy of the right lung mass was performed. Finally, pulmonary metastatic meningioma was diagnosed.

Distant extracranial metastasis and malignant transformation of meningioma involve the genetic alteration of a tumor, which should be studied further.

Spinal Giant Cell Tumor (GCT) is a primary low-grade malignant aggressive tumor of the spine and is more prevalent in the third and fourth decades of life.Spinal GCT frequently occurs in the sacrum. The most common presentation of spinal GCT is pain. Spinal GCT is seldom observed as an asymptomatic, incidental radiological occurrence.Based on the clinic-radiological findings, differential diagnoses of spinal GCT are Aneurismal Bone Cyst (ABC), plasmacytoma, symptomatic hemangioma, and Tuberculosis (TB). A biopsy is crucial for a definitive diagnosis. Because of the rich vascular supply about 24 hours prior to operation, Digital Subtraction Angiography (DSA) with tumor embolization is recommended. The treatment of choice for these tumors is complete, extralesional surgical resection which is not usually possible. General treatment is resorted as incomplete partial resection following local radiotherapy. The method of choice for reconstruction is cement or metallic cages and because of the high recurrence rate, bone graft is avoided. The local recurrence rate in the spinal column is lower than in other areas.

Methods and Materials/Patients: 

The spinal GCT incidence, manifestations, diagnosis, and management were concisely reviewed. Using the keywords of GCT, GCT manifestations, GCT complications, GCT management, and GCT incidence, all the relevant articles were retrieved from Google Scholar, Medline, and PubMed, reviewed critically, and analyzed.

Spinal GCT rarely presents as an incidental finding in radiologic studies. Because of the high vascular supply of GCTs, preoperative embolization must be performed.
The ideal treatment of spinal GCT is complete surgical tumor excision and when not possible, intralesional resection is an alternative treatment. The prognosis of spinal GCT is not good as other primary spinal tumors because of incomplete excision of the tumor and following high recurrence rate.

Spinal GCTs are complex clinical entities. Operation is obligatory, and postoperative close follow-up is mandatory to stop recurrences early

In patients with spondylolisthesis, both conservative and surgical approaches are considered based on the stage of the disease. However, in addition to the technical characteristics of the surgery and the stage of the disease, the underlying characteristics of the patients may also affect the therapeutic prognosis. In this regard, some studies have indicated that the surgical prognosis is worse in diabetic and hypertensive patients and also preoperative medical treatments, such as anticoagulants may be effective in the prognosis of the disease. The aim of this study was to evaluate the role of underlying risk factors, such as diabetes mellitus, hypertension, and anticoagulant conditions (such as aspirin) in worsening outcomes after surgery in patients with spondylolisthesis.

Methods and Materials/Patients: 

This cross-sectional study was conducted on 130 patients suffering from spondylolisthesis and scheduled for surgery. According to baseline characteristics, 65 patients with a history of diabetes mellitus, hypertension, and receiving aspirin were categorized as the case group, and 65 sex- and age matched individuals without such comorbidities as the control group. Preoperative and postoperative radicular pain intensity, wound healing, and discharge from the surgical site were considered the study outcomes.

The two groups with and without comorbidities were matched for gender, mean age, mean body mass index, and time of operation. Preoperative pain intensity was similar in the groups, but those with comorbidities experienced higher radicular pain severity postoperatively. We showed no difference in the rate of surgical site discharging, but the lack of wound healing was significantly higher in those with comorbidities.

In patients with spondylolisthesis and candidates for surgical treatment, a history of diabetes mellitus, hypertension, and aspirin can be associated with a worse prognosis, including no improvement in pain and lack of wound healing.

Background and Importance:

 Sequestrated thoracic disc herniation after a traumatic event without an apparent spinal fracture or dislocation is an extremely rare scenario.

Evaluation of an elderly female with acute paraparesis secondary to a fall down to the ground revealed a right-sided extruded disc at the level of T10-T11. At 6-month follow-up, she made a dramatic recovery following an appropriate surgical intervention.

With occurrence of acute paraparesis following a traumatic event, MRI of the vertebral column is necessary, even in the absence of tomographic evidence of fracture-dislocation

Every year, traumatic brain injuries lead to more than one million admissions to emergency rooms and more than 50,000 deaths, and millions of disabilities worldwide, among all ages and genders. This study aimed to examine the effects of selenium added to oral nutritional therapy on the mortality rate and length of hospital stay in patients with subarachnoid hemorrhage admitted to the intensive care unit (ICU) for six months.

Methods and Materials/Patients: 

This clinical trial included 100 patients admitted to the ICU of Loghman Hakim Hospital, Tehran, Iran. These patients were then randomly assigned to intervention or control groups. Standard oral solutions were administered to both groups according to recommended guidelines. Along with the standard nutritional intake, the participants in the intervention group were given 1000 μg of selenium (Selenase-Biosyn, Germany) on the first day of feeding, dissolved in 100 mL of normal saline for 30 minutes, followed by 500μg of selenium daily for 10 days. We screened patients for GCS, and APACHE-II scores, as well as cortisol levels on days 1 and 10.

The APACHE-II mean score on the 10th day was significantly different between the two groups, and this was also true before the intervention. In terms of mortality rates, there was no significant difference between the control group and the intervention group. Neither the control group nor the intervention group spent significantly more time in ICU.

The effects of selenium on other variables were unclear, although mortality rates did not differ significantly between the two groups. Considering the confounding variables through regression analysis, the APACHE-II variable was negatively impacted by selenium, but taking into account the significant effect of age, a definitive conclusion cannot be made.

Healthcare students highly affect the general public regarding transferring knowledge about novel therapeutic approaches. Therefore, assessing and updating their knowledge about the application of new strategies in the treatment of different diseases is very important. The present study was designed to evaluate the level of the students’ knowledge about stem cells and their application in neurological disorders at the Guilan University of Medical Sciences (GUMS).

Methods and Materials/Patients: 

In this cross-sectional study, a questionnaire was designed in three sections. Exclusion criteria were reluctance to participate in the project or answer to less than 20% of the questions. Inclusion criteria included studying at GUMS and willingness to participate in the project and answer the questionnaire. The questionnaire was distributed in all GUMS faculties, including medicine, paramedicine, nursing and midwifery, dentistry, health, and pharmacy. The data were analyzed by SPSS v. 16 through Pearson correlation coefficient, independent t-test, oneway analysis of variance (ANOVA), and Cronbach’s alpha.

According to the total awareness score, 51.2% of students showed very poor and 39.7% showed poor knowledge about stem cells and their application in neurological diseases. The knowledge score of the students in the medical faculty was higher than non-medical and was dependent on their educational year. In addition, medical students showed no significant difference in neither knowledge (F=1.406, P=0.221) nor attitude (F=0.603, P=0.697) scores. Fortunately, 72.2% of students had moderate and 20.6% had a strong attitude toward stem cell applications. A moderate correlation was observed between attitude toward stem cells and knowledge about the application of stem cells (r=0.325, P=0.000).

GUMS students’ knowledge level was poor toward stem cells and their application in neurological diseases. It is suggested to include some courses about stem cells in the educational curriculum. However, the student’s attitude toward the use of stem cells was encouraging.

The present study was conducted to investigate the effects of granulocyte colony-stimulating factor (G-CSF) after acute spinal cord injury on increasing a grade of improvement entitled American spinal cord injury association impairment scale (AIS) as an individual participant data (IPD) meta-regression analysis of clinical trials. Methods and Materials/Patients: According to our search strategy, four studies were selected. Multilevel ordered logistic regression modeling was used to predict AIS grade with G-CSF administration and time variable (first day and a 3-month follow-up). The IDs of the studies as well as the time series variable were imported to the random part of the model. Odds ratio (OR) and 95% confidence interval (CI) were reported.

A total of 277 samples were studied. A fixed effect model was performed at first. Accordingly, using G-CSF was associated with increased AIS grade (lower impairment) (OR=1.503, 95% CI=1.110-2.035) adjusted with time series (OR=1.868, 95% CI=1.378-2.532). In the mixed effect model, G-CSF was again associated with increased AIS grade (OR=1.780, 95% CI=1.301- 2.436) adjusted with time series (OR=2.152, 95% CI=1.406-3.294).

The present meta-analysis showed the protective effect of GCS-F observed as an improvement in AIS grade. This protecting effect was further after adjusting the random effects of time series and individual studies. Although multilevel modeling could reduce our limitations, it should be regarded that the number of trials was not enough to establish strong conclusions.

Although rod bending is a universal method for maintaining lumbar lordosis (LL), its long-term efficacy in short-segment posterior fusion is still a challenge. This study aimed at evaluating the long-term effect of rod bending in patients with grade one L4/L5 spondylolisthesis with a short segment fusion.

Methods and Materials/Patients:

 A double-blind prospective randomized clinical trial was conducted from 2016 to 2018 and patients who met the inclusion criteria were enrolled in the study. The participants were randomized into two treatment arms: open posterior fusion with rod bending and without rod bending. The baseline data, including leg and back pain scores, were evaluated before surgery. Lumbar, focal, and segmental lordosis were measured before surgery. After surgery and a one-year follow-up, pain scores and lordosis measurements were re-evaluated and compared between and within groups.

A total of 60 patients were analyzed. Leg and back pain scores improved significantly after the follow-up in both groups (P<0.0001). However, there was no significant difference between the two groups before and after the surgery. LL did not change in either group after surgery. Focal and segmental lordosis significantly increased in both groups but showed no difference between the groups at either time. Complications were not significantly different in either group.

In this study, no significant difference concerning the radiological and pain outcomes was observed in either group; therefore, rod bending to reach the desired LL may be an unnecessary spend of time.

Background and Importance:

Spinal Epidural Hematoma (EDH) is a rare clinical entity that occurs spontaneously and in patients with spine injury. Most of the patients require laminectomy and evacuation of spinal EDH. MRI of the spine with MRA is the radiological investigation of choice. The study aimed to review the cases with spinal EDH and discuss its etiology, pathogenesis, investigations, and various management strategies.

This study was a retrospective analysis of five spinal EDH cases admitted at our institute in the time period between August 2020 and August 2021. Four patients underwent laminectomy and evacuation, while one was managed conservatively because of rapid clinical improvement. The patients’ functional outcome was assessed by the use of American spinal cord injury association Impairment Scale (AIS) before and after treatment. Four of the five patients included in our study had significant neurological improvement. One of the patient who presented late to us had poor neurological recovery despite the surgical intervention.

 Surgical evacuation of spinal EDH within 48 hours of onset of symptoms ensures good clinical recovery. Spontaneous resolution is possible in some cases if they have an improvement in neurological status early in the course of the disease. Hence we conclude that immediate prompt treatment in spinal EDH patients ensures maximum functional recovery. Patients with spinal EDH needs close follow-up and periodical neurological examination

Background and Importance:

 Skull base osteomyelitis (SBO) is a complex disease process often confused with malignancy due to clinical and radiological masquerade. Extensive changes have recently occurred in the clinical course and management of the disease, attributed to improvements in neurosurgical procedures, diagnostic modalities, and the introduction of new antibiotics and management techniques thus reducing the associated morbidities and mortalities. However, SBO continues to pose a major challenge in the form of early diagnosis and management and can be the cause of devastating complications and high fatality associated with the disease.

Here we provide the clinical profile, investigation, management, and outcome of 5 cases of SBO, all of whom were thoroughly examined for the neurological deficit, complete blood count, inflammatory markers, and radiographic imaging. Biopsy and microbiological culture reports were collected and patients were followed up.

Early diagnosis and culture-specific antibiotic treatment have been shown to provide good outcomes. Due to its rarity, large case series of SBO are insufficiently found in the literature.

Background and Importance:

 Medulloblastoma (MB) is regarded as a scarce primary brain neoplasm in adulthood, originating from the fourth ventricle or the cerebellum, and cerebellopontine angle (CPA)-MB has been described less often in the literature. Few cases of CPA MB have been reported in the English-written literature, most of which are intra-axial, mainly in children; adults' extra-axial CPAMB is even scarcer. To the best of the authors’ knowledge, 12 cases of extra-axial CPA MBs have been reported in the English-written literature.

A 23-year-old man presented to our center complaining of a generalized pulsatile headache, imbalance, swallowing impairment, and right-sided hearing loss for the past 20 days. Computed tomography (CT) scan of the brain showed a hyper-dense extra-axial mass lesion (41*37mm) in the right CPA with a significant compression effect on the fourth ventricle, causing a three ventricular obstructive hydrocephalus. Magnetic resonance imaging (MRI) showed a well-defined heterogeneous extra-axial, lobulated, dural-based mass lesion in the right CPA, hypointense on the T1 sequence, and hyperintense on the T2 sequence compared with the adjacent parenchyma, which has a bright heterogeneous enhancement during gadolinium injection. A significant mass effect was observed on the adjacent parenchyma, brain stem, and fourth ventricle without evidence of parenchymal edema. The patient underwent emergent surgery the next day regarding the mass effect and hydrocephalus. On the postoperative examination in the intensive care unit, no new neurological deficit was detected, and the swallowing and gag reflex significantly improved.

Though rare, clinical considerations, along with early supportive radiologic measures, should be considered in subjects with suspected MB. A total tumor excision approach followed by aggregative chemotherapy/radiotherapy is designed to hinder tumor relapse.

 Modic changes are alterations in the Spine endplates and subchondral bone signal absorption, which can be seen by MRI. Today, no studies have investigated the effect of vitamin D and alendronate as oral drugs on the reduction and modification of Modic changes after degenerative spine fusion surgery. Aim the study was to Evaluation of the efficacy of oral vitamin D and alendronate administration in patients with low back pain and Modic changes which undergoing lumbar fusion surgery.

81 middle age women with normal range of serum Vitamin D had enrolled in three groups who underwent lumbar fusion surgery according to neurosurgical criteria.   Group 1 (n = 27) received additional oral alendronate, Group 2 (n=27) received oral vitamin D for six months postoperatively, and whereas group 3 (n = 27) received no drug (except simple analgesics and antibiotics).patients follow with visual analog scale (VAS) and oswestry disability index (ODI), also MRI has done before and six month after surgery.

There was no significant difference in VAS and ODI between the three groups (P-value = 0.416, P-value = 0.601, respectively) but the mean VAS and ODI in all three groups decreased over six months, which was statistically significant (P-value < 0.001). MODIC change in all three groups changed significantly over 6 months (P-value < 0.01,). In the Vitamin D and Alendronate groups, MODIC 3 increased significantly, but MODIC 2 and MODIC 1 decreased significantly in the Vitamin D and No medication groups, respectively.

it is supposed to oral vitamin D administration has an acceptable effects not only on clinical outcome after lumbar spinal fusion surgery because of degenerative surgery, but also has a good effect on vertebral endplate modic change compared oral bisphosphonate.

The majority of the TBI patients are those with mild traumatic brain injury (mTBI). However, due to the absence of symptoms in brain imaging until long after the injury, the manifestations of cognitive impairments remain undiagnosed. Therefore, cognitive screening is considered a key measure in these patients. One of the common screening tools for evaluating cognitive impairments is the MMSE test. The present study aimed to determine the cut-off point, sensitivity, and specificity of the MMSE test in mTBI patients.

Methods and Materials/Patients:

In this observational and cross-sectional-analytical study, the statistical population was all patients with mTBI who were injured in the first half of 2022. The case group included 79 mTBI patients admitted to the trauma, neurosurgery, and ICU departments of Poursina Hospital in Rasht in the first half of 2022, who had been referred to the same hospital as well as the Velayat specialized clinic for rehabilitation and re-visit, and the control group included 79 normal healthy individuals. Both groups were cognitively evaluated by the MMSE test on two occasions with an average time interval of 2-3 weeks.

The results of the Discriminant analysis showed a cut-off point of 27/28 as the probable point of cognitive impairment. Also, for identifying the cognitive impairment in mTBI patients, this test reported low sensitivity of 0.43-0.58 and a moderate specificity of 0.69-0.80 in two tests.

 In screening for possible mild cognitive impairment in mTBI patients, the MMSE is relatively useful and should not be used solely to replace a comprehensive neuropsychological evaluation with diagnostic purposes.

In the management of aneurysmal subarachnoid hemorrhage (aSAH), endocrine dysfunction is infrequently considered. Pituitary (neuroendocrine) dysfunction is highly prevalent after aSAH, leading to residual symptoms such as decreased cognition and quality of life. Although hypopituitarism following SAH may present with non-specific subtle symptoms, it can lead to potentially serious consequences if left undiagnosed.

Methods and Materials/Patients: 

This study was performed to observe the incidence and pattern of neuroendocrine alterations in cases of acute aSAH. A total of 25 patients with acute SAH within 7 days of ictus were included in this prospective study, and an endocrine assessment was performed. The pituitary axes were evaluated for possible dysfunctions, including somatotropic, gonadotropic, corticotropic, and thyrotropic axes.

A total of 25 SAH cases (10 males and 15 females; mean age 55.24 years) were included in the study. Aneurysms were more commonly found in the anterior circulation (n=22) than in the posterior circulation (n=3). Most of the patients presented with the Hunt-Hess grade of 1, followed by grades 3, 2, and 4, respectively. Growth hormone deficiency (48%) was the most common pituitary dysfunction, followed by adrenocorticotrophic hormone (24%), gonadotropins (FSH/LH) (24%), and thyroid stimulating hormone (16%) deficiencies, respectively. Single pituitary axis neuroendocrine dysfunction was noted in 9 patients (36%) and multiple pituitary axes dysfunction was observed in 8 patients (32%). Overall, 17 patients (68%) had neuroendocrine dysfunction in single or multiple pituitary hormone axes.

Neuroendocrine dysfunction in acute aSAH is 68%. Accordingly, 32% of the participants had single-axis pituitary dysfunction and 36% had multiple axes pituitary dysfunction. The most common endocrine dysfunction is growth hormone deficiency (48%), followed by adrenocorticotrophic hormone, gonadotropins (LH & FSH), and thyroid stimulating hormone. Therefore, it is suggested to include hormonal evaluation in the management of acute SAH for better clinical outcomes.

Paroxysmal sympathetic hyperactivity (PSH) is a clinical syndrome characterized by paroxysmal and transient episodes of fever, tachypnea, tachycardia, hypertension, diaphoresis, and dystonia following non-noxious stimuli. It is a rare clinical condition and is seen in patients with acquired brain injury (trauma, meningitis, encephalitis, and stroke). Paroxysmal sympathetic hyperactivity-assessment measure (PSH-AM) is a clinical tool for diagnosing PSH. This study aims to describe the clinical characteristics and the outcomes of PSH.

Of the 412 patients admitted to the neurosurgery intensive care unit at PSGIMSR, Coimbatore, India, 11 (2.6%) patients were diagnosed to have PSH according to the PSH-AM scale. Trauma (72%) was the leading cause of the development of PSH. All patients (100%) had developed at least two PSH episodes per day that persisted for at least 3 consecutive days. Tachycardia and tachypnea were the most common symptoms noted in all PSH patients. The Glasgow Outcome Score (GOS) was less than 3 in 72% of PSH cases at the time of discharge, indicating a poor outcome.

Traumatic brain injury remained the leading cause of PSH. The duration of hospitalization was increased in patients with PSH. Along with the prompt treatment of the primary disease, appropriate medications to overcome sympathetic hyperactivity ensure better recovery for these patients. Patients with PSH had relatively poor GOS at the time of discharge.

Background and Importance: 

Fracture-dislocation of the thoracic or lumbar spine (traumatic spondyloptosis) occurs in less than 5% of all spinal injuries mainly affecting the ventral direction.

A paraplegic young man was admitted to Shahid Kamyab Hospital in Mashhad City, Iran due to a motor vehicle accident. Computerized tomography (CT) showed a complete posterior dislocation of the T10 vertebral body on T9, with the superior articular processes of T9 bilaterally locked in the inferior endplate of T10 and complete fractures of the posterior elements.

The spinal dislocation was re-aligned by a combination of Harrington fixation and pedicular screws leading to spinal fusion. Six months after surgery, the patient was still paraplegic but the sensory symptoms in the lower extremities and clean intermittent catheterization improved.

Preoperative blood product preparation is a common practice in neurosurgical patients. However, over-requesting of blood is common and leads to the wastage of blood bank resources. Machine learning (ML) is currently one of the novel computational data analysis methods for assisting neurosurgeons in their decision-making process. The objective of the present study was to use machine learning to predict intraoperative packed red cell transfusion. Additionally, a secondary objective focused on estimating the effectiveness of blood utilization in neurosurgical operations.

Methods and Materials/Patients:

 This was a retrospective cohort study of 3,021 patients who had previously undergone neurosurgical operations. Data from the total cohort were randomly divided into a training dataset (N=2115) and a testing dataset (N=906). The supervised ML models of various algorithms were trained and tested with test data using both classification and regression algorithms.

Almost all neurosurgical conditions had a cross-match to transfusion ratio of more than 2.5. Support vector machine (SVM) with linear kernel, SVM radial kernel, and random forest (RF) classification had a performance with good AUC of 0.83,0.82, and 0.82, respectively, while RF regression had the lowest root mean squared error and mean absolute error.

In almost all neurosurgical surgeries, preoperative overpreparation of blood products was detected. The ML algorithm was proposed as a high-performance method for optimizing blood preparation and intraoperative consumption. Furthermore, ML has the potential to be incorporated into clinical practice as a calculator for the optimal cross-match to transfusion ratio.

It is still unclear whether the surgical or conservative approach has the best recovery and the least adverse outcomes after the treatment of patients with traumatic brain injury (TBI), especially the elderly. The use of invasive versus conservative therapies in elderly patients with TBI is controversial, and the current brain surgery procedures for the elderly require further evaluation.

Methods and Materials/Patients:

 In this retrospective cohort study, the medical records of 238 patients with TBI (119 surgical patients and 119 patients treated with conservative methods) over the age of 65 were reviewed. The patients were compared for the degree of recovery indicated by the Glasgow Outcome Score (GOS) and postoperative complications.

No difference was found in the primary Glasgow Coma Scale (GCS) between surgical and conservative approaches, but after two treatment protocols, the assessment of GCS and GOS showed a significant difference between the two groups; however, after adjusting baseline parameters in a multivariable logistic regression model, the difference between the two groups in CGS and recovery state turned to insignificance. There was no difference between surgical and conservative management in the post-treatment sequels, including contusion, hydrocephalus, myocardial infarction, pulmonary infection, and death. However, the recurrence of hematoma was significantly higher in those who were treated by the conservative method even after multivariate regression modeling.

In TBI patients aged over 65 years, surgical management can result in more favorable outcomes compared with the conservative approach.

Background and Importance: 

Osteopetrosis is an inherited disease that causes the thickening of the cranial bone. The need for both cerebral decompression and intracranial volume-enlarging cranioplasty in the same surgical session in a patient suffering from rising intracranial pressure is critical and a very rare decision in neurosurgical practice. The only indication that can lead to this surgery is osteopetrosis.

A 24-year-old female patient with osteopetrosis was admitted with the complaint of severe headache that did not respond to medical treatment, and surgery was decided. After decompressive craniectomy was performed with difficulties, cranioplasty with titanium mesh was performed in the same session to protect the cerebral tissue, close the defect area, and give more space to the cerebral tissue. It was observed that the complaints of increased intracranial pressure were completely resolved in the early postoperative period and the one-year clinical follow-up. The surgical intervention technique and the radiological findings obtained during the follow-up are presented.

Performing cranioplasty with titanium mesh, which is used to protect and save cerebral tissue in patients with osteopetrosis, seems the most appropriate choice.

Spinal osteotomy is a general term for techniques applied to correct spinal deformity. The aims of osteotomy are to create a normal range of spine curvature, pain relief, and to improve quality of life. In the cases where spinal deformities cannot be corrected using instrumentation alone or by facet or ligament release, osteotomy is indicated. In spinal osteotomies, spinal alignment is corrected by removing part of the spinal bone. Osteotomies can be performed as anteroposterior or posterior-only procedures with a greater predilection for posterior-only procedures. Different types of osteotomy are available, including the Smith-Petersen osteotomy (SPO), Ponte osteotomy (PO), pedicle subtraction osteotomy (PSO), corner osteotomy (CO), or bone-disc-bone osteotomy (BDBO), vertebral column decancellation (VCD) and vertebral column resection (VCR).

Methods and Materials/Patients:

 In this narrative study, to provide up-to-date information, we precisely reviewed articles in the osteotomies context. Using the keywords spinal osteotomy, spinal deformity, Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection (VCR), vertebral column decancellation (VCD), Ponte osteotomy (PO), corner osteotomy (CO), all the relevant articles were retrieved from PubMed, Google Scholar, Medline, and critically reviewed and analyzed.

In the spine surgery, osteotomy is performed to correct the deformity in uncorrectable spinal deformity. The suitable type of osteotomy is selected based on the etiology, type, and apex of deformity, surgeon's experience, availability of blood and bleeding control agents, and availability of intensive care. A wider acceptance of posterior-only procedures exists in osteotomy.

In spinal deformity surgery, more degrees of correction are needed for better cosmetic results, and for this purpose, spinal osteotomy has a central role. For this reason, all spine surgeons should be familiar with these osteotomy techniques.

Background and Importance:

Tuberous sclerosis, also known as Bourneville's disease is a rare autosomal dominant disease affecting multiple systems. In this case report, we emphasize the importance of clinical criteria instead of genetic analysis in diagnosing tuberous sclerosis and the need for rigorous follow-up of patientsto prevent complications.

Here we present a case of a 10-year-old boy presenting with intractable seizure and hypo-pigmented patches on his face and back of trunk. In neuroimaging evaluation, subependymal giant cell astrocytoma was diagnosed. Further, hisabdominal ultrasound showed multiple hamartomatous lesions in the liver and bilateral kidney. His cardiology and dental evaluation were normal. The dermatologist diagnosed a shagreen patch on the back of his trunk. Based on the latest clinical diagnostic criteria, he was diagnosed with a case of tuberous sclerosis and has been on the rigorous follow-up ever since.

Since tuberous sclerosis is a multisystem disease, early diagnosis is necessary to prevent acute symptoms and prevent long-term complications. Here we emphasize the need to use clinical criteria instead of genetic study for early diagnosis of tuberous sclerosis.

Surgical site infections (SSIs) in spine surgeries represent one of the most common hospital-acquired infections. SSI (refers to surgical wound infection within 30 days of surgery or 1 year after implant) portends a huge disease burden with devastating consequences for the patient and the hospital facilities with physical and psychological trauma to the patient and it is associated with an increased rate of morbidity and mortality. Despite improvements in the surgical protocol for asepsis and the role of prophylactic antibiotics in clean spine surgeries, a substantial increase still exists in the rate of SSIs. It is essential to review and identify factors predisposing patients with spinal problems to SSIs and its goal is to formulate a local protocol that helps to curtail SSIs and can be replicated in any setting in the world, considering the limitations of our setting. This study aims to review the risk factors for SSI following spine surgeries considering a 54-year-old woman with obesity who had SSI and highlights prevention ways.

Methods and Materials/Patients:

 This study includes the search of the literature using several platforms, such as Google Scholar, Hinari, PubMed, Academia, and other search engines with related keywords to surgical site infections in spine surgery. The retrieved articles were reviewed and in some parts, the narrative case of the 54-year-old obese woman was discussed in the literature.

A total of 37 articles were found that matched the search words and satisfied the objective of the study. These articles were reviewed and used in writing this manuscript.

SSIs are on the increase, and identifying risk factors on a patient basis is key to prevention. Protocol on preventive measures should be strictly followed to avoid catastrophes associated with SSIs.

Improvement of neurological disorders in patients with incomplete spinal cord injury (SCI) remains an important issue worldwide. This study aimed to explore the outcomes and complications of patients with incomplete SCI in the thoracolumbar region within one year after trauma.

Methods and Materials/Patients:

 In this longitudinal prospective study, patients with traumatic incomplete SCI were studied. The demographic and clinical variables including age, sex, site of injury, motor force, sensory disorder, and sphincter dysfunction were recorded on admission and 3, 6, 9, and 12 months after discharge. SPSS software, version 28 was used for data analysis.

Out of 120 patients with incomplete SCI, 100 patients were included. The mean age of the participants was 32.39±7.47 years and the mean duration of hospitalization was 14.78±3.81 days. The most common injury site was T12-L1 (43%). Over time, the average motor force of patients increased. The lowest and highest averages were observed during hospitalization and 12 months after discharge,
respectively. No significant difference was observed in the paired comparison of motor force at 3, 6, 9, and 12 months after discharge. The frequency of sensory disorders decreased over time. The highest and lowest frequencies belonged to the hospitalization time (81%) and 12 months after discharge (9%). No significant difference was observed between the time intervals of 6, 9, and 12 months, as well as
the time of hospitalization and discharge. Over time, the frequency of sphincter dysfunction decreased. Pulmonary infection (12%) and bed sores (9%) were the complications observed during hospitalization. Complications observed 12 months after admission were bed sores (21%) and venous thrombosis (17%).

The highest recovery rate of motor force was recorded within the first three months. The frequency of sensory and sphincter disturbances in patients decreased over time with the highest recovery rate during the first six months after the injury.