Romanian Neurosurgery <p>Call for Papers - Vol. XXXV, No. 2 (June 2021)<br />Submission Deadline: May 1, 2021</p> London Academic Publishing en-US Romanian Neurosurgery 1220-8841 Lumbar disc herniation <p>Lumbar disc hernia represents one of the most frequent neurosurgical pathologies, consisting of a posterior migration of the nucleus pulposus which protrudes through the surrounding protective connective tissue. The patient usually exhibits leg pain, paraesthesia or a variable degree of discomfort at the lower extremities, those clinical characteristics are correlated to the extent of nucleos pulposus protrusion. Regarding neuroimaging diagnosis, the gold standard of evaluation is Magnetic resonance imaging in different sequences which highlights a precise topography of the herniated disc. Currently, in a well-digitalized era, machine learning and deep learning algorithms are used to assess the sensibility of detecting a lumbar disc hernia, with promising results. In those cases requiring surgical intervention, besides the open lumbar microdiscectomy, a less invasive surgical approach regularly used in the medical practice is endoscopic lumbar discectomy, being limited to cases where a wide intraoperative perspective is not necessary. In the actual neurosurgical management, postoperative complications following lumbar disc hernia surgery are rare and accessible to manage.</p> Corneliu Toader Bogdan-Gabriel Bratu Razvan-Adrian Covache-Busuioc Luca-Andrei Glavan Matei Serban Alexandru Vlad Ciurea Copyright (c) 2024 2024-07-03 2024-07-03 139 148 Pre-rupture syndrome <p>Oculomotor nerve palsy can be a strong indicator of an internal carotid artery aneurysm, specifically of the posterior communicating artery, due to the anatomical positioning within the basal cisterns of the subarachnoid space, which allows for nerve compression. This condition can predict an acute subarachnoid haemorrhage, associated with a high mortality rate, often presenting with sudden, severe headaches, with or without deficits. The pathophysiology theories include direct mechanical compression by the aneurysmal sac, arterial pulsations, and nerve tissue oedema from venous obstruction. In cases of unruptured aneurysms, nerve irritation is less common. This palsy occurs in about one-third of cases.</p> <p>Aneurysmal orientation can vary (lateral, superior, inferior, medial, posterior), and due to the nerve’s anatomical position, aneurysms in the postero-lateral-inferior position are more likely to cause nerve damage. Treatment opinions vary from observation to intervention, with options including traditional neurosurgery and endovascular embolization. The latter is increasingly preferred due to its efficacy and lower risk profile.</p> <p>A clinical case involves a 56-year-old female presenting with ptosis, diplopia, and ipsilateral mydriasis. Imaging confirmed a posterior communicating artery aneurysm with a maximum diameter of 5.3 mm and a 3 mm bleb. Endovascular coiling was performed successfully, excluding the aneurysm from circulation without complications. Post-treatment, the patient was discharged in good condition with recommendations for periodic monitoring.</p> <p>In conclusion, while no single best treatment exists for posterior communicating artery aneurysms with oculomotor nerve palsy, early intervention (surgical or endovascular) and patient monitoring are crucial for preventing complications and ensuring quality of life.</p> Monica Manisor Petru Coltea Cosmin-Nicodim Cindea Alexandru Breazu Tamas Kerekes Vicentiu Saceleanu Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 149 153 Outcomes of dynamic lumbar fixation in young patients with minimal lumbar instability <p><strong>Background Data: </strong>Lumbar instability is considered an essential aetiology of low back pain (LBP) which is always accompanied by considerable disability. &nbsp;The term ‘instability’ remains poorly defined. But it is most broadly explained by any change of the normal mechanism of spinal motion which leads to pain and/or neurological impairment. It was reported that ‘Segmental instability can be defined as a pathological reaction to the applied loads, characterized by motion in motion segments more than normal constraints. The dynamic system can stabilize an unstable segment adequately but permits more mobility in the fixed levels than the conventional fixation systems.</p> <p><strong>Study design: </strong>prospective, consecutive study</p> <p><strong>Patients and Methods:</strong> This study was conducted in Mansoura University hospitals over one year (starting from September 2019 till August 2020) Twenty patients who presented with back pain fulfilled our criteria and were included in this study and underwent surgery for lumbar fixation using a hybrid performance system with dynamic coupler. The history of all patients was taken and they were subjected to clinical examination and preoperative full radiological examination. Visual Analogue Scale (VAS) was used to evaluate POP. Regular follow-up visits were arranged for our cases 6 weeks, three months and 6 months postoperative.</p> <p><strong>Results</strong><em>:</em> This study included&nbsp; 20 patients (7 males and 13 females). The ages of the studied patients ranged from 20 to 33 years. 9 patients presented with L4- 5 affection, 8 patients with L3- 4 affection and three patients with L2-3 affection. The mean basal VAS score was 5.45 (range=4-6) while the mean six months VAS score was 0.40 (range=0-1) with a statistically significant difference from the basal VAS score (p ? 0.001). Also, the results show that post-operative QoL scale scores was significantly higher (p? 0.001) compared with pre-operative QoL scale scores (Physical function (54.30 vs. 67.10), limitations due to physical health (55.55 vs. 67.90)).</p> <p><strong>Conclusion</strong><em>:</em> The current study suggested that Dynamic lumbar fixation provides favourable and stable clinical mid-term results in patients suffering from a degenerative lumbar spinal disease (DLSD) and can be a considerable alternative to fusion surgery in these patients.</p> Kareem Abdel Gawad Ashraf S. Zidan Amin Sabry Hesham Elsobky Mohamed Ramadan Copyright (c) 2024 2024-07-03 2024-07-03 154 161 Clinical effectiveness of progesterone in acute traumatic spinal cord injury <p><strong>Aim</strong>: With only limited treatment options in acute spinal cord injury (SCI) currently available, we aimed to investigate the effect of progesterone on neurological recovery after acute SCI.</p> <p><strong>Material and Methods</strong>: Randomised double-blind placebo-controlled single-centre trial on 128 patients of acute SCI (within 24 hours of injury) was conducted at our institute with the approval of the ethics committee. Eligible patients were allocated to the progesterone or placebo arm. Of 133 eligible patients, one from the placebo arm expired in the acute phase while 4 were lost to follow-up, leaving 128 patients in the study.68 patients remained in the progesterone arm and 60 in placebo. Patients in the progesterone arm received intramuscular progesterone while those in the placebo received intramuscular isotonic saline twice daily for five consecutive days. Neurological assessment was done at baseline, day six, first and sixth months using the American Spinal Injury Association (ASIA) score and motor and sensory actual neural recovery (ANR) scores.</p> <p><strong>Results:</strong> Baseline characteristics were comparable between the groups. At the end of six months, significant improvement occurred in motor and sensory ASIA scores in the progesterone arm (p=&lt;0.01). Compared with the placebo, motor scores were significantly higher in the progesterone arm at 6 months while sensory scores were not (p= &lt;0.01 and p= 0.59 respectively). Additionally, at 6 months, motor ANR was significantly higher in the progesterone arm vs placebo (p=&lt;0.01 vs 0.65). Early progesterone administration (within six hours of injury) was associated with significantly higher motor and sensory ASIA scores at 6 months (p= &lt;0.01vs0.04 respectively).</p> <p><strong>Conclusion: </strong>Administration of intramuscular progesterone within 24 hours in acute SCI was associated with better neurological recovery. Further multicentric studies are required to shed more light on the strength and consistency of this improved outcome.</p> Ashish Rai Jitendra S. Shekhawat Gaurav Jain Sripadma P.V. Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 162 170 Multilevel interlaminar fenestration with soft tissue decompression in lumbar canal stenosis <p><strong>Introduction:</strong> Lumbar Canal Stenosis is the narrowing of the Spinal Canal and/or the intervertebral foramina, which causes compression of the thecal sac and/or caudal roots at a single vertebral level. Stenosis may be local, segmental, or generalised; bone or soft tissue can cause it. Stenosis can involve the bony canal, dural sac or both.[9]</p> <p><strong>Aim:</strong> Assessment of outcomes of multilevel fenestration with soft tissue decompression in lumbar canal stenosis.</p> <p><strong>Material and method:</strong> A prospective study comprised patients with two or more lumbar canal stenosis levels. The Study eliminated patients with infective pathology or recurrent surgery on identical levels. The surgical technique of canal decompression via multilevel fenestrations was used in this study, which enables the decompression of the neural structures while preserving as much of the bony and ligamentous structures as possible. Post-op clinical measures such as motor, sensory, post-op complications, and VAS score improvement assessed study outcomes.</p> <p><strong>Result:</strong> Studies showed improvement in symptoms of pain, motor power and sensory deficit, post-operative improvement in VAS score for pain, and improved quality of life in almost all the patients from day 7 to day 60 after surgery.</p> <p><strong>Conclusion:</strong> The study shows that “Multilevel interlaminar fenestration with Soft Tissue Decompression in Lumbar Canal Stenosis” is a feasible, safe, and effective approach to lumbar canal stenosis and is associated with minimal complications and minimal perioperative morbidity.</p> Atul Agarwal Ruchi Mittal Amit Kumar Sharma Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 171 175 Anterior cervical surgery for the treatment of cervigonenic headache caused by cervical spondylosis <p>Cervicogenic headache (CEH) is a common disorder with cervical spine-specific nociceptive headache symptoms. Cervicogenic headaches have been studied for years, but diagnosis and treatment are continually evolving. Due to non-specific criteria and its relationship with cervical degenerative illness, diagnosis may be underestimated. In many situations, it contributes to myelopathy or radiculopathy. Local anaesthetic blocks are used to confirm the diagnosis, however, non-invasive methods are being explored. Identifying the nociceptive origin improves pain management. Physical therapy and percutaneous interventional procedures are used to treat isolated CEH. However, cervical decompression and/or fusion are often performed in situations of cervical myelopathy and/or radiculopathy. Here we report a 57-year-old female with cervicogenic headache treated with anterior lower cervical discectomy to relieve cervical myelopathy and/or radiculopathy headaches.</p> Fadhil Yunus Kuntawi Aji Sabri Muhammad Deni Nasution Nindi Lizen Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 176 179 Current insights and surgical interventions in craniovertebral junction instability <p><strong>Abstract</strong></p> <p>Background: The Craniovertebral Junction (CVJ) is prone to various pathologies, including instability and congenital anomalies. Understanding these conditions and their management strategies is critical for effective treatment.</p> <p>Materials and Methods: A systematic search was conducted in Science Direct and PubMed databases following PRISMA guidelines. Inclusion criteria encompassed studies addressing craniovertebral instability and associated pathologies. Six systematic investigations were assessed for methodological quality. Data extraction involved 702 patients with CVJ issues, among which 129 had related conditions, while 279 displayed normal CVJ. Surgical interventions encompassed various techniques such as C1-C2 fixation, posterior decompression, and screw placements.</p> <p>Results: Among 702 patients studied, atlantoaxial subluxation, basilar invagination, and odontoid fractures were observed in 129 cases. Surgical treatments showed favorable outcomes, with fusion achieved within a year post-surgery for both C1-C2 fixation techniques and posterior decompression strategies. Studies highlighted successful outcomes in cases of cervical myelopathy, especially with early occipitocervical fusion.</p> <p>Conclusion: Managing atlantoaxial instability remains a debated topic, with varying success rates observed in different surgical interventions. Recommendations emphasize the importance of stabilization techniques and imaging modalities for effective preoperative planning and postoperative care. However, limitations in the available data underscore the need for further research to refine treatment strategies for better patient outcomes in this complex area of spinal pathology.</p> <p><strong>Keywords: </strong>Craniovertebral junction, atlantoaxial instability, Basilar invagination, fusion, CVJ pathologies&nbsp;</p> Daniel Encarnación Santos Gianluca Scalia Ismail Bozkurt Alexander Volovish Ariel Tapia Sierra Jack Wellington Bipin Chaurasia Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 180 188 Clinical outcomes of tubular microdiscectomy with 18mm diameter tubular retractor for lumbar disc herniation <p><strong>Introduction</strong>: Tubular microdiscectomy is one of the minimally invasive techniques for spine surgery. This prospective study aims to evaluate the clinical outcomes of using a tubular microdiscectomy with an 18 mm dilator for the treatment of lumbar disc herniation over a 2-year period.</p> <p><strong>Methods</strong>: A prospective observational study of 57 patients who had undergone a first-time, single-level lumbar discectomy presented with single-sided radiculopathy with or without backache was done. Perioperative and postoperative results were assessed by documenting operative time, estimated blood loss, length of stay, rate of wound infection, neurological deficits in post-op period, rate of cerebrospinal fluid leak and resumption of work. Pain assessment was done with VAS score at admission, at discharge and in follow up.</p> <p><strong>Results</strong>: A total of 57 patients were included in the study. The average duration of surgery was 64 minutes. The average duration from surgery to discharge was 35.5 hours. The average time for complete resolution of radicular symptoms was 8.5 days. The median time for return to work was 20 days. Two patients experienced cerebrospinal fluid (CSF) leak due to inadvertent durotomy. The mean Visual Analog Scale (VAS) value at admission was 9.5087, which significantly reduced to 1.49 at discharge.</p> <p>Follow-up assessments at 15 days, 1 month, 3 months and 1 year revealed sustained improvements in clinical outcomes.</p> <p><strong>Conclusion</strong>: Tubular microdiscectomy with an 18 mm dilator demonstrates favourable clinical outcomes for patients having single-level lumbar disc prolapse intervertebral disc causing radiculopathy and low backache, less blood loss intraoperatively, small scar, lesser hospital stay and early return to work.</p> Praveen Kumar Tripathi Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 189 194 Variation in optic recess angle with optic chiasm position <p><strong>Background</strong>: The position of the optic chiasm relative to surrounding structures is critical in planning surgical interventions for suprasellar lesions. This study explored the relationship between the angle of the optic chiasm and lamina terminalis (OC-LT) and the position of the optic chiasm.</p> <p><strong>Methods</strong>: The study comprised 140 individuals who underwent midsagittal and axial MRI-T2 scans. The position of the optic chiasm was classified into three categories: sellar, prefixed, and postfixed. The OC-LT angle was measured in the midsagittal section.</p> <p><strong>Results</strong>: The angle between OC-LT varied from 30 to 66 degrees with a mean of 46.6 degrees. The sellar position of the optic chiasm was predominant (85.2%), with smaller angles (30-39 degrees) significantly associated with a sellar chiasm location. Most cases with postfixed optic chiasm fell within a 40-49 degree angle range.</p> <p><strong>Conclusions</strong>: The OC-LT angle variability can be linked to the position of the optic chiasm. Predominantly, smaller angles correlated with a sellar position of the optic chiasm, while larger angles were associated with a postfixed optic chiasm. This information is crucial for surgical planning in the suprasellar region.</p> Mostafa H. Algabri Ali Adnan Asmaa H. AL-Sharee Sajjad G. Al-Badri Rania H. Al-Taie Mustafa Ismail Samer S. Hoz Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 195 199 Configurational changes of ruptured intracranial aneurysms at the window between pre-operative CTA and the definite clipping surgery <p><strong>Background: </strong>Ruptured intracranial aneurysms may face configurational changes in size and shape resulting from extreme weakness in their wall. These configurational changes are associated with an amplified risk of rupture and surgical challenges as these aneurysms have proven to be unstable. However, to our knowledge, no previous studies have addressed the issue of configurational aneurysmal changes between the patient’s presentation (radiological images) and intraoperative findings. This paper aims to compare aneurysmal size and shape between pre-operative Computed tomography angiography and intraoperative lesion characteristics in a cohort of patients presented to our centre.</p> <p><strong>Methods: </strong>A retrospective analysis was performed on cases admitted to the Neurosurgery Teaching Hospital in Baghdad, Iraq, and underwent microsurgical clipping of ruptured aneurysms. Their records were checked for aneurysmal configurational changes by comparing pre-operative radiological images and intra-operative findings.</p> <p><strong>Results: </strong>Of the 275 patients, 5 cases were enrolled with aneurysmal configurational changes. Three of them were females, and two were males. The pre-operative aneurysmal shapes based on Computed tomography angiography were (3 unicyst and two conical shapes) and the range of aneurysmal size was (7-11 mm) with a mean of 9 mm. Compared to intra-operative findings, there were total aneurysmal shape changes (connected cyst in 4 patients and spherical aneurysm in one patient). The range of aneurysmal size was (7-11 mm) with a mean of 9 mm.</p> <p><strong>Conclusion: </strong>Intracranial aneurysms may undergo configurational changes through the time between pre-op imaging and surgery; early detection of these changes may ensure optimal management of such cases.</p> Hagar A. Algburi Mustafa Ismail Tabarek M. Al-Nuaimi Zainab T. Alzeyadi Jafar M. Sabbar Ahmed K. Al-Kishawi Rania H. Al-Taie Mahmood F. Al-Zaidy Mohammed A. Alrawi Samer S. Hoz Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 200 204 Neurosurgical management of posterior communicating artery aneurysmal perforators <p><strong>Background</strong>: Posterior communicating artery (PCom) aneurysms are prevalent intracranial aneurysms, frequently leading to subarachnoid haemorrhage and third nerve palsy. "True" perforators originating directly from the PCom aneurysmal sac are rare and pose unique surgical challenges. We present two illustrative cases where "true" PCom perforators were identified during surgery, necessitating tailored microsurgical approaches.</p> <p><strong>Case Reports</strong>: In case one, a 35-year-old female presented with a large PCom aneurysm. During surgery, a modified clipping technique successfully preserved a perforator originating from the aneurysmal sac. In case two, a 36-year-old male with a PCom aneurysm was found to have a perforator supplying the mesial temporal cortex. Sacrificing this perforator was necessary for aneurysm clipping.</p> <p><strong>Conclusion</strong>: This paper underscores the rarity of "true" PCom perforators and their impact on microsurgical approaches. Preoperative imaging techniques often fail to detect these small-calibre vessels, highlighting the importance of intraoperative identification. Tailored approaches based on individual anatomy and clinical context are essential. While endovascular procedures provide alternatives, adaptability in microsurgical techniques remains crucial for cases requiring intraoperative perforator management. Overall, understanding the complex vascular intricacies of PCom aneurysms, including "true" perforators, is vital for neurosurgeons. The delicate balance between preservation and necessity, along with ongoing research for improved preoperative identification, stands as the cornerstone for enhancing surgical outcomes in these complex cases.</p> Ali M. Neamah Mustafa Ismail Aktham O. Al-Khafaji Saja A. Albanaa Sajjad G. Al-Badri Almutasimbellah K. Etaiwi Mays S. A. Ahmed Mahmood F. Al-Zaidy Samer S. Hoz Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 205 210 A 21 cm long intra-medullary tuberculoma of dorsal spinal cord <p>Intramedullary tuberculoma (IMT) is a rare form of spinal tuberculosis. The incidence of this disease is 01-02/100,000 patients<sup> (1)</sup>. Occurs by hematogenous dissemination from focus elsewhere in the body. Magnetic resonance imaging (MRI) is helpful for diagnosing IMT at an early stage and it is also very useful in follow-up. CSF PCR studies are confirmatory. Histopathology is the Gold Standard. AKT drug therapy is the mainstay of treatment for IMT, with surgery indicated in select patients. Here, we describe a female patient with long-segment dorsal intramedullary tuberculoma with compressive myelopathy treated with surgery and put on AKT who improved clinically.</p> Hrushikesh Kharosekar Skhandeshwaran P. Vernon Velho Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 211 215 Intestinal perforation due to a ventriculoperitoneal shunting catheter <p><strong>Introduction: </strong>The ventriculoperitoneal (VP) shunt allows the drainage of excess cerebrospinal fluid; among its gastrointestinal complications are intestinal volvulus, pseudocyst, and perforation, the last of which is rare but potentially serious, with a frequency between 0.1% and 0.7% and a mortality rate around 15%. We present the case of a male child who required VP shunt colocation and suffered GI tract perforation with transanal protrusion.</p> <p><strong>Case report: </strong>A three-year-old male with a long clinical history of pilocytic astrocytoma in the posterior fossa that was partially resected in February 2022 and with VP shunt placement since March 2022. He was diagnosed with an intestinal perforation and anal externalization due to a VP shunt. He required surgery and management with combined antimicrobials.</p> <p><strong>Discussion: </strong>Although the aetiology of GI tract perforation due to a VP shunt is not fully established, some risk factors have been described, including the use of abdominal trocars, rigid distal catheters, silicone allergies, and children's thin intestine walls. Treatment must be individualized, with some principles including external drainage of the proximal part until the CSF fluid reaches a biochemically near-normal state and becomes sterile on culture; secondly, the administration of intravenous antibiotics; and finally, the removal of the perforating section of the catheter.</p> <p><strong>Conclusions: </strong>Bowel perforation due to a VP shunt is an extremely rare entity whose aetiology is not fully established, primarily affects children and may be mostly related to chronic-irritative gastrointestinal distress. Individualizing treatment is the cornerstone of the therapeutic approach that includes VP shunt replacement, antimicrobial therapy, and management of life-threatening complications.</p> Alejandro Rojas Urrea Daniela Arias Mariño Lorena García Agudelo Marco Antonio Rojas Gutierrez Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 216 220 An exceptional presentation of pituitary apoplexy in thyrotoxicosis <p>Pituitary apoplexy (PA) is a rare and potentially life-threatening condition characterized by severe headaches, vomiting, visual disturbances, ophthalmoplegia, altered mental status, and possible pan-hypopituitarism. A macroadenoma-induced pituitary haemorrhage is the primary cause. Various factors such as systemic hypertension, altered intracranial pressure, head trauma, anticoagulation, and pregnancy can trigger PA. A 35-year-old non-smoking male presented with headaches and an enlarged thyroid gland. Initial imaging revealed a haemorrhage in the sellar area, prompting a clinical diagnosis of pituitary apoplexy with T3 thyrotoxicosis. Despite the absence of visual impairment, conservative management was chosen, including anti-hypertensive therapy and follow-up MRI after three months. PA diagnosis can be challenging without prior identification of a pituitary tumour. Imaging modalities like MRI are crucial for diagnosis, and radiological follow-up is recommended. The relationship between PA and hyperthyroidism remains unclear, necessitating further investigation in patients presenting with PA symptoms.</p> Dipak Chaulagain Volodymyr Smolanka Andriy Smolanka Taras Havryliv Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 221 223 Neuroimaging findings from a case of neurocysticercosis <p><strong>Introduction</strong>: Human cysticercosis occurs when humans ingest <em>Taenia solium</em> eggs from the fecal-oral route. The infection in the central nervous system is called neurocysticercosis and is considered the principal cause of late-onset epilepsy in endemic countries in Latin America, Asia, and Africa.</p> <p><strong>Case report:</strong> 71-year-old female in a state of neglect with a medical history of untreated rheumatoid arthritis. She presented her first seizure episode. Cerebral magnetic resonance imaging with contrast reported parenchymal and subarachnoid neurocysticercosis in different stages.</p> <p><strong>Discussion</strong>: The high incidence of neurocysticercosis in endemic countries is associated with poverty conditions such as less hygienic conditions and permanent contact with domestic animals. The four stages of classification of neurocysticercosis is useful for pathologists and radiologists to identify the life cycle of the parasite within the body and the specific imaging findings of each phase. After diagnosis, treatment includes the use of niclosamide or praziquantel.</p> <p><strong>Conclusions</strong>: neurocysticercosis is a public health problem in endemic countries that requires further attention. Clinical manifestations are variable and neuroimaging findings are essential to making a correct diagnosis.</p> Alejandro Rojas Urrea Daniela Arias-Mariño Mónica Paola Niño Moreno Natalia Sanchez Coronel Lorena García Agudelo Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 224 227 Spinal arachnoid cysts <p><strong>Objectives</strong>: Spinal arachnoid cysts (SAC) are rare lesions. There are many uncertainties regarding details about Intradural and Extradural SAC. We present a series of 12 cases of SAC along with a comprehensive review of the literature. In this review, we discussed the differences between Intradural and Extradural SAC pertaining to demography, pathogenesis, surgical procedures and outcomes.</p> <p><strong>Methods</strong>: We retrospectively collected the data of 12 patients of SAC treated at our Institute from 2012 to 2023. The age, gender, clinical, radiological, surgical data and outcome were noted. An extensive review of the literature was done to analyse and note the differences between Intradural and extradural SAC and their surgical management.</p> <p><strong>Results</strong>: In our series of 12 patients, 7 had Extradural SAC(58.3%), 3 had Intradural SAC(25%) and 2 had Intramedullary SAC(16.7%). . Of the 12 patients, 4 were males and 8 were females (1:2). Age range was 9 to 64 years and the mean age was 34.42 ± 17.71 years. There were four paediatric patients in the series. The most common symptoms reported at presentation are weakness of limbs(81.9%),back pain(36.4%), sensory symptoms(36.4%), radicular pain (18.2%), and bladder disturbances(9.1%). Out of the 12 patients, surgery was done in 11 patients and one patient was managed conservatively.</p> <p><strong>Conclusions</strong>: From the review of the literature, intradural SAC was twice as common as extradural SAC. Ventrally located SACs are more common in Intradural locations as compared to Extradural. The intradural SACs were more commonly located in the thoracic and cervical regions when compared to extradural SACs which were located commonly in the thoracolumbar, thoracic and lumbar regions. Extradural SACs were mostly Primary and the mainstay of treatment is complete or partial excision of the cyst with identification and ligation of the communicating pedicle. Selective laminectomy, partial excision of the cyst and wide fenestration to sustain CSF flow is the recommended treatment in Intradural SAC.</p> Kiran Chand Velivela Amit Kumar Thotakura Nageswara Rao Marabathina Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 228 235 Acute synchronous bilateral extradural hematoma, a scarcely reported, rare entity <p><strong>Objective</strong>: Extradural hematomas (EDHs) are contact injuries resulting from blunt trauma to the skull. It may be unilateral or bilateral. Bilateral acute extradural hematoma (EDH) was rarely reported before the advent of computed tomography. Mortality rates vary from 10.0%-40.0% and are an index of alertness and efficiency of health care and hospital set-up. EDH is an injury with preventable mortality in most cases. Bilateral acute extradural hematomas no longer confer high mortality of pre-CT era because of early diagnosis on CT, and prompt neurosurgical intervention. We present our experience with Bilateral EDH cases with an aim to investigate clinical, GCS score, and radiological features and also to analyse outcomes in these patients.</p> <p><strong>Material and methods: </strong>We analyzed cases of EDH who presented at our centre from January 2023 to December 2023 and further investigated ten cases of bilateral EDH. All the patients were examined clinically and a plain computerized tomography scan of the head was performed. The clinical details of all patients, GCS at admission and discharge, radiological findings on CT and neurosurgical intervention performed, and GOS (Glasgow outcome score) were noted.</p> <p><strong>Results: </strong>Road traffic accident was the reason for traumatic brain injury in all the cases. The GCS at admission was between 13–15 in 2 patients, 8–12 in 6 and 3–7 in 2 patients. Bilateral EDH was found in all of our patients .9 out of 10 cases were males. On CT head underlying fracture was seen in all cases. The localization of epidural hematomas in CT scans was bifrontal in four of the cases. All cases were treated with surgical management. The GOS Score was 5 in eight of the patients.</p> <p><strong>Conclusion:</strong> Posttraumatic bilateral acute extradural hematoma is a rare entity, but now does not show the high mortality previously seen in the preCT era. This is due to early radiological diagnosis on CT and profuse monitoring combined with expeditious operative procedures.</p> Vibhu Shankar Parashar Pankaj Arora Ritesh Garg Priyanka Aswal Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 236 241 A comprehensive review on anterior endoscopic cervical discectomy <p>Anterior endoscopic cervical discectomy (AECD) represents a groundbreaking surgical technique that has garnered considerable interest in recent times due to its minimally invasive nature for addressing cervical disc herniation. This review endeavours to conduct a thorough examination of the existing literature concerning AECD, encompassing its indications, surgical technique, clinical outcomes, advantages, limitations, and potential complications. Through a meticulous analysis of the available data, this review aims to evaluate the effectiveness, safety, and overall viability of AECD as a substitute for conventional open surgical methods in addressing cervical disc issues. By delving into these aspects, the review seeks to provide insights into the potential role of AECD in enhancing patient outcomes and optimizing the management of cervical disc pathology.</p> Muhammad Jehanzeb Ahtesham Khizar Inaam Elahi Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 242 256 A prospective study to evaluate the role of repetitive trans-cranial magnetic stimulation in treatment of chronic low back pain <p><strong>Introduction</strong>: Chronic Low Back Pain (CLBP) is a disabling musculoskeletal condition with a high prevalence in developing and developed countries. There are many treatment modalities but none of them provides a satisfactory and consistent cure. Recently focus has shifted to neuromodulation to cure chronic pains. The U.S. Food and Drug Administration (FDA) approved the use of Repetitive TMS (rTMS) in the management of Pain in 2013. Since then, centres across the world have been using Transcranial Magnetic Stimulation (TMS) as a noninvasive modality for the treatment of various pain conditions. rTMS is a variation of TMS where stimulation is provided in sessions to create long-term excitation in the brain cortex. Evidence on the effectiveness of rTMS for CLBP is scarce due to limited rigorous clinical trials. This study is the first of its kind undertaken in India to critically analyze the role of rTMS in the treatment of CLBP.</p> <p><strong>Materials &amp; Methods</strong>: In this single institutional prospective, single-blind study, we enrolled 40 patients of CLBP sharing similar clinical profiles. They were divided into a test group and a sham group. In the test group patients were given rTMS in addition to conventional treatment while in the sham group, patients were taken through the procedure of rTMS without actually being administered it. A figure-of-eight-shaped coil was used focusing on the Left M1 area and Dorsolateral prefrontal cortex to administer the rTMS by a trained physician. Visual Analogue Scores (VAS) were noted before and after the procedure. Each patient was continuously monitored during the procedure for any side effects. Subsequently, they were interviewed and followed up for 6 months. At the end of 6 months, data was compiled and conclusions were drawn.</p> <p><strong>Result:</strong> In our study, we found that 90 per cent of patients in the test group reported a reduction in VAS score by 30 per cent reduction while the remaining had a 20 per cent reduction in pain scores. 90 per cent of subjects in the sham group reported a marginal improvement in VAS score which can be attributed to the placebo effect. Most patients in the test group reported an improvement in quality of life at the end of six months. None of the patients suffered any untoward side effects during or after the procedure.</p> <p><strong>Conclusion: </strong>Based on our study we conclude that rTMS is a safe procedure and it can be used as a modality in treating CLBP with satisfactory outcomes. Although the sample size was small, it is the first study of its kind undertaken in India to evaluate the role of rTMS-based neuromodulation in treating this chronic disabling condition. However, to be accepted as a standard of care for CLBP it will require further multi-institutional robust clinical trials with long-term follow-up.</p> Shashivadhanan Mannu Tiwari Ankit Singhal Nandish M. Sachin Dhanwade Ritwik Mishra Neerav Porwal Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 257 261 Colloid cyst of the third ventricle <p style="line-height: 150%; margin: 0mm 0mm 8.0pt 0mm;"><strong><span lang="EN-IN" style="color: #08083a;">Background: </span></strong><span lang="EN-IN" style="color: #08083a;">In the past, microsurgical resection was</span><span lang="EN-IN"> considered the gold standard treatment for colloid cysts. The endoscopic approach is gaining popularity and has been recognized as a safe and effective alternative to open surgery. </span></p> <p style="line-height: 150%; margin: 0mm 0mm 8.0pt 0mm;"><span lang="EN-IN">Aims<strong>: </strong>To evaluate our results, safety and efficacy of the endoscopic approach </span></p> <p style="line-height: 150%; margin: 0mm 0mm 8.0pt 0mm;"><span lang="EN-IN"><strong><span style="color: #08083a;">Materials and methods:</span></strong> This retrospective study included seven patients with colloid cysts who underwent endoscopic resection between May 2020 and April 2022. Patient records, radiological images, and surgical notes were assessed. Follow-up data, including clinical and radiological details, were retrieved. Postoperative Computed tomography (CT) was performed, and magnetic resonance imaging (MRI) was performed in all patients.</span></p> <p style="line-height: 150%; margin: 0mm 0mm 8.0pt 0mm;"><span lang="EN-IN"><strong><span style="color: #08083a;">Result: </span></strong><span style="color: #08083a;">Seven patients aged range 27-56 years 4 males and 3 females underwent endoscopic resection of the tumor during the study period.</span> All patients presented with headaches. The mean diameter of the cyst was 10.6(range 8 -14mm), and the mean operating time was 126(range 100 -180 min). All patients underwent the single burr hole and single port technique. Six patients underwent transforaminal surgery and one patient underwent trans-septal corridor. GTR was achieved in six patients. One patient underwent near-total resection with coagulation of the capsule. None of the endoscopic procedures was converted to open resection. No patient had a recurrence, and the mean follow-up period was 24.3 (range 16 to 36 months). There were no deaths during the follow-up period. No residual cysts were observed on postoperative MRI in any patient. </span></p> <p style="line-height: 150%; margin: 0mm 0mm 8.0pt 0mm;"><strong><span lang="EN-IN" style="color: #08083a;">Conclusion: </span></strong><span lang="EN-IN">Endoscopic excision of colloid cysts is an effective and safe alternative method. Although the follow-up time was short, the residual cyst wall remained asymptomatic without any evidence of growth after near excision and coagulation of the wall.</span></p> Mohammad Kaif Abhishek Kumar Kuldeep Yadav Deepak Kumar Singh Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 262 266 Evaluation of the need for debulking in meningioma surgery by a retrospective analysis of our case series <p><strong>Introduction</strong>: The primary aim of meningioma surgery should be total excision. However, subtotal excision is considered first if the main vascular structures and the cranial nerves are at risk. The ‘primum non nocere’ principle should always be considered. A clinical study where the emphasis is on en bloc resection without debulking in suitable cases, in contrast to the classic approaches, could therefore prove useful.</p> <p><strong>Method</strong>: The meningioma cases operated at the ?zmir Bak?rçay University Çi?li Training and Research Hospital’s Neurosurgery Clinic between 2021 and 2023 were retrospectively evaluated. There were no exclusion criteria. The demographic features of the patients who had undergone debulking or en bloc resection and the anatomical, pathological, surgical and clinical features of the meningiomas were evaluated and the results were presented as percentages.</p> <p><strong>Results</strong>: A total of 21 patients, consisting of 5 males (23.8%) and 16 females (76.2%), were included in the study. The mean age was 58.8 (28-90) years. En bloc resection was performed in 18 (85.7%) and debulking in 3 (14.3%) of the 21 cases. The other results are presented within the article.</p> <p><strong>Conclusion</strong>: En bloc resection could be an important surgical strategy to decrease the surgical duration and bleeding amount in appropriate cases.</p> Ümit Kocaman Emre Çavuşoğlu Copyright (c) 2024 Romanian Neurosurgery 2024-06-15 2024-06-15 267 273