Background Immunoglobulin G4–related disease (IgG4-RD) is a recently identified multisystemic fibroinflammatory condition of unclear etiology. IgG4-RD of the epidural tissue causing spinal cord compression is extremely rare. Case description Here, we present a 27-year-old male with epidural mass, causing spinal cord compression at the level of D5-D6. The mass proved pathologically to be epidural inflammatory pseudotumor (IPT) related to IgG4. Spinal decompression was done. The patient was started on steroid treatment and reported a complete resolution of his symptoms over a 3 years’ follow-up period. Conclusion To the authors’ knowledge, this is the first case of IgG4-related epidural IPT and spinal cord compression in Bahrain and the Middle East. IgG4-RD should always be considered as a part of the differential diagnosis of spinal tumors.

BACKGROUND Cranioplasty can be carried out using either fresh, frozen autologous bone or synthetic substitutes. Ordering artificial 3 dimensional (3D) implants is challenging and time consuming depending on geographical location. In this article, we share our experience using a streamlined process of producing 3D computer-assisted design (CAD) implants using commercially available 3D printers and silicone molds that can be easily replicated with consistent results and are associated with good outcomes. OBJECTIVE To develop patient-specific implants for patients with cranial defects that are accurate, consistent, low cost, and easy to replicate while reducing operator-dependent factors. METHODS We present data from 15 patients who underwent cranioplasty with 3D CAD-designed gentamicin-impregnated bone cement implants that were molded using the cold injection technique. RESULTS The technique was consistent in result production, required little postdemolding manipulation, and showed no dimensional variation in design. Postoperative computed tomography scans showed excellent implant fit, and patients had a low complication rate. CONCLUSION We have demonstrated a technique of mold preparation that is efficient and that produces a reliable result. Polymethyl methacrylate implants molded using this technique showed better reproducibility, higher accuracy, and precision than other types of implants and required minimal postdemolding clean-up.

Transverse sacral fracture is a rare entity in the pediatric age group, primarily resulting from a fall from height. This case report stresses the importance of proper neurological assessment, adequate imaging and highlights different modalities of management of this fracture. We report a case of a 13-year-old child with type III Roy-Camille sacral fracture with associated bladder and bowel dysfunction. The patient underwent spinopelvic fixation and decompression of the sacral canal. The patient partially regained bowel and urinary function and had improved motor function after three months of follow-up. Operative management is generally advocated for such fractures. Keywords: Decompression; Bone fractures; Neural tube; Pediatrics; Sacrum

Background: Cerebral radiation necrosis (CRN) is a complication caused by radiation therapy (RT) used for treating high-grade intracranial neoplasms. It is essential to be aware of this condition as it can be frequently mistaken for tumor recurrence. Herein, we report a case of misdiagnosis of CRN in a young male, which has heavily influenced his clinical history.Case Presentation: We report a 25-year-old male diagnosed with right frontal convexity meningioma based on computerized tomography (CT)/magnetic resonance imaging (MRI). The operation achieved a macroscopically complete tumor resection. The histopathology was an atypical meningioma. Accordingly, the patient received RT. The patient reported new-onset of generalized seizures and worsening of left hemiparesis three months after completion of RT. MRI showed abnormal peripheral enhancement in the right frontal region involving the genu of the corpus callosum and extensive brain edema. Magnetic resonance spectrometry (MRS) changes were suggestive of tumor recurrence. The patient underwent surgery with total resection of the lesion. The histopathology was CRN without evidence of tumor recurrence. Due to refractory progressive brain edema, the patient’s clinical status deteriorated until he expired.Conclusion: CRN carries morbidity and mortality as a complication from brain irradiation. There is no single modality that can reliably distinguish CRN from recurrent tumor. Therefore, a multimodality approach highly recommended.

Introduction. Atypical Meningioma (AM) is at high risk of local failure. The role of radiation therapy (XRT) as an adjuvant to surgical resection is incompletely defined. The most deleterious consequence of brain-directed XRT is radiation necrosis. Brain radionecrosis (BRN) after AM has been rarely reported. The relevant literature is reviewed, highlighting its diagnostic challenges. Case Presentation. We report a 25-year-old male with a BRN after adjuvant XRT for AM, which has been misdiagnosed as a recurrent neoplastic lesion upon magnetic resonance spectroscopy (MRS) examination. Surgery and histopathological description were made and yielded a definitive diagnosis of BRN. The patient was treated by dexamethasone with concomitant hyperbaric oxygen therapy (HBO2). The patient showed a further progression of the disease. Therefore, he was elected to receive bevacizumab. However, the patient finally died for refractory brain edema. Conclusion. BRN is a relatively rare instance after XRT for AM. There is no single modality that can reliably distinguish BRN from tumour recurrence.  Therefore, reaching an early prompt treatment decision is challenging.