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Background: Anterior cervical discectomy and fusion (ACDF) is a well-accepted treatment option for patients with cervical spine disease. Three- and four-level discectomies are known to be associated with a higher complication rate and lower fusion rate than single-level surgery. This study was performed to evaluate and compare zero-profile fixation and stand-alone PEEK cages for three- and four-level ACDF.Methods: Two cohorts of patients who underwent ACDF for the treatment of three- and four-level disease were compared. Thirty-three patients underwent implantation of zero-profile devices that included titanium screw fixation (Group A). Thirty-five patients underwent implantation of stand-alone PEEK cages without any form of screw fixation (Group B).Results: In Group A, twenty-seven patients underwent a three-level and six patients a four-level ACDF, with a total of 105 levels. In Group B, thirty patients underwent a three-level and five patients underwent a four-level ACDF, with a total number of 110 levels. In Group A, the mean preoperative visual analog scale score (VAS) for arm pain was 6.4 (range 3-8), and the mean postoperative VAS for arm pain decreased to 2.5 (range 1-7). In group B, the mean preoperative VAS of arm pain was 7.1 (range 3-10), and the mean postoperative VAS of arm pain decreased to 2 (range 0-4). In Group A, four patients (12%) developed dysphagia, and in Group B, three patients (9%) developed dysphagia. Conclusions: This study found zero-profile instrumentation and PEEK cages to be both safe and effective for patients who underwent three- and four-level ACDF, comparable to reported series using plate devices. Rates of dysphagia for the cohort were much lower than reports using plate devices. Zero-profile segmental fixation devices and PEEK cages may be considered as viable alternatives over plate fixation for patients requiring multi-level anterior cervical fusion surgery.

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Brain tumours represent a major focus of research in chemotherapy, radiotherapy and neurosurgery. The principle that guides all of these disciplines is: be effective on the tumour with fewer effects on normal brain tissue. In surgical sciences this concept has become known as 'minimally invasive surgery'. The development of endoscopic techniques has had a revolutionary impact in several disciplines such as urological, gastrointestinal and thoracic surgery. In neurosurgery, the use of the endoscope was initially limited to the treatment of hydrocephalus. Only during the last few decades have the indications for endoscopy -which has been driven by global technological progress, leading to the development of image-guided surgery, intra-operative-imagingdedicated surgical instruments and increasingly efficient endoscopesbeen extended to other pathologies such as aneurysms and tumours. Historical BackgroundUntil the 1960s, neurosurgical procedures for brain tumours were The Endoscopic TechniqueThe endoscope has become part of the equipment in all neurosurgical operating theatres and the surgeon can rely on low-profile endoscopes with straight or variably angled views, xenon light source, irrigation sheaths for cleaning the lenses inside the operating field and endoscope holders to perform bimanual dissection, as in microsurgery. Nevertheless, the endoscope is far from being commonly applied as a visualising tool during microsurgical procedures: the endoscope-assisted technique is devoted to surgery for aneurysms and cerebellopontine tumours. The reasons for this lie in the marked differences between the two imaging modalities. Despite the fact that several systems integration strategies have been applied, 3