Introduction The cervical spine is a highly mobile segment of the spinal column, liable to a variety of diseases and susceptible to trauma. It is a complex region where many vital structures lie in close proximity. Lateral mass screw fixation has become the method of choice in stabilizing subaxial cervical spine among other posterior cervical fixation techniques whenever the posterior elements are absent or compromised. Objective This study examined cervical specimens of cadavers and cervical computed tomography (CT) scans to minimize as much as possible complications of cervical lateral mass screw placement such as vertebral artery or nerve root injuries, facet joint violations, or inadequate placement. Methods Forty normal cervical CT scans, obtained from the emergency unit as part of the trauma workup, were included in this study plus 10 cervical cadaveric specimens obtained from the Alexandria Neuro-anatomy laboratory. There were three fixed parameters for screw insertion in this study. First, the point of screw insertion was the midpoint of the lateral mass; it was the crossing point between the sagittal and axial planes of the posterior cortex of the lateral mass. Second, the direction of the screw in the craniocaudal plane was 30 degrees cranially to avoid facet joint penetration. Third, the exit point of the screw was located on the ventral cortex of the lateral mass just lateral to the root of the transverse process in the midaxial cut of each lateral mass, to make a sound bicortical fixation without injuring the vertebral artery or the nerve root. The selected screw trajectory in this study was the line drawn between the inlet and exit points. The depth and width of the lateral mass of the cervical vertebrae from C3 to C7 were measured as well as the angle of screw trajectory from the sagittal plane. All these measures were applied on the cadaveric specimens to make sure that no injury to the vertebral artery, nerve root, or facet joint occurred. Results As regards the collected measurements of the lateral mass of all subaxial cervical vertebrae, the study revealed that the average depth of the lateral mass was 12.83 ± 1.28 mm. The average width of the lateral mass was 11.92 ± 0.96 mm. The average divergent angle of bicortical screw insertion without injury to the vertebral artery or the nerve root was 19.51 ± 1.83 degrees. As regard the cadaveric specimens, based on all the collected measurements taken from the CT scans, there was no reported injury to the vertebral arteries or nerve roots or penetration to the facet joints. Conclusion Lateral mass fixation can be applied easily and safely for all levels of subaxial cervical spine from C3 to C6 with the following parameters: (1) the point of entry is the midpoint of the lateral mass; (2) the screw trajectory is directed 30 degrees cranially and 20 degrees laterally; (3) the screw length is 13 to 15 mm.

Hydrocephalus is a very common disease in developing countries. Congenital aqueductal obstruction and post-inflammatory hydrocephalus come on the top of the list of causes of hydrocephalus. Till the recent introduction of cranial endoscopy and despite their frequent complications, shunts were considered as the mainstream treatment for this disease. Endoscopic third ventriculostomy (ETV), especially for obstructive hydrocephalus, introduced a new era of treatment that is free of lifetime shunt dependency. This study was done to assess the efficacy of ETV for treating post-inflammatory hydrocephalus in a unique group of patients thus preventing—if possible—the lifetime shunt dependency and suffering. ETV was tried as a first-line therapy in 35 children (23 males and 12 females) with hydrocephalus proved to be secondary to intracranial infection. Mean age was 9.2 months (4-15). Twenty-four patients (68.6%) were below the age of 6 months while 11 patients (31.4%) were above 6 months. Twenty-five patients (71.4%) had a head circumference of 3 cm and 10 patients (28.6%) had a 5 cm or more increase in the head circumference above the 95th percentile. All the patients included were followed postoperatively with regular clinical, computerized tomography (CT), and magnetic resonance imaging (MRI) examinations as well as cerebrospinal fluid (CSF) analysis and culture. The overall success of ETV was 55.9% (19/34). Nine (81.9%) out of the 11 patients that were endoscopically documented to have aqueductal obstruction showed improvement. While out of the 23 patients with patent aqueduct, only 10 patients (43.4%) had improved. Procedure-related complications were not encountered. CSF leakage from the surgical wound occurred in three patients and mild CSF infection occurred in one patient. ETV is a simple, safe, and effective method in treating not only obstructive hydrocephalus due to non-inflammatory etiology, but also post-inflammatory hydrocephalus especially when the aqueduct is obstructed. An overall 50% improvement in our study and even more in other series encourage the trial of getting rid of the lifetime shunt complications and suffering.

Background data: Post spinal surgery infection is not uncommon. It is considered as one of the most annoying complication following surgery on the spine. The major burdens of post spinal surgery infection are time and money consuming. Infections have a considerable effect on post-operative morbidity and mortality. Purpose: The aim of this study was to identify the possible risk factors, preventive measures, diagnostic tools and the ideal management procedures. Study design: Retrospective study. Patients and methods: This is a retrospective study which was carried out on 35 patients operated upon (either primary or revision) for variable spinal lesions from 2006 till 2016 and complicated by post spinal surgery infection. No patient was operated upon for primary pre-existing spinal infection or congenital lesions. Patients were operated upon by same surgeon in the same hospital. On presentation, the patients were diagnosed to have post-operative infection by clinical examination, laboratory and radiological investigations. All patients were re-admitted to the hospital where the proper management was done. Results: Most of cases were associated with pre-operative risk factors and intra or post-operative complications. Cervical disc prolapse (8 patients) was the most common lesion in the cervical region group, whereas lumbar disc prolapse (12 patients) was the most common lesion in lumbar group. Six patients suffered from complications (durotomy in 5 patients and right common iliac artery injury in one patient). Superficial infection was encountered in 12 patients and deep infection was diagnosed in 19 patients, whereas combined infection was diagnosed in 4 patients. Surgical management that needed general anesthesia was provided to 22 patients whereas conservative management was provided to 13 patients. Out of 35 cases, only one patient died from the complications of infection. Conclusion: Post spinal surgery infection is a devastating complication that needs multi-modalities for prevention and control. Neutralization of the pre-operative risk factors can dramatically reduce the post-operative infections. Once diagnosed, the patients with infection must be hospitalized and extensive management should be applied.

Introduction: Thalamic space-occupying lesions (SOL) are considered challenging for microsurgical removal. Unfortunately, the pathological features of lesions occurring in the thalamic region are different with a wide variation in clinical behavior and outcome. Although microsurgery is still the gold standard in the management of these lesions through different approaches, questions remain whether surgery is feasible and safe in these patients and what are the alternatives? It is well known that stereotactic techniques may be favorable especially in cystic, small, multiple lesions and in combination with adjuvant therapy. Transventricular endoscopic approach is also an alternative technique to combine tumor biopsy and treatment of hydrocephalus. Aim of the study: The identification of the different procedures for the management of thalamic SOL in respect to the age of the patient, the clinical condition, and the site of the lesion as well as its extent and pathology. Patients and methods: This prospective study included 35 patients having thalamic lesions with a mean age of 27 years old who were treated with different approaches including microsurgical, stereotactic, and endoscopic approaches. The clinical outcome was assessed as the same, improved, deteriorated, or died in comparison to the initial clinical status, while the radiological control was measured as no gross residual, residual < 10% and residual > 10%. Chi-square test was used to test the association between two categorical variables. Results: Thirty-five patients were included in this study, 20 were males and 15 were females. Eight cases were children, and 27 cases were adults. The most common clinical presentation was contralateral hemiparesis. The most common pathology was pilocytic astrocytoma. Radiological studies showed that the total thalamic type was the most common topographic variant and that 10 cases had hydrocephalus treated with CSF diversion procedures. For the definitive lesion, 2 cases underwent endoscopic biopsy and cystoventriculostomy and 18 cases had stereotactic technique in the form of biopsy, aspiration, and ommaya reservoir application, while 15 cases had microsurgery through different approaches with stereotactic technique preceding surgery in 2 of them. Conclusion: The main factors involved in choosing the appropriate approach included nature of the lesion (solid or cystic, multiplicity), suspected pathological type, and diffusion tensor imaging. Abscesses are best treated with stereotaxy, while non-neoplastic cystic lesions (other than abscesses) related to the ventricles are best treated with endoscopy. For the remaining pathologies, maximum surgical removal is the best management. Best lesion control was provided by microsurgery.

No abstract