Background Cauda equina syndrome (CES) is caused by compression of nerves in the lumbar spine below the conus medullaris. Symptoms include progressive weakness in the lower extremities, back pain with sciatica, saddle anesthesia, and urinary or bowel dysfunction. These symptoms vary in intensity and onset, and can sometimes be an emergency. The standard surgical procedure for CES typically involves a microscope-assisted interlaminar decompression with laminotomy and sequestrectomy, with or without partial, rather than complete, discectomy. However, endoscopic spine surgery was introduced as an alternative method in the treatment of CES. We aimed to evaluate the feasibility and clinical efficacy of percutaneous endoscopic interlaminar lumbar discectomy (PEILD) for the treatment of CES. Methods A retrospective study of 25 patients with CES who underwent PEILD surgery from May 2017 to April 2022 at our institution, and the data were collected and retrospectively analyzed. All patients complained of incomplete or complete cauda equina manifestations. These patients may have one or more lumbar disc herniations and unilateral or bilateral nerve root compression. We used clinical examination, Macnab criteria, Oswestry Disability Index (ODI) score, and Visual Analog Scale (VAS) score to evaluate the outcome. Results A total of 25 patients with a mean age of 38.32 years (range 18-60 years) were included in our study. Of these 25 patients, 16 were males (64%), and 9 were females (36%), with an average follow-up of 1 year. The main complaint was sciatica, hypoesthesia (including saddle hypoesthesia and anesthesia), weakness, impotence, and sphincteric disturbance (including urinary hesitancy, urgency, frequency, or retention). We performed PEILD in all patients. About 20 patients had no postoperative complications (80%). The most common complications were superficial wound infection, cerebrospinal fluid (CSF) leak, pseudomeningocele, and discitis. The preoperative mean ODI score for low back pain for our patients was 61.76%. One year postoperatively, the mean ODI score improved to 13.36%. The preoperative mean VAS score for leg pain was 6.47. One year after surgery, the mean VAS score significantly decreased to 1.81. Conclusion PEILD as a minimally invasive surgery could be considered a valid surgical option for treatment of different stages of CES; however, it has a steep learning curve and needs high surgical experience to ensure adequate decompression, especially in complete CES.
Abstract Decompressive craniectomy (DC) is a life-saving procedure for severe traumatic brain injury and stroke but results in loss of cranial integrity, impaired cerebral blood flow (CBF), altered cerebrospinal fluid (CSF) dynamics, and cognitive dysfunction. Cranioplasty is believed to restore these physiological disturbances. However, prospective imaging-based evaluations remain limited in this context, particularly in Indian populations. This study prospectively assessed the impact of cranioplasty on CBF, CSF flow dynamics, and neurocognitive recovery. A prospective observational study was conducted on 100 patients undergoing cranioplasty following DC. CBF was quantified using arterial spin-labeling MRI across bilateral frontal, temporal, parietal, and occipital lobes. CSF dynamics including peak positive velocity (PPV), peak negative velocity (PNV), and net flow were measured at the aqueduct and foramen of Magendie using phase-contrast MRI. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) preoperatively, early postoperatively, and at 3 months. Pre–post changes were analyzed using paired tests with significance set at p < 0.05. Cranioplasty resulted in significant improvement in CBF across all lobes bilaterally (p < 0.001) with more pronounced gains on the ipsilateral side. CSF flow showed marked increase in PPV and PNV at both anatomical levels (p < 0.001) accompanied by improved net flow. MoCA scores improved significantly from baseline, with 90% of patients achieving scores in the normal cognitive range at 3 months (p < 0.001). No major postoperative complications were observed. Cranioplasty significantly enhances cerebral perfusion, CSF dynamics, and cognitive function following DC. These findings underscore the physiological value of cranioplasty and support the integration of advanced imaging to guide postoperative recovery and optimize timing of reconstruction.
Abstract Trochlear nerve schwannomas (TNSs) are exceptionally rare benign tumors, accounting for a very small fraction of intracranial schwannomas. Due to their deep locations and slow growth, they often reach a considerable size before diagnosis. Giant or multiloculated cystic variants are exceptionally uncommon and present significant diagnostic and surgical challenges. A 32-year-old female presented with headache and dizziness but no diplopia. Magnetic resonance imaging revealed a giant multiloculated cystic lesion extending from the posterior fossa to the right temporal lobe, causing obstructive hydrocephalus. The mass was removed through a right paramedian supracerebellar transtentorial approach under intraoperative neurophysiological monitoring. The tumor was confined between the two tentorium leaflets, with the trochlear nerve entering and exiting the lesion. Gross total resection was achieved with an uneventful postoperative course. Histopathology confirmed a World Health Organization Grade I schwannoma with Antoni A–B architecture and diffuse S-100 positivity. A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (2020) guidelines, identifying 45 surgically treated cases, analyzed together with the present case (n = 46). The mean age was 44.7 years, with an approximately equal sex distribution. Most tumors (76.1%) were located in the ambient or crural cisterns, followed by the quadrigeminal cistern (10.8%) and cisterno-cavernous region (8.7%). Diplopia and trochlear nerve palsy were the most common presenting symptoms. Gross total resection was achieved in 80.4% of patients, while postoperative trochlear palsy occurred in 60.8%. No malignant transformation or early recurrence was reported. This case represents one of the largest TNSs described and the second known lesion arising between the tentorial leaflets. Awareness of this unique anatomic configuration is essential for accurate preoperative diagnosis and surgical planning. A meticulous, anatomy-guided microsurgical approach enables complete resection while preserving neurological function in select cases.
Objectives The study aims to assess the prevalence of vertebral endplate cavities (VECs) after anterior cervical discectomy and fusion (ACDF) using polyetheretherketone (PEEK) cages by CT and to estimate their impact on fusion. Study Design A retrospective computed tomography (CT)-based study. Methods The term "cavity" was used to describe the endplate changes. CT analysis of the VECs and fusion status following ACDF with PEEK cages was conducted by two observers. VECs were assessed according to the size, multiplicity, location, and presence of sclerosis. Results A total of 46 consecutive patients (20 males and 26 females) were enrolled in the study. The mean age at surgery was 50.43 +/- 11.37 years. A total of 96 levels were fixed. The mean follow-up was 30.87 +/- 25.371 months (range, 6-96 months). VECs were found at 30 levels (31.3%) by both observers. The level of agreement was regarded as almost perfect. All the VECs were small (< 5 mm). Definite fusion was seen in 50 levels (52.1%) by observer 1 versus 52 levels (54.2%) by observer 2. The level of agreement was regarded as almost perfect. With both observers, the presence of VECs was significantly related to the fusion status ( p <= 0.05). However, the follow-up period, the levels, age, sex, and cigarette smoking had no statistical significance with fusion status. Conclusion Our study confirmed the existence of VECs following ACDF using PEEK cages in about one-third of our patients (31.3%). These VECs tend to be small (< 5 mm) in size and might be associated with nonunion.
