Iranian Journal of Neurosurgery
Volume:7 Issue: 2, Spring 2021

Chronic low Back Pain (CLBP) is one of the most common musculoskeletal disorders with possible psychological consequences for the patients. This study aimed to review all evidence on the effectiveness of psychological interventions in improving the mental status of people with CLBP and providing recommendations for future therapeutic interventions.

This systematic review was conducted on the articles published from January 2010 to December 2020. The keywords included “psychology”, “intervention”, “low back pain”, “chronic disease”, “quality of life”, “empowerment”, “psychotherapy”, “psychological interventions”, “clinical trials”, and “randomized clinical trials” in the indexing databases of Magiran, PubMed, Scopus, and Google Scholar. Of the total 1740 articles found, 14 articles were selected for review.

The results showed that Cognitive-Behavioral Therapy (CBT) and its combination therapies with mindfulness techniques played an influential role in improving psychological status and quality of life, and reducing pain perception in CLBP patients. The lack of RCT (randomized controlled trial) research and follow-up to assess long-term outcomes are the main limitations of the studies conducted in Iran.

It is recommended that psychological interventions be considered alongside medical therapies to improve CLBP patients’ adjustment to chronic condition and their quality of life. Researchers and therapists should consider treatment programs based on RCT plans and long-term follow-up.

The major concerns related to the Endoscopic Endonasal Transsphenoidal (EET) surgery for sellar and suprasellar tumors include the risks of post-operative Cerebrospinal Fluid (CSF) leak, leading to morbidity and at times mortality, due to severe meningitis. Time is required to develop possible preventive measures that can reduce the risk of post-operative CSF rhinorrhea. The present study aimed to evaluate the effects of pre-operative CSF diversion by lumbar drainage in EET tumor surgeries on preventing post-operative CSF leak and its effect on the length of hospital stay.

 We conducted a prospective study on 20 patients with a pituitary tumor that underwent EET surgery between October 2018 and December 2019. Preoperative Lumbar Drain (LD) was inserted after induction in all explored patients. The tumor was excised with continuous intraoperative CSF drainage. Post-operatively, the LD was kept for 3 days and clamped for the next 24 hours. If no evidence of CSF rhinorrhea was present, it was removed. Complications related to CSF drainage, CSF leak, and hospital stays were evaluated.

Our study population consisted of 13(65%) men and 7(35%) women, with Mean±SD age of 39.8±10.71 years. The most commonly presented complaint was visual disturbance (60%) and the least common symptom was urinary disturbance (5%). The intra-operative leak was detected in 9(45%) patients, while the post-operative leak was present in only 1(5%) patient. LD blockage significantly contributed to post-operative CSF leak (P=0.001). The Mean±SD hospital stay in the post-operative period was 8.85±3.22 days with 65% of patients having a hospital stay of <7 days. Other post-operative complications (e.g. diabetes insipidus, electrolyte imbalance, and hormonal disturbances) were mainly responsible for prolonged post-operative hospital stay (P=0.001).

Pre-operative LD, apart from helping to reduce the incidence of post-operative CSF leak, is not associated with an overall increased post-operative hospital stay.

Spontaneous Intracranial Hypotension (SIH) is a rare cause of headaches. It commonly presents with newly-developed persistent postural headaches and resolves with conservative treatment but rarely becomes a life-threatening disease. We retrospectively reviewed all cases of SIH patients treated in our institution for over ten years. Their clinical and radiological findings and the treatment given were analyzed. Their outcomes were assessed at a minimum of one year of follow-up.

We retrospectively reviewed all cases of SIH patients treated in our institution over ten years. Clinicoradiological aspects, as well as the treatment given, were analyzed. The outcome was assessed at a minimum of one year of follow-up.

Six cases of SIH were studied. The Mean±SD age of the study population was 41.6±2.87 years. Four cases (66%) were female. The most common symptom was orthostatic headache which was present in all of them. The Mean±SD duration of symptoms before the diagnosis of SIH was 3±1.78 months. Four cases were managed conservatively, while one patient was managed with surgery and the other with epidural patch repair. The exact site of the leak could be delineated in 2 cases (33%). Two patients who were managed invasively for Cerebrospinal Fluid (CSF) the leak had a subdural hematoma. All patients had a favorable outcome at one year of follow-up.

Prompt and early identification of changes in symptom pattern and the onset of subdural hematoma are essential markers of shifting to definitive management rather than continuing conservative measures. Subdural hematoma, secondary to SIH, warrants evacuation if it causes clinical deterioration.

Brown-Sequard Syndrome (BSS) is a rare neurological condition resulting from a hemisection injury to or unilateral compression on the spinal cord. The common causes of BSS that are amenable to be treated surgically can be divided into traumatic and non-traumatic injuries. Traumatic injuries are often reported as the main cause of BSS. However, non-traumatic injuries of the spinal cord are more seen in recent years. This study aims to classify and update surgically treatable causes of BSS.

Retrospective data of 17 patients operated for BSS between 2008 and 2020 were included. The long-term outcomes of these patients were evaluated. In addition, a comprehensive search in PubMed, Scopus, and CINAHL was conducted for the retrieval of all relevant studies.

Magnetic Resonance Image (MRI) of our patients revealed Cervical Disc Herniation (CDH), spinal canal stenosis with cervical spondylosis, epidural hematoma, and ossification of the posterior longitudinal ligament. The postoperative outcomes of our cases ranged from partial to complete recovery. While the patients with acute epidural hemorrhage achieved complete recovery after surgery, neurological deficits in the other patients, especially those with severe cervical spinal canal stenosis, persisted despite adequate surgical decompression. The systematic literature review revealed that CDH is the most common non-traumatic surgically treatable cause of BSS, followed by spinal cord herniation and spinal epidural hematoma.

Non-traumatic injuries of the spinal cord accompanied by narrowed cervical spinal canal pathologies are prominent surgically treatable causes of BSS. Contrary to the definition made 100 years ago, BSS can occur spontaneously due to underlying pathologies rather than major traumatic injuries.

Dural ectasia is circumferential extension or dilatation of the dural sac, it is commonly associated with Neurofibromatosis type 1 (NF1). Because NF1 is associated with a high likelihood of tumor formation, it is critical to distinguish it from other posterior mediastinal cancers such as neurofibroma, neuroblastoma, and ganglioneuroma. Scoliosis is the most frequently observed feature in NF1 patients with spinal deformities. Moreover, there are several distinctive radiographic features, including dural ectasia, defective pedicles, and spondylolisthesis, which are relatively less common in these patients. Surgery may be performed for stabilization of the spine. 

The present study reports on a 62-year-old female with neurofibromatosis type 1 who was referred for an unusual chest X-ray and chest Computed Tomography (CT) revealing a thoracic mass while she was hospitalized and under observation for dyspnea. The chest X-ray film showed homogenous opacity with a well-defined margin in the right apex. The chest CT showed an enlarged intervertebral foramen and defected vertebral arch around the mass and scoliosis. Although the pre-operative diagnosis was dumbbell type neurinoma, the tumor was found to be a protrusion of dura mater with spinal fluid out of the spinal canal. Part of the wall was excised, the residual opening was repaired, and surgical stabilization was performed. 

Retrospectively, magnetic resonance imaging showed the characteristics of thoracic dural ectasia and anterior meningocele, which, in an asymptomatic case, require regular radiographic follow-ups. Surgical intervention is an alternative for patients with spinal deformities or symptomatic patients due to the adverse effects of spinal cord compression and mediastinal structures.

Spinal Subdural Hematoma (SSH) is a rare condition with an unknown incidence in the general population. Iatrogenic spinal subdural hematoma radiologically mimicking a prolapsed dorsolumbar disc has not been published in the literature.

A 65-year-old female presented with altered sensorium and generalized weakness for 3 days evaluated by a neurologist who diagnosed it as a metabolic encephalopathy with Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) with severe anemia and hypothyroidism. She underwent a diagnostic lumbar puncture and following which, within 24 hours, she developed weakness of both the lower limbs. MRI of dorsolumbar spine was done which revealed D12-L1 extruded disc causing severe compression to the conus medullaris with D12-L2 subarachnoid lesion and cord edema. On opening the dura, a large organized hematoma on the anterior aspect of the conus was seen and evacuated.

Spinal subdural hematoma presents with a spectrum of signs and symptoms. Although MRI is the investigation of choice but SSH presenting like a prolapsed intervertebral disc on MRI is one of its kinds and should be kept in mind since it carries a grave prognosis if not treated early with emergency decompression.

Chondrosarcoma is a rare malignant cartilage forming tumor, usually arising from long bones and rarely observed in the cranium. In the cranium, it commonly arises from the skull base with the skull vault being a highly unusual site. 

We present the case of a 30-year female presenting with complaints of headache for 6 months. The patient was found to have large chondrosarcoma in the right frontoparietal region, which is an extremely rare location. The final diagnosis was based on histological examination, suggestive of well-differentiated chondrosarcoma [the World Health Organization (WHO); grade I]. 

Cranial vault chondrosarcoma is an uncommon histological diagnosis with surgery as the primary treatment option; however, adjuvant radiotherapy plays a definitive role, especially in aggressive or incomplete removed cases.

Note: Complying with the professional duty of the journal, we sent the letter written by Ali Tayebi Meybodi entitled “Celebrating the Ostād” assigned for publication in the current issue of IrJNS to the authors of a previously published letter entitled “A Tribute to Dr. Seyed Ali Fakhr Tabatabaei: A Legendary Neurosurgeon” by Zahid Hussain Khan and Mehdi Zeinalizadeh. This is a response by the authors to Ali Tayebi Meybodi.