Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Skipping Cross Links in Posterior Spine Surgery: A Review 49 56 EN Misagh Shafizad Associate Professor of Neurosurgery, Spine Fellowship, Department of Neurosurgery, Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran. Kaveh Haddadi Assistant Professor of Neurosurgery, Orthopedic Research Center, Imam Khomeini Hospital, Sari, Iran. Background and Aim: Given the conflicting and unreliable evidence for using cross-links in posterior spine surgery, this review was conducted to highlight the different features and usefulness of these augmentation devices in spine surgeries. Methods and Materials/Patients: After searching databases using specific keywords, the relevant articles were ultimately selected and evaluated. Results: Biomechanically investigating the use of cross-links has not resulted in unanimous explanations for their effect. The site and direction of cross-links have been rarely investigated in the literature. Some studies recommended eliminating their application from clinical practice; nevertheless, these studies do not necessarily yield clinical benefits. Posterior spinal fixation with pedicle screws and without cross-links offers stability in all the planes in most clinical conditions. Conclusion: Excluding the cross-links in posterior spine surgery may shorten the operation time and reduce hospital costs. Researchers have reported other problems for cross-links such as late pain, device failure, infections, device prominence, and pseudarthrosis which may be obliterated through the avoidance of their combination in a spinal construct; nevertheless, the results of animal models of the application of special cross-links in a degenerative disorder or deformity suggest that diagonal cross-links provide the highest stability of the construct if they are matched with a rodonly system or with transverse cross-link constructs resulting in a rectangular configuration.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Cerebrospinal Fluid Dynamics Study: A Unique Tool for Management of Chiari 1 Malformation Patients 57 66 EN Varun Aggarwal MS., MCh., Assistant Professor, Department of Neurosurgery, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India Navodhya Jindal MS., MCh., Assistant Professor, Department of Neurosurgery, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India Seema Rohilla MD., Professor of Radiodiagnosis, Department of Radiodiagnosis, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India Hitesh . MS., MCh., Assistant Professor, Department of Neurosurgery, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India Ishwar Singh MS., MCh., Assistant Professor, Department of Neurosurgery, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India Background and Aim: Chiari I malformation(CIM) is defined as descent of cerebellar tonsils  5mm or more below the foramen magnum, with or without associated syrinx. Degree of tonsillar descent has a poor correlation with the progression of disease and symptomatology. Abnormal CSF dynamics at foramen magnum is the main pathophysiological factor responsible for the progression of tonsillar descent, syrinx formation and hence symptomatology. The aim of this study is to correlate CSF dynamic changes with the clinicoradiological profile of CIM patients. Methods and Materials/Patients: A prospective longitudinal study was done in 25 patients of CIM out of which 24 patients underwent standard midline suboccipital craniectomy with augmented duraplasty and 1 patient had ventriculoperitoneal shunt surgery for hydrocephalus. CSF flow study was done in sagittal as well as in axial sections at the level of foramen magnum using cine flow magnetic resonance imaging (MRI). Clinical and radiological assessment in reference to CSF flow parameters was done before and after decompression surgery. Results: After suboccipital decompression 23 out of 24 patients had relief in their symptoms and 1 patient had progressive syringomyelia. Postoperative MRI scan at 3months showed round shaped tonsils in all 24 patients. Ten out of 11 patients with syrinx had reduction in diameter of syrinx cavity.  Peak CSF flow velocities reduced significantly (p value < 0.05) in the postoperative period and correlated well with the clinicoradiological improvement. Conclusion: Abnormal CSF flow dynamics is responsible for the progression of disease and symptomatology in CIM patients. Cine flow MRI is a useful tool in the management of CIM patients both for proper selection of surgical candidates and in post-operative follow-up.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Three-Year Survival Rate in All Kinds of Glioma Tumors in One Institution, Iran, 2001-2010 67 72 EN Masih Rezaee Division of Pulmonary, Allergy and Sleep Medicine, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, Unites States. Bahram Amin Mansour Department of Neurosurgery, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. Background and Aim: The survival rate of brain tumors has not yet been reported in Iran. The purpose of this study, given the lack of such information, was to evaluate the 3-year survival rate in patients with all kinds of glioma tumors. Methods and Materials/Patients: This study was descriptive and retrospective, including 222 patients who had been diagnosed clinically with one type of glioma tumor and admitted to Al-Zahra hospital, Isfahan, Iran during 2001-2010. All patients (for minors, their parents) were contacted by phone. They were asked about the 3-year survival rate following their tumor resection surgery. Data such as patient’s age on admission, gender, histological diagnosis of tumor, and treatment regimen (surgical/non-surgical, radiation, and/or chemotherapy) were collected from medical records. The 3-year survival rate and frequency of each tumor based on age and gender were measured. Results: The 3-year survival rates for Glioblastoma Multiform (GBM) and anaplastic astrocytoma were 8.7% and 0%, respectively following surgery and chemo-radiation. These tumors were categorized as high-grade glioma with poor prognosis. The 3-year survival rate for diffuse astrocytoma, low-grade oligodendroglioma, low-grade ependymoma, and pilocytic astrocytoma following surgery and radiation were 100%, 95.2%, 100%, and 100%, respectively. These tumors were categorized as low-grade glioma, which has a good prognosis. Conclusion: In this study, the 3-year survival rate in patients with low-grade glioma following surgery and radiation was almost 100%. In contrast, the 3-year survival rate in patients with highgrade glioma following surgery and chemo-radiation was almost 0%.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Hemorrhages Seen on Brain Images After Mild Traumatic Brain Injury May Increase the Risk of Post-concussion Syndrome 73 82 EN Seddigheh Eslamparast Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Zoheir Rehianian Neuroscience Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran Sara Ramezani Department of Neurosurgery, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran Background and Aim: Mild Traumatic Brain Injury (mTBI) mostly develops the symptoms that may persist for over three months known as Post-Concussion Syndrome (PCS). However, the PCS potential risk for mTBI victims is not well-identified. Here, we investigated the putative risk factors of PCS. Methods and Materials/Patients: In a cross-sectional study, we collected (HIS) the demographic, clinical, and radiological data using the hospital information system in 388 mTBI patients who passed at least 3 months since the onset of their injury and referred to Poursina hospital from March 2017 to December 2018. The patients were examined to diagnose PCS by a general physician using the phone interview via the Rivermead Post-concussion Symptoms Questionnaire (RPQ). The subjects were separated into groups with and without PCS. Data were analyzed by parametric t-test, Chi-square test and multiple logistic regression. Results: One-hundred ninety one out of 388 mTBI patients consented to complete the RPQ and around 59% of cases experienced PCS. There was no significant difference in the demographic variables and past medical history between groups. However, the previous psychological disease was particularly associated with PCS (P>0.043). Length of hospitalization, functional outcome during discharge, and post-resuscitation consciousness did not show any significant association with PCS (P<0.05). Interestingly, initial abnormal brain scan, fronto-temporal lesion, and accompanied hematoma (hemorrhages) were identified as risk factors of mTBI-induced PCS. The risk of PCS was found to increase by 7.2 times in mTBI patients demonstrated as an abnormality in their initial brain scans (P<0.001). A directly proportional relationship was found between the occurrence of the syndrome and the fronto-temporal lesion (P<0.017). Accompanied hematoma enhanced the risk of PCS by 2.6 times (P<0.04). Conclusion: This study emphasized the significance of early brain scan data for the prediction of PCS and the necessity of proper follow-up care for the at-risk population. The reported data from this study might be applied as an objective trajectory to measure PCS in those who simulated PCS for the litigation.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Inion Bony Solitary Plasmocytoma: A Case Report 83 88 EN Vivek Agrawal Sir. H. N Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India Kunal M.Ch Dholakia Sir. H. N Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India Background and Importance: Plasma Cell Dyscrasias (PCD) are a heterogeneous group of diseases having a spectrum from multiple myeloma to solitary plasmacytoma, a rare subtype, which constitutes 2 to 5% of all PCD. It typically involves axial bones but the involvement of skull bone is very rare. Case Presentation: We are reporting a case of inion bony lesion with venous sinus infiltration in a 55-year-old male patient, presented with pain, imbalance in walking, and swelling in the occipital region. Brain MRI suggested an extra-axial lesion with skull involvement and venous sinus infiltration. The tumor was infiltrating into the sinus with patent torcular venous confluence. Tumor decompression followed by radiosurgery of residual lesion was considered in pre-operative surgical planning. It was diagnosed as a case of myeloma cell disease on histopathology. Postoperative myeloma work-up confirmed the absence of any systemic involvement. The patient was given a course of radiotherapy. Conclusion: One-year follow-up with repeated MRI and myeloma investigations in the 3rd month, 6th months, and 1 year did not show any finding suggestive of progression to multiple myeloma. The follow-up of brain MRI showed a complete resolution of the residual tumor.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Reversal of Degenerative Changes in Cervical Spine Following Bipolar Release in a Neglected Case of Congenital Muscular Torticollis: A Case Report 89 92 EN Nima Derakhshan MD, Assistant Professor of Neurosurgery, Department of Neurosurgery, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran Arefe Rahimikhorrami MD, Student Research Committee, Department of Neurosurgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Background & Importance: Congenital Muscular Torticollis (CMT) is a common cause of torticollis in children. Despite the easy diagnosis, rare cases may be neglected and untreated during the management of the patients, which can not only impose cosmetic problems for them but also affect the cervical spine with accelerated degeneration. Most patients with CMT can be managed non-surgically with medical and physical therapies but surgery is indicated in some cases when non-surgical attempts are unsuccessful. Case Presentation: Herein, we are reporting a 16-year-old female with neglected CMT, and neck pain secondary to severe degenerative changes. We believe that neglected and untreated CMT cases may present with accelerated spine degeneration and surgical intervention should be considered promptly to reverse this process. Conclusion: Surgical intervention not only produces good cosmetic results but also reverses the degeneration process and protects the patient from disabling deformities later in life.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 The Implications of Global Neurosurgery for Low- and Middle-income Countries: The Case of Cameroon 93 100 EN Ulrick Sidney Kanmounye Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA Nathalie C. Ghomsi Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon Dylan Djiofack Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon Francklin Tétinou Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon Stéphane Nguembu Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon Yvan Zolo Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon Ignatius Esene Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon The unequal distribution of neurosurgical resources and diseases in the world contributes to inequality. Eight in 10 neurosurgical cases needing essential neurosurgical care are found in Low- and Middle-Income Countries (LMICs); however, LMICs lack the neurosurgical resources to address these needs. Besides, where neurosurgical care is available, it is not financially accessible to the majority of patients. Global Neurosurgery is a rapidly growing field that places a priority on improving health outcomes and achieving health equity for all people affected by neurosurgical conditions. To achieve safe, accessible, and affordable neurosurgical care for all, LMIC neurosurgeons should participate in national and international global neurosurgical activities, develop disruptive solutions to local problems and work with local stakeholders to address global neurosurgery problems.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 6 2 2020 4 1 Prioritizing the Neurosurgical Patients’ Care: Limited Resources and Successful Management in COVID-19 Pandemic 101 103 EN Moshiur Rahman Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh. Gaousul Azam Dhaka Medical College Hospital, Dhaka, Bangladesh. Avijit Dey Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh. Ezequiel Garcia-Ballestas Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia. Amit Agrawal Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India. Luis Rafael Moscote-Salazar Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia. Robert Ahmed Khan Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh. COVID-19 has become an alarming pandemic for our earth. Worldwide, healthcare workers including neurosurgeons are facing challenges in prioritizing neurosurgical patients. Here we have tried to draw attention to the effective management of patients with limited resources. Prioritizing surgical cases in emergencies, overseeing triage framework for neurosurgeries, rebuilding of the inpatient service, should be of utmost priority. Neurosurgeons should point in the amendment as far as a good life for everybody, while still prioritizing equity in the distribution of services.