OBJECTIVE: To present the results from the clinical presentation, the imaging diagnostics, surgery and postoperative status of 17 patients with cervical spine metastases, to analyse all data and make the respective conclusions and compare them with the available data in the literature. PATIENTS AND METHODS: The study analysed data obtained by patients with metastatic cervical tumours treated in St George University Hospital over a period of seven years. All patients underwent diagnostic imaging tests which included, separately or in combination, cervical x-rays, computed tomography scan and magnetic-resonance imaging. Severity of neurological damage and its pre-and postoperative state was graded according to the Frankel Scale. For staging and operating performance we used the Tomita scale and Harrington classifi cation. RESULTS: Seven patients had only one affected vertebra, 4 patients -two vertebrae, one patient -three vertebrae, 2 patients -four vertebrae, and in the other 3 patients more than one segment was affected. Surgery was performed in 12 patients. One level anterior corpectomy was performed in 6 patients, three patients had two-level surgery, and one patient -three-level corpectomy; in the remaining 2 cases we used posterior approach in surgery. Complete corpectomy was performed in 4 patients, subtotal corpectomy was used in 6 patients and partial -in 2 patients. Anterior stabilization system ADD plus® (Ulrich GmbH & Co. KG, Ulm, Germany) was implanted in 2 patients; in 8 patients anterior titanium plate and bone graft were used, and in 1 patient -posterior cervical stabilization system. CONCLUSIONS: Because of the pronounced pain syndrome and frequent neurological lesions as a result of the cervical spine metastases use of surgery is justifi ed. The main purpose is to maximize tumor resection, achieve optimal spinal cord and nerve root decompression and stabilize the affected segment.

Mucocele of the paranasal sinuses is a rare disease with slow evolution. It is a benign, encapsulated and destructive formation fi lled with mucous fl uid and tapistrated with respiratory epithelium. Of all the paranasal sinuses, the sphenoid sinus is aff ected in only 1-7% of the cases. We present two cases of mucocele of the sphenoid sinus involving the posterior ethmoidal cells. We consider here their clinical presentation, use of neuroimaging in the diagnosis, surgical care and postoperative results. Both patients presented with a history of persistent headache and in addition, one of them had a paresis of the right oculomotor and abducens nerves. A transnasal endoscopic sphenoidectomy was performed in both patients, in one -with an evacuation of the mucocele and marsupialization, and in the other -with a balloon dilatation of the natural foramen of the sinus. Postoperatively, a complete reversal of the symptoms was observed in both patients. Mucocele of the paranasal sinuses should be considered as a diagnosis in cases of persistent headache with a primarily retrobulbar location and eye symptoms. Computed tomography and magnetic resonance imaging can be used to successfully diagnose the disease. The transnasal endoscopic sphenoidectomy is the therapeutic method of choice which allows evacuation of the mucocele, while the marsupialization allows good drainage and prevents recurrence.

Diffuse axonal injury (DAI) is present in approximately 50% of the cases with severe traumatic brain injury. It is one of the leading causes of morbidity and mortality among children and young individuals worldwide. Generally, DAI occurs as a result of high-velocity accidents. Typically, it presents with loss of consciousness for at least 6 hours and neurological deficit dependent on the brain area that is affected by the injury. The final diagnosis is confirmed by neuroimaging studies such as computed tomography and magnetic resonance imaging. According to the injured brain site, DAI is classified into three grades: Grade I–DAI with axonal lesions in the cerebral hemispheres; Grade II–DAI with focal axonal lesions in the corpus callosum; Grade III–DAI with focal or multiple axonal lesions in the brainstem. Each of the three grades is associated with different outcome.Due to the high disability and mortality rate, DAI represents an important medical, personal and social problem. The aim of the current review is to address the unsolved issues connected with the pathogenesis, diagnostics, treatment and outcome of the diffuse axonal injury.

Background: The purpose of the current study is to identify the correlations between the most important preoperative clinical factors and the outcome of surgery of spinal meningiomas (SM). Methods: We performed a retrospective analysis of the medical history, clinical, paraclinical, neuroimaging, and surgical protocol data in 31 patients with SM who underwent surgical resection at our institution from January 2011 to July 2020. The degree of resection was assessed on the Simpson scale. The modified McCormick scale was used to monitor the effect and outcome of treatment at admission, discharge, and at further follow-up. Results: The average age of the patients was 65 years (37-78). Vertebral pain and motor deficits were the most common initial symptoms that occurred in 26 (89.6%) and 29 (93.5%) patients, respectively. Sphincter disorders were found in 9 (29%) patients. Total resection (Simpson Grade I – II) was achieved in 29 patients (93.5%). We achieved a favorable outcome (McCormick Gr. I to III) in 93.3% of patients. The degree of the neurological deficit (P = 0.026) and the presence of sphincter disorders (P = 0.009) were the preoperative clinical factors that most significantly correlated with the outcome of treatment. Conclusion: The outcome from the surgical treatment of SM correlated significantly with the degree of the preoperative neurological deficit. Therefore, patients presenting with more severe symptoms are expected to have worse outcomes.

Image-guided spinal surgery is becoming increasingly popular because it allows surgeons to achieve minimal invasiveness and maximum precision in the performed procedures. We present our initial experience with two cases operated on using O-arm-based spinal navigation at the Clinic of Neurosurgery in St George University Hospital, Plovdiv, Bulgaria. In the fi rst case, we performed removal of extradural spinal tumor of the sixth thoracic vertebra and O-arm-navigated pedicle screw fi xation. In the second case, we performed O-arm-navigated corpectomy of the fi fth cervical vertebra and anterior spinal reconstruction and fusion with titanium expandable mesh and cervical plate in connection with degenerative narrowing of the cervical spinal canal that lead to clinically manifested myelopathy. The initial experience allows us to conclude that O-arm-based image-guided spinal surgery can lead to considerably higher precision of spinal instrumented procedures. At the same time, it reduces the irradiation dose of the patient and surgical team.

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Background: The clinical presentation of sphenoid sinus meningoencephaloceles (MEC) may have insidious onset and evolution. Contemporary treatment incorporates endoscopic resection via the endonasal route.Case description: We present a case of 3 year old girl who had been complaining of permanent nasal discharge, impeded nasal breathing and difficulty with feeding since she was 5 months old. There was no history of rhinoliquorrhea. Pre-operative magnetic resonance imaging demonstrated MEC that extended from the sellar region through the non-pneumatized sphenoid sinus to the nasopharynx. The lesion was resected via endoscopic endonasal approach. Follow-up rhinoscopy confirmed the absence of post-operative cerebrospinal fluid leak.Conclusion: Endoscopic endonasal approach can be an effective and a safe treatment option for resection of congenital transsphenoidal MEC in early childhood.Keywords: Sphenoid sinus; endoscopic endonasal approach; meningoencephalocele; CSF leak; congenital.

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