Mohammed Aref

Background: Metal hypersensitivity to spinal implants is a rare complication documented predominantly in isolated case reports. While nickel, cobalt, and chromium are the most commonly implicated allergens, titanium alloys used in cervical fusion constructs may also elicit immune-mediated responses. Standalone cages, a common choice in anterior cervical discectomy and fusion (ACDF), are primarily composed of titanium alloy, making them a potential source of metal sensitization. Case Description: We present the case of a patient who underwent ACDF using a standalone titanium alloy cage for cervical spondylotic radiculopathy. Postoperatively, the patient experienced atypical, difficult-to-explain pain with a radiating quality that was inconsistent with the expected surgical recovery pattern. Further history revealed an antecedent self-reported sensitivity to certain jewelry metals. The patient was returned to the operating theatre, the standalone cage was removed, and reconstruction was performed using an iliac crest autograft. Postoperatively, the patient reported notable symptom improvement. As an exploratory observation, a titanium screw from the implant was placed in contact with the patient’s skin, and localized erythema developed within 24 h, providing suspicion of metal hypersensitivity. Conclusions: This case highlights the importance of eliciting a thorough preoperative allergy history, including reactions to jewelry and metal-containing items, before performing instrumented spinal fusion. When metal hypersensitivity is suspected postoperatively, implant removal and replacement with alternative materials might be considered. Skin contact testing may provide helpful adjunctive clues to guide the diagnostic process in suspected metal hypersensitivity.

Background/Objectives: Expanded endoscopic endonasal approaches (EEAs) provide direct ventral access to adult intradural skull base tumors; however, postoperative complications are variably defined and reported in the literature. This review aimed to synthesize the overall spectrum of adult intradural EEA complications and distinguish pathology-specific evidence from large mixed EEA complication cohorts. Methods: A PRISMA 2020 systematic review and meta-analysis searched PubMed/MEDLINE, Embase, and Web of Science from database inception through July 2026. Eligible studies included adults or adult-separable subgroups undergoing expanded EEAs for intradural skull base tumors. The primary outcomes were CSF leak, meningitis or intracranial infection, new neurological deficit or vascular injury/stroke, hydrocephalus, mortality, and postoperative seizures. Pathology-specific adult intradural series with exact counts were quantitatively synthesized when appropriate, and large mixed EEA cohorts were summarized separately when the eligible subgroup was not separable. Results: After full-text eligibility assessment, 48 reports were retained in the extraction-status set. Three strictly adult-only exact-count reports contributed to the primary CSF leak meta-analysis, yielding a random-effects incidence of 23.0% (95% CI, 10.5–43.1%; I² = 78.7%). A sensitivity analysis adding one mixed-age cohort yielded 23.8% (95% CI, 14.5–36.6%; I² = 68.9%), while a broader sensitivity analysis including both mixed-age reports yielded 21.1% (95% CI, 12.2–33.8%; I² = 69.4%). Meningitis was reported in 6/166 patients across four studies (3.6%; 95% exact CI, 1.3–7.7%), and new neurological deficit/vascular injury/stroke was reported in 4/166 patients across four studies (2.4%; 95% exact CI, 0.7–6.1%). Postoperative seizures were reported in 4/652 patients across two studies (0.6%; 95% exact CI, 0.2–1.6%). Large mixed EEA cohorts were summarized separately because adult intradural tumor subsets could not be separated. Conclusions: CSF leak was the most consistently reported complication after expanded EEAs for adult intradural skull base tumors. The strict adult-only random-effects estimate was 23.0%, but it was based on only three studies and showed substantial heterogeneity, limiting its generalizability. Meningitis, neurological/vascular events, and seizures were uncommon in the extractable data and were summarized descriptively rather than being meta-analyzed. Large mixed EEA cohorts provide important safety context but cannot substitute for standardized adult intradural, pathology-specific reporting.

Background/Objectives: Expanded endoscopic endonasal approaches (EEA) provide direct ventral access to adult intradural skull base tumors; however, postoperative complications are variably defined and reported in the literature. This review aimed to synthesize the overall spectrum of adult intradural EEA complications and distinguish pathology-specific evidence from large mixed EEA complication cohorts. Methods: A PRISMA 2020 systematic review and meta-analysis searched PubMed/MEDLINE, Embase, and Web of Science from database inception through July 2026. Eligible studies included adults or adult-separable subgroups undergoing expanded EEA for intradural skull base tumors. The primary outcomes were CSF leak, meningitis or intracranial infection, new neurological deficit or vascular injury/stroke, hydrocephalus, mortality, and postoperative seizures. Pathology-specific adult intradural series with exact counts were quantitatively synthesized when appropriate, and large mixed EEA cohorts were summarized separately when the eligible subgroup was not separable. Results: The full-text screening set included 48 reports. Five exact-count reports, including one mixed-age contextual report, contributed to the CSF leak meta-analysis and yielded a random-effects incidence of 21.1% (95% CI, 12.2%-33.8%; I² = 69.4%). Excluding the mixed-age reports yielded 23.8% (95% CI, 14.5%-36.6%). Meningitis was reported in 6/166 patients (3.6%; 95% exact CI, 1.3%-7.7%), and new neurological deficit/vascular injury/stroke in 4/166 (2.4%; 95% exact CI, 0.7%-6.1%); these rare outcomes were summarized descriptively without continuity correction. Postoperative seizures were reported in 4/652 patients (0.6%) in two studies. Large mixed EEA cohorts have reported CSF leak rates of 1.6%-15.9% but these were not pooled because adult intradural tumor subsets were not separable. Conclusion: CSF leak was the most consistently reported complication after expanded EEA for adult intradural skull base tumors; however, its incidence varied substantially across pathologies and centers. Meningitis, neurological/vascular events, and seizures were uncommon in the extractable data and were better interpreted descriptively than as precise pooled rates. Large mixed EEA cohorts provide important safety context but cannot substitute standardized adult intradural, pathology-specific reporting.

Background/Objective: Intracranial arteriovenous malformations (AVMs) are high-flow cerebrovascular lesions associated with a significant risk of intracranial hemorrhage, neurological morbidity, and mortality. Current management strategies, including microsurgical resection, endovascular embolization, stereotactic radiosurgery, and conservative observation, remain limited by procedural risk and uncertain long-term outcomes. Beta-blockers, particularly propranolol, have recently attracted interest as potential adjunctive therapies because of their vasoconstrictive, antiangiogenic, and vascular remodeling properties. This review evaluates the mechanistic rationale and current evidence regarding beta-blocker use in intracranial AVMs. Methods: A comprehensive literature review was conducted using PubMed, Scopus, and Google Scholar databases through January 2026 using combinations of the terms “arteriovenous malformation,” “AVM,” “beta-blocker,” “propranolol,” “angiogenesis,” “hemorrhage,” and “cerebral cavernous malformation.” Eligible studies included experimental investigations, translational studies, observational cohorts, case reports, clinical trials, systematic reviews, and meta-analyses evaluating beta-blocker use in intracranial AVMs or related vascular malformations. Studies unrelated to cerebrovascular lesions, duplicate reports, and non-English publications were excluded. Given the heterogeneity and limited volume of available AVM-specific literature, findings were synthesized narratively rather than through formal systematic review methodology. Discussion: Preclinical studies suggest that beta-blockers modulate molecular pathways implicated in AVM pathophysiology, including VEGF, HIF-1α, SDF1α/CXCR4, MMP-9, and Notch-associated signaling. These mechanisms may reduce abnormal angiogenesis, endothelial instability, and pathological vascular remodeling. Clinical evidence, however, remains limited to retrospective studies, perioperative reports, and indirect evidence from cerebral cavernous malformations. Observational studies have reported associations between beta-blocker exposure and certain favorable AVM characteristics, including lower rates of hemorrhagic presentation and less complex angioarchitecture. However, these findings are highly susceptible to confounding, reverse causation, and selection bias and should not be interpreted as evidence of disease modification. Conclusions: Beta-blockers cannot currently be recommended as definitive therapy for intracranial AVMs. Their established role remains perioperative hemodynamic control, while potential disease-modifying effects require validation through prospective studies and randomized clinical trials.

Background: 5-aminolevulinic acid (5-ALA)-induced fluorescence is well established in intracranial glioma surgery, aiding tumor visualization and extent of resection. This systematic review evaluates the utility of 5-ALA in spinal tumor surgery, focusing on fluorescence characteristics, resection outcomes, and perioperative safety. Methods: A systematic literature search was performed in Embase, Web of Science, PubMed, and MEDLINE databases; 13 studies met the inclusion criteria. Eligible studies involved human subjects undergoing spinal tumor surgery with intraoperative use of 5-ALA for tumor fluorescence. Primary outcomes assessed included fluorescence response and extent of resection; secondary outcomes included postoperative neurological status and adverse effects. Results: Thirteen studies involved 245 patients whose tumor diagnoses included ependymomas, meningiomas, astrocytomas, neurinomas, and metastatic lesions. Fluorescence rates varied by tumor type; uptake showed high positivity in ependymomas and meningiomas, but inconsistent findings for astrocytomas and metastases. Gross total resection was achieved more frequently in well-circumscribed benign tumors. Although patients experienced favorable postoperative outcomes, transient or persistent neurological deficits occurred in a subset of patients depending on tumor location and surgical complexity. Standard dosing (20 mg/kg preoperatively) was consistent across studies, and adverse effects were limited to expected photosensitivity. Conclusion: 5-ALA enhances intraoperative visualization and may facilitate more complete resection of selected spinal tumors, particularly ependymomas and meningiomas.

Background: Atlantoaxial instability (AAI) and basilar invagination are potentially life-threatening complications in children with Down syndrome. When symptomatic, they may lead to progressive myelopathy, gait disturbance, and eventual quadriparesis. Surgical fixation is indicated in cases of neurological deterioration or radiographic evidence of significant instability. Case Description: A 6-year-old female presented with Down syndrome and a history of complex congenital heart disease who presented with 10 months of progressive quadriparesis. Imaging revealed atlantoaxial subluxation with basilar invagination resulting in cervicomedullary compression. Surgery included an occiput-to-C4 posterior fusion, skipping C3 due to anatomical hypoplasia, performed under neuromonitoring and utilizing intraoperative imaging. Postoperative studies confirmed optimal location of instrumentation, and the patient exhibits continued neurological improvement. Conclusion: Early recognition and timely surgical intervention are critical to manage children with Down syndrome and cervical instability.

Background: Spontaneous spinal epidural hematomas (SSEHs) are a rare. Cervical SSEHs, though less common than thoracic or lumbar variants, pose a heightened risk of morbidity due to proximity to the brainstem and spinal cord making timely diagnosis treatment even more critical. Case Description: A 50-year-old female presented with chronic neck pain for 1 week presented with the rapid onset of a progressive quadriparesis. The cervical magnetic resonance imaging revealed a posterior SSEH extending from C4 to T2, with maximal cord compression at C6–C7; the radiological differential diagnosis favored epidural hematoma versus tumor. She underwent an urgent decompressive laminectomy for evacuation of hematoma; pathology revealed no neoplasia or vascular malformation. Postoperatively, she recovered marked neurological motor function. Conclusion: Cervical SSEHs are rare and require immediate magnetic resonance diagnosis and surgical decompression to optimize neurological recovery.

Hemangiomas are considered slow growing benign neoplasms. Primary thyroid hemangiomas are uncommon and may pose difficulty in diagnosis due to absence of distinctive imaging characteristics and related clinical symptoms. It is crucial to precisely identify these lesions to aid in implementing nonsurgical treatment plans rather than resorting to surgical procedures in certain cases. In this report we present a case of a 76-year-old female who presented with painless, rapid, and sudden notice of right-side neck swelling over a 1-day duration. Her radiological examinations raised the concern of a vascular lesion that was emoblized endovascularly. Then, it was surgically removed, which was eventually determined to be primary thyroid hemangioma. In addition, we present a literature review of previously published cases and discuss tumor pathophysiology, clinical presentations, radiology features, and differential diagnosis.