Badr Hafiz

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: Low back pain (LBP) is a leading cause of musculoskeletal disabilities worldwide. Psychosocial and behavioral factors contribute to the transition from acute pain to chronic disability, and public beliefs regarding LBP may influence treatment outcomes and functional statuses. Objectives: To assess public beliefs regarding LBP in Saudi Arabia using the Back Beliefs Questionnaire (BBQ), evaluate disability among participants with persistent LBP using the Oswestry Disability Index (ODI), and examine the association of these measures with demographic characteristics. Materials and Methods: A cross-sectional survey was conducted in Saudi Arabia between December 2019 and December 2020. A total of 4,052 participants were recruited, of whom 850 submitted incomplete questionnaires and were excluded from the subgroup analyses. The remaining participants completed the Back Beliefs Questionnaire to assess their demographic characteristics and beliefs regarding LBP. Participants with persistent LBP symptoms for > 6 weeks completed the Oswestry Disability Index. The associations between beliefs, disability, and demographic variables were analyzed using chi-square tests. Results: The population demonstrated a combination of evidence-based beliefs and persistent misconceptions regarding LBP. Most participants recognized the benefits of exercise and rejected highly pessimistic beliefs, such as inevitable wheelchair dependence or the inability of doctors to help them. However, many participants believed that LBP would result in lifelong pain and functional limitations. Persistent LBP was reported by 41.7% of the respondents. Among the affected individuals, most had minimal (44.3%) or moderate (25%) disabilities. Significant associations were observed between beliefs and disability levels, as well as between beliefs and demographic variables, including age, educational level, and occupation (all p < 0.05). Participants with more negative beliefs regarding the long-term consequences of LBP demonstrated higher levels of disability. Conclusion: Public beliefs regarding LBP in Saudi Arabia are influenced by misconceptions that may contribute to disability. These findings highlight the importance of evidence-based public education and awareness strategies that address the psychosocial aspects of LBP management.

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.

Intracranial epidermoid cysts are rare congenital lesions accounting for approximately 1% of intracranial tumors. Petrous apex involvement is uncommon and surgically challenging because of the lesion's proximity to critical neurovascular structures. Reports describing minimally invasive endoscope-assisted approaches in this location remain limited. A 32-year-old man presented with progressive right-sided otalgia, pulsatile tinnitus, and hearing loss. Imaging demonstrated a destructive petrous temporal bone lesion with atypical diffusion characteristics, initially suspected to represent a jugular foramen tumor. The patient underwent a minimally invasive endoscope-assisted presigmoid burr hole approach. Intraoperatively, the lesion demonstrated the characteristic pearly appearance of an epidermoid cyst and was resected piecemeal under microscopic and endoscopic visualization. Endoscopic assistance improved visualization of deep and angled extensions beyond the microscopic field. Postoperatively, the patient had preserved facial nerve function, stable hearing, and an uneventful recovery. Histopathological examination confirmed an epidermoid cyst. Petrous apex epidermoid cysts require balancing maximal safe resection with preservation of neurological function. This case highlights the potential utility of a minimally invasive endoscope-assisted approach for improving visualization within constrained skull base corridors while minimizing operative morbidity. Long-term radiological surveillance remains important when complete capsule removal is not safely feasible. https://thejns.org/doi/10.3171/CASE26361.

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: Congenital anomalies of the internal carotid artery (ICA), including hypoplasia, aplasia, and agenesis, are rare vascular conditions with a prevalence below 0.01%. Most patients remain asymptomatic because of collateral cerebral circulation, yet these anomalies may cause cerebrovascular complications, particularly ischemic events and intracranial aneurysm formation. Methods: A narrative literature review was performed to synthesize available data on demographics, embryology, pathophysiology, clinical presentation, imaging evaluation, classification systems, management, and outcomes of congenital ICA anomalies. Results: ICA agenesis is commonly detected incidentally, especially in unilateral cases with adequate collateral pathways. Symptomatic cases, more frequent in bilateral involvement, may present with headache, transient ischemic attack, stroke, or impaired consciousness. Risk factors include bilateral absence, incomplete collateral circulation, and classification patterns such as Lie types C and D and Jamous type 1b, associated with increased hemodynamic stress and aneurysm formation. Computed tomography (CT) angiography, magnetic resonance angiography, and digital subtraction angiography are central to diagnosis, whereas skull base CT distinguishes agenesis from hypoplasia. Management is usually conservative in asymptomatic patients, whereas surgical or endovascular treatment is reserved for aneurysms or hemodynamic compromise. Conclusion: ICA agenesis is a rare but clinically important anomaly. Recognition of variants, imaging features, and complications is essential for diagnosis and procedural planning. Surveillance imaging and individualized management help reduce cerebrovascular morbidity.