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Chronic low-back pain (CLBP) is a common disease with several negative consequences on the quality of life, work and activity ability and increased costs to the health-care system. When pharmacological, psychological, physical and occupational therapies or surgery fail to reduce CLBP, patients may be a candidate for Spinal Cord Stimulation (SCS). SCS consists of the transcutaneous or surgical implantation of different types of electrodes in the epidural space; electrodes are then connected to an Implanted Pulse Generator (IPG) that generates stimulating currents. Through spinal and supraspinal mechanisms based on the “gate control theory for pain transmission”, SCS reduces symptoms of CLBP in the almost totality of well-selected patients and its effect lasts up to eight years in around 75% of patients. However, the evidence in favor of SCS still remains weak, mainly due to poor trial methodology and design. This narrative review is mainly addressed to those professionals that may encounter patients with CLBP failing conventional treatments. For this reason, we report the mechanisms of pain relief during SCS, the technical features and some clinical considerations about the application of SCS in patients with CLBP.

Introduction: Major depressive disorder (MDD) is the leading cause of years lost to disability worldwide. Pharmacotherapy and psychotherapy are effective treatments in most depressive episodes; but, about 30% of MDD patients remain symptomatic, and relapse is a common event. Recently, deep brain stimulation (DBS) has emerged as a valid therapeutic option in treatment-resistant depression (TRD) patients.Areas covered: In this paper, the authors summarize the findings of studies focused on these pathophysiologic phenomena and specifically on the role of DBS as a therapeutic option in TRD patients. The authors simply reviewed RCTs, open-label studies, neurophysiological mechanisms of DBS in MDD, and the possible role of different targets. Finally, we suggest possible future options.Expert opinion: Depression is a systems-level disorder, involving several brain structures. Neuroimaging studies demonstrate multiple interconnected regions that modulate different neural networks. DBS can modulate different targets, and others are under investigation. Among these subcallosal cingulate gyrus (SCG), ventral capsule and ventral striatum (VC/VS) seems to be the most relevant targets. We believe that, in the next future, DBS for TRD might become a first-line of treatment, especially using directional leads, that may help us to improve therapeutic effects.

Introduction: Sleep and migraine share a common pathophysiological substrate, although the underlying mechanisms are unknown. The serotonergic and orexinergic systems are both involved in the regulation of sleep/wake cycle, and numerous studies show that both are involved in the migraine etiopathogenesis. These two systems are anatomically and functionally interconnected. Our hypothesis is that in migraine a dysfunction of orexinergic projections on the median raphe (MR) nuclei, interfering with serotonergic regulation, may cause Non-Rapid Eye Movement parasomnias, such as somnambulism. Hypothesis/theory: Acting on the serotonergic neurons of the raphe nuclei, the dysfunction of orexinergic neurons would lead to a higher release of serotonin. The activation of serotonergic receptors located on the walls of large cerebral vessels would lead to abnormal vasodilatation and consequently increase transmural pressure. This process could activate the trigeminal nerve terminals that innervate vascular walls. As a consequence, there is activation of sensory nerve endings at the level of hard vessels in the meninges, with release of pro-inflammatory peptides (e.g., substance P and CGRP). Within this hypothetical frame, the released serotonin could also interact with trigeminovascular afferents to activate and/or facilitate the release of the neuropeptide at the level of the trigeminal ganglion. The dysregulation of the physiological negative feedback of serotonin on the orexinergic neurons, in turn, would contribute to an alteration of the whole system, altering the sleep–wake cycle. Conclusion: Serotonergic neurons of the MR nuclei receive an excitatory input from hypothalamic orexin/hypocretin neurons and reciprocally inhibit orexin/hypocretin neurons through the serotonin 1A receptor (or 5-HT1A receptor). Considering this complex system, if there is an alteration it may facilitate the pathophysiological mechanisms involved in the migraine, while it may produce at the same time an alteration of the sleep–wake rhythm, causing sleep disorders such as sleepwalking. Understanding the complex mechanisms underlying migraine and sleep disorders and how these mechanisms can interact with each other, it would be crucial to pave the way for new therapeutic strategies.

For the ability to modulate the activity of dysregulated networks Deep Brain Stimulation (DBS) of areas involved in reward system and motivational states may have a potential application in addiction despite risks associated with its invasiveness. To date nucleus accumbens core (NAcc) appares to be the most effective target but also anteromedial portion of subthalamic nucleus (STN) and lateral hypothalamus (LH) are studied for clinical purposes. The choice of the target may vary based on the form of addiction: NAcc in alcohol and opiate addiction and STN in cocaine addict patients. Additional studies are still necessary to establish effectiveness and safety of DBS in addiction.

Oxygen-ozone therapy is used to treat degenerative pathology of the spine when surgery is not needed (e.g., removal of a herniated disk). Some authors have described it as a safe and effective procedure in ∼ 70 to 90% of patients. The aim of the therapy is to dehydrate the intervertebral disk and alter its contents. However, this treatment has been associated with some rare but very serious side effects. Both cardiac damage and a case of fulminant septicemia were reported. We describe a case of suspected pulmonary embolism, followed by sudden death, in an elderly woman treated with oxygen-ozone therapy for lumbar pain caused by disk protrusion. We believe a massive pulmonary embolism occurred, probably caused by an intradiskal injection that accidentally punctured a venous vessel and created emboli.

The prefrontal cortex is deputed to higher functions, such as behavior and personality. It includes three regions: ventromedial, orbitofrontal, and dorsolateral. Each of them has a function. Devising, programming, and planning are all conditions related to the dorsolateral cortex, also responsible for rational content and decision. Damage to this region results in apathetic syndrome, a condition that causes loss of interest, initiative, and attention, and in the most severe cases leads to a lethargic state. It is also known as a form of secondary depression, the so-called pseudo-depression syndrome, according to Karl Kleist or apathetic-abulic-akinetic syndrome, according to Alexander Luria. The prefrontal dorsolateral syndrome is responsible for the reduction or abolition of free will. Free will is an expression of individual freedom. It allows the human being to have and express own opinions as well as to respect those of others. Free will is related to moral sense, a binomial which directs the individual towards a proper social conduct. In this review, we describe the effects of the pseudo-depression syndrome on free will, of which we treat both the anatomical site and the social aspect.

Background Surgical decompression of the ulnar nerve (UN) is effective for treating cubital tunnel syndrome (CubTS). Nevertheless, the outcome is not always satisfying. Different surgical, clinical, and imaging findings have been claimed as outcome predictors, but there is no consensus in the literature. We analyzed the outcome-predicting role of ultrasonography (US) of the UN in patients with CubTS and its possible role for diagnosis and follow-up. Methods Patients with CubTS treated by simple UN decompression underwent US and electrodiagnotic (ED) studies of the UN at the elbow before and after surgery. Outcome was evaluated through the Bishop scale. A correlation analysis between pre- and postoperative clinical, US, and ED findings was performed. Results Thirty-six patients were enrolled. Preoperatively, we observed a negative correlation between the motor conduction velocity (MCV) and the transverse (TD) and anteroposterior diameters and cross-sectional area (CSA) of the UN at the precubital (P = 0.001, P = 0.001, P = 0.005) and cubital level (P = 0.02, P = 0.002, P = 0.001). Preoperative precubital TD and CSA were associated with outcome (P = 0.01, P = 0.006) and postoperative MCV (P = 0.004, P = 0.008). The cut-off values TD >6 mm and CSA >23.91 mm2 were predictors of poor outcome. Finally, postoperative cubital TD and CSA values were inversely correlated with outcome (P = 0.0002, P = 0.0007) and postoperative MCV (P = 0.0002, P = 0.0004). Conclusions The US examination of the UN is useful for the management of patients with CubTS as an adjunct to clinical and ED evaluations. US measurements are correlated with pre- and postoperative ED findings and thus are useful for diagnosis and follow-up. Interestingly, specific precubital US measurements are good predictors of outcome.

Background Glioblastoma multiform (GBM), a malignant brain tumour, has a very often poor prognosis. The therapeutic approach is represented by surgery followed by radiotherapy and chemotherapy. Hypoxia is a factor that causes a reduction of both radiotherapy and chemotherapy effectiveness in GBM and other cancers. Through the use of [64Cu][Cu(ATSM)], a hypoxia-targeting positron emission tomography (PET) radiotracer, is possible to identify the presence of hypoxic areas within a lesion and therefore modulate the therapeutic approach according to the findings. Case presentation In this case report, we observed an increase of radiotracer uptake from early acquisition to late acquisition in hypoxia sites and high correlation between [64Cu][Cu(ATSM) PET/CT results and expression of the hypoxia marker HIF-1α. Conclusions [64Cu][Cu(ATSM) PET/CT represents a valid opportunity to reveal in vivo hypoxic areas in GBM lesion which can guide clinicians on selecting GMB patient’s therapeutic scheme.

Cortex neuromodulation is promising approach for treatment of some neurological conditions, especially neuropathic pain and Parkinson's disease. Effects of non-invasive cortical stimulation are short lived; transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS) may be useful to assess the suitability for invasive cortical stimulation. Direct cortical stimulation (DCS) is the method able to provide long-lasting effects in treatment of neuropathic pain and some symptoms of Parkinson's disease through the use of totally implantable systems that ensure a chronic stimulation.

Secretome of primary cultures is an accessible source of biological markers compared to more complex and less decipherable mixtures such as serum or plasma. The protonation state (PS) of secretome reflects the metabolism of cells and can be used for cancer early detection. Here, we demonstrate a superhydrophobic organic electrochemical device that measures PS in a drop of secretome derived from liquid biopsies. Using data from the sensor and principal component analysis (PCA), we developed algorithms able to efficiently discriminate tumour patients from non-tumour patients. We then validated the results using mass spectrometry and biochemical analysis of samples. For the 36 patients across three independent cohorts, the method identified tumour patients with high sensitivity and identification as high as 100% (no false positives) with declared subjects at-risk, for sporadic cancer onset, by intermediate values of PS. This assay could impact on cancer risk management, individual’s diagnosis and/or help clarify risk in healthy populations., Diagnostics: Proton state of secreted proteins in blood helps identify cancer A blood test that measures whether molecules secreted by cells contain titratable proton atoms can accurately discriminate between patients who have cancer and those who don’t. Titratable species may in turn influence the protonation state of a solution, i.e. the number of protons added to and the net charge of that solution. A team led by Natalia Malara from University Magna Graecia in Catanzaro, Italy and Enzo Di Fabrizio from the King Abdullah University of Science and Technology in Thuwal, Saudi Arabia, Francesco Gentile from the University Federico II in Naples, Italy, and Nicola Coppedè from the Institute of Materials for Electronics and Magnetism in Parma, Italy, created an eletrochemical device that can detect faulty metabolism by quantifying the proportion of secreted proteins with and without extra protons—an indicator of abnormal cell division, proliferation and invasion. The researchers tested the device on blood samples from patients with solid tumors and healthy controls. The method identified cancer patients with a high degree of accuracy. If the findings are confirmed in larger trials, the test could help with the screening, diagnosis and management of cancer.

Introduction The way children use the Internet and mobile technologies has changed in the last few years according to the Digital Agenda for Europe. The growing phenomenon of cyberbullying is among the risks associated with the increasing Internet use. Methods of access and use by teenagers are highly important factors in assessing those risks. Materials and methods In order to fight cyberbullying we have developed a strategy with the approval of the Department of Medical and Surgical Sciences of the Magna Graecia University of Catanzaro consisting in three phases: a) Data collection and review b) Critical analysis c) Dissemination. a) We expanded our previous study (2017) with a new cluster; a questionnaire specifically developed to investigate cyberbullying and cyber-grooming among the teenage population. This new cluster, proposed by the ‘Cyber Expert’ program created by the Spanish Policia Nacional, is structured to gauge the students’ awareness and knowledge of what cyberbullying is. We submitted this updated survey to students of the Liceo Scientifico ‘G. Keplero’ in Rome, while also inviting them to provide their feedback on the study itself. b) We reviewed and published the questionnaire as a preprint. The data we gathered strongly hinted at the need for surveys and informational material to use language and concepts adolescents could relate to. c) In order to disseminate our results we will create programs focused on and carefully tuned to our reference population (teenagers) i.e. teacher workshops, informational posters, and extracurricular activities. Results We were happy to find unexpected feedback; students were interested in the results of our survey. Both teachers (60%) and students (80%) showed a significant amount of interest in being advised on the outcome. Although the same sample population had been subject to several other questionnaires in the same timeframe, they only showed interest in following up on our results. Conclusions Moving forward, we are now thinking of ways to share our results with the school community and start the third phase of the program. The next phase will focus on creating posters and informational materials on the most relevant points, as well as organizing teacher workshops in order to raise awareness on relevant topics.

Occipital nerve stimulation (ONS) is electric stimulation of the distal branches of the greater occipital nerve by cylindrical or paddle leads implanted in subcutaneous occipital tissue. This surgical option has emerged as a promising treatment for different types of disabling medical refractory headache and recently also for residual occipital and nuchal pain after previous occipitocervical fusion. The mechanisms of action have not yet been clearly explained: electrical stimulation of the occipital nerve has both peripheral and central effects on the nervous system, which may modulate nociception. ONS is a well-tolerated and safe procedure in comparison with other invasive modalities of treatment. Lead migration/dislodgement is a common complication, but use of new surgical techniques and leads may reduce the rate of this complication.

Occipitocervical fusion is a surgical technique in continuous evolution due to the innovation of devices, operative and instrumentation techniques. The aetiologies responsible for occipitocervical instability are trauma, neoplastic disease, metabolic disease or congenital disease. A variety of stabilization techniques are currently available depending on the type of patient and surgeon's experience. Each of these techniques requires thorough knowledge of the anatomy of the craniovertebral junction.

Background The Internet represents an increasingly common source of health-related information. Internet and Social Media can be used to promote a prudent use of antibiotics. Objective To establish the extent of Internet and Social Media use to search for antibiotic related information and the potential implications in health care among adult population in Italy. Methods This cross-sectional study was conducted from March to May 2017, among a sample of parents of public school students. A 2-stage cluster sample design was planned. An informed consent form and a questionnaire were given to selected students to deliver to their parents. The questionnaire included questions on knowledge, attitudes, and behavior toward antibiotic use, and questions about Internet use to gather information about antibiotics. Results A total of 913 parents completed the questionnaire, with a 67.4% response rate; 22.1% did not know when it was appropriate to use antibiotics. 32.3% of parents reported self-medication with antibiotics. 73.4% of respondents used the Internet to search for information about antibiotic use. Among social networks users, 46.5% reported the use of these media to get information about antibiotics and 45% of instant messaging app users share information about antibiotics. The results of the multiple logistic regression analysis showed that Internet use to search for antibiotic-related information was higher among females, younger subjects, with a higher level of education, in those who reported self-medication with antibiotics and in those who needed additional information on side effects of antibiotics from the GP compared with those who did not need any additional information. Internet use was significantly less likely in participants with cardiovascular diseases and cancer compared with those without chronic conditions, and in those who reported to strongly agree/agree, or were uncertain about antibiotic use without a GP prescription, compared with those who reported to be disagree/strongly disagree. Conclusions Internet and social media are widely used for antibiotic-related information seeking in the Italian population. Health organizations must consider social media within their communication strategy to promote the appropriate Web use for antibiotic-related information seeking in the general population, although more evidence is needed regarding the optimal mix of communication interventions.

Background and purpose This study aims to determine the best choice of breathing exercises (BE) for patients with chronic obstructive pulmonary disease (COPD) via a network meta-analysis. Methods We searched randomized controlled trials (RCTs) of adults with COPD investigating any BEs in MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov databases. The effects of comparative treatment on the St. George Respiratory Questionnaire as the outcome were analysed and ranked according to a surface under the cumulative classification curve (SUCRA) analysis. Results The network meta-analysis included six RCTs involving 280 patients with four intervention groups, comprising control, diaphragmatic breathing training (DBT), yoga, and singing course. Performing SUCRA, we reported that yoga is 75% likely to be the best treatment available as DBT with 66%, instead of 35% for singing and 21% for control. Conclusion DBT and yoga seem to be the best choices for breathing exercises in people with COPD.

Background: Frontal lobe brain tumors often cause psychiatric disorders such as depression, if damage is related to dorsolateral part of the prefrontal cortex.It is more appropriate the term pseudodepression in cases where it is secondary to organic causes, such as in brain tumors. Vice versa, it is a very rare condition in which depressive symptoms anticipate the onset of a brain tumor, as showed by few cases reported in literature. Procedure: We describe a case of pseudodepression syndrome followed 20 years after, by the appearance of a frontal lobe meningioma. Conclusions: There are many hypotheses whereby a depression can anticipate the onset of a brain tumor. According to some authors, depression could be a risk factor for the onset of brain tumors. Hence the need, in a subject suffering from depression, to perform periodic control neuroimaging exams, to detect the possible presence of a brain tumor.

Eligibility criteria of the participants. (DOCX 85 kb)

Hemodialysis headache (HDH) is an infrequent new-onset symptom, occurring mainly in old uremic patients. Type of pain is nonspecific, occurs during hemodialysis treatment, assuming features similar to tension-type headache and representing a problem, also as regards the therapy to be taken. International Headache Society (IHS) has placed this form of headache among the headaches disorders of homeostasis. We found a case of new-onset HDH in old uremic man, presenting with migraine aura features. A similar case has not been reported in literature, placing us some questions: why and how does this happen? What are the mechanisms involved? Role of trigeminal-vascular system and cortical spreading depression as regards the aura could be considered, through the activation of neuroinflammatory events, lastly causing migraine aura. Moreover, the administration of flunarizine strongly improved migraine symptoms in our patient, as happens in migraine syndromes. Definitely, this case leads us to think that some mechanisms involved in headaches will need to be further clarified.

Extra/intradural strip electrode implantation on motor cortex may be possible minimally invasive neurosurgical method for therapeutic neuromodulation in Parkinson's disease (PD). The aim of this review is to assess motor cortex stimulation (MCS) efficacy and safety in advanced PD. Sixteen published articles were included with a total of 130 PD patients treated. In almost all results are from prospective observational open labeled study, only in two studies blinded assessment was carried out. Negative results are reported in three studies. Significant improvement in motor symptoms with remarkable effect on axial symptoms, L-dopa-induced dyskinesia and quality of life are outlined in thirteen studies. Surgical technique involved implant of four-contact strip electrode over M1 in epidural space with exception of few cases in which implant was carried out in subdural space. Surgical procedure was performed contralateral to most affected side with exception of five patients in which it was carried at dominant hemisphere; in four patients electrode implant was bilateral but stimulation was carried out simultaneously on both sides only in two cases. Complications and adverse events occurred very rarely for extradural MCS whereas with higher rate for subdural MCS. Based on review of current literature extra/intradural MCS represents an alternative to deep brain stimulation (DBS) to surgically treat PD patients who are not candidate for DBS. MCS is a minimally invasive neuromodulation procedure with low morbidity-mortality that can relieve all three major symptoms of PD on both sides simultaneously and bilaterally; it has significant effectiveness on axial symptoms, gait disturbances and therapy complications.

Alzheimer’s disease (AD) is a debilitating neurological illness of increasing prevalence. Accumulations of abnormal proteins (beta amyloid and tau protein), inflammatory cascades, abnormal responses to oxidative stress and alteration in oxidative metabolism have been implicated in AD. There are few therapeutic options available for this disorder. Latest research indicates that deep brain stimulation (DBS) may be a method for improving cognitive functions. Many aspects remain unclear, particularly with regard to the optimal target structure. In this review the pathophysiology, neural circuitry and potential neuromodulation options in patients with AD are resumed.

Motor Cortex Stimulation (MCS) is less efficacious than Deep Brain Stimulation (DBS) in Parkinson's disease. However, it might be proposed to patients excluded from DBS or unresponsive to DBS. Ten patients with advanced PD underwent unilateral MCS contralaterally to the worst clinical side. A plate electrode was positioned over the motor cortex in the epidural space through single burr hole after identification of the area with neuronavigation and neurophysiological tests. Clinical assessment was performed by total UPDRS, UPDRS III total, UPDRS III-items 27–31, UPDRS IV, and UPDRS II before implantation in off-medication and on-medication states and after surgery at 1, 3, 6, 12, 18, 24, and 36 months in on-medication/on-stimulation and off-medication/on-stimulation states. We assessed changes of quality of life, throughout the Parkinson's disease quality of life scale (PDQoL-39), and the dose of anti-Parkinson's disease medications, throughout the Ldopa equivalent daily dose (LEDD). During off-medication state, we observed moderate and transitory reduction of total UPDRS and UPDRS total scores and significant and long-lasting improvement in UPDRS III items 27–31 score for axial symptoms. There was marked reduction of UPDRS IV score and LEDD. PDQL-39 improvement was also significant. No important complications and adverse events occurred.

Nummular headache has been recently described as a primary disorder characterized by head pain exclusively felt in a small rounded area typically 2–6 cm in diameter, not attributed to another disorder. Both size and shape of the painful area remain constant since the onset of symptoms. A 57-year-old woman presented with a history of focal episodic pain in a circumscribed area on the right parietal region. The administration of standard oral doses of palmitoylethanolamide and topiramate in combination showed an improvement in pain symptoms and on pain measuring scales.

INTRODUCTION Von Hippel-Lindau (VHL) disease is a dominantly inherited condition associated with tumors in multiple organs, whose treatment requires heightened multidisciplinary teamwork. Therefore, a document summarizing all the pertinent knowledge is needed to enhance coordination of care. EVIDENCE ACQUISITION A systematic review of the literature from the Medline, Embase and Cochrane Central databases was performed. From 1970 to 2017, all articles meeting specific inclusion criteria were included by at least one specialist physician for each field. EVIDENCE SYNTHESIS We included 95 articles, mostly dealing with genetics or management of VHL associated tumors in one organ system. There were no papers discussing the manifestations of VHL altogether, which was the aim of our paper. CONCLUSIONS VHL requires a multidisciplinary management to provide the highest quality of care. Coordination and communication between patients and caregivers is enhanced when knowledge is shared. Gathering together specialists in different domains around the production and reading of a comprehensive document such as the one hereby may contribute to this purpose.

Failed back surgery syndrome (FBSS) is complex and recurrent chronic pain after spinal surgery. Several important patient and surgery related risk factors play roles in development of FBSS. Inadequate selection of the candidates for the spinal surgeries is one of the most crucial causes. The guidelines suggest that conservative management featuring pharmacologic approaches and rehabilitation should be introduced first. For therapy-refractory FBSS, spinal cord stimulation (SCS) is recommended in selected patients. Treatment efficacy for FBSS has increased over the years with the majority of patients experiencing pain relief and reduced medicinal load. Improved quality of life can also be achieved using SCS. Cost-effectiveness of SCS still remains unclear. However evidence for SCS role in FBSS is controversial, SCS can be beneficial for carefully classified patients.

Migraine prophylaxis is a demonstrated viable therapeutic option, providing positive results through the use of drugs, more and more safe and effective. These drugs are anticonvulsant, antidepressant, calcium channel blockers, beta blockers, making a notable contribution according to studies reported in the literature. But they also have side effects, usually less than their efficacy. In this study we report our series of migraineurs with and without aura, treated with prophylactic drugs. In the study we used the drugs of first choice and we used VAS scale to assess pain intensity, checking patients for 8 months, with good results, in some cases excellent. Data from literature show that these new nutraceutical substances, besides to those already in use, are utilized successfully, opening new therapeutic perspectives. Do not resort to symptomatic drugs, it is very important, being rich in adverse, potentially harmful effects, so migraine prophylaxis remains a useful instrument of defense in these patients.

Background. Cerebral aneurysms are relatively common in adults, with a prevalence ranging between 1% and 5%. Subarachnoid hemorrhage, following aneurismal rupture, is a major cause of death and disability in these patients. Matrix Metalloproteinases (MMPs) and Neutrophil Gelatinase-Associated Lipocalin (NGAL) seem to be involved in the pathogenesis and in the clinical course of aneurysms. In this study, we evaluated the relationship between tissue and plasma levels of MMP-9 and NGAL in patient with ruptured and unruptured middle cerebral artery aneurysms. Methods. An open label study was conducted on 7 patients with middle cerebral aneurysms. Three patients had ruptured aneurysms (Group I) and four patients had unruptured aneurysms (Group II). All patients underwent aneurysm clipping. Plasma levels of MMP-9 and NGAL were evaluated through ELISA Test. During the surgery, biopsies of the aneurysmatic arteries were taken and frozen (- 80°C) for Western blot evaluation of MMPs and NGAL expression. Four healthy volunteers (Group III) represented the control group for ELISA testing. Results. Both plasma MMP-9 and NGAL levels were significantly high in aneurysmatic patients respect to those of control patients, and these levels were higher (P < 0.01) in patients with ruptured aneurysms respect to patients with unruptured aneurysms (P < 0.01). The latest findings were similarly evident in tissue evaluation of MMP-9 and NGAL between ruptured and unruptured aneurysms. Conclusion. This study suggests that MMP-9 and NGAL plasma levels may be useful to predict the clinical course of a cerebral aneurysms in order to evaluate the progression of the disease and the tendency of an aneurysm to rupture.

Cervical spinal compression is a serious and rare complication of spinal cord stimulation (SCS) that can occur using leads placed via open surgical approach. The present report describe a case of cervical plate lead implant that developed spinal and radicular compression symptoms after seven years due to the growth of fibrotic epidural mass at the level of lead. A review of literature is provided. A 59-year‑old woman with 3-year history of left arm post‑traumatic complex regional pain syndrome (CRPS) was treated with SCS performed with the implant of paddle lead in the epidural space from C3-C5. Seven years later she reported progressive paresthesia along the spine and the limbs, gait ataxia with sensation of weakness in the legs, increased muscle tone and tendon reflexes in the lower extremities and decrease in effectiveness of stimulation. Cervical CT showed a tissue mass into the cervical canal posteriorly to the lead. This finding was confirmed by MR performed after lead removal that also allowed to document the amount of spinal cord compression. The patient underwent C4-C5-C6 laminectomy and a thick scar was removed from the dura. After surgery there was progressive and incomplete improvement of neurological signs but symptoms related to algodystrophy recurred partly. The formation of hypertrophic epidural scar tissue at the level of lead implant must be taken into consideration in presence of the onset of progressive cervical myelopathy in patient treated with SCS using laminectomy lead.

Motor cortex stimulation (MCS) was proposed by Tsubokawa in 1991 for the treatment of post-stroke thalamic pain. Since that time, the indications enlarged including trigeminal neuropathic pain and other types of central and peripheral deafferentation pain. Clinical knowledge of MCS derives mainly from published individual cases and case series. Mechanisms underlying the effects of MCS are not yet clearly known. Empirical approach is generally used to select the optimal parameters by adjusting the combination of contacts, polarity, frequency, pulse width and amplitude, according to the patient’s pain relief. Complications are relatively rare but long-term loss of efficacy is reported.

Background: Spinal cord stimulation (SCS) is a well-established modality for the treatment of refractory chronic pain and may utilize percutaneous or paddle leads. Methods: The study is conducted at the Unit of Functional Neurosurgery of University “Magna Graecia” of Catanzaro. We perform a retrospective review of our prospective database of 523 SCS patients undergoing surgery for routine indications between January 1993 and December 2013 to evaluate failures rates during trial period and during chronic stimulation. Results: SCS trial was less effective for patients with differentiation neuropathic pain and post herpetic pain. Patients with allodynic dominant pain can feel unpleasant or painful parenthesis during trial stimulation. SCS trial has presented a very low hardware-associated complication rate (lead migration 1.3%) and absence of biological complications. During chronic SCS 29% of cases had equipment failures. In particular mechanical failures occurred in 18% of cases with 8.5% of lead displacements or migrations and 9.5% of lead breakages; biological failures occurred in 11% of cases with 6% of skin erosions and 5% of infections. Conclusion: SCS is a minimally invasive procedure effective in managing medically intractable pain of various origins. Despite advances in the design and production of SCS systems, these devices remain prone to failure from various causes. A careful analysis of mechanical complications coupled to a clinical strategy to minimize the tensile loads on the components of the system should lead to an improvement of the performance of the SCS implanted system and the effectiveness of the stimulation and the long-term reduction in the rate of complications that currently it remains quite significant.

Innovations in the field of deep brain stimulation (DBS) are introduced recently, considering that the fundamentals of DBS remained significantly unchanged over 25 years. Technological advances involve not only DBS hardware but also new patterns of stimulation, brain imaging and pathophysiological pathways. Every effort is done to obtain the best outcome for the patient with the lower adverse effects rates.

Background Circulating Tumor Cells (CTCs) are promising biomarkers for monitoring solid cancer and were used to monitor brain tumors. Here we report two cases in which, for the first time, CTCs were used in cytological diagnostic evaluation to discriminate a space-occupying lesion of the brain. Case presentation Two cases of focal intracranial lesions, unclassified for diagnosis, untreated and apparently symptomatic, were examined after high-contrast resolution Magnetic Resonance Imaging and/or Computed Tomography scans. CTCs were seeded on chamber slides and short-time expanded under the optimized conditions as we previously reported. The first case was a focal lesion localized in the parietal-occipital area in a 67-year-old woman. The second case was a 31-year-old man with an expansive intracerebral lesion localized in the left peri-trigonal area. Both patients underwent excisional biopsy. Histopathological evaluation of the biopsy confirmed the previous cytological diagnoses, and the analysis of the clinical outcomes retrospectively validated both diagnoses. Conclusions The cases here reported illustrate the potential for using expanded CTCs as non-invasive, real-time biopsy. Moreover, non-invasive real-time biopsy can represent an alternative diagnostic tool to be used when a functional area of the brain is at risk of injury from excisional biopsy procedures.

To assess the costs and clinical condition of Failed Back Surgery Syndrome (FBSS) for patients eligible for Spinal Cord Stimulation (SCS) in Italy. A multicentre, retrospective data collection with a maximum time horizon of 12 months was developed. Nine Italian Centers experienced in SCS were involved enrolling 80 patients. Use and costs of healthcare and non-healthcare resources, clinical condition and HR-QoL data were collected through specific questionnaires submitted to patients. Mean monthly costs (EUR 2008) were evaluated according to three perspectives: Patient, National Healthcare System (NHS) and Society. A strong impairment in baseline HR-QoL was documented. Mean utility score was 0.07 (general UK population: 0.70). According to the Oswestry questionnaire, 44% of patients were crippled and 39% severely disabled. All SF-36 dimensions were worse than in normal population. To treat FBSS, monthly expenditure per patient was equal to €177.34, €221.12 and €1,046.12 from the perspectives of Patient, NHS and Society, respectively. Productivity losses accounted for 62% of the societal total costs, while hospitalizations explained 28% of the costs sustained by the NHS. From the patient perspective, the main cost drivers were home care (27%) and travel expenses (26%). This Cost-of-Illness analysis confirms FBSS as a disabling and costly disease.