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Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: “early surgery” and “delayed surgery.” The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the “early surgery” group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the “delayed surgery” group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.

C5 nerve root palsy is a well-known complication after anterior or posterior cervical decompression. Many theories have been proposed but the etiology is still unclear. The use of a winged expandable cage after single or multiple corpectomy is among the used techniques in reconstructing the cervical spine. Herein we report a case of C5 palsy after a three-level corpectomy and reconstruction using this device for the treatment of cervical spondylosis. In our case the preexisting foraminal stenosis, wide anterior decompression and partial improvement of cervical alignment were factors supposed contributing to the palsy.

Background: Cervical magnetic resonance imaging (MRI) is the gold standard exam in the assessment of patients affected by cervical myelopathy and is very useful in planning the operation. Herein we present a series of patients affected by long tract symptoms who underwent dynamic MRI in addition to the static exam. Methods: In the period between March 2010 and March 2012, three-hundred-ten patients referred to our department since affected by neck/arm pain or symptoms related to cervical myelopathy. Thirty-eight patients complained “long-tract symptoms” related to cervical myelopathy. This series of patients was enrolled in the study. All patients underwent clinical and neurological exam. In all the cases, a static and dynamic cervical MRI was executed using a 3.0-T superconducting MR unit (Intera, Philips, Eindhoven, Netherlands). The dynamic exam was performed with as much neck flexion and extension the patient could achieve alone. On T2-weigthed MRI each level was assessed independently by two neuroradiologists and Muhle scale was applied. Results: According to Muhle’s classification of spinal cord compressions, static MRI demonstrated 156 findings: 96 (61.54%) anterior and 60 (38.46%) posterior. Dynamic MRI showed 186 spinal cord compressions: 81 (43.5%) anterior and 105 (56.5%) posterior. The anterior compressions were: grade 1 in 23 cases (28.4%), grade 2 in 52 cases (64.2%), grade 3 in 6 cases (7.4%). The posterior compressions were: 32 (30.48%) of grade 1, 60 (57.14%) of grade 2, 13 (12.38%) of grade 3. Conclusions: The dynamic MRI demonstrated a major number of findings and spinal cord compressions compared to the static exam. Finally, we consider the dynamic exam able to provide useful information in these patients, but we suggest a careful evaluation of the findings in the extension exam since they are probably over-expressed.

In this case report, we demonstrate that the use of a winged expandable cage was able to obtain good clinical and radiological results in a case of cervical tuberculosis with severe kyphosis. However, case series will be necessary to affirm its validity as a stand-alone device for similar cases with high risk of instability.

Background.Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection.Study Design and Aims.Retrospective review focused on clinical assessment, treatment techniques, and outcomes.Methods.A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests.Results.From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions.Conclusions.Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.

Background Despite the progress achieved in recent years, the prognosis of patients with primary brain tumors remains poor. Research efforts have therefore focused on identifying more effective and minimally invasive treatment methods. Magnetic resonance–guided transcranial focused ultrasonography (MRgFUS) is a consolidated minimally invasive therapeutic technique, which has recently acquired a role also in the treatment of some nononcologic intracranial diseases. Methods We reviewed the latest studies to take stock of the potential of MRgFUS. Results The objective of the research in the last decade was to apply FUS also to the treatment of intracranial neoplastic diseases, using both the thermal effects (thermal ablation) and, above all, the ability to permeabilize the blood-brain barrier and modify the tumor microenvironment. This strategy may allow the use of drugs that are poorly active on the central nervous system or active selectively at high doses, minimize the side effects, and substantially modify the prognosis of patients affected by these diseases. Conclusions In the future, targeted drug delivery, immunotherapy, and gene therapy will probably become main players in the treatment of brain neoplasms, with the aid of MRgFUS. In this way, it will be possible to directly intervene on tumor cells and preserve healthy tissue.

Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences. Materials and Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance. Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as 'other' was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ 2 < 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences (P > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05). Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence. © 2019 Journal of Craniovertebral Junction and Spine | Published by Wolters Kluwer - Medknow.

This is a retrospective study on 18 patients affected by thoraco-lumbar junction burst fractures (TLJBF) A3 or A4 at computed tomography (CT) scan who referred to our hospital. To assess the surgical results in terms of pain and quality of life in a series of neurologically intact patients affected by TLJBF who underwent surgery after 3-4 months from the injury. In literature there is controversy if pain could be an indication for surgery in TLJBF and series of patients conservatively managed with success have been reported.A retrospective study on 18 patients is reported. Patients included in this series were neurologically intact and affected by a TLJBF A3 or A4 at CT scan, the height of the burst vertebral body was50%, spinal canal invasion was30% and kyphosis deformity30 degrees. Pain and quality of life were evaluated using graphic rating scale (GRS) and EuroQol (EQ-5D) scores on admission, at the clinical follow-up and in post-surgical period.Comparing pre- and post-operative EQ-5D, the scores had a statistically significant decrease after the operation (P0.001) [pre-surgery EQ-5D was 2.60 (SD =0.67), post-surgery EQ-5D was 1.37 (SD =0.41)]. Also analyzing the EQ5D-VAS scores, the t-test revealed that surgery (P0.01) improved the quality of life with statistically significance (EQ5D-VAS pre =43.89, SD =12.43 and EQ5D-VAS post =73.33, SD =10.84). Analyzing pre- and post-surgical GRS scores, the pain decreased significantly with the maximum mean difference among the 2nd and 3rd month before surgery and at 12 months after surgery (respectively D =5.444, P0.001 and D =5.167, P0.001).Conservatively managed patients affected by TLJBF require a strict clinical follow-up since pain sometimes is present in the following months and it affects the quality of life. Surgery should be considered for these cases.

Objective and Importance To demonstrate the curative reconstruction of two giant fusiform aneurysms using a combination of flow-diverter stents and self-expanding stents for intracranial use. Clinical Presentation Two cases that would have been difficult to manage with standard methods: one patient with deficiencies of cranial nerves VI and VII on the left, acute diplopia, and an aneurysm of the vertebrobasilar bifurcation, the other with diplopia, deficiencies of cranial nerves III and VI, and an aneurysm of the intracavernous internal carotid artery. Intervention or Technique Complete reconstruction was achieved using a combination of flow-diverter and self-expandable stents. Follow-up investigations at 6 months demonstrated the complete reconstruction of the arteries and angiographically determined disappearance of the aneurysms with resolution of the clinical profile. The patients' outcome was excellent (modified Rankin Scale: 0). Conclusion This technique enables safe and definitive treatment of lesions that would be difficult to manage with other methods. The greater metal surface does not seem to interfere with the perforating arteries originating from the segments involved.

Objectives: Decompressive craniectomy (DC) is a surgical therapy used to treat patients foreseen to be at risk for high intracranial pressure (ICP). In this retrospective case control study, mortality, ICP values, neurocritical care (NCC) manage- ment necessity, and long-term neurologic status were examined in patients treated with DC and in a matched control group. Methods: The primary end-points were all-cause mortality and functional status of NCC patients both at discharge and at a 6 month follow-up. Secondary end-points were ICP values at established time points and the use of advanced NCC therapies. Patients who underwent primary DC were matched with individuals with similar demographic and pre-intervention ICP values who had been treated with standard NCC management alone. Results Neurologic status outcome at discharge and the 6 month follow-up was significantly better in patients treated with DC compared to those in the control group: Glasgow Outcome Scale (GOS) 4-5 in 15 versus 5 patients; p = 0.033, and 16 versus 6 patients, p = 0.033. Mortality at 6 months was similar in the study groups (10 versus 16 patients; p = 0.212). ICP values were similar at NCC admission but were better controlled 24 hours after DC than in the control group. Fewer patients treated with DC needed advanced NCC medical therapies. Conclusions: DC is an effective way to normalize ICP levels while reducing the need for aggressive medical therapies. Survival rate and neurological outcome in patients treated with DC were found to be better than in those receiving only medical treatment.

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients’ satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.

The diagnosis of low back pain (LBP) is complex and multifactorial, and a clear etiology responsible for the symptoms is often not detectable. Clinical history and neurological examination are essential for differential diagnosis, because they allow the identification of the specific pathology. The radiological investigation allows to confirm diagnosis, but the indication must always be correlated with clinical findings to not perform unnecessary diagnostic procedures. Management of LBP can involve many specialists – neurosurgeon, orthopedist, physiatrist, physiotherapist – everyone with different knowledge and experience because very often the cause is multifactorial. However, it is mandatory to clarify diagnosis of LBP; in this way, the clinical pathway is fundamental to understand pathogenesis and to determine appropriate treatment.

The cervicothoracic junction (CTJ) is defined as the area extending from vertebral segments C7 to T4. Because most pathological processes occur in the anterior segment of the vertebrae, the anterior approach is usually the best surgical option, allowing neural decompression, stabilization and restoration of anatomical spinal alignment. Nevertheless, it represents a big challenge for the spinal surgeon for the presence of important anatomical structures of the upper mediastinum: manubrium, thymus gland, left and right brachiocephalic veins (or innominate veins), right brachiocephalic artery, left common carotid artery, aortic arc, esophagus, trachea and thoracic duct. Varied approaches to the CTJ have been described in literature [low lateral anterior cervical approach (LACA), full sternotomy, lateral parascapular thoracotomy, clavicular dissection]. Among them, the low LACA combined with manubriotomy is the most used and safe (1).

Management of spinal degenerative deformities always represents a challenge for the spinal surgeon. We report a case of revision surgery for adult scoliosis, focusing of most common errors in pre-surgical management and criteria for reoperation. We analyzed the spino-pelvic parameters on the standing whole-spine X-ray and the role of sagittal balance. To restore 45° of lumbar lordosis, we performed a L3 Pedicle Subtraction Osteotomy (PSO), along with L2-L3 and L3-L4 eXtreme Lateral Interbody Fusion (XLIF). In cases of adult scoliosis, careful preoperative planning is necessary in an attempt to avoid difficult, expensive, and high-risk additional procedures.

Objective Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. Methods We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to 2014. Results 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. Conclusions We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Background The aim of this work is to describe in detail the complex 3-dimensional organization of the white matter of the temporal lobe and discuss the surgical implications of the approaches to lesions located into the mesial temporal region and within the temporal horn and the atrium of the lateral ventricles. Methods Sixteen human cerebral hemispheres fixed in a 10% formalin solution for at least 40 days were studied. After removal of the arachnoid membrane, the hemispheres were frozen at −15°C for at least 14 days, and the Klingler technique, which consists of the microscopic dissection and progressive identification of white matter fibers, was performed. Results The dissection allowed us to appreciate the topographical organization of the white matter of the temporal lobe identifying the most important association, projection, and commissural fasciculi. The dissection from the lateral side allowed the progressive visualization of the superior longitudinal fasciculus and its components, the extreme and external capsule, the uncinate fasciculus, the inferior fronto-occipital fasciculus, the anterior commissure, the internal capsule, and the optic radiations. The dissection was completed from the inferior and medial side for identification of the cingulum and the fornix. Conclusions The complex 3-dimensional organization of the white matter substance of the temporal lobe is characterized by 2 main systems of boundaries: the sagittal stratum and the temporal stem. Their knowledge is essential for the appropriate treatment of pathologies localized in this region as demonstrated by the 2 clinical cases presented in this work.

AIM To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one. METHODS We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability. RESULTS The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring. CONCLUSION Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms “ganglion cyst” to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.

Spinal infections are rare (their incidence is estimated in about the 5% of all osteomyelitis) and severe pathologies. They are usually identified with different names, as disk space infection, spondylodiscitis, and vertebral osteomyelitis. Spondylodiscitis is the most frequent among spinal infections. The etiology might be due to bacteria, fungi, and parasites and might affect many anatomical structures. The reported incidence is increased in the last years.[1,2] The disease can be classified according to the involved anatomical structure: Vertebral osteomyelitis Discitis and spondylodiscitis Spinal canal infections Adjacent soft tissue infections. In adult patients, the terms osteomyelitis and spondylodiscitis can be considered as more appropriate since an isolated discitis is rarely an isolated entity,[3] but in pediatric patients, it can be occasionally found.[4] The diagnosis might be challenging, often causing a delay in the identification of the pathology. On the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of radiological, microbiological, and bioptic examinations.

Objective To analyze outcomes of patients surgically treated for calcified spinal meningiomas and to determine factors associated with surgical morbidity. Methods Between January 2000 and June 2013, a total of 54 patients underwent surgical resection of a spinal meningioma: 37 of these cases showed various degrees of calcification, confirmed by histopathologic analysis. The clinical evaluation was performed according to the American Spinal Injury Association Impairment Scale. At the last follow-up, neurologic status improved in 19 cases and remained unchanged in 20 cases; just 1 case worsened. According to the American Spinal Injury Association Impairment Scale, neurologic status was classified into 3 levels: poor (A + B), fair (C), and good (D + E). Neurologic status improvement (NSI) during postoperative time (considered as a transition from one lower level to the higher) was analyzed in relationship to the patient's age, length of clinical history, spine level, meningioma's position inside the spinal canal, and its degree of calcification. Results A statistically significant relationship between NSI and the degree of ossification of the meningioma was observed. in particular, a direct relationship with microcalcified meningiomas and an inverse relationship with ossified meningiomas. No relationship was observed between NSI and patient's age, length of clinical history, and the site of the lesion into the vertebral canal. Conclusions The univariate analysis confirms that the degree of calcification affects the outcome, because extensive tumor calcification is associated with an increased surgical morbidity probably.

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation.

INTRODUCTION Cervical kyphosis is a progressive cervical sagittal plane deformity that may cause a reduction in the ability to look horizontally, breathing and swallowing difficulties, sense of thoracic oppression and social isolation. Moreover, cervical kyphosis can cause myelopathy due to a direct compression by osteo-articular structures on the spinal cord or to a transitory ischaemic injury. The treatment of choice is surgery. The goals of surgery are: nervous structures decompression, cervical and global sagittal balance correction and vertebral stabilization and fusion. PRESENTATION OF CASE In October 2008 a 35 years old woman underwent surgical removal of a cervical-bulbar ependymoma with C1–C5 laminectomy and a C2–C5 laminoplasty. Five months after surgery, the patient developed a kyphotic posture, with intense neck and scapular girdle pain. The patients had a flexible cervical kyphosis. Therefore, we decided to perform an anterior surgical approach. We performed a corpectomy C4–C5 in order to achieve the anterior decompression; we placed a titanium expansion mesh. DISCUSSION Cervical kyphosis can be flexible or fixed. Some authors have reported the use of anterior surgery only for flexible cervical kyphosis as discectomy and corpectomy. This approach is useful for anterior column load sharing however it is not required for deformity correction. CONCLUSION The anterior approach is a good surgical option in flexible cervical kyphosis. It is of primary importance the sagittal alignment of the cervical spine in order to decompress the nervous structures and to guarantee a long-term stability.

Purpose The aim of the study is to use an algorithm previously published to decide whether to perform open surgery or percutaneous surgery with short fixation in patients with thoraco-lumbar junction and lumbar spine fractures, and to compare retrospectively surgical and conservative options of treatment. Methods Between 2005 and 2009, two groups of 25 patients were analyzed to compare retrospectively surgical and conservative option of treatment to assess perception of pain and to evaluate quality of life during treatment, to evaluate how quickly patients return to work and to their daily activities, to evaluate patients’ satisfaction. X-ray controls were performed to evaluate the fusion rate at 3 and 6 months and CT scans at 6 months. Results The surgical group had a better functional recovery, a better quality of life and returned to work earlier in comparison to the conservative group. Conclusions We can conclude that the percutaneous procedure seems to give better results in terms of satisfaction and return to normal activities, although both procedures guarantee excellent fusion rates.

Objective: cervical spondylotic myelopathy is a progressive degenerative cervical spine disease. During later stages of segmental degeneration, kyphosis of the cervical spine can occur and further compromise the spinal cord and nerve roots. Optimal surgical approach remains controversial. The choice to perform an anterior, posterior or combined approach depends on: sagittal alignment, number of involved levels, main compression localization, and clinical status. The anterior approach is recommended when compression involves primarily anterior horn of spinal cord. Methods: between January 2001 and December 2005, 121 patients (42 F, 79 M, mean age 62 years) were operated for cervical spondylosis (98 myelopathy, 23 radiculopathy). Anterior surgical approach was performed in 81 patients. 63 patients were operated performing multilevel discectomy and fusion (ACDF) and 18 patients performing corpectomy and fusion and anterior plating (ACCF). Preoperative documentation collected consisted of cervical X-ray (static-dynamic), cervical spine TC, cervical MRI. Clinical documentation permitted us to obtained clinical status of each patient based on JOA, NDI and VAS. A Clinical and radiological follow-up was performed at 1 month, 3 months, 1 year, 6 years, 12 years. Results: the fusion rate was calculated based on the static and dynamic X-ray (flexion and extension position), only a little percentage of patients underwent CT scan. There were no significant differences between ACDF and ACCF in clinical outcome at 6 years evaluated by VAS and NDI. The rate of fusion at 6 years for 2 levels ACCF (92%) was higher than that for 2 levels ACDF (86%) but is not statistically significative. Conclusion: classifying degenerative disease and biomechanics feature, preoperatively in necessary to guide the surgeon to choose the best anterior approach for cervical spondylosis.

Awake craniotomy is the technique of choice in patients with brain tumours adjacent to primary and accessory language areas (Broca's and Wernicke's areas). Language testing should be aimed to detect preoperative deficits, to promptly identify the occurrence of new intraoperative impairments and to establish the course of postoperative language status. Aim of this case series is to describe our experience with a dedicated language testing work up to evaluate patients with or at risk for language disturbances undergoing awake craniotomy for brain tumour resection. Pre- and intra operative testing was accomplished with 8 tests. Intraoperative evaluation was accomplished when patients were fully cooperative (Ramsey < 3). Postoperative evaluation was scheduled at early (within 21 days) and long-term follow-up (3–6 months). Twenty consecutive patients were prospectively recruited. Preoperative language testings were normal in 9 patients (45%), showed mild to moderate language deficit in 8 (40%) and seve...

Background context The cervicothoracic junction (CTJ) is always a difficult area for anterior approaches. Among them, low anterior cervical approach alone or combined with manubriotomy is the most frequently used. Purpose To study the need of manubriotomy. Study design/setting Comparison of last guidelines proposed in literature. Patient sample Seven patients treated between March 2010 and March 2011. Methods All the patients were scanned on with computed tomography and magnetic resonance of the spinal column before surgery. Measurements by Teng and Karikari were applied in all the cases. An illustrative case is showed. Results The anterior approaches to the CTJ are reviewed. The most recent guidelines by Teng and Karikari are easy to apply and careful. The results obtained were the same in all the cases with good outcome. Conclusions Manubriotomy permits a good exposure of the CTJ area with a low rate of complications. Either Teng and Karikari's guidelines can be used to estabilish the need of manubriotomy.

Ballism consists of violent flinging limb movements due to nvoluntary, arrhythmic proximal muscles contractions, usually nvolving only upper extremities of one side of the body (hemibalism). The arm is thrown into space and projected forward and ideways with flexion and rotation on its axis. Like the chorea, the emiballism generates phasic discharges and short synchronous otor unit potentials in the agonist muscles without activation of he antagonists. It is generally caused by injuries to the subthalamic ucleus of Luys or, more extensively, to the basal ganglia such as schemic or hemorrhagic infarctions, diencephalic tumors, inflamations and metabolic paraneoplastic syndromes [1]. Hemiballism esponds in part to neuroleptics. Primary or secondary cortical or subcortical brain tumors usully provoke seizures, focal neurological deficits, higher functions mpairments, or headache [2]. Cortical masses responsible for xtrapyramidal symptoms are not known in the literature. Rarely, arge intracranial lesions may cause movement disorders through mechanism of direct mechanical compression or torsion of the asal ganglia [1,2]. Two cases of small convexity meningiomas just bove the pre-motor cortex causing tremors which disappeared fter tumor removal have been reported [3].

Introduction Minimally invasive percutaneous surgery of the spine is used to treat thoracolumbar junction and lumbar spine fractures by percutaneous fixation. Once fusion has been obtained, it is possible to remove the percutaneous instrumentation after 6 - 12 months. We report the case of an obliged removal of the fixation system at 12 months following operation in a patient with a pre-existing compensated and asymptomatic idiopathic scoliosis. Case Presentation A 48-year-old patient affected by a compensated asymptomatic idiopathic scoliosis with an L3 type A3 fracture. The patient underwent a percutaneous short fixation L2 - L4. In the following months the patient presented progressive worsening of the low back pain and walking difficulties. The percutaneous fixation system was then removed using the same surgical access. Conclusions This particular case explains well the importance of biomechanical balance when a spinal fixation should be perform, and demonstrate how an underestimation of this aspect may cause a worsening of symptoms even if the surgical procedure was correctly performed. It is evident that the removal procedure can lead clinical benefit to a patient, in which the fixation system created a decompensation of the curvature of the spine, thus causing biomechanical alterations and generating pain. In these cases, it may be opportune to limit the fracture reduction during the surgical procedure to modify the least possible the pre-existing scoliosis and to increase the patient’s comfort after the operation. The biomechanical behaviour of the spine is specific for each patient so only a careful detection of it could lead to an optimal therapeutic result.

After single or multilevel cervical corpectomy for the treatment of different diseases, many surgical options have been proposed over the years. As a single device, a winged expandable titanium cage (WETC) has been developed. We report the use of this device and our clinical results at 24 months of follow-up in a prospective series of 34 patients who underwent single or multilevel corpectomy for the treatment of cervical spondylosis. Thirty-four consecutive patients underwent single or multilevel cervical corpectomy followed by the insertion of a WETC for the treatment of cervical spondylosis at Department of Neurology and Psychiatry "Sapienza" University of Rome, Italy, from May 2011 to May 2013. Patients affected by cervical spondylosis with cervical lordosis >0° were included. Patients affected by cervical lordosis

Only 25% of patients with Low Back Pain (LBP) have a clear clinical and radiological evidence of a lumbar spine disease and about 30% of patients surgically treated for LBP develop a Failed Back Surgery Syndrome (FBSS). So in the light of this is necessary to ask some questions: is the origins of the LBP always located in the lumbar spine or are there any other pain generators which can provoke it? Why so many patients operated for lumbar disease develop FBSS? Is the FBSS always related to a failure of the procedure or may it be attributable to other causes? The sacroiliitis is responsible for about ¼ of cases of LBP and FBSS. This is due to the fact that the lumbosacral fusion alters the biomechanics of complex sacrum-pelvis causing a joint overload that ends in a real adjacent segment disease. The LBP is a multifactorial condition in which the pain generator must be carefully studied before planning any therapeutic strategy.

Spinal trauma is a very common disease, associated with spinal cord injury in 15-30% of cases. The treatment is affected both from non-modifiable variables (fracture’s morphology and biomechanics of the trauma, fracture site, neurological status, primary or secondary comorbidities) both from modifiable variables (first aid and hospital transportation, supportive therapy, surgical timing etc.). The role of the surgical timing after acute thoraco-lumbar spinal cord injury is still one of the most controversial points actually debated in literature. Surgical treatment is conditioned both by the general conditions of the patient both by the extent of the neurological deficit. In literature are described three possible windows for surgical timing: early surgery , performed in the first 48 hours; intermediate surgery, performed between 48 hours - 7 days; late surgery, performed after 7 days from the injury. In the light of the debatment actually under discussion in literature, the real question is: The implementations of the early surgery have effectively a role in the management of thoraco-lumbar spine injury and, if so, when is mandatory? Actually, based on the literature evidence, is extremely difficult to find a clear indication.

Some specially imaging of magnetic resonance imaging, the diffusion-weighted imaging (DWI), the diffusion tensor imaging and fractional anisotropy (FA), are useful to described, detect, and map the extent of spinal cord lesions. FA measurements may are used to predicting the outcome of patients who have spinal cord lesions. Fiber tracking enable to visualizing the integrity of white matter tracts surrounding some lesions, and this information could be used to formulating a differential diagnosis and planning biopsies or resection. In this article, we will describe the current uses for DWI and fiber tracking and speculate on others in which we believe these techniques will be useful in the future.

The evolution of the surgical treatment of petroclival meningiomas (PMs) has led to a tendency to abandon complex petrous approaches and return to "less-aggressive" skull base approaches.To propose a classification of PMs and establish the role of the combined supra-infratentorial presigmoid retrolabyrinthine (CSIPR) approach in the treatment of PMs rigorously matching the anatomical definition.A retrospective analysis was conducted of 51 cases of PMs strictly adhering to the anatomical definition who were operated on from January 1990 to December 2011. On the basis of the different patterns of growth from a common anatomical region of origin, a classification of PMs in 4 groups is proposed.Gross total resection was achieved in 32 patients (63%) and subtotal resection (at least 90% tumor volume removal) in 14 patients (27%). Each of the 4 groups of the proposed classification lends itself to be removed by a distinct surgical approach. Statistical analysis confirmed that such group-approach pairings significantly correlate with radical surgical removal (P0.001). Despite the high incidence of early postoperative complications, at late follow-up 82% of patients were free of significant postoperative neurological deficits (95% confidence interval: 70-90). Comparable neurological improvement was observed limited to cases treated by CSIPR (P = 0.60).For each PM group, the most suitable approach was identified in terms of surgical radicality and low postoperative morbidity. CSIPR can be considered the approach of choice for the most frequent group of PMs in our series. We believe that the CSIPR remains a valuable option for the treatment of PMs.

The anterior approach is a well-known surgical technique for the treatment of degenerative diseases of the lumbar spine. Through this approach is possible to perform arthrodesis, arthroplasty, discectomy, corpectomy to treat a lot of degenerative conditions. The ALIF procedure is one of the most widely used technique, and is argued to have biomechanical advantages over posterior approaches for lumbar spinal fusion: restoration of disk height and lumbar lordosis, reduction of listhesis, restoring of coronal and sagittal balance.

Over the last few years, some hemocomponents have been used advantageously in clinical neurosurgical practice, not systemically via transfusion but topically as a sealant (fibrin glue). This has diverted the attention of many authors to the role of platelets in the healing process. The combination of hyper-concentrated platelets and fibrin glue (fibrinogen, XIII factor, fibronectin) with activated thrombin produces a platelet gel that can be easily applied to "difficult" wounds. This topical use of hemocomponents has gained an important role in regenerative medicine. The authors have considered the possibility of using a preparation with a high autologous platelet concentration applied in addition to autologous bone during vertebral postero-lateral fusion. The aim of the procedure is to induce a higher rate of vertebral fusion. Between November 2007 and November 2008, 14 patients (9 men and 5 women, mean age 58.9) underwent laminectomy, vertebral stabilization and postero-lateral fusion. The number of vertebral levels involved in stabilization was: 1 in 2 patients, 2 in 5 patients, 3 in 5 patients, 4 in 1 patient and 5 in 1 patient. Platelet gel was obtained by taking 16 ml of peripheral venous blood from the patient. For this procedure two patented test tubes were used for each patient, with a capacity of 8 m each. These make up the REGEN-THT(®) (Thrombocyte Harvesting Tube) system that makes it possible to obtain 8 ml of autologous platelet gel in 40-45 min. The addition of Ca gluconate and ethanol at 95% makes it possible to obtain a preparation of plasma rich in platelets and activated thrombin with a platelet concentration five times superior to the haematic one. The platelet gel is combined with fragments of autologous bone and synthetic bone during surgical operation. To allow a comparative assessment of the degree of fusion achieved with and without application of the platelet preparation in each patient, it was arbitrarily decided to use it in only one half of the operative field. All patients underwent serial CT scans 3 and 6 months after surgery as well as plain X-rays to evaluate bone fusion. The reconstructed CT images, especially in sagittal and axial planes, permitted an evaluation of the degree of vertebral fusion and "bone growth". The fusion rate was calculated measuring the increment of bone density on CT images, by means of an evaluation of the ROI (HU) in the newly formed bone, and comparing bone density within the bone callus formed by autologous and synthetic bone alone in the one to which the platelet preparation had been added. A good rate of fusion was observed in all patients. Furthermore, a comparative analysis of ROI at 3 and 6 months after surgery demonstrated a high increase in the fusion rate during the first 3 months after surgery. After 6 months the differences in ROI between the two sides had balanced out. However, at 6-month follow-up examination, bone density in the half of the surgical field in which platelet gel had been added to autologous-heterologous bone was higher in comparison to the contralateral one. Bony neoformation after posterior-lateral arthrodesis is well-evident 3 months after surgery and usually continues gradually for the following 18-24 months. The autologous platelet preparation used seems to accelerate bony deposition and to promote tissue healing, increasing bone density at the level of posterior-lateral arthrodesis. Moreover, this preparation has low production costs and is easy to apply.

The spinal cord is a very rare location for extra-ventricular neurocytomas. Composed of small round cells with neuronal differentiation, neurocytoma has a particularly favourable prognosis. Long disease-free intervals have been observed in patients who received sub-total removal and radiotherapy. A careful intra-operative frozen section examination is helpful in avoiding excessive surgical tissue disturbance and to identify the best treatment option. To date, eight cases of neurocytoma of the spinal cord have been described. We report three more patients; one with very long survival, and review the published literature for this condition.

Objective To analyze the risk factors of worst outcome associated with moderate head injury. Methods Data on patients with moderate head injury were collected prospectively in 11 Italian neurosurgical units over a period of 18 months. Patients older than 18 years with blunt head injury and at least one Glasgow Coma Scale (GCS) score between 9 and 13 were enrolled. The outcome was determined at 6 months using the Glasgow Outcome Scale. Results We analyzed 315 patients. Initial computed tomographic scans showed a diffuse injury type I or II in 63%, a mass lesion in 35%, and traumatic subarachnoid hemorrhage in 42% of the patients. The risk of progression toward a mass lesion was 23% when the admission computed tomographic scan showed diffuse injury type I or II. An emergency craniotomy was performed in 22% of the patients, delayed surgery was performed in 14%, and both were performed in 25%. A favorable outcome was obtained in 74% of the patients. When the GCS score was 9 or 10, the predictor of worst outcome was a motor GCS score of 4 or lower (odds ratio [OR], 8.08; 95% confidence interval [CI], 1.22-67.35; P = 0.008), but when the GCS score was 11 to 13, the factors associated with worst outcome were neuroworsening (OR, 3.43; 95% CI, 1.45-8.17; P = 0.002), seizures (OR, 7.94; 95% CI, 1.18-64.48; P = 0.02), and medical complications (OR, 4.24; 95% CI, 1.74-10.33; P = 0.0006). Conclusion There is a high percentage of surgery and worsening on computed tomographic scans in patients with moderate head injury. Neuroworsening, seizures, and medical complications as outcome predictors were more strongly associated with a GCS score of 11 to 13, whereas a low motor GCS score was more outcome-related in patients with GCS scores of 9 and 10.

Background Intensive insulin therapy to maintain blood glucose at or below 6.11 mM reduces morbidity and mortality after cardiac surgery and morbidity in medical intensive care unit (ICU) patients. The authors investigated the clinical safety and outcome effects of intensive insulin therapy compared to conventional insulin therapy in patients receiving postoperative intensive care after neurosurgical procedures. Methods In this prospective randomized controlled trial, 483 patients undergoing elective or emergency brain surgery were prospectively and randomly assigned either to intensive insulin therapy (241 patients), receiving insulin titrated to maintain blood glucose levels within the range of 4.44-6.11 mM, or to conventional insulin therapy (242 patients), receiving insulin to maintain blood glucose levels below 11.94 mM. Primary endpoint was incidence of hypoglycemia (defined as blood glucose < 2.78 mM). Efficacy measures included the length of ICU stay, infection rate, and 6 months follow-up Glasgow outcome scale score and overall survival. Results Hypoglycemia episodes were more frequent in patients receiving intensive insulin therapy, median (min-max): 8 (0-23) versus 3 (0-4); P < 0.0001. The length of stay in the ICU was shorter (6 vs. 8 days; P = 0.0001), and the infection rate was lower (25.7% vs. 39.3%; P = 0.0018). Glasgow outcome scale score and overall survival at 6 months were similar in the two groups. Conclusions Intensive insulin therapy in patients admitted to a postoperative neurosurgical ICU after brain surgery is associated with iatrogenic hypoglycemia, but it can also reduce the infection rate and shorten the ICU stay.

OBJECTIVE: This preliminary study considers the feasibility and the results of anterior screw fixation in elderly patients with remote Type II axis fractures. Odontoid fractures are the most common fractures of the cervical spine in people 70 years of age or older. In developing countries, direct anterior fracture fixation is replacing posterior fusion in many cases. Recently, it has been demonstrated that patient age does not influence the outcome in terms of fusion after odontoid screw fixation. There is considerable disagreement about correct treatment in the case of remote fractures. In the literature, there have been no studies considering the feasibility and results of anterior screw fixation in elderly patients with remote Type II axis fractures. METHODS: From 1989 to 2005, we observed 9 patients over the age of 65 years with isolated Type II remote fractures of the dens. All fractures were considered to be inveterate, as the traumatic events had occurred 6 to 12 months earlier. All fractures were treated with anterior infibulation of the dens with single 3.5-mm cannulated screws. RESULTS: A bony fusion was radiologically documented in 7 patients (77%) 4 to 16 months after the intervention. In 1 patient, a fibrous union was observed. The neurological status remained unchanged in all patients, and no patients showed any neurological impairment at the time of follow-up. CONCLUSION: According to our preliminary study, the technique appears to be feasible for remote axis fractures within 12 months of trauma, and it seems to be safe for elderly patients. Further data from additional studies are needed.

Microsurgical training is mandatory for the optimal education of modern neurosurgeons. Even though this is a widely acknowledged statement and a lot of institutions around the world practice training in laboratory, the recent literature lacks tip and tricks on how to start a laboratory from scratch, what would be a convenient anesthesia, and what kind of exercises are appropriate. We present our experience in 16 microsurgical training courses settled up at our institutions. Two hundred eleven rodents were dissected. We will describe the organization of the laboratory and of the training courses and we will discuss its practical impact on the residency program.

To investigate whether esmolol is effective in attenuating postoperative hemodynamic changes related to sympathetic overdrive.Clinical study.Operating room of a university hospital.60 ASA physical status I, II, and III patients, age 18 to 65 years, scheduled for elective craniotomy for supratentorial neurosurgery.Patients were given total intravenous anesthesia (TIVA) during emergence from anesthesia and up to 60 minutes after extubation. Those patients who had hypertension (defined as an increase in systolic blood pressure20% from baseline values) and tachycardia (defined as an increase20% in heart rate from baseline) received a loading dose of 500 microg/kg esmolol in one minute, followed by an infusion titrated stepwise (50, 100, 200, and 300 microg/kg per min) every two minutes.The mean dose and duration of esmolol therapy were measured.Of 60 patients, 49 (82%) who received propofol-remifentanil TIVA developed significant tachycardia and hypertension soon after extubation. Treatment with esmolol (500 microg/kg in bolus maintained at a mean rate of 200 +/- 50 microg/kg per min) effectively controlled hypertension and tachycardia in 45 of 49 patients (92%; P0.05) within a mean 4.30 +/- 2.20 minutes. After extubation, mean esmolol infusion time was 29 +/- 8 minutes.In patients undergoing elective neurosurgery with propofol-remifentanil TIVA, a relatively small esmolol dose and short infusion time effectively blunts early postoperative arterial hypertension and tachycardia.

The authors report their personal experience with a surgical series of 16 cases of cerebral radiation-induced gliomas, defining diagnostic criteria and surgical and clinical characteristics. There were ten males and six females, with a median age of 45.9 years. Irradiation had initially been given for acute lymphoblastic leukemia (ALL) in six cases, tinea capitis in four cases, scalp hemangioma in three cases, cutaneous hemangioma, cavernous angioma, and medulloblastoma in one case each. There were 14 cases of glioblastoma (grade IV WHO) and 2 cases of astrocytoma (grade II WHO), with a mean latency time of 17 years (range: 6-26 years). For glioblastomas mean survival time was 10.4 months, accounting for 1-3% of all the glioblastomas treated. A thorough revision of the pertinent literature revealed some clinical-biological peculiarities.