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Background: In the last decade, application of the high-definition exoscope to different neurosurgical procedures has been reported in the literature. We described the first experience with the VITOM ® -3D (Video Telescope Operating Microscope, Karl Storz Endoscopy, Tuttlingen, Germany) for the surgical treatment of intradural extra-medullary tumors., Methods: Five neurosurgical procedures for the removal of intradural extra-medullary tumors were performed with the VITOM ® -3D. Patients' population, feasibility of surgery under the exoscope visualization, VITOM ® -3D's technical and optical characteristics, and surgical outcome were analyzed., Results: All surgeries were performed following the common steps of spinal neurosurgical intradural procedures. The exoscope offered excellent, magnified, and brilliantly illuminated high-definition images of the surgical field in all the described cases. All the reported surgical operations were successfully completed under exoscope magnification from both the technical as well as the clinical points of view. No complications potentially related to the use of the exoscope occurred. Working environment ergonomics and trainees learning experience were the most relevant benefits associated with the use of exoscope., Conclusions: VITOM ® -3D may represent a valid visualization tool in spinal procedure for intradural extra-medullary tumors. Our preliminary experience can be useful in better define the role of VITOM ® -3D in neurosurgery.

Context: Chordomas are rare primary tumors of bone characterized by local aggressiveness and poor prognosis. The surgical exeresis plays a critical role for their management. Objective: The aim was to provide an overview of the surgical management of chordomas of the mobile spine and sacrum, describing the most common surgical approaches, the role of surgical margins, the difficulties of en block resection, the outcomes of surgery, the recurrence rate and the use of associated therapies. Methods: We performed a systematic search using the keywords "chordoma" in combination with "surgery", "spine", "sacrum" and "radiotherapy". Results: Fifty-eight studies, describing 1359 patients with diagnosis of chordoma were retrieved. 17 studies were performed on subjects with cervical chordomas and 49 focused on patients with sacrococcygeal chordomas. The remaining studies included patients with chordomas in cranial region and/or mobile spine and/or sacroccygeal region. The recurrence rate ranged from 25% to 60% for cervical chordomas, and from 18% to 89% for sacrococcygeal chordomas. Conclusion: Despite the remarkable advances in the local management of chordoma performed in the last decades, the current results of surgery alone are still unsatisfactory. The radical en bloc excision of tumour is technically demanding, particularly in the cervical spine. Although radical surgery must still be considered the gold standard for the management of chordomas, a multidisciplinary approach is required to improve the local control of the disease in patients who undergo both radical and non-radical surgery. Adjuvant radiation therapy increases the continuous disease-free survival and the local recurrence-free survival. Level of evidence: Systematic review; level III.

Introduction: Multiple Myeloma (MM) typically involves the spine and causes bone pain, pathological fractures and spinal cord compression with possible consequent neurological deficits. This retrospective study reports the results of surgery on a selected population of patients who underwent surgery for symptomatic spinal myeloma., Materials and Methods: A total of 26 patients who underwent surgery for spinal myeloma with neurological involvement were studied retrospectively. Neurological evaluation was performed according to the Frankel grade. Characteristics of this population, reconstructive techniques and surgery-related complications were reviewed., Results: The tumours involved the thoracic spine in 13 patients, the lumbar spine in 10 patients, and the cervical spine in three patients. The most common approach was a posterior-only approach (70%), followed by a staged, combined approach (20%), and an anterior-only approach (10%). The mean postoperative survival time was 43 months (range: 8-60 months). A significant improvement in neurological function was observed in the study population after surgery (p=0.001). There were seven early postoperative complications, two late complications and five surgery-related complications., Discussion: Surgery in selected patients affected by spinal myeloma with neurological involvement is associated with good clinical outcomes and neurological recovery and an acceptable rate of complications. Neurological deficit and segmental instability can be treated sufficiently in most cases by the implementation of a posterior-only approach; however, the final treatment should, when possible, include adjuvant chemotherapy and radiotherapy and rigorous bracing., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Although many patients with cervical spine metastases are treated surgically, it is unknown whether certain subsets achieve better pain relief and improvement of neurologic function., Questions/purposes: (1) Does tumor removal with reconstruction improve the neurologic status? (2) Is any subset of patients more likely to have neurological recovery from palliative surgery? (3) What is the rate of surgery-related complications?, Patients and Methods: We retrospectively reviewed 46 patients who had palliative surgery for metastatic solid tumor metastases of the subaxial cervical spine. Indications were neurologic deficits, life expectancy longer than 6 months, and a Karnofsky Performance Score of 50 to 70. Surgery consisted of anterior tumor removal and reconstruction with titanium mesh cages and/or tricortical iliac crest allograft plus plate fixation or of a combined procedure with adjunctive posterior decompression and stabilization with lateral mass screw fixation. Postoperatively, neurologic Frankel score grade, Karnofsky Performance Score, and complications were recorded., Results: Five of 18 nonambulatory patients (Frankel B/C) became ambulatory again (Frankel D). No patients were Frankel Grade E preoperatively, whereas 19 of 46 gained Frankel Grade E after surgery. One patient worsened neurologically and died 4 months after surgery. Patients with neoplastic pachymeningitis had less neurologic recovery than those without. Complications included dural tears (three), wound infection (three), and tumor relapse at the same or an adjacent level (four). Two of these four patients had instrumentation-related complications., Conclusions: Surgery improved clinical and neurologic status according to Frankel score; patients with neoplastic pachymeningitis are likely to experience less neurologic recovery., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Study Design: A case report and literature review of the treatment of "noncommunicating" syringomyelia. OBJECTIVE.: The aim of this report is to document the timing and the treatment of hydromyelia holocord after surgical treatment for both tethering and retethering of spinal lipoma., Summary of Background Data: Syringomyelia associated with spinal lipoma presents a different pathogenesis and treatment in comparison to the "communicating" hydromyelia in the myelomeningocele. After the primary retethering operation performed in symptomatic patients, recurrent retethering can occur with an increase of the syringomyelia signs and symptoms., Methods: Syringomyelia treated with a thin silastic tube passed from the syrinx to the subarachnoidal space for drainage and decompression. Prior operations were: (1) initial untethering at birth, (2) second untethering at 5 years of age, (3) posterior fossa and cervical decompression., Results: Magnetic resonance imaging 6 months post shunt operation demonstrated decompression of the hydromyelia holocord and syringobulbia with improvement of motor function of the legs and improvement in sensory symptoms., Conclusion: Usefulness of syrinx-subarachnoidal shunt is demonstrated in this case report after unsuccessful decompression and detethering. When the enlargement of the ependymal channel is greater than 50% of the spinal cord's diameter, neurologic, and urological symptoms are evident and the patient benefitted from cord untethering and syrinx drainage. (1) The terminal "noncommunicating" syringomyelia in lumbar sacral lipoma has been reported to be associated with retethering in spinal lipoma in the 25% of the cases. (2) The rise of distal syringomyelia isn't only linked to the kind of the spinal lipoma, but also to the difficulty to obtain the untethering and a smooth cerebrospinal fluid flow between the subarachnoidal space and the ependymal canal. (3) In patients with hydromyelia holocord greater than the 50% of the spinal cord's diameter a myelotomy and insert an ependymal channel/syrinx to the subarachnoidal space shunt can resolve of the syrinx. In this case, the enlargement of the ependymal channel in "noncommunicating" syringomyelia associated with lumbosacral lipoma is greater than 50% of the spinal cord's diameter; neurologic and urological symptoms occurred and the patient benefited from cord untethering and concurrent syrinx drainage.

In patients with thoracolumbar spine metastasis, surgery is aimed at patient healing only when patient has a good prognosis with long life expectancy. In patients with short life expectancy a less aggressive surgical approach of posterior decompression and stabilization could improve patient care and allow for neurological recovery. Thirty-two consecutive patients affected by symptomatic thoracolumbar spine metastases with short life expectancy and good Karnofsky index (50-70) were subjected to surgery and reviewed retrospectively. After tumor embolization, surgery consisted of posterior decompression and stabilization with laminar hooks in the dorsal spine, and laminar hooks or lumbar pedicle screws. Patient's Karnofsky Index, average survival, Frankel neurological status, and pain were recorded before and after surgery, together with surgery related complications. Primary tumors were breast carcinoma (nine patients), renal cell carcinoma (three), lung carcinoma (four), GI tract carcinoma (six), prostate carcinoma (two), carcinoma of the uterus (two), melanoma (three), and malignant tumors at other different sites (three). Average survival after surgery was 23 months, with highest survival rates in renal cancer and breast carcinoma patients, and poorest survival rates in lung and dedifferentiated carcinoma. Karnofsky index improved from average 61 to 72% post-operatively. After surgery patients experienced significant overall improvement of Frankel score and decrease of referred pain. Hospitalization stay was on average 10 days. Results showed that operative treatment of symptomatic spinal metastases in patients with poor prognosis and good general health status improves or preserves neurological function, allows for adjuvant treatments to be performed and has a role in improving general health status in most patients.

Primary melanoma of the central nervous system (CNS) is rare and primary spinal melanoma (PSM) is even more unusual. Preoperative diagnosis of melanocytic lesion as a PSM is difficult, because of the heterogeneous magnetic resonance (MR) signal intensity, due to hemorrhagic foci and melanin deposits. We describe the case of a 68 year-old male with a MR showing at Th8-Th9 level a well-defined intramedullary lesion; for the characteristics of hemorrhagic signal on MR and its association with a presumptive brain cavernoma, a preoperative diagnosis of intramedullary cavernous angioma was suspected. Pathological examination revealed a melanoma, and for the absence of other localizations outside the spinal cord, a diagnosis of primary spinal melanoma was established. The growth of PSM is slower and survival is longer than in the most common spinal metastasis from skin melanoma. Patients who undergo surgical excision, alone or associated with additional treatments, often show a long survival. We report this case to underline the importance and difficulties concerning the preoperative diagnosis of a hemorrhagic intramedullary lesion.

On the experience of 73 patients, the authors state their guidelines on the treatment of bone metastases on the cervical spine. Most of the cases on which no vertebral collapse occur neither neurological deficit, radiation therapy and external support are suggested. Surgery is necessary on case of severe bone destruction, collapse with or without subsequent neurological impairment. Anterior excision is considered the best approach, sometimes complemented by posterior stabilisation.