Search

Pyogenic vertebral osteomyelitis (PVO) is still a rare pathology. However, its incidence is on the rise. This is due to an increasing population with predisposing factors. Also, the availability of more effective diagnostic tools has brought it increasingly to the surgeon’s attention. In this study the patients were treated in the Neurosurgery Division of the Department of Neurological Sciences and Psychiatry of the Sapienza University of Rome, between 2001 and 2009. They had thoracolumbar pyogenic spondylitis. This study was undertaken in order to identify the correct diagnostic and therapeutic treatment needed in such cases. From the cases studied here, it is evident that spinal infections can be extremely insidious and that diagnosis tends to be reached late. Surgery, along with the antibiotic treatment, allows for eradication of the causes of the pathology by the reclamation of the affected region. Surgery is also fundamental in helping to recover vital functions and in restoring as much as possible the correct curvature of the rachises. The use of an anterolateral approach is dictated by the necessity of obtaining 360° stability as well as by the need to clear away extensive infections, which are not always reachable using a posterior approach.

Abstract Ischemia of the basal ganglia as an immediate consequence of minor head injury in children is rare (< 2% of all ischemic stroke in childhood) and is due to vasospasm of the lenticulostriate arteries. The clinical history of these lesions is particularly favourable because they are usually small, and also because the facial-brachial-crural hemiparesis typical of this pathology usually regresses after a period ranging from several weeks to several months, despite the persistence of an ischemic area on MRI. This is due to the well known neuronal plasticity of the CNS, in particular, of the primary motor cortex. The most effective therapeutic approach appears to be the conservative one, although the best treatment regimen is still not well defined. Young patients should be closely monitored and treated conservatively with osmotic diuretics to reduce perilesional edema. At the same time, however, it is very important to exclude, by means of instrumental and laboratory studies, conditions that could favour the onset of ischemia, including emboligen heart disease, thrombophilia and acute traumatic arterial dissections. Generally speaking, the prognosis in these cases is good. The authors describe their experience treating a 10-month old baby girl, with a left lenticular nucleus ischemia and report a literature review.

Abstract Background There are several non-neoplastic lesions which mimick intramedullary spinal cord neoplasm in their radiographic and clinical presentation. These can be classified as either infectious (TB, fungal, bacterial, parasytic, syphilis, CMV, HSV) and non-infectious (sarcoid, MS, myelitis, ADEM, SLE) inflammatory lesions, idiopathic necrotizing myelopathy, unusual vascular lesions and radiation myelopathy. Although biopsy may be indicated in many cases, an erroneous diagnosis of intramedullary neoplasm can often be eliminated pre-operatively. Case description the authors report a very rare case of intramedullary non-specific inflammatory lesion of unknown origin, without signs of infection or demyelinization, in a woman who showed no other evidence of systemic disease. Conclusions Intramedullary lesions that mimick a tumor can be various and difficult to interpret. Preoperative MRI does not allow a certain diagnosis because these lesions have a very similar signal intensity pattern. Specific tests for infective pathologies are useful for diagnosis, but histological examination is essential for establishing a certain diagnosis. In our case the final histological examination and the specific tests that we performed have not cleared our doubts regarding the nature of the lesion that remains controversial.

Abstract Background Paragangliomas affecting the filum terminale are extremely rare, benign tumors. The literature yielded thirty-two cases of paraganglioma in this site. Case presentation A 49 year-old-man, whose presenting symptoms were low back pain and left leg weakness, was diagnosed as having a paraganglioma of the filum terminale. The clinical, histological and radiological characteristics of this case, that brings the total number of cases described to 33, are discussed in the light of published data. Conclusions This extremely rare pathology can usually be successfully treated by total surgical resection, which represents the gold standard. In the event of incomplete removal, assiduous long-term follow-up is mandatory.

Purpose: To evaluate the impact of pelvic balance, physical activity, and fear-avoidance in a cohort of patients undergoing decompression and instrumented fusion for degenerative lumbar stenosis.Materials and Methods: This study includes consecutive patients undergoing decompression and instrumented fusion for degenerative lumbar stenosis by one main surgeon from January 2014 to January 2015. Patients were interviewed by a psychologist and underwent standing whole spine X-ray. Lumbar and pelvic parameters (PI, SS, PT, iPT, LL) were measured by an independent spinal surgeon. Physical activity was measured with the International Physical Activity Questionnaire (IPAQ). The "fear-avoidance" was measured with the Tampa Scale for Kinesiophobia (TSK). Back pain was assessed by the Graphic Rating Scale (GRS). The disability was assessed by the Roland-Morris Low Back Pain and Disability Questionnaire. Statistical interpretation of the data was performed using SPSS v19 software (SPSS Inc, Chicago, Illinois).Results: The sample included 51 patients underwent standard posterior laminectomy and instrumented fusion. Surgery has a positive global impact on the perceived low back pain. No significant (Spearman) correlations emerged among pelvic parameters and the pre- and post-surgical GSR. Patients were divided into three groups according to the IPAQ scores after the operation: "inactive" (I), "minimally inactive" (m-I), and "HEPA". Significant differences emerged between IPAQ and Roland-Morris scores (F(2, 48) = 5.48, p = 0.007): the "inactive" (M(R-M) = 11.3) or "minimally active" (M(R-M) = 9.8) groups scored significantly higher than the "HEPA" group (M(R-M) = 4.7). Tampa scores correlated with gender (rho = -0.408, p = 0.003) and with BMI (rho = -0.369, p = 0.008). Females and obese patients reported higher levels of Tampa scores. Significant relationship was found between Tampa scores and pre-GSR (rho(pre) = 0.250, p = 0.08) and significant with post-surgical GSR (rho(post) = 0.275, p = 0.05) and with post-Roland-Morris score (rho(post) = 0.599, p < 0.01).Conclusion: The fear-avoidance and the physical inactivity are related to the highest levels of low back pain, more than pelvic imbalance. "Inactive" and "fear-avoidant" patients have also the worst outcome after surgery and the worst level of disability. [ABSTRACT FROM AUTHOR]

Purpose: The stage of unstable dysfunction, also defined as "active discopathy" by Nguyen in 2015 and configuring the first phase of the degenerative cascade described by Kirkaldy-Willis, has specific pathoanatomical and clinical characteristics (low back pain) in the interested vertebral segment, without the presence of spondylolisthesis in flexion-extension radiography. This clinical condition has been defined as "microinstability" (MI). The term has currently not been recognized by the scientific community and is subject of debate for its diagnostic challenge. MI indicates a clinical condition in which the patient has a degeneration of the lumbar spine, causing low back pain, and radiological examinations do not show a spondylolisthesis.Methods: We elaborated a clinical score test based on preoperative radiological examinations (static and dynamic X-Rays, CT and MRI) to detect and assess MI. Then, we enrolled 74 patients, all the levels from L1 to S1 were analysed, for a total amount of 370 retrospectively analysed levels. We excluded patients with degenerative scoliosis, as it is related to an advanced stage of degeneration. The test has been developed with the aim of furnishing quantitative data on the basis of the aforementioned radiological examinations and of elaborating a diagnosis and a treatment for the degenerative pathology in dysfunctional phase, responsible for low back pain.Results: We performed a statistical analysis on the results obtained from the test in terms of significativity and predictive value with a 1-year follow-up, calculating the p value and the χ (2) value.Conclusions: In patients with low back pain and negative dynamic X-Rays, an accurate analysis of the radiological exams (CT, MRI, X-Rays) allows to formulate a diagnosis of suspect MI with a good predictive value. This situation opens many clinical and medicolegal scenarios. The preliminary results seem to validate the test with a good predictive value, especially towards ASD, but they need further studies. On the basis of the results obtained, the test seems to allow a good classification of the dysfunctional phase of the degenerative cascade, identifying and classifying MI as a pathologic entity, defining its pathoanatomical and clinical relevance and elaborating a treatment algorithm. [ABSTRACT FROM AUTHOR]

Spinal synovial cysts are cystic dilatations of the synovial membrane that may arise at all levels of the spine. We describe our experience, paying attention to diagnosis, surgical treatment, and long-term follow-up. Between 1995 and 2007, 18 patients were surgically treated. Of these, three patients were excluded from the study because they presented spinal instability at pre-operative assessment. All patients were evaluated pre-operatively with CT, MRI, and dynamic X-rays, and underwent surgery for removal of the cyst by hemilaminectomy and partial arthrectomy. All patients were evaluated with early MRI and had a minimum 2-year follow-up by dynamic X-rays. None of the patients required instrumented fusion due to the absence of radiological signs of instability on the pre-operative dynamic tests. In all patients, there was an immediate resolution of the symptoms, with evidence of complete removal of the cysts on post-operative MRI. At 2-year follow-up, all patients underwent dynamic X-rays and responded to a questionnaire for evaluation of outcome. None of them showed signs of relapse. The gold standard for treatment is surgery, even though other conservative treatment regimens have been proposed. Correct surgical strategy relies on pre-operative assessment of biomechanical stability for deciding whether patients need instrumented fusion during cyst removal. Patients with no instability signs are suitable for hemilaminectomy with partial arthrectomy, preserving 2/3 of the medial portion of the articular facet, because this represents a valid option of treatment with a low risk of complications and a low rate of relapse. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]