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INTRODUCTION: Malignant tumors of anterior skull base represent a surgical challenge because of their anatomical location, the necessity of achieving negative margins, and the often-cosmetically disfiguring transfacial approaches needed. Recently, expanded endonasal endoscopic approaches (EEEA) have been developed, either alone or combined with transcranial approaches for treatment of these malignant lesions. We report our experience to illustrate the relative safety and effectiveness of the EEEA for skull base malignancies alone or combined when possible with minimally invasive approaches or traditional surgery. METHODS: From June 2009, 13 patients harbouring malignant neoplastic lesions of anterior skull base were treated at our department. Four patients affected by sinonasal malignancies with extension in anterior cranial fossa underwent to combined open subfrontal or minimally invasive supra orbital approach and EEEA. In 2 patients with respectively esthesioneuroblastoma and maxillary sinus squamous cell carcinoma a combined supraorbital key-hole craniotomy and EEEA were perfomed. Seven clival metastases with VI cranial nerve palsy were approached by the EEEA supplemented by neuronavigation. RESULTS: Gross total removal was performed in 9 out of 13 patients. In the other cases partial resection, but with adequate decompression and diagnosis were achieved. There were no mortality, 1 patient had infection and 1 deep vein thrombosis. CONCLUSIONS: In our experience EEEA are an integral part of the neurosurgical armamentarium for the treatment of the skull base malignancies. In properly selected cases, it affords similar oncologic outcomes with lower morbidity than traditional open approaches. The major potential advantage of the EEEA approach is direct “natural” anatomical route to the lesion without traversing any major neurovascular structures, so obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an antero-medial approach. The complementary information provided by endoscopy can assist the surgeon in safely extend the approach maximizing the extent of resection and decompression in hidden angles. Nonetheless, these minimal access approaches should be considered a complement to well-established open approaches, which are still necessary in most advanced tumors.

The objective of this retrospective study is to evaluate how neck pain is influenced by post-operative cervical alignment in patients operated for cervical spinal trauma.From January 2013 to June 2017, at our department we operated 34 patients with cervical spinal trauma, 22 males and 12 females. Age, sex, level and type of fractures, surgical approach, fixation levels (cervical or cervico-dorsal), preoperative and postoperative CT scan, cervical (C2-C7) Cobb angle (lordotic+10°, straight 0 /+10°, kyphotic0°) at X-rays on sitting position 3 months after surgery, postoperative self-reported neck stiffness scale, preoperative and follow-up ASIA score, pre and postoperative VAS value were evaluated for each patient. Statistical analysis was performed according to the Mann-Whitney and T-test.In this series, 22 patients were operated by anterior approach, 7 patients by posterior approach and 5 by combined approach. Postoperative chronic cervical pain was not correlated with cervical sagittal alignment after surgery, fracture type, surgical approach, fixation level and postoperative ASIA score but is correlated with the presence of neck stiffness (P=0,001). Patients treated with posterior approach (P=0,022) and fracture type C (P=0,026) had higher significantly neck stiffness compared to patients who underwent anterior approach for type B fractures.The presence of abnormal cervical lordosis after surgery for cervical spinal trauma does not correlate with neck pain. Patients treated with posterior fixation had higher neck stiffness and related chronic pain.

INTRODUCTION: Thanks to the increasing life expectancy and to the improvements made in the treatment of systemic diseases and cancer, combined with advancements in imaging technology, the incidence of spinal tumors has greatly increased in the elderly population. Metastases constitute the majority of lesions, while benign tumors accounts for 25-30% of all spinal neoplasms. The hesitation in performing spinal surgery in aged people is related to the greater likelihood of intra and post-operative complications. Despite this concrete risk, the need for histological diagnosis, root and/or spinal cord decompression, pain relief and improvement of quality of life make surgery quite often a necessary option for this cohort. The primary goal of surgery depends on Histology and tumor extension, but the best surgical result should be faced with the minimal invasiveness, in order to decrease the possible spinal instability and postoperative morbidity and mortality. MATERIALS AND METHODS: We report a series of 70 patients, aged 70 years or more, treated by minimally invasive approach from 2008 to 2013. Forty patients harboured spinal bone metastases, 30 patients benign extramedullary lesions, mainly meningiomas. Surgery was performed to achieve diagnosis and/or decompression of neurological structures; the additional aim for benign lesions was total resection and the further surgical indication for spinal metastases was pain relief. RESULTS: Mono or multisegmental hemilaminectomy in order to preserve the spinal stability was performed in all cases of meningiomas, with gross total removal in 28 patients and subtotal resection in 2 patients. Laminectomy and/or vertebroplasty were performed in the 30% of metastatic cases, followed by internal fixation with screws and rods in the majority of cases in order to reduce back pain primary due to spinal instability. Although this last procedure is not intrinsically minimal invasive, it was performed considering the minimally invasive attitude. Improvement of neurological deficits was achieved in 90% of patients with benign lesions and in the 38 % of spinal metastatic group. In this last group pain relief was also reached in 55% of patients. The rate of mortality, major morbidity and postoperative quality of life was comparable to that of the younger patients. CONCLUSIONS: Until the previous decade, age itself represented quite often a contraindication for surgery, particularly because of the presumed high risk of postoperative morbidity and mortality. Nowadays, planning a tailored anesthetic protocol, surgical strategy and meticulous postoperative assistance, surgical treatment can be offered to this cohort of patients, because their quality of life, referring to neurological deficits and pain, can be greatly improved in the vast majority of cases.