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Twenty-three patients affected by severe, refractory angina were submitted to permanent spinal cord stimulation (SCS) and then followed in our outpatient clinic for 24 months. During the follow-up period, the number of weekly angina episodes drastically dropped from 9.2 (preimplant) to 1.8 in the 3rd, 2.5 in the 6th, 4.5 in the 12th, and 4.2 in the 24th month, with a statistically significant difference (P < 0.01) between the first and last values. A significant increase in the average exercise time from 320 +/- 120 seconds (in baseline condition) to 410 +/- 115 seconds (during SCS) was observed at the treadmill stress test (P < 0.01). SGS was well tolerated by all the patients. However, 7 patients died during follow-up (3 myocardial infarctions, 2 noncardiac deaths, and 2 sudden deaths). Three generators were replaced because of battery depletion after 15, 17, and 21 months. No serious complication was observed. In conclusion, in patients with otherwise intractable angina or already submitted to myocardial revascularization, SCS is very effective in reducing the number of angina episodes. The time of the work during exercise stress test is also significantly prolonged. [ABSTRACT FROM AUTHOR]

To determine differences in clinical outcomes in patients harboring both cubital tunnel syndrome (CuTS) and cervical radiculopathy and the influence of the so-called double crush syndrome. Both procedures were performed in 24 patients, mean age 55 years; first group of 14 patients underwent CuTS surgery as a first procedure. Second group of 10 patients underwent anterior cervical discectomy and fusion (ACDF) then ulnar nerve release (UNR). Two patients underwent bilateral nerve surgery and six multiple cervical discectomies. Surgeries consisted in 26 nerve releases with associated external neurolysis in five, and 34 ACDF procedures, with plating in six. Clinical complaints (mean time 12 months) were sensory in 20 arms, with associated motor weakness and hypothenar atrophy involvement in another six. Electromyography changes were mild (two arms), moderate (16 arms), and severe (eight arms). Mean time of follow-up was 3 years (range 18 months-14 years). Clinical improvement was evidenced in 14 patients. Sensory nerve symptoms improved in 13 limbs in both groups and motor improvement was evident in three patients with UNR as first surgery. A comparative cohort of 20 patients with UNR but without cervical radiculopathy was studied to disclose outcome differences. Of these, 13 patients had clinical improvement. No differences were found among groups. In patients with double crush syndrome, factors that seemed to influence a poor CuTS outcome were evolution of symptoms longer than a year, history of multiple neuropathies or radiculopathies, and ACDF performed before UNR.

Object: Olfactory groove meningiomas arise in the midline along the dura of the cribriform plate and may reach a large size before producing symptoms. We conducted a retrospective study of patients with these lesions focused on pre- and post-operative investigations for ophthalmological, personality and cognitive disturbances., Methods: The authors reviewed 36 patients with giant olfactory groove meningiomas surgically treated via a bifrontal approach. Ophthalmological evaluation included visual acuity, fundoscopy and visual fields while psychological evaluation included a Mini-Mental State Examination. Data was collected before, 1 and 12 months after surgery. Formal pre- and post-operative ophthalmological examinations discovered visual deficits in 55.5% of the patients. Within the first month after surgery, improvement of visual acuity and of visual field deficits was observed. In post-operative neuropsychological testing, higher mental functions showed improvement. The most frequent post-operative complication was persistent rhinorrhoea in two patients., Conclusions: Results at longest follow up indicate that cognitive changes and visual deficits will improve in patients with giant olfactory groove meningiomas after a bifrontal approach, without additional neurological deficits.

Tension pneumocephalus is a rare form of pneumocephalus in which the air is under pressure; it is generally due to communication between the atmosphere and the intracranial cavity, and is an infrequent (0.88%) complication of cranial trauma. Tension pneumocephalus causes an increase in intracranial pressure with deterioration of the neurological situation and requires emergency treatment. Endoscopic surgery of the paranasal sinuses, which is generally applied in the diagnosis and treatment of fistulas with cerebrospinal fluid leakage, was here used to treat a case of pneumocephalus due to cranio-ethmoidal communication, in a patient we had treated previously for severe cranio-facial trauma.

The differential diagnosis of anteromedial knee pain is extensive and can be associated with meniscal tear, medial collateral ligament sprain, or pes anserinus bursitis. An association between knee pain and a peripheral nerve sheath tumor has rarely been reported. The authors describe the case of a 44-year-old man with a saphenous nerve schwannoma who presented with vague pain in the medial aspect of his knee mimicking the clinical presentation of a meniscal tear.

Objective: In the last years the use of interbody fusion devices with an anterior spinal lumbar approach has become a common procedure for the treatment of degenerative disc disease and spinal instability. We analysed our series of a simplified endoscopic approach to the anterior spine and made a review of the retroperitoneal endoscopically assisted approach to the anterior lumbar spine in the international literature., Methods and Results: From 1999 through 2002, twenty consecutive "balloon-assisted endoscopic retroperitoneal gasless (BERG)" lumbar fusions were performed at San Filippo Neri Hospital in Rome, Italy. The surgical indications included patients with grade I or II spondylolisthesis and symptomatic degenerative disc disease with foraminal stenosis. Fourteen patients underwent a single level fusion (4 cases at L4-L5; 10 cases at L5-S1) and six patients underwent a double level fusion (L4-L5 and L5-S1). Mean operating time was 135 minutes (single level fusion), 175 minutes (double level fusion) and the mean intraoperative blood loss was 177 mL. No perioperative complications were observed and no procedure was converted to open surgical fusion. Patients were allowed to ambulate on the second postoperative day. Fusion was achieved in nineteen patients (fusion rate of 95%) 12 months after surgery., Conclusions: The BERG technique is a safe, effective, simplified, less technically demanding alternative approach when performing ALIF procedures, without the morbidity associated with laparoscopic or traditional approaches.

Pure intramedullary spinal-cord metastases (ISCM) are a rare manifestation of cancer. We report a case of ISCM from gastric cancer. A 68-year-old man, treated with total gastrectomy for a gastric cancer, presented 9 months later with paresis of the left arm, pain and dissociated sensory loss. Magnetic resonance imaging revealed a pure intramedullary lesion at the C3-C5 level. After surgical resection, pathological findings revealed an undifferentiated adenocarcinoma of gastric origin. To our knowledge, this is only the second report of ISCM from gastric cancer in the literature.

Background: The sporadic finding of an acoustic intrameatal meningioma stimulated the authors to the present study. An analysis of the cases previously reported in the literature aimed to outline a preliminary account about biological, radiological and surgical specific hallmarks of these tumours., Methods: Eight previous cases of meningiomas, meeting the prerequisite of origin and situation within the internal acoustic canal, have been discovered in the known literature since 1975. A further case was recently observed in our experience. The cases in the series showed no sex prevalence and in most of them the age of incidence was comprised between the fifth and sixth decade of life. Hearing loss was the prevalent symptom, lasting 1 month to 7 years before presentation. Myelocisternography, myelo-CT or high resolution CT/MR revealed no specific radiological features to distinguish small intrameatal meningiomas from the more frequently occurring vestibular schwannomas, while CT scan with bone algorithm could point out valuable indirect details for differential diagnosis. Various surgical approaches, i.e. middle fossa, translabyrinthine and retromastoid, were utilized by the different authors., Results: Basing on apparent individual surgical preference, one of three different surgical routes (translabyrinthine, middle fossa, retromastoid) was chosen for 10 procedures in 9 patients. In all, except two cases the impression at surgery was of complete tumour removal., Conclusions: The possibility for meningiomas to recur and invade the surrounding bone requires a differential diagnosis from vestibular schwannomas. In the absence of intrinsic distinctive signs, radiological evaluation of peritumoral bone alterations could help diagnosis. Although the various surgical routes have often proved effective, temporal bone invasion justifies more extensive approach even in small tumours.

The case of a 86-year-old female victim of cervical trauma with C5-C6 fracture-luxation and bilateral locked facets is hereinafter described. The case was reputed representative of the complexity in deciding between conservative and surgical treatment in spine surgery. Conservative management would have been dictated by the additional risks linked to the age of the patient, whereas the surgical treatment would have been favored by the easy access to the anterior cervical spine for reduction and fixation. On the way to plan the definitive treatment, the patient died by pulmonary embolism. The controversial aspects and the indication to anticoagulant therapy in spinal surgery, frequently faced in the treatment of spine trauma in patients of this age group, are discussed in this case report.

Intraoperative positioning still constitutes a basic problem in the microsurgical removal of intracerebral lesions, either deep-seated or without cortical appearance. We treated different types of lesions (cavernous angiomas, intraventricular tumors, gliomas, and metastases), by combining stereotactic targeting with the standard microsurgical technique. The dedicated software for the three-dimensional reconstruction of stereotactic CT images allowed us to determine the least traumatic surgical trajectory and the exact location of the lesion intraoperatively, with minimum manipulation of healthy cerebral tissue. We believe that the main indication for this technique is the removal of small, encapsulated or well-defined lesions without cortical appearance or in critical areas, while a direct inspection of the area is still essential in order to evaluate surgical removal in the case of infiltrating tumors.

Objective and Importance: Neuroma of the 11th nerve disclosed by subarachnoid bleeding is a very rare condition. Clinical diagnosis is almost impossible, but previous episodes of muscle spasm and mild signs of subarachnoid hemorrhage with a hematoma in the cisterna magna should suggest magnetic resonance imaging as well as angiography., Clinical Presentation: We present a case of an 11th nerve neuroma disclosed by subarachnoid bleeding. Previous episodes of muscle spasm and neck pain treated with nonsteroid anti-inflammatory drugs had been overlooked, preventing the neuroma from being diagnosed at that time. The computed tomographic scan showed an intracisternal hematoma spreading into the subarachnoid space. The hematoma appeared heterogeneous on the magnetic resonance image, and a tumor mass growing into the cisterna magna against the brain stem was also revealed., Intervention: The tumor was totally removed by a suboccipital craniectomy and C1 laminectomy. It originated from the spinal root of the 11th nerve, from which it was able to be dissected without damage to the nerve., Conclusion: To our knowledge, this is the first reported case of an 11th nerve neuroma disclosed by a subarachnoid hemorrhage. Furthermore, this is the seventh documented case of an 11th nerve neuroma developing in the cisterna magna. We emphasize the importance of a high index of suspicion for the rare instances of hematic density limited to the cisterna magna, especially if associated with recurring episodes of localized neck pain and muscle spasm treated with nonsteroid anti-inflammatory drugs.

The present report describes the case of a 48 year-old woman who had undergone two separate lumbar laminectomies for a L4-L5 disc. She was admitted for a recurrent sciatica of 6-months duration, which failed to respond to conservative treatment. Myelogram on admission was negative. However CT showed a far laterally placed bulging L4-L5 disc. The patient was successfully reoperated on using a paramedian posterolateral approach on the side of the lesion. The rationale for this approach is discussed.

The AA. report the case of a giant carotid cavernous aneurysm; clinical onset was a VI cranial nerve paralysis, and diagnosis was based upon CT and angiographic findings. They describe balloon catheter technique used to exclude aneurysm, followed by carotid ligature. They eventually emphasize radiologic and neurophysiologic studies, and clinical follow up months later.

Coexistence of posterior fossa aneurysms and AVMs on the same feeding artery is very rare; the case of an association of two saccular aneurysms of the posterior inferior cerebellar artery with a cerebellar arteriovenous malformation of the same artery is reported. Theories concerning etiology are reported as well.

The AA. have employed CT scan in studying the latest 10 cases in a series of 50 carpal tunnel syndromes; CT scans have then been confronted with EMGs and surgical findings. Usefulness of CT scan is enhanced in pre and postoperative study of this pathology.

The authors report the case of a patient submitted to an operation of spinal tumors with multiple localization which, beside enriching the rare observations existing in literature, presents and hypertensive hypertension hydrocephalus with non common pathogenesis and points out considerable difficulties of interpretation of the histologic picture. After examining literature and describing the case in detail, the authors discuss the etiopathogenesis of hydrocephalus and examine the histologic aspect of extirpated tumors.

The AA. report the case of an anterior inferior cerebellar artery aneurysm (XVIIIth in world literature). Reviewing literature on the subject, they recall anatomical and clinical variations of AICA aneurysms, and report surgical techniques usually employed.