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Since the end of the nineteenth century, the wide dissemination of Pott's disease has ignited debates about which should be the ideal route to perform ventrolateral decompression of the dorsal spine in case of paraplegia due to spinal cord compression in tuberculosis spondylitis. It was immediately clear that the optimal approach should be the one minimizing the surgical manipulation on both neural and extraneural structures while optimizing the exposure and surgical maneuverability on the target area. The first attempt was reported by Victor Auguste Menard in 1894, who described, for the first time, a completely different route from traditional laminectomy, called costotransversectomy. The technique was conceived to drain tubercular paravertebral abscesses causing paraplegia without manipulating the spinal cord. Over the following decades, many other routes have been described all over the world, thus demonstrating the wide interest on the topic. Surgical development has been marked by the new technical achievements and by instrumental/technological advancements, until the advent of portal surgery and endoscopy-assisted techniques. In this article, the authors retraced the milestones of this history up to the present days, through a systematic review on the topic.

Background Intraforaminal lumbar disk herniations (IFDHs) represent a heterogeneous and relatively uncommon disease; their treatment is technically demanding due to the anatomical relationships with nerve roots and vertebral joints. Over time, several approaches have been developed without reaching a consensus about the best treatment strategy. Materials and methods Authors comparatively analyze surgical operability and exposure in terms of quantitative variables between the different microsurgical approaches to IFDHs, defining the impact of each approach on surgical maneuverability and exposure on specific targets.A comparative microanatomical laboratory investigation was conducted. The operability score (OS) was applied for quantitative analysis of surgical operability. Results Transarticular and combined translaminar-trans-pars-interarticularis approaches result in providing the best surgical exposure and maneuverability on all targets with surgical controls on both nerve roots, at the expense of a higher risk of iatrogenic instability. Trans-pars-interarticularis approach reaches comparable levels of operability, even limited to the pure foraminal area (lateral compartment); similar findings were recorded for partial facetectomy on the medial compartment. The contralateral interlaminar approach provides good visualization of the foramen without consensual favorable maneuverability, which should be considered the main drawback. Conclusions Approach selection has to consider disease location, the possible migration of disk fragments, the degree of nerve root involvement, and risk of iatrogenic instability. According to the findings, authors propose an operative algorithm to tailor the surgical strategy, based both on the precise definition of anatomic boundaries of exposure of each approach and on surgical maneuverability on specific targets.

Stereotactic radiosurgery (SRS) in combination with immunotherapy (IT) is increasingly used in the setting of melanoma and non-small cell lung cancer (NSCLC) brain metastases (BM). The synergistic properties of this treatment combination are still not deeply understood. IT-SRS appropriate combination has been envisioned as a strategic point in patients' management. Authors performed a systematic review on current evidences up to December 2020. The impact of SRS-IT and different IT schedules on survival, local/distant intracranial control and toxicity, as well as predictive factors for relevant oncological and radiological outcomes has been analyzed. Authors retrieved 23 pertinent studies. Combining SRS with IT resulted in a significant improvement in OS and lesion response with no increase in radionecrosis, hemorrhage or other complications. The present review suggests that combining IT to SRS is safe and effective in providing a significant improvement in relevant clinical and radiological outcomes in melanoma and NSCLC BMs patients.

Cranial meningoencephalocele is a rare condition consisting of the herniation of meninges, CSF, and brain tissue through a cranial or skull base defect. Sphenoid sinus lateral recess meningoencephalocele is of particular interest due to the complex anatomy surrounding the bone defect and their demanding surgical management. In this technical note, we reported a step-by-step description of a rare case of sphenoid sinus lateral recess meningoencephalocele causing headache due to recurrent cerebrospinal fluid leak treated with a subtemporal craniotomy with extradural middle cranial fossa drilling and meningoencephalocele removal with multilayer reconstruction. The transcranial route is a safe and effective treatment for sphenoid sinus lateral recess meningoencephalocele repair. The subtemporal extradural approach allows for an optimal exposure of the relevant anatomy minimizing risks and improving the possibility to perform an effective multilayer skull base reconstruction.

Epinephrine is frequently used as an inotropic and vasopressor agent in critically ill patients requiring hemodynamic support. Data from observational trials suggested that epinephrine use is associated with a worse outcome as compared with other adrenergic and nonadrenergic vasoactive drugs. We performed a systematic review and meta-analysis of randomized controlled trials to investigate the effect of epinephrine administration on outcome of critically ill patients.PubMed, EMBASE, and Cochrane central register were searched by two independent investigators up to March 2019.Inclusion criteria were: administration of epinephrine as IV continuous infusion, patients admitted to an ICU or undergoing major surgery, and randomized controlled trials. Studies on epinephrine administration as bolus (e.g., during cardiopulmonary resuscitation), were excluded. The primary outcome was mortality at the longest follow-up available.Two independent investigators examined and extracted data from eligible trials.A total of 5,249 studies were assessed, with a total of 12 studies (1,227 patients) finally included in the meta-analysis. The majority of the trials were performed in the setting of septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine. We found no difference in all-cause mortality at the longest follow-up available (197/579 [34.0%] in the epinephrine group vs 219/648 [33.8%] in the control group; risk ratio = 0.95; 95% CI, 0.82-1.10; p = 0.49; I = 0%). No differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay were observed.Current randomized evidence showed that continuous IV administration of epinephrine as inotropic/vasopressor agent is not associated with a worse outcome in critically ill patients.

Background Delirium after cardiac surgery is associated with adverse outcomes, including prolonged hospital stay, prolonged intensive care unit stay, and increased mortality. Effective preventive interventions and treatments still are largely unknown. Aim This systematic review aimed to gather and summarize the existing evidence from randomized trials concerning interventions studied in the prevention or treatment of delirium in adult patients undergoing cardiac surgery. Methods A systematic review of the literature using a key word strategy and Boolean operators was performed. PubMed and the Cochrane and Scopus databases were searched for pertinent studies until July 2018 (no inception limit). Results Of 2,556 articles identified, 56 studies met the inclusion criteria and were included in the review—39 addressed pharmacologic strategies and 17 nonpharmacologic interventions. Interestingly, 51 (91%) trials focused on delirium prevention and only 5 (9%) on delirium treatment. Most of the analyzed studies were recent double-blind, single-center trials conducted in Europe or North America, with a low risk of bias. Overall, 38 different interventions were identified: 15 (26%) interventions were performed before surgery, 20 (36%) in the operating room, and 21 (38%) after surgery. The most frequently analyzed strategies were the administration of dexmedetomidine, ketamine, antipsychotics, glucocorticoids, propofol, opioids, volatile anesthetics, local anesthetics, and remote ischemic preconditioning. The analyzed strategies were extremely heterogenous, and dexmedetomidine was the most promising measure able to prevent the development of postoperative delirium. Conclusions In the present systematic review of 56 randomized controlled trials that examined 38 interventions, the authors found that dexmedetomidine was the most frequently studied agent and that it might reduce the occurrence of delirium after cardiac surgery.

The current standard of care for surgically inaccessible low-grade brainstem gliomas (BS-LLGs) is external-beam radiotherapy (RT). Developments toward more innovative conformal techniques have focused on decreasing morbidity, by limiting radiation to surrounding tissues. Among these Gamma Knife radiosurgery (SRS-GK) has recently gained an increasingly important role in the treatment of these tumors. Although SRS-GK has not yet been compared with conventional RT in patients harboring focal BS-LGGs, clinical practice has been deeply influenced by trials performed on other tumors. This is the first meta-analysis on the topic, systematically reviewing the most relevant available evidence, comparing RT and SRS-GK as primary treatments of BS-LGGs, focusing on survival, clinical outcome, oncological control, and complications. Predictive factors have been systematically evaluated and analyzed according to statistical significance and clinical relevance.