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Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: “early surgery” and “delayed surgery.” The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the “early surgery” group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the “delayed surgery” group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.

Background Acute subdural hematoma represents an important cause of disability and mortality. Its surgical treatment takes advantage of two surgical procedures: craniotomy and decompressive craniectomy, nevertheless the effectiveness of one procedure rather than the other is still debated. This study was conducted to identify which of the surgical procedures could provide better neurological outcome after traumatic acute subdural hematoma; as a secondary endpoint, the study tries to settle pre-operative prognostic factors useful to identify the most appropriate surgical technique for every specific patient and kind of trauma. Methods A retrospective analysis was performed on patients who underwent craniotomy or decompressive craniectomy between January 2010 and July 2017 at the Department of Neurosurgery of Umberto I Hospital in Rome. Ninty-four patients were selected and reviewing clinical records, pre-operative and post-operative's data were collected (e.g. GCS, mechanism of trauma, CT findings, mortality rate, neurological outcome at discharge, mRS at 12 months). Data were analyzed using X2 test and the F test. The multivariate analysis was performed using a stepwise logistic regression. The analysis was carried out using SPSS software and a p value ≤ 0.05 was considered significant. Results On 94 patients 46.8% underwent decompressive craniectomy and 53.2% underwent craniotomy. The mortality rate was (53.2%); it was shown to be related to a GCS 60 years old (p = 0.0001). Decompressive craniectomy was performed most frequently for high energy trauma (p =0.006); the mean GCS at admission was 7.91 for decompressive craniectomy and 9.64 for craniotomy (p = 0.05). Patients who underwent decompressive craniectomy and survived surgery showed a better neurological outcome compared to those who underwent craniotomy (p = 0.009). The evaluation of mRS after 12 months didn't show a statistically significant difference between the two groups. Conclusions In case of high energy trauma and GCS ≤8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS ≤8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy.

Background Ependymoma accounts for 3%–9% of all neuroepithelial tumors. Giant cell ependymoma (GCE) is a rare and distinct variant, with only 22 cases described in the literature. The 2007 World Health Organization classification first acknowledged this rare subtype. The cytologic features of GCE include the presence of pleomorphic giant cells with several cellular atypias, which at intraoperative frozen diagnosis may appear to be high-grade glial lesions. Despite its apparently malignant histology, GCE seems to be a neoplasm with a relatively good prognosis. Extended tumor removal is the gold standard without adjuvant treatment. Case Description We describe the first case, to our knowledge, of GCE situated at the cervicomedullary junction in a 62-year-old patient. Surgery was performed with combined intraoperative monitoring of motor evoked potentials and somatosensory evoked potentials. Intraoperative frozen diagnosis revealed a high-grade glial neoplasm; however, gross total resection was achieved. The definitive diagnosis was GCE. At follow-up evaluation 11 years after surgery, the patient did not present with any tumor recurrence. Conclusions As the intraoperative diagnosis can be misleading, whenever a cleavage plane is recognized, it is essential to perform a gross total resection with the aid of intraoperative neurophysiologic monitoring, to improve prognosis and neurologic outcome. Data reported in the literature show that prognosis is mainly influenced by grade of resection.

Background: Intramedullary (IM) schwannomas are rare entities representing 0.3%−1% of intramedullary tumors and 1.1% of spinal schwannomas. Beside many theories proposed, their rare occurrence might be related to the absence of Schwann cells in the spinal cord. Pediatric IM schwannomas are uncommon, and in the absence of neurofibromatosis they are extremely rare. To date, few cases have been reported in the literature. Case Description: We describe the case of an 8-year-old female affected by a progressive paraparesis. Neuroradiologic investigations showed an oval-shaped mass at the level of T10-T11. The patient underwent surgery, performed under neurophysiologic monitoring. The patient was operated on with complete removal of the lesion. The postoperative course was uneventful. Conclusions: The clinical, neuroradiologic, and intraoperative findings are presented, along with a review of the literature. Despite the number of lesions potentially compressing the spinal cord, IM schwannoma is rare but should be taken into account in the differential diagnosis. © 2018 Elsevier Inc.

C5 nerve root palsy is a well-known complication after anterior or posterior cervical decompression. Many theories have been proposed but the etiology is still unclear. The use of a winged expandable cage after single or multiple corpectomy is among the used techniques in reconstructing the cervical spine. Herein we report a case of C5 palsy after a three-level corpectomy and reconstruction using this device for the treatment of cervical spondylosis. In our case the preexisting foraminal stenosis, wide anterior decompression and partial improvement of cervical alignment were factors supposed contributing to the palsy.

Background: Cervical magnetic resonance imaging (MRI) is the gold standard exam in the assessment of patients affected by cervical myelopathy and is very useful in planning the operation. Herein we present a series of patients affected by long tract symptoms who underwent dynamic MRI in addition to the static exam. Methods: In the period between March 2010 and March 2012, three-hundred-ten patients referred to our department since affected by neck/arm pain or symptoms related to cervical myelopathy. Thirty-eight patients complained “long-tract symptoms” related to cervical myelopathy. This series of patients was enrolled in the study. All patients underwent clinical and neurological exam. In all the cases, a static and dynamic cervical MRI was executed using a 3.0-T superconducting MR unit (Intera, Philips, Eindhoven, Netherlands). The dynamic exam was performed with as much neck flexion and extension the patient could achieve alone. On T2-weigthed MRI each level was assessed independently by two neuroradiologists and Muhle scale was applied. Results: According to Muhle’s classification of spinal cord compressions, static MRI demonstrated 156 findings: 96 (61.54%) anterior and 60 (38.46%) posterior. Dynamic MRI showed 186 spinal cord compressions: 81 (43.5%) anterior and 105 (56.5%) posterior. The anterior compressions were: grade 1 in 23 cases (28.4%), grade 2 in 52 cases (64.2%), grade 3 in 6 cases (7.4%). The posterior compressions were: 32 (30.48%) of grade 1, 60 (57.14%) of grade 2, 13 (12.38%) of grade 3. Conclusions: The dynamic MRI demonstrated a major number of findings and spinal cord compressions compared to the static exam. Finally, we consider the dynamic exam able to provide useful information in these patients, but we suggest a careful evaluation of the findings in the extension exam since they are probably over-expressed.

In this case report, we demonstrate that the use of a winged expandable cage was able to obtain good clinical and radiological results in a case of cervical tuberculosis with severe kyphosis. However, case series will be necessary to affirm its validity as a stand-alone device for similar cases with high risk of instability.

Background.Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection.Study Design and Aims.Retrospective review focused on clinical assessment, treatment techniques, and outcomes.Methods.A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests.Results.From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions.Conclusions.Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.

Cervicomedullary tumors (CMTs) are rare intramedullary neoplasms located at the junction of the cervical spine and brainstem. Intra-axial tumors of this vital region are poorly defined by recent literature searches because brainstem gliomas and CMTs have been generally considered surgical inaccessible lesions due to their perceived high risk of neurological morbidity. The advent of MRI brought about recognition that brainstem tumors are a heterogeneous collection of tumor types with major differences in presentation and survival, resulting in various classification systems. In 1987, Epstein and Winsoff described CMTs as an isolated subgroup. According to their analysis, the majority of these tumors are histologically benign and slow-growing neoplasms which long duration of symptoms and considered amenable to radical resection.

Chiari malformations (CM) represent a group of anomalies characterized by descent of the cerebellar tonsils or vermis into the cervical spinal canal. These malformations can be associated with abnormalities such as hydrocephalus, spina bifida, hydromyelia, syringomyelia, curvature of the spine (kyphosis and scoliosis) and tethered cord syndrome. Hereditary syndromes and other disorders that affect growth and bone formation-such as craniosynostosis, Ehlers-Danlos syndromes and Klippel-Feil syndrome-can also be associated with CM.The literature concerning treatment is large, and an extensive range of therapeutic protocols have been described. The literature is inclined in favour of surgery; however, there is controversy over when to perform surgery and which procedure is most appropriate. Lately, the indications for stabilization have been under discussion.In this paper we review the literature and discuss the historical background, anatomical forms, pathophysiology, clinical presentation, relationships with other diseases and diagnostic procedures for these abnormalities.

Postoperative cerebrospinal fluid (CSF) leak still represents the main limitation of endonasal endoscopic surgery. The aim of the study is to classify the risk of postoperative leak and to propose a decision-making protocol to be applied in the preoperative phase based on radiological data and on intraoperative findings to obtain the best closure.One hundred fifty-two patients were treated in our institution; these patients were divided into 2 groups because from January 2013 the closure technique was standardized adopting a preoperative decision-making protocol. The Postoperative CSF leak Risk Classification (PCRC) was estimated taking into account the size of the lesion, the extent of the osteodural defect, and the presence of intraoperative CSF leak (iCSF-L). The closure techniques were classified into 3 types according to PCRC estimation (A, B, and C).The incidence of the use of a nasoseptal flap is significantly increased in the second group 80.3% versus 19.8% of the first group and the difference was statistically significant P < 0.0001. The incidence of postoperative CSF leak (pCSF-L) in the first group was 9.3%. The incidence of postoperative pCSF-L in the second group was 1.5%. An analysis of the pCSF-L rate in the 2 groups showed a statistically significant difference P = 0.04.The type of closure programmed was effective in almost all patients, allowing to avoid the possibility of a CSF leak. Our protocol showed a significant total reduction in the incidence of CSF leak, but especially in that subgroup of patients where a leak is usually unexpected.

Background Despite the progress achieved in recent years, the prognosis of patients with primary brain tumors remains poor. Research efforts have therefore focused on identifying more effective and minimally invasive treatment methods. Magnetic resonance–guided transcranial focused ultrasonography (MRgFUS) is a consolidated minimally invasive therapeutic technique, which has recently acquired a role also in the treatment of some nononcologic intracranial diseases. Methods We reviewed the latest studies to take stock of the potential of MRgFUS. Results The objective of the research in the last decade was to apply FUS also to the treatment of intracranial neoplastic diseases, using both the thermal effects (thermal ablation) and, above all, the ability to permeabilize the blood-brain barrier and modify the tumor microenvironment. This strategy may allow the use of drugs that are poorly active on the central nervous system or active selectively at high doses, minimize the side effects, and substantially modify the prognosis of patients affected by these diseases. Conclusions In the future, targeted drug delivery, immunotherapy, and gene therapy will probably become main players in the treatment of brain neoplasms, with the aid of MRgFUS. In this way, it will be possible to directly intervene on tumor cells and preserve healthy tissue.

In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient’s survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics. Herein, we report the patient’s selection and technique to execute the TES for cases of thoracic metastasis. This surgery is technically demanding so the patient’s selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor’s progression is “limited” by local barriers as demonstrated by histological studies.

Background Unruptured intracranial aneurysms (UIAs) are increasingly identified and are an important health-care burden; in the past they were commonly treated by surgical clipping, but nowadays endovascular coil embolization is increasingly employed as an alternative. Methods The Unruptured Aneurysms Italian Study (UAIS) is a multicentric cooperative prospective study aimed to delineate the "State of the Art" of UIAs treatment in Italy. 51 Italian Neurosurgical and Neuroradiological Units, representatives of all 20 Italian regions are involved in the Study. Results UAIS started on June 2003 and ended on July 2007. 1138 patients were collected by that date, but 181 were ruled-out due to severe violation of the protocol; 957 had complete data and could be statistically evaluated. Conclusions UAIS demonstrates that the treatment of UAs, as performed in Italy as a Nation, is effective in improving long-term outcome vs. natural history, particularly in aneurysms larger than 7 mm.

Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences. Materials and Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance. Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as 'other' was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ 2 < 0.001). No statistical differences were observed between discectomy or herniectomy, for the treatment of the recurrence, and the incidence for the second recurrences (P > 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05). Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence. © 2019 Journal of Craniovertebral Junction and Spine | Published by Wolters Kluwer - Medknow.

Objective The endoscopic technique is in many cases the technique of choice for the removal of pituitary adenomas. Extended endoscopic approaches make it possible to remove lesions with suprasellar and parasellar extension and fibrous consistency. We identify some characteristics that might point to the adoption of an expanded approach in the preoperative phase. Methods We considered 66 consecutive cases treated for pituitary macroadenomas. All patients underwent preoperative magnetic resonance imaging and computed tomography, as well as postoperative magnetic resonance imaging. From the analysis of surgical reports and preoperative radiologic investigations, we extracted data related to size, extension, morphologic characteristics, consistency, and type of approach used (sellar or expanded). The degree of removal was judged to be total, near total, subtotal, or partial. Results The data showed that in some cases it is possible to assume in advance that there is a need for an expanded endoscopic approach. The features that led to an extended approach for extracapsular dissection of the lesion were the size of the tumor; an hourglass/dumbbell shape; lateral extension to the suprasellar carotid artery; Knosp degree 3 or 4; contrast enhancement heterogeneity; intratumoral hemorrhage, erosion, or discontinuity of the sellar floor; and increased sellar depth, which predicts increased thickness. Conclusions The ability to predict the consistency of pituitary adenomas allows the surgeon to design a surgical procedure tailored to the patient. This approach has advantages concerning the extent of resection and allows a radical strategy with a single surgical procedure to be pursued.

This is a retrospective study on 18 patients affected by thoraco-lumbar junction burst fractures (TLJBF) A3 or A4 at computed tomography (CT) scan who referred to our hospital. To assess the surgical results in terms of pain and quality of life in a series of neurologically intact patients affected by TLJBF who underwent surgery after 3-4 months from the injury. In literature there is controversy if pain could be an indication for surgery in TLJBF and series of patients conservatively managed with success have been reported.A retrospective study on 18 patients is reported. Patients included in this series were neurologically intact and affected by a TLJBF A3 or A4 at CT scan, the height of the burst vertebral body was50%, spinal canal invasion was30% and kyphosis deformity30 degrees. Pain and quality of life were evaluated using graphic rating scale (GRS) and EuroQol (EQ-5D) scores on admission, at the clinical follow-up and in post-surgical period.Comparing pre- and post-operative EQ-5D, the scores had a statistically significant decrease after the operation (P0.001) [pre-surgery EQ-5D was 2.60 (SD =0.67), post-surgery EQ-5D was 1.37 (SD =0.41)]. Also analyzing the EQ5D-VAS scores, the t-test revealed that surgery (P0.01) improved the quality of life with statistically significance (EQ5D-VAS pre =43.89, SD =12.43 and EQ5D-VAS post =73.33, SD =10.84). Analyzing pre- and post-surgical GRS scores, the pain decreased significantly with the maximum mean difference among the 2nd and 3rd month before surgery and at 12 months after surgery (respectively D =5.444, P0.001 and D =5.167, P0.001).Conservatively managed patients affected by TLJBF require a strict clinical follow-up since pain sometimes is present in the following months and it affects the quality of life. Surgery should be considered for these cases.

Introduction Accurate hemostasis in surgical practice is critical. The need for optimal atraumatic hemostasis has become compelling in neurosurgery. A simple and safe gelified hemostatic matrix is often used. This prospective study evaluates two different hemostatics, FloSeal (Baxter Healthcare, Deerfield, Illinois, United States) and Surgiflo (Ethicon, Somerville, New Jersey, United States), for bleeding control during spine surgery, considering their efficacy, safety, and ease of use. Materials and Methods From January 2012 to December 2013, we recruited 149 patients. Inclusion criteria were age between 25 and 80 years, diagnosis of degenerative or traumatic pathology of the lumbar or thoracolumbar spine, and persistent bleeding not responding to standard hemostatic techniques. All patients underwent laminectomy or laminoarthrectomy, with exposure of the perivertebral venous plexus. Our aim was to stop the bleeding completely in the operative field by application of hemostatic gel. All patients were evaluated during the follow-up period with a clinical and neurologic examination. All patients underwent a computed tomography scan 3 months after the intervention. Results We included 149 patients in our study: 98 men and 51 women. Overall, 92 patients were affected by a degenerative condition and 57 by traumatic pathology. A total of 42 patients had anticoagulant and/or antiaggregant therapy preoperatively. In all cases, massive bleeding originated from the epidural venous plexus. FloSeal was used in 86 cases and Surgiflo in 63. A complete hemostasis was achieved in all patients within 3 minutes, 30 seconds and 7 minutes (FloSeal, 5 minutes, 35 seconds ± 52 seconds; Surgiflo, 5 minutes, 32 seconds ± 54 seconds). Statistical analysis did not show any association between coagulation time and hemostatics, age, sex, and the pathology treated. Previous therapy with antiaggregants and/or anticoagulants determined a slight increase in the time of hemostasis without any statistical differences. The clinical and radiological follow-up showed no evidence of postsurgical hematomas. Conclusions Comparative analysis of the two products did not show any relevant differences in terms of efficacy and ease of use or their effectiveness in bleeding control. Their use was valid even in patients who used antiaggregant/anticoagulant drugs preoperatively. Both FloSeal and Surgiflo can be considered good choices for controlling bleeding in spinal surgery.

Objective and Importance To demonstrate the curative reconstruction of two giant fusiform aneurysms using a combination of flow-diverter stents and self-expanding stents for intracranial use. Clinical Presentation Two cases that would have been difficult to manage with standard methods: one patient with deficiencies of cranial nerves VI and VII on the left, acute diplopia, and an aneurysm of the vertebrobasilar bifurcation, the other with diplopia, deficiencies of cranial nerves III and VI, and an aneurysm of the intracavernous internal carotid artery. Intervention or Technique Complete reconstruction was achieved using a combination of flow-diverter and self-expandable stents. Follow-up investigations at 6 months demonstrated the complete reconstruction of the arteries and angiographically determined disappearance of the aneurysms with resolution of the clinical profile. The patients' outcome was excellent (modified Rankin Scale: 0). Conclusion This technique enables safe and definitive treatment of lesions that would be difficult to manage with other methods. The greater metal surface does not seem to interfere with the perforating arteries originating from the segments involved.

Objectives: Decompressive craniectomy (DC) is a surgical therapy used to treat patients foreseen to be at risk for high intracranial pressure (ICP). In this retrospective case control study, mortality, ICP values, neurocritical care (NCC) manage- ment necessity, and long-term neurologic status were examined in patients treated with DC and in a matched control group. Methods: The primary end-points were all-cause mortality and functional status of NCC patients both at discharge and at a 6 month follow-up. Secondary end-points were ICP values at established time points and the use of advanced NCC therapies. Patients who underwent primary DC were matched with individuals with similar demographic and pre-intervention ICP values who had been treated with standard NCC management alone. Results Neurologic status outcome at discharge and the 6 month follow-up was significantly better in patients treated with DC compared to those in the control group: Glasgow Outcome Scale (GOS) 4-5 in 15 versus 5 patients; p = 0.033, and 16 versus 6 patients, p = 0.033. Mortality at 6 months was similar in the study groups (10 versus 16 patients; p = 0.212). ICP values were similar at NCC admission but were better controlled 24 hours after DC than in the control group. Fewer patients treated with DC needed advanced NCC medical therapies. Conclusions: DC is an effective way to normalize ICP levels while reducing the need for aggressive medical therapies. Survival rate and neurological outcome in patients treated with DC were found to be better than in those receiving only medical treatment.

Endoscopic disc surgery (EDS) for lumbar spine disc herniation is a well-known but developing field, which is increasingly spreading in the last few years. Rate of recurrence/residual, complications, and outcomes, in comparison with standard microdiscectomy (MD), is still debated and need further data. We performed an extensive review based on the last 6 years of surgical series, systematic reviews, and meta-analyses reported in international, English-written literature. Articles regarding patients treated through endoscopic transforaminal or interlaminar approaches for microdiscectomy (MD) were included in the present review. Papers focused on endoscopic surgery for other spinal diseases were not included. From July 2009 to July 2015, we identified 51 surgical series, 5 systematic reviews, and one meta-analysis reported. In lumbar EDS, rate of complications, length of hospital staying, return to daily activities, and overall patients’ satisfaction seem comparable to standard MD. Rate of recurrence/residual seems higher in EDS, although data are nonhomogeneous among different series. Surgical indication and experience of the performing surgeon are crucial factors affecting the outcome. There is growing but still weak evidence that lumbar EDS is a valid and safe alternative to standard open microdiscectomy. Statistically reliable data obtained from randomized controlled trials (better if multicentric) are desirable to further confirm these results.

The diagnosis of low back pain (LBP) is complex and multifactorial, and a clear etiology responsible for the symptoms is often not detectable. Clinical history and neurological examination are essential for differential diagnosis, because they allow the identification of the specific pathology. The radiological investigation allows to confirm diagnosis, but the indication must always be correlated with clinical findings to not perform unnecessary diagnostic procedures. Management of LBP can involve many specialists – neurosurgeon, orthopedist, physiatrist, physiotherapist – everyone with different knowledge and experience because very often the cause is multifactorial. However, it is mandatory to clarify diagnosis of LBP; in this way, the clinical pathway is fundamental to understand pathogenesis and to determine appropriate treatment.

The cervicothoracic junction (CTJ) is defined as the area extending from vertebral segments C7 to T4. Because most pathological processes occur in the anterior segment of the vertebrae, the anterior approach is usually the best surgical option, allowing neural decompression, stabilization and restoration of anatomical spinal alignment. Nevertheless, it represents a big challenge for the spinal surgeon for the presence of important anatomical structures of the upper mediastinum: manubrium, thymus gland, left and right brachiocephalic veins (or innominate veins), right brachiocephalic artery, left common carotid artery, aortic arc, esophagus, trachea and thoracic duct. Varied approaches to the CTJ have been described in literature [low lateral anterior cervical approach (LACA), full sternotomy, lateral parascapular thoracotomy, clavicular dissection]. Among them, the low LACA combined with manubriotomy is the most used and safe (1).

The treatment of vertebral instability has evolved over the years with the aim of searching and developing the most effective and less invasive procedure to reduce and to neutralize dynamically the metameric hypermobility; pedicle screw fixation (PSF) has been widely employed to reach vertebral fixation and fusion and still remains the “gold standard” technique [1, 2]. PSF is associated with well-known risks [3, 4] such as increased rates of cerebrospinal fluid leakage, fracture of the pedicles during screw insertion, transient/permanent injury to nervous structures, and deep wound infections. Furthermore, as a result of muscle dissection and long operative times, some disadvantages can be evident, such as postoperative back pain and long postoperative recovery time [5]. There are risks of exposure to ionizing radiations for the surgeon and the whole operating room staff, other than for the patient, due to the use of fluoroscopic guidance for the implantation of pedicle screws (PS) [4, 6]. The muscle dissection related to surgical exposure leaded to the development of minimally invasive procedures, at the cost of increased exposure to ionizing radiations. This has led to the development of a lot of different devices, some of them used indiscriminately in recent years but with questionable long-term results. In this context, a major role was played by interspinous devices, generally used in degenerative lumbar spine disease. Interspinous posterior device (IPD) is a term used to identify a relatively recent group of implants employed in the treatment of lumbar spinal degenerative disease. This kind of device is classified as part of the group of the dynamic stabilization systems of the spine. The concept of dynamic stabilization has been actually replaced by the principle of dynamic neutralization of the hypermobility, with the intention of clarifying that the primary aim of this kind of systems is not the preservation of the movement but the dynamic neutralization of the segmental hypermobility, which is at the base of the pathological condition. The surgical indications for the implantation of an IPD are the spinal stenosis and neurogenic claudication, assuming that its function is the enlargement of the neural foramen and the decompression of the roots forming the cauda equina in the central part of the vertebral canal. Recently, it has been noticed that those devices have significant problems in terms of clinical follow-up, since the action exercising on the vertebral body has an appreciable effect on the biomechanics of the lumbar spine. This is why in the last few years new devices have been introduced, the so-called interspinous anchors (IA) or interspinous fusion devices (IFD). Those differ from the IPD as their aim is the fusion of the spinous processes on which they are anchored, and therefore the target is spinal stabilization by arthrodesis and not the dynamic neutralization of the hypermovement. The question that requires response is: are those devices able to replace arthrodesis with plates and screws in lumbar instability?

Management of spinal degenerative deformities always represents a challenge for the spinal surgeon. We report a case of revision surgery for adult scoliosis, focusing of most common errors in pre-surgical management and criteria for reoperation. We analyzed the spino-pelvic parameters on the standing whole-spine X-ray and the role of sagittal balance. To restore 45° of lumbar lordosis, we performed a L3 Pedicle Subtraction Osteotomy (PSO), along with L2-L3 and L3-L4 eXtreme Lateral Interbody Fusion (XLIF). In cases of adult scoliosis, careful preoperative planning is necessary in an attempt to avoid difficult, expensive, and high-risk additional procedures.

Objective Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. Methods We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to 2014. Results 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. Conclusions We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Background The aim of this work is to describe in detail the complex 3-dimensional organization of the white matter of the temporal lobe and discuss the surgical implications of the approaches to lesions located into the mesial temporal region and within the temporal horn and the atrium of the lateral ventricles. Methods Sixteen human cerebral hemispheres fixed in a 10% formalin solution for at least 40 days were studied. After removal of the arachnoid membrane, the hemispheres were frozen at −15°C for at least 14 days, and the Klingler technique, which consists of the microscopic dissection and progressive identification of white matter fibers, was performed. Results The dissection allowed us to appreciate the topographical organization of the white matter of the temporal lobe identifying the most important association, projection, and commissural fasciculi. The dissection from the lateral side allowed the progressive visualization of the superior longitudinal fasciculus and its components, the extreme and external capsule, the uncinate fasciculus, the inferior fronto-occipital fasciculus, the anterior commissure, the internal capsule, and the optic radiations. The dissection was completed from the inferior and medial side for identification of the cingulum and the fornix. Conclusions The complex 3-dimensional organization of the white matter substance of the temporal lobe is characterized by 2 main systems of boundaries: the sagittal stratum and the temporal stem. Their knowledge is essential for the appropriate treatment of pathologies localized in this region as demonstrated by the 2 clinical cases presented in this work.

Background Treatment for spinal trauma is affected by both nonmodifiable and modifiable variables. The aim of this study was to compare early surgery with intermediate and late surgery to determine the benefits of spinal reconstruction in neurological recovery and functional restoration in patients with thoracolumbar fractures.

AIM To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one. METHODS We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability. RESULTS The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring. CONCLUSION Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms “ganglion cyst” to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.

Spinal infections are rare (their incidence is estimated in about the 5% of all osteomyelitis) and severe pathologies. They are usually identified with different names, as disk space infection, spondylodiscitis, and vertebral osteomyelitis. Spondylodiscitis is the most frequent among spinal infections. The etiology might be due to bacteria, fungi, and parasites and might affect many anatomical structures. The reported incidence is increased in the last years.[1,2] The disease can be classified according to the involved anatomical structure: Vertebral osteomyelitis Discitis and spondylodiscitis Spinal canal infections Adjacent soft tissue infections. In adult patients, the terms osteomyelitis and spondylodiscitis can be considered as more appropriate since an isolated discitis is rarely an isolated entity,[3] but in pediatric patients, it can be occasionally found.[4] The diagnosis might be challenging, often causing a delay in the identification of the pathology. On the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of radiological, microbiological, and bioptic examinations.

Objective To analyze outcomes of patients surgically treated for calcified spinal meningiomas and to determine factors associated with surgical morbidity. Methods Between January 2000 and June 2013, a total of 54 patients underwent surgical resection of a spinal meningioma: 37 of these cases showed various degrees of calcification, confirmed by histopathologic analysis. The clinical evaluation was performed according to the American Spinal Injury Association Impairment Scale. At the last follow-up, neurologic status improved in 19 cases and remained unchanged in 20 cases; just 1 case worsened. According to the American Spinal Injury Association Impairment Scale, neurologic status was classified into 3 levels: poor (A + B), fair (C), and good (D + E). Neurologic status improvement (NSI) during postoperative time (considered as a transition from one lower level to the higher) was analyzed in relationship to the patient's age, length of clinical history, spine level, meningioma's position inside the spinal canal, and its degree of calcification. Results A statistically significant relationship between NSI and the degree of ossification of the meningioma was observed. in particular, a direct relationship with microcalcified meningiomas and an inverse relationship with ossified meningiomas. No relationship was observed between NSI and patient's age, length of clinical history, and the site of the lesion into the vertebral canal. Conclusions The univariate analysis confirms that the degree of calcification affects the outcome, because extensive tumor calcification is associated with an increased surgical morbidity probably.

Aneurysms arising from the ophthalmic artery trunk (OAT) are very rare, particularly in the artery's intracranial course. The onset of a subarachnoid hemorrhage (SAH) from a ruptured OAT aneurysm in this segment is extremely rare. We present a case and discuss the anatomy, clinical significance, and therapeutic options for an aneurysm at this site. We also retrospectively analyzed the record of a patient with a ruptured aneurysm of the intracranial segment of the OAT and conducted a comprehensive and systematic review of the PubMed and Scopus databases for literature on this pathology. Only one case report of SAH from an aneurysm of the intracranial segment of the OAT was published in the literature. Only in our case was the intracranial OAT segment aneurysm discovered in the acute phase of SAH. Conventional angiography with three-dimensional acquisition may help detect aneurysms at this level. Detailed knowledge of the anatomy of the OAT is of paramount importance for both surgical and endovascular approaches. Surgical treatment is complex because of difficulties in accessing the orbital region and the risk of optic nerve and vascular injuries. Endovascular treatment, when feasible, could be a good alternative to reduce the risk of loss of vision related to surgical manipulation.

INTRODUCTION Cervical kyphosis is a progressive cervical sagittal plane deformity that may cause a reduction in the ability to look horizontally, breathing and swallowing difficulties, sense of thoracic oppression and social isolation. Moreover, cervical kyphosis can cause myelopathy due to a direct compression by osteo-articular structures on the spinal cord or to a transitory ischaemic injury. The treatment of choice is surgery. The goals of surgery are: nervous structures decompression, cervical and global sagittal balance correction and vertebral stabilization and fusion. PRESENTATION OF CASE In October 2008 a 35 years old woman underwent surgical removal of a cervical-bulbar ependymoma with C1–C5 laminectomy and a C2–C5 laminoplasty. Five months after surgery, the patient developed a kyphotic posture, with intense neck and scapular girdle pain. The patients had a flexible cervical kyphosis. Therefore, we decided to perform an anterior surgical approach. We performed a corpectomy C4–C5 in order to achieve the anterior decompression; we placed a titanium expansion mesh. DISCUSSION Cervical kyphosis can be flexible or fixed. Some authors have reported the use of anterior surgery only for flexible cervical kyphosis as discectomy and corpectomy. This approach is useful for anterior column load sharing however it is not required for deformity correction. CONCLUSION The anterior approach is a good surgical option in flexible cervical kyphosis. It is of primary importance the sagittal alignment of the cervical spine in order to decompress the nervous structures and to guarantee a long-term stability.

Purpose The aim of the study is to use an algorithm previously published to decide whether to perform open surgery or percutaneous surgery with short fixation in patients with thoraco-lumbar junction and lumbar spine fractures, and to compare retrospectively surgical and conservative options of treatment. Methods Between 2005 and 2009, two groups of 25 patients were analyzed to compare retrospectively surgical and conservative option of treatment to assess perception of pain and to evaluate quality of life during treatment, to evaluate how quickly patients return to work and to their daily activities, to evaluate patients’ satisfaction. X-ray controls were performed to evaluate the fusion rate at 3 and 6 months and CT scans at 6 months. Results The surgical group had a better functional recovery, a better quality of life and returned to work earlier in comparison to the conservative group. Conclusions We can conclude that the percutaneous procedure seems to give better results in terms of satisfaction and return to normal activities, although both procedures guarantee excellent fusion rates.

Objective: cervical spondylotic myelopathy is a progressive degenerative cervical spine disease. During later stages of segmental degeneration, kyphosis of the cervical spine can occur and further compromise the spinal cord and nerve roots. Optimal surgical approach remains controversial. The choice to perform an anterior, posterior or combined approach depends on: sagittal alignment, number of involved levels, main compression localization, and clinical status. The anterior approach is recommended when compression involves primarily anterior horn of spinal cord. Methods: between January 2001 and December 2005, 121 patients (42 F, 79 M, mean age 62 years) were operated for cervical spondylosis (98 myelopathy, 23 radiculopathy). Anterior surgical approach was performed in 81 patients. 63 patients were operated performing multilevel discectomy and fusion (ACDF) and 18 patients performing corpectomy and fusion and anterior plating (ACCF). Preoperative documentation collected consisted of cervical X-ray (static-dynamic), cervical spine TC, cervical MRI. Clinical documentation permitted us to obtained clinical status of each patient based on JOA, NDI and VAS. A Clinical and radiological follow-up was performed at 1 month, 3 months, 1 year, 6 years, 12 years. Results: the fusion rate was calculated based on the static and dynamic X-ray (flexion and extension position), only a little percentage of patients underwent CT scan. There were no significant differences between ACDF and ACCF in clinical outcome at 6 years evaluated by VAS and NDI. The rate of fusion at 6 years for 2 levels ACCF (92%) was higher than that for 2 levels ACDF (86%) but is not statistically significative. Conclusion: classifying degenerative disease and biomechanics feature, preoperatively in necessary to guide the surgeon to choose the best anterior approach for cervical spondylosis.

Awake craniotomy is the technique of choice in patients with brain tumours adjacent to primary and accessory language areas (Broca's and Wernicke's areas). Language testing should be aimed to detect preoperative deficits, to promptly identify the occurrence of new intraoperative impairments and to establish the course of postoperative language status. Aim of this case series is to describe our experience with a dedicated language testing work up to evaluate patients with or at risk for language disturbances undergoing awake craniotomy for brain tumour resection. Pre- and intra operative testing was accomplished with 8 tests. Intraoperative evaluation was accomplished when patients were fully cooperative (Ramsey < 3). Postoperative evaluation was scheduled at early (within 21 days) and long-term follow-up (3–6 months). Twenty consecutive patients were prospectively recruited. Preoperative language testings were normal in 9 patients (45%), showed mild to moderate language deficit in 8 (40%) and seve...

Background context The cervicothoracic junction (CTJ) is always a difficult area for anterior approaches. Among them, low anterior cervical approach alone or combined with manubriotomy is the most frequently used. Purpose To study the need of manubriotomy. Study design/setting Comparison of last guidelines proposed in literature. Patient sample Seven patients treated between March 2010 and March 2011. Methods All the patients were scanned on with computed tomography and magnetic resonance of the spinal column before surgery. Measurements by Teng and Karikari were applied in all the cases. An illustrative case is showed. Results The anterior approaches to the CTJ are reviewed. The most recent guidelines by Teng and Karikari are easy to apply and careful. The results obtained were the same in all the cases with good outcome. Conclusions Manubriotomy permits a good exposure of the CTJ area with a low rate of complications. Either Teng and Karikari's guidelines can be used to estabilish the need of manubriotomy.

Ballism consists of violent flinging limb movements due to nvoluntary, arrhythmic proximal muscles contractions, usually nvolving only upper extremities of one side of the body (hemibalism). The arm is thrown into space and projected forward and ideways with flexion and rotation on its axis. Like the chorea, the emiballism generates phasic discharges and short synchronous otor unit potentials in the agonist muscles without activation of he antagonists. It is generally caused by injuries to the subthalamic ucleus of Luys or, more extensively, to the basal ganglia such as schemic or hemorrhagic infarctions, diencephalic tumors, inflamations and metabolic paraneoplastic syndromes [1]. Hemiballism esponds in part to neuroleptics. Primary or secondary cortical or subcortical brain tumors usully provoke seizures, focal neurological deficits, higher functions mpairments, or headache [2]. Cortical masses responsible for xtrapyramidal symptoms are not known in the literature. Rarely, arge intracranial lesions may cause movement disorders through mechanism of direct mechanical compression or torsion of the asal ganglia [1,2]. Two cases of small convexity meningiomas just bove the pre-motor cortex causing tremors which disappeared fter tumor removal have been reported [3].