Intraforaminal ozone therapy and particular side effects: preliminary results and early warning.

BACKGROUND: The term "low back pain syndrome" represents a complex nosological entity. The therapeutic approach is often only symptomatic and not etiologic. METHODS: Since 2013, 186 patients (97 males and 89 females, mean age 59.8 years) have undergone microsurgery for lumbar disc hernia or lumbar segmental stenosis. Among these patients, 23 had been previously treated with ozone therapy by the intraforaminal approach and 28 by intraforaminal steroid injections in other hospitals between 12 and 24 months before our clinical evaluation. These patients received 16 applications in an 8-week period (standard therapy). RESULTS: During the surgery, many hard adhesions between the soft tissues and bony structures were unexpectedly discovered. In particular, it was noted that the root contracted and had firm adhesions to the dural sac and/or fragmented disc, which were difficult to resolve. These specific pathological patterns were observed only in the patients who received ozone injections by the intraforaminal approach. We did not find any pathological abnormalities in the patients who did not receive any injections or who received intraforaminal steroid injections. Thus, we could exclude that the tissue damage was due to the mechanical action of the needle. CONCLUSION: It is important to assert that ozone therapy procedures can be associated with several major complications. Therefore, performing a revision of the guidelines and protocols for ozone therapy application is indispensable.

Corpectomy and expandable cage replacement versus third generation percutaneous augmentation system in case of vertebra plana: rationale and recommendations.

BACKGROUND: To evaluate the role of third generation percutaneous vertebral augmentation systems (Spine Jack®) as alternative to the corpectomies and expandable cages replacement (X-Core® Adjustable VBR System) in the treatment of vertebra plana (VP) as complication of the osteoporosis vertebral fracture (OVF). METHODS: Spine Jack® is a new device for mechanical kyphoplasty (MK). It is a titanium implant designed to restore the height of the vertebral body in OVF, primary or secondary bone tumors, or traumatic fractures. The X-Core® adjustable VBR System is a vertebral body replacement device indicated for use in the thoracolumbar spine (T1 to L5). The preoperative radiographic exams, computed tomography (CT), and magnetic resonance imaging (MRI) were performed in all cases. Clinical outcome measures included preoperative and postoperative Oswestry Disability Index (ODI), Visual Analog Scale pain score (VAS), neurologic examination, complications, estimated blood loss, and operating time. Postoperative radiographic evaluations were made at 1, 6, and 12 months. RESULTS: The anterior and middle column reconstruction by Spine Jack represents a valid alternative to the corpectomy in the patients affected by VP, especially in case elderly and/or high operative risk. In case of Spine Jack use, the correct indications must be respected: the hyperintense signal in STIR MRI sequences to the level of the fractures must be present. The eventual posterior spinal cord compression represents a relative contraindication. In case it would be superior to 1/3 and 2/3 respectively in case of fractures level above and below the spinal cord, a direct posterior spinal cord decompression must be performed. CONCLUSIONS: Avoiding the corpectomy, it is possible to reduce the operating time and the associated risks, as well as reducing blood loss.

Spontaneous corpectomy and anterior arthrodesis in lumbar spine: how Ankylosing Spondylitis can resolve a vertebral fracture.

Between the 80% and 90% of vertebral fractures in over 65 years people are due to osteoporosis. Over the 30% of patients affected by vertebral osteoporosis fractures needs of surgical treatment and the 12% presents complications requiring an invasive surgical approach. We report an unusual case of spontaneous corpectomy and anterior arthrodesis occurred in a patient suffering from Ankylosing Spondylitis. This event invites us to reflect about the magnitude of the biological power of the bone healing, even in adverse conditions.

Third-generation percutaneous vertebral augmentation systems.

Currently, there is no general consensus about the management of osteoporotic vertebral fractures (OVF). In the past, conservative treatment for at least one month was deemed appropriate for the majority of vertebral fractures. When pain persisted after conservative treatment, it was necessary to consider surgical interventions including: vertebroplasty for vertebral fractures with less than 30% loss of height of the affected vertebral body and kyphoplasty for vertebral fractures with greater than 30% loss of height. Currently, this type of treatment is not feasible. Herein we review the characteristics and methods of operation of three of the most common percutaneous vertebral augmentation systems (PVAS) for the treatment of OVF: Vertebral Body Stenting(®) (VBS), OsseoFix(®) and Spine Jack(®). VBS is a titanium device accompanied by a hydraulic (as opposed to mechanical) working system which allows a partial and not immediate possibility to control the opening of the device. On the other hand, OsseoFix(®) and Spine Jack(®) are accompanied by a mechanical working system which allows a progressive and controlled reduction of the vertebral fracture. Another important aspect to consider is the vertebral body height recovery. OsseoFix(®) has an indirect mechanism of action: the compaction of the trabecular bone causes an increase in the vertebral body height. Unlike the Vertebral Body Stenting(®) and Spine Jack(®), the OsseoFix(®) has no direct lift mechanism. Therefore, for these characteristics and for the force that this device is able to provide. In our opinion, Spine Jack(®) is the only device also suitable for the treatment OVF, traumatic fracture (recent, old or inveterate) and primary or secondary bone tumors.

The double tunnels technique: an alternative minimally invasive approach for carpal tunnel syndrome.

OBJECT: The purpose of this study was to assess the effectiveness and safety of an alternative minimally invasive technique for the treatment of carpal tunnel syndrome (CTS). METHODS: This was designed as a prospective, randomized, open-label, blinded end point evaluation (PROBE) study. The active comparison was double tunnels technique (DTT) (Group A, 110 patients) versus standard open decompression of the median nerve (control [Group B], 110 patients). Patient recruitment started in January 2011. The primary outcomes were the functional Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) scores and visual analog scale (VAS) scores for pain (pVAS) at Weeks 2 and 4, and at Months 3, 6, and 12. The secondary outcome was the aesthetics (aVAS) score at Weeks 2 and 4, and at Months 3, 6, and 12. RESULTS: The Student t-test and ANOVA were used, and the results were considered statistically significant if the p value was ≤0.05 for continuous variables. The DTT is a tissue-sparing approach that allows the surgeon to limit the length of the incision (0.6±0.05 cm) and to respect the palmar fascia and the subcutaneous tissue. Recovery from wrist pain, night pain, numbness, stiffness, and weakness was achieved more effectively and quickly compared with the standard approach. Better BCTSQ, pVAS, and aVAS scores were observed in Group A. CONCLUSIONS: The DTT is a safe and effective approach for the treatment of CTS. This technique entails faster recovery times, better aesthetic outcomes, and lower risks of complications.

Technical note: microdiscectomy and translaminar approach.

Lumbar disk herniation (LDH) is a degenerative pathology. Although LDH generally occurs without migration of the fragment to the levels above or below, in 10% of the cases, this circumstance might happen. In these cases, the standard interlaminar approach, described by Caspar cannot be performed without laminotomies, interlaminectomies, or partial or total facetectomies. The translaminar approach is the only "tissue-sparing" technique viable in cases of cranially migrated LDH encroaching on the exiting nerve root in the preforaminal zones, for the levels above L2-L3, and in the preforaminal and foraminal zones, for the levels below L3-L4 (L5-S1 included, if a total microdiscectomy is unnecessary). This approach is more effective than the standard one, because it resolves the symptoms; it is associated with less postoperative pain and faster recovery times without the risk of iatrogenic instability, and it can also be used in cases with previous signs of radiographic instability. The possibility to spare the flavum ligament is one of the main advantages of this technique. For these reasons, the translaminar approach is a valid technique in terms of safety and efficacy. In this article the surgical technique will be extensively analyzed and the tips and tricks will be highlighted.

Microdiskectomy and translaminar approach: minimal invasiveness and flavum ligament preservation.

Study Design Retrospective study. Objective The interlaminar approach represents the standard procedure for the surgical treatment of lumbar disk herniation (LDH). In the case of disk herniations in the "hidden zone," it could be necessary to perform laminotomies or laminectomies and partial or total facetectomies to remove the herniated fragment, thus leading to iatrogenic instability. The objective of the study is to evaluate the translaminar approach, in terms of the results, safety, and efficacy compared with the standard approach. Methods Since February 2010, 38 patients (26 men and 12 women; mean age 50.9 years, range 31 to 78 years) with LDH and migration into the hidden zone underwent a microdiskectomy by the translaminar approach. Using a micro-diamond dust-coated burr, a translaminar hole (8 ± 2 mm) was made, with subsequent exposure of the involved root and removal of the fragment. A clinical follow-up was performed at months 1, 3, 6, and 12 using the visual analog scale and the Oswestry Disability Index. All patients were evaluated according to the Spangfort score. Postoperative radiographic evaluations were done at 1, 6, and 12 months (dynamic radiographic studies done at 6 and 12 months). Results In over 60% of cases, L4-L5 was the involved disk. The visualization of the roots was successfully achieved through a translaminar approach. No laminotomies, laminectomies, or partial or total facetectomies were performed. The flavum ligament was always spared. A severe intraoperative bleeding episode occurred in 5% of the cases, due to involvement of the epidural veins, but it did not result in prolonged operative time (mean duration 60 ± 10 minutes). The patients showed a gradual resolution of the back pain and a progressive resolution of the radicular pain and the neurologic deficits. No sign of radiographic instability was documented during the follow-up. No infections, dural tears, or spinal cord injuries occurred. No revision surgery was performed. Conclusion The translaminar approach is the only tissue-sparing technique viable in case of cranially migrated LDH encroaching on the exiting nerve root in the preforaminal zones, for the levels above L2-L3, and in the preforaminal and foraminal zones, for the levels below L3-L4 (L5-S1 included, if a total microdiskectomy is not necessary). The possibility to spare the flavum ligament is one of the main advantages of this technique. According to our experience, the translaminar approach is an effective and safe alternative minimally invasive surgical option.

Deficit of social cognition in subjects with surgically treated frontal lobe lesions and in subjects affected by schizophrenia.

The ability of humans to predict and explain other people's behaviour by attributing independent mental states such as desires and beliefs to them, is considered to be due to our ability to construct a "Theory of Mind". Recently, several neuroimaging studies have implicated the medial frontal lobes as playing a critical role in a dedicated "mentalizing" or "Theory of Mind" network in the human brain. In this study we compare the performance of patients with right and left medial prefrontal lobe lesions in theory of mind and in social cognition tasks, with the performance of people with schizophrenia. We report a similar social cognitive profile between patients with prefrontal lobe lesions and schizophrenic subjects in terms of understanding of false beliefs, in understanding social situations and in using tactical strategies. These findings are relevant for the functional anatomy of "Theory of Mind".