Combined Anterior Odontoid Screw Fixation and C1-C2 Jefferson Fracture Anterior Fixation: A Step-by-Step Technical Note.

BACKGROUND: Combined triple atlas (C1)-axis (C2) fixation has been described in previous literature as a safe, effective, and minimally invasive procedure for complex atlas and odontoid fractures that allows for a greater range of motion compared with posterior approaches and atlanto-occipital fusion. However, it is rarely performed due to the occipital-cervical diastasis resulting from often-fractured C1 joint masses. No evidence-based consensus has been reached regarding the treatment of complex atlantoaxial fractures, and the choice of surgical strategy is based only on clinical experience. METHODS: We report the combined triple C1-C2 fixation technique with manual reduction of the joint masses during patient positioning on the operating table, which allowed for effective stabilization during a single surgical session. We describe our experience in the management of a 75-year-old patient presenting with an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. RESULTS: We provide a step-by-step guide for combined triple C1-C2 anterior fixation with manual fracture reduction and describe the clinical case of an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. CONCLUSIONS: Combined triple C1-C2 fixation represents a safe and efficient minimally invasive anterior approach for complex type II fractures of C1 with type II odontoid fractures. Manual reduction of the joint masses during patient positioning allows for effective stabilization in a single surgical session.

Extreme Lateral Interbody Fusion (XLIF) with Lateral Modular Plate Fixation: Preliminary Report on Clinical and Radiological Outcomes.

The lateral transpsoas approach (extreme lateral interbody fusion, or XLIF) allows surgeons to use various lordotic cage sizes to help restore intervertebral disk height, correct sagittal alignment, and improve fusion rates. The use of standalone devices has consistently raised doubts due to the high risk of complications and inadequate functional recovery that a circumferential arthrodesis can support. The recent introduction of a novel XLIF cage with adapted lateral plate fixation (XLPF) may further enhance the structural rigidity, consolidating the cage and plate into a singular modular entity. Nine patients from our surgical centers underwent a procedure of 1-level XLIF with XLPF in selected cases. We observed that XLPF does not extend the intraoperative footprint and provides immediate rigidity to the anterior column without any additional risk of complications and with minimal increased time compared to the traditional cage implant procedure. Although it has been shown that the use of interbody fusion cages with supplemental posterior fixation improves stabilization in all directions, the technique of standalone lateral cages may also have a place in spine surgery in that the stability may be sufficient in selected cases, such as junctional syndrome and in some forms of degenerative scoliosis.

Percutaneous pedicle screw fixation without arthrodesis of 368 thoracolumbar fractures: long-term clinical and radiological outcomes in a single institution.

PURPOSE: Traumatic thoracolumbar (TL) fractures are the most common vertebral fractures. Although a consensus on the preferred treatment is missing, percutaneous pedicle screw fixation (PPSF) has been progressively accepted as treatment option, since it is related to lower soft tissues surgical-injury and perioperative complications rate. This study aims to evaluate the long-term clinical-radiological outcomes after PPSF for TL fractures at a single tertiary academic hospital. METHODS: This is a retrospective cohort study. Back pain was obtained at preoperative, postoperative and final follow-up using Visual Analog Scale. Patient-reported outcomes, the Oswestry Disability Index and the 36-Item Short Form, were obtained to asses disability during follow-up. Radiological measures included Cobb angle, mid-sagittal index, sagittal index (SI) and vertebral body height loss. A multivariate regression analysis on preoperative radiological features was performed to investigate independent risk factors for implant failure. RESULTS: A total of 296 patients with 368 TL fractures met inclusion criteria. Mean follow-up was 124.3 months. The clinical and radiological parameters significantly improved from preoperative to last follow-up measurements. The multivariate analysis showed that Cobb angle (OR = 1.3, p < 0.001), SI (OR = 1.5, p < 0.001) and number of fractures (OR = 1.1, p = 0.05), were independent risk factors for implant failure. The overall complication rate was 5.1%, while the reoperation rate for implant failure was 3.4%. CONCLUSIONS: In our case series, PPSF for TL injuries demonstrated good long-term clinical-radiological outcomes, along with low complication and reoperation rates. Accordingly, PPSF could be considered as a valuable treatment option for neurologically intact patients with TL fractures. Additionally, in this cohort, number of fractures ≥ 2, Cobb angle ≥ 15° and sagittal index ≥ 21° were independent risk factors for implant failure.

Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Expandable Cages: Increased Risk of Late Postoperative Subsidence Without a Real Improvement of Perioperative Outcomes: A Clinical Monocentric Study.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is one of several approaches to lumbar interbody fusion that has proven to be a safe and effective treatment for symptomatic lumbar degenerative disease The clinical outcomes of MIS-TLIF are generally favorable, but there is still controversy regarding its ability to restore sagittal alignment. For this reason, expandable transforaminal lumbar interbody fusion cages have been developed and designed to improve ability to restore disc height and segmental lordosis. The use of expandable cages in transforaminal lumbar interbody fusion has increased drastically; however, it is not clear how effective cage expansion is in regard to disc space lordosis, distraction, and long-term outcome. METHODS: We reviewed a cohort of patients with symptomatic lumbar degenerative disc pathology who underwent MIS-TLIF at our institution. We compared clinical and radiographic outcomes of expandable versus nonexpandable cage use in MIS-TLIF focusing on mean changes in segmental lordosis, disc height, and postoperative complications. The results were compared with other studies reported in the international literature. RESULTS: Mean change in segmental lordosis was not significantly different between the 2 groups. A significantly higher rate of postoperative subsidence was demonstrated in the expandable cage group. CONCLUSION: This study established that expandable cage use in single-level transforaminal lumbar interbody fusion did not reduce the rate of postoperative complications, but rather significantly increased a patient's risk of postoperative subsidence. Expandable cages do not presently demonstrate improved clinical outcomes or improved sagittal alignment compared with static cages.

Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery.

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.

Spinal cordectomy for the management of thoracic malignant intraspinal tumors in paraplegic or irreversibly, severely paraparetic patients: A technical remark.

BACKGROUND: Malignant Intramedullary Spinal Cord Tumor are a relatively uncommon entity affecting patients whose prognosis is quickly and relentlessly dismal. Since the '50s Spinal Cordectomy' has been advocated for the surgical management of these conditions, but to date, no standard operative protocol has been reported yet. OBJECTIVE: Although apparently "easy", burdened by virtually no further risk for the neurological function in paraplegic or severely paraparetic patients, SCt conceals notable pitfalls and surgical problems that are to date not yet completely discussed. The objective of the present paper is therefore to report a detailed stepwise description of the surgical technique. METHODS AND RESULTS: SCt addresses the problem of reaching a surgical radicality in patients whom neurological preoperative conditions have already irreversibly declined to a deep nonfunctional motor impairment and whose preoperative Brain MRI scan rules out intracranial seeding. The dural sac along with the radicular pouches must be considered as possible seeding and recurrence locations therefore such structure should be "en-bloc" removed. The cranial medullary end of the resection should be identified on the ground of the preoperative MRI and intraoperatively confirmed with fresh histological examinations ruling out the presence of tumor cells above the cordectomy. Due to the topographic and functional medullary arterial anatomy, no SCt should be performed above T3. The risk of postoperative sagittal imbalance is high and therefore a concurrent posterior vertebral stabilization is required. CONCLUSION: Spinal Cordectomy is a safe and feasible "last chance" treatment to prolong survival in paraplegic or severely paraparetic patients.

Minimally Invasive Surgery for the Treatment of Traumatic Monosegmental Thoracolumbar Burst Fractures: Clinical and Radiologic Outcomes of 144 Patients With a 6-year Follow-Up Comparing Two Groups With or Without Intermediate Screw.

STUDY DESIGN: This was a retrospective study of the clinical and radiologic outcomes of traumatic thoracolumbar (TL) burst fractures. OBJECTIVES: We aimed to evaluate the clinical and radiologic outcomes after 6 years of follow-up of 144 patients with monosegmental TL burst fractures treated with percutaneous short-segment pedicle screw fixation, comparing two groups with versus without placement of an intermediate screw at the fractured vertebra. SUMMARY OF BACKGROUND DATA: Traumatic TL fractures are the most common vertebral fractures, especially at the TL junction (T10-L2). Minimally invasive surgery (MIS) is a valuable treatment option for traumatic TL burst fractures. MATERIALS AND METHODS: The clinical outcomes and radiologic parameters (Cobb angle, midsagittal index, and sagittal index) of 144 patients with traumatic monosegmental TL fractures treated with MIS were evaluated preoperatively, postoperatively, and after 3 and 6 years of follow-up. Patients were categorized into a nonintermediate screw group (nISG) and an intermediate screw group (ISG), and the groups were compared. RESULTS: There were 71 patients (49.3%) in the nISG and 73 patients (50.7%) in the ISG. The radiologic parameters improved significantly more from the preoperative evaluation to the 6-year follow-up in the ISG than in the nISG (P<0.025). There were no significant differences in the mean Oswestry Disability Index (ODI) and Visual Analog Scale scores at the 6-year follow-up between the ISG and the nISG: 15.6% (ISG) versus 16.8% (nISG) for ODI (P<0.1) and 2.2 (ISG) versus 2.4 (nISG) for Visual Analog Scale score (P<0.85) (P<0.73). CONCLUSIONS: MIS showed good clinical outcomes 6 years after surgery in both the ISG and the nISG. The additional intermediate screw significantly improved radiologic parameters but not clinical outcomes.

The Real Impact of an Intraoperative Magnetic Resonance Imaging-Equipped Operative Theatre in Neurovascular Surgery: The Sapienza University Experience.

The fundamental role of technological instruments in contemporary Neurosurgery is undisputed, and intraoperative magnetic resonance imaging (MRI) represents one of the best examples. The use of a modern high-field magnet and the possibility to match the MRI with an operative microscope and an integrated neuronavigation system has led to successful results in the surgical treatment of different diseases. At our institute, we have performed surgery routinely with the aid of intraoperative MRI over the last 15 years. The aim of this article is to report our experience in the management of neurovascular lesions with the use of this device. We experienced that intraoperative MRI enhanced the surgical experience, leading to an improved postoperative outcome in the treatment of different lesions, such as arteriovenous malformations, dural arteriovenous fistulas, intracranial cavernous angiomas, and intracranial aneurysms. There are several advantages provided by the use of intraoperative MRI. The use of intraoperative MRI coupled with the planning station and the neuronavigation system allows one to obtain preoperative 3-dimensional reconstructions of the vessels, which aids the definition of the anatomy of each neurovascular lesion. Furthermore, the possibility performing an intraoperative scan allows a comparison with preoperative images and, subsequently, the updating of the surgical strategy. Intraoperative diffusion-weighted imaging can detect possible territorial ischemia that would be amenable to intensive treatment. Although increased costs, increased surgical times, increased anesthesiology times, and the possible increased risk of surgical infection may represent some major limitation, the use of intraoperative MRI-equipped operative theaters with integrated neuronavigation systems can prove extremely helpful in the management of neurovascular conditions.

Comparison of pure lateral and oblique lateral inter-body fusion for treatment of lumbar degenerative disk disease: a multicentric cohort study.

PURPOSE: The most effective interbody fusion technique for degenerative disk disease (DDD) is still controversial. The purpose of our study is to compare pure lateral (LLIF) and oblique lateral (OLIF) approaches for the treatment of lumbar DDD from L1-L2 to L4-L5, in terms of clinical and radiological outcomes. MATERIALS AND METHODS: 45 patients underwent lumbar interbody fusion for pure lumbar DDD from  L1-L2 to L4-L5 through LLIF (n = 31, mean age 62.1 years, range 45-78 years) or OLIF (n = 14, mean age 57.4 years, range 47-77 years). Clinical evaluations were performed with ODI and SF-36 tests. Radiological assessment was based on the modification of coronal segmental Cobb angles and segmental lumbar lordosis (L1-S1). RESULTS: On ODI and SF-36, all patients presented good results at follow-up, with 26% the difference between the LIF and OLIF groups on ODI scale in the post-operative period, and 3.9 and 8.8 points difference on physical and mental SF-36 in favor of OLIF. Radiological parameters improved significantly in both groups. The mean correction was 6.25° for cCobb (11.3° in LIF and 1.9° in OLIF), 2.5° for sLL (2° in LLIF and 4° in OLIF). CONCLUSIONS: LLIF and OLIF represent safe and effective MIS procedures for the treatment of lumbar DDD. LLIF had some risks of motor deficit and monitoring is mandatory, though it addressed more the coronal deformities. OLIF did not imply risks for motor deficits, but attention should be paid to vascular anatomy. It was more effective in kyphotic segmental deformities. These slides can be retrieved under Electronic Supplementary material.

A purely functional Imaging based approach for transcortical resection of lesion involving the dominant atrium: Towards safer, imaging-guided, tailored cortico-leucotomies.

BACKGROUND AND STUDY OBJECT: The Dominant Atrium (DA) is a crossroad of eloquent white matter bundles difficult to preserve with a standard "anatomical" approach. The aim of this work is to evaluate the results of a cohort of patients who underwent surgery with the aid of a purely functional MRI and DTI-based approach. MATERIALS AND METHODS: 43 patients suffering from lesions involving the DA have been included in the final cohort and studied in regards to quality of life (KPS); a special attention was lent on the incidence of new or worsening of preexisting neurological deficits, with a focus on motor, visual and speech disturbances after the surgical treatment. Patient, surgery and lesion-related data were recorded to identify the relationships with outcome. Eloquent areas fMRI and the course of Arcuate Fasciculus (AF), Inferior frontooccipital fasciculus (IFOF), Optic radiation (OR) and corticospinal tract (CST) have been investigated with preoperative MRI sequences and DTI reconstruction. RESULTS: The final cohort consisted of 43 patients, 19 males and 24 females; average age was 56.8 years. We recorded 9 transient and 3 permanent postoperative deficits, only one of those was caused by an edema interference with DTI reconstruction. Preoperative functional status, histology and volume of the lesion proved to be independent factors affecting results. CONCLUSIONS: A purely functional surgical approach to the DA provided promising preliminary results. A direct DTI-fMRI visualization of the eloquent structures proximal to DA allows surgeon to conceive an ultra-precise and "tailored" cortico-leucotomy for an optimal exposure of the lesion.

Real Impact of Intraoperative Magnetic Resonance Imaging in Newly Diagnosed Glioblastoma Multiforme Resection: An Observational Analytic Cohort Study From a Single Surgeon Experience.

BACKGROUND: The goal of surgery for brain glioma is to maximize the extent of tumor resection, avoiding postoperative functional impairment. Intraoperative (Io) magnetic resonance imaging (MRI) has emerged as an effective tool to guide a safer glioma resection. The objective of this study is to assess the real impact of Io MRI in O-6-methylguanine-DNA methyltransferase and non-O-6-methylguanine-DNA methyltransferase methylated glioma surgery. METHODS: A total of 129 patients suffering glioblastoma who underwent craniotomy for tumor resection were retrospectively evaluated between March 2009 and January 2017 at 2 different affiliated hospitals of the same university. We compared a subgroup of 65 patients operated on without Io MRI (group A) with a second subgroup of 64 patients who underwent surgery with the aid of Io MRI (group B). Volumetric analyses of the extent of resection (EOR) were performed using gadolinium-enhanced T1-weighted imaging. All surgical procedures were performed by a single surgeon (the senior author). RESULTS: The average EOR increased from 86.23% ± 10.51% for group A to 94.01% ± 7.42% in patients included in group B. The secondary end points of this study were progression-free survival (PFS) and overall survival (OS). PFS was found to be 5.38 ± 2.32 months for group A versus 7.89 ± 2.75 months for group B. Regarding OS, the average value was 13.38 ± 4.06 months for group A versus 16.43 ± 3.41 months for group B. CONCLUSIONS: We can affirm that 1.5-T Io MRI is a safe and effective technique, and its use optimizes significantly both the extent of glioma resection and the survival of patients.

Completely Thrombosed Distal Middle Cerebral Artery Aneurysm Mimicking a Cavernous Angioma: Case Report and Review of the Literature.

BACKGROUND: Distal middle cerebral artery (MCA) aneurysms originate from branches of MCA distal to its main bifurcation or the peripheral branches. Distal MCA aneurysms are uncommon compared with saccular aneurysms, which develop along the proximal trunks of MCA. However, thrombotic aneurysms, characterized by organized intraluminal thrombus and solid mass, are frequently in the large and giant size range, whereas complete thrombosis of non-giant MCA aneurysms is very rare. CASE PRESENTATION: We present the clinical case of a 53 years-old woman with a completely thrombosed medium distal MCA aneurysm mimicking a cavernous angioma. She came to our emergency department after the onset of tinnitus and persistent headache. Magnetic resonance imaging performed subsequently showed a nodular mass surrounded by edema located in the temporal lobe with a homogeneous peripheral contrast enhancement. Furthermore, angiography showed regular flow in the MCA and confirmed the diagnosis of cavernous angioma. The patient underwent surgery, and the lesion was found to be a thrombosed aneurysm originating from the distal temporal branch of the left MCA (M2 segment). CONCLUSIONS: To our knowledge, this is the first report of a thrombosed distal medium MCA aneurysm that mimicked a cavernous angioma. The completely thrombosed aneurysm can be confused with intracranial lesions or cavernous malformations, which can have similar radiographic features without angiographic anomalies, so it is mandatory to consider the possibility of a thrombosed aneurysm for a correct differential diagnosis.

Motor Outcomes After Surgical Resection of Lesions Involving the Motor Pathway: A Prognostic Evaluation Scale.

BACKGROUND: Preservation of function is essential in surgical resection of lesions involving the motor pathways. The aim of this work is to evaluate the effect of anatomic features of lesions located in the motor pathway on neurologic and functional outcome. We propose an evaluation score to assess the risk of postoperative worsening. METHODS: A total of 92 patients suffering from lesions involving the motor pathways have been studied for what concerns motor functions (muscular strength scale [MRC]) after surgical treatment. Patient-related, surgery-related, and lesion-related data were recorded to identify relations with motor outcomes. Cortical surfacing of the lesion and amount of millimeters of interface between the lesion and corticospinal tract have been investigated with preoperative magnetic resonance imaging sequences and tractographic reconstructions. RESULTS: Means of the MRC Scale preoperative and 7 days postoperative were 3.6 ± 2.23 and 3.8 ± 2.28 for the upper limbs, and 4.1 ± 2.31 and 4.4 ± 2.33 for the lower limbs, respectively. Patients that were stable or improved at 7 days from surgery were 82.6%. The anatomic features investigated have been summed up in a single score (envelopment/surfacing [ES]). In cases of ES classes V and VI, a total cumulative predicted worsening rate was 24.2% and 14.8%, respectively. The risk of worsening was 1.682 times greater for the higher ES classes (IV-VI). CONCLUSIONS: The anatomic features of lesions are crucial in the prediction of motor outcome. The new proposed score (ES score) is useful to stratify motor function prognosis.

Primary Lymphomas of the Skull Base from a Neurosurgical Perspective: Review of the Literature and Personal Experience.

Primary lymphomas of the skull base are exceedingly rare and thus not commonly dealt with in everyday clinical practice. Primary diffuse large B cell lymphoma is the most commonly found (30-40% of primary non-Hodgkin lymphomas of the bone). This article reports a case of primary lymphoma of the skull base and reviews all the relevant literature in the PubMed, National Institutes of Health Library, and Google Scholar databases to outline the clinical, diagnostic, and surgical traits of this yet widely unexplored pathology. The incidence of cases peaks between 60 and 70 years of age; those affected tend to be mostly male. The clinical presentation of this pathology is usually abrupt with headache and acute deficit of cranial nerves that improves dramatically with intravenous corticosteroid therapy. The abducens nerve is most commonly involved. Imaging can be unclear because corticosteroid medications can significantly alter magnetic resonance imaging findings, at least in the early stages of the disease, similarly to what happens for primary brain lymphomas ("the ghost tumor"). Cavernous sinus, parasellar region, upper clivus, and Meckel cave are usually found to be already affected by the time a diagnosis can be made. The intracavernous internal carotid artery is usually encased by the lesion rather than displaced. Because of the anatomical pattern of primary lymphomas of the skull base and their well-known chemosensitivity, surgery is usually only used for diagnosis. Surgical approaches for primary lymphoma of the skull base include transcranial and transnasal-transsphenoidal endoscopy and microsurgery as well as other minimally invasive techniques. Due to the rarity of this neoplasm, there are no definitive data regarding the overall survival rate among patients.

Comparison of minimally invasive surgery with standard open surgery for vertebral thoracic metastases causing acute myelopathy in patients with short- or mid-term life expectancy: surgical technique and early clinical results.

OBJECT Spinal metastasis is common in patients with cancer. About 70% of symptomatic lesions are found in the thoracic region of the spine, and cord compression presents as the initial symptom in 5%-10% of patients. Minimally invasive spine surgery (MISS) has recently been advocated as a useful approach for spinal metastases, with the aim of decreasing the morbidity associated with more traditional open spine surgery; furthermore, the recovery time is reduced after MISS, such that postoperative chemotherapy and radiotherapy can begin sooner. METHODS Two series of oncological patients, who presented with acute myelopathy due to vertebral thoracic metastases, were compared in this study. Patients with complete paraplegia for more than 24 hours and with a modified Bauer score greater than 2 were excluded from the study. The first group (n = 23) comprised patients who were prospectively enrolled from May 2010 to September 2013, and who were treated with minimally invasive laminotomy/laminectomy and percutaneous stabilization. The second group (n = 19) comprised patients from whom data were retrospectively collected before May 2010, and who had been treated with laminectomy and stabilization with traditional open surgery. Patient groups were similar regarding general characteristics and neurological impairment. Results were analyzed in terms of neurological recovery (American Spinal Injury Association grade), complications, pain relief (visual analog scale), and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] QLQ-C30 and EORTC QLQ-BM22 scales) at the 30-day follow-up. Operation time, postoperative duration of bed rest, duration of hospitalization, intraoperative blood loss, and the need and length of postoperative opioid administration were also evaluated. RESULTS There were no significant differences between the 2 groups in terms of neurological recovery and complications. Nevertheless, the MISS group showed a clear and significant improvement in terms of blood loss, operation time, and bed rest length, which is associated with a more rapid functional recovery and discharge from the hospital. Postoperative pain and the need for opioid administration were also significantly less pronounced in the MISS group. Results from the EORTC QLQ-C30 and QLQ-BM22 scales showed a more pronounced improvement in quality of life at follow-up in the MISS group. CONCLUSIONS In the authors' opinion, MISS techniques should be considered the first choice for the treatment for patients with spinal metastasis and myelopathy. MISS is as safe and effective for spinal cord decompression and spine fixation as traditional surgery, and it also reduces the impact of surgery in critical patients. However, further studies are needed to confirm these findings.

Pure percutaneous pedicle screw fixation without arthrodesis of 32 thoraco-lumbar fractures: clinical and radiological outcome with 36-month follow-up.

PURPOSE: To evaluate the outcome of pure percutaneous fixation of unstable single level fractures at the thoraco-lumbar junction (A1 to B2 Magerl/AO Spine). METHOD: Neurological intact patients were included in a 2-year prospective study (follow-up 36 months). Two groups were considered: the group in which additional short bilateral screws in the fractured vertebra were placed was called lordorizing screw group (LSG), the other was called non lordorizing screw group (nLSG). Clinical outcome was evaluated using the SF-36, the Oswestry disability index and the recovery time needed to go back work. The following radiological parameters were also evaluated on the follow-up exams: the Mid-Sagittal Index, the Cobb's angle and the Sagittal Index. RESULTS: In the LSG, the correction values of MSI, Cobb's angle and SI were statistically significantly higher than in nLSG. CONCLUSION: When feasible we recommend a pure percutaneous short segment pedicle screw fixation adding a lordorizing screw.

Temporal window of metabolic brain vulnerability to concussions: mitochondrial-related impairment--part I.

OBJECTIVE: In the present study, we investigate the existence of a temporal window of brain vulnerability in rats undergoing repeat mild traumatic brain injury (mTBI) delivered at increasing time intervals. METHODS: Rats were subjected to two diffuse mTBIs (450 g/1 m height) with the second mTBI delivered after 1 (n = 6), 2 (n = 6), 3 (n = 6), 4 (n = 6), and 5 days (n = 6) and sacrificed 48 hours after the last impact. Sham-operated animals were used as controls (n = 6). Two further groups of six rats each received a second mTBI after 3 days and were sacrificed at 120 and 168 hours postinjury. Concentrations of adenine nucleotides, N-acetylated amino acids, oxypurines, nucleosides, free coenzyme A, acetyl CoA, and oxidized and reduced nicotinamide adenine dinucleotides, oxidized nicotinamide adenine dinucleotide phosphate, and reduced nicotinamide adenine dinucleotide, reduced nicotinamide adenine dinucleotide phosphate nicotinic coenzymes were measured in deproteinized cerebral tissue extracts (three right and three left hemispheres), whereas the gene expression of N-acetylaspartate acylase, the enzyme responsible for N-acetylaspartate (NAA) degradation, was evaluated in extracts of three left and three right hemispheres. RESULTS: A decrease of adenosine triphosphate, adenosine triphosphate/adenosine diphosphate ratio, NAA, N-acetylaspartylglutamate, oxidized and reduced nicotinamide adenine dinucleotide, reduced nicotinamide adenine dinucleotide, and acetyl CoA and increase of N-acetylaspartate acylase expression were related to the interval between impacts with maximal changes recorded when mTBIs were spaced by 3 days. In these animals, protracting the time of sacrifice after the second mTBI up to 1 week failed to show cerebral metabolic recovery, indicating that this type of damage is difficult to reverse. A metabolic pattern similar to controls was observed only in animals receiving mTBIs 5 days apart. CONCLUSION: This study shows the existence of a temporal window of brain vulnerability after mTBI. A second concussive event falling within this time range had profound consequences on mitochondrial-related metabolism. Furthermore, because NAA recovery coincided with normalization of all other metabolites, it is conceivable to hypothesize that NAA measurement by 1H-NMR spectroscopy might be a valid tool in assessing full cerebral metabolic recovery in the clinical setting and with particular reference to sports medicine in establishing when to return mTBI-affected athletes to play. This study also shows, for the first time, the influence of TBI on acetyl-CoA, N-acetylaspartate acylase gene expression, and N-acetylaspartylglutamate, thus providing novel data on cerebral biochemical changes occurring in head injury.

Temporal window of metabolic brain vulnerability to concussions: oxidative and nitrosative stresses--part II.

OBJECTIVE: In the present study, we investigated the occurrence of oxidative and nitrosative stresses in rats undergoing repeat mild traumatic brain injury (mTBI) delivered with increasing time intervals. METHODS: Rats were subjected to two diffuse mTBIs (450 g/1 m height), with the second mTBI delivered after 1 (n = 6), 2 (n = 6), 3 (n = 6), 4 (n = 6), or 5 days (n = 6). The rats were sacrificed 48 hours after the last mTBI. Sham-operated animals were used as controls (n = 6). Concentrations of biochemical indices of oxidative stress (malondialdehyde, ascorbic acid, reduced and oxidized glutathione) and nitrosative stress (nitrite, nitrate) were synchronously measured by high-performance liquid chromatography in deproteinized tissue extracts (three right + three left hemispheres for each group of animals). RESULTS: Increase of malondialdehyde, reduced/oxidized glutathione ratio, nitrite, nitrate, and decrease of ascorbic acid and glutathione were dependent on the interval between impacts with maximal changes recorded when mTBIs were spaced by 3 days. Biochemical markers of oxidative and nitrosative stresses were near control levels only in animals receiving mTBIs 5 days apart. CONCLUSION: This study shows the remarkable negative contribution of reactive oxygen species overproduction and activation of inducible nitric oxide synthase in repeat mTBI. Because these effects were maximal when mTBIs were spaced by 3 days, it can be inferred that occurrence of a second mTBI within the temporal window of brain vulnerability not only causes profound derangement of mitochondrial functions, but also induces sustained oxidative and nitrosative stresses. Both phenomena certainly play a major role in the overall brain tissue damage occurring under these pathological conditions.

Hypothesis of the postconcussive vulnerable brain: experimental evidence of its metabolic occurrence.

OBJECTIVE: We evaluated the effects of two consecutive concussive injuries on brain energy metabolism and N-acetylaspartate (NAA) to investigate how the temporal interval between traumatic events influences overall injury severity. METHODS: Rats were injured to induce diffuse traumatic brain injury (TBI) (mild, 450 g/1 m; severe, 450 g/2 m). In two groups, two mild TBIs were delivered in 3- or 5-day intervals. Three additional animal groups were used: single mild TBI, single severe TBI, and sham. All animals were killed 48 hours postinjury. Adenosine 5'-triphosphate (ATP), adenosine diphosphate, and NAA concentrations were analyzed with high-performance liquid chromatography on deproteinized whole brain extracts. RESULTS: In control animals, the NAA concentration was 9.17 +/- 0.38 micromol/g wet weight, the ATP concentration was 2.25 +/- 0.21 micromol/g wet weight, and the ATP-to-adenosine diphosphate ratio was 9.38 +/- 1.23. These concentrations decreased to 6.68 +/- 1.12 micromol/g wet weight, 1.68 +/- 0.24 micromol/g wet weight, and 6.10 +/- 1.21 micromol/g wet weight, respectively, in rats that received two mild TBIs at a 5-day interval (P < 0.01; not different from results in rats with single mild TBI). When a second TBI was delivered after 3 days, the NAA concentration was 3.86 +/- 0.53 micromol/g wet weight, the ATP concentration was 1.11 +/- 0.18 micromol/g wet weight, and the ATP-to-adenosine diphosphate ratio was 2.64 +/- 0.43 (P < 0.001 versus both controls and 3-day interval; not different from rats receiving a single severe TBI). CONCLUSION: The biochemical modification severity in double TBI is dependent on the interval between traumatic events, which demonstrates the metabolic state of the vulnerable brain after mild TBI. These data support the hypothesis of the application of proton magnetic resonance spectroscopy to measure NAA as a possible tool to monitor the full recovery of brain metabolic functions in the clinical setting, particularly in sports medicine.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair.

BACKGROUND: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. METHODS: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. RESULTS: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. CONCLUSIONS: Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.