Interscapular Pain after Anterior Cervical Discectomy and Fusion: Does Zygapophyseal Joints over Distraction Play a Role?

Introduction: Anterior cervical discectomy and fusion (ACDF) for cervical disc herniation (CDH) is commonly performed. Specific post-operative complications include dysphagia, dysphonia, cervicalgia, adjacent segment disorder, cage subsidence, and infections. However, interscapular pain is commonly reported by these patients after surgery, although its mechanisms have not been clarified yet. Methods: This retrospective series of 31 patients undergoing ACDF for CDH at a single Academic Hospital. Baseline and post-operative clinical, radiological, and surgical data were analyzed. The linear regression analysis was conducted to identify any factor independently influencing the incidence rate of post-operative interscapular pain. Results: The mean age was 57.6 ± 10.8 years, and the M:F ratio was 2.1. Pre-operative mean VAS-arm was 7.15 ± 0.81 among the 20 patients reporting brachialgia, and mean VAS-neck was 4.36 ± 1.43 among those 9 patients reporting cervicalgia. At 1 month, interscapular pain was still reported by 8 out of the 17 patients who experienced it post-operatively, and it was recovered in all patients after 2 months. The regression analysis showed that interscapular pain was not directly associated with age (p = 0.74), gender (p = 0.46), smoking status (p = 0.44), diabetes (0.42), pre-operative brachialgia (p = 0.21) or cervicalgia (p = 0.48), symptoms duration (p = 0.13), baseline VAS-arm (p = 0.11), VAS-neck (p = 0.93), or mJOA (p = 0.63) scores, or disc height modification (p = 0.90). However, the post-operative increase in the mean zygapophyseal joint rim distance was identified as an independent factor in determining interscapular pain (p = 0.02). Conclusions: Our study revealed that the onset of interscapular pain following ACDF may be determined by over distraction of the zygapophyseal joint rim. Then, proper sizing of prosthetic implants could reduce this painful complication.

Atlantoaxial Anterior Transarticular Screw Fixation: Indications and Surgical Technique.

Posterior atlantoaxial screw fixation is a widely adopted therapeutic option for C1-C2 instability secondary to fractures or dislocation, degenerative diseases, or tumors at this level. Anterior transarticular screw fixation (ATSF) is an effective alternative to the posterior approaches, presenting several advantages despite being scarcely known and rarely chosen.In this chapter, we describe the ATSF step by step, illustrating its variations reported in literature, and we critically analyze the several advantages and contraindications of this technique. Moreover, we provide a list of tips and tricks on the surgical procedure, including critical operating room settings-the result of more than 10 years of experience in the field by a senior author.ATSF is a valid strategy for the treatment of different diseases occurring at the level of the atlantoaxial complex that needs consideration. Given the significant learning curve of this strategy, some hints may be essential to begin introducing this technique in the personal armamentarium of a spine surgeon so that they can perform ATSF safely and effectively.

Two-Level Corpectomy and Fusion vs. Three-Level Anterior Cervical Discectomy and Fusion without Plating: Long-Term Clinical and Radiological Outcomes in a Multicentric Retrospective Analysis.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing. METHODS: The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes. RESULTS: Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction ≥ 1° (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted. CONCLUSIONS: Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated.

Stand-Alone Oblique Lumbar Interbody Fusion (OLIF) for the Treatment of Adjacent Segment Disease (ASD) after Previous Posterior Lumbar Fusion: Clinical and Radiological Outcomes and Comparison with Posterior Revision Surgery.

Background: Radiological evidence of adjacent segment disease (ASD) has been reported to have a prevalence of more than 30% and several risk factors have been reported. The aim of this study is to evaluate the clinical and radiological outcomes of patients with symptomatic ASD treated with stand-alone OLIF and compare results with a posterior revision surgery cohort. Methods: This is a retrospective case-control study. Clinical-patient-reported outcomes were obtained at preoperative, postoperative and final follow-up visits using the Short Form (SF-36) scale, the Oswestry Disability Index (ODI) and the visual analog scale (VAS). Radiological measures include lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental coronal Cobb angle and intervertebral disc height (DH). The data are compared with a retrospective series of patients that underwent a posterior revision surgery for ASD. Results: Twenty-eight patients in the OLIF group and 25 patients in the posterior group meet inclusion criteria. The mean ages at the time of the surgery are 65.1 years and 67.5, respectively. The mean follow-up time is 36.1 months (range of 14-56). The clinical outcomes significantly improve from preoperative values from the surgery in both groups. The radiological parameters are significantly improved postoperatively and were maintained at the last follow-up in both groups. A statistically significant difference is observed between the two groups for minor complication rate, length of surgery, blood loss and DH restoration. Conclusions: Stand-alone OLIF is an effective and safe technique with low morbidity and complication rates for the treatment of selected patients with symptomatic ASD following a previous lumbar fusion.

Percutaneous carbon-PEEK instrumentation for spine tumors: a prospective observational study.

BACKGROUND: Minimally invasive spine surgery (MISS) has been progressively accepted as a useful approach for spine tumors. Recently released carbon-PEEK implants have been already reported as effective in open surgeries for spine tumors. This study aimed to evaluate the feasibility, surgical, clinical and radiological outcomes of a new percutaneous carbon-PEEK instrumentations for spine tumors. METHODS: This is a prospective case-control observational study. Demographical, clinical, surgical, and radiological data were collected from May 2018 to August 2019. Visual Analogue Scale for back pain (VAS), the Oswestry Disability Index (ODI) Questionnaire, EORTC QLQ-C30 questionnaire for quality of life, and ASIA Impairment Scale (AIS) were collected before surgery and at 6 weeks and follow-up (FU) visits. Data were compared with the control group, a retrospective series of 23 metastatic patients that underwent titanium pedicle screw fixation. RESULTS: Twenty-one patients met inclusion criteria. Mean age was 59.2 years (range, 35-78) and mean FU was 14.2 months (7-22). Thoracic spine was involved in 14 (66.7%) cases, lumbar spine in 7 (33.3%). The mean length of surgery was 75 (42-185) minutes, mean blood loss was 90ml (50-215) and every patient was mobilized within 24 hours after surgery. The VAS (8.3±1.1 to 2.9±1.0, P<0.05) and ODI (54.6±11.7 to 25.1±5.4, P<0.05) scores significantly improved over follow-up. AIS improved in 7 (33.3%) patients and remained unchanged in 14 (66.7%). The EORTC QLQ-C30 global health/QoL, functional and symptomatic scales significantly improved postoperatively and at the last follow-up. Only two minor complications (9.5%) were recorded. No statistically significant difference was observed between the two groups related to clinical, radiological outcomes, complications rate and implant failure. CONCLUSIONS: Percutaneous Carbon/PEEK implants could be considered as alternative to standard titanium implants in oncological patients, according to their lower rate of MRI artifacts, facilitating radiological FU and adjuvant radiotherapy. Further clinical trials and biomechanical evaluations are needed to confirm our preliminary results.

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.

The Potential Role of Dysregulated miRNAs in Adolescent Idiopathic Scoliosis and 22q11.2 Deletion Syndrome.

Background: Adolescent idiopathic scoliosis (AIS), affecting 2-4% of adolescents, is a multifactorial spinal disease. Interactions between genetic and environmental factors can influence disease onset through epigenetic mechanisms, including DNA methylation, histone modifications and miRNA expression. Recent evidence reported that, among all clinical features in individuals with 22q11.2 deletion syndrome (DS), scoliosis can occur with a higher incidence than in the general population. Methods: A PubMed and Ovid Medline search was performed for idiopathic scoliosis in the setting of 22q11.2DS and miRNA according to PRISMA guidelines. Results: Four papers, accounting for 2841 individuals, reported clinical data about scoliosis in individuals with 22q11.2DS, showing that approximately 35.1% of the individuals with 22q11.2DS developed scoliosis. Conclusions: 22q11.2DS could be used as a model for the study of AIS. The DGCR8 gene seems to be essential for microRNA biogenesis, which is why we propose that a possible common pathological mechanism between scoliosis and 22q11.2DS could be the dysregulation of microRNA expression. In the current study, we identified two miRNAs that were altered in both 22q11.2DS and AIS, miR-93 and miR-1306, thus, corroborating the hypothesis that the two diseases share common molecular alterations.

Next-Generation Sequencing Comparative Analysis of DNA Mutations between Blood-Derived Extracellular Vesicles and Matched Cancer Tissue in Patients with Grade 4 Glioblastoma.

The biological heterogeneity of glioblastoma, IDH-wildtype (GBM, CNS WHO grade 4), the most aggressive type of brain cancer, is a critical hallmark, caused by changes in the genomic mutational asset and influencing clinical progression over time. The understanding and monitoring of the mutational profile is important not only to reveal novel therapeutic targets in this set of patients, but also to ameliorate the clinical stratification of subjects and the prognostic significance. As neurosurgery represents the primary technique to manage GBM, it is of utmost importance to optimize alternative and less invasive methods to monitor the dynamic mutation profile of these patients. Extracellular vesicles (EVs) are included in the liquid biopsy analysis and have emerged as the biological mirror of escaping and surviving mechanisms by many tumors, including glioblastoma. Very few studies have investigated the technical feasibility to detect and analyze the genomic profile by Next-Generation Sequencing (UMI system) in circulating EVs of patients with grade IV glioblastoma. Here, we attempted to characterize and to compare the corresponding matched tissue samples and potential variants with pathogenic significance of the DNA contained in peripheral-blood-derived EVs. The NGS analysis has revealed that patients with grade IV glioblastoma exhibited lesser DNA content in EVs than controls and that, both in EVs and matched cancer tissues, the NF1 gene was consistently mutated in all patients, with the c.2568C>G as the most common pathogenic variant expressed. This study supports the clinical utility of circulating EVs in glioblastoma as an eligible tool for personalized medicine.

Referencing for anterior atlantoaxial trans-articular osteosynthesis: a radiological study and proposal of a decisional algorithm.

PURPOSE: Anterior trans-articular C1-C2 screw placement can be considered as a surgical alternative in different conditions affecting the atlantoaxial region. While its rigidity is similar to posterior Magerl and Harms techniques, it also provides some surgical advantages. However, the literature lacks papers exhaustively describing indication criteria, surgical steps, and pitfalls. METHODS: This is a radiological study on 100 healthy subjects. Thin-layer CT scans of the craniovertebral junction were retrieved from the institutional database. The coronal inclination of the C1-C2 joint rim and the depth of the entry point of the screw with respect to the anterior profile of C2 were measured. The antero-posterior and the medio-lateral surgical corridors for the screw placement, and the wideness of the target area on the upper surface of C1 were also measured. RESULTS: The multivariate analysis showed that the coronal inclination of the C1-C2 articular joint rim strongly influences the surface extension of the C1 target area; the depth of the entry point and the C1-C2 articular rim inclination seem to be independent factors in influencing both the medio-lateral and the antero-posterior surgical corridors wideness. A decisional algorithm on whether to perform an anterior or posterior approach to the atlantoaxial region was also proposed. CONCLUSIONS: We can conclude that, as much as the C1-C2 articular rim is tending to the horizontal line, and as deeper is the entry point of the screw on the anterior profile of C2, as easier the anterior C1-C2 trans-articular screw placement will result.

Carmustine Wafers Implantation in Patients With Newly Diagnosed High Grade Glioma: Is It Still an Option?

Background: The implantation protocol for Carmustine Wafers (CWs) in high grade glioma (HGG) was developed to offer a bridge between surgical resection and adjuvant treatments, such as radio- and chemotherapy. In the last years, however, a widespread use of CWs has been limited due to uncertainties regarding efficacy, in addition to increased risk of infection and elevated costs of treatment. Objective: The aims of our study were to investigate the epidemiology of patients that underwent surgery for HGG with CW implantation, in addition to the assessment of related complications, long-term overall survival (OS), and associated prognostic factors. Methods: Three different medical databases were screened for conducting a systematic review of the literature, according to the PRISMA statement guidelines, evaluating the role of BCNU wafer implantation in patients with newly diagnosed HGG. The search query was based on a combination of medical subject headings (MeSH): "high grade glioma" [MeSH] AND "Carmustine" [MeSH] and free text terms: "surgery" OR "BCNU wafer" OR "Gliadel" OR "systemic treatment options" OR "overall survival." Results: The analysis of the meta-data demonstrated that there was a significant advantage in using CWs in newly diagnosed GBM in terms of OS, and a very low heterogeneity among the included studies [mean difference 2.64 (95% CI 0.85, 4.44); p = 0.004; I2149 = 0%]. Conversely, no significant difference between the two treatment groups in terms of PFS wad detected (p = 0.55). The analysis of complications showed a relatively higher rate in Carmustine implanted patients, although this difference was not significant (p = 0.53). Conclusions: This meta-analysis seems to suggest that CWs implantation plays a significant role in improving the OS, when used in patients with newly diagnosed HGG. To minimize the risk of side effects, however, a carful patient selection based mainly on patient age and tumor volume should be desirable.

5-Aminolevulinic Acid False-Positive Rates in Newly Diagnosed and Recurrent Glioblastoma: Do Pseudoprogression and Radionecrosis Play a Role? A Meta-Analysis.

BACKGROUND: Several studies have confirmed the impact of 5-aminolevulinic acid (5-ALA) on the extent of resection in newly diagnosed glioblastoma (GBM). However, there are controversies on the 5-ALA fluorescence status in recurrent GBM surgery, with specific reference to pseudoprogression or radionecrosis; therefore, the safety and accuracy of surgical planning in 5-ALA-assisted procedures in the recurrent context are still unclear. MATERIALS AND METHODS: This is a systematic review and meta-analysis of comparative studies on the use of 5-ALA in newly diagnosed and recurrent GBM, consistently conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data on fluorescence status and correlation between fluorescence and histological findings were collected. We performed a meta-analysis of proportions to estimate the pooled rates of each outcome. RESULTS: Three online medical databases (PubMed, Scopus, Cochrane Library) were screened, 448 articles were evaluated, and 3 papers were finally included for data analysis. Fluorescence rate was not different between newly diagnosed and recurrent GBM [p = 0.45; odds ratio (OR): 1.23; 95% CI: 0.72-2.09; I2 = 0%], while the rate of 5-ALA fluorescence-positive areas not associated with histological findings of GBM cells was higher in recurrent GBM (p = 0.04; OR: 0.24; 95% CI: 0.06-0.91; I2 = 19%). Furthermore, there were no cases of radionecrosis in false-positive samples, while inflammation and signs of pseudoprogression were found in 81.4% of the cases. DISCUSSION AND CONCLUSIONS: Therefore, a robust awareness of 5-ALA potentialities and pitfalls in recurrent GBM surgery should be considered for a cognizant surgical strategy. Further clinical trials could confirm the results of the present meta-analysis.

Clinical Outcomes of Shunting in Normal Pressure Hydrocephalus: A Multicenter Prospective Observational Study.

Background: Normal pressure hydrocephalus (NPH) is characterized by the triad of dementia, gait disturbance and urinary incontinence, all potentially reversible following a ventriculoperitoneal shunt (VPS). This study aims to evaluate the clinical outcomes of shunting in normal pressure hydrocephalus following a new standardized protocol. Methods: This study is designed according to the STROBE guidelines. Demographical, clinical, surgical and radiological data were collected from May 2015 to November 2019. Gait, balance and incontinence data based on the NPH European scale were collected before and after one, six and twelve months of treatment with a VPS. Clinical symptoms and changes of the stoke volume, measured on phase-contrast MRI, were used to evaluate improvement after VPS surgery. Results: One hundred and eighty-one consecutive patients met the inclusion criteria. The mean age was 73.1 years (59−86) and mean follow-up was 38.3 months (13−50). The gait (58.5 ± 14.3 to 70.1 ± 13.4, p < 0.001), the balance (66.7 ± 21.5 to 71.7 ± 22.1, p = 0.001), continence domain (69.9 ± 20.5 to 76 ± 20, p = 0.002) scores and neuropsychological scales showed a statistically significant improvement over the follow-up. The overall improvement after 12 months was present in 91.2% of patients. An overall complication rate of 8.8% and a reoperation rate of 9.4% were recorded, respectively. Conclusions: Surgical treatment by VPS for NPH improves symptoms in most patients, when accurately selected. A standardized protocol and a multidisciplinary team dedicated to this disorder is needed to achieve an early and correct diagnosis of NPH. Follow-up with stroke volume measurement is a valuable tool for the early diagnosis of shunt malfunction or the need for valve adjustment.

COVID-19 pandemic: An update on the reaction attitude of the spine societies and their members worldwide.

BACKGROUND: All surgical specialties have been influenced by the coronavirus disease 2019 (COVID-19) pandemic, and substantial changes have been determined in medical assistance, especially in elective surgery. Several spine societies have published recommendations to provide optimal care during this unique situation. AIM: To discuss the recommendations by many spine societies for the management of spinal diseases during the COVID-19 pandemic. METHODS: The present study was performed according to the PRISMA guidelines. A review of the MEDLINE database (PubMed - National Library of Medicine), Google, and Google Scholar was performed from March 2020 to date for articles published in the English Language. RESULTS: Spine associations and societies worldwide were divided into three groups: Continental, specialty and country-based societies. A total of 27 spine associations were included in this review. There were eight major continental associations, but only one-third of these had published guidelines and recommendations on this topic. On the other hand, the specialty-based societies have not addressed the topic, except in two cases. CONCLUSION: The national spine societies showed the deepest concern on this topic with several publications in scientific journals influenced by the local epidemiological severity. Contrarily, continental and specialty-based societies showed less interest in this topic.

Anterior Corpectomy and Plating with Carbon-PEEK Instrumentation for Cervical Spinal Metastases: Clinical and Radiological Outcomes.

Background: Anterior cervical corpectomy and plating has been recognized as a valuable approach for the surgical treatment of cervical spinal metastases. This study aimed to report the surgical, clinical and radiological outcomes of anterior carbon-PEEK instrumentations for cervical spinal metastases. Methods: Demographical, clinical, surgical and radiological data were collected from 2017 to 2020. The Neck Disability Index (NDI) questionnaire for neck pain, EORTC QLQ-C30 questionnaire for quality of life, Nurick scale for myelopathy and radiological parameters (segmental Cobb angle and cervical lordosis) were collected before surgery, at 6 weeks postoperatively and follow-up. Results: Seventeen patients met inclusion criteria. Mean age was 60.9 ± 7.6 years and mean follow-up was 12.9 ± 4.0 months. The NDI (55.4 ± 11.7 to 25.1 ± 5.4, p < 0.001) scores and the EORTC QLQ-C30 global health/QoL significantly improved postoperatively and at the last follow-up. The segmental Cobb angle (10.7° ± 5.6 to 3.1° ± 2.2, p < 0.001) and cervical lordosis (0.9° ± 6.7 to -6.2 ± 7.8, p = 0.002) significantly improved postoperatively. Only one minor complication (5.9%) was recorded. Conclusions: Carbon/PEEK implants represent a safe alternative to commonly used titanium ones and should be considered in cervical spinal metastases management due to their lower artifacts in postoperative imaging and radiation planning. Further larger comparative and cost-effectiveness studies are needed to confirm these results.

Percutaneous instrumentation with cement augmentation for traumatic hyperextension thoracic and lumbar fractures in ankylosing spondylitis: a single-institution experience.

OBJECTIVE: The typical traumatic thoracolumbar (TL) fracture in patients with ankylosing spondylitis (AS) is a hyperextension injury involving all three spinal columns, which is associated with unfavorable outcomes. Although a consensus on the management of these highly unstable injuries is missing, minimally invasive surgery (MIS) has been progressively accepted as a treatment option, since it is related to lower morbidity and mortality rates. This study aimed to evaluate clinical and radiological outcomes after percutaneous instrumentation with cement augmentation for hyperextension TL fractures in patients with AS at a single institution. METHODS: This cohort study was completed retrospectively. Back pain was assessed at preoperative, postoperative, and final follow-up visits using the visual analog scale (VAS). Patient-reported outcomes via the Oswestry Disability Index (ODI) and the new mobility score (NMS) were obtained to assess disability and mobility during follow-up. Radiological outcomes included the Cobb angle, sagittal index (SI), union rate, and implant failure. Intra- and postoperative complications were recorded. RESULTS: A total of 22 patients met inclusion criteria. The mean patient age was 74.2 ± 7.3 years with a mean follow-up of 39.2 ± 17.4 months. The VAS score for back pain significantly improved over the follow-up period (from 8.4 ± 1.1 to 2.8 ± 0.8, p < 0.001). At the last follow-up, all patients had minor disability (mean ODI score 24.4 ± 6.1, p = 0.003) and self-sufficiency of mobility (mean NMS 7.5 ± 1.6, p = 0.02). The Cobb angle (5.2° ± 2.9° preoperatively to 4.4° ± 3.3° at follow-up) and SI (7.9° ± 4.2° to 8.8° ± 5.1°) were maintained at follow-up, showing no loss of segmental kyphosis. Bone union was observed in all patients. The overall complication rate was 9.1%, while the reoperation rate for implant failure was 4.5%. CONCLUSIONS: Percutaneous instrumentation with cement augmentation for traumatic hyperextension TL fractures in AS demonstrated good clinical and radiological outcomes, along with a high bone union level and low reoperation rate. Accordingly, MIS reduced the complication rate in the management of these injuries of the ankylosed spine.

The Lone Star Retractor System in Neurosurgery.

BACKGROUND: We investigated the role of a self-retaining retractor system, commonly used in ear, abdominal, vascular, urologic and gynecologic surgeries: the Lone Star retractor system. We report our experience in using the Lone Star retractor in different brain surgeries, at a single neurosurgical department. METHODS: In 2019, patients who underwent brain surgery and in which the Lone Star Retractor System was used were considered for inclusion. Clinical and surgical data of included patients were prospectively collected. Postoperative VAS for local pain, and a properly designed intraoperative retractor stability score, were collected. RESULTS: Over 2019, the Lone Stare Retractor was used in 20 neurosurgical procedures: 9 high-grade glioma, 2 low-grade glioma, 4 cerebral metastases, and 5 meningiomas. Postoperative mean VAS score was 3.5 (range: 2-4). Intraoperative retractor stability score mean was 2 in frontal, 2 in pterional, 1.75 in subtemporal, 2 in interhemispheric, and 0.5 in suboccipital approaches. The Stony Brook Scar Evaluation Scale mean value was 4.4 (range: 3-5). CONCLUSIONS: In our institutional experience, the Lone Star retractor showed many advantages in different brain procedures, when compared with standard fishhooks and other retractors.

Long-term Radiologic and Clinical Outcomes after Three-level Contiguous Anterior Cervical Diskectomy and Fusion without Plating: A Multicentric Retrospective Study.

BACKGROUND: Anterior cervical diskectomy and fusion (ACDF) has been providing good surgical, clinical, and radiologic outcomes in patients suffering from cervical degenerative disk disease (DDD). However, the role of anterior plating is still debated, especially in three-level procedures. This study aimed to investigate long-term clinical and radiologic outcomes and complications after three-level contiguous ACDF without plating for cervical DDD. METHODS: Two institutional databases were retrieved (January 2009-December 2014) for patients treated with three-level contiguous ACDF without plating. Minimum follow-up (FU) was 5 years. Demographical data, smoking status, implant types, Neck Disability Index (NDI), visual analog scale (VAS) for neck pain, complications, fusion rate, adjacent segment degeneration (ASD), cervical lordosis (CL), and residual segmental mobility were evaluated. RESULTS: We enrolled 21 patients. Tantalum and carbon fiber cages were implanted, respectively, in 13 and 8 patients. The mean FU length was 5.76 ± 0.87 years. Mean NDI score was 78.29 ± 9.98% preoperatively and 8.29 ± 1.67% at last FU (p < 0.01), whereas mean VAS score decreased from 7.43 ± 1.14 preoperatively to 0.95 ± 0.95 at last FU (p < 0.01). Complications were one postoperative hematoma, one superficial wound infection, and five cases of postoperative dysphagia (recovered within 3 days). The fusion rate was 90% and ASD was reported in three (14%) cases. The mean CL was 6.33 ± 2.70 degrees preoperatively, 8.19 ± 1.97 degrees 3 months after surgery (p = 0.02), and 7.62 ± 1.96 degrees at latest FU. There was no residual mobility on every operated segment at last FU. The smoking status was an independent risk factor for nonfusion in this case series (p = 0.02). CONCLUSIONS: Three-level contiguous ACDF without plating seems to be an effective treatment for cervical DDD. Properly designed comparative clinical trials are needed to further investigate this topic.

Surgical treatment of intracranial blister aneurysms: A systematic review.

BACKGROUND: Intracranial blister aneurysms (BAs) are challenging vascular lesions related to high morbidity and mortality rates. Different surgical and endovascular techniques have been proposed to treat BAs; however, there is no consensus on a preferred treatment. OBJECTIVE: To systematically review the pertinent literature on clinical and radiological outcomes of different surgical treatments for BAs management, to meta-analyze their clinical and radiological outcomes, and compare these results with those from recent meta-analyses on endovascular treatments for BAs. METHODS: The present study was consistently conducted according to the PRISMA guidelines. Five different online medical databases (PubMed, Medline, EMBASE, Scopus, and Web-of-Science) were screened from 2010 through 2020. Papers reporting clinical and radiological outcomes of different surgical treatments for BAs were considered. Event rates were pooled across studies using random-effects meta-analysis. RESULTS: A total of 35 studies reporting on 514 patients (534 aneurysms) were included. Aneurysm clipping in 223 patients (45.4%; 95% CI 21.9-53.8), bypass and trapping in 87 (17.7%; 95% CI 1.89-21.6), clipping and wrapping in 82 (16.7%; 95% CI 3.71-19.0), and wrapping in 33 (6.7%; 95% CI 0.0-4.87) were the mostly common performed treatments. Complete occlusion rate was reported in 90.7% of patients. The complication rate was as high as 61.1%, the mortality rate was 7.4%, and the mean mRS at follow-up was 2.5. CONCLUSIONS: Our meta-analysis suggests that surgical treatments for BAs are related to higher occlusion, complications and mortality rate than endovascular strategies. However, there is a high-heterogeneity among the included studies and data are poorly reported; so comparing the two type of treatments is unreliable in order to establish which one is better.

Fenestration of Peritoneal Catheter to Avoid Abdominal Pseudocyst Formation after Ventriculoperitoneal Shunts: A Technical Note.

Ventriculoperitoneal shunt (VPS) is a well-known procedure in the neurosurgical field. However, it has high complication and reoperation rates. Abdominal pseudocyst (APC) formation is a rare complication of VPS with reports in the literature varying from 4 to 10%. In this article, we report a simple and effective technique, with no additional cost, to avoid APC formation by making small multiple slits along the length of the peritoneal catheter.