The role of MRgFUS in the treatment of neuropsychiatric disorders: a state of the art.

INTRODUCTION: Magnetic resonance-guided focused ultrasound (MRgFUS) is a contemporary non-invasive ablative procedure that utilizes high- or low-intensity ultrasound, guided and monitored by magnetic resonance imaging (MRI). While MRgFUS has been established as an effective treatment for conditions like essential tremor and tremor-dominant Parkinson's disease, it has recently emerged as a safe and promising ablative minimally invasive procedure for the management of treatment-resistant psychiatric disorders. Indeed, despite the availability of various pharmacological and behavioral therapies, a subset of psychiatric patients remains refractory to conventional treatments. EVIDENCE ACQUISITION: To assess the feasibility and safety of MRgFUS in psychiatric disorders, a comprehensive literature search in PubMed and Scopus databases was conducted, resulting in the inclusion of five relevant articles in this review. EVIDENCE SYNTHESIS: While data on this innovative procedure are still limited, MRgFUS demonstrates potential as a safer and less invasive surgical technique for treating these disorders. CONCLUSIONS: Continued research efforts and data validation are imperative to establish MRgFUS as an additional, minimally invasive procedure for treatment-resistant psychiatric patients in the near future.

Diffuse idiopathic skeletal hyperostosis: A functional enemy of vertebral stability - Case series and surgical consideration of craniovertebral junction involvement.

Context: Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's syndrome may reduce vertebral mobility, thus affecting the stability of adjacent vertebral segments and promoting spinal stenosis, vertebral dislocation, and unstable fracture secondary to low-energy trauma. Aims: This study aimed to contribute with a case series of three patients affected by DISH undergone surgery with occipitocervical fixation for craniovertebral junction (CVJ) instability since the poor literature about CVJ instability and surgery in patients affected by DISH. Settings and Design: This was a multicentric case series. Subjects and Methods: Literature about CVJ instability and surgery in patients affected by DISH is poor. Thus, we present a case series of three patients affected by DISH, who underwent surgery with occipitocervical fixation with different clinical and radiological patterns. Results: CVJ represents one of the most mobile joints of the spine and is at greater risk for instability. Moreover, instability itself may act as primum movens for several degenerative conditions such as cervical spondylosis, ossification of the posterior longitudinal ligament, and cervical deformities. On the contrary, DISH itself may worsen CVJ instability because of subaxial spine stiffness. In case of DISH, the rigid unit formed by several ossified vertebral bodies acts as a long lever arm, increasing the forces applied to the hypermobile CVJ and reducing the dynamic buffer capability of ossified spine. On the other hand, vertebral instability increases the odds of fractures. In such cases, CVJ posterior instrumentation and fusion is an effective and feasible surgical technique, aimed to restore vertebral stability and to halt the progression of spinal stenosis. Conclusions: Due to the altered dynamics cervical spine along with the possible comorbidities, treatment indication and surgery for patients affected by DISH must be tailored case by case.

"The Double S" Technique: Subfascial Dissection and Temporalis Muscle Splitting to Prevent Cerebrospinal Fluid Leak and Maximize Surgical Exposure.

BACKGROUND: Middle cranial fossa surgery commonly is approached either performing a subtemporal or a pterional craniotomy. To maximize a basitemporal region exposure, an adjunctive bone drilling could be required. In these cases, a watertight dura and temporalis muscle closure are mandatory. OBJECTIVE: To describe a modified temporalis muscle dissection in middle cranial fossa surgery to increase basitemporal region exposure while assuring a safe and effective closure thus avoiding cerebrospinal fluid (CSF) leakage. METHODS: A total of 8 patients have been enrolled. Five pterional and 3 subtemporal approaches were performed. In all cases, the novel subfascial muscle dissection and temporalis muscle splitting technique named "the double S technique," was performed to cut up the temporal muscle. RESULTS: In all cases, a subgaleal drainage was used and removed within 48 hours. No cases of postoperative CSF leak or hematoma collection were reported. CONCLUSIONS: The double S technique is a safe and effective alternative to enhance the basitemporal region exposure while avoiding the potential, common risk of CSF leak.

Aneurysmal bone cyst of the spine in adult patients: A systematic review and comparison of primary vs secondary lesions.

BACKGROUND: Spine aneurysmal bone cysts (ABCs) rarely occur in adults. Primary and secondary lesions may show some differences and require appropriate treatments. OBJECTIVE: To systematically review the literature on adult spine ABCs. METHODS: PubMed, EMBASE, Scopus, and Web-of-Science were searched. Clinical-radiological features, treatments, and outcomes were analyzed and compared between primary vs secondary adult spine ABCs. RESULTS: We included 80 studies comprising 220 patients. Primary spine ABCs were more frequent (76.4%). Main symptoms were lower-back-pain (42.8%) and motor deficits (31.2%). Tumors were mostly thoracic (31.4%) or cervical (26.8%), showing lytic (70.4%) and/or cystic (52.3%) appearances. Surgical resection (79.1%) was preferred over biopsy (20.9%). Most primary ABCs underwent curettage with bone grafting (62.1%) and laminectomy (39.1%) (P < 0.001), while most secondary ABCs underwent corpectomy (51%) and spine fixation (93.9%) (P < 0.001). Radiotherapy was delivered in 58 patients (26.4%), and embolization in 37 (16.8%). Symptomatic improvement was reported in 91.8% cases, with no differences based on etiology nor extent-of-resection. Median follow-up was 28.5 months, significantly superior in secondary ABCs. Secondary ABCs had significantly higher rates of tumor recurrence (19.2%; P = 0.011) and death (5.8%; P = 0.002). CONCLUSION: Surgical resection, radiotherapy, and embolization are effective in managing adult spine ABCs. Secondary tumors have worse prognoses requiring more aggressive treatments.

A Spotlight on the Role of Radiomics and Machine-Learning Applications in the Management of Intracranial Meningiomas: A New Perspective in Neuro-Oncology: A Review.

Background: In recent decades, the application of machine learning technologies to medical imaging has opened up new perspectives in neuro-oncology, in the so-called radiomics field. Radiomics offer new insight into glioma, aiding in clinical decision-making and patients' prognosis evaluation. Although meningiomas represent the most common primary CNS tumor and the majority of them are benign and slow-growing tumors, a minor part of them show a more aggressive behavior with an increased proliferation rate and a tendency to recur. Therefore, their treatment may represent a challenge. Methods: According to PRISMA guidelines, a systematic literature review was performed. We included selected articles (meta-analysis, review, retrospective study, and case-control study) concerning the application of radiomics method in the preoperative diagnostic and prognostic algorithm, and planning for intracranial meningiomas. We also analyzed the contribution of radiomics in differentiating meningiomas from other CNS tumors with similar radiological features. Results: In the first research stage, 273 papers were identified. After a careful screening according to inclusion/exclusion criteria, 39 articles were included in this systematic review. Conclusions: Several preoperative features have been identified to increase preoperative intracranial meningioma assessment for guiding decision-making processes. The development of valid and reliable non-invasive diagnostic and prognostic modalities could have a significant clinical impact on meningioma treatment.

DBS, tcMRgFUS, and gamma knife radiosurgery for the treatment of essential tremor: a systematic review on techniques, indications, and current applications.

INTRODUCTION: Essential tremor (ET) may severely impact patient's Quality of Life. Several techniques such as radiofrequency, deep brain stimulation (DBS), gamma knife (GK) radiosurgery and high-intensity focused ultrasound may be used for the surgical treatment of ET. The aim of this paper is to summarize the most recent available literature on DBS, transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) and GK, and to compare indications, targets, and effectiveness of these surgical techniques for the treatment of ET. EVIDENCE ACQUISITION: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was performed on the three largest medical databases (PubMed, Scopus, and Web of Science). This systematic review is focused on the effectiveness and safety of GK, DBS, and tcMRgFUS as functional neurosurgical techniques for the treatment of ET. The aim of this study was to compare these techniques by evaluating mode, target, effectiveness in improving motor outcomes, and rates of adverse effects. EVIDENCE SYNTHESIS: Articles meeting the predetermined criteria were included. Data for DBS, tcMRgFUS, and GK were analyzed and compared for indications, patient selection, advantages vs. disadvantages, and treatment targets for essential tremor. CONCLUSIONS: DBS, tcMRgFUS and GK are effective techniques for the treatment of ET. Despite different functioning principles, all three surgical techniques require a proper functional diagnosis to define accurate indications for patient selection. Their indication depends upon the patient's neurological condition and their effectiveness relies on proper targeting.

Posterior epidural intervertebral disc migration and sequestration: A systematic review.

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.

Safeness and efficacy of 2-µm handheld thulium laser during microsurgical resection of supratentorial and infratentorial meningiomas: Experience of a single center.

Aims: We performed a retrospective nonrandomized study to analyze the results of a microsurgery of intracranial meningiomas using 2-µm thulium flexible handheld laser fiber (Revolix jr). Methods: From February 2014 to December 2021, 75 nonconsecutive patients suffering from intracranial meningiomas, admitted in our department, have been operated on with microsurgical technique assisted by 2-µm thulium flexible handheld laser. We have reviewed demographic and clinical data to evaluate safety and efficacy of the technique. Results: There were no complications related to the use of the 2-µm thulium laser. We operated on a high percentage of cranial base and tentorial and posterior fossa meningioma in our series. The neurological outcome and degree of resection did not differ from previous series. The neurosurgical team found the laser easy to use and practical for avoiding bleeding and traction. Conclusion: The use of 2-µm thulium fiber handheld flexible laser in microsurgery of intracranial meningiomas seems to be safe and to facilitate tumor resection, especially in "difficult" conditions (e.g., deep seated, highly vascularized, and hard tumors). Even if in this limited retrospective trial the good functional outcome following conventional microsurgery had not further improved, nor the surgical time was reduced by laser, focusing its use on "difficult" (large and vascularized) cases may lead to different results in the future.

Reconstruction of vertebral body in thoracolumbar AO type A post-traumatic fractures by balloon kyphoplasty: a series of 85 patients with a long follow-up and review of the literature.

BACKGROUND: Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal traumas. Optimal management of these fractures still gives rises to much debate in the literature. Currently, one of the treatment options in young patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improving physical function with early return to work activity. The aim of our study was to report VAS, ODI scores, and kyphosis correction following treatment. METHODS: This is a retrospective study to investigate the clinical and radiological results 10 years after percutaneous balloon kyphoplasty followed by cement augmentation with polymethylmethacrylate (PMMA) or calcium phosphate cements (CPC), according to age, in 85 consecutive patients affected by 91 AO spine type A traumatic fractures of the thoracolumbar spine (A1, A2, and A3). Clinical follow-up was performed with the Visual Analogic Scale (VAS) at the preoperative visit and in the postoperative follow-up after 1 week, 1, 6, 12 months, and each year up to 10 years. Additionally, the Oswestry Disability Index (ODI) improvement was calculated as the difference between the ODI scores at the preoperative visit and at final follow-up. Finally, the Cobb angle from this cohort was assessed before surgery, immediately postoperatively, and at the end of follow-up. RESULTS: Kyphoplasty markedly improved pain and resulted in statistically significant vertebral height restoration and normalization of morphologic shape indexes that remained stable for at least 10 years following treatment. CONCLUSIONS: The present study showed that kyphoplasty and cement augmentation are an effective method of treatment for selected type A fractures.

A new tool to improve pedicle screw placement accuracy in navigated spine surgery: a monocentric study.

BACKGROUND: Navigated instrumented spine surgery is burden by a low but significant screw mispositioning risks, respectively, for the 2D imaging system from 15% to 40% and, for the 3D imaging system, ranging from 4.1% to 11.5%. The primary objective of this study was to demonstrate the efficacy of a new screw-like tool in order to further decrease pedicle screws mispositioning rate during vertebral navigated spine surgery. METHODS: Between January and June 2019 an initial case series of 18 patients were enrolled. All patients underwent a pedicle screw fixation, both in thoracic (Th10-Th12) and lumbosacral (L1-S1) spine, using O-arm (Medtronic Navigation, Louisville, CO, USA) and StealthStation S7 surgical navigation system (Medtronic Navigation). Evaluation of pedicle screws placement accuracy using the new tool in adjunct to the classic reference frame, was performed following the Gertzbein and Robbins classification. RESULTS: A total of 94 screws have been placed. Among them, 98.9% were completely inside cortical bone (grade A) and only 1.1% with a breach of less than 2 mm (grade B). CONCLUSIONS: Our new "screw-like" tool coupled to the classic reference frame device could improve accuracy during navigated spine surgery and potentially reducing to zero the risks for screw mispositioning.

Surgical Back Risk Syndrome and Spinal Cord Stimulation: Better Safe Than Sorry.

BACKGROUND: Recurrent and chronic low back pain, caused by degenerative lumbar spondylosis, commonly affects elderly patients, even those with no previous low back surgery. These patients, like those affected by failed back surgery syndrome (FBSS), may become unresponsive to medical conservative treatment and their quality of life could be easily compromised. Moreover, general comorbidities, obesity, and other typical conditions of the elderly may make surgery under general anesthesia riskier than the natural history of the disease. These patients could be considered affected by surgical back risk syndrome (SBRS). METHODS: In this article, we report our preliminary observational prospective study on the role of spinal cord stimulation (SCS) in 3 groups of patients: the FBSS group, the SBRS group, and the "other" group. Selection criteria, treatment modality, and outcomes for each patient group are described and discussed. Moreover, a potentially useful diagnostic and therapeutic flowchart on the management options for lumbar back diseases is discussed. RESULTS: The FBSS group included 25 patients, the SBRS group included 10 patients, and the other group included 3 patients. In 22/25 patients with FBSS (88% of the total), the implantation of a definitive neurostimulator was successful. In almost all patients in both the SBRS and the other groups, the implantation of a definitive neurostimulator was successful. CONCLUSIONS: In our opinion, SCS could be considered as a valid alternative treatment not only in selected patients affected by FBSS but also in selected patients affected by SBRS, in whom back surgery under general anesthesia may be challenging and overcome the potential benefit of the surgery itself. SBRS could be considered a new disease entity to be managed through SCS.

Exosomal Chaperones and miRNAs in Gliomagenesis: State-of-Art and Theranostics Perspectives.

Gliomas have poor prognosis no matter the treatment applied, remaining an unmet clinical need. As background for a substantial change in this situation, this review will focus on the following points: (i) the steady progress in establishing the role of molecular chaperones in carcinogenesis; (ii) the recent advances in the knowledge of miRNAs in regulating gene expression, including genes involved in carcinogenesis and genes encoding chaperones; and (iii) the findings about exosomes and their cargo released by tumor cells. We would like to trigger a discussion about the involvement of exosomal chaperones and miRNAs in gliomagenesis. Chaperones may be either targets for therapy, due to their tumor-promoting activity, or therapeutic agents, due to their antitumor growth activity. Thus, chaperones may well represent a Janus-faced approach against tumors. This review focuses on extracellular chaperones as part of exosomes' cargo, because of their potential as a new tool for the diagnosis and management of gliomas. Moreover, since exosomes transport chaperones and miRNAs (the latter possibly related to chaperone gene expression in the recipient cell), and probably deliver their cargo in the recipient cells, a new area of investigation is now open, which is bound to generate significant advances in the understanding and treatment of gliomas.

Never say never again: A bone graft infection due to a hornet sting, thirty-nine years after cranioplasty.

BACKGROUND: Cranioplasty (CP) is a widespread surgical procedure aimed to restore skull integrity and physiological cerebral hemodynamics, to improve neurological functions and to protect the underlying brain after a life-saving decompressive craniectomy (DC). Nevertheless, CP is still burdened by surgical complications, among which early or late graft infections are the most common outcome-threatening ones. CASE DESCRIPTION: We report the case of 48-year-old man admitted to our neurosurgical unit because of a painful right frontal swelling and 1-week purulent discharge from a cutaneous fistula. He had been undergone frontal CP because of severe traumatic brain injury (TBI) when he was 9-year-old. Since then, his medical history has been being unremarkable without any surgical or infective complication of the graft for 39 years, until he was accidentally stung by a hornet in the frontal region. After the CT scan and laboratory findings had evidenced a probable infection of the graft, the patient was treated by vancomycin and cefepime before he underwent surgical revision of its former CP, with the removal of the graft and the debridement of the surgical field. Subsequent bacteriological tests revealed Staphylococcus aureus as causal agent of that infection. CONCLUSION: This case illustrates an anecdotal example of very late CP infection, due to an unpredictable accident. Due to lack of consensus on risk factors and on conservative or surgical strategy in case of graft infection, we aimed to share our surgical experience.

A thoracic vertebral localization of a metastasized cutaneous Merkel cell carcinoma: Case report and review of literature.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin tumor, which may be related to sun exposure. It can metastasize to lungs, liver and bone, leading to severe morbidity and mortality. Vertebral metastases from MCC are rare. The authors report the tenth case in the literature, a 59-year-old patient with MCC, which was primarily localized in the scalp, and later provoked distant metastasis to the thoracic spinal column. CASE DESCRIPTION: A 59-year-old woman was admitted at our Unit of Neurosurgery with a 4-month history of progressive and severe dorsal back pain, without neurological signs. The patient had been surgically treated for a recidivated MCC in the occipital region in 2007, 2011, and 2013. (In 2013, the surgical treatment also included lateral cervical lymph node dissection). Chemotherapy and radiotherapy had come after the treatments. Magnetic resonance imaging (MRI) of the dorsal spine showed metastatic vertebral involvement with cord impingement of the T7-T8 levels. A total body CT scan revealed lungs and liver metastases, besides vertebral district. After a multidisciplinary consult a palliative surgery was decided and a posterior dorsal approach was employed: Radiofrequency (RF) thermoablation was followed by the injection of cement of T7 and T8 and transpedicle fixation T5-T9. The postoperative course was uneventful and followed by a further adjuvant therapy. CONCLUSION: Spinal metastases from MCC are described in literature only exceptionally. The clinical course is presented, along with a review of literature.