Multilevel mini-open TLIFs and percutaneous pedicle screw fixation: description of a simple technical nuance used to increase intraoperative safety and improve workflow. Tips and tricks and review of the literature.

We describe a technical variation used to enhance intraoperative safety and efficiency in multilevel percutaneous pedicle screw fixation (PPSFs) and mini-open transforaminal lumbar interbody fusion (m-TLIFs). A review of the literature on percutaneous screw insertion techniques and related pitfalls is presented. PPSFs and m-TLIFs are increasingly used techniques in multilevel lumbar degenerative disease. Facetectomy and TLIF are usually performed before inserting ipsilateral pedicle screws. Such techniques can cause unintended violation of the pedicle and injure the dura or neural structures, particularly in multilevel cases. A literature review revealed a lack of intraoperative and fluoroscopic images detailing the technique for multilevel PPSF and m-TLIF(s) performed through tubular, expandable retractors. Thirteen patients with two- to four-level disease underwent multilevel PPSF and m-TLIF (one to four levels). The Kirschner Cage Screw (KCS) technique, consisting of early insertion of K-wires in all pedicles followed by facetectomy and m-TLIF(s) and, finally, screw insertion, was used in order to minimize the risk of dural/neural injuries. Neither CSF (cerebrospinal fluid) leaks nor nerve root injuries nor technique-related complications were encountered with a follow-up ranging from 7 to 38 months (mean 23.6). In conclusion, the KCS technique allows safe identification of the pedicles without opening the canal during m-TLIF(s). Moreover, by visualizing the K-wires inside the retractor, the surgeon can check the pedicle position during facetectomy, and screws can be introduced with a minimal risk of neural or dural injuries. We believe that the proposed technique increases the safety and ease of the procedure, particularly in multilevel cases.

Bilateral tubular minimally invasive surgery for low-dysplastic lumbosacral lytic spondylolisthesis (LDLLS): analysis of a series focusing on postoperative sagittal balance and review of the literature.

PURPOSE: To report our early experience with minimally invasive surgery (MIS) in low-dysplastic lumbosacral lytic spondylolisthesis (LDLLS), and to analyze the impact of surgery on postoperative spino-pelvic and sacro-pelvic parameters. METHODS: Eight patients (mean age 47.6 years) underwent MIS for LDLLS involving in all but one the L5-S1 level. VAS and ODI were used for clinical assessment. Imaging included pre-operative X-rays, CT and MRI scans. Post-operatively, all patients underwent X-rays and CT-scans. Pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS) values as well as lumbar lordosis (LL) have been derived from pre- and post-operative standard X-rays. RESULTS: Mean follow-up is 30.12 months (range 15-42). No complications related to the surgical procedure were observed. Patients reported a satisfactory clinical outcome, as demonstrated by variation in mean VAS (from 9.1 to 3.6) and ODI (from 70.50 to 28.25 %) scores. Comparison between pre- and post-operative sacro-pelvic parameters documented moderate changes, with reduction of PT and increase of SS in all but one patient. Overall sagittal balance of the spine has been evaluated using the sagittal vertical axis (SVA), obtained from post-operative X-rays. Mean value of SVA demonstrated a good sagittal balance of the spine. CONCLUSION: This series demonstrates that MIS is feasible and effective for LDLLS, as witnesses by the satisfactory clinical results maintained at medium-term follow-up. We submit that TLIF is a valid option but an adequately sized and positioned interbody cage is a key factor to allow satisfactory restoration of segmental lordosis.

Long-term therapy with temozolomide is a feasible option for newly diagnosed glioblastoma: a single-institution experience with as many as 101 temozolomide cycles.

OBJECT: The objective of this study was to report the authors' experience with the long-term administration of temozolomide (TMZ; > 6 cycles, up to 101) in patients with newly diagnosed glioblastoma and to analyze its feasibility and safety as well as its impact on survival. The authors also compared data obtained from the group of patients undergoing long-term TMZ treatment with data from patients treated with a standard TMZ protocol. METHODS: A retrospective analysis was conducted of 37 patients who underwent operations for glioblastoma between 2004 and 2012. Volumetric analysis of postoperative Gd-enhanced MR images, obtained within 48 hours, confirmed tumor gross-total resection (GTR) in all but 2 patients. All patients received the first cycle of TMZ at a dosage of 150 mg/m(2) starting on the second or third postsurgical day. Afterward, patients received concomitant radiochemotherapy according to the Stupp protocol. With regard to adjuvant TMZ therapy, the 19 patients in Group A, aged 30-72 years (mean 56.1 years), received 150 mg/m(2) for 5 days every 28 days for more than 6 cycles (range 7-101 cycles). The 18 patients in Group B, aged 46-82 years (mean 64.8 years), received the same dose, but for no more than 6 cycles. O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation status was analyzed for both groups and correlated with overall survival (OS) and progression-free survival (PFS). The impact of age, sex, Karnofsky Performance Scale score, and Ki 67 staining were also considered. RESULTS: All patients but 1 in Group A survived at least 18 months (range 18-101 months), and patients in Group B survived no more than 17 months (range 2-17 months). The long-term survivors (Group A), defined as patients who survived at least 12 months after diagnosis, were 51.3% of the total (19/37). Kaplan-Meier curve analysis showed that patients treated with more than 6 TMZ cycles had OS and PFS that was significantly longer than patients receiving standard treatment (median OS 28 months vs 8 months, respectively; p = 0.0001; median PFS 20 months vs 4 months, respectively; p = 0.0002). By univariate and multivariate Cox proportional hazard regression analysis, MGMT methylation status and number of TMZ cycles appeared to be survival prognostic factors in patients with glioblastoma. After controlling for MGMT status, highly significant differences related to OS and PFS between patients with standard and long-term TMZ treatment were still detected. Furthermore, in Group A and B, the statistical correlation of MGMT status to the number of TMZ cycles showed a significant difference only in Group A patients, suggesting that MGMT promoter methylation was predictive of response for long-term TMZ treatment. Prolonged therapy did not confer hematological toxicity or opportunistic infections in either patient group. CONCLUSIONS: This study describes the longest experience so far reported with TMZ in patients with newly diagnosed glioblastomas, with as many as 101 cycles, who were treated using GTR. Statistically significant data confirm that median survival correlates with MGMT promoter methylation status as well as with the number of TMZ cycles administered. Long-term TMZ therapy appears feasible and safe.

5-ALA fluorescence-assisted surgery in pediatric brain tumors: report of three cases and review of the literature.

5-aminolevulinic acid (5-ALA) has been used for the last 5 years to increase the extent of resection in adult brain tumors, mostly glioblastomas, but it is not approved yet as standard adjuvant treatment in the pediatric population. We report three different cases of pediatric brain tumors (two glioblastomas and one medulloblastoma) recently operated using 5-ALA fluorescence guidance, highlighting how useful it is in pediatric high-grade glioma (but not in medulloblastoma) also and confirming the lack of 5-ALA-related side effects. The first glioma was a recurrent GBM, whilst the second was a primary tumor. In all children, 5-ALA was administrated after discussing its use, including pros and cons, with the parents. 5-ALA fluorescence was a very useful tool to better identify tumor tissue and achieve gross-total tumor resection in GBMs, as confirmed by postoperative magnetic resonance imaging (MRI). In the medulloblastoma case no useful 5-ALA fluorescence was identified. No hematological or dermatological complications nor other side effects related to use of 5-ALA were observed. We submit that 5-ALA fluorescence guided surgery can be safe and useful in pediatric high-grade glioma, although its use in children still remains an off-label indication and requires validation through larger studies.

Adult idiopatic occlusion of Monro foramina: intraoperative endoscopic reinterpretation of radiological data and review of the literature.

Adult idiopathic occlusion of the foramen of Monro (AIOFM) is a rare condition, with only few cases described in the modern literature. We propose that AIOFM may result from unilateral or bilateral occlusion of Monro foramina, as well as from progression of a monolateral hydrocephalus. Different surgical strategies may be required for effective treatment according to the type of occlusion. To date, only 12 cases of AIOFM have been reported in the literature. We report the cases of two patients, aged 20 and 47 years respectively, who presented with intracranial hypertension secondary to bilateral ventricular dilatation due to obstruction at the level of the foramen of Monro. Both patients were successfully treated with endoscopic fenestration of the primarily obstructed foramen of Monro and, in one patient, fenestration of the septum. We propose that septum pellucidum displacement could play a role in the occlusion of the second foramen of Monro. AIOFM can, therefore, result also from unilateral stenosis of Monro. The difference in AIOFM (i.e. unilateral vs bilateral) will be useful in guiding the most suitable surgical approach in this rare condition.

Natural history of neurofibromatosis type 2 with onset before the age of 1 year.

Neurofibromatosis type 2 (NF2) with onset before the first year of life has been anecdotally reported in the literature. We (a) prospectively (years 1997-2012) followed up three unrelated NF2 children, all harbouring NF2 gene mutations whose onset of disease was before age 1 year, and (b) systematically reviewed published reports on NF2 in the youngest age group (i.e. onset <1 year). The present three children had (1) small (<1 cm), bilateral vestibular schwannomas (VSs) detected (as an incidental finding) at magnetic resonance imaging (MRI) by the age of 4 to 5 months that were asymptomatic for 10 to 14 years, with sudden and rapid (<12 months) progression in two cases at the age of 11 and 15 years, respectively; (2) development of large numbers of skin NF2 plaques mainly in atypical locations (i.e. face, hands, legs and knees), which reverted to normal skin appearance at the time of VSs progression; (3) lens opacities (n = 1) and NF2 retinal changes (n = 2) detected as early as age of 3-4 months; (4) diffuse (asymptomatic) high signal lesions at brain MRI in the periventricular regions (alike cortical dysplasia); and (5) unaffected first-degree relatives who did not harbour NF2 gene abnormalities. This represents the youngest NF2 group with the longest prospective follow-up so far reported. NF2 may present as a congenital form with bilateral VSs presenting as early as the first months of life and with natural history different to that which occurs in classical NF2.

Spinal neurofibromatosis with central nervous system involvement in a set of twin girls and a boy: further expansion of the phenotype.

BACKGROUND: Familial spinal neurofibromatosis is a form of neurofibromatosis 1 (NF1), consisting of extensive, symmetrical, histologically proven, multiple neurofibromas of the spinal roots at every level and of all major peripheral nerves sometimes associated with typical NF1 stigmata; most cases underlie NF1 gene mutations. OBJECTIVES: The objectives of this study are (1) to report the findings in a set of 16-year-old monozygotic twin girls and a 14-year-old boy and (2) to review the existing literature. METHODS AND RESULTS: In this article, we report the cases of three children who (1) had manifested mildly different symptomatic neuropathy (twins, aged 4 years; and a boy, aged 9 years) associated with massive, symmetrical neurofibromas; (2) had few café-au-lait spots with irregular margins and pale brown pigmentation; (3) were presented with, at brain magnetic resonance imaging (MRI), bilateral, NF1-like high-signal abnormalities in the basal ganglia; (4) yielded missense NF1 gene mutations in exon 39; and (5) had unaffected parents with negative NF1 genetic testing as well as discuss 12 families and 20 sporadic and 5 additional cases that presented spinal neurofibromatosis within classical NF1 families (53 cases) that were reported in the literature. CONCLUSIONS: This article presents the first report on (1) spinal neurofibromatosis in a set of affected monozygotic twins; (2) the earliest onset of the disease; and (3) the occurrence of high signal lesions in the brain at MRI.

Zero-P: a new zero-profile cage-plate device for single and multilevel ACDF. A single institution series with four years maximum follow-up and review of the literature on zero-profile devices.

PURPOSE: To analyze the prospectively collected data in a series of patients treated with single- or multilevel ACDF with a stand-alone, zero-profile device, focusing on clinico-radiological outcome, complications and technical hints, and to review the literature on such new devices. METHODS: Eighty-five patients harboring symptomatic DDD underwent ACDF with the Zero-P cage-plate: 29 at 1-level and 56 at 2-4 levels (total 162 devices). In the multilevel group, 9 patients received a combination of Zero-P and stand-alone cages (hybrid implants). This study focuses on 32 patients with follow-up ranging from 20 to 48 months. NDI, SF-36 and arm pain VAS scores were registered preoperatively and at follow-up visits. Dysphagia was assessed using the Bazaz score. Imaging included X-rays, CT and MRI, also to assess the presence of vertebral body fractures in multilevel cases. Paired Student t test was used for statistical analysis. RESULTS: SF-36 and NDI showed a statistically significant improvement (p < 0.01) and mean arm pain VAS score decreased from 79 to 41. X-rays and CT demonstrated, respectively, a 94.5 % and a 92 % fusion rate. Three patients complained of moderate and two of mild transient dysphagia (15.5 %). No device-related complications occurred and no fractures, secondary to four screws insertion in one vertebral body (i.e., swiss cheese effect), were detected in multilevel cases. In patients with extensive anterior osteophytes only a "focal spondylectomy" was required. CONCLUSION: The Zero-P device is safe and efficient, even in multilevel cases. Dysphagia is minimal, extensive anterior osteophytectomy is unnecessary and technical hints may ease the surgical workflow. This is the largest series, with the longest follow-up, reported.

Disappearance of degenerative, non-inflammatory, retro-odontoid pseudotumor following posterior C1-C2 fixation: case series and review of the literature.

PURPOSE: Retro-odontoid pseudotumor, not related to inflammatory or traumatic conditions, is an uncommon pathology. Atlanto-axial instability has been advocated to explain the pathophysiology of retro-odontoid pseudotumor's formation and growth. Despite pseudotumor direct removal through transoral or lateral approach represented the main surgical strategy for a long time, in the last decade several authors highlighted the possibility to treat retro-odontoid pseudotumor by occipito-cervical or C1-C2 fixation without removal of the intracanalar tissue. The goal of this study is to analyze the data collected in a series of patients suffering from cervical myelopathy due to non-inflammatory, degenerative retro-odontoid pannus and treated by posterior C1-C2 fixation. The relevant literature is also reviewed. METHODS: Five patients, not suffering from inflammatory diseases, were treated between 2009 and 2012. Abnormalities of cranio-cervical junction and/or lower cervical spondylotic degeneration were observed in all patients. No evidence of atlanto-axial instability was demonstrated. Clinical and radiological evaluation included pre- and post-operative Nurick score as well as pre- and post-operative X-rays, CT and MRI. In one case, CT scan highlighted an eggshell calcification of the pannus. All patients underwent either a C1-C2 fixation (C1 lateral mass and C2 isthmus-pedicle screws) or occipito-cervical fixation (2 patients) in cases of C0-C1 fusion. RESULTS: Follow-up ranges from 22 to 45 months (mean 32) in four patients. One patient died of surgery-unrelated disease. Nurick score changes suggest a clinical improvement in four cases. Neuro-radiological evaluation shows a progressive but incomplete reduction of thickness of retro-odontoid pseudotumor in one patient, and its disappearance in the other three cases. A second-stage transoral or posterior lateral approach was not required. CONCLUSION: Although the etiopathogenesis of non-inflammatory, i.e., degenerative, retro-odontoid pseudotumor is still controversial, our series (the second largest on degenerative retro-odontoid pannus in the literature) confirms that a posterior approach may be sufficient and transoral surgery is not required.

Bilateral tubular minimally invasive approach for decompression, reduction and fixation in lumbosacral lythic spondylolisthesis.

This video demonstrates the minimally invasive surgical technique used in a 56-year-old woman suffering from L-5 spondylolysis and grade 2 L5-S1 spondylolisthesis. The first author used expandable tubular retractors bilaterally to perform neural decompression, mini-open TLIF, spondylolysthesis reduction and L5-S1 pedicle screw fixation. L-5 cement augmentation was performed through cannulated and fenestrated screws to enhance resistance to screw pull-out secondary to reduction maneuvers. Sequential surgical steps related to microsurgery, spondylolysthesis reduction and instrumentation are shown and commented. We submit that in cases of lythic spondylolisthesis a bilateral traversing and exiting nerve roots decompression is a safer option prior to performing the deformity reduction and fixation; the proposed minimally invasive technique may help in reducing surgical morbidity and improving postoperative recovery. The video can be found here: http://youtu.be/G4Qdg-A-Y3M.

Giant cell ependymoma of the cervical spinal cord: case report and review of the literature.

Ependymomas account for 2-6% of all central nervous system neoplasms. They develop from the ependymal cells that line the ventricular cavities of the brain and the central canal of the spinal cord, as well as from ependymal clusters in the filum terminale. Giant cell ependymoma (GCE) is a rare subtype, with few cases reported, mostly in the brain. We describe the case of a cervical spinal cord ependymoma with pleomorphic giant cells and focal calcifications occurring in a 25-year-old woman. Magnetic resonance imaging revealed a large multicystic and partially enhancing intramedullary tumour extending from C2 to C5. Intraoperative analysis of frozen section tissue fragments suggested a malignant tumour; however, an obvious cleavage plane was present around most of the mass, and a macroscopically complete tumour removal could be achieved. Subsequently, paraffin sections and immunohistochemical investigations revealed unequivocal evidence of a GCE with focal calcifications. This case, the second giant-cell ependymoma to be described in the spinal cord and the first with focal calcifications, highlights the features of GCE and the discrepancy between the worrisome histological appearance, the surgical findings and the clinical relatively good prognosis.

Early results and review of the literature of a novel hybrid surgical technique combining cervical arthrodesis and disc arthroplasty for treating multilevel degenerative disc disease: opposite or complementary techniques?

We report the clinical and radiological results on the safety and efficacy of an unusual surgical strategy coupling anterior cervical discectomy and fusion and total disc replacement in a single-stage procedure, in patients with symptomatic, multilevel cervical degenerative disc disease (DDD). The proposed hybrid, single-stage, fusion-nonfusion technique aims either at restoring or maintaining motion where appropriate or favouring bony fusion when indicated by degenerative changes. Twenty-four patients (mean age 46.7 years) with symptomatic, multilevel DDD, either soft disc hernia or different stage spondylosis per single level, with predominant anterior myeloradicular compression and absence of severe alterations of cervical spine sagittal alignment, have been operated using such hybrid technique. Fifteen patients underwent a two-level surgery, seven patients received a three-level surgery and two a four-level procedure, for a total of 59 implanted devices (27 disc prostheses and 32 cages). Follow-up ranged between 12 and 40 months (mean 23.8 months). In all but one patient clinical follow-up (neurological examination, Nurick scale, NDI, SF-36) demonstrated significant improvement; radiological evaluation showed functioning disc prostheses (total range of motion 3-15 degrees ) and fusion through cages. None of the patients needed revision surgery for persisting or recurring symptoms, procedure-related complications or devices dislocations. To the authors' best knowledge, this is the first study with the longest available follow-up describing a different concept in the management of cervical multilevel DDD. Although larger series with longer follow-up are needed, in selected cases of symptomatic multilevel DDD, the proposed surgical strategy appears to be a safe and reliable application of combined arthroplasty and arthrodesis during a single surgical procedure.

Anatomic midline marking during cervical arthroplasty with ProDisc-C: an alternative, simple, and reliable method: technical note.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report the results of a different, and previously undescribed, technique to anatomically mark the midline during cervical arthroplasty. SUMMARY OF BACKGROUND DATA: The ProDisc-C prosthesis should be implanted in the vertebral body midline. Current standard technique for midline marking usually relies on intraoperative fluoroscopy to locate on anteroposterior (AP) x-rays a midpoint between the uncinate processes and superimposed to the intervening spinous process. Nevertheless, uncinate process can be used as anatomic landmarks to size the proper width of the prosthesis and implant a suitable device well centered in the midline. METHODS: Two groups of ProDisc-C prostheses were analyzed and compared for midline alignment. Group 1: 68 prostheses were implanted using a different technique to identify the anatomic midline. Soft disc hernia and/or spondylotic disease (whose degree was not a contraindication for arthroplasty), either at single or multiple levels, were the underlying diseases. Group 2: 19 ProDisc-C implanted using the standard fluoroscopic technique to mark the midline. RESULTS: Postoperative analysis of AP digital x-rays revealed in group 1a mean difference of -0.35 mm between the 2 halves of the prosthesis' inferior plate in respect to the defined midline. Sixty prostheses (88.2%) had an eccentric position ranging between 0.1 and 2.2 mm. Five prostheses (7.3%) were in a more significantly eccentric position by 4 to 5.5 mm. In 3 cases (4.4%), the eccentric positioning was between 2.5 and 4 mm. SD was + or - 2.18. In group 2, the mean difference was -0.07 mm. Only 1 prosthesis (5.2%) was in eccentric position by 6.14 mm. Five devices (26.3%) were in eccentric position by > or = 2 mm. The remaining 13 prostheses (68.4%) showed an eccentric position ranging between 0.36 and 1.82 mm. SD was + or - 2.02. Statistical analysis was performed using the Student t test. CONCLUSIONS: This study confirms that in cases of soft disc hernia or moderate spondylosis, the anatomic midline marking technique is a safe, reliable, and effective option. It is as accurate as the current fluoroscopic-guided technique and gives the opportunity either to reduce patient's and surgeons' exposure to radiations or to shorten the operation time by reducing the overall fluoroscopy and avoiding performing AP x-rays.

Multilevel Anterior Cervical Diskectomy and Fusion with Zero-Profile Devices: Analysis of Safety and Feasibility, with Focus on Sagittal Alignment and Impact on Clinical Outcome: Single-Institution Experience and Review of Literature.

BACKGROUND: In multilevel degenerative conditions posterior approaches are often preferred, but anterior approaches provide comparable clinical results and better alignment. Anterior plating entails higher rates of soft tissue injuries and dysphagia, particularly in multilevel cases. This study evaluates efficacy and safety of zero-profile devices in 3- and 4-level anterior cervical diskectomy and fusion, analyzing patients' clinical and radiologic long-term outcomes. METHODS: We prospectively enrolled 24 patients with cervical spondylotic myeloradiculopathy who underwent 3- and 4-level anterior cervical diskectomy and fusion with the zero-profile device. Mean follow-up was 39 months (range 24-72). Nurick grading was used for myelopathy, Neck Disability Index and Visual Analog Scale scores for arm and neck pain, and Short Form 36 survey for physical and mental health status. Postoperative radiograph and computed tomography were obtained after surgery, at 6 and 12 months, and at last follow-up to assess fusion rate and complications. Cervical alignment was measured by Cobb angle. Incidence of postoperative dysphagia was monitored according to Bazaz dysphagia index. RESULTS: On last computed tomography scan, fusion was present in 49% of spaces (40 of 82). Mean neck and arm pain visual analog scale decreased from 6.7-1.6 (P < 0.01) and 5.9-0.9 (P < 0.01), respectively. Improvements in the Short Form 36 survey and Neck Disability Index were documented (P < 0.01). Lordosis was restored in all patients. Five of 24 patients complained of mild dysphagia (20.8%): in three (12.5%) short-term dysphagia and in two (8.3%) medium-term dysphagia. No long-term dysphagia (≥6 months) was observed. CONCLUSION: Anterior cervical diskectomy and fusion with a zero-profile device is effective and safe for 3- and 4-level cervical spondylotic myeloradiculopathy. It allows to restore cervical lordosis and achieve long-term satisfactory clinical outcome.

Portable Intraoperative Computed Tomography Scan in Image-Guided Surgery for Brain High-grade Gliomas: Analysis of Technical Feasibility and Impact on Extent of Tumor Resection.

BACKGROUND: Intraoperative magnetic resonance imaging is the gold standard among image-guided techniques for glioma surgery. Scant data are available on the role of intraoperative computed tomography (i-CT) in high-grade glioma (HGG) surgery. OBJECTIVE: To verify the technical feasibility and usefulness of portable i-CT in image-guided surgical resection of HGGs. METHODS: This is a retrospective series control analysis of prospectively collected data. Twenty-five patients (Group A) with HGGs underwent surgery using i-CT and 5-aminolevulinic acid (5-ALA) fluorescence. A second cohort of 25 patients (Group B) underwent 5-ALA fluorescence-guided surgery but without i-CT. We used a portable 8-slice CT scanner and, in both groups, neuronavigation. Extent of tumor resection (ETOR) and pre- and postoperative Karnofsky performance status (KPS) scores were measured; the impact of i-CT on overall survival (OS) and progression-free survival (PFS) was also analyzed. RESULTS: In 8 patients (32%) in Group A, i-CT revealed residual tumor, and in 4 of them it helped to also resect pathological tissue detached from the main tumor. EOTR in these 8 patients was 97.3% (96%-98.6%). In Group B, residual tumor was found in 6 patients, whose tumor's mean resection was 98% (93.5-99.7). The Student t test did not show statistically significant differences in EOTR in the 2 groups. The KPS score decreased from 67 to 69 after surgery in Group A and from 74 to 77 in Group B (P = .07 according to the Student t test). Groups A and B did not show statistically significant differences in OS and PFS (P = .61 and .46, respectively, by the log-rank test). CONCLUSION: No statistically significant differences in EOTR, KPS, PFS, and OS were observed in the 2 groups. However, i-CT helped to verify EOTR and to update the neuronavigator with real-time images, as well as to identify and resect pathological tissue in multifocal tumors. i-CT is a feasible and effective alternative to intraoperative magnetic resonance imaging. Portable i-CT can provide useful real-time information during brain surgery and can be easily introduced in neurosurgical theaters in daily practice.

Smooth dissection of ligamentum flavum for lumbar microdiscectomy. Preliminary report of this personal technique.

A newly designed technique for preservation of the ligamentum flavum (LF) during the lumbar discectomy is presented. This technique allows the evacuation of the lumbar herniated disk, without removal or laminar disinsertion of the LF. This ligament is smoothly dissected longitudinally in its more lateral portion, obtaining, after discectomy, the contact of the 2 margins with restoration of its functional integrity. Forty-five patients were operated on with this technique. We feel that this technique could offer advantages in reduction of epidural fibrosis and of decreased risk of dural injury, and is helpful to the surgeon in the case of recurrence of discal herniation.

Role of intraoperative indocyanine green video-angiography to identify small, posterior fossa arteriovenous malformations mimicking cavernous angiomas. Technical report and review of the literature on common features of these cerebral vascular malformations.

OBJECTIVE: To illustrate the usefulness of intraoperative indocyanine green videoangiography (ICG-VA) to identify the nidus and feeders of a small cerebellar AVM resembling a cavernous hemangioma. To review the unique features regarding the overlay between these two vascular malformations and to highlight the importance to identify with ICG-VA, and treat accordingly, the arterial and venous vessels of the AVM. METHODS: A 36-year old man presented with bilateral cerebellar hemorrhage. MRI was equivocal in showing an underlying vascular malformation but angiography demonstrated a small, Spetzler-Martin grade I AVM. Surgical resection of the AVM with the aid of intraoperative ICG-VA was performed. After hematoma evacuation, pre-resection ICG-VA did not reveal tortuous arterial and venous vessels in keeping with a typical AVM but rather an unusual blackberry-like image resembling a cavernous hemangioma, with tiny surrounding vessels. Such intraoperative appearance, which could also be the consequence of a "leakage" of fluorescent dye from the nidal pathological vessels, with absent blood-brain barrier, into the surrounding parenchymal pathological capillary network, is important to be recognized as an unusual AVM appearance. RESULTS: Post-resection ICG-VA confirmed the AVM removal, as also shown by postoperative and 3-month follow-up DSAs. CONCLUSIONS: Despite technical limitations associated with ICG-VA in post-hemorrhage AVMs, this case together with the intraoperative video, demonstrates the useful role of ICG-VA in identifying small AVMs with peculiar features.

A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multicenter AOSpine international study on 479 patients.

STUDY DESIGN: Prospective, multicenter international cohort. OBJECTIVE: To evaluate outcomes of surgical decompression for cervical spondylotic myelopathy (CSM) at a global level. SUMMARY OF BACKGROUND DATA: CSM is a degenerative spine disease and the most common cause of spinal cord dysfunction worldwide. Surgery is increasingly recommended as the preferred treatment strategy for CSM to improve neurological and functional status and quality of life. The outcomes of surgical intervention for CSM have never been evaluated at an international level. METHODS: Between October 2007 and January 2011, 479 symptomatic patients with image evidence of CSM were enrolled in the prospective, multicenter AOSpine CSM-International study from 16 global sites. Preoperative and postoperative clinical status, functional impairment, and quality of life were evaluated using the modified Japanese Orthopaedic Assessment Scale, Nurick Scale, Neck Disability Index, and Short-Form-36v2. Preoperative and 12- and 24-month postoperative outcomes were compared using mixed-model analysis of covariance for repeated measurements. RESULTS: The study cohort consisted of 310 males and 169 females, with a mean age of 56.37 ± 11.91 years. There were significant differences in age, etiology, and surgical approaches between the regions. At 24 months postoperatively, the mean modified Japanese Orthopaedic Assessment Scale score improved from 12.50 (95% confidence interval [CI], 12.24-12.76) to 14.90 (95% CI, 14.64-15.16); the Neck Disability Index improved from 36.38 (95% CI, 34.33-38.43) to 23.20 (95% CI, 21.24-25.15); and the SF36v2 Physical Component Score and Mental Composite Score improved from 34.28 (95% CI, 33.46-35.10) to 40.76 (95% CI, 39.71-41.81) and 39.45 (95% CI, 38.25-40.64) to 46.24 (95% CI, 44.94-47.55), respectively. The rate of neurological complications was 3.13%. CONCLUSION: Surgical decompression for CSM is safe and results in improved functional status and quality of life in patients around the world, irrespective of differences in medical systems and sociocultural determinants of health. LEVEL OF EVIDENCE: 3.

Relationship between IL-18 and sICAM-1 serum levels in patients affected by coeliac disease: preliminary considerations.

OBJECTIVES: Cytokine production from activated T cells play a pathogenetic role in mucosal lesions of coeliac disease (CD). Active interleukin (IL)-18 is expressed in the small intestinal mucosa in CD but not in healthy controls. IL-18 enhances intercellular adhesion molecule-1 (ICAM-1) expression. We analyzed IL-18 serum levels in CD patients before and after gluten-free diet and the possible correlation with soluble ICAM-1 (sICAM-1) serum levels. METHODS: The study comprises ten CD patients before and after gluten free diet and ten healthy controls. Serum IL-18 and sICAM-1 levels were assayed by immunoenzymatic methods. RESULTS: Serum IL-18 and sICAM-1 levels were significantly higher in patients with CD before diet with respect to healthy controls (P<0.05), with a highly significant correlation between the two parameters (Rho=0.800, P=0.0167). Gluten free diet significantly reduces IL-18 and sICAM-1. CONCLUSION: Our findings show that IL-18 serum concentrations correlated with the clinical status of CD patients suggesting a role for this cytokine in the pathophysiology of this disease.

Primary C1-2, intradural, extramedullary meningeal sarcoma with glial fibrillary acidic protein-immunoreactive components: a spinal gliosarcoma? Case report and review of the literature.

The authors report an exceedingly rare case of a patient harboring a primary, spinal, C1-2, intradural, extramedullary meningeal sarcoma in which there were glial fibrillary acidic protein-immunoreactive components, but, importantly, no physical connection with neural tissue. On initial diagnostic imaging, neuroradiological features suggestive of a spinal meningioma were demonstrated in this 73-year-old man. He underwent a C1-2 laminectomy and removal of the posterior ring of the foramen magnum, and the lesion was excised. Histological and immunohistochemical testing showed a gliosarcoma. The clinical, radiological, and operative data are reviewed, as are the histopathological findings. To the authors' knowledge, this is the first case of a primary spinal intradural extramedullary gliosarcoma reported in the literature.