The "state of the art" of intraoperative neurophysiological monitoring: An Italian neurosurgical survey.

Introduction: Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question: The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods: A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results: A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions: The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.

Bone marrow washout for multilevel vertebroplasty in multiple myeloma spinal involvement. Technical note.

INTRODUCTION: Vertebral involvement is found in a high percentage of multiple myeloma (MM) patients, often requiring multilevel surgical treatment to reduce pain and disability and to receive prompt access to oncological care. We describe the clinical use of washout technique for multilevel vertebroplasty in MM patients with diffuse spinal involvement. The aim of this technique is to reduce the risk of pulmonary fat embolism after cement injection and possibly to increment the amount of cement and treated levels in one surgical stage. METHODS: Three patients were treated with the washout technique prior to multilevel vertebroplasty for thoracolumbar diffuse spinal involvement in multiple myeloma. We describe the surgical technique and review the pertinent literature. RESULTS: The technique is clinically safe and effective in reducing pain, without significant complications. Two six-level vertebroplasties were performed in one case, allowing a larger amount of cement injected and a prompt start of the oncological treatment. CONCLUSIONS: Multilevel vertebroplasty in MM patients with diffuse spinal involvement carries the advantages of reducing pain, avoid repeated surgeries and faster return to oncological regimen. Cardiovascular complications, including pulmonary embolism, are rare but can have fatal consequences. It is mainly due to bone marrow mobilization during cement injection and the risk increases with the amount of cement injected and the number of treated levels. Despite multilevel treatment at the same stage, we did not observe any significant complication in our series. Further studies are needed to confirm the preliminary results of this technique. These slides can be retrieved under electronic supplementary material.

Stent augmentation of an anterior odontoid screw for type 2 odontoid fracture-dislocation in the elderly population: Report of two cases and literature review.

The fixation of type 2 odontoid fractures poses significant challenges in the elderly population due to coexistent osteoporosis and communition resulting in a high failure rate with conventional anterior screw fixation. Two elderly patients with unstable odontoid peg fractures and coexistent osteoporosis were treated with stentoplasty and anterior odontoid screw fixation. Additional anterior transarticular C1-2 screws were placed to address C1-2 instability. Both patients made an uneventful clinical recovery. One of the anterior C1-2 screws loosened due to the poor purchase in the osteoporotic bone in one patient. This did not affect the final outcome, and both the patients demonstrated maintained reduction and good alignment of odontoid peg after 2 years of follow-up. There was no intraoperative cement leak, pseudoarthrosis, or loss of reduction. Stentoplasty coupled with the anterior odontoid screw is a safe technique that can provide a biomechanically sound fixation of type 2 odontoid fractures in the presence of osteoporosis and significant communition.

The role of laminoplasty in preventing spinal deformity in adult patients submitted to resection of an intradural spinal tumor. Case series and literature review.

OBJECTIVE: Laminectomy has normally been used as a standard approach for intradural spinal tumors but this procedure is associated with spinal instability and deformity. Laminoplasty was developed to overcome these limitations. Controversies still exist regarding its actual role in preventing spinal deformity in adults. The aim of our study was to determine the impact of laminoplasty on the prevention of spinal deformity's onset or worsening in adult patients submitted to intradural spinal tumors resection. METHODS: We retrospectively reviewed the data of 43 consecutive adult patients, who underwent either laminectomy or laminoplasty for spinal intradural tumor resection, between January 2006 and May 2011. We evaluated the role of sex, spinal segment (cervical, thoracic, lumbar), tumor location (intra- or extra-medullary), procedure (laminoplasty or laminectomy), number of treated levels (≤2 vs >2), presence of pre-operative deformity and pre-operative Modified McCormick Scale (≤2 vs >2) in the development or worsening of spinal deformity, using Fisher's exact test and multivariate logistic regression analysis. RESULTS: Nine patients developed deformity or experienced a worsening of pre-operative deformity at latest follow-up. Among the considered potential prognostic factors, laminectomy (p=0.03) and evidence of pre-operative spinal deformity (p=0.009) were significantly associated with new-onset or worsening of spinal deformity. At logistic regression analysis, only the performed surgical procedure emerged as independent prognostic factor (p=0.044). No CSF leak was recorded in the laminoplasty cohort. CONCLUSIONS: No new-onset spinal deformities, no CSF leaks and a lower rate of spinal deformity progression were observed after laminoplasty for intradural intra- or extra-medullary tumor resection.

Tarlov cysts: a controversial lesion of the sacral spine.

The primary aim of our study was to provide a comprehensive review of the clinical, imaging, and histopathological features of Tarlov cysts (TCs) and to report operative and nonoperative management strategies in patients with sacral TCs. A literature review was performed to identify articles that reported surgical and nonsurgical management of TCs over the last 10 years. Tarlov cysts are often incidental lesions found in the spine and do not require surgical intervention in the great majority of cases. When TCs are symptomatic, the typical clinical presentation includes back pain, coccyx pain, low radicular pain, bowel/bladder dysfunction, leg weakness, and sexual dysfunction. Tarlov cysts may be revealed by MR and CT imaging of the lumbosacral spine and must be meticulously differentiated from other overlapping spinal pathological entities. They are typically benign, asymptomatic lesions that can simply be monitored. To date, no consensus exists about the best surgical strategy to use when indicated. The authors report and discuss various surgical strategies including posterior decompression, cyst wall resection, CT-guided needle aspiration with intralesional fibrin injection, and shunting. In operative patients, the rates of short-term and long-term improvement in clinical symptoms are not clear. Although neurological deficit frequently improves after surgical treatment of TC, pain is less likely to do so.

Craniotomy repair with the retrosigmoid approach: the impact on quality of life of meticulous reconstruction of anatomical layers.

INTRODUCTION: Various cranial repairs have been described to limit the incidence of cerebrospinal fluid (CSF) leak, the rate of infections, postoperative headache and local discomfort in patients undergoing cerebello-pontine angle surgery. MATERIALS AND METHODS: The aim of this study was to evaluate the impact of a feasible craniotomy procedure and cranial repair technique, which does not require bone replacers or filling materials, on postoperative outcome. We analysed postoperative results in a series of 34 patients undergoing cerebello-pontine angle surgery. DISCUSSION AND CONCLUSIONS: We observed a statistically significant reduced incidence of local discomfort, postoperative headache and CSF leak in patients who underwent such a reconstructive technique compared to those undergoing retrosigmoid craniectomy.

Cervical extramedullary lymphomatoid granulomatosis.

Lymphomatoid granulomatosis (LYG) is a rare multisystem disease involving most frequently the lung, kidney and skin. LYG is characterized by an infiltration of atypical lymphocytoid and plasmocytoid cells, with granulomatous inflammation in an angiocentric and angiodestructive pattern. There have been only a few reports of spinal involvement of LYG. To our knowledge, we report the first patient with cervical extramedullary LYG undergoing surgical removal of a lesion causing spinal cord compression, and review the pertinent literature. The patient underwent C5-partial T1 laminectomy with partial removal of the lesion and decompression of the spinal cord. A diagnosis of a grade III LYG was made and chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) was administered. The patient was in good neurological condition at the 6-month follow-up but died 5 months later because of systemic progression of the disease. Although prognosis of LYG remains poor, surgery can be considered to improve pain relief and neurological morbidity of spinal LYG.

Downregulation of thymosin beta4 in neural progenitor grafts promotes spinal cord regeneration.

Thymosin beta4 (Tbeta4) is an actin-binding peptide whose expression in developing brain correlates with migration and neurite extension of neurons. Here, we studied the effects of the downregulation of Tbeta4 expression on growth and differentiation of murine neural progenitor cells (NPCs), using an antisense lentiviral vector. In differentiation-promoting medium, we found twice the number of neurons derived from the Tbeta4-antisense-transduced NPCs, which showed enhanced neurite outgrowth accompanied by increased expression of the adhesion complex N-cadherin-beta-catenin and increased ERK activation. Importantly, when the Tbeta4-antisense-transduced NPCs were transplanted in vivo into a mouse model of spinal cord injury, they promoted a significantly greater functional recovery. Locomotory recovery correlated with increased expression of the regeneration-promoting cell adhesion molecule L1 by the grafted Tbeta4-antisense-transduced NPCs. This resulted in an increased number of regenerating axons and in sprouting of serotonergic fibers surrounding and contacting the Tbeta4-antisense-transduced NPCs grafted into the lesion site. In conclusion, our data identify a new role for Tbeta4 in neuronal differentiation of NPCs by regulating fate determination and process outgrowth. Moreover, NPCs with reduced Tbeta4 levels generate an L1-enriched environment in the lesioned spinal cord that favors growth and sprouting of spared host axons and enhances the endogenous tissue-repair processes.

Cranial and spinal subdural empyema.

Subdural empyema represents a loculated suppuration between the dura and the arachnoid. It has been described either intracranially or in the spinal canal, the latter localization being quite rare. It is a rare but serious illness with a declining mortality rate but rather frequent neurological sequelae. Morbidity and mortality in intracranial and spinal subdural empyema directly relate to the delay in diagnosis and therapy. The epidemiology, etiology, pathophysiology and symptoms of spinal subdural empyema and cranial subdural empyema are somewhat different, but brain and spinal subdural empyema are not always two different entities. An adequate treatment strategy should be selected on a case-by-case basis, especially for patients with a massive CNS involvement, where management represents a challenge.

Primary cerebral lymphomatoid granulomatosis: report of four cases and literature review.

BACKGROUND: Lymphomatoid granulomatosis (LYG) is an angiocentric and angiodestructive lymphoreticular proliferation, which usually involves the lungs, but may also involve the central nervous system (CNS). Unique involvement of the CNS has been reported rarely. We report our experience with LYG confined to the brain and review the pertinent literature. PATIENTS AND METHODS: From January 1995 to September 2007, we identified patients with isolated brain LYG through a search of the histopathology database of the Catholic University of Rome; medical and radiological data were analyzed. Immunophenotype, in situ hybridization analysis of EBV-encoded small RNAs (EBER ISH) and immunoglobulin rearrangement studies were performed on the pathological specimens. RESULTS: Four patients with brain-LYG (male/female 1:1, mean age 44 years) underwent surgery in the study period. Subsequent therapy was tailored according to LYG grading. At the latest follow-up (range from 18 to 221 months), patient conditions had improved in all cases. EBER ISH was negative in all cases. Study of the IgH chain gene documented a monoclonal pattern in two cases. CONCLUSIONS: CNS-LYG is a rare disease that should be considered in the differential diagnosis of both diffuse and space-occupying cerebral lesions. Primary cerebral LYG seems not to be associated with EBV and appears to have a better prognosis than systemic LYG with CNS localization, which is frequently EBV positive.

Prognostic relevance of SOCS3 hypermethylation in patients with glioblastoma multiforme.

Alterations in the signal transduction pathways are key mechanisms in the pathogenesis of de novo glioblastoma multiforme (GBM), which are also involved in the resistance to chemo- and radiotherapy. Here, we analyzed the methylation status and mRNA expression of suppressor of cytokine signaling (SOCS)1-2-3, 3 of the most important inhibitory molecules of the signal transduction circuitry, in 46 GBM specimens. The relationship between methylation status of SOCS1-2-3 and clinical outcome was investigated. Using methylation-specific PCR (MS-PCR) and sequencing, after bisulphite modification, we found that the promoter of SOCS1-2-3 was methylated in 24, 6.5 and 35% of GBM, respectively. Real-time analysis showed that in methylated GBM, mRNA expression for SOCS1-2-3 was reduced by 5, 3 and 7-folds, respectively, when compared with unmethylated GBM. Moreover, methylation of SOCS3 promoter significantly associated with an unfavorable clinical outcome (p < 0.0002). Our data suggest that methylation of SOCS3 may be involved in the pathogenesis of GBM and in the resistance of this neoplasm to conventional treatment.