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.

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.

Percutaneous Balloon Compression for Trigeminal Neuralgia. A Comparative Study Between the Fluoroscope Guided and Neuronavigated Technique.

Percutaneous balloon compression (PBC) is a safe and effective procedure in the treatment of trigeminal neuralgia (TN) due to its simplicity, low cost and the possibility of being repeated in case of pain recurrence. Foramen ovale (FO) cannulation is accomplished with the assistance of intraoperative C-arm fluoroscopy. Recently, several authors have reported successful application of intraoperative CT navigation as well. The reported advantages of CT navigation are linked to better spatial orientation and the low rate of attempts for FO cannulation. However, these advantages should be considered in the face of concerns regarding increased radiation dose to the patient and its possible adverse effects. Here we compared the fluoroscopic guided and neuronavigated PBC techniques in terms of efficacy and radiological exposure. We retrospectively analyzed 37 patients suffering for TN and submitted to PBC. We observed a significant improvement of pain at 1 month FU compared with the pre-operative in both groups (p < 0.0001 and p < 0.0001, respectively). A significant increase in radiation exposure was found in the neuronavigated group compared with the fluoroscopy group (p < 0.0001). We suggest the use of neuronavigated PBC only in selected cases, such as patients with multiple previous operations, in whom a difficult access can be pre-operatively hypothesized.

Spinal Cord High-Frequency Stimulation. The Current Experience and Future Directions.

Spinal cord stimulation (SCS) is a neuromodulation technology that has emerged as a valid treatment for chronic intractable neuropathic pain. After conventional tonic SCS, new waveforms of stimulation, like high frequency (HF), have proved that they can provide safe and effective pain relief. In addition, SCS is now being utilized more broadly as a potential treatment for a range of indications, including motor disorders and spasticity. Our study presents a retrospective analysis of 20 patients with heterogenous aetiologies of neuropathic pain treated with HF stimulation, after a standardized protocol in a temporary trial. We observed a significant improvement in pain relief according to comparisons of numerical rating scale (NRS) scores before the procedure, after the clinical trial and at latest follow-up. Two unusual clinical cases were also reported, and the pertinent literature was discussed.

Spinal Epidural Atypical Meningioma: Case Report and Review of the Literature.

Spinal atypical meningiomas are rare, and those whose main extension is in the epidural space are anecdotal. Here, we report a case of a young woman presenting with sensory disturbances and a radiological diagnosis of a dorsal epidural sleeve-like mass. The surgical resection of the lesion allowed the decompression of the spinal cord and led to the histopathological diagnosis of atypical meningioma. At the 3-month follow-up, her neurological recovery was complete. Because of the gross total removal of the lesion, adjuvant radiotherapy was not performed: At the 2-year follow-up, no recurrence of disease was detected. A comprehensive literature review was performed, and just two more case reports on epidural atypical meningiomas were found in the English literature. Through this case report and literature review, we described a rare manifestation of spinal meningioma that entered into a differential diagnosis for extradural spinal lesions, such as secondary malignancies.

Toward the End of the Funnel: The Ventriculus Terminalis-The State of Art of an Ancient Entity with a Recent History.

PURPOSE: The ventriculus terminalis (VT), also called the fifth ventricle, is a small cavity containing cerebrospinal fluid (CSF) that is in the conus medullaris in continuity with the central canal of the spinal cord. In adults, persistent VT is a very rare entity, and the diagnosis is incidental in most cases. Rarely, VT may become symptomatic for still-uncertain reasons but most often for its cystic dilatation. The management of these selected cases is still controversial and sometimes associated with unsatisfactory outcomes. METHODS: We performed a critical review of the existing literature on the management of symptomatic VT in adults. The etiology, pathophysiology, and treatment of VT are presented and discussed, focusing on the best timing for surgery. RESULTS: Conservative management, marsupialization, or the placement of a T drain have been reported. The existing classifications describe the most correct approach for each clinical presentation, but scarce importance has been given to the delay from symptoms' onset to surgical treatment. CONCLUSION: Although different cases have been described in the literature, this rare pathology remains unknown to most neurosurgeons.

An Overview of Recent Advances in Anterior Cervical Decompression and Fusion Surgery.

Anterior cervical diskectomy and fusion (ACDF) has evolved significantly in the last few years with the aim of enhancing effectiveness and safety while reducing hospitalization and healthcare-related costs. Transitioning from iliac crest autografts to allografts minimizes donor-site complications like pain, infections, and hematoma. Allograft options, such as polyetheretherketone (PEEK) and tantalum, vary in their osteoinductive properties and elastic modulus, influencing fusion rates, time, and the rate of subsidence. Recently introduced zero-profile cages offer bone fixation through screws, resulting in reduced blood loss, improved spinal alignment, and decreased complications like dysphagia and adjacent segment disease. Intraoperative neuromonitoring (IONM) has gained widespread use. The North American Spine Society (NASS) 2023 recommendations endorse IONM in cervical deformity corrections and myelopathy cases. Insufficient studies hinder clear radiculopathy recommendations, but emerging research supports IONM for patients at greater risk of C5 nerve root injury or positional injury. Advancements in hemostatic agents, such as gelatin sponges, oxidized cellulose, and fibrin sealants, contribute to safety by reducing postoperative hematoma rates and eliminating the need for drainage. Innovations like the exoscope, endoscope, and computed-tomography (CT) navigation have transformed surgical practices. Exoscopes are emerging as an alternative to microscopes, offering benefits like a smaller footprint, adjustable positioning, lower costs, and shared intraoperative views for educational purposes. The use of endoscope offers the possibility of performing a minimally invasive technique with improved results in terms of cosmesis and patient-perceived outcome. CT navigation can be useful in high-risk procedures, such as cervical plate placement for major instability. This paper provides an overview of cutting-edge technologies in ACDF surgery, emphasizing cage materials and designs, safety measures, and operating room advancements. It also highlights areas for future research, underlining the procedure's continuous evolution.

Are oral anticoagulants a risk factor for mild traumatic brain injury progression? A single-center experience focused on of direct oral anticoagulants and vitamin K antagonists.

BACKGROUND: Mild traumatic brain injury (TBI) in anticoagulated patients is a common challenge for emergency departments because of lack of appropriate epidemiological data and huge management variability for those under oral anticoagulation therapy. Given the discrepancies between guidelines, the aim of the present study was to quantify the association between oral anticoagulant therapy (either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC)) and the post-traumatic intracranial hemorrhage worsening compared to admission CT scan. METHODS: We included all consecutive records of patients admitted to our emergency department for mild TBI as chief complaint and with a positive admission CT scan. After statistical univariate comparison, cause-specific hazard ratio (HR) and 95% confidence interval (CI) were determined with the use of Cox proportional hazard model. RESULTS: In the study period, 4667 patients had a CT scan for mild TBI; 439 (9.4%) were found to have intracranial hemorrhage. Among these patients, 299 (68.1%) were prescribed observation and control CT: 46 (15.38%) were on anticoagulant therapy, 23 (50%) on VKA, and 23 (50%) on DOAC. In multivariate analysis, only oral anticoagulation therapy was significantly associated to an increased risk of intracranial hemorrhage progression (HR 2.58; 95% CI 1.411-4.703; p = .002 and HR 1.9; 95% CI 1.004-3.735; p = .0048 for VKA and DOAC, respectively). Surgery was due to isolated subdural hematoma in 87.5% of cases, to subdural hematoma associated with intraparenchymal hemorrhage in 9.38% and to intraparenchymal hemorrhage only in 3.12%; 13 cases (4.35%) deceased in intensive care unit. CONCLUSIONS: In our series, anticoagulation was associated to a significant increase in intracranial progression, leaving the question open as to what this implies in current clinical practice; subdural hematoma was the major finding associated to evolution and surgery. Against this background, further studies are needed to clarify patients' management and DOAC safety profile compared to VKA in mild TBI.

New Tools and Techniques to Prevent CSF Leak in Cranial and Spinal Surgery.

Cerebro-spinal fluid (CSF) leak in cranial and spinal surgery seriously threatens the clinical prognosis of surgical cases exposing the patients to higher risk of infection, prolonged hospital stay, and need of reoperation. Ultimately, this cascade of events may lead to life-threatening complications, as in cases of meningitis/encephalitis, spondylodiscitis, subdural hematomas, and severe pneumocephalus. Moreover, CSF leak causes a consistent rise in healthcare-related costs which are nearly doubled in CSF leak cases after craniotomy or in spinal surgery. The risk of CSF leak tends to be higher in patients undergoing transnasal endoscopic surgery, posterior fossa craniotomies, and spinal surgery, while being considered a quite rare finding in supratentorial brain surgery. Here we analyzed the different implications of this issue focusing on the usefulness of new technologies and surgical strategies to prevent it. CSF leak rate may vary from 4% in transsphenoidal procedures to 32% in posterior fossa craniotomies. In spinal surgery, CSF leak may be a consequence of elective intradural surgery, accounting for 18% of the procedures, or being a result of incidental durotomies, ranging from 1 to 17% in different surgical series. Dural closure's reinforcement using different new dural sealants plays an important role in preventing these events. Moreover, the use of neuronavigation systems in skull base and posterior fossa surgery can help to minimize the size of approach and reduce the incidence of CSF leak. New minimally invasive spinal approaches, such as minimally invasive decompression for spinal degenerative disorders or performing selective laminotomies over laminectomies for intradural spinal pathology are very useful techniques to prevent CSF leak in this kind of surgery. In conclusion, although CSF leak remains a risky complication in neurosurgery, its prevention and treatment significantly benefited from advances in biomaterials and surgical technique.

A systematic review and meta-analysis of factors affecting the outcome of the epidural blood patching in spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) is an often misdiagnosed condition resulting from non-iatrogenic cerebrospinal fluid (CSF) hypovolemia, typically secondary to spinal CSF leakage. Patients commonly present with posture-related headache, nausea, and vomiting. Following failure of conservative measures, epidural blood patching (EBP) is the most commonly performed intervention for spinal CSF leaks. The authors performed a systematic review and meta-analysis of existing literature to evaluate the role of different factors possibly affecting the efficacy of the EBP procedure. In accordance with the PRISMA guidelines, PubMed/Medline and SCOPUS databases were searched. Six eligible articles were retrieved. Five hundred patients were treated for SIH with EBP, of which 300 reported good response defined as complete remission of symptoms within 48 h after the first EBP requiring no further invasive treatment. Among the factors available for meta-analysis, none was found to be statistically significant in affecting the efficacy of the EBP procedure. A largely symmetrical funnel plot is reported for all the variables evaluated, indicating that publication bias did not play a significant role in the observed effects. The current knowledge about SIH and the EBP is scarce. The existing literature is contradictory and insufficient to aid in clinical practice. More studies are needed to draw significant conclusions that may help in the identification of patients at higher risk of EBP failure, who may benefit from different approaches.

The reliability and quality of online patient education videos for vestibular schwannoma.

BACKGROUND: A recent trend of looking for health-related conditions on the Internet has been described, with up 70% of searchers stating that online sources have affected their medical decision-making. Patients with vestibular schwannomas (VS) use online sources, including videos, to seek information about treatment alternatives and outcomes and surgeons experience. Our study investigates the reliability and quality of VS-related online videos. METHODS: In April 2020, a search was launched on YouTube for the key terms 'vestibular schwannoma,' 'acoustic neuroma,' 'eighth cranial nerve schwannoma,' and 'eighth cranial nerve neuroma.' Results were screened for possible inclusion. Three authors independently used the DISCERN instrument to evaluate the reliability and quality of the included videos. Factors possibly influencing popularity were investigated. RESULTS: The initial search yielded 6416 videos. 38 videos were included in the final analysis. The average DISCERN score was 2.76, indicating overall poor quality and reliability of information. Only 5% scored 4.0 or more (unbiased videos that offer evidence-supported information); 31% scored between 3.0 and 3.99, and 63% scored 2.99 or less. Videos describing symptoms or the patient's clinical presentation were slightly more popular than videos without these characteristics. Surgical videos (videos containing clips of surgical procedures) were significantly more popular than non-surgical videos (p = .024) despite being of similarly poor quality (DISCERN score 2.85 vs. 2.74, respectively). CONCLUSIONS: Available patient educational videos for VS are of mixed quality and reliability: the authors describe the strengths and pitfalls of existing YouTube videos. Considering that VS is a pathology with multiple available management modalities, and that patients' decision-making is affected by the information available on the Internet, it is of great importance that good-quality informative material be released by medical, academic, or educational institutions.

Comparison between deep brain stimulation and magnetic resonance-guided focused ultrasound in the treatment of essential tremor: a systematic review and pooled analysis of functional outcomes.

The current gold standard surgical treatment for medication-resistant essential tremor (ET) is deep brain stimulation (DBS). However, recent advances in technologies have led to the development of incisionless techniques, such as magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy. The authors perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to compare unilateral MRgFUS thalamotomy to unilateral and bilateral DBS in the treatment of ET in terms of tremor severity and quality of life improvement. PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and SCOPUS databases were searched. 45 eligible articles, published between 1990 and 2019, were retrieved. 1202 patients were treated with DBS and 477 were treated with MRgFUS thalamotomy. Postoperative tremor improvement was greater following DBS than MRgFUS thalamotomy (p<0.001). A subgroup analysis was carried out stratifying by treatment laterality: bilateral DBS was significantly superior to both MRgFUS and unilateral DBS (p<0.001), but no significant difference was recorded between MRgFUS and unilateral DBS (p<0.198). Postoperative quality of life improvement was significantly greater following MRgFUS thalamotomy than DBS (p<0.001). Complications were differently distributed among the two groups (p<0.001). Persistent complications were significantly more common in the MRgFUS group (p=0.042). While bilateral DBS proves superior to unilateral MRgFUS thalamotomy in the treatment of ET, a subgroup analysis suggests that treatment laterality is the most significant determinant of tremor improvement, thus highlighting the importance of future investigations on bilateral staged MRgFUS thalamotomy.

X-ray exposure in odontoid screwing for Anderson type II fracture: comparison between O-arm and C-arm-assisted procedures.

BACKGROUND: Since the odontoid fractures become increasingly common in the aging population, technical improvements are even more needed. The odontoid screwing has been progressively preferred by many surgeons in type II fractures according to the Anderson-D'Alonzo classification system. However, X-ray exposure remains an issue for surgeons and OR staff members. The aim of the present study was to investigate the feasibility of using the O-Arm for odontoid screwing comparing the radiation exposure to the standard C-Arm. METHODS: Patients consequently referred to our center for odontoid type II fractures, from January 2018 to April 2019, eligible for odontoid screwing were enrolled in the present study. They were operated on using either C-Arm or O-Arm-assisted procedures. The surgical duration, number of acquisitions, global X-ray exposure for the OR staff and patients, and screw placement accuracy were evaluated. RESULTS: No differences in terms of patients' demographical characteristics and surgical duration were reported. The number of acquisitions, intraoperative and global X-ray dose, for the OR staff and patients, was lower in O-Arm-assisted procedures (p < 0.05). The screws were all well positioned. CONCLUSIONS: Since the surgical outcomes seem to be similar using the O-Arm for odontoid screwing, the lower X-ray exposure and the possibility for checking the instrumentation positioning with 3D reconstructions before leaving the OR should be considered.

The role of non-rigid cervical collar in pain relief and functional restoration after whiplash injury: a systematic review and a pooled analysis of randomized controlled trials.

PURPOSE: Whiplash injury (WI) represents a common diagnosis at every emergency department. Several investigations have been conducted to compare the different medical managements for non-surgical cases. However, the role of the immobilization with a non-rigid cervical collar (nRCC) for pain management and range of motion (RoM) preservation has not been completely clarified. METHODS: We performed a systematic review of the randomized control trials (RCTs) and a pooled analysis in order to investigate the role of the nRCC for pain management, scored through the visual analogue scale (VAS) and the RoM, by comparing the use of a nRCC (for 1-2 weeks) with a non-immobilization protocols, regardless of the association with physical therapy (PhT). Only patients with whiplash-associated disorders grade I-II were included. Due to a certain heterogeneity across the RCTs, follow-up period time range resetting was necessary in order to pool the data. RESULTS: A total of 141 papers were reviewed; 6 of them matched the inclusion criteria and were admitted to the final study. Pooled analysis showed that nRCC does not improve the outcome in terms of VAS score and RoM trends along the follow-up. Moreover, VAS and RoM trends seem to further improve at long-term follow-up in non-immobilization associated with PhT group. CONCLUSIONS: This pooled analysis of the available RCTs shows the absence of an advantage of the immobilization protocol with a nRCC after a WI. On the contrary, non-immobilization protocols show an overall better trend of pain relief and neck mobility recovery, regardless of the association of PhT. These slides can be retrieved under Electronic Supplementary Material.

Cervical Spine Involvement in a Challenging Case of Accidental Strangulation.

Although strangulation is generally homicidal, the scientific literature reports several cases in which it is suicidal or even accidental. The former eventuality is particularly interesting because extremely atypical ligatures (such as locks of hair), complex dynamics, and uncommon findings can be involved. Only a meticulous evaluation of the body and of both direct and circumstantial evidence can help in the complex differential diagnosis that includes murder, suicide, and accident. In accidental strangulation, the number and severity of injuries depend on the magnitude of applied force. This implies that high-energy strangulation (in our case, caused by the entanglement of a scarf in an electrical generator) can produce a complex polytrauma. In this case, accidental self-strangulation caused widespread, posttraumatic subarachnoid hemorrhaging, laceration of the larynx, and fracture-dislocation of the C2/C3 vertebrae. We believe that all these events contributed to the death of the victim, but the complexity of the polytrauma and the lack of direct evidence did not allow us to determine a univocal cause-effect chain.

Real-time intraoperative contrast-enhanced ultrasound (CEUS) in vascularized spinal tumors: a technical note.

BACKGROUNDS: Intra-operative ultrasound (ioUS), and the recently introduced contrast-enhanced ultrasound (CEUS) demonstrated to be an extremely valuable tool in oncological cerebral neurosurgery. METHODS: The authors applied ioUS/CEUS techniques to spinal oncological surgery as showed in the illustrative case of a dorsal hemangiopericytoma. RESULTS AND CONCLUSIONS: ioUS and CEUS provide real-time information that proved useful in identifying both vascular and parenchymatous tumoral patterns, anatomical relations with nervous structure, plan surgical strategy, and identify residuals. It allows to visualize unexposed anatomical and pathological structures within the parenchyma and is a valuable guide during resection.

Atlantoaxial Joint Distraction with a New Expandable Device for the Treatment of Basilar Invagination with Preservation of the C2 Nerve Root: A Cadaveric Anatomical Study.

BACKGROUND: Atlantoaxial joint distraction has been advocated for the decompression of the brain stem in patients affected by basilar invagination, avoiding direct transoral decompression. This technique requires C2 ganglion resection and it is often impossible to perform due to the peculiar bony anatomy. We describe a cadaveric anatomical study supporting the feasibility of C1-C2 distraction performed with an expandable device, allowing easier insertion of the tool and preservation of the C2 nerve root. METHODS: In five adult cadaveric specimens, posterior atlantoaxial surgical exposure was performed and an expandable system was inserted within the C1-C2 joint. The expansion of the device, leading to active distraction of the joint space, together with all the surgical steps of the technique was recorded with anatomical pictures and the final results were checked with a computed tomography (CT) scan. RESULTS: Insertion of the device was easily performed in all cases without anatomical conflict with the C2 ganglion; CT scans confirmed the distraction of the C1-C2 joint. CONCLUSION: This cadaveric anatomical study confirms the feasibility of the introduction of an expandable and flexible device within the C1-C2 joint, allowing it's distraction and preservation of the C2 ganglion.

The use of surgical sealants in the repair of dural tears during non-instrumented spinal surgery.

PURPOSE: To compare the success in repair of dural tears (DTs) using two different surgical sealants in non-instrumented lumbar spinal surgery and evaluate the incidence of associated short- and long-term complications. METHODS: Twenty-three patients undergoing non-instrumented spinal surgery with intraoperative DTs were included both retrospectively and prospectively in this study. External signs of CSF leakage, neurological deficits, and infection-related complications were investigated postoperatively. The persistence of low-back pain was also evaluated and postoperative MRI was performed in all patients. DTs were repaired intraoperatively using suture with or without a dural patch. Eleven patients received an application of fibrin glue (Tissucol(®); Baxter, Inc., IL, USA) and 12 patients received an application of bovine serum albumin glutaraldehyde surgical adhesive (BioGlue(®) Surgical Adhesive; CryoLife, GA, USA). These patients were followed up at 3 months and 1 year postoperatively. RESULTS: Successful intraoperative DT repair was obtained in all cases. Three patients in the Tissucol group presented with CSF leakage in the early postoperative period. There were no complications observed in the patients treated with BioGlue. At 3-month follow-up, no incidences of neurological or infection-related complications were observed in either group. There was no statistically significant difference in VAS between the two treatment groups. CONCLUSIONS: Intraoperative DTs can be easily repaired by many effective techniques. However, in our experience, the use of BioGlue is an effective adjunct to immediate dural repair, being comparable in terms of efficacy and safety to the use of fibrin glue, potentially decreasing the incidence of associated short- and long-term complications.

Unusual complication of condrocostal implant in rhinoplasty.

A 67-year-old patient with a casual diagnosis of a foreign body within the frontal sinus outreaching the frontal cerebral parenchyma was treated. Results of anamnestic examination revealed that the patient underwent rhinoplasty with condrocostal implant of the nasal dorsum fixed to the anterior wall of the frontal sinus using a Kirschner wire 2 years ago. A combined transnasal endoscopic and transcranic approach was performed to remove the foreign body.

Unsatisfactory Neurological Outcome in an Intramedullary Thoracic Intermediate-Grade Melanocytoma-Systematic Review and Illustrative Case.

BACKGROUND: Intramedullary melanocytomas are exceedingly rare, with only twenty-four cases reported up to now. They present as local invasive tumors despite their benign biological behavior. Attempting a complete safe resection often results in severe post-operative neurological deficits, as in our case presented here. METHODS: A systematic review was conducted across the PubMed and Scopus databases including studies published till February 2024. RESULTS: A total of 19 studies were included, encompassing 24 cases. A similar distribution between sexes was noted (M:F 13:11), with ages ranging from 19 to 79 years. The thoracic segment was most affected, and intermediate-grade melanocytoma (19 cases) was the most common histotype. Radiographically, intramedullary melanocytomas usually appear as hyperintense hemorrhagic lesions peripheral to the central canal with focal nodular enhancement. Intraoperatively, they are black-reddish to tan and are tenaciously adherent lesions. In the sampled studies, IONM employment was uncommon, and post-operative new-onset neurological deficits were described in 16 cases. Adjuvant RT was used in four cases and its value is debatable. Recurrence is common (10 cases), and adjuvant therapies (RT or repeated surgery) seem to play a palliative role. CASE PRESENTATION: A 68-year-old woman presented with a three-year history of worsening spastic paraparesis and loss of independence in daily activities (McCormick grade 4). An MRI revealed an intramedullary tumor from Th5 to Th7, characterized by T1-weighted hyperintensity and signs of recent intralesional hemorrhage. Multimodal neuromonitoring, comprising the D-Wave, guided the resection of a black-tan-colored tumor with hyper-vascularization and strong adherence to the white matter. During final dissection of the lesion to obtain gross total resection (GTR), a steep decline in MEPs and D-Wave signals was recorded. Post-operatively, the patient had severe hypoesthesia with Th9 level and segmental motor deficits, with some improvement during neurorehabilitation. Histopathology revealed an intermediate-grade melanocytoma (CNS WHO 2021 classification). A four-month follow-up documented the absence of relapse. CONCLUSIONS: This literature review highlights that intramedullary T1 hyperintense hemorrhagic thoracic lesions in an adult patient should raise the suspicion of intramedullary melanocytoma. They present as locally aggressive tumors, due to local invasiveness, which often lead to post-operative neurological deficits, and frequent relapses, which overwhelm therapeutic strategies leading to palliative care after several years.