Preoperative elastoplasty of aggressive vertebral hemangiomas in elderly patients: a new strategy for reducing intraoperative bleeding and complications.

PURPOSE: Preoperative elastoplasty could be an alternative strategy for treating aggressive vertebral hemangiomas (VHs) in frail patients needing for spinal cord decompression, combining the advantages of embolization and vertebroplasty. METHODS: Three elderly patients with spinal cord compression from thoracic aggressive VHs underwent XperCT-guided percutaneous injection of silicone (VK100), filling the whole affected vertebra, followed by a decompressive laminectomy. At 12-months follow-up no recurrences, vertebral collapse or segmental kyphosis were noted at the CT scans, with patients reporting an improvement of preoperative neurological deficits, VAS and Smiley-Webster pain scale (SWPS) parameters. RESULTS: With its elastic modulus, non-exothermic hardening, and lower viscosity than PMMA, VK100 allowed a preoperative augmentation of the affected vertebral body, pedicles, and laminae without complications, with a controlled silicone delivery even in part of VH's epidural components thanks to XperCT-guidance. CONCLUSION: When facing highly bony erosive VH encroaching the spinal canal, VK100 combines the advantages of embolization and vertebroplasty especially in elderly patients, permeating the whole VH's angioarchitecture, significantly reducing tumor.

The neurosurgical outpatient clinic: comparison between accesses in public and private activities.

BACKGROUND: Neurosurgical clinic assesses presence and extent of pathologies of central and peripheral nervous system or disorders affecting the spine, to identify most effective treatment and possible recourse to surgery. The aim of the study is to evaluate the appropriateness of request for a neurosurgical consult both in private and in public outpatient clinics. MATERIALS AND METHODS: We collected and analyzed all the reports of outpatient visits of public and private clinic over a period between January and December 2018. RESULTS: There were 0.62% real urgent visits in the public sector and 1.19% in the private sector (p = 0.05). Peripheral pathologies represented 12.53% and 6.21% of pathologies evaluated in public and private sector respectively (p < 0.00001). In addition, 15.76% of visits in public lead to surgery, while they represented 11.45% in private (p = 0.0003). CONCLUSIONS: No study is available comparing accesses of patients in neurosurgical outpatient clinics. In public clinic, visits are booked as urgent on the prescription of the general practitioner: in reality, only 5% of these visits were really confirmed as urgent by the specialist. Peripheral pathologies are more frequent in public clinic, while cranial pathologies are more frequent in private one. Patients with cranial pathologies prefer to choose their surgeon by accessing private clinic.

Erector spinae plane block for perioperative pain management in neurosurgical lower-thoracic and lumbar spinal fusion: a single-centre prospective randomised controlled trial.

BACKGROUND: Erector spinae plane block is a locoregional anaesthetic technique widely used in several different surgeries due to its safety and efficacy. The aim of this study is to assess its utility in spinal degenerative and traumatic surgery in western countries and for patients of Caucasian ethnicity. METHODS: Patients undergoing elective lower-thoracic and lumbar spinal fusion were randomised into two groups: the case group (n = 15) who received erector spinae plane block (ropivacaine 0.4% + dexamethasone 4 mg, 20 mL per side at the level of surgery) plus postoperative opioid analgesia, and the control group (n = 15) who received opioid-based analgesia. RESULTS: The erector spinae plane block group showed significantly lower morphine consumption at 48 h postoperatively, lower need for intraoperative fentanyl (203.3 ± 121.7 micrograms vs. 322.0 ± 148.2 micrograms, p-value = 0.021), lower NRS score at 2, 6, 12, 24, and 36 h, and higher satisfaction rates of patients (8.4 ± 1.2 vs. 6.0 ± 1.05, p-value < 0.0001). No differences in the duration of the hospitalisation were observed. No erector spinae plane block-related complications were observed. CONCLUSIONS: Erector spinae plane block is a safe and efficient opioid-sparing technique for postoperative pain control after spinal fusion surgery. This study recommends its implementation in everyday practice and incorporation as a part of multimodal analgesia protocols. TRIAL REGISTRATION: The study was approved by the local ethical committee of Romagna (CEROM) and registered on ClinicalTrials.gov (NCT04729049). It also adheres to the principles outlined in the Declaration of Helsinki and the CONSORT 2010 guidelines.

Lumbar interbody fusion using oblique (OLIF) and lateral (LLIF) approaches for degenerative spine disorders: a meta-analysis of the comparative studies.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Historically, posterior approaches to the lumbar spine have allowed surgeons to manage degenerative conditions affecting the lumbar spine. However, spinal muscles injury, post-surgical vertebral instability, cerebrospinal fluid (CSF) leakage, and failed back surgery syndrome (FBSS) represent severe complications that may occur after these surgeries. Lumbar interbody fusion using anterior (ALIF), oblique (OLIF), or lateral (LLIF) approaches may represent valuable surgical alternatives, in case fusion is indicated on single or multiple levels. METHODS: The present study is a systematic review, conducted according to the PRISMA statement, of comparative studies on OLIF, and LLIF for degenerative spine disorders, and a meta-analysis of their clinical-radiological outcomes and complications. RESULTS: After screening 1472 papers on PubMed, Scopus, and Cochrane Library, only 3 papers were included in the present study. 318 patients were included for data meta-analysis, 128 in OLIF group, and 190 in LLIF group. There were no significative differences in terms of surgical (intraoperative blood loss and surgical duration) and clinical (VAS-back, VAS-leg, and ODI scores) outcomes, or fusion rates at last follow-up (> 2 years). Significantly higher rates of abdominal complications, system failure, and vascular injuries were recorded in the OLIF group. Conversely, postoperative neurological symptoms and psoas weakness were significatively more common in LLIF group. CONCLUSIONS: The meta-analysis suggests that OLIF and LLIF are both effective for lumbar degenerative disorders, although each of them presents specific complications and this should represent a relevant element in the surgical planning.

Influence of nutritional status on the clinical outcome of patients with chronic subdural hematoma: a prospective multicenter clinical study.

BACKGROUND: Elderly patients present a higher risk of developing chronic subdural hematomas (CSDHs) together with increased risk of malnutrition. The nutritional status may affect outcomes, response to treatments, and prognosis. Influence on other kinds of diseases was investigated showing an increased risk of mortality, morbidity, and adverse outcomes. However, no studies are available on its possible role for the outcome of patients with CSDH. This study aims to evaluate a possible relationship between the nutritional status and the clinical outcome of patients who underwent CSDH surgery. METHODS: This is a multicenter prospective study enrolling all patients treated for CSDH. Demographic and clinical data were collected. For nutritional status evaluation, we used the Mini Nutritional Assessment (MNA). Chi-square test was used for comparing clinical variables of patients and logistic regression analysis was used for defining the impact of the aforementioned variables on the clinical outcome. RESULTS: We enrolled 178 patients. Modified Rankin scale (mRS) was 0-2 pre-operatively in 23.6% of patients and post-operatively in 61.2% of patients. Total assessment MNA score was >23.5 in 47.8% of patients. Ninety-three patients (52.2%) presented a normal nutritional status, 63 (35.4%) were at risk of malnutrition and 22 (12.4%) were malnourished. The mean follow-up was 2.6 months. Malnourished patients were at higher risk of a worse outcome (OR 81; CI = 9-750). CONCLUSION: This study suggests that nutritional status represents a strong predictor of outcome. Our results, albeit preliminary, demonstrated malnutrition is correlated to the risk of worse clinical outcome for patients undergoing surgery for chronic subdural hematoma. Further investigations with wider casuistry and multiple nutritional scores are required to validate our data.

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

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

FUSE-ML: development and external validation of a clinical prediction model for mid-term outcomes after lumbar spinal fusion for degenerative disease.

BACKGROUND: Indications and outcomes in lumbar spinal fusion for degenerative disease are notoriously heterogenous. Selected subsets of patients show remarkable benefit. However, their objective identification is often difficult. Decision-making may be improved with reliable prediction of long-term outcomes for each individual patient, improving patient selection and avoiding ineffective procedures. METHODS: Clinical prediction models for long-term functional impairment [Oswestry Disability Index (ODI) or Core Outcome Measures Index (COMI)], back pain, and leg pain after lumbar fusion for degenerative disease were developed. Achievement of the minimum clinically important difference at 12 months postoperatively was defined as a reduction from baseline of at least 15 points for ODI, 2.2 points for COMI, or 2 points for pain severity. RESULTS: Models were developed and integrated into a web-app ( https://neurosurgery.shinyapps.io/fuseml/ ) based on a multinational cohort [N = 817; 42.7% male; mean (SD) age: 61.19 (12.36) years]. At external validation [N = 298; 35.6% male; mean (SD) age: 59.73 (12.64) years], areas under the curves for functional impairment [0.67, 95% confidence interval (CI): 0.59-0.74], back pain (0.72, 95%CI: 0.64-0.79), and leg pain (0.64, 95%CI: 0.54-0.73) demonstrated moderate ability to identify patients who are likely to benefit from surgery. Models demonstrated fair calibration of the predicted probabilities. CONCLUSIONS: Outcomes after lumbar spinal fusion for degenerative disease remain difficult to predict. Although assistive clinical prediction models can help in quantifying potential benefits of surgery and the externally validated FUSE-ML tool may aid in individualized risk-benefit estimation, truly impacting clinical practice in the era of "personalized medicine" necessitates more robust tools in this patient population.

Surgical treatment of metastatic pheochromocytomas of the spine: a systematic review.

Metastatic pheochromocytoma of the spine (MPS) represents an extremely rare and challenging entity. While retrospective studies and case series make the body of the current literature and case reports, no systematic reviews have been conducted so far. This systematic review aims to perform a systematic review of the literature on this topic to clarify the status of the art regarding the surgical management of MPS. A systematic review according to PRISMA criteria has been performed, including all studies written in English and involving human participants. 15 papers for a total of 44 patients were finally included in the analysis. The median follow-up was 26.6 months. The most common localization was the thoracic spine (54%). In 30 out of 44 patients (68%), preoperative medications were administered. Open surgery was performed as the first step in 37 cases (84%). Neoadjuvant treatments, including preoperative embolization were reported in 18 (41%) cases, while adjuvant treatments were administered in 23 (52%) patients. Among those patients who underwent primary aggressive tumor removal and instrumentation, 16 out of 25 patients (64%) showed stable disease with no progression at the final follow-up. However, the outcome was not reported in 14 patients. Gross total resection of the tumor and spinal reconstruction appear to offer good long-term outcomes in selected patients. Preoperative alpha-blockers and embolization appear to be useful to enhance hemodynamic stability, avoiding potential detrimental complications.

Simplified four-step retropharyngeal approach for the upper cervical spine: technical note.

PURPOSE: In this paper, we propose a simplified four-step retropharyngeal approach, whose aim is getting straight to the upper cervical spine minimizing complications. METHODS: While the classical retropharyngeal approach includes about 11 steps, ours is a four-step approach: patient positioning, skin-platysma incision, hyoid bone superolateral dissection and retropharyngeal blunt exposure. We avoid several steps of the classical anterior retropharyngeal approach, particularly dissection of submandibular gland, facial veins, external carotid artery and thyroid artery, bellies of the digastric muscle, hypoglossal nerve, thyrohyoid membrane and the internal branch of superior laryngeal nerve. RESULTS: We have adopted this technique for five patients: two patients had a C2-C3 herniated disk with myelopathy, two patients had unstable Hangman fracture with no bone fusion after 2-month treatment with rigid collar, and one patient had a C2-C3 osteophyte with dysphagia. The intraoperative time needed for reaching the retropharyngeal space was 15 (first case), 9 (second case), 7 min (third case-illustrative case-and fourth case), 8 min (fifth case). No complications occurred. CONCLUSION: Our simplification, avoiding several steps, is simple, effective, safe, and rapid and requires a simple learning curve.

Spontaneous Repositioning of Isolated Blow-In Orbital Roof Fracture: Could Wait and See Be a Strategy in Asymptomatic Cases?

BACKGROUND: Treatment of isolated blow-in orbital roof fractures is still debated due to their anatomical complexity and the potential ocular and neurological related injuries. Surgery is advised in symptomatic cases while there is still controversy regarding the preferred treatment for those patients asymptomatic. OBJECTIVE: To explore the suitability of a conservative management with close imaging follow-up in asymptomatic isolated blow-in orbital roof fractures. METHODS: A single-case experience has been integrated into a systematic review of the literature to support the discussion on this specific traumatic lesion. Studies written in English and pertaining adult human subjects were further filtered according to the following eligibility criteria: clear definition of fracture's pattern, absence of concomitant cranio-facial injuries requiring management, proper description of treatment timing and outcome. RESULTS: The literature regarding treatment of isolated orbital roof fractures is of poor quality partly due to the rarity of such lesions. A total of 4 studies limited to small case series with 13 patients in total discuss thoroughly management options and timing of treatment. In particular, displaced blow-in fractures were treated conservatively in 4 patients with only 2 benefitting from this approach. Our patient showed a spontaneous realignment of a posttraumatic blow-in orbital roof deformity and at 12-month follow-up conservative management appeared a safe and effective strategy. A short-term wait-and-see approach with aggressive follow-up imaging could probably represent a reasonable option for treatment of isolated blow-in orbital roof fractures without neurological or ocular symptoms. Since literature remains confined to limited case series, future multicenter studies adopting shared evaluation parameters would help in standardizing the indications for this subset of craniofacial injuries.

Type II odontoid fracture in elderly patients treated conservatively: is fracture healing the goal?

PURPOSE: Analysis of functional outcome of elderly patients with type II odontoid fractures treated conservatively in relation to their radiological outcome. METHODS: A total of 50 geriatric patients with type II odontoid fractures were treated with Aspen/Vista collars. On admission, each patient was assessed assigning ASA score, modified Rankin Scale (mRS-pre) and Charlson Comorbidity Index (CCI). From 12-15 months after treatment, functional evaluations were performed employing a second modified Rankin Scale (mRS-post) together with Neck Disability Index (NDI) and Smiley-Webster pain scale (SWPS). Radiological outcome was evaluated through dynamic cervical spine X-rays at 3 months and cervical spine CT scans 6 months after treatment. Three different conditions were identified: stable union, stable non-union and unstable non-union. Surgery was preferred whenever a fracture gap > 2 mm, an antero-posterior displacement > 5 mm, an odontoid angulation > 11° or neurological deficits occurred. RESULTS: Among the 50 patients, 24 reached a stable union, while 26 a stable non-union. Comparing the two groups, no differences in ASA (p = 0.60), CCI (p = 0.85) and mRS-pre (p = 0.14) were noted. Similarly, no differences in mRS-post (p = 0.96), SWPS (p = 0.85) and NDI (p = 0.51) were observed between patients who reached an osseous fusion and those with a stable fibrous non-union. No effects of age, sex, ASA, mRS-pre, fracture dislocation and radiological outcome were discovered on functional outcome. At logistic regression analysis, female sex and high values of CCI emerged associated with worse NDI. CONCLUSIONS: In geriatric type II odontoid fractures, pre-injury clinical status and comorbidities overcome imaging in determining post-treatment level of function. Hard collar immobilization led to a favourable functional outcome with mRS-post, NDI and SWPS values diffusely encouraging whatever a bony union or a fibrous non-union was obtained. These slides can be retrieved under Electronic Supplementary Material.

Functional Outcome After Odontoid Fractures in the Elderly.

While several papers on mortality and the fusion rate in elderly patients treated surgically or non-surgically for odontoid fractures exist, little information is available on quality of life after treatment. The aim of treatment in these patients should not be fracture healing alone but also quality of life improvement.A literature search using PubMed identified seven papers including information on functional evaluation of 402 patients.Patients treated with anterior screw fixation had a good functional outcome in 92.6% of cases. This percentage seemed to decrease in octogenarians. Less information was available for patients treated with posterior approaches; it would seem that up to a half of such patients experienced pain and limitations in activities of daily living after surgery. Patients treated with a halo device had a functional outcome that was worse (or at least no better) than that of patients treated with surgery, with absence of limitations in activities of daily living in 77.3% of patients. Patients treated with a collar had a good functional outcome in the majority of cases, with absence of limitations in activities of daily living in 89% of patients.More studies are needed for evaluation of functional outcome, especially in patients treated with a collar, a halo device or a posterior approach.

Efficacy of Microsurgical Sublabial Approach (MSA) Versus Endoscopic Endonasal Approach (EEA) for the Treatment of Pituitary Adenomas Based on Radiological and Hormonal Outcome.

BACKGROUND: The purpose of this study was to compare the surgical efficacy of the microsurgical sublabial approach (MSA) versus the endoscopic endonasal approach (EEA) for the treatment of pituitary adenomas, based on short-term (12 months) radiological and endocrinological follow-up. METHODS: One hundred and fourteen patients affected by pituitary adenoma were enrolled at our Unit between January 2007 and February 2012; 72 were treated with MSA, and 42 with EEA. The preoperative parameters considered were: type of lesion (secreting or nonsecreting), lesion size, presence of intralesional hemorrhage, lesion perimeter (nodular vs. uniform), intrasellar vs. suprasellar, involvement of cavernous sinus, and osteodural infiltration. Hormonal assays and magnetic resonance imaging (MRI) scans were performed at 12 months after the surgical procedure. RESULTS: Univariate analysis of the data documented a statistically significant difference in favor of MSA for the subgroups of secreting adenomas (90.9 % vs. nonsecreting 48.3 %), microadenomas (100 % vs. macroadenomas 57.1 %), adenomas without osteodural infiltration (87.5 % vs. 55.5 % with the infiltration) or those without intralesional hemorrhage (75 % vs. 45.9 % with the hemorrhage), and growth hormone (GH) adenomas (88.8 % vs. 43.7 %). Multivariate analysis confirmed the greater effectiveness of MSA for the treatment of micro-secreting adenomas. CONCLUSIONS: Recent advances in the EEA for treating pituitary adenomas could lead to this modality replacing the microsurgical technique. In our experience the MSA allowed us to achieve better results in the treatment of microadenomas.

Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes.

BACKGROUND: Several disc disease nomenclatures and approaches for LDH exist. The traditional midline bone-destructive procedures together with approaches requiring extreme muscular retraction are being replaced by muscle sparing, targeted, stability-preserving surgical routes. The increasing speculation on LDHs and the innovative corridors described to treat them have lead to an extensive production of papers frequently treating the same topic but adopting different terminologies and reporting contradictory results. METHODS: The review of such literature somehow confounding gave us the chance to regroup by surgical corridors the vast amount of approaches for LDH differently renamed over time. Likewise, LDHs were simplified in intra-foraminal (ILDH), extra-foraminal (ELDH), and intra-/extra-foraminal (IELDH) in relation to precise anatomical boundaries and extent of bulging disc. RESULTS: Through the analysis of the papers, it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation. CONCLUSIONS: The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions.

Association between polymorphisms rs1333040 and rs7865618 of chromosome 9p21 and sporadic brain arteriovenous malformations.

BACKGROUND: The chromosomal locus 9p21 is a novel genetic marker for a variety of cardiovascular and cerebrovascular diseases. In a recent study, we have demonstrated an association between the single nucleotide polymorphism (SNP) rs1333040C>T on chromosome 9p21 and sporadic brain arteriovenous malformations (BAVMs). Here, we extended our analysis to an additional SNP on chromosome 9p21 (rs7865618A>G) and increased our sample size including BAVMs from two different Italian neurosurgical centers. METHODS: We studied 206 patients with sporadic BAVMs and 171 unaffected controls. Genomic DNA was isolated from peripheral blood and the rs1333040C>T and rs7865618A>G polymorphisms were assessed by PCR-RFLP using the BsmI and MspI restriction endonucleases, respectively. For each SNP, we performed dominant, recessive, and additive genetic models. RESULTS: The distribution of the three possible genotypes of rs1333040 (TT, TC and CC) was statistically different between cases and controls (p = 0.0008). The TT genotype was significantly associated with BAVMs both in the dominant (p = 0.013) and recessive (p = 0.012) models. The T allele was significantly associated with BAVMs in the additive model (p = 0.002). Also the distribution of the three possible genotypes of rs7865618 (GG, AG and AA) was statistically different between cases and controls (p = 0.005), and the GG genotype and G allele were significantly associated with BAVMs in the dominant (p = 0.032), recessive (p = 0.007), and additive models (p = 0.009). We also detected a significant association between BAVMs with large nidus size and the GG genotype and G allele of rs7865618 and the TT genotype of rs1333040. A deep venous drainage was instead associated with the TT genotype of the rs1333040 and the GG genotype of the rs7865618. The occurrence of bleeding was associated with the TT genotype and T allele of rs1333040, while the presence of seizures appeared associated with the GG genotype of rs7865618. CONCLUSIONS: SNPs of the 9p21 region, in addition to be genetic markers for coronary artery disease, stroke, and intracranial aneurysms, are associated with sporadic BAVMs. These results extend and strengthen the role of the 9p21 chromosomal region as a common risk factor for cerebrovascular diseases.

Hypothalamic Hemangioma-like Pilocytic Astrocytoma in an Adult Patient: A Systematic Review with a Focus on Differential Diagnosis and Neurological Presentation.

Background: Pilocytic astrocytoma (PCA) are commonly observed as slow-growing noncancerous brain tumors in pediatric populations, but they can also occur in adults, albeit rarely. When located in diencephalic regions, particularly in the hypothalamus, they present unique diagnostic and management challenges due to their rarity and overlapping clinical and radiological features with other intracranial pathologies. This systematic review aims to provide a comprehensive understanding of hypothalamic PCA in adults, focusing on their differential diagnosis, neurological presentation, diagnostic modalities, treatment strategies. A case illustration is also described in order to better underline all the difficulties related to the diagnostic process. Material and methods: A systematic literature search was conducted in the PubMed/MEDLINE, Embase, and Scopus databases up to November 2023 to identify studies. Results: The systematic literature search identified a total of 214 articles. Following screening by title and abstract and full-text review, 12 studies were deemed eligible and are included here. Conclusions: Adult-onset PCA in diencephalic regions pose diagnostic challenges due to their rarity and overlapping features with other intracranial lesions. Advanced imaging techniques play a crucial role in diagnosis, while surgery remains the cornerstone of treatment. Multidisciplinary collaboration is essential for the optimal management and long-term follow-up of these patients.

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

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

A novel, reusable, realistic neurosurgical training simulator for cerebrovascular bypass surgery: Iatrotek® bypass simulator validation study and literature review.

Background: Microanastomosis is a challenging technique requiring continuous training to be mastered. Several models have been proposed, but few effectively reflect a real bypass surgery; even fewer are reusable, most are not easily accessible, and the setting is often quite long. We aim to validate a simplified, ready-to-use, reusable, ergonomic bypass simulator. Methods: Twelve novice and two expert neurosurgeons completed eight End-to-End (EE), eight End-to-Side (ES), and eight Side-to-Side (SS) microanastomoses using 2-mm synthetic vessels. Data on time to perform bypass (TPB), number of sutures and time required to stop potential leaks were collected. After the last training, participants completed a Likert Like Survey for bypass simulator evaluation. Each participant was assessed using the Northwestern Objective Microanastomosis Assessment Tool (NOMAT). Results: When comparing the first and last attempts, an improvement of the mean TPB was registered in both groups for the three types of microanastomosis. The improvement was always statistically significant in the novice group, while in the expert group, it was only significant for ES bypass. The NOMAT score improved in both groups, displaying statistical significance in the novices for EE bypass. The mean number of leakages, and the relative time for their resolution, also tended to progressively reduce in both groups by increasing the attempts. The Likert score expressed by the experts was slightly higher (25 vs. 24.58 by the novices). Conclusions: Our proposed bypass training model may represent a simplified, ready-to-use, reusable, ergonomic, and efficient system to improve eye-hand coordination and dexterity in performing microanastomoses.

Transpars approach for L5-S1 foraminal and extra-foraminal lumbar disc herniations: technical note.

BACKGROUND: The short pars and the narrowed surgical corridor for far lateral L5S1 herniation make the transpars approach challenging. The aim of this study is to determine the feasibility, efficacy, and safety of the transpars microscopic approach for the treatment of L5-S1 foraminal and extraforaminal lumbar disc herniation. METHODS: From 2015 to 2019, patients with L5-S1 far lateral lumbar disc herniation were prospectively recruited. Drug intake, working days lost, NRS-leg, NRS-back, nerve-root palsy, Oswestry disability-index, Macnab criteria were recorded before surgery and at follow-up. Patients were seen at 1-6-12 months after surgery. Lumbar dynamic X-rays were performed at 6-12 months after surgery and again at 2-4 years after surgery. Key-steps of surgery are described. RESULTS: Fourteen patients were enrolled. NRS-leg and NRS-back scores significantly improved (from 7.93 to 1.43 and from 3.2 to 0.6, respectively; P<0.0001). Oswestry Score significantly decreased (from 63.14 to 19.36 at 12 months; P<0.0001). L5 Root palsy improved in all cases (from 3.72/5 to 5/5; P<0.0001). At 12-months, excellent or good outcome (Macnab criteria) was achieved in 12 (85.7%) and 2 (14.3%) patients, respectively. All patients who were not retired returned to work within 30 days after surgery. No recurrence, instability or re-operations occurred. CONCLUSIONS: The trans pars microscopic approach is feasible, safe, and effective for L5-S1 foraminal and extraforaminal disc herniation. During surgery, the key-point is the oblique working angle, directed caudally, parallel to L5 pedicle. The iliac crest does not seem to constitute an obstacle.

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

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