Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review.

PURPOSE: The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS: A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS: A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS: A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.

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.

Epidural bleeding secondary to a synovial cyst rupture: a case report and review of literature.

Hemorrhage into a juxtafacet cyst is rare and cyst rupture with hemorrhagic extension into the epidural space is even less commonly seen. We describe the case of a patient with a hemorrhagic synovial cyst with rupture associated to abundant bleeding in the epidural space. A 61-year-old man had a 5-month history of worsening low back pain radiating into the right leg with associated weakness and numbness. A magnetic resonance imaging scan showed the presence of a mild anterior spondylolisthesis of L5 on S1 with increased synovial fluid into both facet joints. A suspected synovial cyst of the right facet joint at level L5-S1, with signal characteristics consistent with hemorrhage was seen. Caudally, epidural blood was evident from S1 to S2 that involved spinal canal and right S1 and S2 foramens. These findings were confirmed at surgery.

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.

Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience.

Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.

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.

Percutaneous instrumentation with cement augmentation for traumatic hyperextension thoracic and lumbar fractures in ankylosing spondylitis: a single-institution experience.

OBJECTIVE: The typical traumatic thoracolumbar (TL) fracture in patients with ankylosing spondylitis (AS) is a hyperextension injury involving all three spinal columns, which is associated with unfavorable outcomes. Although a consensus on the management of these highly unstable injuries is missing, minimally invasive surgery (MIS) has been progressively accepted as a treatment option, since it is related to lower morbidity and mortality rates. This study aimed to evaluate clinical and radiological outcomes after percutaneous instrumentation with cement augmentation for hyperextension TL fractures in patients with AS at a single institution. METHODS: This cohort study was completed retrospectively. Back pain was assessed at preoperative, postoperative, and final follow-up visits using the visual analog scale (VAS). Patient-reported outcomes via the Oswestry Disability Index (ODI) and the new mobility score (NMS) were obtained to assess disability and mobility during follow-up. Radiological outcomes included the Cobb angle, sagittal index (SI), union rate, and implant failure. Intra- and postoperative complications were recorded. RESULTS: A total of 22 patients met inclusion criteria. The mean patient age was 74.2 ± 7.3 years with a mean follow-up of 39.2 ± 17.4 months. The VAS score for back pain significantly improved over the follow-up period (from 8.4 ± 1.1 to 2.8 ± 0.8, p < 0.001). At the last follow-up, all patients had minor disability (mean ODI score 24.4 ± 6.1, p = 0.003) and self-sufficiency of mobility (mean NMS 7.5 ± 1.6, p = 0.02). The Cobb angle (5.2° ± 2.9° preoperatively to 4.4° ± 3.3° at follow-up) and SI (7.9° ± 4.2° to 8.8° ± 5.1°) were maintained at follow-up, showing no loss of segmental kyphosis. Bone union was observed in all patients. The overall complication rate was 9.1%, while the reoperation rate for implant failure was 4.5%. CONCLUSIONS: Percutaneous instrumentation with cement augmentation for traumatic hyperextension TL fractures in AS demonstrated good clinical and radiological outcomes, along with a high bone union level and low reoperation rate. Accordingly, MIS reduced the complication rate in the management of these injuries of the ankylosed spine.

Histomorphology and immunohistochemical patterns in degenerative disc disease and clinical-radiological correlations: a prospective study.

PURPOSE: Degenerative disc disease (DDD) is a common condition causing low-back pain, disability and, eventually, neurological symptoms. This investigation aimed to investigate intervertebral disc DDD-related changes, evaluating histomorphology and cytokines secretion, and their clinical-radiological correlations. METHODS: This is a monocentric prospective observational study. A cohort of patients who underwent microdiscectomy for DDD, from June 2018 to January 2019, were enrolled. Discs samples were examined for histomorphology, chondrons count, immunohistochemistry for Hif-1α, Nf200 and Egr-1. Demographical and clinical data were also collected. RESULTS: Twenty patients were finally included. MRI evaluation showed a Modic I alteration in nine patients and a Modic II in 11. The disability grade was low-moderate (ODI score was ≤ 40%) in eight patients and high (ODI score > 40%) in 12. The Modic I was associated with a low-moderate disability in two (22%) patients and to a high disability in seven (88%) (p < 0.01). In Modic I group and in ODI > 40% groups, there were a significative higher mean disability grade 48.4 (± 8.3)%, number of chondrons per section, cells per chondron, Nf200+ nerve fibers and Hif-1α expression, compared with Modic II and ODI ≤ 40% groups, respectively. There were no differences in terms of Egr-1 expression. CONCLUSIONS: The discs with Modic I MRI signal could represent potential targets for medical treatments, whereas Modic II seems to be a more likely point of no return in a degenerative process. Therefore, further investigations are to better investigate inflammatory pathways and degenerative mechanisms in DDD.

The anterior-to-psoas approach for interbody fusion at the L5-S1 segment: clinical and radiological outcomes.

OBJECTIVE: Over the last few decades, many surgical techniques for lumbar interbody fusion have been reported. The anterior-to-psoas (ATP) approach is theoretically supposed to benefit from the advantages of both anterior and lateral approaches with similar complication rates, even in L5-S1. At this segment, the anterior lumbar interbody fusion (ALIF) requires retroperitoneal dissection and retraction of major vessels, whereas the iliac crest does not allow the lateral transpsoas approach. This study aimed to investigate clinical-radiological outcomes and complications of the ATP approach at the L5-S1 segment in a single cohort of patients. METHODS: This is a prospective single-center study, conducted from 2016 to 2019. Consecutive patients who underwent ATP at the L5-S1 segment for degenerative disc disease or revision surgery after previous posterior procedures were considered for eligibility. Complete clinical-radiological documentation and a minimum follow-up of 12 months were set as inclusion criteria. Clinical patient-reported outcomes, such as the visual analog scale for low-back pain, Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) scores, as well as spinopelvic parameters, were collected preoperatively, 6 weeks after surgery, and at the last follow-up visit. Intraoperative and perioperative complications were recorded. The fusion rate was evaluated on CT scans obtained at 12 months postoperatively. RESULTS: Thirty-two patients met the inclusion criteria. The mean age at the time of surgery was 57.6 years (range 44-75 years). The mean follow-up was 33.1 months (range 13-48 months). The mean pre- and postoperative visual analog scale (7.9 ± 1.3 vs 2.4 ± 0.8, p < 0.05), Oswestry Disability Index (52.8 ± 14.4 vs 22.9 ± 6.0, p < 0.05), and SF-36 (37.3 ± 5.8 vs 69.8 ± 6.1, p < 0.05) scores significantly improved. The mean lumbar lordosis and L5-S1 segmental lordosis significantly increased after surgery. The mean pelvic incidence-lumbar lordosis mismatch and pelvic tilt significantly decreased. No intraoperative complications and a postoperative complication rate of 9.4% were recorded. The fusion rate was 96.9%. One patient needed a second posterior revision surgery for residual foraminal stenosis. CONCLUSIONS: In the present case series, ATP fusion for the L5-S1 segment has resulted in valuable clinical-radiological outcomes and a relatively low complication rate. Properly designed clinical and comparative trials are needed to further investigate the role of ATP for different L5-S1 conditions.

Spinal Meningiomas Prognostic Evaluation Score (SPES): predicting the neurological outcomes in spinal meningioma surgery.

Among many factors leading to a worse functional prognosis in spinal meningioma (SM) surgery, in a previous study, we recognized anterior/anterolateral axial topography, sphincter involvement at first evaluation, surgery performed on a recurrence, and worse preoperative functional status. The purpose of this paper is to evaluate the cumulative weight of these factors on prognosis through a multinomial logistic regression model performed on an original evaluation scale designed by the authors on the ground of the experience of the neurosurgical departments of our University. The original SM database composed of 173 cases was classified in regard to sex, age, symptoms, axial and sagittal location, Simpson grade resection, and functional pre/postoperative status. Fine presurgical and follow-up reevaluations were available. The authors propose a scale (Spinal Meningiomas Prognostic Evaluation Score (SPES)) of preoperative evaluation to assess the surgery-related risk of neurological worsening experienced by the patients included in the present cohort. The authors describe a strong statistical association between the SPES and the follow-up Frankel and McCormick scores (r = - 460 and .441, p .001, both). Through a univariate ANOVA analysis, we disclosed that patients presenting scores 2 and 3 had a significantly higher association to lesser Frankel and McCormick postoperative scores, in respect to patients presenting SPES scores 0-1 (univariate ANOVA, p .008 and .011). Anterior or anterolateral axial location, operating on a recurrence of SM, sphincter involvement, and worse functional grade at onset present, along with the SPES scores are fairly predictive and reliable in respect to the long-term results of patients suffering from SM.

Long-term clinical outcomes after bilateral laminotomy or total laminectomy for lumbar spinal stenosis: a single-institution experience.

OBJECTIVELumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.METHODSThe authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.RESULTSTwo hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58-77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).CONCLUSIONSBilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients' symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.

Comparison of pure lateral and oblique lateral inter-body fusion for treatment of lumbar degenerative disk disease: a multicentric cohort study.

PURPOSE: The most effective interbody fusion technique for degenerative disk disease (DDD) is still controversial. The purpose of our study is to compare pure lateral (LLIF) and oblique lateral (OLIF) approaches for the treatment of lumbar DDD from L1-L2 to L4-L5, in terms of clinical and radiological outcomes. MATERIALS AND METHODS: 45 patients underwent lumbar interbody fusion for pure lumbar DDD from  L1-L2 to L4-L5 through LLIF (n = 31, mean age 62.1 years, range 45-78 years) or OLIF (n = 14, mean age 57.4 years, range 47-77 years). Clinical evaluations were performed with ODI and SF-36 tests. Radiological assessment was based on the modification of coronal segmental Cobb angles and segmental lumbar lordosis (L1-S1). RESULTS: On ODI and SF-36, all patients presented good results at follow-up, with 26% the difference between the LIF and OLIF groups on ODI scale in the post-operative period, and 3.9 and 8.8 points difference on physical and mental SF-36 in favor of OLIF. Radiological parameters improved significantly in both groups. The mean correction was 6.25° for cCobb (11.3° in LIF and 1.9° in OLIF), 2.5° for sLL (2° in LLIF and 4° in OLIF). CONCLUSIONS: LLIF and OLIF represent safe and effective MIS procedures for the treatment of lumbar DDD. LLIF had some risks of motor deficit and monitoring is mandatory, though it addressed more the coronal deformities. OLIF did not imply risks for motor deficits, but attention should be paid to vascular anatomy. It was more effective in kyphotic segmental deformities. These slides can be retrieved under Electronic Supplementary material.

Surgical management of coronal and sagittal imbalance of the spine without PSO: a multicentric cohort study on compensated adult degenerative deformities.

PURPOSE: Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative thoracolumbar and lumbar kyphoscoliosis by a non posterior subtraction osteotomy technique. METHODS: We operated 22 painful thoracolumbar and lumbar compensated degenerative deformities by anterior (ALIF), extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion and grade 2 osteotomy (SPO) to restore lumbar lordosis and mobilize the coronal curve. Two-stage surgery, first anterior and after 2 or 3 weeks posterior, was proposed when the Oswestry Disability Index (ODI) was equal to or greater than 50% and VAS more than 5. All patients were submitted to X-ray and clinical screening during pre, post-operative and follow-up periods. RESULTS: We performed 5 ALIFs, 39 XLIFs, 8 TLIFs, 32 SPOs. No major complications were recorded and complication rate was 18% after lateral fusion and 22.7% after posterior approach. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p < 0.05). Clinical follow-up (mean 20.5; range 18-24) was satisfactory in all cases, except for two due to sacroiliac pain. Mean preoperative VAS was 7.7 (range 6-10), while ODI was 67% on average (range 50-78). After two-stage surgery, VAS and ODI decreased, respectively, to 2.4 (range 2-4) and 31% (range 25-45), while their values were 4 (range 2-6) and 35% (range 20-55) at the final follow-up. CONCLUSION: Current follow-up does not allow definitive conclusions. However, the surgical approach adopted in this study seems promising, improving balance and clinical condition of adult patients with a compensated sagittal degenerative imbalance of the thoracolumbar spine.

Clinical and Neuropsychological Outcome After Microsurgical and Endovascular Treatment of Ruptured and Unruptured Anterior Communicating Artery Aneurysms: A Single-Enter Experience.

BACKGROUND: Anterior communicating artery (ACoA) aneurysms have a high risk of rupture. Morbidity and mortality following rupture are higher than at other sites. The aim of this study was to evaluate the long-term clinical and neuropsychological outcomes of patients treated for ruptured and unruptured ACoA aneurysms: a comparison between surgical and endovascular treatment was performed. METHOD: All patients surgically or endovascularly treated for ruptured and unruptured ACoA aneurysms at our institution between January 2011 and December 2013 (n=50) were retrospectively reviewed. The Glasgow outcome score and the following neuropsychological tests were used to define the clinical and neuropsychological outcomes, respectively: The Stroop color and word test and the Stroop interference score digit span forward and backward test, phonemic and semantic verbal fluency tests, Rey auditory verbal learning test, comprehensive trail making test, and the Beck Depression Inventory. FINDINGS: 28 patients (56 %) underwent surgical treatment and 22 (44 %) endovascular coiling; there were 31 (63 %) ruptured and 19 (37 %) unruptured aneurysms. At 1 year follow-up for ruptured aneurysms, clinical outcome was better in the endovascular group; neuropsychological assessment showed a greater deterioration only in the memory domain in the patients treated surgically for ruptured aneurysms. CONCLUSION: The presence of subarachnoid hemorrhage is more important than the type of treatment in determining the clinical and neuropsychological outcomes of ACoA treatment; these outcomes can be improved by adequate rehabilitation protocols.

Functional Magnetic Resonance Imaging (fMRI), Pre-intraoperative Tractography in Neurosurgery: The Experience of Sant' Andrea Rome University Hospital.

BACKGROUND: The goal of neurosurgery for cerebral intraparenchymal neoplasms of the eloquent areas is maximal resection with the preservation of normal functions, and minimizing operative risk and postoperative morbidity. Currently, modern technological advances in neuroradiological tools, neuronavigation, and intraoperative magnetic resonance imaging (MRI) have produced great improvements in postoperative morbidity after the surgery of cerebral eloquent areas. The integration of preoperative functional MRI (fMRI), intraoperative MRI (volumetric and diffusion tensor imaging [DTI]), and neuronavigation, defined as "functional neuronavigation" has improved the intraoperative detection of the eloquent areas. METHODS: We reviewed 142 patients operated between 2004 and 2010 for intraparenchymal neoplasms involving or close to one or more major white matter tracts (corticospinal tract [CST], arcuate fasciculus [AF], optic radiation). All the patients underwent neurosurgery in a BrainSUITE equipped with a 1.5 T MR scanner and were preoperatively studied with fMRI and DTI for tractography for surgical planning. The patients underwent MRI and DTI during surgery after dural opening, after the gross total resection close to the white matter tracts, and at the end of the procedure. We evaluated the impact of fMRI on surgical planning and on the selection of the entry point on the cortical surface. We also evaluated the impact of preoperative and intraoperative DTI, in order to modify the surgical approach, to define the borders of resection, and to correlate this modality with subcortical neurophysiological monitoring. We evaluated the impact of the preoperative fMRI by intraoperative neurophysiological monitoring, performing "neuronavigational" brain mapping, following its data to localize the previously elicited areas after brain shift correction by intraoperative MRI. RESULTS: The mean age of the 142 patients (89 M/53 F) was 59.1 years and the lesion involved the CST in 66 patients (57 %), the language pathways in 24 (21 %), and the optic radiations in 25 (22 %). The integration of tractographic data into the volumetric dataset for neuronavigation was technically possible in all cases. In all patients intraoperative DTI demonstrated a shift of the bundle position caused by the surgical procedure; its dislocation was both outward and inward in the range of +6 mm and -2 mm. CONCLUSION: We found a high concordance between fMRI/DTI and intraoperative brain mapping; their combination improves the sensitivity of each technique, reducing pitfalls and so defining "functional neuronavigation", increasing the definition of eloquent areas and also reducing the time of surgery.

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 Rehabilitation of Spinal Cord Injury Patients in Europe.

In Western European countries there is an incidence of traumatic spinal cord injury (SCI) of 16 to 19.4 new cases per million inhabitants per year. Since World War II, European physicians have been fundamental in the development of SCI medicine, starting from Sir Ludwig Guttman, who developed the idea of the integrated treatment of these patients. More recently, scientists from Germany and Switzerland have developed a new rehabilitative approach, Body Weight Support Treadmill Training, based on the concept of activity-based therapy and aimed at restoring walking in SCI patients. This review highlights issues concerning different organizational systems and health policies within and outside Europe.

Adjacent segment pathology: natural history or effect of anterior cervical discectomy and fusion? A 10-year follow-up radiological multicenter study using an evaluation scale of the ageing spine.

PURPOSE: Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on. METHODS: Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004-2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale. RESULTS: Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up. CONCLUSIONS: The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.

Dynamic intraoperative MRI in transsphenoidal resection of pituitary macroadenomas: a quantitative analysis.

PURPOSE: To compare intraoperative dynamic contrast-enhanced (dCE) sequences with conventional CE (cCE) in the evaluation of the surgical bed after transsphenoidal removal of pituitary macroadenomas. MATERIALS AND METHODS: Twenty-one patients with macroadenoma were selected. They all underwent intraoperative magnetic resonance imaging (iMRI) (1.5T) acquisitions during transsphenoidal resection of the tumor. For each patient, dCE and cCE images were acquired in the operating room after tumor removal. The mean values of surgical cavities volumes were measured and statistically compared through Student's t-test analysis. Informed consent to iMRI was obtained from the patients as a part of the surgical procedure. Institutional Review Board (IRB) approval was obtained. RESULTS: No patient showed recurrence within at least 1 year of follow-up. Two patients showed residual tumor in the iMRI. Intraoperative analysis of the remaining 19 demonstrated that the mean value of the surgical cavities was significantly bigger in dCE than in cCE images (2955 mm(3) vs. 1963 mm(3) , respectively, P = 0.022). CONCLUSION: This study demonstrated underestimation of surgical cavity by conventional iMRI, simulating residual tumor and potentially leading to unnecessary surgical revision.