Emergency Treatment of Cervical Vertebromedullary Trauma: 10 Years of Experience and Outcome Evaluation.

OBJECTIVE: The aim of the study is to identify and validate, through the recording of clinical and radiological data, the different surgical approaches and treatments valid for most subaxial cervical dislocation fractures and whether there is an advantage from using an anterior approach rather than a posterior approach and conversely.. MATERIAL AND METHODS: A retrospective study was carried out analyzing the case history of the last 10 years of vertebromedullary traumas treated at the spine surgery unit of the Policlinico Gemelli in Rome. Data on surgical timing, American Spinal Injury Association (ASIA) scores for neurological damage, and subsequent assessments on recovery, survival, and mortality were also examined. RESULTS: A total of 80 patients were treated: 50 by the posterior approach, 24 by the anterior approach, and six by the double approach. Our average follow-up time was 4.2 years. A prevalence of surgery with the posterior approach was noted. We observed the worsening of cervical kyphosis about 15 months after the trauma in two cases treated with the posterior approach alone. A second surgical treatment was performed in these patients. One of these patients underwent an anterior fusion; the other case underwent a posterior revision because the patient had ankylosing spondylitis. Although we found no statistically significant difference in outcomes between the various surgical treatments, in this retrospective study, we analyzed the characteristics and outcomes of cervical spine injuries that required surgical treatment. CONCLUSION: The aim of surgery in unstable cervical spine injuries should be to reduce and stabilize the damaged segment, maintain lordosis, and decompress when indicated. The optimal choice of surgical approach and treatment, or its superiority in terms of outcomes, remains a debated issue.

Lateral Approach to the Cervical Spine to Manage Degenerative Cervical Myelopathy and Radiculopathy.

BACKGROUND: The cervical lateral approach can enlarge the spinal canal and foramen to achieve an effective neural decompression without needing spine stabilization. For this review, the authors' main objective was to illustrate the rationale, advantages, disadvantages, complications, and pitfalls of this technique, highlighting also areas for future development. MATERIALS AND METHODS: A Medline via PubMed database search was carried out by using both keywords, namely "cervical oblique corpectomy," "multilevel oblique corpectomy and foraminotomy," and "lateral vertebrectomy," and Medical Subject Headings (MeSH) terms from 1 January 1991, up to 31 December 2021. RESULTS: The analyzed articles suggested that the use of such a technique has declined over time; only 29 clinical studies met all the inclusion criteria and were retained for data analysis, including 1200 patients undergoing such an approach for the management of degenerative cervical myelopathies (DCMs) or of radiculopathies. The main etiopathogeneses were cervical stenosis, degenerative disk disease, or a mix of them-78% of which had a favorable outcome; the most frequent complications were transient and permanent Horner syndrome in 13.6% and 9.2% of cases, respectively. Long-term stability was reported in 97% of patients. CONCLUSION: Multilevel cervical oblique vertebrectomy and/or lateral foraminotomy allow wide neural structure decompression and optimal stability given that the physiological spinal motion is preserved.

A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

Surgical Treatment of Chiari Malformation in Adults: Comparison of Surgical Techniques Described in the Literature and Our Experience.

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Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section.

Introduction: Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery. Research question: Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection. Material and methods: A PRISMA based literature search was performed to select the most relevant papers on the topic. Results: Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery. Discussion and conclusion: This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.

The role of imaging in the pre- and postoperative evaluation of posterior occipito-cervical fusion.

PURPOSE: Occipitocervical fusion is required when the occipitoatlantal joint is unstable. The purpose of this paper is to discuss the role of imaging in the pre- and postoperative evaluation of posterior occipitocervical fusion (POCF), focusing on contoured loop fixation by Hartshill and Songer instrumentation. MATERIALS AND METHODS: We studied 21 patients (eight males, 12 females; age range 6-70 years; mean age 32.6 years) with craniocervical instability who underwent POCF with Hartshill U-shaped rod and Songer sublaminar wires. Pre- and postoperative radiographic, computed tomography (CT) and magnetic resonance (MR) imaging examinations were performed in all patients. A 3- to 6-month period of external orthosis with halo vest, sterno-occipitalmandibular immobiliser (SOMI) brace or Philadelphia collar followed surgery. Follow-up was 12-96 (mean 53.1) months. RESULTS: Clinical assessment using the Frankel scale revealed improvement or deterioration arrest in all but two patients: one with C3 failure and halo destabilisation; the other, who had exhibited myelopathy signs on preoperative MR imaging and persistent basilar impression, showed increasing and progressive neurological deficits despite successful POCF. CONCLUSIONS: Pre- and postoperative imaging is extremely useful in patients scheduled to undergo POCF. Preoperative MR screening of basilar impression associated with possible spinal cord lesions appears mandatory to predict possible deterioration and prevent undesired failure of the operation and it may suggest the need for an alternative surgical approach, such as the transoral approach.

Women in Neurosurgery: Historical Path to Self-Segregation and Proposal for an Integrated Future.

Despite the rising percentage of women accessing the medical profession over the last few decades, surgical specialties are still largely male-dominated; in particular, a remarkable gender disparity is evident in neurosurgery, where only 19% of practitioners are females. Although women may be reluctant to choose a challenging specialty like neurosurgery due to concerns around how to balance family and career, it must be admitted that prejudices against female neurosurgeons have been deeply rooted for long, prompting many to give up and switch track to less demanding subspecialties. Among those who have persisted, many, if not most, have experienced difficulties in career progression and received unequal treatment in comparison with their male counterparts. In 1989, a group of 8 female neurosurgeons founded Women in Neurosurgery (WINS), an organization that aimed to guarantee inclusivity in neurosurgery, encouraging a better and more egalitarian working environment. Thereafter, WINS sessions were regularly promoted at international conferences, offering female neurosurgeons a platform to report issues related to gender discrimination. Over recent years, the mission of WINS sessions in national and international conferences has taken an unexpected deviation; they have progressively become supplementary scientific sessions with only women neurosurgeons as speakers, thus paving the road to a form of self-segregation. This tendency has also resulted in the establishment of sections of only female neurosurgeons within some national societies. Although there remains a faction that fiercely supports the WINS mindset of reserved spaces for women, such segregation is an upsetting prospect for those who believe that science and professionalism have no gender; a growing part of the global neurosurgical community believes that the conception of a "female neurosurgery" and a "male neurosurgery" is misguided and counterproductive and consider the existence of the WINS as anachronistic and no longer necessary.

Advances in videoassisted anterior surgical approach to the craniovertebral junction.

At the present time, an update to the classical microsurgical transoral decompression is supported by the most recent literature dealing with the introduction of the endoscopy in spine surgery. In this paper, we present all the reported experience on the surgical approaches to anterior cranioveretebral junction (CVJ) compressive pathology managed by endoscopy. Surgical strategies dealing with decompressive procedures by using an open access, microsurgical technique, neuronavigation and endoscopy are summarized.Endoscopy represents a useful complement to the standard microsurgical approach to the anterior CVJ. Endoscopy can be used via transnasal, transoral and transcervical routes; it facilitates visualisation and better decompression without the need for soft palate splitting, hard palate resection, or extended maxillotomy. Although neuronavigation enhances orientation within the surgical field, intraoperative fluoroscopy helps to recognize residual compression.Under normal anatomical conditions, there appear to be no surgical limitations for the endoscopically assisted transoral approach compared with the pure endonasal and transcervical endoscopic approaches.The endoscope has a clear role as "support" to the standard transoral microsurgical approach since 30° angulated endoscopy increases the surgical area exposed over the posterior pharyngeal wall and the extent of the clivus.

Neuromodulation of cerebral blood flow by spinal cord electrical stimulation: the role of the Italian school and state of art.

Hosobuchi first studied the effect of spinal cord stimulation (SCS) on cerebral blood flow (CBF) in human beings along with the demonstration that SCS can improve peripheral blood flow. Following these clinical and experimental observations Hosobuchi first used cervical SCS for the treatment of cerebral ischemia in man. Further experimental reports suggested so far that SCS 1) drastically prevents cerebral infarction progression along with a reduction in infarct volume in cats; 2) improves clinical symptoms of patients in persistent vegetative states; 3) suppress headache attacks in migraneous patients; 4) significantly reduces ischemic brain oedema in rats; 5) increase locoregional blood flow in high grade brain tumors. The authors found that SCS can produce either an increase of CBF or a reduction or no effect. In patients studied with both SPECT technique and transcranial Doppler (TCD) the sign of the induced variations, when present in both, as the same. Cervical stimulation produces more frequently an increase in CBF (61% of cervical stimulations). The authors' experimental studies confirm that SCS 1) interacts with CO2 with the mechanism of regulation of CBF in a competitive way and produce a reversible functional sympathectomy; 2) produces similar flowmetric changes in the brain as well as in the eyes; 3) can improve both clinical and haemodynamic ischemic stroke in humans; 4) prevents hemodynamic deterioration in the experimental combined ischemic and traumatic brain injury; 5) prevents experimental early vasospasm.

Hyper flow and intracranial hypertension in diffuse axonal injury: an update to gennarelli doctrine.

Twelve consecutive paediatric (six) and adult (six) patients harbouring a neuroradiological pattern consistent with diffuse axonal injury (DAI) along with slit ventricles underwent haemodynamic study in the Intensive Care Unit of our University. All the patients had GCS scores less than 8 after a severe brain injury. serial head computed tomography (CT) and magnetic resonance (MR) scans demonstrated a radiological pattern of DAI. Transcranial Doppler Sonography (TCD) of the middle cerebral arteries was performed through the temporal bone window in all the patients. All patients but one underwent a continuous monitoring of intracranial pressure (ICP) and cerebral extraction of 02 (CEO2). Therapy with barbiturates and hyperventilation was necessary in all the cases. In two patients (one adult and one paediatric) a bilateral decompressive craniectomy was performed in order to decrease a severe intracranial hypertension. Hyperflow along with intracranial hypertension, variably responsive to barbiturate therapy, was observed in all the patients by means of TCD and CEO2. In our patients intracranial hypertension along with hyperflow syndrome were found associated with DAI. Medical as well as surgical treatments were tailored according to the haemodynamic study.

Natriuretic peptides, antidiuretic hormone and hyponatraemia after acute craniocerebral injury.

We investigated the physiological mechanisms involved in central hyponatraemia in patients with acute craniocerebral injury (ACI). We measured blood concentrations of natriuretic peptides, antidiuretic hormone (ADH), and endogenous digitalis-like substance (EDLS), blood and urine sodium concentrations, and the plasma and urine osmolality in 68 patients with ACI and 24 healthy control subjects. A total of 27 ACI patients were hyponatraemic and the majority of these had grievous or severely grievous craniocerebral injuries. Blood concentrations of EDLS and ADH in hyponatraemic ACI patients were significantly higher compared with normonatraemic ACI patients and control subjects. Blood EDLS and sodium concentrations were negatively correlated with each other, whereas EDLS was positively correlated with urine sodium concentration and with urine osmotic pressure. Hyponatraemic ACI patients require different treatment based on the cause of their central hyponatraemia, so it is important to undertake a comprehensive analysis of each patient's physiological status.

Morphological and functional MR imaging of Lhermitte-Duclos disease with pathology correlate.

Lhermitte-Duclos disease (LDD) is a rare benign lesion of uncertain pathogenesis characterised by distortion of the normal cerebellar laminar cytoarchitecture. We report a case of LDD thoroughly characterized by advanced magnetic resonance imaging techniques, with diffusion-weighted, perfusion-weighted and post-gadolinium sequences. Imaging showed restricted diffusion consistent with high cellularity, high degree of vascularity and preserved blood-brain barrier permeability, correlating with pathology.

A new animal model for monitoring the early cerebral vasospasm after subarachnoid haemorrhage.

AIM: Spasm of cerebral arteries is a complication associated with subarachnoid haemorrhage. The aim of the present work is to find an experimental model of reliable, simple and in vivo monitoring of ''early'' basilar artery spasm after subarachnoid haemorrhage (SAH). Early spasm occurs within minutes of the SAH, its duration is approximately 1 hour. The need of different morphological and haemodynamic methods to evaluate experimental early spasm is reported. METHODS: To overcome intracranial surgical manipulations and biological of contrast and fixation media we designed a model that allows in vivo functional monitoring of basilar blood flow far away from the spasm without direct surgical and chemical interferences. Seventeen adult Burgundy rabbits were studied. RESULTS: Under homeostatic monitoring ''on-line'' carotid blood flow (carotid BF) .changes produced by SAH in cisterna magna of 12 (plus 5 sham treated) animals were studied from the common carotid artery after external carotid artery occlusion before, during SAH up to the end of the experiments. All the animals underwent digital subtraction cerebral panangiography (CPA) after SAH obtaining a significant increase of carotid BF only when basilar vasospasm was shown by CPA. CONCLUSIONS: Carotid BF increase during basilar vasospasm was defined ''functional. monitoring'' of early spasm.

Spinal cord stimulation and cerebral haemodynamics.

After the demonstration that spinal cord stimulation (SCS) can improve peripheral blood flow it was Hosobuchi ('86) who first studied the effect of SCS on cerebral blood flow (CBF) in human beings. Our group found that SCS can produce either an increase of CBF or a reduction or no effect. In patients studied with both SPECT technique and TCD, the sign of the induced variations, when present in both, was the same. Cervical stimulation produces more frequently an increase in CBF (61% of cervical stimulations). Our experimental studies confirm that SCS and CO2 interact with the mechanism of regulation of CBF in a competitive way and produce a reversible functional sympathectomy. Further experimental reports suggest that SCS 1) drastically prevents cerebral infarction progression in cats; 2) improves clinical symptoms of patients in persistent vegetative states; 3) suppress headache attacks in migraneous patients; 4) significantly reduces ischemic brain oedema in rats. Following these clinical and experimental observations, Hosobuchi first used cervical SCS for the treatment of cerebral ischemia in man ('91). More recently we confirmed the therapeutic effect of SCS on ischemic stroke in humans, experimental brain injury and cerebral vasospasm in rabbits.