Correlation Between Cervical Spine Sagittal Alignment and Clinical Outcome After Standalone Intersomatic Titanium Cage CeSPACE for Cervical Anterior Discectomy and Fusion in Cervical Degenerative Disk Diseases.

The aim of this study was to determine the relationship between cervical spine sagittal alignment and clinical outcomes after using a standalone intersomatic titanium cage CeSPACE for anterior cervical discectomy and arthrodesis. We present our clinical experience in a group of 180 patients with a mean follow-up for at least 2 years. Patients were evaluated by clinical and radiological assessment preoperatively, immediately after surgery and at regular follow-up. There were 97 male and 83 female patients (average age: 56.6 years) who were preoperatively affected by cervical radiculomyelopathy that was due to spondylosis or cervical disk herniation and who underwent surgical treatment. All patients underwent an anterior discectomy and interbody fusion through the positioning of one or more levels of the CeSPACE device. Compared with the preoperative scores, improvement was seen in postoperative visual analog scale (VAS) scores and Neck Disability Index (NDI) values. The standalone intersomatic titanium cage CeSPACE for anterior cervical discectomy and arthrodesis improved radiculomyelopathy and increased the probability of cervical kyphotic alignment. However, cervical sagittal alignment after surgery was not significantly associated with clinical outcomes in terms of postoperative improvement in VAS scores and NDI values. Similarly, the change in cervical sagittal alignment was not related to visual analog scale scores or Neck Disability Index values.

Inula viscosa (L.) Aiton leaves and flower buds: Effect of extraction solvent/technique on their antioxidant ability, antimicrobial properties and phenolic profile.

This study was designed to establish the most effective solvent/technique for extracting antioxidant phytoconstituents from leaves and flower buds of Inula viscosa (L.) Aiton (Asteraceae) grown wild in Morocco. Maceration and hot extraction with methanol or water and Soxhlet ethanol extraction were utilized. The antioxidant potential was evaluated in vitro by DPPH, reducing power, and ferrous ions chelating activity assays. I. viscosa leaf and flower bud extracts displayed the strongest effect in the DPPH test, being the Soxhlet ethanol the most active ones (IC50 = 54.24 ± 0.21 µg/mL and 39.77 ± 0.23 µg/mL); thus, they were selected for further investigations. The antimicrobial efficacy of the Soxhlet ethanol extracts against ATCC and food isolates strains was assayed; the leaf extract showed the best activity, and Candida albicans was the most sensitive strain (MIC = 125 µg/mL). The extracts resulted non-toxic against Artemia salina. Among the phenolics characterised by HPLC-PDA-ESI-MS, hispidulin hexoside, patuletin and spinacetin were identified for the first time.

Flavonoid profile, antioxidant and antiglycation properties of Retama sphaerocarpa fruits extracts.

Retama sphaerocarpa occurs in the Mediterranean area of North-east Africa and in the Iberian Peninsula, and grows on a variety of soil types and climatic conditions. Used in Algerian folk medicine, it is a valuable species for revegetation and soil restoration. The aim of this study is to evaluate flavonoid composition and antioxidant and antiglycation properties of methanolic and aqueous extracts from R. sphaerocarpa fruits. HPLC-PDA/ESI-MS was used to identify/quantify flavonoid content. Antioxidant activity was evaluated by Folin-Ciocalteu, ORAC, FRAP, TEAC, and DPPH assays, and antiglycation capability by glucose/fructose-BSA assay. Results showed that fruits contain isoflavones (daidzein and genistein derivatives) and flavonols (apigenin, isorhamnetin, kaempferol and quercetin derivatives), and extracts (especially the methanolic one, richer in flavonoids) possess good in vitro antioxidant and antiglycation properties. These findings evidence that R. sphaerocarpa fruits are a source of valuable phytochemicals, with potential applications in the field of phytopharmaceuticals and in food industry.

Betula pendula leaves: polyphenolic characterization and potential innovative use in skin whitening products.

The research of new tyrosinase inhibitors is currently important for the development of skin whitening agents; particularly, birch leaves extracts are included in many skin cosmetic products. In this study, the potential ability of Betula pendula leaves ethanolic extract (BE) was evaluated on mushroom tyrosinase activity. Results showed that BE was capable to inhibit dose-dependently l-DOPA oxidation catalyzed by tyrosinase. The inhibition kinetics, analyzed by Lineweaver-Burk plots, showed a noncompetitive inhibition of BE towards the enzyme, using l-DOPA as substrate. The inhibitory mechanism of BE as studied by spectrophotometric analysis, demonstrated its ability to chelate copper ion in the active site of tyrosinase. In addition, BE exhibited Fe(2+)-chelating ability (IC(50)=614.12±2.14 µg/mL), reducing power and radical-scavenging properties (IC(50)=137.22±1.98 µg/mL). These results suggest the usefulness of birch leaves extracts in cosmetic and pharmaceutical industries for their skin-whitening and antioxidant effects. Determination of the polyphenolic compounds in BE extracts was afterward achieved by means of high-performance liquid chromatography (HPLC) with photodiode array (PDA) and mass spectrometry (MS) detection. A total of 25 compounds were positively identified, through the complementary analytical information, and are reported in such a matrix for the first time. Knowledge on the qualitative composition and contents of these natural sources in fact represents mandatory information, for rational consumption and correlation of the beneficial effects to the specific amounts.

Phenolic composition and biological activities of Juniperus drupacea Labill. berries from Turkey.

The present study was designed to define the phenolic profile and the biological potential of berries methanol extract of Juniperus drupacea Labill. from Turkey. The total phenolic content (Folin-Ciocalteau assay) was 48.06±0.99mgGAE/g extract. The HPLC-DAD-ESI-MS analysis allowed the determination of the complete phenolic profile of J. drupacea berries. Phenolic acids represented more than 60% of the total phenolics, and tyrosol was the major one (1324±0.64µg/g extract); within the flavonoids amentoflavone was detected as the main constituent (927±0.35µg/g extract). The extract exhibited good antioxidant properties, as determined by different in vitro models: DPPH test (IC(50) 0.38±0.02mg/mL), reducing power (12.63±0.14ASE/mL), Fe(2+) chelating ability (IC(50) 2.26±0.06mg/mL), and TBA test (IC(50) 2.47±1.13µg/mL). Cytotoxicity against Artemia salina was highlighted (LC(50) 489.47±27.8µg/mL), and a significant decrease (p⩽0.05; p⩽0.01) in HepG2 cells viability was observed at the higher concentrations (5-10µg/mL). The extract displayed good antibacterial activity towards Gram-positive bacteria and in particular Staphylococcus aureus was the most susceptible strain (MIC 78.12µg/mL).

Non-traumatic sphenoidal intradiploic arachnoid cyst as a cause of trigeminal neuralgia. A case report.

Non-traumatic intradiploic arachnoid cyst is a rare condition. We describe a young man with typical trigeminal neuralgia and intradiploic arachnoid cyst at the greater wing of the sphenoid. The patient was successfully treated with medical therapy. To our knowledge, this is the first case report of a possible correlation between trigeminal neuralgia and intraosseous arachnoid cyst. We describe the clinical case, the possible pathogenetic mechanism and briefly review the literature.

Adult syringomielia. Classification, pathogenesis and therapeutic approaches.

Syringomyelia is characterized by the presence of cystic cavities inside the spinal cord, with an incidence estimated of 8.4 new cases/year/100 000 people. The cavities are usually located inside the cervical cord, although they can extend upwards and/or downwards. The underlying cause of all types of syringomyelia is an alteration in physiologic cerebrospinal fluid (CSF) flow dynamics. Four different main types may be described in descending order of frequency: associated with Chiari I malformations, associated with vertebral trauma, associated with basilar invagination and associated with hydrocephalus. Conservative treatment is not recommended as the surgical procedure stops the progress of the disease with clinical improvement being the rule. Early surgical treatment is highly recommended before the establishment of gross neurological deficits occurs. Treatment is urged in case of clinical deterioration or when the follow-up MRI studies show increase in size and extension of the syringomyelic cavity. The first step in the surgical treatment is a precise diagnosis of its etiology to direct the treatment to the underlying cause. Treatment directed to normalize CSF flow homeostasis should be case tailored. Surgical measures that aim to reconstruct the continuity of the subarachnoid space at the site of the block are the first treatment option. Shunting is advocated when reestablishment of the pathways proves impossible or as a second procedure.

Trigeminal neurinoma associated with Chiari malformation and syringomyelia.

We report a 36 year-old woman who presented with headaches and hypoesthesia of the face. MRI revealed a large dumbbell shaped trigeminal neurinoma extending into both the middle and the posterior cranial fossae. In addition, there was a Chiari I malformation and syringomyelia. Within two months of tumor resection, both the Chiari malformation and the syringomyelia resolved. The association of an intracranial space-occupying lesion with Chiari malformation and syringomyelia is reviewed.

Giant pituitary adenoma invading the clivus.

A 26-year-old man was admitted with complaints of worsening of vision for one month. Investigations revealed a large sellar and parasellar tumor mass invading into both the cavernous sinuses. The tumor invaded the clivus and both petrous apices. It was radically but partially resected through a transsphenoidal approach. Following surgery, the patient showed symptomatic improvement. The residual tumor was treated by radiation treatment. The case is discussed and the literature on the subject is briefly reviewed.

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach.

STUDY DESIGN: Definitive and unequivocal evidence to support the practice of early or late surgery is still lacking in clinical studies. Accordingly, meta-analysis is one of the few methods that offer a rational, statistical approach to management decision. A review of the clinical literature on spinal cord injury with emphasis on the role of early surgical decompression and a meta-analysis of results was performed. OBJECTIVES: To determine whether neurological outcome is improved in traumatic spinal cord-injured patients who had surgery within 24 h as compared with those who had late surgery or conservative treatment. METHODS: A Medline search covering the period 1966-2000, supplemented with manual search, was used to locate studies containing information on indication, rationale and timing of surgical decompression after spinal cord injuries. The analysis included a total of 1687 eligible patients. RESULTS: Statistically, early decompression resulted in better outcome compared with both conservative (P<0.001) and late management (P<0.001). Nevertheless, analysis of homogeneity showed that only data regarding patients with incomplete neurological deficits who had early surgery were reliable. CONCLUSIONS: Although statistically the percentage of patients with incomplete neurological deficits improving after early decompression appear 89.7% (95% confidence interval: 83.9, 95.5%), to be better than with the other modes of treatment when taking into consideration the material available for analysis and the various other factors including clinical limitations; early surgical decompression can only be considered as practice option for all groups of patients.

Cerebellar liponeurocytoma. Case report with considerations on prognosis and management.

BACKGROUND: Cerebellar liponeurocytoma has only recently been recognized as a distinct clinicopathological entity. Although the few cases described in literature support the relatively benign nature of this lesion, optimum treatment strategy and long term behaviour still have to be defined. CLINICAL PRESENTATION: This 61-year-old man came under our observation with unspecific signs of intracranial hypertension and a symptomathology revealing a probable posterior fossa lesion. Imaging studies showed a cerebellar mass lesion with prevalent adipose content. INTERVENTION: Gross total tumour removal was performed. The pathological examination revealed a lesion composed of medulloblastoma-like cells with prominent areas of lipidisation. A review of literature has been made in an attempt to investigate on recurrence patterns, importance of the extent of removal and the usefulness of radiotherapy. CONCLUSION: The few cases reported in literature so far seem to confirm the relatively benign nature of cerebellar liponeurocytoma. No radiotherapy was given in our case and the reasons for this decision are reported.

Traumatic intracerebellar hemorrhagic contusions and hematomas.

BACKGROUND: Traumatic intracerebellar hemorrhagic contusions and hematomas (TIHC) are unusual lesions and their surgical management remains controversial. METHODS: From January 1990 to July, 1998, 3290 patients underwent computed tomography for acute head trauma at our Institution. Eighteen patients (0.54%) were retrospectively identified as harboring TIHC. Patients were divided into two groups. In Group I (n=78) GCS at admission was > or = 9. Seven patients presented with isolated TIHC and one with an associated supratentorial lesion. Three patients exhibited an evolving clinico-radiological course. In Group II patients (n=10) GCS at admission was < or = 7. All but one presented with severe supratentorial lesions and associated brainstem signs. RESULTS: In group I six patients had their TIHC managed conservatively, and two were operated on, and all recovered completely. In group II, two patients were operated on. The outcome was poor in 90% of cases. CONCLUSIONS: TIHC constitute a protean clinico-pathological entity. Non-comatose patients with intracerebellar clots less than 3 cm in diameter should be treated conservatively and expected to make a good recovery. Surgery is indicated for larger hematomas causing cisternal and IV ventricle compression ab initio or as a result of their secondary evolution. In severely ill patients admitted comatose, it is generally the primary brain stem damage and the concomitant severe supratentorial lesions to dictate the prognosis. In these cases obliteration of the posterior fossa cisterns is the most reliable indicator of poor outcome.

Cerebellar liponeurocytoma: immunohistochemical and ultrastructural study of a case.

The clinical, histopathological, and ultrastructural features of a cerebellar liponeurocytoma are reported. The tumor, a 3-cm mass localized in the right cerebellar hemisphere, was resected from a 61-year-old man clinically presenting with symptoms of intracranial hypertension. The lesion was composed of small, in some areas closely packed, medulloblastoma-like cells with prominent areas of lipidization phenomena. Moreover, mitoses, cellular atypia, and numerous vascular structures were focally observed. Glial and neuronal differentiation was immunohistochemically noted (glial fibrillary acidic protein, synaptophysin, neurofilaments, and neuron-specific enolase positivity). The p53 oncoprotein was detected in the majority of neoplastic cells and a moderate proliferation activity, evaluated by Mib-1 antibody, was focally appreciated. Ultrastructural study did not show evident neuritic processes, synapses, or dense core neuroendocrine granules. This cerebellar tumor previously called lipidized medulloblastoma and recently renamed cerebellar liponeurocytoma is considered an adult neoplasm with excellent prognosis histologically presenting prominent lipidized areas and, at the immunohistochemical and ultrastructural level, both glial and neuronal differentiation. The present study provides the first description of a less differentiated and histologically more aggressive form of this unusual tumor.

Antibiotic prophylaxis in clean neurosurgery.

Two regimens of antibiotic prophylaxis are in use at our institution. These protocols consist in perioperative administration of a single dose of amoxicillin-clavulanic acid of 2.2 g at induction and 8 h later and irrigation of the surgical wound with rifamycin before closure. In cases of dirty surgery, placement of external shunts or foreign bodies, we administer vancomycin 1.5 g/die and ceftazidime 6 g/die for 72 h. A retrospective study of all the clean operations we performed in the last 2 years yielded a total of 793 consecutive procedures with three postoperative wound infections. These results are in agreement with the majority of series reported in literature, although different prophylactic protocols are applied and in some cases no prophylactic antibiotics are administered at all. The use of these agents in clean neurosurgery remains, as a matter of fact, controversial. In order to further investigate this issue we took three or more intraoperative samples for culture in 40 clean cases. Only in 2% of these samples were cultures positive. Although lacking statistical significance, these results are interesting indications of the appropriateness of antimicrobial prophylaxis in clean neurosurgery and invite further investigation in that direction.

Benign recurrence of a cerebellar pilocytic astrocytoma 45 years after gross total resection.

OBJECTIVE AND IMPORTANCE: Cerebellar pilocytic astrocytomas are common benign tumours of childhood and mostly easy to treat because of their location and conformation. Nevertheless, unpredictable recurrence as well as the lack of features to predict the rare malignant changes after first removal, still represent a challenging problem. CLINICAL PRESENTATION: A 54 years old man presented with a recurrence of a cerebellar pilocytic astrocytoma 45 years after complete removal. INTERVENTION: Gross total resection was performed. The pathological examination confirmed the same histological pattern as the first tumour. DISCUSSION: Current opinions about management and recurrence of pilocytic astrocytomas are discussed with a review of the literature.

Posterior fusion and implantation of the SOCON-SRI system in the treatment of adult spondylolisthesis.

Surgery for adult patients with lumbar and lumbosacral spondylolisthesis is reserved for those with intractable radiculopathy, claudication, or symptomatic spinal instability. Internal fixation, in which posterior fusion, transpedicular screw fixation, and implantation of titanium devices are performed, has been advocated to improve fusion rates and clinical results. Fourteen consecutive patients with Grade II to III lumbar and lumbosacral spondylolisthesis who underwent posterior decompression, reduction, autologous posterior facet joint arthrodesis, and SOCON-SRI implantation are retrospectively reviewed. All patients underwent complete preoperative clinical and neuroradiological evaluation. Treatment consisted of posterior decompressive surgery and implantation of the SOCON-SRI system (transpedicular screws, prebent longitudinal rods, and one locking-screw clamps). Distraction of the interbody space and rotation were performed to achieve an optimum spinal realignment. The facet joints were fused by using autologous bone graft. The authors obtained detailed clinical, functional, economic, and neuroradiological follow-up data for up to 14 months (range 8-18 months). The efficacy of the treatment was evaluated by comparing pre- and postoperative data. Pain was decreased in all cases, neurological dysfunction ameliorated in 50%, and functional and economic status was improved in 78% and 100%, respectively. No cases of fusion failure or instrumentation-related complications occurred. The authors describe their results of treating patients with spondylolisthesis in the light of the rationale for surgery and the more recent pertinent literature.

Is there a group of early surgery aneurysmal SAH patients who can expect to achieve a complete long-term neuropsychological recovery?

There is a significant controversy regarding the effect of early surgical intervention for microsurgical aneurysm clipping on long-term cognitive recovery. Although new strategies in surgical and medical management have progressively reduced the morbidity and mortality rates related to subarachnoid haemorrhage (SAH), the overall quality of life of aneurysm patients has been reported to remain unsatisfactory. In fact, even in the presence of a good neurological recovery following an aneurysmal SAH, patients may show persistent emotional and psychological disturbances. The aim of this study was to analyse the long-term cognitive, neuropsychological and emotional status of a group of patients, subjected to early surgery aneurysm treatment, and having SAH characteristics generally considered predictive of a favourable outcome. Patients were submitted to a complete battery of neuropsychological tests designed to assess a full range of cognitive and attentional functions. The results of the neuropsychological evaluation did not detect evidence of any significant cognitive deterioration as compared to control volunteers and to the published age-adjusted test norms. These results indicate that early aneurysm surgery, coupled with modern microneurosurgical techniques and aggressive medical management is associated with a good neurological outcome and a full recovery of cognitive, neuropsychological and emotional performances in a subset of patients with favourable clinical characteristics.

Peritumoral subarachnoid hemorrhage in microsurgical transitional interface type meningioma: may the interface play a role?

The evidence of an intracranial hemorrhage from a meningioma, in comparison with bleeding from different intracranial tumours, is very infrequent. The pathophysiological mechanisms that can explain the possibility of bleeding from meningiomas have not been yet completely clarified. We report a case of a left parasagittal meningotheliomatous meningioma, situated in the premotor cortex, presenting with a peritumoral hemorrhage, at the interface between the meningioma and the brain parenchyma, and strictly confined within the subarachnoid space. A detailed immunohystochemical study of the tumour was performed. The neuroradiological and neurosurgical analysis of the tumour-to-brain interface, served to understand the pathophysiology of this uncommon behaviour. Other possible pathomechanisms explaining bleeding from meningiomas, in the light of the more recent literature are discussed.