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.

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.

Calcified Epidural Hematoma after Conservative Treatment of Acute Epidural Hematoma in the Pediatric Population: A Systematic Review.

BACKGROUND: Acute traumatic epidural hematoma (EDH) is a complication in 2-3% of pediatric head injuries. Surgery is mandatory in symptomatic cases; otherwise, conservative treatment is a valid approach, especially in the pediatric population. Ossified epidural hematomas (OEHs) have been reported in the pediatric population as a rare complication of conservative EDH management, although the exact incidence remains unknown. The progressive increase in conservative management may lead to increases in the OEH incidence over the next few years. Our study aimed to systematically review OEH incidence, management strategies, characteristics (thickness, inner/outer calcifications), complication rates, time to surgery after the EDH diagnosis, and clinical outcomes. SUMMARY: A systematic review was conducted in accordance with the PRISMA guidelines. Studies reporting diagnoses and clear descriptions of OEH after EDH in pediatric patients were considered eligible. Sixteen studies, including 18 pediatric patients aged 0-18 years, were included. Head trauma was the most common cause of OEH. Seven (38.8%) OEHs were treated less than 1 month after EDH diagnosis. Surgery was performed in 17 cases (94.44%), while 1 asymptomatic case (5.56%) was managed conservatively. KEY MESSAGES: Surgery was the most commonly used treatment for OEH. Data for conservative treatment of OEH are limited. Magnetic resonance imaging or ultrasound within the first 2 months, to check for EDH resolution, may be crucial to rule out complications in pediatric patients.

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 Diffuse Idiopathic Skeletal Hyperostosis (DISH) Involving the Cervical Spine: Technical Nuances and Outcome of a Multicenter Experience.

STUDY DESIGN: Retrospective multicenter. OBJECTIVES: diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH. METHODS: Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA. RESULTS: 24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel (P = 0.12) to the burr (P = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level (P = 0.15). Use of curved chisel reduced the surgical times (P = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more (P = 0.04) and shorter waiting times for surgery (P < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery. CONCLUSION: The "age of DISH" counts more than patients' age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.

Use of the SpineJack direct reduction for treating type A2, A3 and A4 fractures of the thoracolumbar spine: a retrospective case series.

BACKGROUND: Compression injuries of the thoracolumbar spine without neurological impairment are usually treated with minimally invasive procedures. Intravertebral expandable implants represent an alternative strategy in fractures with low fragments' displacement. METHODS: Patients with A2, A3 and A4 fractures of the T10-L2 spinal segment without neurological impairment, fracture gap >2 mm, vertebra plana, pedicle rupture, pedicle diameter <6 mm, spinal canal encroachment ≥50%, and vertebral body spread >30% were treated with the SpineJack device. Patients with pathological/osteoporotic fractures were excluded. Demographic and fracture-related data were assessed together with vertebral kyphosis correction, vertebral height restoration/loss of correction and final kyphosis. The modified Rankin Scale (mRS), Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Smiley-Webster Pain Scale (SWPS) and EuroQol-5D (EQ-5D) were evaluated at 1 (-post), 6 and 12 months (-fup) after surgery. Statistical analysis was performed and p values ≤0.05 were considered significant. RESULTS: Fifty-seven patients were included in the study. Patients aged >60 years reported worse kyphosis correction (<4°) with more postoperative complications, while vertebral plasticity in younger patients, fragmentation-related greater remodeling in A3/A4 fractures, and treatments within 7 days of trauma determined superior wedging corrections, with better EQ-5D-post and mRS-fup. Cement leakages did not affect functional outcome, while female gender and American Society of Anesthesiologists (ASA) score of 3-4 were associated with worse ODI-fup and VAS-fup. Although fracture characteristics and radiological outcome did not negatively influence the clinical outcome, A2 fracture was a risk factor for complications, thus indirectly compromising both the functional and radiological outcome. CONCLUSION: With spread of <30%, the SpineJack is an alternative to minimally invasive fixations for treating A3/A4 thoracolumbar fractures, being able to preserve healthy motion segments in younger patients and provide an ultra-conservative procedure for elderly and fragile patients.

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.

Ct guided reference markers for spinal dorsal lesions: A safe and valuable tool impacting intraoperative localization time.

BACKGROUND: Intraoperative localization of the correct spine level can be challenging when dealing with the thoracic spine; especially in morbidly obese patients and in mid-thoracic spine lesions. Different radiological reference markers techniques for dorsal surgery have been reported without a clear DAP (effective dose), localization and surgical time analysis. PURPOSE: The aim of the study is to analyze the radiological reference markers technique in terms of localization time and radiation dose during surgery for dorsal lesions. METHODS: We used a radiopaque marker (fiducial) directly positioned before surgery over the lamina or the spinous process using CT scan for precise localization and vertebra count. We prospectively collected data about patients who underwent preoperative thoracic localization between April 2015 and September 2018 at Neurosurgery Department of Ferrara University Hospital. Clinical data as pathology, related surgical technique, radiological exams, localization time and radiation exposure were analyzed. RESULTS: 19 patients who underwent preoperative radiopaque marker (fiducial) positioning and 11 patients who underwent fluoroscopy technique were enrolled. No complications related to fiducial placement and no wrong-level occurred. The localization time with the fiducial was reduced dramatically (3 min vs 15 min of the standard technique). The average DAP (effective dose) for the fiducial group was 20 Gy-cm2 compared with 16 Gy-cm2 of the traditional group. CONCLUSION: The use of preoperative fiducial for intraoperative localization of the target level in the thoracic spine dramatically reduce the location time without a significantly higher DAP (effective dose).

Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study.

OBJECTIVE: Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures. METHODS: The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma. RESULTS: Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not. CONCLUSIONS: Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.

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.

Intraoperative Doppler ultrasound as a means of preventing vertebral artery injury during Goel and Harms C1-C2 posterior arthrodesis: technical note.

Vertebral artery injury (VAI) is a potential catastrophic complication of Goel and Harms C1-C2 posterior arthrodesis. Meticulous study of preoperative spinal CT angiography together with neuronavigation plays a fundamental role in avoiding VAI. Doppler ultrasonography may be an additional intraoperative tool, providing real-time identification of the vertebral artery (VA) and thus helping its preservation.Thirty-three consecutive patients with unstable odontoid fractures underwent Goel and Harms C1-C2 posterior arthrodesis. Surgery was performed with the aid of lateral fluoroscopic control in 16 cases (control group) that was supplemented by Doppler ultrasonography in 17 cases (Doppler group). Two patients in each group had a C1 ponticulus posticus. In the Doppler group, Doppler probing was performed during lateral subperiosteal muscle dissection, stepwise drilling, and tapping. Blood flow velocity in the V3 segment of the VA was recorded before and after posterior arthrodesis. All patients had a 12-month outpatient follow-up, and outcome was assessed using the Smiley-Webster Pain Scale. Neither VAI nor postoperative neurological impairments were observed in the Doppler group. In the control group, VAIs occurred in the 2 patients with C1 ponticulus posticus. In the Doppler group, 1 patient needed intra- and postoperative blood transfusions, and no difference in terms of Doppler signal or VA blood flow velocity was detected before and after C1-C2 posterior arthrodesis. In the control group, 3 patients needed intra- and postoperative blood transfusions.Useful in supporting fluoroscopy-assisted procedures, intraoperative Doppler may play a significant role even during surgeries in which neuronavigation is used, reducing the chance of a mismatch between the view on the neuronavigation screen and the actual course of the VA in the operative field and supplying the additional data of blood flow velocity.

Functional Outcome of Elderly Patients Treated for Odontoid Fracture: A Multicenter Study.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: Analysis of impact of conservative and surgical treatments on functional outcome of geriatric odontoid fractures. SUMMARY OF BACKGROUND DATA: Treatment of odontoid fractures in aged population is still debatable. METHODS: One hundred fourty-seven consecutive odontoid fractures in elderly patients were classified according to Anderson-D'Alonzo and Roy-Camille classifications. Philadelphia type collar was always positioned and kept as a treatment whenever acceptable. Halo-vest, anterior screw fixation, C1-C2 posterior arthrodesis, and occipito-cervical fixation were the other treatments adopted. Conservative or surgical treatment strategy was more significantly influenced by antero-posterior displacement (< or >5 mm) and by surgeon decision. On admission ASA, modified Rankin scale (mRS-pre) and Charlson Comorbidity Index (CCI) were assessed. Modified Rankin scale (mRS-post), Neck Disability Index (NDI), and Smiley Webster Pain Scale (SWPS) were administered 12 to 15 months after treatment to estimate functional outcome in terms of general disability, neck-related disability, and ability to return to work/former activity. Risk of treatment crossover was calculated considering factors affecting outcome. Fracture healing process in terms of fusion-stability, no fusion-stability, no fusion-no stability was evaluated at 12 months through a cervical computed tomography (CT) scan. Dynamic cervical spine x-rays were obtained whether necessary. No fusion-stability was considered an adequate treatment goal in our geriatric population. Chi square/Fisher exact test and logistic regression were performed for statistical anal. RESULTS: Overall 67 patients were treated conservatively whereas 80 underwent surgery. Collar was adopted in 45 patients, while anterior odontoid fixation and C1-C2 posterior arthrodesis were preferred for 30 patients each. 79.8% of patients showed good outcomes according to NDI. No significant differences were observed between patients of 65 to 79 years and more than or equal to 80 years (P = 0.81). CCI greatly correlated with mRS-post, with higher indexes in 68.8% of cases characterized by good outcomes (P = 0.05). mRS-pre correlated with NDI (P < 0.000001) and mRS-post (P = 0.04). CCI, mRS-pre, and surgery were associated with worse NDI, while both C1-C2 posterior arthrodesis and occipito-cervical stabilization were associated with worse mRS-post, respectively in 40% and 30% of cases. Younger patients had a higher risk of treatment crossover. CONCLUSION: mRS-pre and CCI provided two independent predictive values respectively for functional outcome and post-treatment disability. Compared with conservative immobilizations, surgery revealed no advantages in the elderly in terms of functional outcome. LEVEL OF EVIDENCE: 3.

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.

Unstable thoracic spine fracture with aortic encroachment: A potentially fatal association and a suggested treatment.

BACKGROUND: The coexistence of an unstable spinal fracture with a pending aortic lesion is potentially catastrophic and a therapeutic challenge as to timing of treatment, assigning priorities and selecting the best approach. CASE REPORT: A 41 year-old healthy male victim of bike accident. Imaging revealed a fracture of 6th and 7th thoracic vertebrae with a bone fragment in close proximity to the descending thoracic aorta. After consultation with spine/vascular surgeons and interventional radiologists it was decided to secure the potential aortic injury with an endovascular stent-graft followed by posterior vertebral instrumentation for fracture's reduction. DISCUSSION/CONCLUSION: A multi-specialists teamwork approach is mandatory. Vascular lesion is priority, followed by vertebral surgery. As to the treatment options, we suggest a "best but still safest" philosophy: endovascular repair and posterior spinal instrumentation should be considered first in the acute stage.

Delayed post-traumatic frontal sinus mucopyocoele presenting with meningitis.

PURPOSE: To highlight a rare but potentially serious complication of frontal sinus injuries. PATIENT: A case of delayed post-traumatic frontal sinus mucopyocoele presenting with meningitis in a 23-year-old male patient is reported. DISCUSSION: The anatomy of the frontal sinus is described in relation to the pathogenesis of muco(pyo)coele formation and the relevant literature is reviewed. CONCLUSION: This case, in our opinion, emphasizes the importance of thorough evaluation and adequate management of craniofacial trauma involving the paranasal sinuses, with special regard to paediatric patients. Mucocoeles and mucopyocoeles are rare complications that can develop many years after trauma, thus necessitating a virtually life-long follow-up.