A one-session circumferential reconstruction in thoracic and lumbar spine fractures using a small expandable cage.

AIM: Circumferential reconstruction of thoracic and lumbar vertebrae is most frequently performed in two sessions. The authors assessed feasibility, safety and results of a surgical technique in which the use of a small cage allows a less invasive strategy. In addition, since the authors perform urgent decompression in specific cases of spinal cord injury, feasibility of this technique in emergency was verified. METHODS: In two Neurosurgical Departments, between May 2001 and May 2006, 62 patients with thoracic or lumbar fractures were operated on using this technique. X-rays were performed postoperatively and around 45 days from surgery. Three-dimension-computed tomography (3D-CT) scans were performed at 3, 6 and 12 months. Neurological evaluations were repeated at every outpatient visit. After screw insertion at the adjacent levels and traditional transpedicular circumferential decompression, further bone is removed to excavate a niche in the vertebral body and the contiguous discs are removed. The expandable cage, filled with bone fragments, is inserted horizontal or oblique laterally to the sac and applied vertical inside that niche and then expanded. The circumferential stabilization is completed with bone grafting and posterior instrumentation. RESULTS: 3D-CT scans showed sound fusion and no manifest correction loss. Nineteen patients improved at least one grade in the ASIA scale and 11 gained neuromeric levels. CONCLUSION: This technique, fairly undemanding and feasible also in emergency, proved to be safe and resistant. Two-year follow-up demonstrated thriving fusion and steady alignment. It is a valuable surgical therapy to selected cases of burst fracture.

Posterior lumbar interbody fusion with peek cages: personal experience with 20 patients.

AIM: The use of interbody cages to obtain fusion in the lumbar spine has increased noticeably in the last few years. They are used both with and without posterior stabilization. In our institution a prospective analysis to determine whether PEEK cages can be used as a stand alone device has been performed. METHODS: The 20 patients with PEEK cages had clinical and radiological follow-up with controls at 1, 3, 6 and 9 months. RESULTS: The clinical results were considered satisfactory in 75% of the cases. There were no intra-or perioperative complications. There was no displacement of the cages. No signs of unsuccessful fusion were observed. CONCLUSIONS: Interbody PEEK cages fulfill the objective of stabilizing the treated segment immediately and subsequently. They can be used as stand alone devices with the correct surgical technique and following precise indications.

Increase in 20-50 Hz (gamma frequencies) power spectrum and synchronization after chronic vagal nerve stimulation.

OBJECTIVE: Though vagus nerve stimulation (VNS) is an important option in pharmaco-resistant epilepsy, its mechanism of action remains unclear. The observation that VNS desynchronised the EEG activity in animals suggested that this mechanism could be involved in VNS antiepileptic effects in humans. Indeed VNS decreases spiking bursts, whereas its effects on the EEG background remain uncertain. The objective of the present study is to investigate how VNS affects local and inter regional syncronization in different frequencies in pharmaco-resistant partial epilepsy. METHODS: Digital recordings acquired in 11 epileptic subjects 1 year and 1 week before VNS surgery were compared with that obtained 1 month and 1 year after VNS activation. Power spectrum and synchronization were then analyzed and compared with an epileptic group of 10 patients treated with AEDs only. RESULTS: VNS decreases the synchronization of theta frequencies (P < 0.01), whereas it increases gamma power spectrum and synchronization (< 0.001 and 0.01, respectively). CONCLUSIONS: The reduction of theta frequencies and the increase in power spectrum and synchronization of gamma bands can be related to VNS anticonvulsant mechanism. In addition, gamma modulation could also play a seizure-independent role in improving attentional performances. SIGNIFICANCE: These results suggest that some antiepileptic mechanisms affected by VNS can be modulated by or be the reflection of EEG changes.

Cranial bone flap fixation with microplates and screws: a new application technique. Technical note.

A new technique of microplates/screws application for bone flap refixation is described. The microplates are fitted into a shaped bone groove in such a way that the hardware is flush with the edges of the groove thus avoiding definite palpable scalp prominence of the skin under hairless portions of the scalp.

Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach.

OBJECTIVE: A new surgical approach to foraminal disc herniation is proposed. METHODS: The procedure was performed in 28 patients during a span of 3 years. The herniation was purely foraminal in 18 patients and mainly foraminal with a definite extraforaminal component in the other 10 patients. Surgical treatment was offered only after 6 weeks of therapy with anti-inflammatory drugs and strict bed rest had proved to be ineffective. SURGICAL TECHNIQUE: To unroof the foraminal compartment, an ovoid fenestration (10 x 5 mm) is cut, with its major longitudinal axis at the level of the pars interarticularis, just medially and slightly off-center under the lateral isthmic notch, i.e., below the pedicle projection. This fenestration exposes the foraminal root compressed by the herniated disc, which can be easily removed. RESULTS: Treatment was successful in all patients, with swift remission of pain and only mild postoperative discomfort. All patients resumed their occupations as usual within 10 to 30 days after the operation, according to type of work. Mean follow-up is 24 months (range, 12-36 mo), without any return of pain. CONCLUSION: We propose pars interarticularis fenestration because it spares, with minimal bone removal, the facet joints and the anatomic continuity of the pars interarticularis, yet properly exposes the foraminal compartment both medially and laterally and thereby permits optimal removal of the disc herniation.

Intramedullary astrocytoma with cartilage formation. Case report.

A case of intramedullary astrocytoma with cartilage formation is reported. The presence of bone or cartilage in a glioma is most unusual and has been described only in the brain, characteristically in ependymomas and astrocytomas of the midline. As far as we know, the present is the first intramedullary case. The histological and immunohistochemical findings are discussed in the light of the various hypotheses that attempt to explain the presence of cartilage within a glioma.

Iatrogenic spinopelvic cerebro-spinal fluid fistula. Case report.

Perineurial cysts usually affect the lumbosacral spinal nerve roots, but sometimes they can erode the sacrum and reach the retroperitoneal space. In such cases misdiagnosis can lead to an improper treatment and cause serious complications. A presacral mass was diagnosed in a young woman during routine ultrasound investigation, and an exploratory laparotomy was performed. A large, fluid-containing cyst was found and marsupialized into the pelvis. After operation the patient experienced headache, vomiting and VI cranial nerve palsy whenever she stood up. By radiculography a iatrogenic spinopelvic cerebro-spinal fluid fistula was diagnosed, which required further surgery to be repaired. The presence of a giant perineurial cyst in the pelvis in unusual but must be considered in the differential diagnosis of presacral masses; the exceptionally rare case reported in this paper is exemplar of the harmful complications that an incautious procedure can determine.

Defective expression of interferon-gamma, granulocyte-macrophage colony-stimulating factor, tumor necrosis factor alpha, and interleukin-6 in activated peripheral blood lymphocytes from glioma patients.

The ability of a mannoprotein antigen from Candida albicans (MP) or interleukin-2 (IL-2) to induce cytokines in cultures of peripheral blood mononuclear cells (PBMC) of glioma patients and healthy controls was evaluated by mRNA expression and by protein secretion. The subjects studied were all responsive to both MP and IL-2, as assayed by lymphoproliferation of PBMC cultures. In control subjects, MP and IL-2 were strong inducers of IFN-gamma, IL-1 beta, TNF-alpha, and GM-CSF mRNA expression, but only MP was able to induce considerable levels of IL-6 and IL-2 mRNA expression. In MP-activated PBMC from glioma subjects, a highly defective IFN-gamma, together with a significant reduction in TNF-alpha and GM-CSF mRNA expression, was observed. This impairment was paralleled by a decreased accumulation of IL-6 and IL-2 mRNA. The pattern of cytokine mRNAs in IL-2-activated PBMC of glioma patients confirmed the impairment of IFN-gamma mRNA expression paralleled by a reduction in IL-6, TNF-alpha and GM-CSF mRNA, compared with healthy subjects. Coherently, in PBMC cultures from glioma patients, there was a clear-cut decrease in the secretion of IL-6 and TNF-alpha and especially of IFN-gamma compared with healthy controls. No or very low levels of IL-4, IL-10, and TGF-beta 2 mRNA expression were detected in PBMC cultures of both glioma and control populations, irrespective of the activation conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Crossed aphasia. An update.

The aim of this article is to present an update of a rare but interesting problem: "crossed aphasia". This term indicates the presence of aphasia after unilateral cerebral lesion of the hemisphere ipsilateral to the patient's dominant hand. We report two cases, review the most relevant literature, and analyze clinical, neuroanatomical, and neurophysiological aspects, taking in consideration the various interpretations proposed to explain this unusual language disorder.

Medulloblastoma in late adults: report of two cases and critical review of the literature.

The authors describe two cases of medulloblastoma occurring in two men aged 71 and 67 years respectively. Medulloblastoma in late adults (older than 65 years) is an exceptional occurrence, and in this age group is generally of the classic type. Our first case was exceptional for the long survival of the patient compared with those so far reported for the same age group.

Ultrasound-guided brain biopsy: a personal experience with emphasis on its indication.

Between January 1989 and June 1991, 40 ultrasound-guided biopsies of supratentorial brain lesions exceeding 15 mm in diameter were performed. The apparatus used was Berger's neurobiopsy set, intraoperative 5 = MHz transducer, and a B-mode scanner. In 38 cases (95%) the procedure provided a histological diagnosis at the first attempt; in two patients, early in the present series, biopsy was repeated by computed tomography-guided technique due to insufficient samples. Operative mortality was zero and there were no septic complications. Clinical symptoms were stationary after the procedure in 34 cases; two cases temporarily worsened due to postbiopsy edema and subcortical hemorrhage, respectively; and four other cases showed an improvement as a result of evacuation of neoplastic cysts. Histologically, there were 24 primary malignant tumors, eight low-grade glial tumors, five metastatic tumors, two abscesses, and one lymphoma. The ultrasound method for brain lesion biopsy was found to be a simple, quick, and low-cost method that gave reliable results. It is indicated for supratentorial lesions over 15 mm in diameter that do not demand absolute anatomical accuracy.

Isolated haemangioblastoma of spinal cord: report of 18 cases and a review of the literature.

Eighteen cases of isolated spinal haemangioblastoma are presented. 13 patients were male and 5 female; average age was 34 years. The site of the tumour was bulbo-cervical in 1 case, cervical in 6, cervico-thoracic in 2, thoracic in 7, thoraco-lumbar in 2. Surgical excision of the tumor was total in all cases and peri-operative mortality was 5%. At average follow-up of 11 years, 8 patients had died (4 from neurological causes and 4 from non-neurological disease), and 9 survived; symptoms and signs improved in 11 cases, and were not improved in 6. The biological and pathological characteristics of this tumour are reported in the light of the present 18 cases and those reported in the literature.

Medulloblastoma in children and in adults: a comparative study.

We report on the clinical and pathological characters and factors influencing prognosis in a consecutive series of 20 cases of medulloblastoma presenting in childhood and of 20 cases of the tumour presenting in adulthood. The significant differences which emerged were compared with the findings of the largest published series. Medulloblastoma is more often lateral in site and desmoplastic in histology in adults than in children. On our evidence the age at tumour onset not affect survival.

Cell mediated cytotoxicity and cytokine production in peripheral blood mononuclear cells of glioma patients.

A mannoprotein preparation (MP) from Candida albicans induced MHC-unrestricted cytotoxicity in peripheral blood mononuclear cells (PBMC) from healthy subjects, but not in those from glioma-bearing subjects. The two groups of subjects did not significantly differ in the number of cells bearing typical natural killer (NK) markers (both in resting and MP stimulated PBMC) and NK activity. However, interferon gamma (IFN-gamma) production was in tumour patients minimal or significantly reduced, as compared to healthy subjects, following PBMC stimulation by MP or phytohaemoagglutinin, respectively. In addition, minimal, if any, stimulation of interleukin-2 (IL-2) production was achieved in MP stimulated PBMC from glioma patients. Considering the pivotal role of the above cytokines in immune responses, particularly in those concerning generation of antitumour effectors, our results consistently suggest that defective cytokine production is one possible mechanism of immunological impairment in glioma patients. They also provide indirect support for a possible clinical use of IFN-gamma as an immunopotentiating agent in gliomatous subjects.

Effect of phorbol esters on the susceptibility of a glioma cell line to lymphokine-activated killer cell activity.

The mechanisms by which lymphokine-activated killer (LAK) cells exert their cytotoxic effects are not well understood. This study demonstrates that phorbol ester pretreatment of a LAK cell-sensitive glioma cell line (SNB-19) induced a significant decrease in the susceptibility of cells to LAK cell-mediated lysis. This effect was produced by low concentrations of the tumor-promoting phorbol ester, phorbol-12,13-myristate acetate (PMA), and was reversible. Protein kinase C (PKC) inhibitors failed to block this phenomenon. No apparent alteration in the ability of LAK cells to bind to their targets was observed. Thus, PMA may have exerted its effects by a mechanism that does not require PKC, or these glioma cells may possess an isozyme of PKC which is insensitive to the inhibitors used in these studies.

Role of autocrine stimulation in a glioma cell line.

It has recently been shown that autocrine stimulation can play a pivotal role in the development and progression of a variety of neoplasms, including malignant gliomas. In this paper is reported how a glioma cell is able to be stimulated by basic fibroblast growth factor (bFGF) and, at the same time, to produce a growth factor which shares with bFGF many biological and biochemical properties.

Malignant monstrocellular brain tumours. A study of 42 surgically treated cases.

A series of 42 cases of monstrocellular brain tumour (MBT) who received surgery over a 34 year period is reviewed with the aim of gaining more understanding of the biology of this oncotype. A case of benign pleomorphic xanthoastrocytoma was identified among the cases and is discussed in another paper. In this series, as in most others taken from the literature, MBTs were more frequent in young subjects (55% were under 50 years of age and 17% were children) and presented as a superficially located (63%), often sharply circumscribed (42%) mass. The mean survival time for 24 patients treated by surgery and radiotherapy (RT) was 57 weeks compared to 32 weeks for 12 treated by surgery alone (p less than 0.02). Patients younger and older than 50 years showed the same survival and the slightly better course of children did not reach statistical significance. Besides postoperative RT, the only other factor that showed a significantly positive influence on survival was the presence of a definite lymphocytic infiltration (LI) in the tumour (p less than 0.05). This result confirms our previous study on the prognostic influence of LI in glioblastoma (GB). Actually, we noted that the prolonged survival of both MBT and GB patients exhibiting a definite LI (67% and 11.5%, respectively, in the two series) was strikingly similar. We conclude that MBT is a peculiar oncotype with a probably better prognosis than GB in the majority of cases. Lymphocytes seem to play a major prognostic role and giant-monstrous cells are indirectly implicated, reasonably enhancing the host's immune response by magnifying the antigenic stimulus.

Immunotherapy of malignant gliomas.

Some recent immunological approaches to therapy of cancer are briefly considered. The possibility of the application of immunotherapy to malignant gliomas was investigated in vitro, evaluating the cytotoxic activity of Interleukin-2-activated lymphocytes against cultured human glioma cells. The possibility of generating valid cytotoxic effectors from glioma patients peripheral blood was also investigated in consideration of the immunological alterations reported in such patients.