Costotransversectomy in the Surgical Treatment of Mediolateral Thoracic Disk Herniations: Long-Term Results and Recent Minimally Invasive Technical Adjuncts.

Thoracic herniated disks are relatively rare. They account for approximately 2% of all intervertebral herniated disks in large series. Traditional surgery via laminectomy has frequently yielded disappointing results, although the recent literature reports that anterior calcified thoracic herniation was successfully treated with this approach. This issue has encouraged a search for alternatives, such as anterolateral, lateral, and posterolateral approaches to the thoracic spine. From January 2009 to December 2019, we selected 66 patients harboring a symptomatic median-paramedian herniated disk at the level of the thoracic spine, treated at the authors' institutions. The present experience would give further support to the use of costotrasversectomy, along with its "mini-invasive" modifications, as a suitable and safe approach for thoracic disk disease. Although we must admit that endoscopy is likely to become the gold standard of surgical method in the future and that the anterior approach with mini-toracotomy without rib removal will become popular, the future scenario could certainly reserve an important place for the approach we have used in the surgical management of this challenging spinal pathology, mainly because of the approach's versatility and short learning curve.

Extraforaminal Disk Herniation Treatment with Surgical Exploration by Unilateral Intertransversarii Microsurgical Approach.

BACKGROUND: In this study we evaluated the role of a unilateral intertransversarii microsurgical approach for the treatment of extraforaminal lumbar disk herniations (ELDHs), with short-, medium-, and long-term follow-up. METHODS: We retrospectively evaluated 96 patients who had undergone surgery for ELDH between 2001 and 2012 at our Institution. All the patients had been examined before the intervention, immediately after, and at 6 weeks, 6 months, and 18 months after the intervention. All the patients underwent surgical exploration with a unilateral intertransversarii microsurgical approach. After a midline incision was made, the paraspinal muscles were retracted laterally up to the transverse process, in order to visualize the intertransversarii ligament. Removal of this ligament allows microsurgical exposure of the extraforaminal pathology. If necessary, interlaminar microsurgical exploration is performed in the same session. RESULTS: At 6-week postoperative follow-up we noted a significant decrease of pain both in patients who suffered from leg pain and in patients who reported back pain. Also, sensory and motor deficits had improved considerably. At 6-month postoperative follow-up we observed a further improvement in the clinical conditions of almost all patients. At the 18-month postoperative follow-up we observed a very low incidence of relapse of neurological symptoms. CONCLUSION: Our technique can be reasonably proposed because of its low morbidity, fast recovery, and short hospital stay.

Reversible Pisa syndrome associated to subdural haematoma: case-report.

BACKGROUND: Pisa Syndrome or Pleurothotonus is a relatively rare truncal dystonia, characterized by tonic flexion of the trunk and head to one side with slight rotation of the body. Since frequently associated to specific drugs such as antipsychotics and cholinesterase inhibitors or to Parkinson Disease, a pathophysiological role of cholinergic-dopaminergic imbalance has been suggested. We report here the first case of Pisa Syndrome due to an extracerebral pathology as subdural haematoma. CASE PRESENTATION: A hypertensive patient was admitted to Our Department for subacute onset of tonic flexion and slight rotation of the trunk associated to progressive motor deficit in left upper limb after a mild head trauma without loss of consciousness occurred around three month before. No previous or current pharmacological interventions with antidepressant, neuroleptic or anticholinergic drugs were anamnestically retrieved. Familiar and personal history was negative for neurological disorders other than acute cerebrovascular diseases. Acutely performed cerebral MRI with DWI showed a voluminous right subdural haematoma with mild shift of median line. After surgical evacuation, both motor deficit and truncal dystonia were dramatically resolved. At one-year follow up, the patient did not develop any extrapyramidal and cognitive signs or symptoms. CONCLUSIONS: According to many Authors, the occurrence of truncal dystonia during several pharmacologic treatments and neurodegenerative disorders (such as Alzheimer disease and parkinsonian syndromes) supported the hypothesis that a complex dysregulation of multiple neurotransmitter systems are involved. We suggest a possible role of basal ganglia compression in pathogenesis of truncal dystonia by means of thalamo-cortical trait functional disruption and loss of proprioceptive integration. A further contribution of the subcortical structure displacement that alters motor cortex connectivity to basal ganglia may be postulated.

Endoscopic Lumbar Disc Surgery Experience with the TESSYS Technique in 253 Case Series.

Background: Herniated lumbar disc (HLD) is a widespread medical problem which can require surgery. Minimally invasive surgical management can represent an extremely valuable option for patients suffering from HLDs. Transforaminal endoscopic lumbar discectomy is an alternative to classical microdiscectomy which was proposed more than two decades ago and has evolved technologically with time. Methods: The transforaminal endoscopic spine system (TESSYS) technique has been introduced in recent years and offers the advantage of performing a controlled foraminal augmentation with full nerve root protection. We started using this technique in 2016 and prospectively evaluated the results of endoscopic TESSYS-based operations performed in a three-year period until the end of 2019. Selection criteria were very strict, and we included only patients with unilateral radicular pain with no instability who failed conservative therapy. Out of the 253 patients operated on in that time span, 183 were available for follow-up evaluation. Results: After surgery, there was a clinically significant improvement of all symptoms which basically lasted in the long-term follow-up. Complications were limited and generally minor. Redo surgery with microdiscectomy was required only in four cases. Obesity did not play a clear negative role in patients' outcome. Conclusions: Endoscopic transforaminal discectomy with the TESSYS technique represents a valuable management option for patients harbouring unilateral herniated lumbar disc located laterally.

Hypothalamic dysfunctions as a late consequence of surgical opening of the lamina terminalis. A controversial hypothesis.

BACKGROUND: Opening of the lamina terminalis is often used in surgery of the optico-chiasmatic region. Consequently, alteration of cerebral-spinal fluid (CSF) dynamics can occur after this manoeuvre, thus potentially translating into clinical complications. Herein, we describe 2 cases in which clinically relevant hypothalamic dysfunctions developed after few days opening of the lamina terminalis both patients showed mild to moderate preoperative hydrocephalus which improved postoperatively. CASES DESCRIPTION: In a patient with ruptured aneurysm of the basilar bifurcation, opening of the lamina terminalis was performed prior to acute-stage clipping. On postoperative day 7th, the patient developed significant subdural hygroma, mild disturbances of consciousness and increase of ADH concentration. These clinical features resolved only following subdural hygroma drainage and ventricular-peritoneal shunting. One previously operated patient in whom the lamina terminalis had been opened to remove a sizeable parasellar tumour showed a similar post-operative course. In this patient, sole subdural hygroma drainage was not an effective treatment, and the patient died subsequently for complications related to long-standing, though mild, hypothalamic dysfunction. CONCLUSIONS: Our experience may suggest that hypothalamic dysfunctions should be reminded as a possible, although rare, complication following the opening of the lamina terminalis. This clinical condition, if not properly managed, may contribute to trigger severe life-threatening complications.

Plasma Cytokines Level and Spinal Cord MRI Predict Clinical Outcome in a Rat Glial Scar Cryoinjury Model.

Traumatic injury of the spinal cord is still one of the most challenging problems in the neurosurgical practice. Despite a long history of implementation of translational medicine in the field of spinal cord injury (SCI), it remains one of the most frequent causes of human disability and a critical situation for world healthcare systems. Here, we used our rat model of the of unilateral controlled SCI induced by a cryoinjury, which consistently reproduces glial scarring and posttraumatic cyst formation, and specifically evaluated histological, bioimaging and cytokine data. We propose a 10-grade scoring scale, which can objectively estimate the extent of damage of the experimental SCI according to the magnetic resonance imaging (MRI) results. It provides a homogeneous and reliable visual control of the dynamics of the posttraumatic processes, which makes it possible to clearly distinguish the extent of early damage, the formation of glial scars and the development of posttraumatic syringomyelic cysts. The concentration of cytokines and chemokines in the plasma following the experimental SCI increased up to two orders of magnitude in comparison with intact animals, suggesting that a traumatic injury of the spinal cord was accompanied by a remarkable cytokine storm. Our data suggested that the levels of IL-1α, IL-1ß, TNFα, GRO/KC, G-CSF, IFNγ and IL-13 may be considered as a reliable prognostic index for SCI. Finally, we demonstrated that MRI together with plasma cytokines level directly correlated and reliably predicted the clinical outcome following SCI. The present study brings novel noninvasive and intravital methods for the evaluation of the therapeutic efficacy of SCI treatment protocols, which may be easily translated into the clinical practice.

A New Precision Minimally Invasive Method of Glial Scar Simulation in the Rat Spinal Cord Using Cryoapplication.

According to the World Health Organization, every year worldwide up to 500,000 people suffer a spinal cord injury (SCI). Various animal biomodels are essential for searching for novel protocols and therapeutic approaches for SCI treatment. We have developed an original model of post-traumatic spinal cord glial scarring in rats through cryoapplication. With this method the low-temperature liquid nitrogen is used for the cryodestruction of the spinal cord tissue. Forty-five Sprague Dawley (SD) non-linear male rats of the Specific-pathogen-free (SPF) category were included in this experimental study. A Th13 unilateral hemilaminectomy was performed with dental burr using an operating microscope. A specifically designed cryogenic probe was applied to the spinal cord for one minute through the created bone defect. The animals were euthanized at different time points ranging from 1 to 60 days after cold-induced injury. Their Th12-L1 vertebrae with the injured spinal cord region were removed "en bloc" for histological examination. Our data demonstrate that cryoapplication producing a topical cooling around-20°C, caused a highly standardized transmural lesion of the spinal cord in the dorsoventral direction. The lesion had an "hour-glass" shape on histological sections. During the entire study period (days 1-60 of the post-trauma period), the necrotic processes and the development of the glial scar (lesion evolution) were contained in the surgically approached vertebral space (Th13). Unlike other known experimental methods of SCI simulation (compression, contusion, etc.), the proposed technique is characterized by minimal invasiveness, high precision, and reproducibility. Also, histological findings, lesion size, and postoperative clinical course varied only slightly between different animals. An original design of the cryoprobe used in the study played a primary role in the achieving of these results. The spinal cord lesion's detailed functional morphology is described at different time points (1-60 days) after the produced cryoinjury. Also, changes in the number of macrophages at distinct time points, neoangiogenesis and the formation of the glial scar's fibrous component, including morphodynamic characteristics of its evolution, are analyzed. The proposed method of cryoapplication for inducing reproducible glial scars could facilitate a better understanding of the self-recovery processes in the damaged spinal cord. It would be evidently helpful for finding innovative approaches to the SCI treatment.

Prospective comparative study of intraoperative balloon electronic brachytherapy versus resection with multidisciplinary adjuvant therapy for recurrent glioblastoma.

BACKGROUND: Intraoperative balloon electronic brachytherapy (IBEB) may provide potential benefit for local control of recurrent cerebral glioblastomas (GBMs). METHODS: This is a preliminary report of an open-label, prospective, comparative cohort study conducted in two neurosurgical centers with ongoing follow-up. At recurrence, patients at one center (n = 15) underwent reresection with IBEB while, at the second center (n = 15), control subjects underwent re-resection with various accepted second-line adjuvant chemoradiotherapy options. A comparative analysis of overall survival (OS) and local progression-free survival (LPFS) following re-resection was performed. Exploratory subgroup analysis based on postoperative residual contrast-enhanced volume status was also done. RESULTS: In the IBEB group, median LPFS after re-resection was significantly longer than in the control group (8.0 vs. 6.0 months; log rank χ2 = 4.93, P = 0.026, P < 0.05). In addition, the median OS after second resection in the IBEB group was also significantly longer than in the control group (11.0 vs. 8.0 months; log rank χ2 = 4.23, P = 0.04, P < 0.05). CONCLUSION: These hypothesis-generating results from a small cohort of subjects suggest putative clinical benefit in OS and LPFS associated with maximal safe re-resection of recurrent GBM with IBEB versus re-resection and standard adjuvant therapy, a hypothesis that deserves further testing in an appropriately powered clinical trial.

Precision Medicine in Non-Communicable Diseases.

The increase in life expectancy during the 20th century ranks as one of society's greatest achievements, with massive growth in the numbers and proportion of the elderly, virtually occurring in every country of the world. The burden of chronic diseases is one of the main consequences of this phenomenon, severely hampering the quality of life of elderly people and challenging the efficiency and sustainability of healthcare systems. Non-communicable diseases (NCDs) are considered a global emergency responsible for over 70% of deaths worldwide. NCDs are also the basis for complex and multifactorial diseases such as hypertension, diabetes, and obesity. The epidemics of NCDs are a consequence of a complex interaction between health, economic growth, and development. This interaction includes the individual genome, the microbiome, the metabolome, the immune status, and environmental factors such as nutritional and chemical exposure. To counteract NCDs, it is therefore essential to develop an innovative, personalized, preventative, early care model through the integration of different molecular profiles of individuals to identify both the critical biomarkers of NCD susceptibility and to discover novel therapeutic targets.

Masseter-to-Facial Cranial Nerve Anastomosis: A Report of 30 Cases.

BACKGROUND: Facial nerve paralysis (FP) is a possible complication of cerebellopontine angle tumor surgery. Several donor nerves have been used in the past for facial reanimation. We report the results of 30 cases of masseter-to-facial anastomosis. OBJECTIVE: To prospectively evaluate the efficacy of V to VII anastomosis after FP. METHODS: In a prospective study, we included 30 consecutive patients with FP (20 women and 10 men) whose mean age was 48.8 yr (32-76 yr). In almost all cases, FP developed after cerebellopontine angle tumor surgery (29 patients), whereas in one case, FP occurred after skull base trauma. Pre- and postoperative evaluation of facial nerve function was performed using the House-Brackmann (HB) scale and the Sokolovsky scale, as well as by electromyography. Follow-up ranged from 11 to 51 mo and averaged 22 mo. RESULTS: All patients achieved functional recovery of the facial nerve from VI to either III or IV HB degree. Patients with short time FP showed significantly better postoperative recovery. CONCLUSION: The results of the V to VII anastomosis demonstrate a significant improvement of facial nerve function and virtually no complications.

Long-term Results for the BacJac Interspinous Device in Lumbar Spine Degenerative Disease.

OBJECTIVE: To evaluate the long-term results of using the BacJac interspinous device (Pioneer Surgical Technology Inc.) in a series of patients with degenerative lumbar spine disease. METHODS: Forty-one patients undergoing lumbar surgery with implantation of a BacJac device from 2009 to 2012 were enrolled in the present study. Patients were evaluated using the Oswestry Disability Scale (ODI). RESULTS: Although all patients showed a significant improvement of the ODI score immediately after surgery, only 41% of patients showed a satisfactory outcome. We observed worse results in the patients operated on at the L3-L4 level and in whom the device was implanted in a segment different from the one where surgical decompression had been performed. Weight gain in the months after surgery was also a poor outcome-influencing factor. CONCLUSIONS: This study confirms what is already suggested in the relevant literature regarding the long-term inefficacy of the so-called dynamic stabilization devices.

The Role of 5-ALA in Low-Grade Gliomas and the Influence of Antiepileptic Drugs on Intraoperative Fluorescence.

Objectives: Intraoperative tumor visualization with 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence is widely applied for improved resection of high-grade gliomas. However, visible fluorescence is present only in a minority of low-grade gliomas (LGGs) according to current literature. Nowadays, antiepileptic drugs (AEDs) are frequently administered to LGG patients prior to surgery. A recent in-vitro study demonstrated that AEDs result in significant reduction of PpIX synthesis in glioma cells. The aim of this study was thus to investigate the role of 5-ALA fluorescence in LGG surgery and the influence of AEDs on visible fluorescence. Patients and Methods: Patients with resection of a newly diagnosed suspected LGG after 5-ALA (25 mg/kg) administration were initially included. During surgery, the presence of visible fluorescence (none, mild, moderate, or bright) within the tumor and intratumoral fluorescence homogeneity (diffuse or focal) were analyzed. Tissue samples from fluorescing and/or non-fluorescing areas within the tumor and/or the assumed tumor border were collected for histopathological analysis (WHO tumor diagnosis, cell density, and proliferation rate). Only patients with diagnosis of LGG after surgery remained in the final study cohort. In each patient, the potential preoperative intake of AEDs was investigated. Results: Altogether, 27 patients with a histopathologically confirmed LGG (14 diffuse astrocytomas, 6 oligodendrogliomas, 4 pilocytic astrocytomas, 2 gemistocytic astrocytomas, and one desmoplastic infantile ganglioglioma) were finally included. Visible fluorescence was detected in 14 (52%) of 27. In terms of fluorescence homogeneity (n = 14), 7 tumors showed diffuse fluorescence, while in 7 gliomas focal fluorescence was noted. Cell density (p = 0.03) and proliferation rate (p = 0.04) was significantly higher in fluorescence-positive than in fluorescence-negative samples. Furthermore, 15 (56%) of 27 patients were taking AEDs before surgery. Of these, 11 patients (73%) showed no visible fluorescence. In contrast, 10 (83%) of 12 patients without prior AEDs intake showed visible fluorescence. Thus, visible fluorescence was significantly more common in patients without AEDs compared to patients with preoperative AED intake (OR = 0,15 (CI 95% 0.012-1.07), p = 0.046). Conclusions: Our study shows a markedly higher rate of visible fluorescence in a series of LGGs compared to current literature. According to our preliminary data, preoperative intake of AEDs seems to reduce the presence of visible fluorescence in such tumors and should thus be taken into account in the clinical setting.

A less-invasive technique for harvesting autologous iliac crest grafts for cervical interbody fusion: technical note.

BACKGROUND: A new technique for harvesting autologous iliac bone grafts is described. TECHNIQUE: This technique is mainly based on performing carefully a limited subperiosteal dissection, obliquely directed bone cuts, and avoiding the stripping of the anterior thigh musculature. CONCLUSION: This technique allowed to overcome almost all the problems that can occur when using the traditional technique for iliac crest graft harvesting and was used in over 100 cases of cervical discogenic disease with satisfactory results.

Massive Lumbar Disk Herniation Following "Therapeutic" Water Boiling of the Lower Extremities: Case Report and Literature Review.

BACKGROUND: Legs burning for treating lumbar radicular pain are still in use nowadays in low socioeconomical environments. They are dangerous as the case we report shows clearly. CLINICAL CASE: A 49-year-old man came to our attention with severe flaccid paraparesis occurred 10 days before, almost immediately after he had immersed his legs in boiling water to treat his severe left lumbocrural pain. This was known to be due to a right L3/4 herniated disk diagnosed by magnetic resonance imaging. At the examination he showed severe motor paresis and absent reflexes of his lower limbs, while crural pain was mild and sensation and urinary function were unaffected. The results of his neurologic examination led us to suspect an acute motor axon degeneration related to thermal shock. Lumbar magnetic resonance imaging, performed before the planned electromyogram as an exception to the established routine, showed instead a giant 5- × 5.5-cm, herniated disk compressing the dural sac at L3. CONCLUSIONS: Prompt surgical decompression led to rapid improvement. We discuss here the pathophysiology of this unusual case and point out how medieval practices for treating sciatica-like pain are not only unjustified from a medical viewpoint but also potentially dangerous.

Radiation-induced anaplastic ependymoma mimicking a skull base meningioma: A case report.

The present study describes the case of a 63-year-old woman presenting with headache, dizziness and vomiting due to a an ovoid mass in the left pre-bulbar cistern, apparently arising from the lower clivus and the foramen magnum. The clinical history revealed the subtotal removal of a right cerebellar low-grade glioma 15 years previously and subsequent conventional 60-Gy radiotherapy. Notably, following gross total resection, histopathological examination showed microscopic features that resulted in a diagnosis of anaplastic ependymoma. The patient underwent surgery to remove the mass and post-operative chemotherapy with temozolomide. A progressive improvement of neurological signs and symptoms was observed during the postoperative course. At the 6-month follow-up, the patient was free from clinical and radiological recurrence. The unusual features of this rare secondary brain tumor were the extrassial location in the posterior fossa, the unusual age-associated location of the histological subtype and the fact that it closely mimicked a skull-base meningioma.

Early versus delayed rehabilitation treatment in hemiplegic patients with ischemic stroke: proprioceptive or cognitive approach?

BACKGROUND: Early/intensive mobilization may improve functional recovery after stroke but it is not clear which kind of "mobilization" is more effective. Proprioceptive neuromuscular facilitation (PNF) and cognitive therapeutic exercise (CTE) are widespread applied in post-stroke rehabilitation but their efficacy and safety have not been systematically investigated. AIM: To compare PNF and CTE methods in a two different time setting (early versus standard approach) in order to evaluate different role of time and techniques in functional recovery after acute ischemic stroke. DESIGN: We designed a prospectical multicenter blinded interventional study of early versus standard approach with two different methods by means of both PNF and CTE. SETTING: A discrete stroke-dedicated area for out-of-thrombolysis patients, connected with two different comprehensive stroke centres in two different catchment areas. POPULATION: Three hundred and forty consecutive stroke patient with first ever sub-cortical ischemic stroke in the mean cerebral artery (MCA) territory and contralateral hemiplegia admitted within 6 and 24 hours from symptoms onset. METHODS: All patients were randomly assigned by means of a computer generated randomization sequence in blocks of 4 to one to the 4 interventional groups: early versus delayed rehabilitation programs with Kabat's schemes or Perfetti's technique. Patients in both delayed group underwent to a standard protocol in the acute phase. PRIMARY OUTCOME: disability at 3-12 months. Disability measures: modified Rankin Score and Barthel Index. Safety outcome: immobility-related adverse events. SECONDARY OUTCOME MEASURES: Six-Minute Walking Test, Motricity Index, Mini-Mental State Examination, Beck Depression Inventory. RESULTS: Disability was not different between groups at 3 months but Barthel Index significantly changed between early versus delayed groups at 12 months (P=0.01). Six-Minute Walking Test (P=0.01) and Motricity Index in both upper (P=0.01) and lower limbs (P=0.001) increased in early versus delayed groups regardless rehabilitation schedule. CONCLUSIONS: A time-dependent effect of rehabilitation on post stroke motor recovery was observed, particularly in lower limb improvement. According to our results, rehabilitation technique seems not to affect long term motor recovery. CLINICAL REHABILITATION IMPACT: These results show a significant effect of time but not of technique that may impact the decision making in the acute phase of care.

Entrapment of the Temporal Horn as a Cause of Pure Wernicke Aphasia: Case Report.

Entrapment of the temporal horn is an extremely rare pathologic condition occurring as a result of surgery for tumors, intraventricular infections, hemorrhage, or traumatic events involving the peritrigonal area. We report a case of a 58-year-old man who presented with pure Wernicke aphasia (never described before in the albeit rare cases of isolated temporal horn dilatation) that regressed completely following successful ventriculoperitoneal shunting. The relevant literature is also briefly reviewed.

Lipomas of the pineal region.

BACKGROUND: Intracranial lipomas are rare lesions, representing 0.02% of operated intracranial lesions. Lipomas of the pineal region are even rarer and are reported occasionally in the literature. This is possibly because of the fact that they may give rise to clinical symptoms rather infrequently. When they become symptomatic, some form of management must be contemplated. METHODS: Four cases of lipomas of the pineal region observed in our institute during a 5-year period were investigated, and clinical-diagnostic features were studied. Two of the cases were symptomatic and were submitted to direct surgical treatment. RESULTS: Computed tomography (CT) scanning was performed in 3 cases and magnetic resonance imaging (MRI) in all 4. MRI angiography was performed in the last case. The appearance of the lipoma was quite pathognomonic in the neuroimaging diagnostic test. The infiltrative character of the lesion was better defined by MRI. MRI angiography gave evidence of the upward displacement of the deep veins. Direct surgical approach was performed via a right occipital transtentorial approach in one case and supracerebellar route in another. Neither approach appeared to be superior to the other one. Total removal of the lesion seemed to be impossible because of the infiltrative character of the lesion. Postoperative results were satisfactory even with incomplete removal of the lesion. CONCLUSION: Lipomas of the pineal region are rare. Modern neuroimaging permits a straightforward diagnosis of the nature of intracranial lipomas in general and of these lipomas in particular. Some form of management must be contemplated when these lesions become symptomatic. Direct surgical approach, either via an occipital transtentorial or an infratentorial supracerebellar approach, is feasible. Tumor removal must be dealt with cautiously because total removal is impossible without unacceptable postoperative deficits, and generous partial removal warrants long-term symptomatic improvement.