Full-Endoscopic Lumbar Discectomy: Tips & Tricks for New Users Based on a Retrospective Observational Study of the First 100 Patients.

AIM: To report our institutional experience with full-endoscopic lumbar discectomy (FELD) and analyzed the pertinent literature. MATERIAL AND METHODS: We retrospectively enrolled 100 patients who had undergone full-endoscopic discectomy for lumbar disc herniation using either an interlaminar (IL) or transforaminal (TF) approach. All patients underwent pre-operative imaging. Before and after surgery, patients' pain and disability levels were measured using visual analog scale (VAS) and Oswestry disability index (ODI) respectively. Clinical outcomes were assessed using the modified MacNab criteria. Patients were divided into two groups, Group 1 (cases 1-50) and Group 2 (cases 51-100), and their learning curve factors were compared using a Student's t-test. RESULTS: Sixtynine cases were operated via an IL approach and the remaining 31 cases using a TF approach. There were 4 early conversions in microdiscectomy. The mean operative time of the 96 procedures was 57 min. In Group 1, the mean operative time was 61.7 minutes (range: 35-110); in Group 2, it was 52.3 minutes (range: 25-75). The difference between the two groups was statistically significant (p=0.009). No significant differences were found in conversions, early operations, and recurrences between Groups 1 and 2. Both groups experienced a significant reduction in postoperative VAS and ODI compared to preoperative scores. CONCLUSION: The findings support previously reported information on the safety and effectiveness of the FELD. Herein, we share some practical tips and tricks based on our initial experience and on the review of the available literature, which could facilitate new users. In experienced hands endoscopic techniques make treatment of herniated discs feasible independently of patient age, anatomy, and/or targeted pathology features. Conversely, thoughtful patient selection and careful preoperative planning are highly recommended for new users.

The prognostic value of emergency microsurgical clipping of ruptured anterior circulation aneurysms.

BACKGROUND: The treatment of aneurysmal subarachnoid hemorrhage poses a formidable challenge, given the high mortality rate and associated mortality. Current recommendations are for treatment to be initiated within 24 hours of diagnosis. METHODS: In our study, we compared a cohort of 66 patients who received prompt microsurgical treatment within 6 hours of diagnosis with a cohort of 51 patients who received prompt microsurgical treatment within 12 hours of diagnosis. RESULTS: The modified Rankin Scale was utilized to evaluate the follow-up of patients at 30 days, 12 months, and 18 months following surgery. We performed a parametric comparison of the distributions of the means of groups, and our results indicate that treatment within 6 hours of diagnosis results in a lower incidence of obstructive hydrocephalus and a more favorable outcome. CONCLUSIONS: A favorable outcome was observed in patients who were treated within 6 hours. The availability of a specialized vascular team ensures the highest levels of care.

H3K27-Altered Diffuse Glioma of the Spinal Cord in Adult Patients: A Qualitative Systematic Review and Peculiarity of Radiological Findings.

Background: Primary spinal cord diffuse gliomas (SpDG) are rare tumors that may harbor, like diffuse intrinsic pontine gliomas (DIPG), H3K27M mutations. According to the WHO (2021), SpDGs are included in diffuse midline H3K27-altered gliomas, which occur more frequently in adults and show unusual clinical presentation, neuroradiological features, and clinical behavior, which differ from H3 G34-mutant diffuse hemispheric glioma. Currently, homogeneous adult-only case series of SpDG, with complete data and adequate follow-up, are still lacking. Methods: We conducted a qualitative systematic review, focusing exclusively on adult and young adult patients, encompassing all studies reporting cases of primitive, non-metastatic SpDG with H3K27 mutation. We analyzed the type of treatment administered, survival, follow-up duration, and outcomes. Results: We identified 30 eligible articles published between 1990 and 2023, which collectively reported on 62 adult and young adult patients with primitive SpDG. Postoperative outcomes were assessed based on the duration of follow-up, with outcomes categorized as either survival or mortality. Patients who underwent surgery were followed up for a mean duration of 17.37 months, while those who underwent biopsy had a mean follow-up period of 14.65 months. Among patients who were still alive, the mean follow-up duration was 18.77 months. The radiological presentation of SpDG varies widely, indicating its lack of uniformity. Conclusion: Therefore, we presented a descriptive scenario where SpDG was initially suspected to be a meningioma, but was later revealed to be a malignant SpDG with H3K27M mutation.

Prevalence of Fabry disease and GLA variants in young patients with acute stroke: The challenge to widen the screening. The Fabry-Stroke Italian Registry.

BACKGROUND: Fabry disease (FD) is a treatable X-linked lysosomal storage disorder caused by GLA gene variants leading to alpha-galactosidase A deficiency. FD is a rare cause of stroke, and it is still controversial whether in stroke patients FD should be searched from the beginning or at the end of the diagnostic workup (in cryptogenic strokes). METHODS: Fabry-Stroke Italian Registry is a prospective, multicentric screening involving 33 stroke units. FD was sought by measuring α-galactosidase A activity (males) and by genetic tests (males with reduced enzyme activity and females) in patients aged 18-60 years hospitalized for TIA, ischemic stroke, or intracerebral hemorrhage. We diagnosed FD in patients with 1) already known pathogenic GLA variants; 2) novel GLA variants if additional clinical, laboratory, or family-derived criteria were present. RESULTS: Out of 1906 patients, we found a GLA variant in 15 (0.79%; 95%CI 0.44-1.29) with a certain FD diagnosis in 3 (0.16%; 95%CI 0.03-0.46) patients, none of whom had hemorrhage. We identified 1 novel pathogenic GLA variant. Ischemic stroke etiologies in carriers of GLA variants were: cardioaortic embolism (33%), small artery occlusion (27%), other causes (20%), and undetermined (20%). Mild severity, recurrence, previous TIA, acroparesthesias, hearing loss, and small artery occlusion were predictors of GLA variant. CONCLUSION: In this large multicenter cohort the frequency of FD and GLA variants was consistent with previous reports. Limiting the screening for GLA variants to patients with cryptogenic stroke may miss up to 80% of diagnoses. Some easily recognizable clinical features could help select patients for FD screening.