Haemostatic technique in malignant gliomas.

INTRODUCTION: Haemostasis in brain surgery is mandatory to avoid postoperative re-bleeding and a poor outcome. Postoperative intra-cavity haemorrhage is a frequent complication, especially in surgery of malignant gliomas because of the fragility of pathological vessels. MATERIAL AND METHODS: In this technical note, we describe our 'compression' technique used to achieve haemostasis in adult patients who underwent surgery for supratentorial malignant gliomas (GBM) at our Institute from January 2019 to January 2022. Peri-operative work-up included clinical status, laboratory data and contrast brain CT, performed at 24 hours after surgery, or earlier for patients with neurological worsening. RESULTS: A total of 82 patients was included in this study, 46 males (57%) and 36 females (43%). A post-operative intra-cavity haemorrhage was documented by postoperative CT-scan in 3/82 patients (3.65%), and the mean surgical time was 3.66 hours. No late bleeding was observed 48 hours after surgery. CONCLUSIONS: We have documented the good results of our technique to achieve haemostasis in patients operated for malignant glioma (GBM). The technique described in this study seems to be safe and useful to avoid post-operative bleeding in the surgery of cerebral GBM.

Risk factors for post-traumatic hydrocephalus following decompressive craniectomy.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is one of the main complications of decompressive craniectomy (DC) after traumatic brain injury (TBI). Then, the recognition of risk factors and subsequent prompt diagnosis and treatment of PTH can improve the outcome of these patients. The purpose of this study was to identify factors associated with the development of PTH requiring surgical treatment in patients undergoing DC for TBI. METHODS: In this study, we collected the data of 190 patients (149 males and 41 females), who underwent DC for TBI in our Center. Then we analyzed the type of surgical treatment for all patients affected by PTH and the risk factors associated with the development of PTH. RESULTS: Post-traumatic hydrocephalus (PTH) developed in 37 patients out of 130 alive 30 days after DC (28.4%). The development of PTH required ventriculoperitoneal shunt (VPS) in 34 patients out of 37 (91.9%), while, in the remaining 3 patients, cerebrospinal fluid hydrodynamic (CSF) disturbances resolved after urgent cranioplasty and temporary external lumbar drain. Multivariate analysis showed that the presence of interhemispheric hygroma (p < 0.001) and delayed cranioplasty (3 months after DC) (p < 0.001) was significantly associated with the need for a VPS or other surgical procedure for PTH. Finally, among the 130 patients alive after 30 days from DC, PTH was associated with unfavorable outcome as measured by the 6-month Glasgow Outcome Scale score (p < 0.0001). CONCLUSIONS: Our results showed that delayed cranial reconstruction was associated with an increasing rate of PTH after DC. The presence of an interhemispheric hygroma was an independent predictive radiological sign of PTH in decompressed patients for severe TBI.

Supraorbital subfrontal trans-laminar endoscope-assisted approach for tumors of the posterior third ventricle.

BACKGROUND: Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions. METHODS: Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same trans-laminar approach in four cases. RESULTS: Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13-85 months). Two illustrative cases are presented. CONCLUSIONS: The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.

Treatment of unstable thoracolumbar junction fractures: short-segment pedicle fixation with inclusion of the fracture level versus long-segment instrumentation.

BACKGROUND: The surgical management of thoracolumbar burst fractures frequently involves posterior pedicle screw fixation. However, the application of short- or long-segment instrumentation is still controversial. The aim of this study was to compare the outcome of the short-segment fixation with inclusion of the fracture level (SSFIFL) versus the traditional long-segment fixation (LSF) for the treatment of unstable thoracolumbar junction fractures. METHODS: From December 2009 to February 2014, 60 patients with unstable thoracolumbar junction fractures (T11-L2) were divided into two groups according to the number of instrumented levels. Group 1 included 30 patients treated by SSFIFL (six-screw construct including the fracture level). Group 2 included 30 patients treated by LSF (eight-screw construct excluding the fracture level). Local kyphosis angle (LKA), anterior body height (ABH), posterior body height (PBH), ABH/PBH ratio of fractured vertebra, and Asia Scale Impairment Scale were evaluated. RESULTS: The two groups were similar in regard to age, sex, trauma etiology, fracture level, fracture type, neurologic status, pre-operative LKA, ABH, PBH, and ABH/PBH ratio and follow-up (p > 0.05). Reduction of post-traumatic kyphosis (assessed with LKA) and restoration of fracture-induced wedge shape of the vertebral body (assessed with ABH, PBH, and ABH/PBH ratio) at post-operative period were not significantly different between group 1 and group 2 (p = 0.234; p = 0.754). There was no significant difference between the two groups in term of correction loss at the last follow-up too (LKA was 15.97° ± 5.62° for SSFIFL and 17.76° ± 11.22° for LSF [p = 0.427]). Neurological outcome was similar in both groups. CONCLUSIONS: Inclusion of fracture level in a short-segment fixation for a thoracolumbar junction fractures results in a kyphosis correction and in a maintenance of the sagittal alignment similar to a long-segment instrumentation. Finally, this technique allowed us to save two or more segments of vertebral motion.

Improving the endoscopic endonasal transclival approach: the importance of a precise layer by layer reconstruction.

BACKGROUND. The endoscopic endonasal transclival approach (EETCA) is a minimally-invasive technique allowing a direct route to the base of implant of clival lesions with reduced brain and neurovascular manipulation. On the other hand, it is associated with potentially severe complications related to the difficulties in reconstructing large skull base defects with a high risk of postoperative cerebrospinal fluid (CSF) leakage. The aim of this paper is to describe a precise layer by layer reconstruction in the EETCA including the suture of the mucosa as an additional reinforcing layer between cranial and nasal cavity in order to speed up the healing process and reduce the incidence of CSF leak. METHODS. This closure technique was applied to the last six cases of EETCA used for clival meningiomas (2), clival chordomas (2), clival metastasis (1), and craniopharyngioma with clival extension (1). RESULTS. After a mean follow-up of 6 months we had no one case of postoperative CSF leakage or infections. Seriated outpatient endoscopic endonasal controls showed a fast healing process of nasopharyngeal mucosa with less patient discomfort. CONCLUSIONS. Our preliminary experience confirms the importance of a precise reconstruction of all anatomical layers violated during the surgical approach, including the nasopharygeal mucosa.

Analysis of prognostic factors and the role of epilepsy in neurosurgical patients with brain metastases.

Background: Brain metastases (BMs) represent the most frequent brain tumors in adults. The identification of key prognostic factors is essential for choosing the therapeutic strategy tailored to each patient. Epilepsy can precede several months of other clinical presentations of BMs. This work aimed to study the impact of epilepsy and other prognostic factors on BMs patients' survival. Methods: This retrospective study included 51 patients diagnosed with BMs and who underwent neurosurgery between 2010 and 2021. The impact of BM features and patient's clinical characteristics on the overall survival (OS) was analyzed through uni- and multivariate analysis. Results: The average OS was 25.98 months and differed according to the histology of the primary tumor. The primary tumor localization and the presence of extracranial metastases had a statistically significant impact on the OS, and patients with single BM showed a superior OS to those with multifocal lesions. The localization of BMs in the temporal lobe correlated with the highest OS. The OS was significantly higher in patients who presented seizures in their clinical onset and in those who had better post-surgical Karnofsky performance status, no post-surgical complications, and who underwent post-surgical treatment. Conclusion: Our study has highlighted prognostically favorable patient and tumor factors. Among those, a clinical onset with epileptic seizures can help identify brain metastasis hitherto silent. This could lead to immediate diagnostic-therapeutic interventions with more aggressive therapies after appropriate multidisciplinary evaluation.

Evaluation of prognostic preoperative factors in patients undergoing surgery for spinal metastases: Results in a consecutive series of 81 cases.

Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases. Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients' baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients' overall survival and predictive preoperative factors was analyzed by the Kaplan-Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant. Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors. Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome.

Pre-operative hematological markers as predictive factors for overall survival and progression free survival in glioblastomas.

INTRODUCTION: Several hematological factors, such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), prognostic nutrition index (PNI) and albumin-to-globulin ratio (AGR), have been highlighted as systemic worse prognostic parameters for the outcome in gliomas. The aim of this study is to identify some pre-operative routinely blood tests as predictive parameters for the Overall Survival (OS) and Progression Free Survival (PFS) in glioblastoma (GBM). MATERIALS AND METHODS: From January 2013 to April 2019, 124 patients operated for glioblastoma were analyzed. Data were collected regarding age, sex, Karnofsky performance status (KPS), IDH status, the extent of resection (EOR) and adjuvant therapy. The hematological parameters were collected at admission: neutrophils, lymphocytes and platelets, hemoglobin, lactate dehydrogenase, albumin, NLR, PLR, AGR and PNI. The OS and the PFS were considered as the end-point for the evaluation of the predictive factors. RESULTS: A pre-operative neutrophil count > 7 × 109/L was a worse prognostic factor for OS and PFS at univariate analysis (p = 0.004 and p = 0.025), as well as hypo-albuminemia. Thrombocytosis, lymphopenia and NLR > 4 were associated to a worse OS, at uni- and multivariate analysis, resulting as poor predictive parameters, independently to EOR, the IDH mutation and the adjuvant therapy. CONCLUSIONS: Still nowadays there are no sensitive or specific hematological markers which are routinely applied for detecting and monitoring the treatment-response and the prognosis of glioblastoma. In our study, a pre-operative low cost and widely used blood markers, such as NLR, lymphocytes and platelets could be predictable prognostic factors for the Overall Survival of patients affected by glioblastomas.

Sixth Cranial Nerve Palsy and Craniocervical Junction Instability due to Metastatic Urothelial Bladder Carcinoma.

Metastases involving the clivus and craniocervical junction (CCJ) are extremely rare. Skull base involvement can result in cranial nerve palsies, while an extensive CCJ involvement can lead to spinal instability. We describe an unusual case of clival and CCJ metastases presenting with VI cranial nerve palsy and neck pain secondary to CCJ instability from metastatic bladder urothelial carcinoma. The patient was first treated with an endoscopic endonasal approach to the clivus for decompression of the VI cranial nerve and then with occipitocervical fixation and fusion to treat CCJ instability. At the 6-month follow-up, the patient experienced complete recovery of VI cranial nerve palsy. To the best of our knowledge, the simultaneous involvement of the clivus and the CCJ due to metastatic bladder carcinoma has never been reported in the literature. Another peculiarity of this case was the presence of both VI cranial nerve deficit and spinal instability. For this reason, the choice of treatment and timing were challenging. In fact, in case of no neurological deficit and spinal stability, palliative chemo- and radiotherapy are usually indicated. In our patient, the presence of progressive diplopia due to VI cranial nerve palsy required an emergent surgical decompression. In this scenario, the extended endoscopic endonasal approach was chosen as a minimally invasive approach to decompress the VI cranial nerve. Posterior occipitocervical stabilization is highly effective in avoiding patient's neck pain and spinal instability, representing the approach of choice.

Coil Extrusion into the Naso- and Oropharynx Ten Years after Internal Carotid Artery Pseudoaneurysm Embolization: A Case Report.

Coil migration and extrusion outside the cranial compartment after embolization of cerebral aneurysms represents a very rare complication of the endovascular procedures and few cases are reported in the literature. Instability of the vascular malformation wall and the resolution of the intramural hematoma, especially in pseudoaneurysm, might generate extravascular migration of the coils in the first months after embolization. However, to the best of our knowledge, an extrusion of coil 10 years after embolization has never been reported. We reported the unique case of a patient with coil extrusion into the naso- and oropharynx 10 years after internal carotid artery pseudoaneurysm embolization. The pseudoaneurysm occurred after an internal carotid artery injury during an endoscopic endonasal surgery for a clival giant cell tumor.

Decompressive Craniectomy for Traumatic Brain Injury: The Role of Cranioplasty and Hydrocephalus on Outcome.

OBJECTIVE: After severe traumatic brain injury (sTBI) associated with uncontrollable high intracranial pressure (ICP), today the main challenge for neurosurgeons remains to identify who may obtain benefit from decompressive craniectomy (DC) and which factors after DC influence the prognosis of these patients. The aim of this paper was to identify the pre- and postoperative determinants of outcome after DC. METHODS: This retrospective study included all patients undergoing DC for sTBI from 2003 to 2011. The 6-month outcome, assessed using the Glasgow Outcome Scale (GOS), was dichotomized into favorable (GOS scores 4 and 5) and unfavorable (GOS scores 1-3) outcome. Predictors of outcome were identified by uni- and multivariate analysis. RESULTS: There were 190 patients who underwent DC for sTBI in this study. Sixty patients (31.6%) died within 30 days after DC. Independent prognostic factors for survival after 30 days were Glasgow Coma Scale score at admission greater than 5 (P = 0.002) and bilateral pupil reactivity (P < 0.0001). Thirty days after DC, 67 patients (51.5%) out of 130 had unfavorable outcome (GOS scores 1-3) and 63 patients (49.5%) presented favorable outcome (GOS scores 4 and 5). The independent preoperative prognostic factors for poor outcome were age over 65 years (P < 0.0001) and bilateral absence of pupil reactivity (P = 0.0165). After DC, onset of postoperative hydrocephalus and delayed cranioplasty (3 months after DC) was associated with unfavorable outcome at multivariate analysis (P = 0.002 and P < 0.0001, respectively). CONCLUSIONS: In our study, the development of hydrocephalus after DC for sTBI and delayed cranial reconstruction were associated with unfavorable outcome.

New or Blossoming Hemorrhagic Contusions After Decompressive Craniectomy in Traumatic Brain Injury: Analysis of Risk Factors.

Background: The development or expansion of a cerebral hemorrhagic contusion after decompressive craniectomy (DC) for traumatic brain injury (TBI) occurs commonly and it can result in an unfavorable outcome. However, risk factors predicting contusion expansion after DC are still uncertain. The aim of this study was to identify the factors associated with the growth or expansion of hemorrhagic contusion after DC in TBI. Then we evaluated the impact of contusion progression on outcome. Methods: We collected the data of patients treated with DC for TBI in our Center. Then we analyzed the risk factors associated with the growth or expansion of a hemorrhagic contusion after DC. Results: 182 patients (149 males and 41 females) were included in this study. Hemorrhagic contusions were detected on the initial CT scan or in the last CT scan before surgery in 103 out of 182 patients. New or blossoming hemorrhagic contusions were registered after DC in 47 patients out of 182 (25.82%). At multivariate analysis, only the presence of an acute subdural hematoma (p = 0.0076) and a total volume of contusions >20 cc before DC (p = < 0.0001) were significantly associated with blossoming contusions. The total volume of contusions before DC resulted to have higher accuracy and ability to predict postoperative blossoming of contusion with strong statistical significance rather than the presence of acute subdural hematoma (these risk factors presented respectively an area under the curve [AUC] of 0.896 vs. 0.595; P < 0.001). Patients with blossoming contusions presented an unfavorable outcome compared to patients without contusion progression (p < 0.0185). Conclusions: The presence of an acute subdural hematoma was associated with an increasing rate of new or expanded hemorrhagic contusions after DC. The total volume of hemorrhagic contusions > 20 cc before surgery was an independent and extremely accurate predictive radiological sign of contusion blossoming in decompressed patients for severe TBI. After DC, the patients who develop new or expanding contusions presented an increased risk for unfavorable outcome.

Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion.

OBJECTIVE: To examine the long-term outcomes (minimum of 4.5 years) of endoscopic endonasal odontoidectomy (EEO) with preservation of anterior C1 ring to treat irreducible ventral bulbo-medullary compressions in rheumatoid arthritis (RA) and to illustrate a novel technique of anterior pure endoscopic craniovertebral junction (CVJ) reconstruction and fusion. In fact, long-term clinical studies are still lacking to elucidate the effective role of EEO and whether it can obviate the need for posterior fixation. METHODS: From November 2008 to January 2012, clinical and radiologic data of 7 patients presenting with RA and associated irreducible bulbo-medullary compression treated with EEO were analyzed retrospectively. In all patients, decompression was achieved by EEO with anterior C1 arch preservation. In the last 2 patients, after EEO, we used the spared anterior C1 arch for reconstruction of anterior column of CVJ by positioning, under pure endoscopic guidance, autologous bone and 2 tricortical screws between the anterior arch of C1 and the residual odontoid. All patients were examined clinically with Ranawat classification and radiographically with computed tomography, magnetic resonance imaging, and dynamic radiography immediately after surgery and during follow-up. RESULTS: Adequate bulbo-medullary decompression with anterior C1 arch preservation was obtained in all cases. At follow-up (average, 66.2 months; range, 51-91 months) all patients experienced an improvement at least of one Ranawat classification level and presented no clinical or radiologic signs of instability. CONCLUSIONS: EEO with anterior C1 arch sparing provides satisfying long-term results for irreducible ventral CVJ lesions in RA. The preservation of anterior C1 arch and, when possible, the reconstruction of anterior CVJ can prevent the need for posterior fusion.

Use of equine collagen foil as dura mater substitute in endoscopic endonasal transsphenoidal surgery.

OBJECTIVE: This study describes the use of a novel collagen-based dural substitute in endoscopic endonasal transsphenoidal surgery. METHODS: Operative records were reviewed for a 12-month period for all patients who underwent surgery by means of an endoscopic endonasal transsphenoidal approach since we began using TissuDura (Baxter, Vienna, Austria) collagen-only dural substitute in January 2004. RESULTS: During the 12-month period evaluated, we performed an endoscopic endonasal transsphenoidal operation for a variety of pituitary lesions on 72 consecutive patients. Among these, 15 patients (20.8%) required the implant of the collagen foil. Nine patients (60%) presented an intraoperative CSF leak (3 small weeping of CSF and 6 larger leaks); in these cases, the TissuDura was used against the arachnoid membrane, followed by the other materials used for the repair. In 7 other subjects without any evidence of CSF escape, the collagen foil was used to protect and enforce the arachnoidal membrane descent into the sellar cavity to prevent its possible postoperative rupture and consequent CSF leak. Fibrin glue was used in all cases. A postoperative CSF leak with meningitis occurred in only 1 (6.7%) of the 15 subjects. The patient required a reoperation for CSF fistula repair and intravenous antibiotics. CONCLUSIONS: Even if based on a relatively small patient series, our experience demonstrated that the use of TissuDura in transsphenoidal surgery is safe and biocompatible, as compared with other dural substitutes.

Paradoxical Brain Herniation After Decompressive Craniectomy Provoked by Drainage of Subdural Hygroma.

BACKGROUND: Paradoxical brain herniation (PBH) is a rare and potentially life-threatening complication of decompressive craniectomy (DC) and results from the combined effects of brain gravity, atmospheric pressure and intracranial hypotension causing herniation in the direction opposite to the site of the DC with subsequent brainstem compression. To date, the cases of PBH reported in literature are spontaneous or provoked by a lumbar puncture, a cerebrospinal fluid (CSF) shunt, or ventriculostomy. CASE DESCRIPTION: We present an uncommon case of PBH provoked by percutaneous drainage of a huge subdural hygroma (SH) ipsilateral to the decompressive craniectomy causing mass effect and neurologic deterioration. After percutaneous evacuation of SH, the patient became unresponsive with dilated and fixed left pupil. A brain computed tomography scan showed marked midline shift in the direction opposite to the craniectomy site with subfalcine herniation and effacement of the peripontine cisterns. Paradoxical brain herniation (PBH) was diagnosed. Conservative treatment failed, and the patient required an emergency cranioplasty for reverse PBH. CONCLUSIONS: The present case highlights the possibility that all forms of CSF depletion, including percutaneous drainage of subdural CSF collection and not only CSF shunting and/or lumbar puncture, can be dangerous for patients with large craniotomies and result in PBH. Moreover, an emergency cranioplasty could represent a safe and effective procedure in patients not responding to conservative treatment.

Combined supra-transorbital keyhole approach for treatment of delayed intraorbital encephalocele: A minimally invasive approach for an unusual complication of decompressive craniectomy.

BACKGROUND: Intraorbital encephalocele is a rare entity characterized by the herniation of cerebral tissue inside the orbital cavity through a defect of the orbital roof. In patients who have experienced head trauma, intraorbital encephalocele is usually secondary to orbital roof fracture. CASE DESCRIPTION: We describe here a case of a patient who presented an intraorbital encephalocele 2 years after severe traumatic brain injury, treated by decompressive craniectomy and subsequent autologous cranioplasty, without any evidence of orbital roof fracture. The encephalocele removal and the subsequent orbital roof reconstruction were performed by using a modification of the supraorbital keyhole approach, in which we combine an orbital osteotomy with a supraorbital minicraniotomy to facilitate view and access to both the anterior cranial fossa and orbital compartment and to preserve the already osseointegrated autologous cranioplasty. CONCLUSIONS: The peculiarities of this case are the orbital encephalocele without an orbital roof traumatic fracture, and the combined minimally invasive approach used to fix both the encephalocele and the orbital roof defect. Delayed intraorbital encephalocele is probably a complication related to an unintentional opening of the orbit during decompressive craniectomy through which the brain herniated following the restoration of physiological intracranial pressure gradients after the bone flap repositioning. The reconstruction of the orbital roof was performed by using a combined supra-transorbital minimally invasive approach aiming at achieving adequate surgical exposure while preserving the autologous cranioplasty, already osteointegrated. To the best of our knowledge, this approach has not been previously used to address intraorbital encephalocele.

Microsurgical endoscopy-assisted anterior corpus callosotomy for drug-resistant epilepsy in an adult unresponsive to vagus nerve stimulation.

Because most of the corpus callosotomy (CC) series available in literature were published before the advent of vagus nerve stimulation (VNS), the efficacy of CC in patients with inadequate response to VNS remains unclear, especially in adult patients. We present the case of a 21-year-old female with medically refractory drop attacks that began at the age of 8 years, which resulted in the patient being progressively unresponsive to vagus nerve stimulation implanted at the age of 14 years. Corpus callosotomy was recommended to reduce the number of drop attacks. However, the patient had only mild cognitive impairments and no neurological deficits. For this reason, we were forced to plan a surgical approach able to maximize the disconnection for good seizure control while, at the same time, minimizing sequelae from disconnection syndromes and neurosurgical complications because in such cases of long-lasting epilepsy the gyri cinguli and the arteries can be tenaciously adherent and dislocated with all the normal anatomy altered. In this scenario, we opted for a microsurgical endoscopy-assisted anterior two-thirds corpus callosotomy. The endoscopic minimally invasive approach proved to be quite adequate in this technically demanding case and confirmed that CC may offer advantages, with good results, even in adult patients with drop attacks who have had inadequate response to VNS.

Posterior Titanium Screw Fixation without Debridement of Infected Tissue for the Treatment of Thoracolumbar Spontaneous Pyogenic Spondylodiscitis.

STUDY DESIGN: Retrospective study. PURPOSE: The aim of our study was to analyze the safety and effectiveness of posterior pedicle screw fixation for treatment of pyogenic spondylodiscitis (PSD) without formal debridement of the infected tissue. OVERVIEW OF LITERATURE: Posterior titanium screw fixation without formal debridement of the infected tissue and anterior column reconstruction for the treatment of PSD is still controversial. METHODS: From March 2008 to June 2013, 18 patients with PSD underwent posterior titanium fixation with or without decompression, according to their neurological deficit. Postero-lateral fusion with allograft transplantation alone or bone graft with both the allogenic bone and the autologous bone was also performed. The outcome was assessed using the visual analogue scale (VAS) for pain and the Frankel grading system for neurological status. Normalization both of C-reactive protein (CRP) and erythrocyte sedimentation rate was adopted as criterion for discontinuation of antibiotic therapy and infection healing. Segmental instability and fusion were also analyzed. RESULTS: At the mean follow-up time of 30.16 months (range, 24-53 months), resolution of spinal infection was achieved in all patients. The mean CRP before surgery was 14.32±7.9 mg/dL, and at the final follow-up, the mean CRP decreased to 0.5±0.33 mg/dL (p <0.005). Follow-up computed tomography scan at 12 months after surgery revealed solid fusion in all patients. The VAS before surgery was 9.16±1.29 and at the final follow-up, it improved to 1.38±2.03, which was statistically significant (p <0.05). Eleven patients out of eighteen (61.11%) with initial neurological impairment had an average improvement of 1.27 grades at the final follow-up documented with the Frankel grading system. CONCLUSIONS: Posterior screw fixation with titanium instrumentation was safe and effective in terms of stability and restoration of neurological impairment. Fixation also rapidly reduced back pain.

Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance.

BACKGROUND: During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora. OBJECTIVE: To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities. METHODS: Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case. RESULTS: A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far. CONCLUSION: The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.