New Trends in Spinal Surgery: Less Invasive Anatomical Approach to the Spine. The Advantages of the Anterior Approach in Lumbar Spinal Fusion.

AIM: To describe the history of the anterior approach to the lumbar spine from the beginning to the minimal invasive techniques that the authors have developed, and to discuss its advantages and drawbacks. MATERIAL AND METHODS: The authors collected published data on the evolution of the anterior approach in the lumbar spine, and described its potential in different pathologies focusing on minimally invasive techniques. RESULTS: Several successful techniques of anterior lumbar approach have been developed over the years, leading to a progressive less invasive anatomical exposure of the spine. Anterior approaches of the lumbar spine gained popularity as an alternative to posterior routes in the management of tumors, infections, traumas, degenerative or deformity diseases and as a salvage procedure after posterior surgery. CONCLUSION: Advantages of the retroperitoneal anterior approach of the lumbar spine are well accepted: it preserves the anatomical structures of the abdomen and posterior tension band, avoiding muscle dissection. The implantation of lordotic cages with larger footprint improves local lordosis and fusion rate even in revision surgery. Drawbacks of traditional retroperitoneal approaches may be: vascular injury, deep venous thrombosis, risk of retrograde ejaculation in male in case of L5-S1 dissection. Therefore, several minimal invasive techniques have been developed to decrease the risks related to the traditional approaches. However, a long learning curve is required to achieve good skills and to manage possible technical concerns and complications.

The Impact of Neurosurgical Complications on Patients' Health Status: A Comparison Between Different Grades of Complications.

OBJECTIVE: The aim of this article is to investigate the frequency of neurosurgical complications according to Landriel-Ibañez Classification and their impact on patients' health status. METHODS: Patients undergoing neurosurgical procedures were enrolled in an observational longitudinal study at Neurological Institute Carlo Besta from January 2012 to September 2013. We evaluated patients' health status before surgery, at discharge, and follow-up with the Karnofsky Performance Status Scale (KPS), whereas the Landriel-Ibañez Classification was used to record complications. Descriptive statistics were performed to illustrate the distribution of sociodemographic and clinical data. We used nonparametric tests to compare KPS scores of patients with different grades of complication and to evaluate the differences between preoperative KPS scores, KPS scores at discharge and follow-up. The effect sizes were also calculated. RESULTS: We enrolled 1008 patients. We registered 228 complications (139 grade 1 complications, 63 grade 2 complications, 20 grade 3 complications, and 6 grade 4 complications). All patients with a complication showed KPS scores at discharge that were lower than preoperative scores and KPS scores at follow-up greater than scores at discharge. After patients with grade 4 complications, who had the worst outcomes, those with grade 3 complications were the most compromised after surgery whereas patients with grade 2 complications seemed to have a better health status than patients with grade 1 complication. CONCLUSIONS: Our study highlights the impact of neurosurgical complications on patients' life and contributes to the debate on how define and classify adverse events because a classification only based on treatment seems to be not adequate.

Quality of life measures in Italian neurosurgical patients: validity of the EUROHIS-QOL 8-item index.

PURPOSE: To assess the validity, reliability and factor structure of the Italian version of the EUROHIS-QOL (European Health Interview Survey-Quality of Life) 8-item index in patients who are potential candidates for neurosurgical procedures. METHODS: Cross-sectional study. Patients completed the EUROHIS-QOL 8-item index, a disability and general well-being questionnaire; the Karnofsky performance status scale (KPS) was used as a general measure of functional status. Factor analysis was used to confirm the one-factor structure of the EUROHIS-QOL 8-item index. Reliability was measured using Cronbach's alpha coefficient, item-total correlation and inter-item correlation. Construct validity was assessed with Pearson's coefficient (expected to be below 0.70) and known-group analysis, dividing patients between those KPS >90 and KPS ≤90 (the latter expected to report lower QoL). RESULTS: The one-factor structure was partly confirmed, with two items having low loadings. Cronbach's alpha was 0.78; item-total correlations were below 0.70; and average inter-item correlation was 0.309. Correlations were all significant and moderate; known-group analysis shows that QoL scores were lower in patients with active symptoms (KPS ≤90). CONCLUSIONS: Our findings partly confirm the factor structure and reliability of the EUROHIS-QOL 8-item index, which suggests that it may be a useful and straightforward quality of life measurement technique in neurosurgical departments.

Quality of life, disability, well-being, and coping strategies in patients undergoing neurosurgical procedures: preoperative results in an Italian sample.

BACKGROUND: The aim of this paper is to present the preliminary results of QoL, well-being, disability, and coping strategies of patients before neurosurgical procedure. METHODS: We analysed data on preoperative quality of life (EUROHIS-QoL), disability (WHODAS-II), well-being (PGWB-S), coping strategies (Brief COPE), and functional status (KPS score) of a sample of patients with brain tumours and cerebrovascular and spinal degenerative disease admitted to Neurological Institute Carlo Besta. Statistical analysis was performed to illustrate the distribution of sociodemographic and clinical data, to compare mean test scores to the respective normative samples, and to investigate the differences between diagnoses, the correlation between tests, and the predictive power of sociodemographic and clinical variables of QoL. RESULTS: 198 patients were included in the study. PGWB-S and EUROHIS-QoL scores were significantly lower than normative population. Patients with spinal diseases reported higher scores in WHODAS-II compared with oncological and cerebrovascular groups. Finally sociodemographic and clinical variables were significant predictors of EUROHIS-QoL, in particular PGWB-S and WHODAS-II. CONCLUSION: Our preliminary results show that preoperatory period is critical and the evaluation of coping strategies, quality of life, disability, and well-being is useful to plan tailored intervention and for a better management of each patient.

Disability in Italian neurosurgical patients: validity of the 12-item World Health Organization Disability Assessment Schedule.

The aim of the study was to assess factor structure, internal consistency and validity of the Italian version of the World Health Organization Disability Assessment Schedule 12-item version (WHODAS-12) in patients scheduled for neurosurgical procedures for brain tumours, cerebrovascular or spinal diseases. Disability was assessed with the WHODAS-12, quality of life with the eight-item European Health Interview Survey-Quality of Life, well-being with the Psychological General Well-Being Index-Short and general health with the Karnofsky Performance Status (KPS) scales. Factor analysis was used to confirm WHODAS-12 one-factor structure; root mean square error of approximation (RMSEA) and χ2/d.f. ratio were used to test the model fit. Internal consistency was assessed with Cronbach's α coefficient, item-total correlation and interitem correlation; convergent validity was assessed with Pearson's coefficient and discriminative validity was assessed with the t-test, dividing patients between those with KPS greater than 90 and KPS of 90 or less. The one-factor structure was confirmed (RMSEA=0.079; χ2/d.f.=2.16) and internal consistency was adequate. Correlations between the three outcome measures were significant, negative and moderate; the t-test showed disability scores to be statistically significantly higher in patients with KPS of 90 or less. Our results confirm factor structure and validity of WHODAS-12 in Italian neurosurgical inpatients; we therefore support its use in neurosurgery departments.

Interdural haemorrhage of the posterior fossa due to infraclinoidal carotid artery aneurysm rupture.

Several anatomical studies indicate that the intracranial pachimeninges consist of two dural layers joined together, which divide while bordering the venous sinuses, therefore located in an interdural space. We present here an uncommon case of haematoma due to rupture of an infraclinoidal internal carotid artery aneurysm. The dome of the aneurysm leaned against the posterior wall of the cavernous sinus and, following laceration, pierced the inner dural layer and caused its detachment from the periosteal layer, thus determining a truly interdural haematoma which progressively involved the whole posterior fossa. A 42-year-old female was admitted to our institution with a recent history of thunderclap headache and right ophthalmoparesis. Two cerebral computerised scan tomographies performed elsewhere tested negative for subarachnoid haemorrhage. A cerebral magnetic resonance imaging (MRI) showed a thin collection of blood adjacent to the clivus and all along the wall of the posterior fossa and foramen magnum. A right infraclinoid internal carotid artery aneurysm was also diagnosed, subsequently better highlighted on angiography. The patient underwent surgery with aneurysm clipping. Post-operative course was uneventful, and control angiography showed complete exclusion of the aneurysm from blood circulation. The patient was discharged 5 days later. At 3 months follow-up ophthalmoplegia had disappeared, and the patient had fully recovered. The possibility of a truly interdural location, particularly in cases of non-traumatic parasellar or clival haematomas, must be included in the differential diagnosis of posterior fossa extra-axial haemorrhages. MRI is the test of choice for diagnostic purposes.

Human adult skeletal muscle stem cells differentiate into cardiomyocyte phenotype in vitro.

Cell transplantation to repair or regenerate injured myocardium is a new frontier in the treatment of cardiovascular disease. Most studies on stem cell transplantation therapy in both experimental heart infarct and in phase-I human clinical trials have focused on the use of undifferentiated stem cells. Based on our previous observations demonstrating the presence of multipotent progenitor cells in human adult skeletal muscle, in this study we investigated the capacity of these progenitors to differentiate into cardiomyocytes. Here we show an efficient protocol for the cardiomyogenic differentiation of human adult skeletal muscle stem cells in vitro. We found that treatment with Retinoic Acid directed cardiomyogenic differentiation of skeletal muscle stem cells in vitro. After Retinoic Acid treatment, cells expressed cardiomyocyte markers and acquired spontaneous contraction. Functional assays exhibited cardiac-like response to increased extracellular calcium. When cocultured with mouse cardiomyocytes, Retinoic Acid-treated skeletal muscle stem cells expressed connexin43 and when transplanted into ischemic heart were detectable even 5 weeks after injection. Based on these results, we can conclude that human adult skeletal muscle stem cells, if opportunely treated, can transdifferentiate into cells of cardiac lineage and once injected into infarcted heart can integrate, survive in cardiac tissue and improve the cardiac function.

Loss of heterozygosity studies in extracranial metastatic meningiomas.

Although most meningiomas are slow-growing tumours associated with favourable prognosis, they often present local recurrence after surgical treatment; by contrast, extracranial metastatic meningiomas are rare, occurring in less than 1% of the cases. Risk factors for distal spread remain largely unknown. We report three cases with lung or bone metastases from intracranial recurrent meningiomas. Loss of heterozygosity (LOH) analysis on 1p, 9p, 10q, 14q, and 22q was conducted in available primary, recurrent and metastatic lesions, showing the same LOH pattern in the distal metastases and in the intracranial meningioma. LOH at 1p, 14q and 9p, known to be associated with increased aggressiveness, were found. The results highlight the potential clinical relevance of integrating histopathological studies with molecular genetic analysis in the follow-up of patients with different types of meningiomas.

Neurovascular decompression in trigeminal neuralgia: role of intraoperative neurophysiological monitoring in the learning period.

This paper deals with the first 45 consecutive patients undergoing microvascular decompression (MVD) surgery for trigeminal neuralgia, studied with perioperative brainstem auditory evoked potentials (BAEPs) and electromyography (EMG). We observed a good correlation between the intraoperative BAEP modifications and postoperative hearing function. BAEP monitoring was useful in identifying the manoeuvres that may compromise cochlear nerve function. This improved the surgical technique in the subsequent cases and reduced the incidence of iatrogenic hearing deficits after the learning period. There were no correlations between the entity of the intraoperative EMG discharges and the postoperative facial and trigeminal function. Intraoperative EMG monitoring can be useful during the period of learning as a means of identifying the different nerves in the cisternal tract.