Enhanced Recovery after Cranial Surgery in Elderly: A Review.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. METHODS: Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. RESULTS: Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. CONCLUSIONS: This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.

Nondysraphic Intramedullary Lipoma of the Cervical Spine: A Systematic Review of Management Strategies and Outcomes.

BACKGROUND: Nondysraphic intramedullary lipomas of the cervical spine are extremely rare, and only a few cases have been reported. We aimed to provide a thorough review of the literature regarding patient characteristics, treatment options, and outcomes in these patients. We also provided an illustrative case from our institution, which we added to the pool of patients identified by our review. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature in PubMed/Medline, Web of Science, and Scopus databases was searched. Nineteen studies were included in the final quantitative analysis. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias. RESULTS: We identified 24 patients with nondysraphic cervical intradural intramedullary lipoma of the spinal cord. The patients were predominantly male (70.8%) with a mean age of 30.3 years. Quadriparesis was observed in 33.3% of the cases, while paraparesis occurred in 25% of the patients. Sensory disturbances were observed in 8.3% of the cases. In some patients, the presenting symptoms were neck pain (4.2%) and headache (4.2%). Surgical treatment was performed in 22 cases (91.7%). In 13 cases (54.2%) a subtotal removal was reached, and in 8 cases (33.3%) partial tumor removal was feasible. In 1 case (4.2%) a simple laminectomy was performed. Fourteen patients (58.3%) improved, 6 (25%) were unvaried, and 2 (8.3%) worsened. The mean follow-up was 30.8 months. CONCLUSIONS: Overall, surgical treatment can provide substantial spinal cord decompression improving or stabilizing the neurologic deficits. Experience from our case, along with analysis of reports from the literature, suggests that careful and controlled resection may provide benefits and avoid serious complications otherwise that result from aggressive resection.

A rare case of peri-implant distal radius fracture.

A peri-implant fracture near the volar plate of distal radius represent a very rare injury. The main factor of this lesion is high energy trauma on the wrist. We report a case of a 61-year-old woman with a peri-implant fracture located just proximally to the plate and a fracture of the ulnar head that occurred after a simple fall. The patient was surgically treated by plate and screws removal. The fracture was fixed using a longer volar plate for the radial fracture and a plate for the head ulnar fracture. Different factors such as osteoporosis, BMI and screw position could influence the fracture pattern. However, considering growing use of plates for distal radius fracture fixation, the frequency of these kind of fracture will probably increase.

Lumbar Spinal Fixation Removal by a Minimal Invasive Microscope-Assisted Technique. Case Report with Technical Description.

The concept of minimally invasive spine surgery (MISS) has gained increasing popularity in the last decades. While MISS holds promise for faster patient recovery, and shorter hospital stays, the removal of the surgical fixation, when required, is still performed by an extensive approach often resulting in disabling pain and discomfort. We describe a novel minimal invasive microscope-assisted technique for lumbar spinal fixation removal. This technique has been successfully applied in a 35-year-old man, affected by back pain despite a previous posterior dynamic MISS L4-S1 fixation. The previous skin incisions were opened and under microscopic vision, the screws and the roads were dissected from the scars and removed. The patient was discharged on postoperative day-1. He reported a progressive improvement of the symptoms with a satisfactory cosmetic result. Minimal invasive microscope-assisted technique for spinal fixation removal offers a simple and effective surgical alternative to the traditional open surgery.

Does Hybrid Surgery Improve Quality of Life in Multilevel Cervical Degenerative Disk Disease? Five-Year Follow-up Study.

BACKGROUND: Patient satisfaction is becoming an increasing factor worthy of consideration when evaluating the surgical quality. The correlation between patient satisfaction and surgical outcomes 5 years after cervical hybrid surgery (HS), which incorporates anterior cervical decompression and fusion and cervical disk arthroplasty techniques in multilevel cervical degenerative disk disease, has not been evaluated. METHODS: The aim of this study was firstly to analyze prospectively collected data from a sample of patients (n = 50) treated with cervical HS for selected cases of radiculopathy and myelopathy in order to evaluate pain levels of patients, using the Neck and Arm Pain scale as an expression of visual analog scale. Secondly, we aimed to evaluate health-related quality of life, via the short-form 36, Neck Disability Index, and Japanese Orthopedic Association score. Patients were followed up for more than 5 years. Intraoperative parameters, clinical features, and outcome scores were recorded. Radiologic investigations including disk height and changes in adjacent disk spaces were assessed. RESULTS: Clinical improvements were observed in all outcomes; significant improvements on the Neck Disability Index, visual analog scale, short-form 36, and Japanese Orthopedic Association scores were maintained at 5 years (P < 0.05). The mean disk height resulted restored in all the cases. Temporary dysphagia was rarely observed (3%). No surgery for adjacent-level disease was required. There was no significant difference in the outcomes between radiculopathy and myelopathy groups (P > 0.05). CONCLUSIONS: HS is an effective and safe procedure for the treatment of multilevel cervical degenerative disk disease. Such a surgical construct offers postoperative improvement on pain levels and health-related quality of life.

Emerging Therapeutic Strategies for Traumatic Spinal Cord Injury.

Spinal cord injury (SCI) is a debilitating neurologic condition with tremendous socioeconomic impact on affected individuals and the health care system. The treatment of SCI principally includes surgical treatment and marginal pharmacologic and rehabilitation therapies targeting secondary events with minor clinical improvements. This unsuccessful result mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiologic changes that occur in the injured spinal cord. Once the nervous system is injured, cascades of cellular and molecular events are triggered at varying times. Although the cascade of tissue reactions and cell injury develops over a period of days or weeks, the most extensive cell death in SCI occurs within hours of trauma. This situation suggests that early intervention is likely to be the most promising approach to rescue the cord from further and irreversible cell damage. Over the past decades, a wealth of research has been conducted in preclinical and clinical studies with the hope to find new therapeutic strategies. Researchers have identified several targets for the development of potential therapeutic interventions (e.g., neuroprotection, replacement of cells lost, removal of inhibitory molecules, regeneration, and rehabilitation strategies to induce neuroplasticity). Most of these treatments have passed preclinical and initial clinical evaluations but have failed to be strongly conclusive in the clinical setting. This narrative review provides an update of the many therapeutic interventions after SCI, with an emphasis on the underlying pathophysiologic mechanisms.

Femoral neck's fracture in Fahr's Syndrome: case report.

Fahr's syndrome, also known as "Bilateral Striopallidodentate Calcinosis" (BSPDC) primitive, is a rare neurological disease characterized by the presence of idiopathic, bilateral, symmetrical and abnormal deposition of calcium in areas of the brain that control movements including the basal ganglia, dentate nuclei of the cerebellum, nuclei of thalamus and semi-oval center. We describe a case of a 76-year-old male patient underwent reduction and fixation of a subtrochanteric fracture with intramedullary nail. During post-operative rehabilitation therapists's patient management was difficult due to obvious extrapyramidal symptoms characterized by dysarthria, rigidity, bradykinesia, postural instability. A CT scan, performed for the onset of stiffness and confusion before the operation, showed: IV ventricle eumorphic and in axis; expansion in atrophic sense of supratentorial ventricular system; bilateral, diffuse and coarse calcifications of the basal ganglia in the cerebellar and occipital cortex, elements compatible with Fahr's syndrome. The patient presented repeated postural instability episodes in the upright position, with loss balance tendency and recurrent falls. Fahr's syndrome patient is a "weak" patient, which requires a multi-disciplinary approach in order to prevent the mobility reduction, to improve the condition of postural instability, thus reducing the risk of fractures using preventive measures in domestic environment.

Changing the awareness of physiatrists on musculoskeletal ultrasound: Italy in EURO-MUSCULUS.

The interest of physical and rehabilitation medicine (PRM) physicians in musculoskeletal ultrasonography (MSUS) is increasing. In this study, we aimed to explore the attitudes of a group of Italian physiatrists on this topic before and after a 2½-day MSUS course. A 15-question survey (designed ad-hoc for this study) was administered before the first session of an MSUS course held in the PRM Department of Tor Vergata University, Rome. At the end of the course, a repeat questionnaire with eight of the original 15 questions (on awareness) was administered. The survey contained multiple-choice and open-ended questions addressing three main aspects: personal background, MSUS experience, and awareness about MSUS. All of the course participants (17 physiatrists) completed the precourse and postcourse questionnaires. Almost two-thirds of the participants (11/17) reported that they had never received education on MSUS. Overall, the participants rated MSUS as either 'essential' (8/16) or 'useful to some of my practice' (8/16). All of them stated at both times that physiatrists should perform MSUS themselves and that MSUS education is necessary for physiatrists. Participants' awareness significantly increased on the indications for MSUS, the advantages and the structures that could be evaluated with it. We draw attention to the fact that PRM physicians are increasingly becoming aware of the need for MSUS in clinical practice. Unfortunately, the two barriers (i.e. lack of education and lack of device) against the use of MSUS by physiatrists still seem to exist. Finally, we acknowledge the paramount role of international collaborative efforts (e.g., EURO-MUSCULUS) to speed up and standardize the education process and the clinical application of MSUS in our field.