Clinical, Radiologic, and Surgical Features of Brain Metastases in Colorectal Cancer. A Strong Correlation Between Surgical Patterns and Outcome.

BACKGROUND: Brain metastases (BMs) from colorectal cancer (CRC) are a small percentage of metastatic patients and surgery is considered the best choice to improve survival. While most research has focused on the risk of CRC spreading to the brain, no studies have examined the characteristics of BMs in relation to surgery and outcome. In this study, we evaluate the clinical and radiologic features of BMs from CRC patients who underwent surgery and analyze their outcomes. METHODS: The study is a retrospective observational analysis that included a cohort of 31 patients affected by CRC surgically-treated for their related BMs. For all patients, clinical and surgical data (number, site, side, tumor and edema volume, and morphology) were recorded. RESULTS: Analysis found that synchronous diagnosis and lesion morphology, particularly cystic versus solid, had the most significant impact on survival (6 vs. 22 months, P = 0.04). To compare BMs with cystic morphology to those with solid morphology, a multivariate analysis was conducted. No significant differences were observed between the 2 groups in terms of age, sex, clinical onset, or performance status. The analysis revealed no significant differences in localization with regard to site, tumor and edema volume, biology, or complications rate. CONCLUSIONS: BMs derived from CRC have a significantly different prognosis depending on whether they present as a solid or cystic pattern. Although solid pattern is more common, cystic BMs in this tumor type are less frequent and are associated with a poorer prognosis, regardless of molecular expression, location, size, and adjuvant treatment.

Combined Anterior Odontoid Screw Fixation and C1-C2 Jefferson Fracture Anterior Fixation: A Step-by-Step Technical Note.

BACKGROUND: Combined triple atlas (C1)-axis (C2) fixation has been described in previous literature as a safe, effective, and minimally invasive procedure for complex atlas and odontoid fractures that allows for a greater range of motion compared with posterior approaches and atlanto-occipital fusion. However, it is rarely performed due to the occipital-cervical diastasis resulting from often-fractured C1 joint masses. No evidence-based consensus has been reached regarding the treatment of complex atlantoaxial fractures, and the choice of surgical strategy is based only on clinical experience. METHODS: We report the combined triple C1-C2 fixation technique with manual reduction of the joint masses during patient positioning on the operating table, which allowed for effective stabilization during a single surgical session. We describe our experience in the management of a 75-year-old patient presenting with an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. RESULTS: We provide a step-by-step guide for combined triple C1-C2 anterior fixation with manual fracture reduction and describe the clinical case of an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. CONCLUSIONS: Combined triple C1-C2 fixation represents a safe and efficient minimally invasive anterior approach for complex type II fractures of C1 with type II odontoid fractures. Manual reduction of the joint masses during patient positioning allows for effective stabilization in a single surgical session.

Development of a Novel Device for Decompressive Craniectomy: An Experimental and Cadaveric Study and Preliminary Clinical Application.

BACKGROUND: Decompressive craniectomy is an intervention of established efficacy in patients with intractable cerebral edema. OBJECTIVE: To evaluate a new device used in alternative to decompressive craniectomy. This device is designed to perform an augmentative craniotomy by keeping the bone flap elevated using specific cranial suspension titanium plates and giving the brain enough room to swell. METHODS: We tested the mechanical characteristics of the cranial brackets on dried skulls, on 3D-printed skull models, and on a preserved cadaver head. The resistance of the device was examined through dynamometric testing, and the feasibility of the surgical technique, including the suspension of the bone flap and the skin closure, was investigated on the cadaveric model. A preliminary clinical series of 2 patients is also reported. RESULTS: The laboratory tests have shown that this system allows an adequate expansion of the intracranial volume and it could withstand a force up to 637 ± 13 N in the synthetic model and up to 658 ± 9 N in the human skull without dislocation or failure of the brackets nor fractures of the bone ridges. Preliminary application in the clinical setting has shown that augmentative craniotomy is effective in the control of intracranial hypertension and could reduce the costs and complications associated with the classical decompressive craniectomy technique. CONCLUSION: Preliminary laboratory and clinical results show augmentative craniotomy to be a promising, alternative technique to decompressive craniectomy. Further clinical studies will be needed to validate its efficacy.

Lumbar interbody fusion using oblique (OLIF) and lateral (LLIF) approaches for degenerative spine disorders: a meta-analysis of the comparative studies.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Historically, posterior approaches to the lumbar spine have allowed surgeons to manage degenerative conditions affecting the lumbar spine. However, spinal muscles injury, post-surgical vertebral instability, cerebrospinal fluid (CSF) leakage, and failed back surgery syndrome (FBSS) represent severe complications that may occur after these surgeries. Lumbar interbody fusion using anterior (ALIF), oblique (OLIF), or lateral (LLIF) approaches may represent valuable surgical alternatives, in case fusion is indicated on single or multiple levels. METHODS: The present study is a systematic review, conducted according to the PRISMA statement, of comparative studies on OLIF, and LLIF for degenerative spine disorders, and a meta-analysis of their clinical-radiological outcomes and complications. RESULTS: After screening 1472 papers on PubMed, Scopus, and Cochrane Library, only 3 papers were included in the present study. 318 patients were included for data meta-analysis, 128 in OLIF group, and 190 in LLIF group. There were no significative differences in terms of surgical (intraoperative blood loss and surgical duration) and clinical (VAS-back, VAS-leg, and ODI scores) outcomes, or fusion rates at last follow-up (> 2 years). Significantly higher rates of abdominal complications, system failure, and vascular injuries were recorded in the OLIF group. Conversely, postoperative neurological symptoms and psoas weakness were significatively more common in LLIF group. CONCLUSIONS: The meta-analysis suggests that OLIF and LLIF are both effective for lumbar degenerative disorders, although each of them presents specific complications and this should represent a relevant element in the surgical planning.

Referencing for anterior atlantoaxial trans-articular osteosynthesis: a radiological study and proposal of a decisional algorithm.

PURPOSE: Anterior trans-articular C1-C2 screw placement can be considered as a surgical alternative in different conditions affecting the atlantoaxial region. While its rigidity is similar to posterior Magerl and Harms techniques, it also provides some surgical advantages. However, the literature lacks papers exhaustively describing indication criteria, surgical steps, and pitfalls. METHODS: This is a radiological study on 100 healthy subjects. Thin-layer CT scans of the craniovertebral junction were retrieved from the institutional database. The coronal inclination of the C1-C2 joint rim and the depth of the entry point of the screw with respect to the anterior profile of C2 were measured. The antero-posterior and the medio-lateral surgical corridors for the screw placement, and the wideness of the target area on the upper surface of C1 were also measured. RESULTS: The multivariate analysis showed that the coronal inclination of the C1-C2 articular joint rim strongly influences the surface extension of the C1 target area; the depth of the entry point and the C1-C2 articular rim inclination seem to be independent factors in influencing both the medio-lateral and the antero-posterior surgical corridors wideness. A decisional algorithm on whether to perform an anterior or posterior approach to the atlantoaxial region was also proposed. CONCLUSIONS: We can conclude that, as much as the C1-C2 articular rim is tending to the horizontal line, and as deeper is the entry point of the screw on the anterior profile of C2, as easier the anterior C1-C2 trans-articular screw placement will result.