Vertebral artery dissection caused by atlantoaxial dislocation in a patient with Marfan syndrome.

A small number of case reports have documented a link between atlantoaxial dislocation (AAD) and vertebral artery dissection (VAD), but this association has never been described in patients with hereditary connective tissue disorders. We present a case of an 18-year-old female patient, diagnosed with Marfan syndrome since the age of one, who underwent brain MRA for intracranial aneurysm screening revealing tortuosity of the internal carotid and vertebral arteries as well as atlantoaxial dislocation. Since the patient was asymptomatic, a wait-and-see approach was chosen, but a follow-up MRA after 18 months showed the appearance of a dissecting pseudoaneurysm of the V3 segment of the left vertebral artery. Despite the patient being still asymptomatic, it was decided to proceed with C1-C2 stabilization to prevent further vascular complications. Follow-up imaging showed realignment of the atlantoaxial joint and reduction of the dissecting pseudoaneurysm of the left vertebral artery. In our patient, screening MRA has led to the discovery of asymptomatic arterial and skeletal abnormalities which, if left untreated, might have led to severe cerebrovascular complications. Therefore, AAD correction or close monitoring with MRA should be provided to MFS patients with this craniovertebral junction anomaly, even if asymptomatic.

Preliminary Results of a Prospective Study on Methods of Cranial Reconstruction.

PURPOSE: Given its biological and anatomic features, autologous bone is the first choice for cranioplasty after bone decompression. When autologous bone is not available or must be replaced, surgeons can choose among various materials to create an alloplastic cranioplasty. The Italian Society for Neurosurgery promoted a prospective study conducted at 4 Italian neurosurgical units to compare different methods of cranioplasty and to assess the clinical results and incidence of complications. MATERIALS AND METHODS: Patients older than 14 years who underwent repositioning of autologous bone or 3-dimensional image-guided reconstruction with prostheses made of an alloplastic material (polyetheretherketone, polymethylmethacrylate, or hydroxyapatite) after cranial decompression were enrolled prospectively from January 2008 through December 2013. The collected data included the material used to produce the prosthesis, the type of cranioplasty (primary or secondary), and complications that required surgical removal of the prosthesis (eg, infection, bone resorption, and fracture of the cranioplasty). RESULTS: Ninety-six patients met the study criteria. Fifty cases were reconstructed with hydroxyapatite, 31 with bone, 13 with polymethylmethacrylate, and 2 with polyetheretherketone. Seven patients (7.3%) developed complications related to the cranioplastic implant that required reoperation. These complications included infection (4 cases), bone resorption (2 cases), and fracture of the cranioplastic prosthesis (1 case). Statistical analysis showed a higher rate of complications with the use of autologous bone versus alloplastic materials (P = .03). Owing to the limited number of cases, no statistically meaningful complication was seen among the different alloplastic materials or when the cranioplastic implant was placed as secondary treatment. CONCLUSIONS: These data and those of other reports suggest that cranioplasty conducted using alloplastic 3-dimensional reconstruction materials have a lower rate of complications than those conducted using autologous bone.

Endoscopic endonasal approach for craniovertebral junction pathology: a review of the literature.

OBJECT: The transoral approach is the gold standard for ventral decompression of the brainstem caused by craniovertebral junction (CVJ) pathology. This approach is often associated with significant morbidity, related to swallowing and respiratory complications. The endoscopic endonasal approach was introduced to reduce the rate of these complications. However, the exact role of this approach in the treatment of CVJ pathology is not well defined. METHODS: A comprehensive literature search was performed to identify series of patients with pathology of the CVJ treated via the endoscopie endonasal approach. Data on patient characteristics, indications for treatment, complications, and outcome were obtained and analyzed. RESULTS: Twelve studies involving 72 patients were included. The most common indications for treatment were rheumatoid pannus (38.9%) and basilar invagination (29.2%). Cerebrospinal fluid leak was found in 18% of cases intraoperatively and 4.2% of cases postoperatively. One case of meningitis complicated by sepsis and death represents the procedure-related mortality of 1.4%. Of the patients without preoperative swallowing impairment, 95% returned to oral feeding on the 3rd postoperative day. Ninety-three percent of patients experienced improvement in neurological symptoms after the procedure. CONCLUSIONS: The endonasal endoscopie approach is effective for the treatment of neural compression caused by CVJ pathology. It offers advantages such as lower rates of postoperative dysphagia and respiratory complications when compared with the more traditional transoral approach. However, these 2 approaches should be seen as complementary rather than alternatives. Patient-related factors as well as the surgeon's expertise must be considered when making treatment decisions.

Clinical Application of a High Definition Three-Dimensional Exoscope in Anterior Lumbar Interbody Fusion: Technical Note.

OBJECTIVES: Video-assisted telescope operating monitor (VITOM) or exoscope is currently applied in different surgical specialties with clear visualization advantages in terms of magnification, illumination, and wide field of view. The small and deep surgical field of anterior lumbar interbody fusion (ALIF) seemed to be an ideal setting to assess efficacy of exoscope, also considering limits related to microscopic and endoscopic visualization currently employed. METHODS: We reported our preliminary experience with exoscope in 9 cases of ALIF at L5-S1 level. These data were retrospectively compared with those obtained from an equal sample of ALIF procedures performed with endoscope as visualization instrument. The technical aspects taken into account were time for procedure and blood loss. Reports from the surgeon about ergonomics and confidence with both techniques were also evaluated. RESULTS: Exoscope proved, in our experience, good visualization and ergonomics and unobstructed access to a small and deep surgical field, allowing abundant space to insert and manipulate the instruments. CONCLUSIONS: The instrument contained dimension and its long working distance, superior to endoscope and comparable with operating microscope, showed clear advantages of maneuverability. Moreover, the stereoscopic vision provided by 3-dimensional images proved to be crucial in hand-eye coordination.

Ganglioneurocytoma of the spinal cord: report of a case and review of literature.

A case of ganglioneurocytoma of the spinal cord in a 51-year-old man is reported. Patient presented with a progressively worsening back pain and hyposthenia of lower limbs. Magnetic resonance imaging of the spinal cord revealed an intradural lesion in the T10-11 spinal segments, hyperintense on T1-weighted sequences. Complete resection was achieved. The patient did not show evidence of recurrence 12 months after surgery. On histology, the lesion was composed of round to oval cells with fine granular, slightly eosinophilic to clear cytoplasm suggesting a neurocytic differentiation. Some ganglion cells were observed. Neither significant cytologic atypia nor mitoses were present. The neoplastic cells were strongly positive with synaptophysin and negative with glial fibrillary acid protein. Neurocytomas are uncommon tumors typically arising within the lateral ventricles near the foramen of Monro. Extraventricular neurocytomas have been reported at various sites with rare examples in spinal cord. In the present paper, a case of ganglioneurocytoma of the spinal cord is reported with review of literature and discussion of differences compared to neurocytomas of other sites.

Management of basilar invagination: A historical perspective.

For a long time the terms basilar invagination and platybasia were used interchangeably. Basilar invagination has been defined as a prolapse of the vertebral column into the spinal cord. Platybasia is defined as an abnormal obtuse angle between the anterior skull base and the clivus. The authors review the existing literature and summarize the historical and modern perspectives in the management of basilar invagination. From radiological curiosities, the subject of basilar invagination is now viewed as eminently treatable. The more pronounced understanding of the subject has taken place in the last three decades when on the basis of understanding of the biomechanical subtleties the treatment paradigm has remarkably altered. From surgery that involved decompression of the region, stabilization and realignment now form the basis of treatment.

Oxygen-ozone therapy for herniated lumbar disc in patients with subacute partial motor weakness due to nerve root compression.

Intradiscal oxygen-ozone (O2-O3) chemonucleolysis is a well-known effective treatment for pain caused by protruding disc disease and nerve root compression due to bulging or herniated disc. The most widely used therapeutic combination is intradiscal injection of an O2-O3 mixture (chemonucleolysis), followed by periradicular injection of O2-O3, steroid and local anaesthetic to enhance the anti-inflammatory and analgesic effect. The treatment is designed to resolve pain and is administered to patients without motor weakness, whereas patients with acute paralysis caused by nerve root compression undergo surgery 24-48h after the onset of neurological deficit. This paper reports on the efficacy of O2-O3 chemonucleolysis associated with anti-inflammatory foraminal injection in 13 patients with low back pain and cruralgia, low back pain and sciatica and subacute partial motor weakness caused by nerve root compression unresponsive to medical treatment. All patients were managed in conjunction with our colleagues in the Neurosurgery Unit of Bellaria Hospital and the IRCCS Institute of Neurological Sciences, Bologna. The outcomes obtained are promising: 100% patients had a resolution of motor weakness, while 84.6% had complete pain relief. Our results demonstrate that O2-O3 therapy can be considered a valid treatment option for this category of patients.

Intradural extramedullary Ewing's sarcoma. Recurrence with acute clinical presentation and literature review.

The intradural extramedullary space is an extremely unusual site for the onset of Ewing's sarcoma. We describe a case of recurrence of intradural extramedullary Ewing's sarcoma and review the literature available on this topic.

Long-term results following cranial hydroxyapatite prosthesis implantation in a large skull defect model.

BACKGROUND: A large skull defect may occur after different events such as trauma, tumor resection, and vascular injuries. There is still some doubt about the best material to use for reconstruction. Hydroxyapatite ceramic is one of the materials in use, and its biocompatibility and osteoconductivity are well established. This study evaluated the interaction of a commercial hydroxyapatite custom-made prosthesis implanted in a large skull defect, to assess its osteointegration and its habitability with newly formed bone over time. METHODS: Ten sheep underwent craniectomy and reconstruction of the skull defect with a porous hydroxyapatite cranial prosthesis. The animals were divided into two groups: animals in group A were euthanized after 6 months and animals in group B were euthanized after 12 months. At the end of the experimental periods, each implant was evaluated macroscopically and radiologically, and analyzed by micro-computed tomography, histology, histomorphometry, and microhardness techniques. RESULTS: During the study, no adverse events occurred, and there was no evidence of inflammation or negative tissue reactions. Histology and histomorphometry showed new bone formation inside the implant in both experimental periods; newly formed bone had increased significantly (p < 0.05) by over 300 percent between 6 and 12 months. Three-dimensional micro-computed tomographic analysis showed new bone formation and material remodeling. Microhardness analysis indicated that the mineralization process and the mechanical properties of newly formed bone were not altered. CONCLUSIONS: The hydroxyapatite prosthesis showed its osteoconductivity and good biocompatibility. A low rate of fibrous tissue formation and a high rate of bony regeneration were found.