Application of the NSE score (Neurology-Stability-Epidural compression assessment) to establish the need for surgery in spinal metastases of elderly patients: a multicenter investigation.

PURPOSE: This retropective multicentric study aims to investigate the clinical applicability of the NSE score in the elderly, to verify the role of this tool as an easy help for decision making also for this class of patients. METHODS: All elderly patients (> 65 years) suffering from spinal metastases undergoing surgical or non-surgical treatment at the authors' Institutions between 2015 and 2022 were recruited. An agreement group (AG) and non-agreement group (NAG) were identified accordingly to the agreement between the NSE score indication and the performed treatment. Neurological status and axial pain were evaluated for both groups at follow-up (3 and 6 months). The same analysis was conducted specifically grouping patients older than 75 years. RESULTS: A strong association with improvement or preservation of clinical status (p < 0.001) at follow-up was obtained in AG. The association was not statistically significant in NAG at the 3-month follow-up (p 1.00 and 0.07 respectively) and at 6 months (p 0.293 and 0.09 respectively). The group of patients over 75 years old showed similar results in terms of statistical association between the agreement group and better outcomes. CONCLUSION: Far from the need or the aim to build dogmatic algorithms, the goal of preserving a proper performance status plays a key role in a modern oncological management: functional outcomes of the multicentric study group showed that the NSE score represents a reliable tool to establish the need for surgery also for elderly patients.

Lesson learned in endoscopic endonasal dens resection for C1-C2 spinal cord decompression.

PURPOSE: Endoscopic endonasal approach (EEA) is the safest and most effective technique for odontoidectomy. Nevertheless, this kind of approach is yet not largely widespread. The aim of this study is to share with the scientific community some tips and tricks with our ten-year-old learned experience in endoscopic endonasal odontoidectomy (EEO), which remains a challenging surgical approach. MATERIAL AND METHODS: Our case series consists of twenty-one (10 males, 11 females; age range of 34-84 years) retrospectively analyzed patients with ventral spinal cord compression for non-reducible CVJ malformation, treated with EEA from July 2011 to March 2019. RESULTS: The results have recently been reported in a previous paper. The only intraoperative complication observed was intraoperative cerebrospinal fluid (CSF) leak (9.5%), without any sign of post-operative CSF leak. CONCLUSIONS: Considering our experience, EEO represents a valid and safe technique to decompress neural cervical structures. Despite its technical complexity, mainly due to the use of endoscope and the challenging surgical area, with this study we encourage the use of EEO displaying our experience-based surgical tips and tricks.

Introducing endoscopic assistance on routinary basis for vestibular schwannomas resection: A single centre acceptance analysis.

OBJECTIVE: The use of endoscopic assistance in retrosigmoid approach for tumors of the cerebellopontine angle brought undoubted technological advantages in skull base surgery. Nonetheless, the use of the endoscope is not as widespread as it could be. The aim of the study is to analyze the impressions of neurosurgeons and otologists with different experience in vestibular schwannoma surgery, experiencing the introduction of the endoscope in surgical daily practice. METHODS: All patients undergoing vestibular schwannoma surgery were recruited in the period from January 2019 to December 2020. The endoscope-assistance and a minimum follow-up of 12 months were considered inclusion criteria. An eight items questionnaire was administered to the surgeons who used endoscope-assistance during surgery. RESULTS: A total number of 20 patients were recruited. Five surgeons experienced the use of 0° and 45° optics in the "pre-resection" and "intra-meatal" phases of the procedures. The survey gave positive feedbacks on the introduction of the endoscope in vestibular schwannoma resection. The main drawback was the difficulty to manage the use of angled optics. CONCLUSIONS: Despite the known limitations of the study, the idea of investigating surgeons' impressions on the use of the endoscope could be another motif to explain why this instrument and its diffusion is limited despite its advantages in vestibular schwannoma surgery.

Facial nerve outcome score: a new score to predict long-term facial nerve function after vestibular schwannoma surgery.

Introduction: Patients' quality of life (QoL), facial nerve (FN), and cochlear nerve (CN) (if conserved) functions should be pursued as final outcomes of vestibular schwannoma (VS) surgery. In regard to FN function, different morphologic and neurophysiological factors have been related to postoperative outcomes. The aim of the current retrospective study was to investigate the impact of these factors on the short- and long-term FN function after VS resection. The combination of preoperative and intraoperative factors resulted in designing and validating a multiparametric score to predict short- and long-term FN function. Methods: A single-center retrospective analysis was performed for patients harboring non-syndromic VS who underwent surgical resection in the period 2015-2020. A minimum follow-up period of 12 months was considered among the inclusion criteria. Morphological tumor characteristics, intraoperative neurophysiological parameters, and postoperative clinical factors, namely, House-Brackmann (HB) scale, were retrieved in the study. A statistical analysis was conducted to investigate any relationships with FN outcome and to assess the reliability of the score. Results: Seventy-two patients with solitary primary VS were treated in the period of the study. A total of 59.8% of patients showed an HB value < 3 in the immediate postoperative period (T1), reaching to 76.4% at the last follow-up evaluation. A multiparametric score, Facial Nerve Outcome Score (FNOS), was built. The totality of patients with FNOS grade A showed an HB value < 3 at 12 months, decreasing to 70% for those with FNOS grade B, whereas 100% of patients with FNOS grade C showed an HB value ≥ 3. The ordinal logistic regression showed three times increasing probability to see an HB value ≥ 3 at 3-month follow-up for each worsening point in FNOS score [Exp(B), 2,999; p < 0.001] that was even more probable [Exp(B), 5.486; p < 0.001] at 12 months. Conclusion: The FNOS score resulted to be a reliable score, showing high associations with FN function both at short- and long-term follow-up. Although multicenter studies would be able to increase its reproducibility, it could be used to predict the FN damage after surgery and the potential of restoring its function on the long-term period.

Three-Dimensional Patient-Matched Template Guides Are Able to Increase Mean Diameter and Length and to Improve Accuracy of Cortical Bone Trajectory Screws: A 5-Year International Experience.

OBJECTIVE: To analyze whether significant differences exist between free-hand three-dimensional (3D) planning-guided cortical bone trajectory (CBT) screw placement and 3D-printed template-guided CBT screw positioning in terms of accuracy, size of screws, and potential complications. METHODS: In this retrospective study, data of adult patients in whom CBT screws were placed for lumbar degenerative pathologies were extracted from a prospectively collected database and analyzed. Patients in whom screws were placed using free-hand 3D planning-guided technique were compared with patients in whom screws were positioned using customized 3D-printed templates. Size of the screws, accuracy, clinical outcomes, and complications were analyzed. RESULTS: The study evaluated 251 patients (1004 screws). The free-hand 3D planning-guided group included 158 patients (632 screws), and the 3D-printed template-guided group included 93 patients (372 screws). The 3D-printed template-guided group involved screws of larger size from L3 to S1. Differences between the 2 groups in terms of accuracy parameters reached statistical significance (P ≤ 0.05). CONCLUSIONS: With the use of 3D patient-matched template guides, mean diameter and length of CBT screws could be safely increased due to improved accuracy of screw placement. Based on previous evidence regarding CBT biomechanical properties, these advantages could allow increased fixation strength over traditional convergent pedicle screw trajectories. Further biomechanics studies are needed.

3D-printed guides for cervical pedicle screw placement in primary spine tumor: Case report and technical description.

Introduction: For spine surgeons, dealing with unstable cervical spine has been usually challenging, and this becomes more difficult when facing a primary craniovertebral junction tumor. Primary spine tumor surgery should always include column reconstruction in order to guarantee biomechanical stability of the spine, but surgeons should always be aware that instrumentations could create interferences with postoperative radiations. However, although carbon fiber instrumentations have started to be used in thoracolumbar oncology for few years, these options are still not available for cervical spine. In the reported case, the adopted strategy to obtain adequate column reconstruction was based on the idea of reducing the amount of titanium needed for posterior fixation and maximizing the distance between the radiation target and titanium rods. Case report and aim: We present the case of a 53-year-old woman harboring a craniovertebral junction chordoma. A short occipito-C3 construct was selected. Specifically, titanium cervical pedicle screws were placed by using a new technology consisting in patient-tailored and customized 3D-printed guides. The aim of this case report is to determine the feasibility and safety of 3D-printed guides for cervical pedicle screw (CPS) positioning, even in the case of cervical spine tumor. Conclusion: CPS could represent a good solution by providing strong biomechanical purchase and tailored 3D-printed guides could increase the safety and the accuracy of this challenging screw placement, even in oncological patients.

Endoscopic endonasal odontoidectomy: a long-term follow-up results for a cohort of 21 patients.

BACKGROUND: Endoscopic endonasal odontoidectomy (EEO) has been described as a potential approach for craniovertebral junction (CVJ) disease which could cause anterior bulbomedullary compression and encroaching. Due to the atlantoaxial junction's uniqueness and complex biomechanics, treating CVJ pathologies uncovers the challenge of preventing C1-C2 instability. A large series of patients treated with endonasal odontoidectomy is reported, analyzing the feasibility and necessity of whether or not to perform posterior stabilization. Furthermore, the focus is on the long-term follow-up, especially those whom only underwent partial C1 arch preservation without posterior fixation. METHODS: This study is a retrospective analysis of patients with ventral spinal cord compression for non-reducible CVJ malformation, consecutively treated with EEO from July 2011 to March 2019. Postoperative dynamic X-ray and CT scans were obtained in each case in order to document CVJ decompression as well as to exclude instability. The anterior atlas-dens interval, posterior atlas-dens interval and C1-C2 total lateral overhang were measured as a morphological criteria to determine upper cervical spine stability. RESULTS: Twenty-one patients (11:10 F:M) with a mean age of 60.6 years old at the time of surgery (range 34-84 years) encountered the inclusion criteria. For all 21 patients, a successful decompression was achieved at the first surgery. In 11 patients, the partial C1 arch integrity did not require a posterior cervical instrumentation on the bases of postoperative and constant follow-up radiological examination. In 13 cases, an improvement of motor function was recorded at the time of discharge. Only one patient had further motor function improvement at follow-up. Among the patients that did not show any significant motor change at discharge, 4 patients showed an improvement at the last follow-up. CONCLUSIONS: The outcomes, even in C1 arch preservation without posterior fixation, are promising, and it could be said that the endonasal route potentially represents a valid option to treat lesions above the nasopalatine line.

Quality of Life After Endoscopic Skull Base Surgery: Validation and Reliability of the Italian Version of the Sino-Nasal Outcome Test for Neurosurgery (SNOT-NC).

OBJECTIVE: Expanded endonasal approaches (EEA) have become the main approach to the anterior skull base. A specific questionnaire, the Sino-Nasal Outcome Test for Neurosurgery (SNOT-NC), was developed in German to assess quality of life after EEA. The aim of this study was the cross-cultural adaptation and validation of the Italian version of SNOT-NC. METHODS: Three hundred patients who underwent EEA for anterior skull base diseases were included in the study. An Italian version of SNOT-NC was cross-culturally adapted. Internal consistency, test-retest reliability, construct, and clinical and group validity were analyzed. The Short-Form 36 questionnaire was used for construct validity analysis. RESULTS: The Cronbach α coefficient was 0.862. Only 1 subscale (olfactory disturbance) showed an insufficient internal consistency. The test-retest reliability was excellent (intraclass correlation coefficient between 0.934 and 0.997). The good correlation between SNOT-NC and Short-Form 36 scores (P < 0.05) showed the construct validity of the questionnaire. SNOT-NC was able to distinguish between patients with more or fewer nasal symptoms (P < 0.05). Patients who underwent a transtuberculum/transplanum approach had greater olfactory disturbances compared with other approaches (P < 0.05). CONCLUSIONS: The Italian version of SNOT-NC showed good internal consistency, test-retest reliability, construct, and clinical and group validity, as well as original version. It can be considered a good instrument to evaluate the impact of endoscopic EEA to the anterior skull base.

Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches?

STUDY DESIGN: Literature review. OBJECTIVES: An increasing number of obese patients requires operative care for degenerative spinal disorders. The aim of this review is to analyze the available evidence regarding the role of obesity on outcomes after spine surgery. Peri-operative complications and clinical results are evaluated for both cervical and lumbar surgery. Furthermore, the contribution of MIS techniques for lumbar surgery to play a role in reducing risks has been analyzed. METHODS: Only articles published in English in the last 10 years were reviewed. Inclusion criteria of the references were based on the scope of this review, according to PRISMA guidelines. Moreover, only paper analyzing obesity-related complications in spine surgery have been selected and thoroughly reviewed. Each article was classified according to its rating of evidence using the Sacket Grading System. RESULTS: A total number of 1636 articles were found, but only 130 of them were considered to be relevant after thorough evaluation and according to PRISMA checklist. The majority of the included papers were classified according to the Sacket Grading System as Level 2 (Retrospective Studies). CONCLUSION: Evidence suggest that obese patients could benefit from spine surgery and outcomes be satisfactory. A higher rate of peri-operative complications is reported among obese patients, especially in posterior approaches. The use of MIS techniques plays a key role in order to reduce surgical risks. Further studies should evaluate the role of multidisciplinary counseling between spine surgeons, nutritionists and bariatric surgeons, in order to plan proper weight loss before elective spine surgery.

Endoscopic resection of supergiant pituitary adenoma.

BACKGROUND: Giant pituitary adenomas are a rare finding and the literature is inconclusive regarding the most appropriate approach. In supergiant adenomas, where the size of the tumor is exceptional, both a combine approach versus a solely transcranial or endoscopic approach have been reported.[2,3,5]. CASE DESCRIPTION: In this video, an entirely endoscopic resection of a supergiant pituitary adenoma is demonstrated. The exceptional size (4.5 × 5.8 × 5.4 cm) of the tumor and the peculiarity of the anatomical relations are documented in the video. The anterior cerebral arteries, both the A1 and A2 tracts, as well as the anterior communicating arteries are shown to be posteriorly dislocated and encased by the tumor which is pealed from the arteries themselves. Furthermore, the optic nerves are decompressed and cleaned from any residual tumor. The procedure is highly technically challenging since the furthermost part of the adenoma is also the one attached to the great intracranial arteries. A 45 optic and angle instruments were used for the major part of the surgery. Considering the high risk of postoperative CSF leak, a multilayer closure with nasoseptal flap was chosen. The postoperative MRI showed a gross total resection of the lesion in the absence of any complications and no new neurological nor endocrinological deficit appeared. CONCLUSION: Expanded endoscopic endonasal approach could represent a valuable way to face giant adenoma, providing a direct corridor toward the lesion and safe control of both the chiasmatic vasculature and the anterior communicating artery complex. Multilayer reconstruction is mandatory to avoid postoperative CSF leak.[1,4].

Management of spinal aneurysms associated with arteriovenous malformations: systematic literature review and illustrative case.

PURPOSE: Spinal aneurysms are rare vascular malformations, commonly associated with spinal AVMs. AVM-associated spinal aneurysms are burdened by significant morbidity. The purpose of our study is to evaluate the best treatment strategy for these uncommon vascular lesions and to report an illustrative case. METHODS: We reviewed clinical and radiological data of a patient surgically treated at our institution for a spinal AVM with an associated prenidal aneurysm. According to PRISMA guidelines, a systematic literature review has been performed in order to discuss the best management AVM-associated prenidal aneurysms. RESULTS: In the reported case, the aneurysm showed spontaneous regression at follow-up after surgical removal of the AVM. Only 6 articles reported management of spinal prenidal AVM-associated aneurysms. Basing on our experience and data from literature, surgical treatment of the aneurysm may be indicated along with the resection of the AVM if the aneurysm is close to the nidus. Conversely, if the aneurysm is far away from the nidus or in an unfavorable position, resection of the nidus only may lead to aneurysm regression as in the reported case. CONCLUSIONS: The treatment strategy for AVM-associated spinal aneurysms should be tailored on the single patient. In presence of large aneurysms that cause mass-effect symptoms, when rupture of the aneurysm is suspected or when treatment of the AVM is not proposable, direct treatment of the aneurysm should be considered. Otherwise, when complete resection of the nidus is performed, the eventually associated unruptured aneurysms located in challenging positions can be safely managed conservatively.

Solitary late spinal metastasis from apocrine salivary duct carcinoma: Case report.

BACKGROUND: The salivary duct carcinomas (SDCs) are rare, high-grade neoplasms involving major salivary glands. Parotid is the most frequently involved gland (85%). Apocrine phenotype (histological presence of decapitation secretions) and androgen reception expression define SDC. The clinical course of these tumors is characterized by aggressive local behavior with extraglandular extension, high recurrence rates, early metastases, and poor prognoses. Despite aggressive surgical/radiation therapy management, the rates of locoregional and metastatic relapses are high, and the mortality rates over 48 months approach 65%. Notably, there is no treatment algorithm available for managing vertebral metastases from apocrine SDC. CASE DESCRIPTION: An elderly male presented with MR/CT findings of an isolated T11 vertebral metastasis attributed to a previously treated parotid SDC. On both CT/MR, it was an osteolytic lesion and demonstrated spinal canal infiltration. The patient underwent surgical biopsy/decompression/resection, following which the lesion histopathologically proved to be a SDC. The patient was subsequently treated with 30 Gy in 10 fractions within 2 weeks of discharge. One-month later, the MRI confirmed adequate epidural decompression without recurrence, and 9 months post-operatively, patient remained disease free. CONCLUSION: Isolated metastasis attributed to parotid SDC followed by radiation therapy may result in tumor control.

Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries.

INTRODUCTION: Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate. OBJECTIVE: To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA. MATERIALS AND METHODS: Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra/post-operative complications. RESULTS: A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend. CONCLUSION: Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.

Craniovertebral junction chordomas: Case series and strategies to overcome the surgical challenge.

INTRODUCTION: Chordomas are rare and malignant primary bone tumors. Different strategies have been proposed for chordomas involving the craniovertebral junction (CVJ) compared to other locations. The impossibility to achieve en bloc excision, the impact on stability and the need for proper reconstruction make their surgical management challenging. OBJECTIVE: The objective is to discuss surgical strategies in CVJ chordomas operated in a single-center during a 7 years' experience (2013-2019). METHODS: Adult patients with CVJ chordoma were retrospectively analyzed. The clinical, radiological, pathological, and surgical data were discussed. RESULTS: A total number of 8 patients was included (among a total number of 32 patients suffering from skull base chordoma). Seven patients underwent endoscopic endonasal approach (EEA), and posterior instrumentation was needed in three cases. Three explicative cases were reported: EEA for midline tumor involving lower clivus and upper cervical spine (case 1), EEA and complemental posterior approach for occurred occipitocervical instability (case 2), C2 chordoma which required aggressive bone removal and consequent implant positioning, focusing on surgical planning (timing and type of surgical stages, materials and customization of fixation system) (case 3). CONCLUSION: EEA could represent a safe route to avoid injuries to neurovascular structure in clival locations, while a combined approach could be considered when tumor spreads laterally. Tumor involvement or surgical procedures could give raise to CVJ instability with the need of complementary posterior instrumentation. Thus, a tailored preoperative planning should play a key role, especially when aggressive bone removal and implant positioning are needed.

The Neurology-Stability-Epidural compression assessment: A new score to establish the need for surgery in spinal metastases.

OBJECTIVE: The aim of this study was to translate new evidence about management of spinal metastases in a practical and reliable score for surgeons, radiation oncologists and oncologists, able to establish the need for surgery regardless the available technology and settings. PATIENTS AND METHODS: Three main items were identified and graded: Neurological status (0-5 points), Stability of the spine according to the Spinal Instability Neoplastic Score (SINS) Score (0-5 points), and Epidural compression according to the Epidural Spinal Cord Compression (ESCC) scale (0-3 points). Patients were considered suitable for surgery with ASA score < 4 and ECOG score <3. A retrospective clinical validation of the NSE score was made on 145 patients that underwent surgical or non surgical treatment. RESULTS: Agreement between the undertaken treatment and the score (88.3% of patients), resulted in a strong association with improvement or preservation of clinical status (neurological functions and mechanical pain) (p < 0.001) at 3 and 6 months. In the non-agreement group no association was recorded at the 3 and 6 months follow-up (p 0.486 and 0.343 for neurological functions, 0.063 and 0.858 for mechanical pain). CONCLUSION: Functional outcomes of the study group showed that the proposed NSE score could represent a practical and reliable tool to establish the need for surgery. Agreement between the score and the performed treatments resulted in better clinical outcomes, when compared with patients without agreement. Further validation is needed with a larger number of patients and to assess reproducibility among surgeons, radiation oncologists, and oncologists.

Principles of Cortical Plasticity in Peripheral Nerve Surgery.

Cortical plasticity is a finely regulated process that allows the central nervous system (CNS) to change in response to internal and external stimuli. While these modifications occur throughout normal brain development, interestingly, they are also elicited after peripheral nerve injury and surgery. This article provides an overview of the principle mechanisms of synaptic, neuronal, cortical and subcortical neuroplasticity, with special attention to cortical and subcortical modifications-as suggested by modern neuroimaging techniques-after peripheral nerve surgery. The main nerve transfer techniques for the superior extremities and their effect on cortical plasticity are also described.

III cranial nerve cavernous malformation: A case report and review of the literature.

BACKGROUND: Cavernous malformations generally occur in brain parenchyma but rarely these lesions arise from cranial nerves (CNs). CASE DESCRIPTION: This paper described a case of a woman presented with III CN dysfunction due to the presence of a right III CN cavernoma. Surgical treatment with nerve sparing gross total resection was performed. A 3-month follow-up was documented. CONCLUSION: Only few cases of CNs cavernomas have been described in the literature. These lesions have been described to show a more aggressive behavior compared to intraparenchymal cavernomas, especially in symptomatic patients. Differential diagnosis and surgical treatment could be challenging, especially trying to preserve nerve integrity and function.