Visualization of the nervus intermedius during microvascular decompression in hemifacial spasm: anatomical study.

OBJECTIVE: The surgical anatomy of the nervus intermedius (NI) is highly variable. The aim of this study was to describe the anatomy of the NI during endoscope-assisted microvascular decompression (MVD) in hemifacial spasm (HFS), and the involvement of the nerve in the vascular conflict. METHODS: The authors reviewed a prospectively maintained database for MVDs performed between 2002 and 2022 and extracted clinical data including patient demographics, symptoms, and offending vessel(s). Operative videos and photographs were analyzed retrospectively in an attempt to identify the NI. RESULTS: Endoscopic identification of the NI was possible in 139 of 435 MVDs. The anatomy is very variable. In 79 (56.8%) patients, a single-bundle pattern was detected, whereas a multiple-bundle pattern was identified in 60 (43.2%) patients. Overall the most common pattern was a single-bundle type A (49.7%). In 20.1%, a multiple-bundles type A was identified. In 4.3%, a single-bundle type B was detected. In 2.9% a single-bundle type C was found, and in just 0.7% a multiple-bundles type C was detected. A multiple-origin pattern (type D) was found in 31 patients (22.3%). The NI was frequently involved in the neurovascular conflict (approximately 85%). The type of NI or vascular compression pattern did not affect the results regarding the outcome or recurrence of HFS. CONCLUSIONS: The anatomy of the NI is for the first time evaluated endoscopically in MVD for HFS. The nerve had various anatomical patterns that were clearly identified. Further studies to evaluate the compression patterns in relation to NI neuralgia are warranted.

Spontaneous Regression of a Giant Traumatic Herniated Thoracic Disk: A Case Report and Review of the Literature.

Thoracic disk herniation (TDH) after traumatic injury is a relatively uncommon disease with few cases reported in the literature. Herniated disks in this location typically may result in progressive myelopathy and refractory pain. In the presence of these symptoms, surgical treatment may be indicated since spontaneous regression in this area is less common than that of disk herniations in the cervical or lumbar spine. Herein, we present the case of giant traumatic TDH that occurred at the T9-T10 level and spontaneously resolved after 5 months.We highlight the fact that regression of a herniated disk at the thoracic level may occur even in the absence of treatment. When considering this phenomenon, conservative management of these cases with clinical and radiological monitoring may be an appropriate first-line management for patients without signs of progressive myelopathy or severe refractory pain.

Osteoid Osteoma of the Atlas in a Boy: Clinical and Imaging Features-A Case Report and Review of the Literature.

Osteoid osteoma is a benign osteoblastic tumor, quite uncommon in the spine. We report a case of an osteoid osteoma involving the atlas in a 6-year-old boy, who presented with suboccipital pain and torticollis. Initial radiological findings were ambiguous as magnetic resonance imaging showed mainly edema of upper cervical soft tissues. The subsequent computed tomography depicted a lesion of left lamina of C1. As conservative treatment failed, the lesion was surgically resected and the patient became pain free. To our knowledge, this is the first case of osteoid osteoma involving the atlas associated with abnormal soft tissue reaction reported in literature.

Cutaneous Metastasis from Cervical Spinal Chordoma: Case Report and Literature Review.

BACKGROUND: Chordomas are rare primary tumors of the bone that arise from embryonic notochord. They are locally aggressive tumors with a high tendency for postsurgical recurrence. On the other hand, distant metastases are rare. When they occur, they involve lungs, liver, lymph nodes, and bones. Skin and subcutaneous tissue involvement is even rarer and usually occurs by direct extension of the primary tumor or by local recurrence. Distant cutaneous metastasis from chordoma is an exceptional finding, with fewer than 20 cases reported in the literature. All the cutaneous metastases described derive from sacral chordomas, except for 2 cases in which the source of metastasis is skull-base chordomas. CASE DESCRIPTION: We report the case of a 55-year-old man with skin metastasis from a cervical chordoma. CONCLUSIONS: Metastasis has to be taken into account in the differential diagnosis when a new skin lesion appears in a patient with a past medical history of chordoma. To the best of our knowledge, this is the first case of cutaneous metastasis from spinal cervical chordoma. A systematic literature review was performed.

Cranioplasty in neurosurgery: is there a way to reduce complications?

BACKGROUND: Cranioplasty (CPL) is a surgical procedure that has still a high rate of complications, although it is commonly considered an easy and routine operation. In the literature, cranioplasty complications may rise up to 41% of cases, and the most frequently reported are infections, autologous bone flap resorption, and hematomas. Although possible, poor cosmetic results are rarely mentioned. METHODS: We retrospectively analyzed the cases of 313 patients who underwent 377 surgical procedures for cranioplasty and reoperations for complications between 2008 and 2014. In other 2 patients we performed a new surgical procedure for the prosthesis fracture. Pediatric patients (aging from 5 to 17 years) have been included in this series in order to compare the complication rate between adult and pediatric populations. The clinical-radiological follow-up of these 313 patients lasted between 1 and 6 years. RESULTS: Overall complications for cranioplasty were seen in 38 (12.14%) out of the 313 patients. However, complications requiring surgical therapy were seen in 28 patients who underwent 64 new surgical procedures. Adult male patients represented the majority of the group with cranioplasty complications. In the pediatric group we have not observed any complication requiring more than a clinical observation. Infections and autologous bone resorption were the most frequent complications reported in this series; however, we observed a poor cosmetic result as a concomitant but separate complication in more than 26% of our 313 patients. CONCLUSIONS: In this paper we present an overview of all the possible complications of cranioplasty reported in the literature, comparing them with those observed in our series. We also discuss critically the most evident causes of complications, suggesting, when possible, solutions to avoid or limit them.

Endoscopic Endonasal Odontoidectomy.

Odontoidectomy is the treatment of choice for irreducible ventral cervical-medullary compression. The endonasal endoscopic approach is an innovative approach for odontoidectomy. The aim of this article is to identify in which conditions this approach is indicated, discussing variants of the technique for selected cases of craniovertebral malformation with platybasia. We believe that the technical difficulties of this approach are balanced by the advantages for patients. Some conditions related to the patient and to the anatomy of the craniovertebral junction may favor adoption of the endoscopic endonasal approach, which should be considered complementary and not alternative to standard approaches.

Expanding indications for the extended endoscopic endonasal approach to hypothalamic gliomas: preliminary report.

Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale. Results In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal. Conclusions Despite the limitations of a short follow-up and small sample, the authors' early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.