Systematic Review and Meta-Analysis on Optimal Timing of Surgery for Acute Symptomatic Metastatic Spinal Cord Compression.

Introduction: Symptomatic acute metastatic spinal epidural cord compression (MSCC) is an emergency that requires multimodal attention. However, there is no clear consensus on the appropriate timing for surgery. Therefore, to address this issue, we conducted a systematic review and meta-analysis of the literature to evaluate the outcomes of different surgery timings. Methods: We searched multiple databases for studies involving adult patients suffering from symptomatic MSCC who underwent decompression with or without fixation. We analyzed the data by stratifying them based on timing as emergent (≤24 h vs. >24 h) and urgent (≤48 h vs. >48 h). The analysis also considered adverse postoperative medical and surgical events. The rates of improved outcomes and adverse events were pooled through a random-effects meta-analysis. Results: We analyzed seven studies involving 538 patients and discovered that 83.0% (95% CI 59.0-98.2%) of those who underwent urgent decompression showed an improvement of ≥1 point in strength scores. Adverse events were reported in 21% (95% CI 1.8-51.4%) of cases. Patients who underwent emergent surgery had a 41.3% (95% CI 20.4-63.3%) improvement rate but a complication rate of 25.5% (95% CI 15.9-36.3%). Patients who underwent surgery after 48 h showed 36.8% (95% CI 12.2-65.4%) and 28.6% (95% CI 19.5-38.8%) complication rates, respectively. Conclusion: Our study highlights that a 48 h window may be the safest and most beneficial for patients presenting with acute MSCC and a life expectancy of over three months.

Approaching Intradural Lesions of the Anterior Foramen Magnum and Craniocervical Junction: Anatomical Comparison of the Open Posterolateral and Anterior Extended Endonasal Endoscopic Approaches.

BACKGROUND: Lesions of the foramen magnum (FM) and craniocervical junction area are traditionally managed surgically through anterior, anterolateral, and posterolateral skull-base approaches. This anatomical study aimed to compare the usefulness of a modified extended endoscopic approach, the so-called far-medial endonasal approach (FMEA), versus the traditional posterolateral far-lateral approach (FLA). METHODS: Ten fixed silicon-injected heads specimens were used in the Skull Base ENT-Neurosurgery Laboratory of the University Hospital of Strasbourg, France. A total of 20 FLAs and 10 FMEAs were realized. A high-resolution computed tomography scan was performed for quantitative analysis of the different approaches. The analysis aimed to estimate the extent of surgical exposure and freedom of movement (maneuverability) through the operating channel using a polygonal surface model to obtain a morphometric estimation of the area of interest (surface and volume) on postdissection computed tomography scans using Slicer 3D software. RESULTS: FMEA allows for a more direct route to the anterior FM, with wider brainstem exposure compared with the FLA and an excellent visualization of all anterior midline structures. The limitations of the FMEA include the deep and narrow surgical corridor and difficulty in reaching lesions located laterally over the jugular foramen and hypoglossal canal. CONCLUSIONS: The FMEA and FLA are both effective surgical routes to reach FM and craniocervical junction lesions. Modern skull base surgeons should have a good command of both because they appear complementary. This anatomical study provides the tools for comprehensive preoperative evaluations and selection of the most appropriate surgical approach.

Bibliographic Study and Meta-Analysis of Clinical Outcomes of Full-Endoscopic Spine Surgery for Painful Lumbar Spine Conditions.

BACKGROUND: Full-endoscopic spine surgery (FESS) indications already cover degenerative, infectious, and neoplastic diseases. This study aimed to use a bibliometric search and meta-analysis of the highest-quality studies in the last 20 years to determine the quantity and quality of FESS research, geographic distribution, and the outcomes for lumbar conditions. METHODS: Articles on FESS published from 2000 to 2022 were screened and assessed through Web of Science, PubMed, and Scopus. Also, databases were searched for longitudinal studies to pool in a meta-analysis of patients undergoing FESS for lumbar conditions. After stratifying the risk of bias and having collected the studies of the highest quality, we included the proportion of patients with a satisfactory outcome and intraoperative and postoperative adverse events after the analysis of lumbar spine conditions. RESULTS: A total of 728 articles were identified by the bibliographic search. Between 2000 and 2021, the published articles increased 21-fold. Most were from China (70.15%), followed by South Korea (19.5%). Most were retrospective (68.3%) and regarding treatment of lumbar disease (86.4%). Fifty studies, including 34,828 patients, were pooled in the meta-analysis. More than 85% of patients experienced satisfactory improvement in each of different lumbar conditions. Major adverse events were <2%; recurrence and postoperative dysesthesia rates were within those reported for open or mini-invasive procedures. CONCLUSIONS: This study may fill research gaps on FESS and lead to adequately designed studies. Our meta-analysis showed that FESS for lumbar diseases is a procedure with satisfactory outcomes and low rates of adverse events.

Treatment of thoracolumbar burst fractures: SpineJack vs. posterior arthrodesis-comparison of clinical and radiological outcomes.

Background: Thoracolumbar fractures sometimes require anterior support and post-traumatic deformity correction. SpineJack proved favorable results in cadaveric and clinical studies, with satisfactory pain relief, vertebral height restoration, and low rates of above adjacent fractures, in neurologically intact fractures. We compared patients' clinical and radiological outcomes of thoracolumbar fractures treated either with posterior arthrodesis or SpineJack. Methods: We prospectively collected A2 split and A3, and A4 burst fractures between 2017 and 2021. Patients were stratified in posterior arthrodesis (PA group) and SpineJack (SJ group) and included if age ≥18 years, T11-L3 level, emergent or elective surgery, single or multiple, and neurologically intact. Age, sex, type and level, pain, operative and discharge time, vertebral body heights (VBH), posterior wall retropulsion (PWR), vertebral kyphosis (VK) and local kyphosis (LK) angles, vertebral body (VB) volume, and complications were collected. We then compared clinical-radiographic outcomes between the two groups. Results: We found no significant differences in median postoperative pain while operative time and discharge time were shorter for SJ patients than PA ones (P<0.001). Mean anterior VBH increase was 20.7%, mid-VBH was 25.5%, and posterior VBH was 8.8%, while increase in VB volume was 26.2%. SJ patients had non-inferior VK e LK angles correction to PA ones. Mean PWR value between pre and post SJ implantation was 0.15±0.65 mm, and no adjacent above-level fractures occurred. Conclusions: We showed satisfactory outcomes in a selected range of neurologically intact thoracolumbar split or burst fractures. SJ leads to shorter operative and discharge time and good VB angles and diameters restoration.

A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment.

BACKGROUND: Different procedures have been used for the treatment of lumbar juxtafacet cysts (JFCs). Recently, full-endoscopic cyst excision has been suggested as a reasonable alternative. We performed a meta-analysis to assess the overall rates of favorable outcomes and adverse events for each available treatment and determine the outcome and complication rates concerning spine stability. METHODS: Multiple databases were searched for English-language studies involving adult patients with lumbar JFCs who had been followed for more than 6 months. Outcomes included the proportion of patients with a satisfactory outcome. Adverse events included recurrence and revision rates as well as intraoperative complications. We further stratified the analysis based on the spine's condition (degenerative listhesis vs without degenerative listhesis). RESULTS: A total of 43 studies, including 2226 patients, were identified. Over 80% of patients experienced satisfactory improvement after surgical excision but only 66.2% after percutaneous cyst rupture and aspiration. Overall, recurrence and revision rates were almost double in patients with preoperative degenerative listhesis at the cyst level, especially in the minimally invasive group (2.1% vs 31.3% and 6.8% vs 13.1%, respectively). The rate of full-endoscopic satisfactory outcomes was approximately 90%, with low rates of adverse events (<2%). CONCLUSION: We analyzed the outcome and adverse event rates for each kind of available treatment for JFC. Full endoscopy has outcomes and rates of adverse events that overlap with open and minimally invasive approaches. LEVEL OF EVIDENCE: 2A.

Novel Polyethylene Terephthalate Screw Sleeve Implant: Salvage Treatment in a Case of Spine Instability after Vertebroplasty Failure.

INTRODUCTION: The management of osteoporotic fractures is sometimes rather challenging for spinal surgeons, and considering the longer life expectancy induced by improved living conditions, their prevalence is expected to increase. At present, the approaches to osteoporotic fractures differ depending on their severity, location, and the patient's age. State-of-the-art treatments range from vertebroplasty/kyphoplasty to hardware-based spinal stabilization in which screw augmentation with cement is the gold standard. CASE PRESENTATION: We describe the case of a 74-year-old man with an L5 osteoporotic fracture. The patient underwent a vertebroplasty (VP) procedure, which was complicated by a symptomatic cement leakage in the right L4-L5 neuroforamen. We urgently decompressed the affected pedicle via hemilaminectomy. At that point, the column required stability. The extravasation of cement had ruled out the use of cement-augmented pedicle screws but leaving the pedicular screws alone was not considered sufficient to achieve stability. We decided to cover the screws with a polyethylene terephthalate sleeve (OGmend®) to avoid additional cement leakage and to reinforce the screw strength required by the poor bone quality. CONCLUSION: In the evolving technologies used for spinal surgery, screws sleeve implants such as OGmend® are a useful addition to the surgeon's armamentarium when an increased pull-out strength is required and other options are not available.

Homologous amniotic membrane as a dural substitute in decompressive craniectomies.

INTRODUCTION: A dura mater substitute in decompressive craniectomies must protect the brain while providing a dissection plane between the cortex and myocutaneous layer. The human amniotic membrane (AM) has anti-inflammatory, wound healing, and differentiation properties. We tested AM properties as a dural substitute by comparing the outcomes to biological ones. METHODS: We prospectively collected data on 25 patients who randomly underwent decompressive craniectomy with lyophilized AM patches and 25 in which biological substitutes were utilized between 2015 and 2019. The AM was laid with the epithelial side facing the brain because of the anti-adhesive proprieties, while the chorion facing the myocutaneous flap. We collected data on demographics, neurological status, comorbidities, and surgical outcomes. Additionally, we created a score - dura mimicking score- and reviewed postoperative imaging and pathological specimens. RESULTS: The majority (96%) of AM grafts were integrated into native dura. Thirteen patients scored as excellent and 11 good on our "dura mimicking score", showing tissue integration ability but no cerebral cortex adhesion. The histopathological analysis showed that AM had thick plates of dense fibrous tissue with small reactive vessels, reactive fibroblasts, and lymphocytes infiltrate. The AM group's first outcomes were not different from the biological substitute patients but higher integration rate to the dura and less adhesion to the myocutaneous flap in AM patients. CONCLUSIONS: We documented the anti-adhesive, protective, and integrative properties of AM dural substitute patches in patients who underwent decompressive craniectomies, comparing the intraoperative differences and postoperative outcomes to biological dural substitutes.

Managing Incomplete and Complete Thoracolumbar Burst Fractures (AO Spine A3 and A4). Results from a Prospective Single-Center Study Comparing Posterior Percutaneous Instrumentation plus Mini-Open Anterolateral Fusion versus Single-Stage Posterior Instrumented Fusion.

OBJECTIVE: The treatment strategy for thoracolumbar burst fractures is still debated. The aim of this study is to evaluate clinical and radiologic outcomes of a 2-stage strategy with immediate posterior percutaneous instrumentation and delayed anterolateral fusion (group A) versus a single-stage open posterior instrumented fusion (group B). METHODS: Demographics and clinical and surgical data of patients operated for AO Spine A3 and A4 fractures were prospectively collected. Vertebral height and deformity were evaluated before and after surgery. Visual analog scale score for back pain, Oswestry Disability Index, and 12-Item Short Form Health Survey results for quality-of-life assessment were collected during follow-up. RESULTS: Among the 110 patients enrolled, 66 were allocated to group A and 44 to group B; the most common fractured level was T12 (34%). Postoperative complications were higher in group B, especially the wound infection rate (18% vs. 3%), and pseudomeningocele (14% vs. 0%). The 2-stage approach allowed an average long-term gain of 15.8° at the local kyphosis of fractured vertebra and 5.8° at the regional level (Cobb angle), versus 15.4° and 5.5° in group B. At 2 years follow-up, both groups showed significant functional improvements; however, the visual analog scale and Oswestry Disability Index metrics seemed more favorable for group A patients (P < 0.0001 vs. P < 0.003). A complete fusion rate was obtained in 100% of group A vs. 65% of group B. CONCLUSIONS: Our study indicates that percutaneous instrumentation and anterior fusion or an expandable cage lead to excellent long-term clinical and radiologic outcomes with a lower complication rate and higher fusion rate than those of open posterior approaches.

Opto-chiasmatic apoplexy as a compartment syndrome? Anatomical and surgical considerations on two bleeding cavernous malformations.

OBJECTIVE: Opto-chiasmatic (OC) cavernous malformations are sporadic lesions that are often misdiagnosed clinically and radiologically. Presenting symptoms range from incidental findings to the more frequent and dramatic "chiasmal apoplexy." The present study aims to evaluate the potential role of arachnoidal membranes of the basal cisterns in the onset of OC apoplexy. A possible mechanism resembling a compartment syndrome is discussed through the description of two cases of bleeding cavernomas. METHODS: We describe clinical, radiological, intraoperative findings in two cases of young patients presenting with OC apoplexy from bleeding cavernoma. The first was a 38-year-old man diagnosed with optic neuritis at the first episode of visual acuity deterioration. The second patient was a 22 -year-old woman who suffered two OC apoplexy episodes from a recurrence, which also presented with bleeding. RESULTS: Both patients were operated on via pterional craniotomy and presented a postoperative improvement of visual symptoms. The second patient experienced deterioration 30 months after surgical resection due to rebleeding from a recurrence and required a second operation. Follow-up revealed a good recovery of visual disturbances; MRI at 6 and 3 years showed in both patients an apparent complete removal of the cavernous malformations. CONCLUSION: The cisternal environment where OC cavernous malformations develop and the paradigm of a compartment syndrome could explain the clinical presentation variability. This very rare subset of cavernomas would benefit from a classification system using ad hoc neuroimaging protocols and consistent indications.

Endoscopic Transorbital Approaches to Anterior and Middle Cranial Fossa: A Laboratory Investigation on Surgical Anatomy and Potential Routes.

Background Transorbital neuroendoscopic (TONES) approaches promise to open up new horizons for skull base surgery, offering alternative routes to reach the anterior and middle cranial fossa (ACF and MCF, respectively). Objective The aim of this anatomical study is to acquire new surgical anatomy knowledge and exploit it for the refinement of TONES approaches, as an alternative to open surgery, to reduce the distance to the target, and the risk of neurovascular lesions in pathological conditions extending beyond the orbital cavity. Materials and Methods Six head specimens (12 orbits) were studied/dissected. The orbit was approached and divided in a four clockwise quadrants manner to simulate three transconjunctival routes: the precaruncular (PC), preseptal (PS), and lateral retrocanthal (LRC), and one transpalpebral route-the superior eyelid crease (SLC). The boundaries and the most important anatomical landmarks were identified and are herein duly detailed with particular attention to the neurovascular structures encountered in each of those routes. Results The dissections showed that the PC approach facilitates the treatment of optic nerve and frontal sinus pathologies, whereas LRC appears safer to reach ACF and MCF allowing for a free multiplanar working channel (up to 180 degrees) to the floor, roof, and lateral-to-medial walls. Conclusion The plane of tendon lateral canthal's insertion and the sphenofrontal suture (SFS) were identified as the key anatomical landmarks for TONES approaches. Further studies are warranted to establish a practical clinical algorithm based on the anatomical four clockwise quadrants herein implemented/proposed, and the key surgical landmarks identified.

Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms.

BACKGROUND: There is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients. MATERIALS AND METHODS: A retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses. RESULTS: We identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5-18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5-9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003). CONCLUSION: There was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.

Surgical preference regarding different materials for custom-made allograft cranioplasty in patients with calvarial defects: Results from an internal audit covering the last 20 years.

BACKGROUND: Secondary cranioplasty (CP) plays a key role in restoring cranial vault anatomy and normal brain function following decompressive craniectomy (DC). The scientific literature provides only fragmentary information regarding the best timing and material for CP, making a direct comparison of different materials difficult. OBJECT: To identify and report according to STROBE guidelines local trends in choice of materials for CP, complications rate and surgical outcomes. METHODS: We conducted an audit on secondary CP covering the last 20 years of surgical practice at our Institution. Custom-made CP used over the years were made of: porous hydroxyapatite (PHA), polymetylmethacrylate (PMMA), polyetheretherketone (PEEK), acrylic and titanium. The primary endpoint of this study was the incidence of postoperative complications, such as: implant infection, fracture and dislocation. Secondary endpoints were the followings: patients satisfaction with cosmetic result, rate of implant integration, and long-term neurological outcome. RESULTS: A total of 218 patients were included, given the predominance of PHA (Group A) or PMMA (Group B) CP, a direct comparison was made only between those two groups. Overall reoperation rate was 6.5% versus 28%; implants' osseointegration rate was of 69% versus 24%; satisfaction rate was 66% versus 44%, in Group A and B respectively. CONCLUSIONS: This single-centre study provides Level 3 evidence that PHA yields better outcomes than PMMA CP. Designing a management algorithm for planning and executing CP is difficult for clinical and organizational reasons; till a widespread consensus is reached, neurosurgeons with subspecialty interest in neurotrauma should favor pragmatism and patient safety over costs.

Intracranial Metastases from Prostate Carcinoma: Classification, Management, and Prognostication.

BACKGROUND: Prostate carcinomas rarely metastasize to the central nervous system but, when they do, dural localizations are as common as and far more aggressive than intraparenchymal ones. Those metastases can be further classified according to their extension toward the subdural or extradural space and can frequently simulate other pathologic conditions including chronic subdural hematomas, abscess, and primary bone tumors. Beside the challenges of the preoperative differential diagnostic and complexity of surgical planning and operative excision, subdural metastases seem to carry a much poorer prognosis. METHODS: A series of consecutive patients admitted during a 12-year period through our oncall pathway for subdural/extradural collections or intraparenchymal lesions found, on histologic analysis, to represent intracranial prostate cancer metastases was retrospectively reviewed. RESULTS: A total of 19 patients were included, but only 3 were diagnosed with small cell prostate carcinoma, while the majority had a primary prostate adenocarcinoma. Metastases could be classified as pure subdural space lesions, dural-based lesions, extradural/bony lesions, and pure intraparenchymal lesions. All patients with subdural metastases and 3 out of 5 patients with dural-based lesions required an emergency intervention due to rapidly deteriorating neurologic status. The mean follow-up in our series was 37 months; only subdural localizations had a remarkably unfavorable outcome. CONCLUSIONS: Supported by our experience and the review of the literature, we suggest that a low threshold for contrast-enhanced computed tomography/magnetic resonance imaging is advisable in case of suspicious subdural collection, even in an emergency setting, for patients with previous medical history of prostate cancer.

Intracranial Solitary Fibrous Tumors: A Heterogeneous Entity with an Uncertain Clinical Behavior.

BACKGROUND: Intracranial solitary fibrous tumors (ISFTs) are rare mesenchymal neoplasms originating in the meninges and characterized by very different biologic and clinical behaviors. Benign histotypes, such as hemangiopericytomas, are now considered a cellular phenotypic variant of this heterogeneous group of rare spindle-cell tumors. Owing to their rarity and resemblance to other, more common brain tumors, ISFTs are often poorly recognized and remain a diagnostic challenge. METHODS: We describe a surgical series of 29 patients treated for ISFTs confirmed histologically and through immunohistochemistry. We attempt to provide a focus on the natural history of these pathologies and the need for tailored management. RESULTS: This was a retrospective consecutive series of 29 patients with either solitary fibrous tumor (n = 14) or hemangiopericytoma (n = 15) over a 10-year period. Mean follow-up time was 37.71 months. Recurrence rate was 42.9% for solitary fibrous tumors versus 26.7% for hemangiopericytomas. STAT6 expression was 66.7% in hemangiopericytomas versus 42.9% in SFTs. CONCLUSIONS: Histopathology and immunohistochemical staining (characterized by positive expression of mainly STAT6 but also CD34, Bcl-2 protein, and vimentin) are key in diagnosis and management of ISFTs. Although ISFTs are still considered benign lesions with very rare aggressive evolution, their clinical behavior is largely unpredictable. This study highlights the importance of relying on immunohistochemistry for a thorough definition of the management strategy.

Eight- to ten-year results of a variable geometry stem.

This prospective study was conducted on 108 consecutive implantations straight, cementless, taper-designed stem with variable lateral flare (Pegasus; DePuy, Warsaw, Indiana) at an 8- to 10-year follow-up; DEXA scanning was performed at 3 and 12 months on a second cohort of 40 patients. The mean Harris hip score was 94.2, and no revision was performed. Measurable subsidence of the stem was found in three (2.8%) patients; the subsidence was always measured within the first year of follow-up, and did not progress at the subsequent controls. Bone mineral density decreased at 1 year, 15.1% in zone 1 and 3.4% in zone 7. Uncemented stems with a taper design, which provide a high metaphyseal fit and a low diaphyseal fit, lead to comparable and reproducible long-term results independently from other design characteristics.

Oxidation and oxidation potential in contemporary packaging for polyethylene total joint replacement components.

The packaging and chemical stability of both conventional and highly crosslinked polyethylene (PE) components available for clinical use in Italy were analyzed. A total of 100 sterilized PE components were entered by 18 orthopedic manufacturers into the study. Six of the manufacturers were Italian and the remaining were based in Europe or America. Hydroperoxide, oxidation, and trans-vinylene levels within the PE components were characterized using Fourier-transform infrared spectroscopy (FTIR). None of the 31 gas-sterilized components had detectable free radicals, hydroperoxide content, or oxidation. Among radiation-sterilized inserts, the highest oxidation and hydroperoxide levels were associated with gas-permeable and polymer-barrier packaging. To the authors' knowledge, this is the first study that relates elevated oxidation and hydroperoxide content in gamma-sterilized PE components to certain types of contemporary, polymeric barrier packaging.

Hydatidosis of the pelvis: a case report with a 25-year follow-up.

INTRODUCTION: Hydatid disease involves mainly the liver (66% of the cases) and the lungs (22%), with skeletal involvement being reported in 0.5-2.5% of cases. CASE REPORT: Herein is reported a case of hydatidosis of the hip and pelvis with a follow-up of 25 years. The diagnosis was first done in April 1975 following the local excision of a single hydatid cyst from the ischium of a 25-year-old man complaining of increasing pain and swelling of the left thigh. Histology confirmed hydatid disease of the bone. Local excision was repeated four more times for recurrence of the hydatid cysts in the bone or soft tissues. Antiparasitic medical therapy (albendazole 10 mg/kg daily) was attempted in 1991 but suspended after 2 days due to systemic adverse effects (abdominal pain, diarrhea). The patient had a 12-year relapse-free period with complete absence of any symptoms. CONCLUSION: Such a long symptom-free period confirms that it is not possible to consider bone hydatidosis as being completely healed without the confirmation of a long term follow-up.