The "state of the art" of intraoperative neurophysiological monitoring: An Italian neurosurgical survey.

Introduction: Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question: The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods: A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results: A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions: The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.

Eagle syndrome: An updated review.

Background: This work aims to review the current literature and our experience on vascular Eagle syndrome (ES) that can present misleading clinical presentations and better understand the possible therapeutic strategies. Methods: We reviewed the existing literature on PubMed from January 1, 2017, to December 31, 2022, including the sequential keywords "vascular AND Eagle syndrome," "vascular AND styloid syndrome," "vascular AND elongated styloid process," "vascular AND stylocarotid syndrome," and "Eagle syndrome AND carotid artery dissection." Results: 38 vascular ES cases, including our experience, were analyzed. The most frequent clinical onset was hemiparesis (n 21, 57%), but other regular clinical presentations were aphasia, loss of consciousness, amaurosis, headache, or a combination of the latter. Massive oral bleeding was reported only once in the literature before our case. Twelve patients were treated with only antiplatelet therapy, either single or double. Nine patients were treated with anticoagulation therapy only. In 14 patients, a carotid artery stent was used, associated with anticoagulation or antiplatelet therapy. In 17 cases, a styloid process (SP) resection was performed. Conclusion: ES has many clinical presentations, and carotid artery dissection resulting in oral bleeding seems rare. Literature results and our experience make us believe that when dealing with vascular ES, the best treatment strategy is endovascular internal carotid artery stenting with antiplatelet therapy, followed by surgical removal of the elongated SP to prevent stent fracture.

Deep brain stimulation of the dentato-rubro-thalamic tract in a case of Holmes tremor: a constrained spherical deconvolution (CSD)-guided procedure.

Deep brain stimulation (DBS) is an established treatment for movement disorders, including Holmes tremor (HT). HT is a rest and action tremor that occurs as a late symptom of brainstem lesions such as stroke. Unfortunately, it is frequently refractory to medical treatment, hence DBS surgery may be a good option. Due to variable results, the ideal target for DBS in HT still remains to be established, ranging from the thalamus to the globus pallidus internus, to the subthalamic nucleus. Pre-operative imaging also is very challenging, as the complexity of brain fiber architecture may prevent the correct positioning of the directional lead. Herein, we describe the case of a patient affected by a rubral tremor secondary to a brain hemorrhage, who had advanced pre-operative neuroimaging with constrained spherical deconvolution (CSD)-based tractography obtained from diffusion-weighted imaging (DWI) to identify the dentato-rubro-thalamic tract, involved in the pathophysiology of HT. The patient was then addressed to an awake DBS surgery, and with the help of intraoperative microelectrode recordings, a tailored DRTT-targeted procedure was performed. The stimulation determined an almost complete tremor suppression, with no significant side effects at a follow-up of 6 months, paving the way towards new effective techniques for the planning, i.e., CSD-based tractography and the treatment of refractory tremors.

Modified percutaneous biopsy of the spine: improvement of the technique.

PURPOSE: Biopsy of the spine can be performed by open surgery or percutaneous needle sampling. The first has the highest diagnostic yield while the second is a less invasive procedure with lower rate of complications and shorter hospitalization time. We described a modified technique of percutaneous biopsy using semi-rigid grasping forceps that may offer the advantages of both, open and minimally invasive surgery. METHODS: Thirty consecutive patients with spinal lesions requiring biopsy were admitted to Neurosurgical Unit of Belcolle Hospital (Viterbo, Italy) from January 2017 to September 2021. There was a suspicion of spondylodiscitis in 25 cases and of tumor in 5 cases. Percutanous trans-pedicular spine biopsy has been performed using this new semi-rigid grasping forceps. Combining the opening width, jaw length and full 360° rotation, the device allows a wide and precise sampling. RESULTS: Sampling was sufficient in all cases (100%); tumors was observed in 5 cases (16.7%%) with a percentage of definitive histopathologic diagnosis of 100% (n = 5); among the remaining patients histological examination yielded a diagnosis of spinal infection in 25 cases (100%), and microbiologic culture provided an aetiologic diagnosis in 23 cases (92%). All procedures were well tolerated, and no postoperative complications were observed. Levels involved included: thoracic (T5-T9) in 8 cases, thoracolumbar junction (T10-L2) in 12 cases and lumbar (L3-L5) in 10 cases. CONCLUSIONS: Percutaneous biopsy with the semi-rigid grasping forceps is a safe and effective procedure that can be used for diagnosis of both infectious and tumor lesions of the spine. It allows to obtain a larger specimen volume and to use a multidirectional trajectory for sampling, resulting in a minimally invasive technique with strong ability to yield etiologic diagnosis.

Deep brain stimulation for Parkinson's disease in practice: results of the survey by the Italian Neurosurgery Society.

BACKGROUND: Deep brain stimulation (DBS) is a safe and effective treatment for patients with advanced Parkinson's disease (PD) and many neurosurgical centers in Italy have a DBS program. Considering the prevalence of PD and criteria for DBS implantation, about 3200-10,350 PD patients may benefit from DBS in Italy. The global management of patients underwent DBS is complex and it can be supposed that many differences exist between centers in clinical practice. The Italian Neurosurgery Society (SINch) designed this survey to investigate the state of the art of DBS for PD in Italy. METHODS: A 26-item closed-ended question survey was designed and sanded by email at all Italian Neurosurgery centers. The main topic investigated was DBS teams, anatomical target selection, surgical procedure, neuroimaging, intraoperative target localization, DBS device and patients' follow-up. RESULTS: A total of 23 neurosurgery centers completed the survey. There are mainly low-to medium-volume centers (<20 annual DBS procedures) with dedicated DBS teams. The principal anatomical target used is subthalamic nucleus (STN) and, relative to the surgical technique, it emerges that in Italy DBS are bilaterally implanted in a single-step session with awake anesthesia and with frame-based technique. Final leads positioning is defined by microelectrode recordings (MER) and microstimulation (MS), with limited role of intraoperative neuroimaging (MRI and O-Arm). The stimulation is started at 15 or 30 days from procedure. CONCLUSIONS: Many centers of neurosurgery in Italy have a well-established DBS program for patients with advanced PD and some practical differences in technique between centers exist. Further investigation is needed to investigate specific criteria for selecting one technique over another.

Clinical Effects of Posterior Longitudinal Ligament Removal and Wide Anterior Cervical Corpectomy for Spondylosis.

BACKGROUND: Removing the posterior longitudinal ligament in cervical corpectomy is a controversial issue. It is unclear whether the risks are counterbalanced by clinical benefits. Another unexplored topic is whether the width of the corpectomy affects outcome. METHODS: This cross-sectional retrospective study included consecutive patients who underwent cervical corpectomy for spondylosis by 6 different neurosurgeons. We compared 2 groups, where the posterior longitudinal ligament was either removed (N = 15 patients) or preserved (N = 21 patients). The posterior width of the corpectomy was assessed postoperatively with computed tomography and magnetic resonance imaging. Clinical results were evaluated with the visual analog scale (VAS), Modified Japanese Orthopedic Association scale (MJOAS), Cooper scale, and neck disability index (NDI), in the long-term follow-up. RESULTS: Compared to preservation, removal of the posterior longitudinal ligament produced more favorable clinical results (but not statistically significant), based on the VAS (+41%, P = 0.48), MJOAS (+26.5%, P = 0.62), Cooper scale (+19%, P = 0.75), and NDI (+62%, P = 0.22). Magnetic resonance imagings showed that removing the posterior longitudinal ligament produced greater evagination of the dural sac into the space left by the corpectomy. Improvements in clinical outcome were associated with more posterior bone wall removal in the corpectomy (corpectomy width ≥15.6 mm; P < 0.05), based on the VAS, NDI, and MJOAS. CONCLUSIONS: Removing the posterior longitudinal ligament in cervical corpectomy may produce a better outcome, particularly when associated with more posterior bone wall removal in the corpectomy.

The effect of case-based discussion of topics with experts on learners' opinions: implications for spinal education and training.

PURPOSE: This investigation aimed to examine the extent to which case-based discussion with experts could influence the audience's opinions on the treatment of patients during a continuing medical education event for spine surgeons. METHODS: We conducted a prospective controlled crossover study of 90 surgeons. During a continuing medical education activity using case-based discussion, quiz questions were used which asked participants (attendants and faculty group) their opinions on the best choices about diagnosis and treatment in a number of cases. No answer was considered correct, but we evaluated the number of participants choosing each specific answer among a number of valid options. Quiz questions were collected with an automated response system at the entry and at the end of each case discussion. Change in participant's opinions was estimated from the change in the preferred answers between the entry and exit quizzes. Chi-square analysis was performed to determine significance. RESULTS: Sixty-two attendants out of eighty three (75%) and six faculties out of twelve (50%) responded to the survey. After the case discussion, 68.2% (p < 0.04, Chi-square test) of the attendants changed their opinion on the appropriate treatment. The faculty answers, however, showed no significant change in opinions regarding the identification of the appropriate treatment. CONCLUSIONS: On the basis of our results, case-based discussion driven by experts, as a form of teaching, has a measurable effect in terms of changes in the learners' opinions.

Lumbar ganglion cyst: Nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review.

AIM: To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one. METHODS: We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability. RESULTS: The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring. CONCLUSION: Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms "ganglion cyst" to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.

Acute Spinal Epidural Hematoma After Acupuncture: Personal Case and Literature Review.

BACKGROUND: Spinal acupuncture is a relatively safe and common analgesic treatment, but it may be complicated by serious adverse effects, such as direct spinal cord and nerve root injury, subdural empyema, and epidural abscesses. In this report we compare our case of an extremely uncommon spinal epidural hematoma, which appeared after treatment by acupuncture, with other similar documented cases. CASE DESCRIPTION: This is the case of a 64-year-old man who presented a left hemiparesis associated with paraesthesia. This appeared several hours after acupuncture treatment for left lumbosciatic pain. The cervicothoracic spine magnetic resonance imaging (MRI) scan showed a cervicothoracic spinal epidural hematoma from C2 to T12. The rapid improvement of the patient's neurologic symptoms justified the adoption of a conservative treatment strategy. This gave excellent long-term results. CONCLUSIONS: Although a post-acupuncture spinal epidural hematoma (paSEH) is very rare, there are only 6 documented cases, it is a possible complication from acupuncture on the back. The use of very thin needles can produce bleeding, probably venous, in the epidural space. In general, this evolves more slowly than other kinds of epidural hematomas. The symptoms are also less severe, warranting less frequent surgical intervention, and in general there is a good outcome. The possibility of hematoma makes acupuncture contraindicated in patients who have coagulation disorders. The onset of severe spinal pain after spinal or paraspinal acupuncture treatment should lead to the suspicion of a paSEH, and a spinal MRI should be carried out.

The effect of case-based discussion of topics with experts on learners' opinions: implications for spinal education and training.

PURPOSE: This investigation aimed to examine the extent to which case-based discussion with experts could influence the audience's opinions on the treatment of patients during a continuing medical education event for spine surgeons. METHODS: We conducted a prospective controlled crossover study of 90 surgeons. During a continuing medical education activity using case-based discussion, quiz questions were used which asked participants (attendants and faculty group) their opinions on the best choices about diagnosis and treatment in a number of cases. No answer was considered correct, but we evaluated the number of participants choosing each specific answer among a number of valid options. Quiz questions were collected with an automated response system at the entry and at the end of each case discussion. Change in participant's opinions was estimated from the change in the preferred answers between the entry and exit quizzes. Chi-square analysis was performed to determine significance. RESULTS: Sixty-two attendants out of eighty three (75%) and six faculties out of twelve (50%) responded to the survey. After the case discussion, 68.2% (p < 0.04, Chi-square test) of the attendants changed their opinion on the appropriate treatment. The faculty answers, however, showed no significant change in opinions regarding the identification of the appropriate treatment. CONCLUSIONS: On the basis of our results, case-based discussion driven by experts, as a form of teaching, has a measurable effect in terms of changes in the learners' opinions.

Autologous Skull Bone Flap Sterilization After Decompressive Craniectomy: An Update.

OBJECTIVE: To report new results with ethylene oxide sterilization and new experiences with autogenous bone flaps autoclaved at a high or low temperature for preservation of a bone flap after decompressive craniectomy. METHODS: In 45 patients who underwent a decompressive craniectomy, we determined bone flap preservation with ethylene oxide and with high- or low-temperature autoclave sterilization. RESULTS: The bone flap was repositioned after a mean of 10 weeks in the ethylene oxide group and after 6 weeks in the other sterilization groups. A bone flap infection developed in 1 patient (2%), which required removal and subsequent methyl methacrylate cranioplasty. In 1 child, the bone flap had partially reabsorbed after 12 months. In all other patients, esthetic results were good after an average follow-up of 42 months. At follow-up, computed tomography or magnetic resonance imaging of the bone flap showed preservation of structural features with apparent fusion and revitalization at the bone flap margins. CONCLUSIONS: Ethylene oxide and high- or low-temperature autoclave bone sterilization techniques for the preservation of autologous bone flaps after decompressive craniectomy were safe, rapid, and inexpensive.

Clinical remarks on acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients.

OBJECTIVE: This study aimed to identify specific findings related to acute post-traumatic atlanto-axial rotatory subluxation in pediatric patients. METHODS: We studied 14 children with acute atlanto-axial rotatory subluxations after a craniocervical injury admitted to a hospital during a 6-year period. Clinical and radiologic findings were reviewed to identify new findings related to atlanto-axial rotatory subluxation. RESULTS: Most patients exhibited a typical picture of atlanto-axial rotatory subluxation, but 1 child also experienced transient blindness that was related to peculiar anatomic findings on neuroradiologic images. A characteristic C2-C3 anterior pseudosubluxation was detected among the radiographic signs. Magnetic resonance imaging showed no clear break in the alar ligaments, which were oriented horizontally. However, unlike the case in adult anatomy, in these children, the alar ligaments were laterally attached at the occipital condyle-axis condylar joints. In all children, atlanto-axial rotatory subluxation spontaneously reduced within a few hours after short bed rest without halter traction but with a cervical collar. No recurrence was observed during follow-up. CONCLUSIONS: Acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients is a rapidly resolving disease of the craniocervical junction. The disease appears to be related to an elasticity of the contralateral alar ligament, which is attached to the occipital condyle-axis condylar joint. Neurological symptoms (blindness) occurred in 1 patient when the vertebrobasilar blood flow was impaired and no compensation was provided from the anterior circulation. Use of a cervical collar and short bed rest without halter traction is recommended, based on our observations of complete recovery and no recurrence after the use of this treatment strategy.

Multilevel oblique corpectomies as an effective surgical option to treat cervical chordoma in a young girl.

Chordomas are malignant tumors arising from notochordal remnants. They are the most frequent tumors of the spine after plasmacytomas. Only 6% of chordomas are localized to the cervical level. In young patients, chordomas are rare and unpredictable. Despite this, the treatment of choice remains the total resection, as much as possible, followed by proton beam radiation. This case was managed using a precarotid and retrocarotid approach at the same time. The tumor was completely resected with the edges free from disease. The cervical spine was stabilized with an anterior plating C2-C4. Eighteen months after surgery the patient is still free from illness. Multilevel oblique corpectomies are an available and safe option for the treatment of upper cervical chordomas.

Cervical congenital spondylolytic spondylolisthesis associated with duplication of the vertebral artery: case report.

BACKGROUND CONTEXT: Cervical bilateral congenital spondylolysis with spondylolisthesis is an abnormality both of congenital and mechanical origin, characterized by its primary feature, cervical bilateral spondylolysis. We are unaware of any reports describing cervical congenital spondylolytic spondylolisthesis associated with duplication of the vertebral artery. PURPOSE: To report the case of a patient affected with cervical bilateral congenital spondylolysis with spondylolisthesis associated with duplication of the vertebral artery. STUDY DESIGN: A unique case report from a university hospital and a literature review. PATIENT SAMPLE: An 18-year-old man who arrived at the emergency department complaining of neck pain starting from a car accident 5 days ago. METHODS: Neurologic examination and images taken by ordinary radiographs, magnetic resonance imaging (MRI) scans, ordinary computed tomography (CT) scans, and CT angiograms with three-dimensional (3D) reconstruction. RESULTS: Neurologic examination did not find evidence of strength deficit in upper extremities. Ordinary radiographs of the cervical spine showed spondylolisthesis of C6 and C7 and a cortical cleft between the superior and inferior articular facets of the C6 vertebra and spina bifida of the C6 and C2 vertebrae and an abnormal appearance of the remnant spinous processes of the cervical vertebrae. Magnetic resonance imaging confirmed the abnormalities that had been noted on the radiographs. Computed tomography scans of the cervical spine showed congenital spondylolytic spondylolisthesis and spina bifida of the C6 vertebra and duplication of the vertebral artery. They also showed double origins of the vertebral artery depicted by 3D angiographic reconstruction. Conservative treatment of wearing a cervical collar and receiving muscle relaxants and anti-inflammatory drugs was effective. With the pain completely subsided, the patient was discharged 5 days after arriving at the emergency department. CONCLUSIONS: Vascular abnormalities should be suspected and investigated in cases of congenital spondylolysis or spondylolytic spondylolisthesis. We strongly suggest performing angio-CT or angio-MRI and 3D reconstruction in these cases. Awareness of the presence of a duplicated vertebral artery and the course of its limbs could significantly help planning in cases proceeding to surgery.

Abdominal aortic rupture and spondylodiscitis: emergent EVAR and staged spinal fixation.

Concomitant aortic aneurismal pathology and vertebral erosion are seldom reported in literature. The differential diagnosis between a primary vertebral disease affecting the aortic wall and a primary aortic pathology causing a vertebral disruption is quite difficult. We report on a patient presenting with increasing lumbar pain and neurologic lower limbs deficit due to a vertebral erosion accompanied by aortic rupture treated by emergent endovascular aortic repair procedure and then staged vertebral fixation. Microbiological tests on intraoperative periaortic fluid collection samples showed no clear sign of infection and clinical conditions progressively improved. At 12-month follow-up, the patient is in good clinical condition, with a small residual walking impairment and no clinical, laboratory, or imaging sign of aortic endograft infection.

Twelfth nerve paresis induced by an unusual posterior fossa arachnoid cyst: case report and literature review.

There are only three cases of arachnoid cysts inducing twelfth nerve paresis described in English medical literature. We herein report one more instance. Six weeks after surgery, the patient has almost fully recovered. This case underlines the importance of considering the arachnoid cyst as a possible cause of twelfth nerve paresis.

Anterior surgical approaches to the cervicothoracic junction: when to use the manubriotomy?

BACKGROUND CONTEXT: The cervicothoracic junction (CTJ) is always a difficult area for anterior approaches. Among them, low anterior cervical approach alone or combined with manubriotomy is the most frequently used. PURPOSE: To study the need of manubriotomy. STUDY DESIGN/SETTING: Comparison of last guidelines proposed in literature. PATIENT SAMPLE: Seven patients treated between March 2010 and March 2011. METHODS: All the patients were scanned on with computed tomography and magnetic resonance of the spinal column before surgery. Measurements by Teng and Karikari were applied in all the cases. An illustrative case is showed. RESULTS: The anterior approaches to the CTJ are reviewed. The most recent guidelines by Teng and Karikari are easy to apply and careful. The results obtained were the same in all the cases with good outcome. CONCLUSIONS: Manubriotomy permits a good exposure of the CTJ area with a low rate of complications. Either Teng and Karikari's guidelines can be used to estabilish the need of manubriotomy.

Basal ganglia stroke due to mild head trauma in pediatric age - clinical and therapeutic management: a case report and 10 year literature review.

Ischemia of the basal ganglia as an immediate consequence of minor head injury in children is rare (< 2% of all ischemic stroke in childhood) and is due to vasospasm of the lenticulostriate arteries. The clinical history of these lesions is particularly favourable because they are usually small, and also because the facial-brachial-crural hemiparesis typical of this pathology usually regresses after a period ranging from several weeks to several months, despite the persistence of an ischemic area on MRI. This is due to the well known neuronal plasticity of the CNS, in particular, of the primary motor cortex. The most effective therapeutic approach appears to be the conservative one, although the best treatment regimen is still not well defined.Young patients should be closely monitored and treated conservatively with osmotic diuretics to reduce perilesional edema. At the same time, however, it is very important to exclude, by means of instrumental and laboratory studies, conditions that could favour the onset of ischemia, including emboligen heart disease, thrombophilia and acute traumatic arterial dissections. Generally speaking, the prognosis in these cases is good. The authors describe their experience treating a 10-month old baby girl, with a left lenticular nucleus ischemia and report a literature review.