Cervical Spondylotic Myelopathy: From the World Federation of Neurosurgical Societies (WFNS) to the Italian Neurosurgical Society (SINch) Recommendations

Cervical spondylotic myelopathy (CSM) is a progressively growing pathology to afford by a spinal surgeon due to the aging of the population, associated with better treatment management and the best diagnosis and treatment solutions are greatly discussed. Nowadays that scientific literature is progressively increasing to identify the gold standard in diagnosis and treatment can be very challenging. This is particularly evident in spinal surgery with many different indications not only in different countries but also in the same local reality. In this scenario, many neurosurgical societies works to identify some guideline or recommendations to help spinal surgeons in daily practice. Furthermore, in an era in which legal issues are increasingly present in clinical practice to have some indications globally accepted can be very useful. World Federation of Neurosurgical Societies (WFNS) few years ago starts this process creating a list of recommendations originating from a worldwide steering committee to respect all the local reality. The spinal section of Italian Neurosurgical Society decides to adopt the WFNS recommendations with some revision basing on Italian scenario. The steering committee of the Spinal Section of Italian Neurosurgical Society identify 7 groups to review the literature of the last 10 years about different topics on CSM and to analyses the WFNS recommendations to adapt it to the Italian daily practice. The statements were discussed and voted in 2 sessions to obtain the final version. A list of recommendations on natural course and clinical presentation; diagnostic tests; conservative and surgical treatment; anterior, posterior and combined surgical treatment; role of neurophysiological monitoring and follow-up and outcome was created with only few new or revised statements respect the ones of WFNS. The Spine Section of Italian Neurosurgical Society create a list of recommendations that represent the more contemporary treatment concepts for CSM as presented in the highest quality clinical literature and best clinical practices available on this subject.

Single-Stage Posterior Transpedicular Corpectomy and 360-Degree Reconstruction for Thoracic and Lumbar Burst Fractures: Technical Nuances and Outcomes.

BACKGROUND: We evaluate the feasibility of a single-stage posterior corpectomy and circumferential arthrodesis with the aid of spinal navigation for the treatment of traumatic thoracolumbar burst fractures. METHODS: This was a single-center, retrospective study. Demographics, clinical, and radiologic data of 19 patients who underwent surgery at our institution for thoracolumbar burst fractures between 2016 and 2019 were collected. All patients enrolled in the present study underwent surgery by means of posterior fixation and transpedicular corpectomy with the aid of an intraoperative image-guided neuronavigation system. RESULTS: Postoperative correction of the vertebral height ratio was achieved in all cases, with an average increase of 23.6% (p = 0.0005). No statistical differences (p = 0.9) were found comparing 1- and 3-month postoperative CT scans, in relation to vertebral height ratio. A statistically significant difference was found between the pre- and postoperative kyphotic angles for the thoracolumbar and lumbar segments (p = 0.0018 and 0.005, respectively), but no difference was found between kyphotic angles at the 3-month follow-up. A unilateral approach was performed on 15 patients (79%), while 4 cases (21%) required a bilateral laminectomy. We did not observe any significant intraoperative complication. CONCLUSION: Single-stage posterior corpectomy and fixation is a safe and effective approach for thoracic and lumbar burst fractures. It provides excellent 360-degree reconstruction in a single surgical stage with satisfactory results in terms of kyphosis reduction, biomechanical stability, and reduced invasiveness. Spinal navigation represents a fundamental tool to overcome some anatomical limits of the presented technique.

Early Management of Spinal Cord Injury: WFNS Spine Committee Recommendations.

Scientific knowledge today is being generated more rapidly than we can assimilate thus requiring continuous review of gold-standards for diagnosis and treatment of specific pathologies. The aim of this paper is to provide an update on the best early management of spinal cord injury (SCI), in order to produce acceptable worldwide recommendations to standardize clinical practice as much as possible.The WFNS Spine Committee voted recommendations regarding management of SCI based on literature review of the last 10 years. The committee stated 9 recommendations on 3 main topics: (1) clinical assessment and classification of SCI; (2) emergency care and early management; (3) cardiopulmonary management. American Spinal Injury Association impairment scale, Spinal Cord Independence Measure, and International Spinal Cord Injury Basic Pain Data Set are considered the most useful and feasible in emergency evaluation and follow-up in case of SCI. Magnetic resonance imaging is the most indicated examination to evaluate patients with symptomatic SCI. In early phase, correction of hypotension (systolic blood pressure < 90 mmHg), and bradycardia are strongly recommended. Surgical decompression should be performed as soon as possible with the ideal surgical time being within 8 hours for both complete and incomplete lesions.

Preoperative Magnetic Resonance and Intraoperative Computed Tomography Fusion for Real-Time Neuronavigation in Intramedullary Lesion Surgery.

BACKGROUND: Image-guided surgery techniques in spinal surgery are usually based upon fluoroscopy or computed tomography (CT) scan, which allow for a real-time navigation of bony structures, though not of neural structures and soft tissue remains. OBJECTIVE: To verify the effectiveness and efficacy of a novel technique of imaging merging between preoperative magnetic resonance imaging (MRI) and intraoperative CT scan during removal of intramedullary lesions. METHODS: Ten consecutive patients were treated for intramedullary lesions using a navigation system aid. Preoperative contrast-enhanced MRI was merged in the navigation software, with an intraoperative CT acquisition, performed using the O-arm TM system (Medtronic Sofamor Danek, Minneapolis, Minnesota). Dosimetric and timing data were also acquired for each patient. RESULTS: The fusion process was achieved in all cases and was uneventful. The merged imaging information was useful in all cases for defining the exact area of laminectomy, dural opening, and the eventual extension of cordotomy, without requiring exposition corrections. The radiation dose for the patients was 0.78 mSv. Using the authors' protocol, it was possible to merge a preoperative MRI with navigation based on intraoperative CT scanning in all cases. Information gained with this technique was useful during the different surgical steps. However, there were some drawbacks, such as the merging process, which still remains partially manual. CONCLUSION: In this initial experience, MRI and CT merging and its feasibility were tested, and we appreciated its safety, precision, and ease.

Delayed otogenic pneumocephalus complicating ventriculoperitoneal shunt.

Tension pneumocephalus complicating ventriculoperitoneal shunt is extremely rare. We report an elderly male who developed delayed tension pneumocephalus 12 months after ventriculoperitoneal shunt for hydrocephalus complicating aneurysmal subarachnoid hemorrhage. Fine-cut reformatted computer tomography scan revealed a large pneumatocele on the petrous apex associated with tegmen tympani defect. The shunt valve pressure was temporarily raised from 120 mm H 2 O to 200 mm H 2 O, and the patient underwent successful subtemporal extradural repair of the bony defect in the temporal bone. Although extremely rare, otogenic tension pneumocephalus is a potentially life-threatening condition, and urgent surgical repair of the bony defect in the temporal bone reduces the risk of both the morbidity and mortality.