Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery.

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.

Rapid spontaneous resolution of lumbar ganglion cysts: A case report.

BACKGROUND: To discuss the rare event of spontaneous resolution of a lumbar ganglion cyst, a personal case report and 25 cases culled from the literature were described in detail. We focused on demographic, classification, clinical and radiological findings, treatment, outcome and radiological resolution. CASE SUMMARY: A 51-year-old man presented to our observation with complaints of low back and right leg pain. Lumbar magnetic resonance imaging (MRI). showed a L4-L5 ganglion cyst. The patient was referred to medical therapy and bracing. After 4 wk, he showed a complete resolution of pain. The complete spontaneous resolution of the cyst was demonstrated by the followed-up MRI. CONCLUSION: Spontaneous resolution of lumbar ganglion is very rare and only 26 cases, including ours, were reported in literature. Different degrees of biomechanical impairment seem to play a fundamental role in the pathogenesis. Related symptoms are essentially represented by low back and/or radicular pain, without significant neurological disorders. Anti-inflammatory drugs, light unloading exercises and brace could be recommended to administrated pain and decrease facet loads. Mean time for clinical improvement was 7 mo, while MRI disappearance occurred in an average time of 11 mo. Therefore, surgery should be applied when conservative treatment, prolonged at least 6 mo, fails.

Arachnoid cyst in young soccer players complicated by chronic subdural hematoma: personal experience and review of the literature.

Arachnoid cysts (ACs) are congenital intracranial benign cavities originating from the meninges during embryological development. Several studies have shown the existence of a relationship between AC and a higher risk to develop ipsilateral chronic subdural hematoma (CSH) especially in a young population. In the presence of an AC, the practice of sport activities may expose young patients to minor head trauma and to an increased risk of developing CSH. We describe three cases of young soccer players with AC associated with CSH. Then, we performed a literature review of all the reported cases in the literature of patients younger than 18 years with AC-associated CSH related to sport practice. A total of 33 cases, including the three cases reported by us, are analyzed. Soccer is the most represented sport activity in this association (39% of cases). The treatment of choice is surgical in all patients, with burr hole or craniotomy in similar proportions. In one-third of patients, the AC has been fenestrated. Outcome is good in all the reported cases. We reviewed the main pathogenic theories, the main surgical strategies described in literature, as well as recurrence rate of CSH, the association of AC and cranial deformities, and the clinical outcome. AC might be associated with skull deformities, but their real incidence remains unclear. The clinical detection of such anomalies should suggest performing further radiological investigations. If the presence of AC is confirmed, the practice of sport activities should not be avoided, as the real incidence of AC-associated CSH is not clear yet and the reported outcomes in literature are good. Surgical treatment of AC-associated CSH should be hematoma removal through burr hole, reserving AC fenestration only for cases with intracystic bleeding or recurrences. The surgeon should adequately advise and inform the young patients and their families that they could have an increased risk of developing CSH given by the presence of the AC, and that they should be referred to a neurosurgical center if they become symptomatic.

Traumatic Sacral Fractures: Navigation Technique in Instrumented Stabilization.

BACKGROUND: Sacral fractures are a challenge regarding treatment and classification. Surgical techniques using spinal navigation systems can improve treatment, especially if used in collaboration among different specialists. METHODS: Between 2015 and 2017, we treated 25 consecutive cases of sacral fracture. Twelve patients (48%) underwent mechanical ventilation due to hypovolemic shock for severe thoracoabdominal trauma; bleeding was blocked with pelvic packing in 9 cases (36%) and transcatheter embolization in 2 cases (8%). External fixation was used in 7 cases (28%). In 20 cases (80%) spinal fractures were associated. All patients were operated on using spinal navigation by a team of neurosurgeons and orthopedic surgeons. RESULTS: The mean time from first observation to surgery was 18 days (range 8-31). Surgical treatment consisted of iliosacral fixation in 19 cases (76%) and spinopelvic fixation in 6 cases (24%). The mean number of screws for spinopelvic fixation was 9.67 (range 6-17) with a mean operation time of 323.67 minutes (range 247-471); in iliosacral osteosynthesis the mean screw number was 1.37 (range 1-3) and mean surgical time was 78.93 minutes (range 61-130). Postoperative computed tomography showed the correct screw placement. Wound infection occurred in 2 cases (8%), managed with vacuum-assisted closure therapy; in 1 case (4%) a sacral screw was removed for decubitus. CONCLUSIONS: Navigation systems in instrumented spinopelvic and sacropelvic reconstruction provide greater safety, reducing learning times and malpositioning. Multidisciplinary management allows us to achieve optimal results, especially when the sacral fracture is combined with spinal and pelvic lesions. The use of navigation systems could represent an important advancement.

Massive intracranial bleeding due to the rupture of a rare spontaneous pseudoaneurysm of the middle cerebral artery in a pediatric patient: case report with clinical, radiological, and pathologic findings.

Intracranial pseudoaneurysm (IPA) is a rare but likely underdiagnosed cause of intracranial hemorrhage, which accounts for just 1-6% of all intracranial aneurysms. Spontaneous IPAs are exceptionally rare, and their etiology and features are not well defined. Herein, we report a case of a pediatric patient who died from massive intracranial bleeding due to the rupture of a spontaneous IPA after undergoing multiple radiological studies and neurosurgical operations. At the postmortem examination of the brain, a giant size pseudoaneurysm of the right middle cerebral artery was observed. Microscopic examination demonstrated variable wall thickness and dense fibrosis focally in the vessel wall with disruption of the media structure together with a loss and fragmentation of the elastic laminae, loss of organization of smooth muscle cells in the media, and multifocal areas of hemorrhage throughout the vessel wall, as well as direct evidence of wall dissection. Since IPAs without any traumatic or infective history are extremely uncommon, further pathologic studies should be performed to clarify spontaneous pseudoaneurysm etiology.

Multidisciplinary management of spontaneous spinal infections: is there a correlation between timing, type of treatment and outcome?

BACKGROUND: Spontaneous spinal infections (SSIs) represent a rare and serious pathological entity. We tried to study a correlation between type of treatment, timing of treatment and clinical outcome through a multivariate analysis of an observational cohort study with the aim to define what is the optimal clinico-therapeutic management. METHODS: We performed a retrospective observational cohort study on all consecutive patients observed in our Institute in a period of 13 years; from 2001 to 2014 we enrolled 50 consecutive patients with symptomatic spontaneous spinal infections (no previous surgery or recent infection in other site), confirmed with diagnostic imaging. The inclusion parameters were: diagnostic imaging, signs and symptoms positive for SSI, no history of recent infection or surgery. Of each parameter analyzed, we calculated mean and standard deviation and when necessary correlation (ρ), covariance (σ) and relation coefficient between type of treatment, timing of treatment and clinical outcome. RESULTS: Our results suggest that an increase of one day from the onset of symptoms and the start of therapy leads to an increase in the Oswestry Disability Index Scale both at 6 months than at 1 year, with a statistical relevance, so our experience shows a statistically significant correlation and a positive co-variance between timing and outcome at 6 months and 1 year. CONCLUSIONS: SSI are rare, very difficult to diagnose and represent a significant clinical problem. If not properly managed, they may lead to significant impact in the quality of life. The most relevant problem is not the treatment, conservative or surgical, but early diagnosis, so a careful physical, laboratory and imaging examination is fundamental, with an important help provided by isolation of the pathogen and histology. In our experience early diagnosis has a fundamental role. In the light of this, current treatment protocols may require a prompt and multidisciplinary management including infectivologists, neuroradiologists and spine surgeons.

Development of a delayed acute epidural hematoma following contralateral epidural hematoma evacuation: case report and review of literature.

The formation of a post-traumatic delayed epidural hematoma (DEDH) is a rare but well-described complication in the literature. It is defined as an extradural bleeding not evident at the first computed tomography (CT) scan performed after trauma, but evidenced by further radiological evaluations. The most supported hypothesis about the mechanism responsible for the formation of a DEDH concerns above all the loss of a tamponade effect given by the reduction of intracranial pressure with medical or surgical treatment. A 30-year-old man was admitted to the emergency department with an epidural hematoma (EDH) associated with a linear calvarial bitemporal coronal fracture. A few hours after the surgical procedure for hematoma evacuation, the patient developed a DEDH contralateral to the site of surgical procedure. The literature review identified other 27 analogue cases. The presence of a calvarial fracture contralateral to the site of a craniotomy and the intraoperative brain swelling during EDH removal are suspicious for the development of DEDH. A CT scan has to be urgently performed in this situation. The timing of postoperative radiological examinations after EDH removal has to consider possible complications and has to be balanced on the basis of patient's clinical condition and neuroradiological data, such as skull fractures or intraoperative anomalies. The development of a DEDH after the surgical removal of an EDH is a rare event, characterized by a high mortality rate. DEDH develops preferentially on the contralateral side and with a concomitant skull fracture.

Total en-bloc spondylectomy through a posterior approach: technique and surgical outcome in thoracic metastases.

BACKGROUND: In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient's survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics. METHOD: Herein, we report the patient's selection and technique to execute the TES for cases of thoracic metastasis. CONCLUSION: This surgery is technically demanding so the patient's selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor's progression is "limited" by local barriers as demonstrated by histological studies.

Thoraco-lumbar fractures with blunt traumatic aortic injury in adult patients: correlations and management.

PURPOSE: Traumatic thoraco-lumbar spine fracture spine with a concomitant blunt aortic injury is uncommon but potentially a fatal association. Our aim was to clarify: morphology of spinal fractures related to vascular damages and vice versa, diagnostic procedures and decision-making process for the best treatment options for spine and vessels. METHODS: We enrolled 42 cases culled from the literature and five personal ones, reviewing in detail by AO Spine Classification, Society of Vascular Surgery classification and Abbreviated Injury Scale for neurological evaluation. RESULTS: Most fractures were at T11-L2 (29 cases; 62%) and type C (17; 70%). 17 (38%) were neurological. Most common vascular damage was the rupture (20; 43%), followed by intimal tear (13; 28%) and pseudoaneurysm (9; 19%). Vascular injury often required open or endovascular repair before spinal fixation. Distraction developed aortic intimal damage until rupture, while flexion-distraction lumbar artery pseudoaneurysm and rotation-torsion full laceration of collateral branches. CT and angio-CT were investigations of choice, followed by angiography. Neurological condition remained unchanged in 28 cases (90%). Overall mortality was 30%, but it was higher in AIS A. CONCLUSION: Relationship between thoraco-lumbar fracture and vascular lesion is rare, but potentially fatal. Comprehension of spinal biomechanics and vascular damages could be crucial to avoid poor results or decrease mortality. Frequently, traction of the aorta and its vessels is realized by C-dislocated fractures. CT and angio-CT are recommended. Spine stabilization should always follow the vascular repair. Early severe deficits worse the prognosis related to neurological recovery and survival. These slides can be retrieved under Electronic Supplementary Material.

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.

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.

Intradural angiomatous meningioma arising from a thoracic nerve root.

BACKGROUND: Spinal intradural meningiomas that arise purely from a nerve root without dural attachments are extremely rare. Spinal meningiomas arise from arachnoidal cap cells in the spinal canal, and growth of these tumors exerts pressure on the spinal cord and nerve roots. CASE DESCRIPTION: A patient presented with a lesion at the T3-T4 level that resembled a schwannoma on magnetic resonance imaging. During surgery, the tumor originated from a spinal nerve root. Pathologically, it was an angiomatous meningioma (AM). CONCLUSIONS: In a review of the literature, we discuss the pathogenesis and surgical strategy for diagnosing and treating these extremely rare AM lesions.

Post traumatic dural sinus thrombosis following epidural hematoma: Literature review and case report.

Dural sinus thrombosis following a head trauma is a rare condition, described in literature along with the lack of consensus regarding diagnosis and management. We present a case of a fifty-year-old man with a head injury and combined supratentorial-subtentorial epidural hematoma who was treated conservatively through the administration of low molecular weight heparin. The diagnosis and management of this condition are discussed based on a literature review. The early diagnosis may prevent potentially treatable poor outcomes.

Spinal epidural hematomas: personal experience and literature review of more than 1000 cases.

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patient's clinical and neurological status at admission, age, and the craniocaudal site.

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.

Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Remarks on 173 Cases.

BACKGROUND: Spinal meningiomas are common spinal tumors, in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring a less favorable prognosis. OBJECTIVE: To correlate these data with clinical/functional outcome. METHODS: Two hundred twenty-four consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these, 51 were excluded for incomplete clinical data or follow-up. The remaining 173 cases were classified in regards to sex, age, symptoms, axial location, Simpson grade resection, and functional pre-/postoperative status. RESULTS: Most recurring onset symptoms were pain (32.9%) and motor deficit (31.8%); thoracic spine was the most severely affected (69.8%). Functional improvement on the follow-up was observed in 86.7% of cases; 6.4% of patients resulted stable and 6.9% worsened. A low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grades I and II) was conducted in 98.8%, and a macroscopically complete removal without dural resection or coagulation (Simpson grade III) was performed in 1.2%. Of the meningiomas, 98.3% were classified as WHO grade I. Recurrence rate was 2.3%, and 7 cases presented complications (4 of 7 required surgical procedure). CONCLUSION: We can affirm that negative prognostic factors in our study were anterior or anterolateral axial location, prolonged presentation before diagnosis, WHO grade >I, Simpson grade resections II and III, sphincter involvement, and worse functional grade at onset.