Imaging characterization of an adult H3 K27M-altered diffuse midline glioma of the medulla oblongata with a confounding steroid response.

We report an uncommon, infratentorial localization of adult H3 K27M-altered diffuse midline glioma arising in a particularly rare site (medulla oblongata). In addition to this unusual presentation, the lesion exhibited a substantial contrast enhancement and size decrease after dexamethasone, generating diagnostic dilemmas. Histology, molecular details, advanced Magnetic Resonance imaging features and differential diagnoses are here described and discussed, as well as common misconceptions about steroid-sensitive mass lesions, and practical difficulties for clinicians involved in the process of making diagnosis.

How I do it: posterior transdural approach for central soft thoracic disk herniation.

BACKGROUND: Thoracic disc herniation (TDH) is a rare condition with severe neurological sequelae. Surgical management is still a matter of debate and challenging. METHOD: We present a modification of the transdural approach for TDH. The approach has been described in a stepwise fashion, analysing pre-, peri-, and postoperative strategies to improve patients' management and reduce approach-related morbidity. CONCLUSION: The modified posterior transdural approach represents an effective technique for TDH, minimizing the risk of spinal cord damages, which can dramatically affect the outcome.

Efficacy of virtual reality to reduce chronic low back pain: Proof-of-concept of a non-pharmacological approach on pain, quality of life, neuropsychological and functional outcome.

OBJECTIVES: Chronic pain, such as low-back pain, can be a highly disabling condition degrading people's quality of life (QoL). Not every patient responds to pharmacological therapies, thus alternative treatments have to be developed. The chronicity of pain can lead to a somatic dysperception, meaning a mismatch between patients' own body perception and its actual physical state. Since clinical evaluation of pain relies on patients' subjective reports, a body image disruption can be associated with an incorrect pain rating inducing incorrect treatment and a possible risk of drug abuse. Our aim was to reduce chronic low-back pain through a multimodal neurorehabilitative strategy using innovative technologies to help patients regain a correct body image. METHODS: Twenty patients with chronic low-back pain were included. Before and after treatment, patients underwent: a neurological exam; a neuro-psychological evaluation testing cognitive functions (memory, attention, executive functions) and personality traits, QoL and mood; pain ratings; sensorimotor functional abilities' testing. Patients underwent a 6 week-neurorehabilitative treatment (total 12 sessions) using virtual reality (VRRS system, Khymeia, Italy). Treatment consisted on teaching patients to execute correct movements with the painful body parts to regain a correct body image, based on the augmented multisensory feedback (auditory, visual) provided by the VRRS. RESULTS: Our data showed significant reductions in all pain rating scale scores (p<0.05); significant improvements of QoL in the domains of physical functioning, physical role functioning, bodily pain, vitality, and social role functioning; improvements in cognitive functions (p<0.05); improvements in functional scales (p<0.05) and mood (p = 0.04). CONCLUSION: This non-pharmacological approach was able to act on the multi-dimensional aspects of pain and improved patients' QoL, pain intensity, mood and patient's functional abilities.

Lumbar plexus nervous distortion in XLIF® approach: an anatomic study.

PURPOSE: XLIF ® is a widely used minimally invasive technique to treat different spine pathologies. The aim of this study was to quantify nerve distortion of lumbar plexus during XLIF ® approach and to correlate it with morphometric data. METHODS: Nine fresh frozen cadaveric specimens were used. All specimens were subjected to the same dissection procedure cored on a left XLIF® approach at L2/L3 and L4/L5 levels. Distortion of cutaneous superficial nerves, femoral nerve (FN) at L4/L5 and genitofemoral nerve (GN) at L2/L3 and L4/L5 while opening the retractor were assessed and analyzed with respect to psoas muscle features. RESULTS: Superficial nerves were slightly displaced but never stretched. FN, as well as GN at L4/L5 level, could be displaced and stretched by the blades. Statistically significant correlation between FN distortion and the amount of psoas fibers interposed between the posterior blade of the retractor and the nerve itself (TCK) was found. GN distortion was found to be related to its clock position on an axial section of psoas muscle seen from cranially at L4/L5. CONCLUSION: FN was in close connection with the deep psoas muscle fibers and it is subjected to anterior translation that correlates with TCK. This mechanism may partly explain the rate of femoral nerve palsy that occurs despite neuromonitoring and safe entry zones respect. The GN location at L4/L5 should be considered not only for its projection in Zone I, but also for its clock position on the psoas muscle surface, since it affects its distortion.

Epidural spinal cord stimulation for neuropathic pain: a neurosurgical multicentric Italian data collection and analysis.

BACKGROUND: Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neuropathic pain refractory to any conservative treatment. The aim of this data collection is to enforce evidence of SCS effectiveness on neuropathic chronic pain reported in the literature and to speculate on the usefulness of the trial period in determining the long-term efficacy. Moreover, the very low percentage of undesired side effects and complications reported in our case series suggests that all implants should be performed by similarly well-trained and experienced professionals. METHOD: A multicentric data collection on a common database from 11 Italian neurosurgical departments started 3 years ago. Two different types of electrodes (paddle or percutaneous leads) were used. Of 122 patients, 73 % (N = 89) were submitted to a trial period, while the remaining patients underwent the immediate permanent implant (N = 33). Statistical comparisons of continuous variables between groups were performed. RESULTS: Most of the patients (80 %) had predominant pain to their lower limbs, while only 17 % of patients had prevalent axial pain. Significant reduction in pain, as measured by variation in visual analogue scale (VAS) score, was observed at least 1 year after implantation in 63.8 % of the cases, 59.5 % of patients who underwent a test trial and 71.4 % of patients who underwent permanent implant at once. No statistical differences were found between the lower-limb pain group and the axial pain group. CONCLUSIONS: No relevant differences in long-term outcomes were observed in previously tested patients compared with patients implanted at once. Through this analysis we hope to recruit new centres, to give more scientific value to our results.

Management of intrathoracic benign schwannomas of the brachial plexus.

Primary tumours of the brachial plexus are rare entities. They usually present as extrathoracic masses located in the supraclavicular region. This report describes two cases of benign schwannomas arising from the brachial plexus with an intrathoracic growth. In the first case the tumour was completely intrathoracic and it was hardly removed through a standard posterolateral thoracotomy. In the second case the tumour presented as a cervicomediastinal lesion and it was resected through a one-stage combined supraclavicular incision followed by left video-assisted thoracoscopic surgery. A brachial plexus tumour should be suspected not only in patients with a supraclavicular or cervicomediastinal mass but also in those with intrathoracic apical lesions. A preoperative magnetic resonance imaging study of brachial plexus should be performed in such cases in order to plan the correct surgical approach.

Unusual presentation of mediastinal neurogenic tumours.

Mediastinal neurogenic tumours generally arise as single benign lesions and their typical location is the costovertebral sulcus. In about 10% of cases mediastinal neurogenic tumours may extend to the spinal canal; occasionally they may extend to the cervical region and, more rarely, may be multiple or associated with other synchronous mediastinal lesions. The treatment of choice is surgical resection. This report describes three cases of unusual presentation of mediastinal benign schwannomas successfully treated at our Hospital. In the first case multiple simultaneous paravertebral lesions were resected through a posterior approach. In the second case a tumour of the posterior mediastinum extending to the cervical region was excised through a one-stage combined supraclavicular incision followed by left mini-invasive video-assisted thoracoscopic surgical techniques. The third case describes a patient with a posterior neurogenic mediastinal tumour with a synchronous parathyroid adenoma of the anterior mediastinum, which were both successfully resected by video-assisted thoracoscopic surgery.

Diagnostic value and surgical implications of the magnetic resonance imaging in the management of adult patients with brachial plexus pathologies.

The imaging of the brachial plexus (BP) cannot easily be achieved because of the extension of the region to be studied, the different tissue compositions of the adjacent anatomic structures and the necessity to work with thin tissue slices. Here is a description of the brachial plexus MRI (bpMRI) protocol that we use for the pre-operative evaluation of patients affected by the following brachial plexus (BP) pathologies: neoplastic, post-traumatic, inflammatory. The surgical implications are discussed. A survey was done on 115 patients (66 males; 49 females; mean age 46.4 years old), which underwent a bpMRI over a 32-month period (32 post-traumatic, 26 neoplastic, 25 affected by inflammatory diseases). Our bpMRI protocol is evaluated according to each mechanism of disease. The bpMRI provides a topographic localization of the tumour showing the nerve dislocations or infiltration by the neoplasm. In traumatic patients we suggest that the bpMRI could be useful to detect the degree of axonal damage when the nerve lesion is in continuity. We also consider the diagnosis and the possible surgical implications for the inflammatory plexopathies. In conclusion, a standardized bpMRI protocol has an invaluable diagnostic value for the surgeons and neurologists. It is only limited by its duration (at least 45 min).