Minimally Invasive Stent Screw-Assisted Internal Fixation Technique Corrects Kyphosis in Osteoporotic Vertebral Fractures with Severe Collapse: A Pilot "Vertebra Plana" Series.

BACKGROUND AND PURPOSE: Fractures with "vertebra plana" morphology are characterized by severe vertebral body collapse and segmental kyphosis; there is no established treatment standard for these fractures. Vertebroplasty and balloon kyphoplasty might represent an undertreatment, but surgical stabilization is challenging in an often elderly osteoporotic population. This study assessed the feasibility, clinical outcome, and radiologic outcome of the stent screw-assisted internal fixation technique using a percutaneous implant of vertebral body stents and cement-augmented pedicle screws in patients with non-neoplastic vertebra plana fractures. MATERIALS AND METHODS: Thirty-seven consecutive patients with vertebra plana fractures were treated with the stent screw-assisted internal fixation technique. Vertebral body height, local and vertebral kyphotic angles, outcome scales (numeric rating scale and the Patient's Global Impression of Change), and complications were assessed. Imaging and clinical follow-up were obtained at 1 and 6 months postprocedure. RESULTS: Median vertebral body height restoration was 7 mm (+74%), 9 mm (+150%), and 3 mm (+17%) at the anterior wall, middle body, and posterior wall, respectively. Median local and vertebral kyphotic angles correction was 8° and 10° and was maintained through the 6-month follow-up. The median numeric rating scale score improved from 8/10 preprocedure to 3/10 at 1 and 6 months (P < .001). No procedural complications occurred. CONCLUSIONS: The stent screw-assisted internal fixation technique was effective in obtaining height restoration, kyphosis correction, and pain relief in patients with severe vertebral collapse.

A randomized controlled TRIal of cognitive BEhavioral therapy for high Catastrophizing in patients undergoing lumbar fusion surgery: the TRIBECA study.

BACKGROUND: Around 20% of patients undergoing spinal fusion surgery have persistent back or leg pain despite surgery. Pain catastrophizing is the strongest psychological predictor for chronic postsurgical pain. Psychological variables are modifiable and could be target for intervention. However, randomized controlled trials evaluating the effectiveness of psychological interventions to reduce chronic pain and disability after spinal fusion in a population of patients with high preoperative pain catastrophizing scores are missing. The aim of our study is to examine whether an intervention targeting pain catastrophizing mitigates the risk of chronic postsurgical pain and disability. Our primary hypothesis is that targeted perioperative cognitive behavioral therapy decreases the risk of chronic postsurgical pain and disability after spinal fusion surgery in high catastrophizing patients. METHODS: We will perform a two-center prospective, single-blind, randomized, controlled study comparing lumbar spinal fusion surgery outcome between 2 cohorts. Adult patients selected for lumbar spinal fusion with decompression surgery and a minimum score of 24 on the pain catastrophizing scale will be randomized with 1:1 allocation for either perioperative cognitive behavioral therapy (intervention group) or a perioperative education plus progressive exercise program (control group). Patients randomized to the intervention group will receive six individual sessions of cognitive behavioral therapy, two sessions before the operation and four after. Primary outcome is the Core Outcome Measures Index at 12 months. Secondary outcomes include pain, disability, depression and quality of life. DISCUSSION: This is the first trial that evaluates the effectiveness of cognitive behavioral therapy as a perioperative tool to improve pain and disability after spinal fusion surgery in comparison with an educational/exercise control intervention, in patients with high levels of pain catastrophizing. If perioperative cognitive behavioral therapy proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcome after spinal fusion surgery. TRIAL REGISTRATION: Clinicaltrials ( NCT03969602 ). Registered 31 May 2019.

Armed Kyphoplasty: An Indirect Central Canal Decompression Technique in Burst Fractures.

BACKGROUND AND PURPOSE: Burst fractures are characterized by middle column disruption and may feature posterior wall retropulsion. Indications for treatment remain controversial. Recently introduced vertebral augmentation techniques using intravertebral distraction devices, such as vertebral body stents and SpineJack, could be effective in fracture reduction and fixation and might obtain central canal clearance through ligamentotaxis. This study assesses the results of armed kyphoplasty using vertebral body stents or SpineJack in traumatic, osteoporotic, and neoplastic burst fractures with respect to vertebral body height restoration and correction of posterior wall retropulsion. MATERIALS AND METHODS: This was a retrospective assessment of 53 burst fractures with posterior wall retropulsion and no neurologic deficit in 51 consecutive patients treated with armed kyphoplasty. Posterior wall retropulsion and vertebral body height were measured on pre- and postprocedural CT. Clinical and radiologic follow-up charts were reviewed. RESULTS: Armed kyphoplasty was performed as a stand-alone treatment in 43 patients, combined with posterior instrumentation in 8 and laminectomy in 4. Pre-armed kyphoplasty and post-armed kyphoplasty mean posterior wall retropulsion was 5.8 and 4.5 mm, respectively (P < .001), and mean vertebral body height was 10.8 and 16.7 mm, respectively (P < .001). No significant clinical complications occurred. Clinical and radiologic follow-up (1-36 months; mean, 8 months) was available in 39 patients. Three treated levels showed a new fracture during follow-up without neurologic deterioration, and no retreatment was deemed necessary. CONCLUSIONS: In the treatment of burst fractures with posterior wall retropulsion and no neurologic deficit, armed kyphoplasty yields fracture reduction, internal fixation, and indirect central canal decompression. In selected cases, it might represent a suitable minimally invasive treatment option, stand-alone or in combination with posterior stabilization.

Spinal Instrumentation Rescue with Cement Augmentation.

BACKGROUND AND PURPOSE: Altered biomechanics or bone fragility or both contribute to spine instrumentation failure. Although revision surgery is frequently required, minimally invasive alternatives may be feasible. We report the largest to-date series of percutaneous fluoroscopically guided vertebral cement augmentation procedures to address feasibility, safety, results and a variety of spinal instrumentation failure conditions. MATERIALS AND METHODS: A consecutive series of 31 fluoroscopically guided vertebral augmentation procedures in 29 patients were performed to address screw loosening (42 screws), cage subsidence (7 cages), and fracture within (12 cases) or adjacent to (11 cases) the instrumented segment. Instrumentation failure was deemed clinically relevant when resulting in pain or jeopardizing spinal biomechanical stability. The main study end point was the rate of revision surgery avoidance; feasibility and safety were assessed by prospective recording of periprocedural technical and clinical complications; and clinical effect was measured at 1 month with the Patient Global Impression of Change score. RESULTS: All except 1 procedure was technically feasible. No periprocedural complications occurred. Clinical and radiologic follow-up was available in 28 patients (median, 16 months) and 30 procedures. Revision surgery was avoided in 23/28 (82%) patients, and a global clinical benefit (Patient Global Impression of Change, 5-7) was reported in 26/30 (87%) cases at 1-month follow-up, while no substantial change (Patient Global Impression of Change, 4) was reported in 3/30 (10%), and worsening status (Patient Global Impression of Change, 3), in 1/30 (3%). CONCLUSIONS: Our experience supports the feasibility of percutaneous vertebral augmentation in the treatment of several clinically relevant spinal instrumentation failure conditions, with excellent safety and efficacy profiles, both in avoidance of revision surgery and for pain palliation.

Neurosurgical aspects of dialysis-related spinal amyloidosis: Report of three cases and a review of the literature.

BACKGROUND AND PURPOSE: Osteoarticular manifestations of beta-2 microglobulin amyloidosis are often diagnosed in long-term dialyzed patients. However, spinal involvement is rare (10-25% of patients), and generally not associated with neurological deterioration. Compression of the spinal cord or roots is extremely rare, and probably under-recognized. METHODS: The authors describe three cases of spinal stenosis presenting with neurological signs in long-term dialyzed patients, prospectively collected over 2 years in two different institutions and treated by surgical decompression. In all three cases, the main cause of neural compression was amyloid deposition in the spine, either extradurally in the ligamentum flavum or intradurally. RESULTS: All patients improved after surgery and did not present any postoperative complications. However, two out of three patients with amyloid in the cervical spine required surgical revision to obtain a satisfactory decompression of the spinal cord. DISCUSSION: The authors discuss spinal amyloidosis which is a well-known complication of long-term dialysis. However, neurological complications such as spinal cord or radicular symptoms have been rarely reported and, when present in dialyzed patients, are symptoms that are often attributed to other causes. To our knowledge, this is the first case series that demonstrates the relationship between neurological deterioration and amyloid depositions in the spinal canal that occur in long-term dialyzed patients. The prevalence of spinal stenosis related to the presence of amyloid in this specific subgroup of patients is probably underestimated.

Two-levels mini-open transforaminal lumbar interbody fusion: technical note.

OBJECTIVE: Mini-open transforaminal lumbar interbody fusion (oTLIF), previously described by Mummaneni et al., is a well-established technique that uses tubular dilators and retractors for treatment of single-level lumbar spinal stenosis. TECHNIQUE: We describe eight patients with two-level spinal stenosis who were operated on with minimally invasive spinal arthrodesis via a transforaminal route with the use of tubular retractors. This approach allowed us to obtain double-level cages insertion in all patients, with direct visualization of pedicular entry points and no screw malpositioning. CONCLUSION: The oTLIF represents a good compromise in patients with two-level lumbar degenerative disease deserving surgery. Compared to standard open TLIF, it is associated with less postoperative muscular trauma, and faster recovery. This seems to be more evident in that category of patients in whom open approaches need longer incisions and more muscular fiber splitting. Compared to percutaneous TLIF (pTLIF), it allows for bilateral root decompression in every case. Bilateral cage insertion was also possible with this technique.

[Neurenteric cyst of the posterior fossa. Case report and review of the literature]. / Kyste neurentérique de la fosse postérieure. A propos d'un cas, revue de la littérature.

Intracranial neurenteric cysts are rare entities. The term is currently used to describe epithelial cysts that are lined with a presumed endodermal-derived epithelium and are mostly located in the posterior fossa. Preoperative diagnosis is often difficult because of their clinical presentation, which may resemble a subarachnoid hemorrhage, and the radiological aspect, which can mimic vascular pathologies. We describe a posterior fossa neurenteric cyst in a 27-year-old woman, who presented with sudden headache as the only symptom and who was addressed to our hospital for subarachnoid hemorrhage. Diagnostic angiography was negative and MRI revealed a prepontine cystic lesion. The patient underwent a posterolateral approach on the right side, with subtotal resection of the lesion. We discuss the embryologic, diagnostic and therapeutic aspects of these cysts and review the literature.

[Management of brain metastases from urological malignancies]. / Prise en charge des métastases cérébrales des cancers urologiques.

Brain metastases account for 30 to 40% of all brain tumors in adults. Even if urological carcinomas are not very common, anti-angiogenic drugs have transformed their prognosis, leading physicians to consider their specific treatment. For the majority of cases, surgery is quite simple with low associated morbidity. Depending on the size and the location, surgery or stereotaxic radiotherapy should be discussed. As soon as the metastasis is suspected a neurosurgerical opinion must be sought before beginning any treatment to coordinate the global management.

[Role and technical aspects of surgery for spinal metastases from urological malignancies]. / Place et Modalités de la chirurgie des métastases vertébrales des cancers urologiques.

The improved survival rate in urologic carcinoma notably due to anti-angiogenic drugs is directly associated with increased incidence of spinal metastases. During spinal metastasis cord compression it has been proved that surgery associated with radiotherapy gives better results that radiotherapy alone. The neurotoxic risk of the spine metastasis must be evaluated before neurological signs appear in order to propose, if necessary decompressive surgery with stabilisation of the lesion. The choices of therapeutic approach are quite large ranging from percutaneous cimentoplasty to vertebral replacement. It is essential that the initial treatment of metastasis be discussed before neurologic signs appear.

Supradiaphragmatic retrochiasmatic craniopharyngioma in an 80-year-old patient operated by extended endoscopic endonasal approach: case report.

BACKGROUND: The transsphenoidal approach is still the optimal procedure for intrasellar infradiaphragmatic craniopharyngiomas. It is also used by many to treat intrasellar tumors which have a suprasellar extension, especially when there is a cystic component. However, this approach is not routinely performed for supradiaphragmatic ones, which are mostly approached by a transcranial route, even if the related morbidity is higher. Endoscopic techniques now allow a better visualization and could permit a widening of indications for the transsphenoidal route to such tumors, especially in older patients. CASE REPORT: We used an extended endonasal endoscopic approach in a 80-year-old man who was diagnosed with a purely supradiaphragmatic craniopharyngioma. Preoperative rapid deterioration of visual function was the primary indication for surgery. Subtotal resection of the tumor was accomplished, as confirmed by intraoperative direct visualization and postoperative MRI. A rapid amelioration of visual function was noted postoperatively. CONCLUSION: Primary endoscopic endonasal surgery for supradiaphragmatic retrochiasmatic craniopharyngiomas in elderly patients could represent a safer approach associated with a lower operative morbidity when compared to transcranial surgery and better postoperative results when compared to conservative treatments currently used. More cases are needed to quantify the risk of CSF leakage, which is currently the main disadvantage of this procedure.

[Isolated jejunal rupture after closed thoraco-abdominal trauma]. / Rottura isolata del digiuno dopo trauma chiuso toraco-addominale.

INTRODUCTION: Short bowel disruption following blunt abdominal trauma is rare and hard to diagnose and to treat. Death rate depends both on timing of surgical procedure and on associated lesions. MATERIAL AND METHODS: We show a case of short bowel isolated lesion following fall from mountain bike, III degree in O.I.S. Classification. Abdominopelvic US and helicoidal CT scan were performed, reveling pneumoperitonaeum due to hollow viscus disruption. Surgical procedure was performed within five hours from trauma. RESULTS: No complications occurred in postoperative period. Upper alimentary tract X-ray proved a regular transit, without any fistula. Patient was discharged on 13th day. CONCLUSION: Laparotomy must not be delayed if there is any doubt about bowel conditions: it's demonstrated that timing of surgical procedure is related to prognosis. If haemodynamic status of the patient allows, careful abdomen CT evaluation is mandatory; adequate nutritional support in postoperative period is also very important.

[The videolaparoscopic treatment of cholecystic common bile duct lithiasis: review of 827 cases]. / Il trattamento videolaparoscopico della litiasi colecisti-coledocica. Studio retrospettivo su 827 casi.

BACKGROUND: The aim of this retrospective study is to verify the progress of the results in 827 patients submitted to videolaparoscopic treatment for cholecysto-choledochus lithiasis during the period >March 1994 - September 2000. METHODS: All the patients had recurring biliary colic, dyspepsia and pain in the upper abdominal quadrants. All clinical forms of cholecystitis were treated. RESULTS: The laparotomic conversions in the case of lithiasis of the gallbladder alone were 8 (0.9%) and 13 (1.5%) as it occured simultaneously with lithiasis of the common bile duct. Mortality was null and morbidity was found in 4 cases, equal to 0.4%. CONCLUSIONS: On the basis of the results obtained cholecystectomy can be implemented on a large scale to include patients of all ages and those in the high risk groups provided that the operating team include expert and skilled surgeons in the laparoscopic method as well as the conventional methods.

[Laparoscopical marsupialization of symptomatic lymphoceles following kidney trans-plantation]. / Marsupializzazione videolaparascopica di linfocele sintomatico secondario a trapianto renale.

Personal experience in the laparoscopic treatment of a lymphocele following kidney transplantation and a review of the literature are presented. We have treated a symptomatic lymphocele, which occurred a month after renal transplantation. It compressed the iliac vessels and obstructed the urine flow. Physical examinations revealed it consisted of two chambers; it measured 12 x 8 x 6 cm. A US-guided puncture was performed and a drainage tube out in place. A continuous flow of lymphatic liquid derived, and therefore we decided on surgical intervention, which was conducted in laparoscopy. A puncture of blue through the drainage tube was performed; under US-guidance, we made an opening in the peritoneal wall and in the wall of the lymphocele. A cauterization of the edges was conducted. An immediate improvement in subjective and objective symptoms was achieved. A four-month follow-up showed minimal residual effusion, slowly disappearing. Literature data and clinical evolution of the patient show that the laparoscopic approach is to be considered the "gold standard" for the treatment of symptomatic lymphocele following kidney transplantation. The authors recommend the use of US-guidance to single out anatomic structures, particularly for surgeons not trained in this procedure.

[Unusual cause of ileal occlusion: a coconut bezoar]. / Una causa insolita di occlusione ileale: un bezoario da noce di cocco.

A coconut phytobezoar was detected in the distal ileum of a 4-year-old boy, admitted for suspected appendicitis. While persimmon or citrus fruit ingestion has been previously reported as cause of phytobezoar intestinal occlusion, it is the first time that coconut pulp is described to cause ileal obstruction in children. No predisposing factor as previous gastric surgery or Meckel's diverticulum was present. The bezoar was successfully milked past the ileocecal valve into the right colon.

[Recurrent thrombosis of the venous supply of the upper extremity]. / Trombosi ricorrente del distretto venoso dell'arto superiore.

The incidence of DVT in axillo-subclavian district is rather low. Up-to-date reports show however it is progressively increasing, owing to the widespread diffusion of intravenous prosthetic devices. While the opportunities of a correct diagnosis are becoming various, particularly because of the development of echo color-Doppler and imaging techniques, there is indecision for the treatment: the question is about a medical and a surgical therapy. Neither the former nor the latter are well established. This case report is about a 61-year-old woman affected by a recurrent DVT of the subclavian and axillary veins, who never underwent operation and/or handling of the venous district. Clinical tests didn't show any well determinate cause of thrombosis. It was decided not to treat the patient surgically, so a medical therapy was undertaken. Now she is completely recovered.