The impact of pelvic balance, physical activity, and fear-avoidance on the outcome after decompression and instrumented fusion for degenerative lumbar stenosis.

PURPOSE: To evaluate the impact of pelvic balance, physical activity, and fear-avoidance in a cohort of patients undergoing decompression and instrumented fusion for degenerative lumbar stenosis. MATERIALS AND METHODS: This study includes consecutive patients undergoing decompression and instrumented fusion for degenerative lumbar stenosis by one main surgeon from January 2014 to January 2015. Patients were interviewed by a psychologist and underwent standing whole spine X-ray. Lumbar and pelvic parameters (PI, SS, PT, iPT, LL) were measured by an independent spinal surgeon. Physical activity was measured with the International Physical Activity Questionnaire (IPAQ). The "fear-avoidance" was measured with the Tampa Scale for Kinesiophobia (TSK). Back pain was assessed by the Graphic Rating Scale (GRS). The disability was assessed by the Roland-Morris Low Back Pain and Disability Questionnaire. Statistical interpretation of the data was performed using SPSS v19 software (SPSS Inc, Chicago, Illinois). RESULTS: The sample included 51 patients underwent standard posterior laminectomy and instrumented fusion. Surgery has a positive global impact on the perceived low back pain. No significant (Spearman) correlations emerged among pelvic parameters and the pre- and post-surgical GSR. Patients were divided into three groups according to the IPAQ scores after the operation: "inactive" (I), "minimally inactive" (m-I), and "HEPA". Significant differences emerged between IPAQ and Roland-Morris scores (F(2, 48) = 5.48, p = 0.007): the "inactive" (M(R-M) = 11.3) or "minimally active" (M(R-M) = 9.8) groups scored significantly higher than the "HEPA" group (M(R-M) = 4.7). Tampa scores correlated with gender (rho = -0.408, p = 0.003) and with BMI (rho = -0.369, p = 0.008). Females and obese patients reported higher levels of Tampa scores. Significant relationship was found between Tampa scores and pre-GSR (rho(pre) = 0.250, p = 0.08) and significant with post-surgical GSR (rho(post) = 0.275, p = 0.05) and with post-Roland-Morris score (rho(post) = 0.599, p < 0.01). CONCLUSION: The fear-avoidance and the physical inactivity are related to the highest levels of low back pain, more than pelvic imbalance. "Inactive" and "fear-avoidant" patients have also the worst outcome after surgery and the worst level of disability.

Post laminoplasty cervical kyphosis-Case report.

INTRODUCTION: Cervical kyphosis is a progressive cervical sagittal plane deformity that may cause a reduction in the ability to look horizontally, breathing and swallowing difficulties, sense of thoracic oppression and social isolation. Moreover, cervical kyphosis can cause myelopathy due to a direct compression by osteo-articular structures on the spinal cord or to a transitory ischaemic injury. The treatment of choice is surgery. The goals of surgery are: nervous structures decompression, cervical and global sagittal balance correction and vertebral stabilization and fusion. PRESENTATION OF CASE: In October 2008 a 35 years old woman underwent surgical removal of a cervical-bulbar ependymoma with C1-C5 laminectomy and a C2-C5 laminoplasty. Five months after surgery, the patient developed a kyphotic posture, with intense neck and scapular girdle pain. The patients had a flexible cervical kyphosis. Therefore, we decided to perform an anterior surgical approach. We performed a corpectomy C4-C5 in order to achieve the anterior decompression; we placed a titanium expansion mesh. DISCUSSION: Cervical kyphosis can be flexible or fixed. Some authors have reported the use of anterior surgery only for flexible cervical kyphosis as discectomy and corpectomy. This approach is useful for anterior column load sharing however it is not required for deformity correction. CONCLUSION: The anterior approach is a good surgical option in flexible cervical kyphosis. It is of primary importance the sagittal alignment of the cervical spine in order to decompress the nervous structures and to guarantee a long-term stability.

Pott's disease: medical and surgical treatment.

OBJECTIVES: To evaluate the best treatment of Pott's disease. MATERIALS AND METHODS: 7 cases of Pott's disease were treated in the department of Neurosurgery of Sapienza University of Rome (Italy) between 2004 to 2011. RESULTS: All patients underwent surgical drainage of abscess and vertebral stabilization. In all cases culture exam showed positivity after 40 days of incubation. After surgery for a period of one year chemotherapy was administered. In all cases MRI scan with gd of the spinal column were performed 12 months after surgery and no recurrence of disease has been shown. DISCUSSION: Pott's disease is defined as vertebral involvement of extrapulmonary Tubercolosis (TB), involving mainly toraco-lumbar tract of the spine. MRI with gd represents the gold standard for the diagnosis. Treatment can be medical, surgical or usually both. The slippery course of the disease often causes a delay in getting to a diagnosis that is not made prior to rising signs, such as large abscess, neurological impairment or vertebral fractures. In these cases medical treatment alone did not show effective results, because no specific antibiotic drug can permeate the abscess's capsule, and an effective concentration is not achieved in the infection's site. Therefore, surgical treatment is necessary to abscess draining and setting the correct medical treatment to mycobacterial eradication.

Microsurgical excision without fusion as a safe option for resection of synovial cyst of the lumbar spine: long-term follow-up in mono-institutional experience.

Spinal synovial cysts are cystic dilatations of the synovial membrane that may arise at all levels of the spine. We describe our experience, paying attention to diagnosis, surgical treatment, and long-term follow-up. Between 1995 and 2007, 18 patients were surgically treated. Of these, three patients were excluded from the study because they presented spinal instability at pre-operative assessment. All patients were evaluated pre-operatively with CT, MRI, and dynamic X-rays, and underwent surgery for removal of the cyst by hemilaminectomy and partial arthrectomy. All patients were evaluated with early MRI and had a minimum 2-year follow-up by dynamic X-rays. None of the patients required instrumented fusion due to the absence of radiological signs of instability on the pre-operative dynamic tests. In all patients, there was an immediate resolution of the symptoms, with evidence of complete removal of the cysts on post-operative MRI. At 2-year follow-up, all patients underwent dynamic X-rays and responded to a questionnaire for evaluation of outcome. None of them showed signs of relapse. The gold standard for treatment is surgery, even though other conservative treatment regimens have been proposed. Correct surgical strategy relies on pre-operative assessment of biomechanical stability for deciding whether patients need instrumented fusion during cyst removal. Patients with no instability signs are suitable for hemilaminectomy with partial arthrectomy, preserving 2/3 of the medial portion of the articular facet, because this represents a valid option of treatment with a low risk of complications and a low rate of relapse.

The use of platelet gel in postero-lateral fusion: preliminary results in a series of 14 cases.

Over the last few years, some hemocomponents have been used advantageously in clinical neurosurgical practice, not systemically via transfusion but topically as a sealant (fibrin glue). This has diverted the attention of many authors to the role of platelets in the healing process. The combination of hyper-concentrated platelets and fibrin glue (fibrinogen, XIII factor, fibronectin) with activated thrombin produces a platelet gel that can be easily applied to "difficult" wounds. This topical use of hemocomponents has gained an important role in regenerative medicine. The authors have considered the possibility of using a preparation with a high autologous platelet concentration applied in addition to autologous bone during vertebral postero-lateral fusion. The aim of the procedure is to induce a higher rate of vertebral fusion. Between November 2007 and November 2008, 14 patients (9 men and 5 women, mean age 58.9) underwent laminectomy, vertebral stabilization and postero-lateral fusion. The number of vertebral levels involved in stabilization was: 1 in 2 patients, 2 in 5 patients, 3 in 5 patients, 4 in 1 patient and 5 in 1 patient. Platelet gel was obtained by taking 16 ml of peripheral venous blood from the patient. For this procedure two patented test tubes were used for each patient, with a capacity of 8 m each. These make up the REGEN-THT(®) (Thrombocyte Harvesting Tube) system that makes it possible to obtain 8 ml of autologous platelet gel in 40-45 min. The addition of Ca gluconate and ethanol at 95% makes it possible to obtain a preparation of plasma rich in platelets and activated thrombin with a platelet concentration five times superior to the haematic one. The platelet gel is combined with fragments of autologous bone and synthetic bone during surgical operation. To allow a comparative assessment of the degree of fusion achieved with and without application of the platelet preparation in each patient, it was arbitrarily decided to use it in only one half of the operative field. All patients underwent serial CT scans 3 and 6 months after surgery as well as plain X-rays to evaluate bone fusion. The reconstructed CT images, especially in sagittal and axial planes, permitted an evaluation of the degree of vertebral fusion and "bone growth". The fusion rate was calculated measuring the increment of bone density on CT images, by means of an evaluation of the ROI (HU) in the newly formed bone, and comparing bone density within the bone callus formed by autologous and synthetic bone alone in the one to which the platelet preparation had been added. A good rate of fusion was observed in all patients. Furthermore, a comparative analysis of ROI at 3 and 6 months after surgery demonstrated a high increase in the fusion rate during the first 3 months after surgery. After 6 months the differences in ROI between the two sides had balanced out. However, at 6-month follow-up examination, bone density in the half of the surgical field in which platelet gel had been added to autologous-heterologous bone was higher in comparison to the contralateral one. Bony neoformation after posterior-lateral arthrodesis is well-evident 3 months after surgery and usually continues gradually for the following 18-24 months. The autologous platelet preparation used seems to accelerate bony deposition and to promote tissue healing, increasing bone density at the level of posterior-lateral arthrodesis. Moreover, this preparation has low production costs and is easy to apply.

Five-year outcome of stand-alone fusion using carbon cages in cervical disc arthrosis.

From January 1, 2001 to December 31, 2003, in the Neurosurgery Department of Rome University o "Sapienza," 167 patients underwent anterior surgery for cervical spondylodiscoarthrosis. The levels treated by the anterior stand-alone technique were: C3-C4 (11%), C4-C5 (19%), C5-C6 (40%), and C6-C7 (30%). All patients underwent left anterior presternocleidomastoid-precarotid approach, microdiscectomy, and interbody fusion using a carbon fiber cage filled with hydroxyapatite. All patients were discharged within 48 h after surgery with cervical orthosis. In one case, a hematoma of the surgical site occurred within 12 h of surgery; for this reason the patient underwent surgical revision and was discharged 4 days later. All patients have worn cervical orthosis for a mean period of 7 weeks and underwent radiological follow-up with cervical RX at 1 and 3 months after surgery. All patients underwent follow-up from 54 to 90 months after surgery, and all of them underwent cervical RX, cervical CT scans for the estimate of fusion, and evaluation of neurological status using VAS and NDI. Of 167 patients, 132 were cooperative for this study, 18 were non-cooperative, and 17 died. The estimation of fusion made by cervical CT scans with sagittal reconstruction showed complete osteointegration of the cage in 115 patients (87.1%), while it showed pseudoarthrosis in 17 patients (12.9%). In 24 patients, we observed adjacent segment degeneration, and 13 of these underwent new surgical procedures in this institute or in another hospital. Clinical evaluation with VAS and NDI showed a good outcome, with poorest benefit in patients over 60 years. The clinical analysis showed a good fusion rate in according with literature, 13% of non-fusion rate without clinical evidence and 20% of ASDegeneration but only 10% had required new surgery. We also observed that patients over 60 years of age had less satisfactory outcome, probably related with the evolution of pathophysiological degeneration of the cervical spine. In the opinion, pseudoarthrosis is caused by malpositioning of the carbon fiber cage.

Multiple disc herniations in a type II diabetic patient: case report and review of the literature.

Disc herniation is a common pathology associated with physical trauma or degenerative diseases. The authors present the case of a patient with 8 disc herniations without known risk factors or other associated pathologies except for a long story of type II diabetes. Basing on studies reported in literature, it can be assumed that diabetes may be the reason of multiple disc herniations in this case.

Evaluation of CZ-resin vials for packaging protein-based parenteral formulations.

Due to the fact that some proteins have a tendency to bind to glass surfaces, plastic CZ-resin vials were evaluated as an alternative material to glass vials for packaging protein-based parenteral formulations. Physico-chemical tests including protein binding, extractable evaluation, oxygen permeation, light transmission and moisture loss were performed. Data show that two proteins (A and B) were found to bind to USP type I glass but not to CZ-resin. The CZ-resin vials passed all USP test specifications for extractables (organic extractable, non-volatile residue and residue on ignition). The oxygen permeation rate (79.06 cm(3)mm/m(2)24 h atm) was consistent with that reported by the vendor (67 cm(3)mm/m(2)24 h atm). The value obtained for light transmission, which was also found to be consistent with that reported by the vendor, shows that these vials offer no protection from light. The average moisture loss from 2 cm(3) vials filled with water was gravimetrically determined to be 0.04 mg/day/vial when the vials were stored at 40 degrees C/75% relative humidity (RH). Assuming a 1cm(3) product fill, this corresponds to approximately a 3% loss over a 2-year period. However, moisture loss was found to be negligible at the typical storage condition of 5 degrees C for protein formulations. The physico-chemical tests indicate that CZ-resin vial is a suitable candidate for packaging parenteral formulations since it shows low moisture loss at typical storage condition of 5 degrees C, and does not leach out extractables. However, it should not be used for light-sensitive and oxygen-sensitive parenteral formulations. For proteins A and B, the CZ-resin vial is a viable alternate to the use of glass vials since it offered significantly less protein binding. Protein binding in general, should be evaluated on a case by case basis, since it may vary for different proteins and under different formulation conditions.

Reconstruction of suboccipital craniectomy with autologous bone chips.

BACKGROUND: In patients submitted to suboccipital craniectomy in whom the bone is not repositioned, there may be a significant aesthetic defect due to lack of bone tissue, sometimes accompanied by paresthaesia and painful symptoms. METHOD: In 15 patients submitted to suboccipital craniectomy, the bone chips were repositioned during wound closure. FINDINGS: At a mean follow up of 19 months (from 6 to 36 months), 2 patients (13%) complained of mild wound discomfort or occasional local pain. Twelve patients underwent control CT-scan. In three cases (25%) the bone fragments had been partly reabsorbed whereas in the other 9 (75%) they either formed a thin (4 patients) or consistent (5 patients) bony wall, with variable degree of adaptation to the contour of the contralateral occipital bone. The best cosmetic and functional results were obtained in young patients in whom the cerebellar parenchyma was well-preserved, as opposed to those in whom a CSF collection had replaced areas of cerebellar tissue. INTERPRETATION: In the majority of cases in whom an osteoplastic suboccipital craniotomy is not possible, repositioning of the bone chips from suboccipital craniectomy is able to restore a bone table, thus allowing morphological and functional recovery of the occipital region.

No evidence for a susceptibility locus for idiopathic generalized epilepsy on chromosome 5 in families with typical absence seizures.

A recent genome-wide scan revealed suggestive evidence for two susceptibility loci for idiopathic generalized epilepsy (IGE) in the chromosomal regions 5p15 and 5q14-q22 in families with typical absence seizures. The present replication study tested the validity of the tentative IGE loci on chromosome 5. Our study included 99 multiplex families in which at least one family member had typical absence seizures. Parametric and non-parametric multipoint linkage analyses were carried out between the IGE trait and 23 microsatellite polymorphisms covering the entire region of chromosome 5. Multipoint parametric heterogeneity lod scores < -2 were obtained along chromosome 5 when a proportion of linked families greater than 50% was assumed under recessive inheritance and > 60% under dominant inheritance. Furthermore, non-parametric multipoint linkage analyses revealed no hint of linkage throughout the candidate region (P > 0.05). Accordingly, we failed to support previous evidence for common IGE loci on chromosome 5. If there is a susceptibility locus for IGE on chromosome 5 then the size of the effect or the proportion of linked families is too small to detect linkage in the investigated family sample.

Occipitocervical pseudomalignant osseous tumor of the soft tissue (Fasciitis ossificans). Case report.

The authors describe the case of a 12-year-old girl in whom a pseudomalignant osseous tumor of the soft tissue was diagnosed. The lesion was resected, and at 3-year postresection follow-up examination, neuroradiological studies demonstrated no recurrence of the tumor.

Supratentorial hemangioblastoma in a patient with breast cancer. A case report.

Patients with breast cancer may develop cerebral metastasis. Radio- and chemotherapy are advocated as an alternative to surgery in such patients. A woman operated on for breast cancer 2 years earlier developed a cerebral lesion. A definite preoperative diagnosis of the lesion was not possible on the basis of CT and MRI findings. The lesion proved to be a supratentorial hemangioblastoma. Neurosurgical treatment is recommended for patients with breast cancer who present a cerebral lesion, since a correct diagnosis may only be possible in the operating theater.

Chronic subdural haematomas in patients aged under 50.

The clinical findings in 31 patients with chronic subdural haematoma (CSH), aged between 20 and 50, are described. Aetiopathogenetic factors responsible for the formation of CSH match those of patients aged over 50 with CSH. A history of cranial trauma was present in 77% of the cases. In the remaining patients, a defect of haemostatic mechanisms was responsible for the subdural blood collection. On the computed tomography (CT) the haematoma generally appears as a thin subdural layer. The reliability of magnetic resonance imaging for detection of CSH makes it the most desirable investigation in such patients. Prognosis is influenced by preoperative clinical status and by the disease responsible for the formation of CSH.

Gunshot wound of the atlas in a youth.

The case of a bullet retained, without causing neurological symptoms, in the anterior arch of a youth's atlas after a gun had been fired a short distance from his mouth is reported. The patient was managed with external stabilization.

Chronic subdural haematoma: a possible relationship with tamoxifen.

Five patients operated on between 6 months and 7 years earlier for breast cancer were surgically treated for chronic subdural haematoma. This unusual association may be explained on the basis of known factors such as coagulative impairment subsequent to chemotherapy, a degree of cerebral atrophy or mild trauma. On the other hand, since four of the patients were taking antioestrogen therapy to control the disease, it is speculated that the oestrogenic properties of tamoxifen may have contributed to subdural bleeding.

Primary benign tumors of the orbital cavity: comparative data in a series of patients with optic nerve glioma, sheath meningioma, or neurinoma.

BACKGROUND: Patients operated on for the most common benign pathologies of the orbital cavity-optic nerve glioma, sheath meningioma and neurinoma-should be surgically treated. However, postoperative visual impairment is frequently inevitable. A wait-and-see policy due to a slow rate of growth of these lesions is criticized. METHODS: Collecting data from three series of patients operated, we compare the surgical procedures and long-term results. RESULTS: "En bloc" removal in patients with optic nerve glioma led to complete visual deficit but ensures excellent long-term prognosis. Because optic nerve meningiomas are typically circumferential to the optic nerve and adhere tightly to the perineural pial microvascular structures, it is impossible to avoid trauma to the optic nerve and recurrences. Patients with neurinoma of the orbital cavity have the most favourable prognosis both in terms of visual function as well as long-term quality of life. Due to its slow rate of growth, a wait-and-see policy can be adopted for optic nerve glioma before deciding on surgical removal, whereas surgical treatment of meningioma may be postponed if symptoms are slight and steady. Removal of orbital cavity neurinoma should not be postponed since surgical outcome is excellent.

Turcot's syndrome: case report and review of the classification.

We report a case of association of a brain tumor with multiple colorectal polyposis and offer an analysis of the relevant literature with a view to revising the classification of the syndrome in relation to familial multiple polyposis and Gardner's syndrome. Differences emerged, depending on the brain tumor type, which suggests that this association may be classified as two distinct syndromes.

Primary spinal malignant schwannomas: clinical and prognostic remarks.

Malignant peripheral nerve sheath spinal tumours are relatively rare. A primary spinal location at onset from the nerve roots is rarely reported in the literature, thus the clinical features and therapeutic results of these spinal malignant tumours are not defined. Six cases of malignant primary spinal schwannomas, 2% of 293 spinal schwannomas operated on in a 38 year period, are reported. Based on an analysis of a limited number of cases, ours and those collected from the literature (21 patients), some suggestions are possible: a) pre-operative clinical presentation and imaging studies are not predictive of malignancy; b) postoperative outcome is poor, especially in patients with von Recklinghausen's disease and after partial removal of the tumour; c) local recurrence and metastases are possible, even after radical surgery and radiotherapy.

Solitary plasmacytoma of the spine: relationship of IGM to tumour progression and recurrence.

The authors report a retrospective study of 15 patients with solitary vertebral plasmacytoma. 15 patients were considered in this study on the basis of the following characteristics: 1) histologically confirmed plasmacytoma following surgical removal; 2) existence of a single vertebral lesion, documented by skeletal and MRI scan; 3) no signs, at diagnosis of disseminated disease by blood laboratory test, urine analysis, sternal puncture, iliac bone marrow biopsy, a total-body CT scan. The clinical course of the patients has been analysed on the basis of the following factors: age, sex, length of clinical history before diagnosis, site, presence/absence of the M component. The M component is an electrophoretically homogeneous immunoglobin. The most significant factors for predicting development of multiple myeloma proved to be the presence /absence of the M component at diagnosis and, to a lesser degree, the age of the patient. In the light of other reports too, it would seem that the presence of the M component at diagnosis is a reflection of aggressive biological and clinical tumour behaviour.

N-methyl-2-pyrrolidone as a cosolvent: relationship of cosolvent effect with solute polarity and the presence of proton-donating groups on model drug compounds.

N-Methyl-2-pyrrolidone (methylpyrrolidone), a cosolvent which has been used in veterinary medicine and in transdermal delivery devices, was investigated as a cosolvent for model drug compounds of widely varying polarity. These compounds were digoxin, sulfamethoxazole, hydrocortisone acetate, theophylline, phenytoin, and reserpine. Methylpyrrolidone was found to be an extremely efficient cosolvent for low solubility polar drugs such as digoxin or drugs containing multiple proton-donating groups such as phenytoin. The increase in solubility observed in aqueous solutions of digoxin and phenytoin to which 0.2 volume fraction of methylpyrrolidone was added was 500x and 65x, respectively. Significant deviations from log-linear solubilization were observed with digoxin, sulfamethoxazole, phenytoin, and reserpine, indicating significant water-solute-cosolvent interactions.