A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

PNET/ESFT of the cranial vault: a case report.

A case of peripheral PNET (PNET/ESFT) of the cranial vault is described. A 56-year-old woman showed a mass with a large cyst in the right temporal region, adherent to the meninges, which caused a left hemiparesis with headache and confusion. The mass was totally removed. The histological examination showed a dense proliferation of small elements, organized in lobules separated by reticulin septa. Many circumscribed necroses, vessels with a thick handcuff of reticulin, a diffuse mucous degeneration and abundant mitoses were present. The cells were positive for Vimentin and CD99. RT-PCR revealed the EWS/FLI1 fusion transcript of the t(11,22) (q24;q12) translocation. The patient presented is the oldest one of the rare cases of dura-based meningioma-mimicking pPNETs till now described. In line with the possible origin from peripheral nerves or roots of cauda equina of non-intracranial tumors, those of the vault may derive from peripheral sensory nerves of the dura. The differential diagnosis must be made with cPNETs which show a worse prognosis and both can benefit from a different chemotherapy.

Evidence for the improved exposure of the ophthalmic segment of the internal carotid artery after anterior clinoidectomy: morphometric analysis.

BACKGROUND: Although resection of the anterior clinoid process (ACP) is valuable in the surgical treatment of aneurysms of the ophthalmic (C6) segment of the internal carotid artery (ICA), quantitative assessment of this adjunct is incomplete. Our morphometric study assesses the effectiveness of the anterior clinoidectomy for exposure of the C6 segment of the ICA. METHODS: Ten formalin-fixed adult cadaveric heads were dissected bilaterally and pterional craniotomies were performed bilaterally. Measurements before and after resection of the ACP included the length of C6 segment of the ICA on its lateral aspect; C6 segment length on its medial aspect; and medial length of the optic nerve from the optic chiasm to falciform ligament (before ACP resection) then to the annulus of Zinn (after ACP resection). FINDINGS: Height and width of the intradural ACP were 8.67 +/- 2.63 and 6.57 +/- 1.68 mm, respectively. After clinoidectomy, mean length of the lateral C6 segment of the ICA increased 60% and mean exposure of the medial C6 segment of the ICA increased 113% (p < 0.001). Exposure of the optic nerve increased 150% (p < 0.001) after clinoidectomy and sectioning of the falciform ligament. No correlations were found between the lengths of the ACP and entire C6 segment, or the ACP size and amount of the C6 segment covered by the clinoid. CONCLUSIONS: Exposure of the C6 segment of the ICA is markedly increased by increase of the mobility of the optic nerve with clinoidectomy and section of the falciform ligament.

Chondrosarcoma of the thoracic spine: total en bloc sagittal resection. A case report.

Chondrosarcomas located in the spine are uncommon tumors and are challenging to manage. A case of a 65-year-old man with a T3-T4 spine chondrosarcoma is reported. The onset of symptoms consisted in progressive dorsal pain with sometimes a girdle-like radiation and, successively, in dysaesthesia and paresthesia from the lower limbs to the thoracic region. After preoperative oncologic and surgical planning the patient underwent a total en bloc resection of the mass. No postoperative adjunctive neurological deficits were recorded. An adjuvant radiation therapy with a dose of 5.500 centigrays (cGy) over four weeks was performed. At one year follow-up the patient is alive with no signs of recurrence on computed tomographic scans and magnetic resonance imaging. We discuss this case with particular emphasis on the preoperative planning, the surgical procedure and related prognosis.

Lateral ventricle subependymomas. Case report taking into particular consideration the aspects of magnetic resonance and review of the literature.

Subependymomas are rare neuroectodermic tumours. The authors report a case of a patient he had a subendymoma in the left lateral ventricle, with particular attention to the MR aspects on these lesions and review of the literature.

Surgical treatment of fractures of the thoracic and lumbar spine via the transpedicular route.

Sixty-seven consecutive patients with burst or dislocation fractures of the thoracic or lumbar spine were submitted to early surgical reduction, via the transpedicular route, over a 5-year period. The first 22 patients received Harrington instrumentation, while transpedicular devices were applied in the last 44 cases, at either the thoracic or the lumbar level. One patient did not receive any spinal instrumentation. This surgical approach was found to be reliable in achieving a near-anatomical reconstruction of the fractured spinal segment. The rate of post-operative complications was low. Placement of transpedicular devices proved to be a safe and effective procedure. The overall results were consistent with the thesis that the transpedicular approach compares favourably with alternative surgical methods.

Delayed worsening of the surgical correction of angular and axial deformity consequent to burst fractures of the thoracolumbar or lumbar spine.

Forty-one patients with burst fractures of the thoracolumbar junction, or the lumbar spine (T12 to L5), were followed for 6-48 months (mean follow-up = 19.9 months) after early surgery (usually within 24 hours). Preoperative, early postoperative, and late postoperative degrees of kyphosis, as well as percent reduction of the height of the vertebral body were calculated and compared. Early postoperative radiologic evaluations showed a statistically significant difference (p < 0.0001) between the mean values of both parameters calculated respectively before and after surgery. The decrease of the surgical correction, from the initial postoperative radiographs to follow-up, was statistically significant (p < 0.0001). However, the final values were better when compared with the preoperative features (p < 0.003 and p < 0.0001, respectively for degree of kyphosis and reduction in vertebral height.

Postoperative cerebral blood flow time-course after early or late surgery for ruptured intracranial aneurysms.

Out of a series of 43 cases operated on for ruptured intracranial aneurysms over a 12-month-period, 32 patients were followed up to 12 months postoperatively with repeated evaluations of cerebral blood flow (a mean of 3.4 studies for each patient), using the Xenon133 inhalation technique. Percent variation of hemispheric CBF from the sex- and age-matched reference values, obtained in both affected and contralateral side at 60-90 days postoperatively, was calculated in each of the patient assigned to one subgroup [a) patients submitted to delayed surgery; b) patients submitted to early surgery with a WFNS score of I-III, and c) patients submitted to early surgery with a WFNS score of IV-V]. The percent differences were averaged and the resulting mean values compared. None of them showed statistically significant differences, suggesting that the timing of surgery did not affect the results, either in good and poor grade patients, as far as cerebral blood flow is concerned. Depression of flow in the affected hemisphere of poor-grade patients was principally related to the preoperative occurrence of an intracerebral haematoma.

Reoperation in the management of post-operative disc space infection.

Post-operative intervertebral disc space infection had been recognised as a clinical entity with its own characteristics. Various treatments have been described. During the last six years 3127 open lumbar intervertebral disc operations were performed of which 15 (0.5%) showed a post-operative discitis. We treated our patients by reoperation of the infected intervertebral disc space. The reason of reoperation consists of acquiring material for bacteriological culture and removing loose fragments. It appears to us that reoperation is facilitating early mobilisation of patients. Also attention is paid to new diagnostic possibilities.

Spinal cord stimulation for the treatment of progressive systemic sclerosis and Raynaud's syndrome.

Progressive Systemic Scleroderma (PSS) is a generalized disease of connective tissue involving the skin, as well as other internal organs. The cutaneous signs are characterized by a progressive sclerosis and loss of function or dexterity in the hands. Between 1987 and 1992, 15 patients affected by scleroderma were treated by means of spinal cord stimulation (SCS) in order to reduce signs and symptoms related to vascular damage. The follow-up ranged from 12 months to 6 years. The study confirms that SCS is an effective therapy in patients with PSS and Raynaud's phenomenon because of its beneficial effects on the Raynaud episodes, ulcers, pain, vascular sclerosis and hand function. This method may have a primary role in the treatment of this chronic disorder because of the high probability of failure of other medical or surgical therapy.

Longitudinal study of cerebral blood flow following early or delayed surgery for ruptured intracranial aneurysms.

Out of a series of 43 cases operated on for ruptured intracranial aneurysms over a 12-month-period, 32 patients were followed up to 12 months postoperatively with repeated evaluations of cerebral blood flow, using the Xenon133 inhalation technique. No statistically significant differences in cerebral perfusion were detected between the subgroups of good-grade patients, who were submitted respectively to early, or delayed surgery. Depression of flow in the affected hemisphere of poor-grade patients was principally related to the preoperative occurrence of an intracerebral haematoma. The overall results were not consistent with the hypothesis that early surgical intervention results in long-lasting effects on the cerebral circulation.

Transpedicular decompression and stabilization of burst fractures of the lumbar spine.

Twenty-seven consecutive patients with neurological impairment due to burst fractures of the lumbar spine were operated upon, via the postero-lateral route, over a 38-month-period. Transpedicular fixation devices [posterior segmental fixator (PSF) or variable screw placement system (VSP)] were applied in all cases, in order to achieve short-segment fusion of the fractured spinal segment. Return to useful motor power or neurological normality (median follow-up: 18.7 months) occurred in 22 cases (81% of the whole series), with this outcome resulting in all but one of the cases with preoperative incomplete neurological deficit. Postoperative encroachment of the spinal canal, degree of kyphotic deformity, and reduction of the vertebral height showed statistically significant differences compared with the corresponding preoperative values.

Radicular compression by extradural spinal endometriosis. Case report.

The case of a 35 years old woman affected by endometriosis located inside the spinal canal in the extradural space at the level of the third left lumbar root, and developing through the corresponding foramen into the paraspinal muscles, is presented. The clinical aspect, radiological picture and surgical treatment are described. Pathogenesis is discussed on the basis of the literature. Furthermore it is stressed that only the histopathological examination gave the correct diagnosis and permitted the definitive hormonal treatment. To our best knowledge no comparable case has been published in the literature.