"The Double S" Technique: Subfascial Dissection and Temporalis Muscle Splitting to Prevent Cerebrospinal Fluid Leak and Maximize Surgical Exposure.

BACKGROUND: Middle cranial fossa surgery commonly is approached either performing a subtemporal or a pterional craniotomy. To maximize a basitemporal region exposure, an adjunctive bone drilling could be required. In these cases, a watertight dura and temporalis muscle closure are mandatory. OBJECTIVE: To describe a modified temporalis muscle dissection in middle cranial fossa surgery to increase basitemporal region exposure while assuring a safe and effective closure thus avoiding cerebrospinal fluid (CSF) leakage. METHODS: A total of 8 patients have been enrolled. Five pterional and 3 subtemporal approaches were performed. In all cases, the novel subfascial muscle dissection and temporalis muscle splitting technique named "the double S technique," was performed to cut up the temporal muscle. RESULTS: In all cases, a subgaleal drainage was used and removed within 48 hours. No cases of postoperative CSF leak or hematoma collection were reported. CONCLUSIONS: The double S technique is a safe and effective alternative to enhance the basitemporal region exposure while avoiding the potential, common risk of CSF leak.

Exosomal Chaperones and miRNAs in Gliomagenesis: State-of-Art and Theranostics Perspectives.

Gliomas have poor prognosis no matter the treatment applied, remaining an unmet clinical need. As background for a substantial change in this situation, this review will focus on the following points: (i) the steady progress in establishing the role of molecular chaperones in carcinogenesis; (ii) the recent advances in the knowledge of miRNAs in regulating gene expression, including genes involved in carcinogenesis and genes encoding chaperones; and (iii) the findings about exosomes and their cargo released by tumor cells. We would like to trigger a discussion about the involvement of exosomal chaperones and miRNAs in gliomagenesis. Chaperones may be either targets for therapy, due to their tumor-promoting activity, or therapeutic agents, due to their antitumor growth activity. Thus, chaperones may well represent a Janus-faced approach against tumors. This review focuses on extracellular chaperones as part of exosomes' cargo, because of their potential as a new tool for the diagnosis and management of gliomas. Moreover, since exosomes transport chaperones and miRNAs (the latter possibly related to chaperone gene expression in the recipient cell), and probably deliver their cargo in the recipient cells, a new area of investigation is now open, which is bound to generate significant advances in the understanding and treatment of gliomas.

Vertebrobasilar junction giant aneurysm: Lessons learned from a neurosurgical audit and anatomical investigation.

The treatment of vascular lesions of the vertebrobasilar junction (VBJ) remains a challenging task in the neurosurgical practice and the gold standard therapy is still under debate. In this article, the authors report a detailed postmortem study of a VBJ giant aneurysm (GA) previously endovascularly treated. Although the decision-making process for the vast majority of neurosurgical treatment can nowadays be accurately carried out during the preoperative planning (i.e., with the aid of neuroimaging fusion protocols, neuronavigation platforms, etc.) meant to maximize the anatomical understanding of the lesions and minimize possible intraprocedural challenges, this postmortem study represents the ultimate essence of neurosurgical audit as the laboratory investigations allowed to reevaluate the clinical history of VBJ GA, and reassess the multiple strategies available for its treatment with a straightforward anatomical perspective. Specifically, the lessons learned through this clinical and laboratory work uphold a great educational value regarding the complex management of those lesions, including the possible role of combined skull base surgical approaches.

Hemostasis in brain tumor surgery using the Aquamantys system.

BACKGROUND: Adequate hemostasis in cranial and spinal tumor surgery is of paramount importance in neurosurgical practice. Generalized ooze bleeding from the surgical walls cavity, coming from neoplastic vessels or nervous tissue, may be problematic. Recent technical advances have dramatically reduced intraoperative complications related to blood loss. Several techniques are usually employed to control hemostasis in tumor surgery, including preoperative embolization, intraoperative hypotension, electrical coagulation, and local application of fibrin sealants or hemostatic matrix, which influence coagulation. MATERIAL AND METHODS: Our aim in this study was to evaluate the efficacy and the safety of the Aquamantys® system (Medtronic Advanced Energy, Portsmouth, NH, USA), a novel bipolar coagulation device that incorporates a new bipolar coagulation technique. This device has been used in 10 consecutive patients affected by cerebral tumor along with the standard microsurgical technique and well-known intraoperative tools. The technique is associated with simultaneous delivery of bipolar radio frequency energy and conductive fluid through its electrode tip. The volume of saline passing by the electrode tip prevents charring and maintains a clean tip. This cools the tissue as it raises the temperature sufficiently to shrink the collagen of veins and arteries. RESULTS: Effective hemostasis was achieved in all the cases. No complications or unwanted reactions associated with the device have been observed. CONCLUSIONS: Our findings suggest that the Aquamantys® system may be a highly effective adjuvant tool in minimizing blood loss in a patient with brain tumor, as well as reducing time of surgery.

Diffuse idiopathic skeletal hyperostosis: A functional enemy of vertebral stability - Case series and surgical consideration of craniovertebral junction involvement.

Context: Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's syndrome may reduce vertebral mobility, thus affecting the stability of adjacent vertebral segments and promoting spinal stenosis, vertebral dislocation, and unstable fracture secondary to low-energy trauma. Aims: This study aimed to contribute with a case series of three patients affected by DISH undergone surgery with occipitocervical fixation for craniovertebral junction (CVJ) instability since the poor literature about CVJ instability and surgery in patients affected by DISH. Settings and Design: This was a multicentric case series. Subjects and Methods: Literature about CVJ instability and surgery in patients affected by DISH is poor. Thus, we present a case series of three patients affected by DISH, who underwent surgery with occipitocervical fixation with different clinical and radiological patterns. Results: CVJ represents one of the most mobile joints of the spine and is at greater risk for instability. Moreover, instability itself may act as primum movens for several degenerative conditions such as cervical spondylosis, ossification of the posterior longitudinal ligament, and cervical deformities. On the contrary, DISH itself may worsen CVJ instability because of subaxial spine stiffness. In case of DISH, the rigid unit formed by several ossified vertebral bodies acts as a long lever arm, increasing the forces applied to the hypermobile CVJ and reducing the dynamic buffer capability of ossified spine. On the other hand, vertebral instability increases the odds of fractures. In such cases, CVJ posterior instrumentation and fusion is an effective and feasible surgical technique, aimed to restore vertebral stability and to halt the progression of spinal stenosis. Conclusions: Due to the altered dynamics cervical spine along with the possible comorbidities, treatment indication and surgery for patients affected by DISH must be tailored case by case.

Aneurysmal bone cyst of the spine in adult patients: A systematic review and comparison of primary vs secondary lesions.

BACKGROUND: Spine aneurysmal bone cysts (ABCs) rarely occur in adults. Primary and secondary lesions may show some differences and require appropriate treatments. OBJECTIVE: To systematically review the literature on adult spine ABCs. METHODS: PubMed, EMBASE, Scopus, and Web-of-Science were searched. Clinical-radiological features, treatments, and outcomes were analyzed and compared between primary vs secondary adult spine ABCs. RESULTS: We included 80 studies comprising 220 patients. Primary spine ABCs were more frequent (76.4%). Main symptoms were lower-back-pain (42.8%) and motor deficits (31.2%). Tumors were mostly thoracic (31.4%) or cervical (26.8%), showing lytic (70.4%) and/or cystic (52.3%) appearances. Surgical resection (79.1%) was preferred over biopsy (20.9%). Most primary ABCs underwent curettage with bone grafting (62.1%) and laminectomy (39.1%) (P < 0.001), while most secondary ABCs underwent corpectomy (51%) and spine fixation (93.9%) (P < 0.001). Radiotherapy was delivered in 58 patients (26.4%), and embolization in 37 (16.8%). Symptomatic improvement was reported in 91.8% cases, with no differences based on etiology nor extent-of-resection. Median follow-up was 28.5 months, significantly superior in secondary ABCs. Secondary ABCs had significantly higher rates of tumor recurrence (19.2%; P = 0.011) and death (5.8%; P = 0.002). CONCLUSION: Surgical resection, radiotherapy, and embolization are effective in managing adult spine ABCs. Secondary tumors have worse prognoses requiring more aggressive treatments.

DBS, tcMRgFUS, and gamma knife radiosurgery for the treatment of essential tremor: a systematic review on techniques, indications, and current applications.

INTRODUCTION: Essential tremor (ET) may severely impact patient's Quality of Life. Several techniques such as radiofrequency, deep brain stimulation (DBS), gamma knife (GK) radiosurgery and high-intensity focused ultrasound may be used for the surgical treatment of ET. The aim of this paper is to summarize the most recent available literature on DBS, transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) and GK, and to compare indications, targets, and effectiveness of these surgical techniques for the treatment of ET. EVIDENCE ACQUISITION: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was performed on the three largest medical databases (PubMed, Scopus, and Web of Science). This systematic review is focused on the effectiveness and safety of GK, DBS, and tcMRgFUS as functional neurosurgical techniques for the treatment of ET. The aim of this study was to compare these techniques by evaluating mode, target, effectiveness in improving motor outcomes, and rates of adverse effects. EVIDENCE SYNTHESIS: Articles meeting the predetermined criteria were included. Data for DBS, tcMRgFUS, and GK were analyzed and compared for indications, patient selection, advantages vs. disadvantages, and treatment targets for essential tremor. CONCLUSIONS: DBS, tcMRgFUS and GK are effective techniques for the treatment of ET. Despite different functioning principles, all three surgical techniques require a proper functional diagnosis to define accurate indications for patient selection. Their indication depends upon the patient's neurological condition and their effectiveness relies on proper targeting.

Reconstruction of vertebral body in thoracolumbar AO type A post-traumatic fractures by balloon kyphoplasty: a series of 85 patients with a long follow-up and review of the literature.

BACKGROUND: Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal traumas. Optimal management of these fractures still gives rises to much debate in the literature. Currently, one of the treatment options in young patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improving physical function with early return to work activity. The aim of our study was to report VAS, ODI scores, and kyphosis correction following treatment. METHODS: This is a retrospective study to investigate the clinical and radiological results 10 years after percutaneous balloon kyphoplasty followed by cement augmentation with polymethylmethacrylate (PMMA) or calcium phosphate cements (CPC), according to age, in 85 consecutive patients affected by 91 AO spine type A traumatic fractures of the thoracolumbar spine (A1, A2, and A3). Clinical follow-up was performed with the Visual Analogic Scale (VAS) at the preoperative visit and in the postoperative follow-up after 1 week, 1, 6, 12 months, and each year up to 10 years. Additionally, the Oswestry Disability Index (ODI) improvement was calculated as the difference between the ODI scores at the preoperative visit and at final follow-up. Finally, the Cobb angle from this cohort was assessed before surgery, immediately postoperatively, and at the end of follow-up. RESULTS: Kyphoplasty markedly improved pain and resulted in statistically significant vertebral height restoration and normalization of morphologic shape indexes that remained stable for at least 10 years following treatment. CONCLUSIONS: The present study showed that kyphoplasty and cement augmentation are an effective method of treatment for selected type A fractures.

Safeness and efficacy of 2-µm handheld thulium laser during microsurgical resection of supratentorial and infratentorial meningiomas: Experience of a single center.

Aims: We performed a retrospective nonrandomized study to analyze the results of a microsurgery of intracranial meningiomas using 2-µm thulium flexible handheld laser fiber (Revolix jr). Methods: From February 2014 to December 2021, 75 nonconsecutive patients suffering from intracranial meningiomas, admitted in our department, have been operated on with microsurgical technique assisted by 2-µm thulium flexible handheld laser. We have reviewed demographic and clinical data to evaluate safety and efficacy of the technique. Results: There were no complications related to the use of the 2-µm thulium laser. We operated on a high percentage of cranial base and tentorial and posterior fossa meningioma in our series. The neurological outcome and degree of resection did not differ from previous series. The neurosurgical team found the laser easy to use and practical for avoiding bleeding and traction. Conclusion: The use of 2-µm thulium fiber handheld flexible laser in microsurgery of intracranial meningiomas seems to be safe and to facilitate tumor resection, especially in "difficult" conditions (e.g., deep seated, highly vascularized, and hard tumors). Even if in this limited retrospective trial the good functional outcome following conventional microsurgery had not further improved, nor the surgical time was reduced by laser, focusing its use on "difficult" (large and vascularized) cases may lead to different results in the future.

A Spotlight on the Role of Radiomics and Machine-Learning Applications in the Management of Intracranial Meningiomas: A New Perspective in Neuro-Oncology: A Review.

Background: In recent decades, the application of machine learning technologies to medical imaging has opened up new perspectives in neuro-oncology, in the so-called radiomics field. Radiomics offer new insight into glioma, aiding in clinical decision-making and patients' prognosis evaluation. Although meningiomas represent the most common primary CNS tumor and the majority of them are benign and slow-growing tumors, a minor part of them show a more aggressive behavior with an increased proliferation rate and a tendency to recur. Therefore, their treatment may represent a challenge. Methods: According to PRISMA guidelines, a systematic literature review was performed. We included selected articles (meta-analysis, review, retrospective study, and case-control study) concerning the application of radiomics method in the preoperative diagnostic and prognostic algorithm, and planning for intracranial meningiomas. We also analyzed the contribution of radiomics in differentiating meningiomas from other CNS tumors with similar radiological features. Results: In the first research stage, 273 papers were identified. After a careful screening according to inclusion/exclusion criteria, 39 articles were included in this systematic review. Conclusions: Several preoperative features have been identified to increase preoperative intracranial meningioma assessment for guiding decision-making processes. The development of valid and reliable non-invasive diagnostic and prognostic modalities could have a significant clinical impact on meningioma treatment.

Posterior epidural intervertebral disc migration and sequestration: A systematic review.

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.

Unusual recurrence of trigeminal neuralgia after microvascular decompression by muscle interposal.

BACKGROUND: Patients with trigeminal neuralgia (TN) and persistent or recurrent facial pain after microvascular decompression (MVD) typically undergo less invasive procedures in the hope of providing pain relief. However, re-operation should be considered in selected patients. CASE REPORT: A 48-year-old woman presented with recurrent trigeminal neuralgia (TN) 3 years following microvascular decompression (MVD). The patient underwent brain magnetic resonance angiography (MRA), which did not reveal neurovascular compression; therefore surgical re-exploration was carried out. During the operation, the fifth cranial nerve was seen without impingement from any blood vessels; however, a very firm tissue was observed and identified as the muscle fragment from the previous MVD procedure. The fifth cranial nerve was carefully separated from the muscle. Thereafter, the right SCA was dissected out from the muscle and suspended by a periosteum tape sutured to the nearby dura. CONCLUSIONS: Our findings, along with similar cases reported in the literature, support the development of new inert materials and alternative surgical strategies that can limit TN recurrence.

A new tool to improve pedicle screw placement accuracy in navigated spine surgery: a monocentric study.

BACKGROUND: Navigated instrumented spine surgery is burden by a low but significant screw mispositioning risks, respectively, for the 2D imaging system from 15% to 40% and, for the 3D imaging system, ranging from 4.1% to 11.5%. The primary objective of this study was to demonstrate the efficacy of a new screw-like tool in order to further decrease pedicle screws mispositioning rate during vertebral navigated spine surgery. METHODS: Between January and June 2019 an initial case series of 18 patients were enrolled. All patients underwent a pedicle screw fixation, both in thoracic (Th10-Th12) and lumbosacral (L1-S1) spine, using O-arm (Medtronic Navigation, Louisville, CO, USA) and StealthStation S7 surgical navigation system (Medtronic Navigation). Evaluation of pedicle screws placement accuracy using the new tool in adjunct to the classic reference frame, was performed following the Gertzbein and Robbins classification. RESULTS: A total of 94 screws have been placed. Among them, 98.9% were completely inside cortical bone (grade A) and only 1.1% with a breach of less than 2 mm (grade B). CONCLUSIONS: Our new "screw-like" tool coupled to the classic reference frame device could improve accuracy during navigated spine surgery and potentially reducing to zero the risks for screw mispositioning.

Surgical Back Risk Syndrome and Spinal Cord Stimulation: Better Safe Than Sorry.

BACKGROUND: Recurrent and chronic low back pain, caused by degenerative lumbar spondylosis, commonly affects elderly patients, even those with no previous low back surgery. These patients, like those affected by failed back surgery syndrome (FBSS), may become unresponsive to medical conservative treatment and their quality of life could be easily compromised. Moreover, general comorbidities, obesity, and other typical conditions of the elderly may make surgery under general anesthesia riskier than the natural history of the disease. These patients could be considered affected by surgical back risk syndrome (SBRS). METHODS: In this article, we report our preliminary observational prospective study on the role of spinal cord stimulation (SCS) in 3 groups of patients: the FBSS group, the SBRS group, and the "other" group. Selection criteria, treatment modality, and outcomes for each patient group are described and discussed. Moreover, a potentially useful diagnostic and therapeutic flowchart on the management options for lumbar back diseases is discussed. RESULTS: The FBSS group included 25 patients, the SBRS group included 10 patients, and the other group included 3 patients. In 22/25 patients with FBSS (88% of the total), the implantation of a definitive neurostimulator was successful. In almost all patients in both the SBRS and the other groups, the implantation of a definitive neurostimulator was successful. CONCLUSIONS: In our opinion, SCS could be considered as a valid alternative treatment not only in selected patients affected by FBSS but also in selected patients affected by SBRS, in whom back surgery under general anesthesia may be challenging and overcome the potential benefit of the surgery itself. SBRS could be considered a new disease entity to be managed through SCS.

Aneurysm clipping following endovascular coil embolization: a report of two cases.

BACKGROUND: Treatment of intracranial aneurysms by Guglielmi detachable coil (GDC) embolization is a useful therapeutic alternative to surgery. This procedure is attractive as a minimally invasive approach to treat cerebral aneurysms; however, is not devoid of complications or failure and retreatment, with either a surgical or endovascular technique, may often be required. CASE REPORTS: Two cases are presented in which surgery was required after coil embolization. In one case, surgical treatment was performed one month later because of regrowth and subsequent bleeding of the aneurysm. In the second case, surgical treatment was carried out six months later because of recanalization of the vascular malformation. Surgical treatment excluded both aneurysms from the cerebral circulation. CONCLUSIONS: In this paper the authors illustrate their experience and underline the difficulty of aneurysm surgery with coils in place.

The role of erythropoietin in neuroprotection: therapeutic perspectives.

Nervous system diseases are very complex conditions comprising a large variety of local and systemic responses. Several therapeutic agents interfering with all or in part the biochemical steps that ultimately cause neuronal death have been demonstrated to be neuroprotective in preclinical models. However, all the agents so far investigated have inexorably failed in the phase III trials carried out. A large body of evidence suggests that the hormone erythropoietin (EPO), besides its well-known hematopoietic action, exerts beneficial effects in the central nervous system. EPO's effect has been assessed in several experimental models of brain and spinal cord injury thus becoming a serious candidate for neuroprotection. The use of EPO as neuroprotectant raises several questions. Besides dosage and therapeutic time window, the safety of recombinant EPO administration in the setting of nervous system diseases takes priority over all other questions. Although recombinant EPO seems to be potentially safe at the neuroprotective proved doses, cardiovascular or cerebrovascular events can occur as a result of its bone marrow stimulating activities. The successful trial using EPO in patients with ischemic stroke and the large body of experimental evidence encourages intensive evaluation of this cytokine to support safe and larger clinical trials in the near future.

Neuroprotection by erythropoietin administration after experimental traumatic brain injury.

A large body of evidence indicates that the hormone erythropoietin (EPO) exerts beneficial effects in the central nervous system (CNS). To date, EPO's effect has been assessed in several experimental models of brain and spinal cord injury. This study was conducted to validate whether treatment with recombinant human EPO (rHuEPO) would limit the extent of injury following experimental TBI. Experimental TBI was induced in rats by a cryogenic injury model. rHuEPO or placebo was injected intraperitoneally immediately after the injury and then every 8 h until 2 or 14 days. Forty-eight hours after injury brain water content, an indicator of brain edema, was measured with the wet-dry method and blood-brain barrier (BBB) breakdown was evaluated by assay of Evans blue extravasation. Furthermore, extent of cerebral damage was assessed. Administration of rHuEPO markedly improved recovery from motor dysfunction compared with placebo group (P<0.05). Brain edema was significantly reduced in the cortex of the EPO-treated group relative to that in the placebo-treated group (80.6+/-0.3% versus 91.8%+/-0.8% respectively, P<0.05). BBB breakdown was significantly lower in EPO-treated group than in the placebo-treated group (66.2+/-18.7 mug/g versus 181.3+/-21 mug/g, respectively, P<0.05). EPO treatment reduced injury volume significantly compared with placebo group (17.4+/-5.4 mm3 versus 37.1+/-5.3 mm3, P<0.05). EPO, administered in its recombinant form, affords significant neuroprotection in experimental TBI model and may hold promise for future clinical applications.

Neuroprotective potential of erythropoietin and darbepoetin alfa in an experimental model of sciatic nerve injury. Laboratory investigation.

OBJECT: The objectives of this study were to examine whether the systemic administration of recombinant human erythropoietin (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery in a rat model of sciatic nerve injury, and to compare the effects of these agents in the model. METHODS: Thirty male Sprague-Dawley rats received a crush injury to the left sciatic nerve and subsequently underwent either placebo treatment, daily injections of rHuEPO, or weekly injections of darbepoetin alfa. RESULTS: Both rHuEPO and darbepoetin alfa were effective in reducing neurological impairment and improving compound muscle action potentials following nerve injury. Darbepoetin alfa, however, shortened the duration of peripheral nerve recovery'and facilitated recovery from the neurological and electrophysiological impairment following crush injury significantly better than rHuEPO. Examination of the footprint length factor data revealed that darbepoetin alfa-treated animals recovered preinjury function by postoperative Day 10, 4 days earlier than animals treated with rHuEPO and 11 days earlier than animals treated with placebo. CONCLUSIONS: These results suggest that recovery of neurological function in a model of peripheral nerve injury is more rapid with weekly administration of darbepoetin alfa than with daily rHuEPO treatment. Agents that facilitate nerve regeneration have the potential to limit the extent of motor endplate loss and muscle atrophy. The administration of EPO in its long-lasting recombinant forms affords significant neuroprotection in peripheral nerve injury models and may hold promise for future clinical applications.