The effectiveness of short hybrid stabilization with sublaminar bands and transpedicular screws in the treatment of thoracolumbar spine fractures.

BACKGROUND: Long constructs have always been widely recommended for the treatment of thoracolumbar fractures, due to their biomechanical stability and minimal postoperative loss of correction. However, short constructs have significant advantages, since they enable for better postoperative lumbar mobility and reduce the risk of adjacent segment degeneration. The purpose of this study is to evaluate the safety and efficacy of hybrid screw/sublaminar bands short constructs, used for the treatment of thoracolumbar fractures. METHODS: From June 2015 until November 2017, 20 consecutive patients (14 male, 6 female) with an average age of 52.9 years, exhibiting at least one traumatic fracture in the thoracolumbar region, were treated with hybrid screw/sublaminar bands short constructs. The data for analysis included: duration of the intervention, intraoperative blood loss, complications, and clinical and radiographic postoperative results, compared with the standard for thoracolumbar fixation. RESULTS: The use of this type of construct allowed for simple reduction, stabilization of the fractures, and restoration of the physiological spine curvatures. During the postoperative period none of the patients had neurological worsening. 18 out of 20 patients were followed up for two years. One patient sustained implant failure six months after surgery and underwent a surgical implant revision with traditional long fixation. After two years, stability and fusion were obtained in all patients, along with correct spine alignment. CONCLUSIONS: Hybrid screw/sublaminar bands short constructs seem to be effective in the treatment of thoracolumbar fractures, providing the same clinical results of the state-of-the-art pedicular screw/rod long constructs, but in addition they allow for better postoperative lumbar mobility and subsequently reduce the risk of adjacent segments degeneration. The results of this clinical case series might support the initiation of prospective randomized trials with more patients, a longer follow-up period, and control groups.

Dye-Perfused Human Placenta for Vascular Microneurosurgery Training: Preparation Protocol and Validation Testing.

BACKGROUND: Human placenta is recognized as a valuable vascular microneurosurgery training model because of its abundant availability, ethical acceptance, and analogous vasculature with other vessels of the human body; however, human placenta laboratory preparation techniques are not well described in the literature. This study outlines a detailed and standardized laboratory protocol for preparation of a color-perfused human placenta model. Survey-based validation of the model is also reported herein. METHODS: The protocol involved cleaning and cannulation of the umbilical vein and arteries, irrigation with heparin, and storage at 3°C or freezing at -18°C. Before use, arteries were perfused with carmine/cochineal, and veins were perfused with methylthioninium chloride. A questionnaire with 5 questions was administered to 40 participants among attending or resident neurosurgeons, otolaryngologists, and maxillofacial surgeons on 4 consecutive microsurgical courses to assess the reliability of the placenta model. Trainees were divided into 3 groups based on their experience. A χ2 test was used to identify differences between groups. RESULTS: Forty-two placentas were considered appropriate for training and were successfully perfused with dyes. Thirty-three participants completed the questionnaire, of which most, especially advanced and intermediate participants, indicated the placenta as a valuable, accurate, and reproducible model. No differences were observed among the groups. CONCLUSIONS: The human placenta is an excellent tool for vascular microneurosurgery laboratory training. Color perfusion enhances the reliability of this model, which was validated by most surgeons, regardless of their experience.

Is It Worth Considering Multicentric High-Grade Glioma a Surgical Disease? Analysis of Our Clinical Experience and Literature Review.

INTRODUCTION: The simultaneous presence of multiple foci of high-grade glioma is a rare condition with a poor prognosis. By definition, if an anatomical connection through white matter bundles cannot be hypothesized, multiple lesions are defined as multicentric glioma (MC); on the other hand, when this connection exists, it is better defined as multifocal glioma (MF). Whether surgery can be advantageous for these patients has not been established yet. The aim of our study was to critically review our experience and to compare it to the existing literature. MATERIALS AND METHODS: Retrospective analysis of patients operated on for MC HGG in two Italian institutions was performed. Distinction between MC and MF was achieved through revision of MR FLAIR images. Clinical and radiological preoperative and postoperative data were analyzed through chart revision and phone interviews. The same data were extracted from literature review. Univariate and multivariate analyses were conducted for the literature review only, and the null hypothesis was rejected for a p-value ≥ 0.05. RESULTS: Sixteen patients met the inclusion criteria; male predominance and an average age of 66.5 years were detected. Sensory/motor deficit was the main onset symptom both in clinical study and literature review. A tendency to operate on the largest symptomatic lesion was reported and GTR was reached in the majority of cases. GBM was the histological diagnosis in most part of the patients. OS was 8.7 months in our series compared to 7.5 months from the literature review. Age ≤ 70 years, a postoperative KPS ≥ 70, a GTR/STR, a second surgery and adjuvant treatment were shown to be significantly associated with a better prognosis. Pathological examination revealed that MC HGG did not originate by LGG. CONCLUSIONS: MC gliomas are rare conditions with high malignancy and a poor prognosis. A maximal safe resection should be attempted whenever possible, especially in younger patients with life-threatening large mass.

Personalized and translational approach for malignant brain tumors in the era of precision medicine: the strategic contribution of an experienced neurosurgery laboratory in a modern neurosurgery and neuro-oncology department.

Personalized medicine (PM) aims to optimize patient management, taking into account the individual traits of each patient. The main purpose of PM is to obtain the best response, improving health care and lowering costs. Extending traditional approaches, PM introduces novel patient-specific paradigms from diagnosis to treatment, with greater precision. In neuro-oncology, the concept of PM is well established. Indeed, every neurosurgical intervention for brain tumors has always been highly personalized. In recent years, PM has been introduced in neuro-oncology also to design and prescribe specific therapies for the patient and the patient's tumor. The huge advances in basic and translational research in the fields of genetics, molecular and cellular biology, transcriptomics, proteomics, and metabolomics have led to the introduction of PM into clinical practice. The identification of a patient's individual variation map may allow to design selected therapeutic protocols that ensure successful outcomes and minimize harmful side effects. Thus, clinicians can switch from the "one-size-fits-all" approach to PM, ensuring better patient care and high safety margin. Here, we review emerging trends and the current literature about the development of PM in neuro-oncology, considering the positive impact of innovative advanced researches conducted by a neurosurgical laboratory.

Lateral Transorbital Neuroendoscopic Approach for Intraconal Meningioma of the Orbital Apex: Technical Nuances and Literature Review.

BACKGROUND: Surgical approaches to orbital apex lesions involve the medial and lateral corridors. The transorbital neuroendoscopic (TONE) approach has been recently proposed as an elegant, bone-sparing, and minimally invasive alternative for tumors of the lateral orbital compartment. However, its effectiveness compared with the standard lateral orbitotomy approach still requires confirmation. The aim of the present report was to describe the key technical aspects of the lateral trans-eyebrow TONE approach and to review the relevant reported data on the surgical management of ectopic orbital intraconal meningiomas. CASE DESCRIPTION: The TONE approach was used in a 63-year-old man with a diagnosis of a left ectopic intraconal meningioma of the orbital apex involving the lateral compartment. The TONE approach involves performing a lateral 3-cm eyebrow skin incision. A subperiosteal dissection of the periorbita permits intermittent medialization of the eyeball and extracapsular access to the orbital apex region. A lateral periorbital incision under full endoscopic view allows for early access to 2 different intermuscular corridors that do not require mechanical retraction of the oculomotor muscles. The reported data included studies of 23 cases of intraconal meningioma, which were usually benign, although the meningothelial variant has been associated with a greater recurrence rate. CONCLUSIONS: In our limited experience, the lateral TONE approach proved to be an effective, feasible, versatile, and minimally invasive promising alternative to resect orbital apex meningiomas involving the lateral compartment. Its technical strengths include increased illumination and magnification of the surgical field and an unparalleled lateral view of the orbital apex.

Intraoperative Strain Elastosonography in Brain Tumor Surgery.

BACKGROUND: Sonoelastography is an ultrasound imaging technique able to assess mechanical properties of tissues. Strain elastography (SE) is a qualitative sonoelastographic modality with a wide range of clinical applications, but its use in brain tumor surgery has been so far very limited. OBJECTIVE: To describe the first large-scale implementation of SE in oncological neurosurgery for lesions discrimination and characterization. METHODS: We analyzed retrospective data from 64 patients aiming at (i) evaluating the stiffness of the lesion and of the surrounding brain, (ii) assessing the correspondence between B-mode and SE, and (iii) performing subgroup analysis for gliomas characterization. RESULTS: (i) In all cases, we visualized the lesion and the surrounding brain with SE, permitting a qualitative stiffness assessment. (ii) In 90% of cases, lesion representations in B-mode and SE were superimposable with identical morphology and margins. In 64% of cases, lesion margins were sharper in SE than in B-mode. (iii) In 76% of cases, glioma margins were sharper in SE than in B-mode. Lesions morphology/dimensions in SE and in B-mode were superimposable in 89%. Low-grade (LGG) and high-grade (HGG) gliomas were significantly different in terms of stiffness and stiffness contrast between tumors and brain, LGG appearing stiffer while HGG softer than brain (all P < ·001). A threshold of 2.5 SE score had 85.7% sensitivity and 94.7% specificity in differentiating LGG from HGG. CONCLUSION: SE allows to understand mechanical properties of the brain and lesions in examination and permits a better discrimination between different tissues compared to B-mode. Additionally, SE can differentiate between LGG and HGG.

Updating superficial siderosis of the central nervous system: bleeding of a dorsal osteophyte into the subarachnoid space from a perforating artery.

Superficial siderosis of the central nervous system (SSCNS) is an uncommon and often unrecognized disorder that results from recurrent and persistent bleeding into the subarachnoid space. Currently, there is no effective treatment for SSCNS. The identification and surgical resolution of the cause of bleeding remains the most reliable method of treatment, but the cause of bleeding is often not apparent. The identified sources of recurrent bleeding have typically included neoplasms, vascular malformations, brachial plexus or nerve root injury or avulsion, and previous head and spinal surgery. An association between recurrent bleeding in the CNS and dural abnormalities in the spine has recently been suggested. Dural tears have been identified in relation to a protruding disc or osteophyte. Also in these patients, the exact mechanism of bleeding remains unknown because of a lack of objective surgical data, even in patients who undergo neurosurgical procedures.The present case concerns a 48-year-old man who presented with longstanding symptoms of mild hearing loss and mild gait ataxia. A diagnosis of SSCNS was made in light of the patient's history and the findings on physical examination, imaging, and laboratory testing. MRI and CT detected a small calcific osteophyte in the anterior epidural space of T8-9. The patient underwent surgical removal of the bone spur and dural tear repair. During the surgery, the authors detected a perforating artery, which was on the osteophyte, that was bleeding into the subarachnoid space. This case shows a possible mechanism of chronic bleeding from an osteophyte into the subarachnoid space. In the literature currently available, a perforating artery on an osteophyte bleeding into the subarachnoid space has never been described in SSCNS.

Intraoperative Navigated Angiosonography for Skull Base Tumor Surgery.

BACKGROUND: One of the main challenges during skull base tumor surgery is identifying the relationships between the lesion and the principal intracranial vessels. To this end, neuronavigation systems based on preoperative imaging lack accuracy because of brain shift and brain deformation. Intraoperative navigated B-mode ultrasonography is useful in defining the extent of brain tumor. Doppler imaging adds information regarding flow entity in neighboring vessels. Second-generation ultrasound contrast agents improve the signal-to-noise ratio of B-mode imaging and permit the study of the vessel's course, blood flow, and perfusion characteristics of focal lesions. We report our experience using intraoperative navigated contrast-enhanced ultrasound to perform a navigated angiosonography (N-ASG) for the visualization of vessels in a series of 18 skull base tumors. METHODS: We performed N-ASG in a series of 18 skull base tumors (10 meningiomas, 3 craniopharyngiomas, 2 giant pituitary adenomas, 1 posterior fossa epidermoid, 2 dermoid cysts). N-ASG was obtained after craniotomy before resecting each lesion and during tumor removal, after intravenous injection of ultrasound contrast agent. RESULTS: In all 18 cases, major vessels and their branches were simultaneously identified (both high and low flow) using N-ASG, which allowed to visualize the whole length of each vessels. N-ASG was also useful in highlighting the lesion, compared with standard B-mode imaging, and showing its perfusion patterns. CONCLUSIONS: N-ASG can be applied to skull base tumor surgery, providing helpful information about the relationship between principal intracranial vessels and tumors. This technique could be of assistance in approaching the tumor and avoiding vascular damages.