Treatment algorithm for spontaneous spinal infections: A review of the literature

Background: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Methods: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. Results: Literature reveals that on the basis of a clinical suspicion, the…

Is Aspirin a Worthy Candidate in Preventing Intracranial Aneurysm Rupture?

Subarachnoid hemorrhage (SAH) usually occurs with a thunderclap headache or the worst headache of a patient's life, leading to a neurologic emergency. Among cases of nontraumatic SAH, 80%–85% are caused by ruptured intracranial aneurysms (IAs) and comprise 3% of all strokes in high-income countries In the years 2000–2008, the incidence of SAH was 4–7 per 100,000 person-years in high-income and low-to middle-income countries. Outcome after aneurysmal SAH depends on several factors, including severity of the initial hemorrhage, rebleeding, perioperative medical management, and timing and technical success for vascular malformation exclusion from the cerebral circulation. It has been estimated…

Lumbar facet joint stabilization for symptomatic spinal degenerative disease: A systematic review of the literature

Objective: Lumbar spinal degenerative disease (LSDD), unresponsive to conservative therapy, is commonly treated by surgical decompression and interbody fusion. Since facet joint incompetence has been suggested as responsible for the entire phenomenon of spinal degeneration, facet stabilization can be considered as an alternative technique to treat symptomatic spinal degenerative disease. The purpose of this study was to systematically review the literature for studies utilizing lumbar facet joint fixation techniques for LSDD to assess their safety and efficacy. Methods: A systematic literature review was performed following the preferred reporting items for systematic reviews and meta-analy…

Current Concepts and Perspectives on Brain Arteriovenous Malformations: A Review of Pathogenesis and Multidisciplinary Treatment.

Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. T…

Microwave Ablation for Metastatic Spinal Tumors

Early Onset of Guillain–Barré Syndrome Following Lumbar Disc Herniation Surgery: An Unexpected Clinical Evolution

Letter: Guillain–Barré syndrome (GBS), is a neurologic complication rarely reported following a spinal surgery procedure.1, 2, 3, 4, 5, 6 GBS is a potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. It is the most common cause of acute flaccid paralysis, with an annual global incidence of approximately 1–2 per 100,000 person-years.7 Although the clinical presentation of the disease is heterogeneous, patients typically present with weakness and sensory signs in the legs that progress to the arms and cranial muscles. Disease progression can be rapid in approximately 20% of patients with respiratory failure requiring mech…

Concept of Spectrobiopsy Facing Gliomas: Rational and Future Perspectives Related to Target Therapy

Gliomas represent the most common primary intracranial tumors with an estimated incidence of 31% of all central nervous system neoplasms. Lesions originated from glial cells are extremely heterogeneous, ranging from low grade to high grade with different clinical and biological malignancy. Glioblastoma multiforme (GBM) is the most aggressive and frequent primary malignant tumor of the central nervous system in adults. Even though in the past decades considerable efforts have been made in the therapeutic management of this type of tumor,2 the prognosis after diagnosis of GBM remains extremely poor, reaching a median overall survival of 12–18 months. In 2016 the World Health Organization clas…

The Ipsilateral Interhemispheric Transprecuneal Approach to the Atrium: Technical Considerations and Clinical Outcome on a Series of 7 Patients

Surgical removal of tumors of the atrium is challenging due to their deep location, vascularization, and to their complex three-dimensional relationships with the highly functional white matter fibers of the region. To assess the feasibility and the effectiveness of the ipsilateral interhemispheric transprecuneus approach (IITA) for tumors involving the atrium and the posterior third of the temporal horn, a retrospective chart review of all patients who had undergone a surgical treatment for intraventricular tumors between January 2008 and January 2017 was performed, and the step-by-step approach is described. Ten patients affected by lesions of the atrium of the lateral ventricle underwent…

Letter to the Editor. Idiopathic normal pressure hydrocephalus: is 1-year follow-up enough?

Minimally Invasive Surgery for Decompression in Chiari I Malformation

Chiari malformations (CMs) includes different pathologies sharing common anatomic deformities of the brainstem and cerebellum. CM type I was originally introduced by Hans Chiari and described as an “elongation of the tonsils and the medial parts of the inferior lobes of the cerebellum into cone-shaped projections which accompany the medulla oblongata into the spinal canal.” The prevalence of CM has been estimated to be between 0.1% and 0.5%, but it is possible that higher rates will be identified since the increasing the use of magnetic resonance imaging (MRI) in common clinical practice. Clinical studies have shown an equal prevalence in both sexes without particular ethnic or geographic d…

Conservative Management for Odontoid Cervical Fractures: Halo or Rigid Cervical Collar?

Odontoid fractures are the most common fractures of the cervical spine, especially in the elderly. They account for approximately one third of cervical spine fractures, and with the aging of the world population, the incidence and clinical and social relevance of such pathology are likely to increase. Odontoid fractures may occur from high-energy mechanisms, particularly in younger patients, but low-energy trauma may be the causative factor in the geriatric population. Overall, the treatment of patients with odontoid process fractures is based on the type of the fracture, patient's health status, age, association with neurologic deficits, and personal preference of the surgeon. Relative ind…

Microsurgical Management of Intracranial Aneurysms After Flow Diversion Failure

Subarachnoid hemorrhage (SAH) occurring after an intracranial aneurysm rupture has an incidence of 10.5 per 100,000 person-years and accounts for about 5% of strokes. The resulting outcome depends on several factors including the severity of the initial hemorrhage, rebleeding, perioperative medical management, and the timing and technical success for aneurysm treatment. The overall mortality rates from 32%−67% with 10%–20% of patients with long-term dependence due to brain damage. It is well known that 12% of patients die before achieving medical treatment and 25% die within the first 24 hours. Again, 40%–60% mortality rate occurs within 30 days. Among the surviving patients, about one thir…

Innovations in the Art of Microneurosurgery for Reaching Deep-Seated Cerebral Lesions.

Deep-seated cerebral lesions have fascinated and frustrated countless surgical innovators since the dawn of the microneurosurgical era. To determine the optimal approach, the microneurosurgeon must take into account the characteristics and location of the pathological lesion as well as the operator's range of technical expertise. Increasingly, microneurosurgeons must select between multiple operative corridors that can provide access to the surgical target. Innovative trajectories have emerged for many indications that provide more flexible operative angles and superior exposure but result in longer working distances and more technically demanding maneuvers. In this article, we highlight 4 …

Maximizing the Extent of Resection in High-Grade Glioma.

High-grade gliomas (HGGs) are devastating tumors associated with one of the worst prognoses in oncology. Glioblastoma multiforme (GBM) is the most frequently reported histologic type, with a median survival after surgery and combined treatment with chemotherapy and radiotherapy of 12–16 months. Several studies have shown that the extent of resection (EOR) of the contrast-enhancing part of the tumor improves survival in patients with HGGs, although the quest to achieve optimal oncologic outcomes must be tempered with the neurologic result following radical resection. To date, limited evidence exists on the relationship between EOR and level of clinical benefit for patients with HGGs. Brown e…

Hybrid Anterior Cervical Discectomy
and Fusion and Cervical Disc Arthroplasty: An Analysis of Short-Term Complications, Reoperations, and Readmissions

Management of Odontoid Cervical Fracture

Fractures of the cervical odontoid process are the most common fractures of the cervical tract, accounting for one third of all cervical spine fractures. They are more frequent in elderly patients, and with the aging of the world population, their incidence and clinical and social relevance are expected to increase in the near future. The mechanisms underlying odontoid fractures differ according to patient age, with high-energy mechanisms being the causative factor frequently encountered in younger patients and low-energy trauma commonly occurring in elderly patients. Despite rising incidence and costs, there is considerable uncertainty regarding the optimal management for these fractures, …

The Palliative Care in the Metastatic Spinal Tumors. A Systematic Review on the Radiotherapy and Surgical Perspective

Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutic management of spinal metastases remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteri…

ANATOMICAL DISSECTION AND ANALYSIS OF THE STRUCTURES OF THE UPPER LIMB

In 2015, a whole body dissection course was proposed by the University of Palermo, Palermo, Italy, thanks to the cooperation with the University of Malta, Msida, Malta. The purpose of this study was to show the the difference between the studyof anatomy on books and on corpses. The article focuses its attention on the dissection method of the upper limb. The astudy was performed on two corpses, a male and a female, by using a basic surgeon kit. Blunt dissection method was used for fasciae, innards and to isolate vascular-nervous structures from the fat; we used scalped for cutis, sub cutis, muscles, fasciae, veins, arteries and nerves of the upper limb from the shoulder to the hand. The upp…

Dysphagia Prevention in Anterior Cervical Discectomy Surgery: Results from a Prospective Clinical Study

Background: Dysphagia is a common complication after anterior cervical discectomy surgery (ACDS). Recent studies have shown that reducing the endotracheal tube cuff pressure, local irrigation with methylprednisolone, and minimizing the pharynx/esophagus retraction can decrease the incidence of postoperative dysphagia after ACDS. This is the first study assessing the efficacy of all these 3 measures simultaneously. Methods: This prospective study included 35 patients (group 1) who underwent ACDS with the adoption of all the 3 preventive measures. Group 1 was compared with a homogenous group of 35 patients who underwent regular ACDS (group 2). Postoperative dysphagia and odynophagia were eval…

Commentary on: Microwave Ablation for Metastatic Spinal Tumors

Management of Complex Cerebral Aneurysms

BACKGROUND: Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures.METHODS: Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 6…

Magnetic Resonance Spectrobiopsy for Prediction of Isocitrate Dehydrogenase Mutation in Glioma

Despite the existence of multimodal therapy paradigm, high-grade gliomas (HGGs) remain devastating tumors associated with one of the worst prognoses. Glioblastoma (GBM) is the most frequent reported histologic type with a median survival, after surgery and combined treatment with chemotherapy and radiotherapy, ranging from 12 to 16 months. The poor prognosis is due to the lack of therapeutic efficacy of chemical agents and irradiation in hypoxic tumor areas. Experimental studies have investigated several molecules with the aim to counteract several downstream signaling important in tumor progression, unfortunately without conclusive results. Several studies have shown that the extent of res…

Role of Erythropoietin in Cerebral Glioma: An Innovative Target in Neuro-Oncology

Background: Erythropoietin (EPO) is a cytokine primarily involved in the regulation of erythropoiesis. In response to hypoxia–ischemia, hypoxia-inducible factor 1 induces EPO production, which, in turn, inhibits apoptosis of erythroid progenitor cells. By the same mechanism and acting through other signaling pathways, EPO exerts neuroprotective effects. Increased resistance to hypoxia and decreased apoptosis are thought to be important mechanisms for tumor progression, including malignant glioma. Because recent studies have demonstrated that EPO and its receptor (EPOR) are expressed in several tumors and can promote tumor growth, in the present study, we investigated EPO and EPOR expression…

Does Hybrid Surgery Improve Quality of Life in Multilevel Cervical Degenerative Disk Disease? Five-Year Follow-up Study.

Background: Patient satisfaction is becoming an increasing factor worthy of consideration when evaluating the surgical quality. The correlation between patient satisfaction and surgical outcomes 5 years after cervical hybrid surgery (HS), which incorporates anterior cervical decompression and fusion and cervical disk arthroplasty techniques in multilevel cervical degenerative disk disease, has not been evaluated. Methods: The aim of this study was firstly to analyze prospectively collected data from a sample of patients (n = 50) treated with cervical HS for selected cases of radiculopathy and myelopathy in order to evaluate pain levels of patients, using the Neck and Arm Pain scale as an ex…

Resting-State Functional Magnetic Resonance Imaging for Surgical Neuro-Oncology Planning: Towards a Standardization in Clinical Settings

Resting-state functional magnetic resonance imaging (rest-f-MRI) is a neuroimaging technique that has demonstrated its potential in providing new insights into brain physiology. rest-f-MRI can provide useful information in pre-surgical mapping aimed to balancing long-term survival by maximizing the extent of resection of brain neoplasms, while preserving the patient’s functional connectivity. Rest-fMRI may replace or can be complementary to task-driven fMRI (t-fMRI), particularly in patients unable to cooperate with the task paradigm, such as children or sedated, paretic, aphasic patients. Although rest-fMRI is still under standardization, this technique has been demonstrated to be feasible…

Prevention of lumbar reherniation by the intraoperative use of a radiofrequency bipolar device: A case-control study.

Objective: The most common complication after lumbar discectomy is reherniation. Although many studies have investigated factors that may increase the reherniation risk, few are agreed upon all. It has been suggested that limited nucleus removal is associated with higher reherniation risk, while more aggressive nucleus removal can result in increased disc degeneration. Here, we assessed the efficacy of a coblation-assisted microdiscectomy in adult patients undergoing single-level disc surgery. Methods: We prospectively compared the reherniation rate in 75 patients (Group 1) undergoing single-level lumbar disc surgery completed with the radiofrequency bipolar system Aquamantys® (Medtronic, M…

Resting-State Functional Magnetic Resonance Imaging for Brain Tumor Surgical Planning: Feasibility in Clinical Setting.

The aim of this study was to introduce resting-state functional magnetic resonance imaging (rest-fMRI) capability for brain tumor surgical planning. rest-fMRI is an emerging functional neuroimaging technique potentially able to provide new insights into brain physiology and to provide useful information regarding brain tumors in preoperative and postoperative settings. rest-fMRI evaluates low-frequency fluctuations in the blood oxygen level–dependent signal while the subject is at rest during magnetic resonance imaging examination. Multiple resting-state networks have been identified, including the somatosensory, language, and visual networks, which are of primary importance for surgical pl…

Natural Course, Clinical Profile, and Treatment Strategies for Cerebral Cavernous Malformations

A large body of evidence has suggested that the natural biology for symptomatic cerebral cavernous malformations (CCMs) is dynamic. These lesions exhibit a temporal clustering epiphenomenon and usually manifest with multispectral clinical patterns, the most relevant being hemorrhagic and seizurogenic events. Most patients with cerebral cavernous malformations are asymptomatic, and the lesions are detected as incidentalomas. However, association with the CCM3 gene, Zabramski type I and II lesions, and brainstem location have the propensity to increase the bleeding events. The rebleeding risk is 20%/year per lesion, which supports the need for surgical strategies for brainstem cavernous malfo…

Avoiding Complications in Aneurysm Ligation: Operative Tips and Tricks

Preventing possible complications during brain aneurysm surgery is mandatory to ensure a better outcome for patients. Currently, it is possible to rely on some technologic innovations such as motor evoked potential, endoscope-assisted surgery, dye with indocyanine green, and video angiography capable of supporting the surgeon's work. The innovation process has mainly assisted the endovascular technique compared with surgery. The latter, apart from some new technical expedients, always requires anatomic knowledge and optimal technical preparation. A careful patient selection, adequate surgical exposure, use of microsurgical techniques in expert hands, and meticulous postoperative management …

Emerging Therapeutic Strategies for Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a debilitating neurologic condition with tremendous socioeconomic impact on affected individuals and the health care system. The treatment of SCI principally includes surgical treatment and marginal pharmacologic and rehabilitation therapies targeting secondary events with minor clinical improvements. This unsuccessful result mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiologic changes that occur in the injured spinal cord. Once the nervous system is injured, cascades of cellular and molecular events are triggered at varying times. Although the cascade of tissue reactions and cell injury develops over a period of days …

Revision Surgery for Primary Spinal Tumor: Too Little Too Late

Primary tumors of the spine are rare and represent less than 8% of all bone tumors.1 Because of their low prevalence, they are often misdiagnosed and consequently managed improperly. Unlike metastatic spine tumors, some primary tumors can be cured. Spine tumors are classified according to their histology. How- ever, patient age and anatomic location add relevant information on the biological behavior of the tumor. In children, the most frequent spinal tumors are malignant and are represented by neuroblastoma and sarcoma. In adults, the most common spinal tumors are multiple myeloma, osteosarcoma, histiocytosis, chordoma, and hemangioma. These tumors often develop in the anterior vertebral b…

Anterior cervical discectomy and fusion is more effective than cervical arthroplasty in relieving atypical symptoms in patients with cervical spondylosis

Background and purpose Patients with cervical spondylosis often present with concurrent 'atypical symptoms' of unknown etiology that have been associated with cervical spondylotic disease, including dizziness, headache, nausea, tinnitus, blurred vision, palpitations, and memory and gastrointestinal disturbances. Few studies have addressed whether surgical intervention to treat classic symptoms of cervical spondylosis can also effectively alleviate atypical symptoms. Accordingly, the purpose of this study is to compare the ability of cervical arthroplasty (CA) and anterior cervical discectomy and fusion (ACDF) to alleviate atypical symptoms associated with cervical spondylosis. Materials and…

When Neuroprotection Becomes a Potential Ally of High-Grade Glioma.

Despite the use of multimodal treatment regimens, high-grade gliomas (HHGs) are tumors invariably associated with a poor prognosis. The median patient survival after diagnosis is approximately 1 year, through surgery/radiation and chemotherapy treatments.To date, traditional approaches fail to treat efficiently HHGs because surgery does not completely remove the tumor without damaging the brain, radiation therapy cannot be used beyond a certain threshold dose, and chemotherapy has shown limited efficacy and toxic effects. Notwithstanding many attempts at improving outcome using novel agents, the treatment of this disease has not improved in more than a decade. Although scientific and techno…

Cisternostomy: A Timely Intervention in Moderate to Severe Traumatic Brain Injuries: Rationale, Indications, and Prospects.

Traumatic brain injury (TBI) represents a major public health concern worldwide, with no significant change in its epidemiology over the last 30 years. After TBI, the primary injury induces irreversible brain damage, which is untreatable. The subsequent secondary injury plays a critical role in the clinical prognosis because without effective treatment it will provide additional tissue damage. The resulting scenario is the rise in intracranial pressure (ICP) with the development of progressive neurological deficits. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies among which is decompressive hemicraniectom…

The Quest for Predictors of Shunt-Dependent Chronic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Toward a Tailored Approach for Permanent Shunt-Dependency Following Aneurysmal Subarachnoid Hemorrhage

Innovation in Neurosurgery: The Concept of Cognitive Mapping

In recent years, advances in cortical-subcortical mapping, intraoperative neurophysiology, and neuropsychology have increased the ability to remove intrinsic brain tumors, expanding indications and maximizing the extent of resection. This has provided a significant improvement in progression-free survival, time of malignant transformation (in low-grade gliomas), and overall survival. Although current techniques enable preservation of language and motor functions during surgery, the maintenance of a complex set of functions defined with the term cognition is not always achievable. Cognition is defined as every neural process underlying a high human function and includes motor haptic and visu…

Introducing the concept of “CSF-shift edema” in traumatic brain injury

Brain edema after severe traumatic brain injury (TBI) plays an important role in the outcome and survival of injured patients. It is also one of the main targets in the therapeutic approach in the current clinical practice. To date, the pathophysiology of traumatic brain swelling is complex and, being that it is thought to be mainly cytotoxic and vasogenic in origin, not yet entirely understood. However, based on new understandings of the hydrodynamic aspects of cerebrospinal fluid (CSF), an additional mechanism of brain swelling can be considered. An increase in pressure into the subarachnoid space, secondary to traumatic subarachnoid hemorrhage, would result in a rapid shift of CSF from t…

Long-Term Efficacy of Shunt Therapy in Idiopathic Normal Pressure Hydrocephalus.

Background: Idiopathic normal pressure hydrocephalus (iNPH) is one of the very few treatable types of dementia. Shunt therapy has been shown to be effective in improving symptoms. However, the long-term results of cerebrospinal fluid diversion are variable. The aim of this retrospective study was to investigate long-term outcomes of patients with idiopathic normal pressure hydrocephalus treated with ventriculoperitoneal shunt by using programmable valves. Methods: Symptoms before treatment were recorded. Clinical symptoms and outcome after ventriculoperitoneal shunt were assessed based on changes in gait, urinary incontinence, and cognitive dysfunction at yearly follow-up spanning at least …