Search

The authors regret that in the published version online the name of the author Giuseppe Maria DELLA PEPA appears in the wrong way: it should be DELLA PEPA GM (and not Pepa GMD). The original article has been corrected.

The role of surgery in the management of primary central nervous system lymphomas (PCNSL) is currently confined to diagnosis. However, over recent years, an increasing number of papers have suggested a possible positive prognostic impact of surgery in selected cases. The present work aims to perform a meta-analysis of the available literature evidence. A meta-analysis with meta-regression on the role of surgical resection compared to biopsy in the management of PCNSL was conducted according to the PRISMA statement, searching MEDLINE via PubMed and Embase. The random effect model was used. The quality of evidence was assessed using the GRADE framework. After screening 1395 records, we included 11 papers in our analysis. Patients who underwent surgical resection harbored superficial and single-lesion tumors. At 1-, 2-, and 5-year follow-up, progression-free survival did not differ between the two groups, while overall survival favored resection, even if in a non-significant fashion. Meta-regression analysis showed that the overall survival rate at 2 years, but not at 1 or 5 years, was significantly influenced by tumor location. There were no differences in terms of age, sex, Karnofsky performance status, adjuvant therapy, or procedure-related complications. Overall, the quality of evidence is low. The results of the present meta-analysis do not change the current standard of care for PCNSL. However, surgery could be non-inferior to biopsy with an acceptable risk profile in selected patients harboring single and superficial lesions. The low quality of evidence prompts future randomized studies.

Background: Intraoperative neuromonitoring is crucial for facial nerve preservation in cerebellopontine angle (CPA) surgery. Among the available techniques, the role of intraoperative corticobulbar facial motor evoked potentials (FMEPs) is unclear. Objective: To evaluate the significance of intraoperative FMEPs as indicators for early and late postoperative facial nerve function (FNF) in CPA tumor resection and the feasibility of their integration with standard monitoring techniques. Methods: An institutional series of 83 patients who underwent surgery under intraoperative monitoring for CPA extra-axial tumor resection was reported. A pair of needle electrodes was used to record FMEP from orbicularis oculi (OOc) and orbicularis oris (OOr) muscles at baseline, at the end of surgery and minimum values recorded. From FMEP amplitudes, minimum-to-baseline amplitude ratio (MBR), final-to-baseline amplitude ratio (FBR), and recovery value, intended as FBR minus MBR, were calculated. These indices were correlated with early and late postoperative FNF. Results: Our analysis demonstrated that higher FBR (both from OOc and OOr) and MBR (from OOr only) were associated with a good early and late FNF; a higher MBR from OOc was significantly associated with a good late FNF. The most accurate index in predicting early FNF was FBR measured from OOr with a cutoff of 35.56%, whereas the most accurate index in predicting late FNF was FBR as measured from OOc with a cutoff of 14.29%. Conclusion: Our study confirmed that FMEPs are reliable predictors of early and late postoperative FNF in CPA surgery and could be easily integrated with standard intraoperative neuromonitoring techniques.

The cerebellopontine angle (CPA) is a highly complex anatomical compartment consisting of numerous nervous and vascular structures that present mutual and intricate spatial relationships. CPA surgery represents, therefore, a constant challenge for neurosurgeons. Over the years, neurosurgeons have developed and refined several solutions with the aim of maximizing the surgical treatment effects while minimizing the invasiveness and risks for the patient. In this paper, we present our integrated approach to CPA surgery, describing its advantages in treating pathologies in this anatomical district. Our approach incorporates the use of technology, such as neuronavigation, along with advanced and multimodal intraoperative neuromonitoring (IONM) techniques, with the final goal of making this surgery safe and effective.

Preservation of facial nerve function (FNF) during neurosurgery for cerebellopontine angle (CPA) tumors is paramount in elderly patients. Corticobulbar facial motor evoked potentials (FMEPs) allow assessment intraoperatively of the functional integrity of facial motor pathways, thus improving safety. We aimed to evaluate the significance of intraoperative FMEPs in patients 65 years and older. A retrospective cohort of 35 patients undergoing CPA tumors resection was reported; outcomes of patients aged 65–69 years vs. ≥70 years were compared. FMEPs were registered both from upper and lower face muscles, and amplitude ratios (minimum-to-baseline, MBR; final-to-baseline, FBR; and recovery value, FBR minus MBR) were calculated. Overall, 78.8% of patients had a good late (at 1 year) FNF, with no differences between age groups. In patients aged ≥70 years, MBR significantly correlated with late FNF. At receiver operating characteristics (ROC) analysis, in patients aged 65–69 years, FBR (with 50% cut-off value) could reliably predict late FNF. By contrast, in patients aged ≥70 years, the most accurate predictor of late FNF was MBR, with 12.5% cut-off. Thus, FMEPs are a valuable tool for improving safety in CPA surgery in elderly patients as well. Considering literature data, we noticed higher cut-off values for FBR and a role for MBR, which suggests an increased vulnerability of facial nerves in elderly patients compared to younger ones.

The role of surgery in the management of primary central nervous system lymphomas (PCNSL) is currently confined to diagnosis. However, over recent years, an increasing number of papers have suggested a possible positive prognostic impact of surgery in selected cases. The present work aims to perform a meta-analysis of the available literature evidence. A meta-analysis with meta-regression on the role of surgical resection compared to biopsy in the management of PCNSL was conducted according to the PRISMA statement, searching MEDLINE via PubMed and Embase. The random effect model was used. The quality of evidence was assessed using the GRADE framework. After screening 1395 records, we included 11 papers in our analysis. Patients who underwent surgical resection harbored superficial and single-lesion tumors. At 1-, 2-, and 5-year follow-up, progression-free survival did not differ between the two groups, while overall survival favored resection, even if in a non-significant fashion. Meta-regression analysis showed that the overall survival rate at 2 years, but not at 1 or 5 years, was significantly influenced by tumor location. There were no differences in terms of age, sex, Karnofsky performance status, adjuvant therapy, or procedure-related complications. Overall, the quality of evidence is low. The results of the present meta-analysis do not change the current standard of care for PCNSL. However, surgery could be non-inferior to biopsy with an acceptable risk profile in selected patients harboring single and superficial lesions. The low quality of evidence prompts future randomized studies.

Introduction: Chronic low back pain can be due to many different causes, including degenerative spondylolis-thesis (DS). For patients who do not respond to conservative management, surgery remains the most effective treatment. Open laminectomy alone and laminectomy and fusion (LF) for DS have been widely investigated, however, no meta-analyses have compared minimally invasive decompression with posterior elements preservation (MID) techniques and LF. Minimally invasive techniques might provide specific advantages that were not recognized in previous studies that pooled different decompression strategies together. Materials and Methods: This was a systematic review and meta-analysis, according to the PRISMA statement, of comparative studies reporting surgical, clinical and radiological outcomes of MID and LF for DS. Results: A total of 3202 papers were screened and 7 were finally included in the meta-analysis. MID is associated Minimally Invasive Decompression with Posterior Elements Preservation Versus Laminectomy and Fusion For Lumbar Degenerative Spondylolisthesis: A Systematic Review and Meta-Analysis of Surgical, Clinical and Radiological Outcomes RICCIARDI/STIFANO/STURIALE/D’ONOFRIO/OLIVI/MONTANO with a shorter surgical duration and hospitalization stay, and a lower intraoperative blood loss and residual low back pain; however, the residual disability grade was lower in the LF group. Complication rates were similar between the two groups. The rate of adjacent segment degeneration was lower in the MID group, whereas data on radiological outcomes were heterogeneous and not suitable for data-pooling. Conclusions: This meta-analysis suggests that MID might be considered as an effective alternative to LF for DS. Further clinical trials will be needed to confirm our results, better investigate radiological outcomes, and identify patient subgroups that may benefit the most from specific techniques.

The surgical injury of the intracranial portion of the facial nerve (FN) is a severe complication of many skull base procedures, and it represents a relevant issue in terms of patients' discomfort, social interactions, risk for depression, and social costs. The aim of this study was to investigate the surgical and functional outcomes of the most common facial nerve rehabilitation techniques. The present study is a systematic review of the pertinent literature, according to the PRISMA guidelines. Two different online medical databases (PubMed, Scopus) were screened for studies reporting the functional outcome, measured by the House-Brackman (HB) scale, and complications, in FN early reanimation, following surgical injuries on its intracranial portion. Data on the VII-to-VII and XII-to-VII coaptation, the surgical technique, the use of a nerve graft, the duration of the deficit, and complications were collected and pooled. The XII-to-VII end-to-side coaptation seems to provide higher chances for functional restoration (HB 1-3) than the VII-to-VII (68.8% vs 60.6%), regardless of the duration of the palsy deficit, the use or not of a nerve graft, and the use of stitches or glues. However, its complication rate was as high as 28.6%, and a second procedure is then often needed. The XII-to-VII side-to-end coaptation is the most effective in providing a functional outcome (HB 1-3), even though it is associated to a higher complication rate. Further trials are needed to better investigate this relevant topic, in terms of health-related social costs and patients' quality of life.

Background: Despite recent treatment developments, back pain and related disabilities still represent a challenge for practitioners. Among the available surgical techniques, many different features and outcomes have been investigated; however, aesthetic result was missing among them. The present investigation was designed to prospectively compare patient-oriented aesthetic results after minimally invasive surgery (MIS) and standard open surgery (SOS) for the lumbar spine. Methods: This was a prospective observational study with 1-year follow-up. Patients who underwent SOS were assigned to group 1 and MIS to group 2. Patient-oriented aesthetic result evaluation was collected using a dedicated visual aesthetic analogue scale. The Vancouver Scar Scale was used to exclude objective underlying influencing factors. The Oswestry Disability Index and a 10-point itemized visual analogue scale for back pain were administered to assess the clinical and functional status. Follow-up data were collected before discharge at 1, 6, and 12 months. Statistical analysis was conducted, and P < 0.05 was considered as significant. Results: We enrolled 74 patients, 44 in group 1 and 30 in group 2. The 2 groups were homogeneous for demographic and clinical data. No clinical or functional differences were measured at the end of follow-up. Visual aesthetic analogue scale reported greater mean values in group 1 at every follow-up time. Conclusions: Patients seem to prefer the aesthetic result from a single midline incision after SOS compared with MIS. The use of specific techniques could be considered if there is scientific evidence reporting greater aesthetic outcome, having similar clinical and functional ones.

We describe the case of a 33-year-old woman with a history of over 15 years of a slow growing firm osseous-like right retroauricular mass. Surgical resection was easily performed using a sharp technique, because of a clear cleavage plane. The histologic diagnosis was a rare, unexpected, protuberant fibro-osseous lesion named “Bullough lesion.” Only few cases of this benign pathologic entity have been described in English literature. Clinical differential diagnosis must be done with osteoma, periosteal chondroma, and other fibro-osseous lesions such as fibrodysplasia and ossifying fibroma. Because of the paucity of data, the natural history of this lesion is unknown and serial clinical and radiological follow-up is advised.

Background: Minimally invasive surgery (MIS) has been providing many solutions in spine surgery, and several technical variations and instrumentation systems are available. The aim of our study is to investigate the best system to perform a hybrid technique in lumbar spine fusion procedures. Methods: Sixteen patients were enrolled and randomly assigned to 1 of the 4 groups reported later. The first step in any case was midline incision, fascia exposure, and, using trocars, intravertebral transpedicle Kirschner wires (KWs) positioning through the fascia. Group definitions were A) KWs were affixed to surgical towels; B) screws with metal extensors were placed and KWs removed; C) screws with plastic extensors (K2M) were placed and those extensors were affixed to surgical towels; and D) screws without extensors or tulips (Nuvasive) were positioned. We locked the system at the end of procedure, after posterior decompression and translumbar interbody fusion cage placement. Procedures’ features were rated using properly designed questionnaires by surgeons. Results: Metal extensors were rated lower than other systems in any aspect. C and D groups’ procedures were higher rated than those in A and B in all examined fields. Furthermore, group D's procedures were reported more comfortable during facetectomy, diskectomy, and cage placement. Surgeons reported Precept Modular (Nuvasive) as the most comfortable and useful system in the hybrid technique. Conclusions: Precept Modular seems to be the most useful system when performing hybrid technique in lumbar fusion procedures. Furthermore, it results in the only one that provides the opportunity to easily and quickly switch from minimally invasive surgery to open surgery, avoiding muscles’ injuries.

Objective: This study aimed to quantify the discrepancy between intraoperative and postoperative segmental lordosis in patients operated on for lumbar degenerative diseases, with 3 different fixation techniques: open posterolateral instrumentation alone (PLI) or in association with lumbar interbody cages (transforaminal lumbar interbody fusion [TLIF] or extreme lateral interbody fusion [XLIF]). Methods: We retrospectively reviewed all adult patients affected by single-segment degenerative spondylotic disease who underwent PLI alone or percutaneous posterolateral instrumentation (pPLI) in association with TLIF or XLIF between April 2015 and December 2017 at our institution. Group I included patients who underwent PLI with transpedicular screws and rods, interlaminar bilateral decompression, and posterolateral fusion with autologous bone chips. Group II included patients treated with pPLI + TLIF using a complete unilateral arthrectomy. Group III included patients operated on with minimally invasive retroperitoneal pPLI + XLIF. Results: No major complications were reported. The mean segmental loss of lordosis values ranged from 9.17% to 12.28% in Group I, from 6.31%–9.43% in Group II, and from 3.05%–4.71% in Group III. The statistical analysis revealed that pPLI + XLIF maintained a higher segmental lordosis than PLI and pPLI +TLIF in each operated segment (P < 0.05). pPLI + TLIF was more effective than PLI in reducing the loss of lordosis at L4-L5 and at L5-S1 (P < 0.05) but not at L3-L4 (P = 0.12). Conclusions: The documented mismatch between the preoperative and postoperative lumbar lordosis might affect the clinical outcome. Its relevance depends on the surgical technique used at the single level.

We reported the results of minimally invasive spinal decompression (MISD) in patients with degenerative spondylolisthesis (DS) associated with lumbar spinal stenosis (LSS) and performed a literature review in order to evaluate the clinical and radiological outcomes, the complications and reoperation rate of MISD procedures in these patients. Data of 28 patients submitted to MISD for DS associated to LSS were reviewed. We evaluated the Visual Analogue Scale (VAS) both for low back pain (LBP) and legs pain, the Oswestry Disability Index (ODI) and the degree of the slippage. A PubMed search of the English literature was conducted. Only papers with more than 10 patients and reporting explicitly data of patients with DS were included in the analysis. We found a statistically significant improvement of LBP, legs pain and ODI in our series. The degree of slippage was stable at follow-up (FU) with no need of reoperation. No major complications occurred. In our literature review, we were able to analyze the differences in ODI in 156 patients and the differences in Japanese Orthopedic Association (JOA) score in 218 patients. We observed a statistically significant improvement of ODI and JOA score at FU compared to pre-operative. The percentage of slippage, evaluated in 283 patients, was unchanged at FU compared to pre-operative. The overall complication rate was 1.6%. The overall reoperation rate was 4.5%. MISD procedures are safe and effective in patients with DS associated to LSS and are associated to low morbidity and significant improvement of disability without progression of slippage.

N/A

A vast amount of literature has been published investigating the factors associated to the recurrence of a chronic subdural hematoma (SDH). However, little exists in the literature about the best medical management of the residual SDH in order to prevent the recurrence. Moreover only few studies quantitatively assess clinical and radiological outcomes of residual post-operative SDH. In this study, to our knowledge, we report the first series of chronic SDH with a quantitative outcomes analysis of the effects of fluid therapy on residual post-operative SDH. Moreover we discuss the pertinent literature. We reviewed clinical and outcome data of 39 patients (44 SDH; 12 F, 27 M) submitted to a burr-hole evacuation of a SDH. The mean age was 76.97 ± 7.77 years. All patients had a minimum 3-month follow-up (FU). Post-operatively, an intravenous saline solution was started in all cases (2000 ml in 24 h) and administered for 3 days. Then an oral hydration with 2 l per day of water was started and continued as outpatients. Glasgow Coma Scale (GCS), Karnofsky Performance Status (KPS), SDH volume and midline shift were evaluated pre-operatively, post-operatively and at FU. We found a statistically significant improvement of post-operative and at FU GCS and KPS compared to the pre-operative. SDH volume and midline shift were also statistically significant reduced in the post-operative and at FU. No complication occurred. Only 1 patient required a reoperation at 3 months FU for neurological worsening. Oral fluid therapy is a safe and effective treatment for residual SDH.