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Background: Cranioplasty is both a functional and aesthetical therapeutic option. In the clinical scenario every cranioplasty's material is potentially qualified to achieve the goal of calvarian reconstruction but there is a lack of agreement about the optimum choice, especially between the heterologous ones. The choice of cranioplasty widely depends on surgeon's personal preferences. In this retrospective multicentric study a comparative analysis of hydroxyapatite or titanium cranioplasties was carried on analyzing the main factors considered by the surgeon to choose a material rather than another one. Our results and data were compared with those reported in the scientific literature and a flow-chart regarding the therapeutic approach in the choice of the most suitable cranioplasty was proposed and discussed., Methods: The authors present a multicentric study considering 2 groups of patients who underwent 2 different kinds of cranioplasty: hydroxyapatite and titanium. The outcomes measures included the surgical timing and the maintenance of post-operative subgaleal drain., Results: A total of 40 patients that had cranioplasty treatment were evaluated. The surgical technique was analyzed. In patients that underwent titanium cranioplasty we observed a reduction in the operative times and in subgaleal drain maintenance. In relation to the age, comorbidity, and neurological status a score, called most suitable material (MSM), was elaborated and a therapeutic algorithm is proposed., Conclusions: This study confirms the known advantages and drawback of titanium and hydroxyapatite prostheses. Thanks to the lessons learned from our experience on this field, we elaborated the MSM score that coupled with the therapeutic flow-chart proposed could address the choice of the MSM for a specific patient., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: The craniovertebral junction (CVJ) can be affected by a variety of congenital or acquired anomalies. Because of its complexity, a careful evaluation of bones and ligamentous structures in all three planes is required. This can be achieved by studying the CVJ in terms of several anatomical and radiological lines that have been visualized to facilitate understanding of its surgical anatomy. In this study we aimed to review the state-of-the art craniometric CVJ lines and approaches., Methods: In December 2016 a PubMed search was performed, including the search terms 'CVJ surgical approach/line', 'cervical approach', 'craniometric measurement', 'CVJ anatomy' and 'ventral/dorsal/far-lateral approach'. Anatomical and radiological lines and angles evaluated on traditional radiography, computed tomography (CT) scanning or magnetic resonance imaging (MRI) in the axial/sagittal/coronal views were included and described., Results: Several measurements and radiological landmarks were included to evaluate the anatomy of the CVJ. They were fully described and categorized on the basis of the anatomical plan and the surgical or diagnostic purpose they are used for., Conclusion: Among the numerous radiological measurements described, it has been shown that McRae's line, Chamberlain's line, McGregor's line, the Redlund-Johnell method and Ranawat's line are the most widely used and reliable ones for evaluating skull base craniometry. Secondly, the hard palate line (HPL), nasoaxial line (NAxL) and palatine-inferior dental arch line (PIA) are used to preoperatively assess the ventral endonasal or transoral surgical approaches. Thirdly, the C7 slope has been demonstrated as a reliable predictor of occipitocervical and spinopelvic alignment in CVJ fusion.

Background: A type II odontoid fracture, if unstable, can cause spinal cord damage. In this case, it is essential to choose the correct treatment-but the issues of what the correct treatment is and which of the different surgical options is best are quite controversial. In this paper we present strategies for treatment of type II odontoid fracture., Materials and Methods: Thirty consecutive cases of type II odontoid fracture were treated at the Division of Neurosurgery at Villa Sofia Hospital in Palermo (23 cases) and at the Neurosurgical Clinic, University Hospital of Palermo (seven cases), from January 2011 to August 2016. Four patients were treated with external immobilization. Twenty-six patients underwent a surgical procedure., Results: There was no mortality related to the surgical procedure. One patient had a pre- and postoperative neurological deficit, and remained tetraparetic. Follow-up radiological studies in the surgically treated group showed bone union in 21 patients and stable fibrous union in one., Conclusion: In our and other authors' experience, when the direction of the fracture line is down and forward, external immobilization can be sufficient for healing. Anterior odontoid screw fixation can be considered the treatment of choice for unstable odontoid fractures (with a horizontal, down and back, or comminuted fracture line) without dislocation or with dislocation less than 7 mm.When the odontoid fracture is associated with a Jefferson fracture or dislocation greater than 7 mm, stabilization of C1-C2 may be necessary. In this case, placement of screws in the dens and in the joints through a single approach represents the most valid technique.In the case of an inveterate fracture of the dens with severe C1-C2 dislocation, the surgical operation that offers the best prospects is posterior stabilization, utilizing the Guo technique.

Background: The variety of symptoms and radiological findings in patients with Chiari malformation type I makes both the indication for surgery and the technical modality controversial. We report our 5-year experience, describing our technique and critically evaluating the clinical results., Methods: Between 2012 and 2016, 25 patients (15 female and 10 male; mean age 39.2 years) underwent posterior fossa decompression for Chiari malformation type I. Their clinical complaints included headache, nuchalgia, upper limb weakness or numbness, instability, dizziness and diplopia. Syringomyelia was present in 12 patients (48%). Suboccipital craniectomy was completed in all cases with C1 laminectomy and shrinkage of the cerebellar tonsils by bipolar coagulation; duraplasty was performed with a suturable dura substitute., Results: Gratifying results were observed in our series. Symptoms and signs were resolved in 52% of patients, and 20% of patients had an improvement in their preoperative deficits. The symptoms of six patients (24%) were essentially unchanged, and one patient (4%) deteriorated despite undergoing surgery. Generally, patients with syringomyelia on magnetic resonance imaging (MRI) showed less symptomatic improvement after surgery. The syrinx disappeared in seven of 12 patients, and complications occurred in three patients (12%)., Conclusion: Cerebellar tonsil reduction and restoration of cerebrospinal fluid (CSF) circulation provided clinical improvement and a stable reduction in the syrinx size in the vast majority of treated patients, with a low rate of complications.

The craniovertebral junction (CVJ) is a complex anatomical area upon which most of the motion of the upper cervical spine depends [1]. Because of its unique range of motion, the CVJ is subject to several types of traumatic injury; it has been shown that odontoid fractures are the most common ones in the general population and are the most common isolated spinal fractures [2]. Accounting for up to 18% of all cervical fractures, odontoid fractures are the most common ones in elderly patients [3], in whom they account for up to 60% of spinal cord injuries [4].

Rheumatoid arthritis (RA) is a chronic inflammatory disorder, characterized by polyarticular inflammation causing progressive joint damage and disability. The mechanisms underlying its pathogenesis involve activation of innate and adaptive immunity, microvascular endothelial cell activation, and inflammatory infiltration of lymphocytes and monocytes into the synovium. Spinal involvement in RA is not typical; when it occurs, the main radiological features are (1) atlantoaxial subluxation (AAS), which is the most typical form of cervical spine involvement; (2) cranial settling-also known as basilar impression, atlantoaxial impaction or superior migration of the odontoid-which is the most severe form of associated spinal instability; and (3) subaxial subluxation. A combination of these alterations may occur. Synovitis is characterized by infiltration of innate and adaptive immune cells; joint destruction is a consequence of activation of synovial fibroblasts, which acquire aggressive, inflammatory, invasive features, associated with increased chondrocyte catabolism and synovial osteoclastogenesis.Neck pain is the most frequent symptom of spinal involvement in RA; it occurs in 40-80% of patients and is mostly localized at the craniocervical junction. Other symptoms-caused by compression of neural structures such as the greater occipital nerve (at C2), the nucleus of the spinal trigeminal tract and the greater auricular nerve-are occipital neuralgia, facial pain and ear pain, respectively. Irritation of the lesser occipital nerve (at C1) can cause pain in the suboccipital region. Sometimes patients may complain of a sensation of their head falling down with flexion, weakness, reduced endurance, loss of ability, gait alterations, paraesthesias or other symptoms due to cord and medullary compression, and upper or lower motor neuron signs, or both. Surgical management of RA remains a challenging field.

Introduction: The HLA genes, as well as the innate immune KIR genes, are considered relevant determinants of viral outcomes but no study, to our knowledge, has evaluated their role in the clinical setting of acute viral encephalitis., Results: Subjects with acute viral encephalitis in comparison to subjects without acute viral encephalitis showed a significantly higher frequency of 2DL1 KIR gene and AA KIR haplotypes and of HLA-C2 and HLA-A-Bw4 alleles. Subjects without acute viral encephalitis showed a higher frequency of interaction between KIR2DL2 and HLAC1. Multiple logistic regression analysis showed the detrimental effect of HLA-A haplotype and HLA-C1, HLA-A-BW4 HLA-B-BW4 T alleles, whereas multiple logistic regression showed a protective effect of AB+BB KIR haplotype and a detrimental effect of interaction between KIR3DL1 and HLA-A-Bw4., Discussion: Our findings of a lower frequency of activating receptors in patients with acute encephalitis compared to controls could result in a less efficient response of NK cells. This finding could represent a possible pathogenetic explanation of susceptibility to acute symptomatic encephalitis in patients with viral infection from potentially responsible viruses such as Herpes virus., Materials and Methods: 30 Consecutive patients with symptomatic acute viral encephalitis and as controls, 36 consecutive subjects without acute encephalitis were analyzed. The following KIR genes were analyzed, KIR2DL1, 2DL2, 2DL3, 2DL5, 3DL1, 3DL2, 3DL3, 2DL4, 2DS1, 2DS2, 2DS3, 2DS4, 2DS5, 3DS1, 2 pseudogenes (2DP1 and 3DP1) and the common variants of KIR2DL5 (KIR2DL5A, KIR2DL5B)., Competing Interests: CONFLICTS OF INTEREST The authors declare no conflicts of interest.

Background: We compiled a comprehensive literature review on the anatomic and clinical results of endoscopic approaches to the craniocervical junction (CVJ) to better contribute to identify the best strategy., Methods: An updated literature review was performed in the PubMed, OVID, and Google Scholar medical databases, using the terms "Craniovertebral junction," "Transoral approach," "Transnasal approach," "Transcervical approach," "Endoscopic endonasal approach," "Endoscopic transoral approach," "Endoscopic transcervical approach." Clinical series, anatomic studies, and comparative studies were reviewed., Results: Pure endonasal and cervical endoscopic approaches still have some disadvantages, including the learning curve and the deeper surgical field. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging option to standard microsurgical techniques for transoral approaches to the anterior CVJ. This approach should be considered as complementary rather than an alternative to the traditional microsurgical transoral-transpharyngeal approach., Conclusions: The transoral approach with sparing of the soft palate still remains the gold standard compared with the pure transnasal and transcervical approaches because of the wider working channel provided by the former technique. The transnasal endoscopic approach alone appears to be superior when the CVJ lesion exceeds the upper limit of the inferior third of the clivus., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The importance of a complete resection of high-grade gliomas (HGGs) has been highlighted in scientific literature, in order to limit tumor recurrence and above all to improve disease-free survival rates. Several fluorescent biomarkers have been tested to improve intraoperative identification of residual tumor; 5-aminolevulinic acid (5-ALA) and fluorescein sodium (FS) are now starting to play a central role in glioma surgery. We performed a retrospective analysis on 47 patients operated for HGGs. Here we report our preliminary data., Methods: Data of 47 consecutive patients with HGG have been collected in our study (25 males, 22 females; mean age: 60.3 years, range: 27-86 years). Fluorescein (5 mg/kg of body weight) was injected intravenously right after the induction of general anesthesia. A YELLOW 560 filter was used on an OPMI Pentero 900 microscope (Carl Zeiss Meditec, Oberkochen, Germany) to complete a microsurgical tumor removal. Glioma resection and quality of life were evaluated preoperative and postoperatively., Results: Gross total resection (GTR) was achieved in 53.2% ( n = 25) of patients. A subtotal resection (STR) (>95%) was achieved in 29.8% ( n = 14), while a partial resection (PR) (<95%) was obtained in 17% ( n = 8) of patients. Overall, in 83% ( n = 39) of patients who underwent fluorescence-guided surgery the resection rate achieved was >95%. No adverse effects correlated to fluorescein have been recorded., Conclusion: Fluorescein seems to be safe and effective in the resection of HGGs, allowing a high rate of gross total removal of contrast enhanced areas., Competing Interests: There are no conflicts of interest.

Background: Percutaneous techniques have increasingly gained popularity in recent years. The application of technological innovation, including neuromonitoring techniques, has the potential to increase the safety and efficacy of these procedures., Methods: Thirty patients suffering from osteoporotic dorsolumbar burst fracture were prospectively enrolled in this study. The patients underwent percutaneous fenestrated pedicle screw fixation augmented with polymethylmethacrylate (PMMA) injection. A novel surgeon-dedicated neuromonitoring device was used in order to increase the safety and the accuracy of the screw insertion. A second group of 30 patients who did not undergo neuromonitoring during percutaneous pedicle screw placement, matched for demographic characteristics, constituted the control group., Findings: A total of 296 screws were inserted. All treated patients had a good outcome, documented by an improvement in visual analogue scale (VAS) scores. Excellent trajectories were achieved in all patients. Cobb's angle and anterior vertebral height were satisfactorily restored in all study group patients. Three misplaced screws in three patients and a case of PMMA leakage without neurological deficits were observed in the control group, whereas no complication was recorded in the study group (p = 0.03)., Conclusions: Neuromonitoring in cement-augmented percutaneous pedicle screw placement appears to improve surgeon confidence during surgery, reducing the risk of screw misplacement or cement leakage.

Background: Tremor is a disabling condition, common to several neurodegenerative diseases. Lesioning procedures and deep brain stimulation, respectively, of the ventralis intermedius nucleus for intentional tremor, and of the subthalamic nucleus for parkinsonian resting tremor, have been introduced in clinical practice for patients refractory to medical treatment. The combination of high-energy focused ultrasound (HIFUS) with sophisticated magnetic resonance (MR) instrumentation, together with accurate knowledge of the stereotactic brain coordinates, represents a revolution in neuromodulation., Methods: At the Neurosurgical Clinic and the Radiology Department of the University of Palermo,, two patients affected by severe and refractory forms of intentional tremor were treated by MRI-guided FUS (MRgFUS) with a unique 1.5 T MR scanner prototype that uses FUS. This apparatus is the only one of its type in the world.", Findings: This is the first Italian experience, and the second in Europe, of treatment with MRI-gFUS for intentional tremor. But this is the very first experience in which a 1.5 T MRI apparatus was used. In both patients, the treatment completely abolished the tremor on the treated side, with results being excellent and stable after 7 and 5 months, respectively; no side effects were encountered., Conclusion: MRgFUS, recently introduced in clinical practice, and widely used at several clinical centers, has been shown to be a valid therapeutic alternative in the treatment of tremor in several neurodegenerative diseases. It is virtually safe, noninvasive, and very efficacious. We report this technique in which a 1.5 T MR scanner was used. Further investigations with long-term follow up and larger clinical series are needed.

Background: Painful spinal metastases usually occur in malignant neoplastic disease. Treatment for bone metastases has been largely conservative, and it includes the use of high doses of analgesics, radiotherapy, chemotherapy, hormone therapy, and bisphosphonates; however, results are sometimes transient and ineffective. In the presence of neurological involvement a surgical strategy should be considered. Recently, percutaneous procedures such as radiofrequency ablation, vertebroplasty, and kyphoplasty have been introduced as palliative techniques to treat painful vertebral metastases [3, 11, 25]., Methods: In our study we combined the use of radiofrequency ablation with vertebroplasty in the treatment of dorsolumbar metastatic vertebral fractures in order to examine the relationship between restoration of the vertebral structure and decrease in pain. From January 2014 to March 2015 we retrospectively analyzed 18 patients with malignant vertebral lesions who underwent radiofrequency ablation with vertebroplasty followed by cementoplasty, with posterior transpedicle fixation on levels near the lesions. The parameters examined were: demographics, pain relief, and the distribution of polymethylmethacrylate (PMMA) determined by the mean Saliou filling score; all complications were recorded., Findings: The mean age of the patients was 55.72 years (range 34-69); average operative time was 60.4 min (range, 51-72). The average pain index score (visual analog score; VAS) decreased significantly from 8.05 at baseline to 3.0 (p < 0.05) after 6 months. The Saliou filling score revealed a distribution of PMMA in the vertebral body that was satisfactory (12-18) in eight patients, mediocre (6-12) in seven patients, and inadequate (0-6) in the remaining three patients. In two vertebrae, minimal asymptomatic cement leakage occurred in the lateral recess without neurological damage. No pulmonary embolism and no visceral or neural damage was recorded., Conclusion: Radiofrequency ablation combined with vertebroplasty seems to achieve rapid and lasting improvement in clinical symptoms in patients with malignant vertebral lesions. There was wide diffusion of PMMA in the vertebral body, with a mean cement volume of 4.5 ml.

Background: Chronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery., Methods: We report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric instability and persistent or ingravescent disabling low back and leg pain, with a mean duration of symptoms of at least 18 months. A visual analog scale (VAS) was employed for back and leg pain, and the Oswestry Disability Index (ODI) score was determined, and findings were analyzed after 6 months., Findings: No intra- or postoperative complication was recorded. The mean VAS score for back pain decreased from 7.5 to 2.9, while leg VAS decreased from 8.2 to 3.0. Analysis of ODI values showed evident improvement in daily life activities, ranging from a median value of 75.7% to 32.7 % after the stimulation., Conclusion: Spinal cord stimulation has a recognized impact on the pain and on the quality of life of patients with failed back surgery syndrome.

Background: Cranioplasty represents a challenge in neurosurgery. Its goal is not only plastic reconstruction of the skull but also to restore and preserve cranial function, to improve cerebral hemodynamics, and to provide mechanical protection of the neural structures. The ideal material for the reconstructive procedures and the surgical timing are still controversial. Many alloplastic materials are available for performing cranioplasty and among these, titanium still represents a widely proven and accepted choice., Methods: The aim of our study was to present our preliminary experience with a "custom-made" cranioplasty, using electron beam melting (EBM) technology, in a series of ten patients. EBM is a new sintering method for shaping titanium powder directly in three-dimensional (3D) implants., Findings: To the best of our knowledge this is the first report of a skull reconstruction performed by this technique. In a 1-year follow-up no postoperative complications have been observed and good clinical and esthetic outcomes were achieved., Conclusion: Costs higher than those for other types of titanium mesh, a longer production process, and the greater expertise needed for this technique are compensated by the achievement of most complex skull reconstructions with a shorter operative time.

Background Endovascular treatment with stent-assisted Guglielmi detachable coils is an accepted method for treating intracranial giant aneurysms that otherwise would require more invasive or destructive treatment or could not be treated at all. Nevertheless, there is a paucity of information concerning inner postcoiling aneurysmal changes in human subjects over the long term. We report a postmortem analysis of a patient with a giant aneurysm at the vertebrobasilar junction (VBJ) who was treated endovascularly and studied pathologically 24 months after treatment. Materials and Method The head was removed at autopsy and prefixed in a 10% neutral buffered formalin solution. The brain was gently removed from the skull base after cutting the intracranial nerves and vascular structures. The giant VBJ aneurysm and its relationship with the brainstem, cranial nerves, and vessels were captured photographically and analyzed. Afterward, under operating microscope guidance, the vertebrobasilar system with the aneurysm was gently and carefully detached from the brainstem and carefully analyzed. Results No complete fibrous obliteration of the aneurysm lumen could be detected in our case, and no endothelialization had taken place 24 months after treatment. Conclusions Our findings agree with those of previous similar reports. Coiling, in particular in large or giant aneurysms, may be burdened by the risk of coil compaction and recanalization, but it has the advantage of not affecting the flow in the perforating arteries., (Georg Thieme Verlag KG Stuttgart · New York.)

In past years non-invasive clinical applications of magnetic resonance-guided focused ultrasound for the treatment of neurological disorders have been hampered by technical limitations that today have been finally overcome. In 2015, for the first time in the world, the very first treatments have been performed in Italy by the use of an affordable 1.5T magnetic resonance unit. The clinical results obtained to date and all the future possible applications are very promising and pave the way towards safe and effective treatment options once unthinkable.

Background: The incidence of central nervous system involvement has increased in the setting of acquired immune deficiency syndrome (AIDS). Although rarely reported, spinal cord compression, in the setting of AIDS, has been associated with primary lymphoma or opportunistic infections., Case Report: The authors describe the case of a young man who was admitted to our institution with rapid and progressive paraplegia. Imaging studies revealed an extramedullary lesion compressing the spinal cord spanning 3 thoracic levels. Surgical treatment was performed, and the compressing process completely excised. Histologic examination of the lesion showed a chronic inflammatory tissue with many necrotic areas without signs of infection or lymphoma. The patient progressively regained normal strength in his legs and was discharged home., Conclusions: In patients with HIV, chronic inflammation can lead to a lesion that compresses the spinal cord and should be considered in the differential diagnosis. Knowledge of this entity gains importance with the increasing incidence of HIV because timely excision can restore neurologic deficits. This condition may be considered a new clinical entity, the true incidence of which will be established using the diagnostic protocols provided and further case reports.