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INTRODUCTION: Posterior percutaneous instrumentation may represent a challenge when multiple levels need to be instrumentated, especially when including the upper thoracic spine. The aim of the present study was to evaluate the technical feasibility and the long-term outcome of such long constructs in different surgical conditions. MATERIALS AND METHODS: This investigation was a retrospective cohort study which included patients who underwent thoraco-lumbar percutaneous fixations. We collected clinical, surgical and radiological data, with a minimum follow-up of 24 months. Health-related quality-oflife, residual pain, instrumentation placement, and complications were studied. RESULTS: A total of 18 procedures were enrolled, in which 182 screws were implanted, (170 positioned in thoracic and 12 in lumbar pedicles, respectively). No surgical complications or hardware failure occurred in our series, 6 out of 182 (3,2%) screws had a partial pedicle breach, without neurological impairment or need for surgical revision. CONCLUSION: According to our results, a fully posterior percutaneous approach for long thoraco-lumbar spine instrumentation can be considered safe and reproducible, although an adequate training is strictly required.

Disc herniation is one of most common causes of spine surgery. Because of the presence of posterior longitudinal ligaments, disc fragments often migrate into the ventral epidural space. A posterior epidural herniation of a disc fragment is a rare occurrence. We report two cases of posterior migrated disc fragments, with, radiological and clinical findings. Because of the rarity of a posterior migration of the intervertebral disc fragments, a differential diagnosis can be challenging. This painful syndrome associated with neurological lower limb deficits can be confused initially, with other posterior epidural spaceoccupying lesions such as tumours, abscess or hematomas. A gadolinium-enhanced MRI scan is the gold standard for a correct diagnosis. Early surgical decompression of the spine with a posterior approach remains the optimal technique in ensuring the best possible outcome for the patient.

OBJECTIVE: The C2 odontoid fractures represent one of the most common cervical spine injuries. Stabilization and immobility are required for a correct treatment. However, in some cases surgical treatment is recommended. There are still no guidelines for Type II odontoid fractures management. The present study aims at determining how non-union could impact on mortality, functional and clinical outcomes in octogenarian patients conservatively treated. PATIENTS AND METHODS: The present investigation is a retrospective case series. All patients with diagnosis of Type II odontoid fractures, over 80 years and conservatively treated in our institution between January 2016 to April 2020 were potentially eligible for the study. The primary outcome was the bony fusion of the fracture after 3 months of conservative treatment. The secondary outcomes were clinical, functional outcomes and mortality. RESULTS: Sixty-four patients were eligible for the study according to inclusion and exclusion criteria. Computer Tomography (CT) evaluation performed 3 months after trauma showed complete fracture healing in 31 patients (48.4%, Fused), while 33 patients (51.6%) were evaluated as non-fused. Among these, 6 months after the CT evaluation, 14 patients were classified as stable, while 19 were classified as unstable. There were no statistically significant changes in clinical and functional outcomes reported in our patient series between patients with complete radiological healing and patients who reported stable fibrous non-union. CONCLUSIONS: In a selected group of elderly patients with a high risk for surgery, the conservative treatment of odontoid Type II fractures can be considered a viable management strategy. The achievement of a stable non-union allows for clinical and functional results comparable to complete fracture healing. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Paracetamol/codeine has shown a strong analgesic activity in several studies conducted among different kind of subjects, including those with trauma. Nevertheless, its efficacy in patients accessing the Emergency Department (ED) for different kind of pain has never been tested. PATIENTS AND METHODS: This is a cross-sectional, observational, prospective, cohort study. Inclusion criteria were patients > 18 year old presenting to the ED for localized traumatic or inflammatory pain involving only extremities. Numeric scale (NRS) was recorded thirty minutes and two hours after the administration of the analgesic therapy, consisting of 15 mg of ketorolac or 1000 mg/60 mg of paracetamol/codeine, both orally. RESULTS: Two-hundred patients were consecutively enrolled; 87 were treated with paracetamol/codeine and 113 with ketorolac. The combination paracetamol/codeine resulted to be not inferior to ketorolac in non-traumatic pain group and trauma group (p = 0.635 and p = 0.482, respectively). Compared to ketorolac, the combination paracetamol/codeine exerted a significantly higher analgesic activity in patients with fractures and muscular pain (p = 0.044) and was more effective in acute pain (p = 0.002), with a significant effect two hours after the administration (p = 0.029). CONCLUSIONS: Paracetamol /codeine is equivalent to ketorolac in non-traumatic pain and post-traumatic pain, but is superior in acute pain and in patients with fractures and muscular pain. Those results play in favor of the use of the combination paracetamol/codeine in patients accessing the ED for non-traumatic or traumatic pain of the extremities. [ABSTRACT FROM AUTHOR]

AIM: Cauda equina syndrome is a rare but highly impairing syndrome involving lower limbs as well as urinary, defecatory and sexual function. In the literature the most investigated sphincter dysfunction is the urinary. Bowel and sexual function are often overlooked since they become more relevant after the acute phase. PATIENTS AND METHODS: Eight consecutive male patients affected by cauda equina syndrome with sphincter dysfunction due to herniated disc disease of lumbar spine were treated between 2007 and 2009. Five patients were followed-up for at least two years. Sexual function was evaluated by IIEF-5 questionnaire; bowel function was investigated by means of clinical and instrumental investigation and manometry. RESULTS: Although little clinical improved, patients still complained severe symptoms at first year follow-up while all but one improved significantly in the following year. At two years followup only the patient whose cauda equina syndrome was misdiagnosed and surgically treated late respect to the onset of the syndrome, complained a persistent severe sexual and bowel dysfunction. CONCLUSIONS: Our results show that a longterm follow-up is mandatory to evaluate the real outcome of surgical managed cauda equine syndrome because short-term evaluation could be misleading about the residual capacity of late neurologic improving. Despite the relatively low number of cases evaluated, our results confirm that early diagnosing and treating the syndrome are relevant for the final outcome. [ABSTRACT FROM AUTHOR]

The aim of the study was to evaluate the feasibility of a limited invasive approach for the treatment of upper thoracic spine disease. Seven patients with type-A thoracic fractures and three with tumors underwent long thoracic stabilization through a minimally invasive approach. Four patients underwent a completely percutaneous approach while the other three underwent a modified hybrid technique, a combination of percutaneous and open approach. The hybrid constructs were realized using a percutaneous approach to the spine distally to the spinal lesion and by open approach proximally. In two patients, the stabilization was extended proximally up to the cervical spine. Clinical and radiographic assessment was performed during the first year after the operation at 3, 6, and 12 months. No technically related complications were seen. The postoperative recovery was rapid even in the tumor patients with neurologic impairment. Blood loss was irrelevant. At one-year follow-up there was no loosening or breakage of the screws or failure of the implants. When technically feasible a completely percutaneous approach has to be taken in consideration; otherwise, a combined open-percutaneous approach could be planned to minimize the invasivity of a completely open approach to the thoracic spine.

Introductionː Cervical disk arthroplasty is a potential alternative procedure to anterior cervical decompression and fusion for the treatment of cervical disk disease. The aim of the study was to perform a systematic literature review on long-term clinical and radiological outcomes after Bryan cervical disk arthroplasty.Material and Methodsː A systematic literature review was performed according to PRISMA guidelines via PubMed and Embase, Scopus, and the Cochrane Library database by using the following keywords: "Bryan prosthesis"; "cervical disk arthroplasty"; "outcomes"; and "long-term follow-up." Eight articles with at least 10 years of follow-up were considered for eligibility.Resultsː In total, 481 patients were enrolled in the studies. Because of the occurrence of multiple treated levels, 588 arthroplasties were performed, divided as follows: 12 C3/4 cervical disk arthroplasties (2.01%), 63 C4/5 (10.71%), 325 C5/6 (55.27%), and 188 C6/7 (31.97%). The mean preoperative cervical lordosis was 13.6 ± 9.3°, whereas the last follow-up value was 12.8 ± 8.7°. In the last follow-up, the mean segmental range of motion was 8.2 ± 3.3°.Discussion: Recent studies have suggested that cervical disk arthroplasty should be safely performed in healthy young patients with disk degeneration who may need future revision surgery. The results suggest that this procedure preserves native cervical spinal biomechanics at long-term follow-up with acceptable adjacent segments disease and periprosthetic ossifications.Conclusionsː Cervical disk arthroplasty has good long-term device survival, motility, adjacent segment degeneration, and clinical outcomes. Therefore, it represents a valid alternative for the treatment of cervical spine degenerative pathologies, especially in young patients., (© 2023. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Purpose: Percutaneous trans-pedicle screws represent a surgical option frequently performed in patients affected by thoracolumbar vertebral burst fractures (A3-A4). The aim of the study was to evaluate the early loss of kyphosis correction and its clinical correlations in a cohort of patients affected by burst spinal fracture treated with percutaneous trans-pedicle screws fixation., Methods: The present investigation consists in a retrospective one center analysis. The primary outcome was the evaluation of the early loss of correction. Secondary outcomes were the bi-segmental kyphosis change, the clinical outcome and the correlation between clinical outcome and the loss of correction., Results: Among 435 patients 97 were included in the study. A mean 3.3° of early loss of correction was observed between postoperative and 1 month follow-up evaluations. The mean anterior vertebral body height change was 3.8 mm. No statistical differences were found in clinical and functional outcomes between patients with >2° or <2° of kyphosis loss of correction., Conclusion: No statistical differences were found between 1 e 6 months postoperative kyphosis loss of correction. The amount of loss of correction seems not to influence clinical outcomes after percutaneous trans-pedicle screw fixation in patients with vertebral burst fractures., Competing Interests: Authors declare that they have no conflict of interest., (© 2021 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Purpose: Many studies reported mid-term clinical and radiological outcomes after cervical disc arthroplasty. Only a few studies analysed the long-term results. The aim of the study was to evaluate the clinical and radiological outcomes in patients treated with single-level Bryan cervical disc arthroplasty after 18 years of follow-up., Methods: This study was a retrospective analysis of institutional databases concerning patients treated with Bryan cervical disc arthroplasty. SF36 PCS, NDI and VAS were used to evaluate clinical and functional outcomes. Standard, flexion-extension X-ray and MRI were used to evaluate the radiological results., Results: Fifty-seven patients treated with single-level Bryan cervical disc arthroplasty completed the 18-year follow-up. At the final follow-up, a residual movement was observed in 32 patients (56%). The treated level range of motion decreased from 10.1° pre-operatively to 6.1° at the last follow-up (p = 0.0021). The range of motion of the adjacent segments and of the cervical spine had no significant change. Disc degeneration of the adjacent segment after 18-year follow-up was observed in 77.1% of treated patients., Conclusion: The clinical and radiographic outcomes 18 years after surgery are acceptable. The treated level range of motion reduction and the adjacent segment degeneration seems not to affect the clinical results after 18 years of follow-up.

The aim of the study is to analyze and report the results of the surgical activity in a spinal unit of a trauma hub in central Italy during COVID-19 pandemic. Surgical activity was compared between COVID 19 pandemic and the same period of time in 2019 at our institution. A 50% reduction of surgical procedures during the last three months was observed compared with the same period of time in 2019. The compliance with the containment rules for the spread of the infection, were sufficient to allow safe surgical activity for the medical teams and patients., Competing Interests: Authors declare that they have no conflict of interest., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Objective: Osteoporosis is a highly prevalent disease worldwide. Consequences of vertebral osteoporotic fractures include pain and progressive vertebral collapse resulting in spinal kyphosis, decreased quality of life, disability and mortality. Minimally invasive procedures represent an advance to the treatment of osteoporotic VCFs. Despite encouraging results reported by many authors, surgical intervention in an osteoporotic spine is fraught with difficulties. Advanced patients age and comorbidities are of great concern., Patients and Methods: We designed a retrospective case-control study on 110 post-menopausal women consecutively visited at our institution. Study population was split in a surgical and a conservative cohort, according to the provided treatment., Results: Kyphoplasty treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients (p < 0.05). EQ5D validated questionnaire also showed a better quality of life at 1 month for surgically treated patients (p < 0.05). SF-12 scores showed greater improvements at 1 month and 3 months with statistically significant difference between the two groups just at 3 months (p < 0.05). At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 54.55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average., Conclusions: Kyphoplasty is a modern minimal invasive surgery, allowing faster recovery than bracing treatment. It can avoid the deformity in kyphosis due to VCF. In fact, the risk to develop a new vertebral fracture after the first one is very high.

Cauda equina syndrome seems to be a very rare complication of spinal manipulations. Only few cases, in fact, were referred in literature in the past decades. Most of them are very old and poorly documented evoking doubts about the pathogenetic relationship between the spinal maneuvers and the onset of the syndrome. We observed and treated a 42-year-old patient who complained a rapid onset of saddle hypoparesthesia and urine retention only a few hours after the spinal manipulation performed for L5-S1 herniated disc. The comparison of the two following MRIs performed before and after the manipulations seems to prove a close pathogenetic relationship. The patient was operated soon after the admission to our emergency department and 1 year later he referred an incomplete recovery of the syndrome. The case offered the opportunity to update the literature. The review revealed only three cases from the beginning of the current century that confirm the rarity of the syndrome. Based on the data emerging from the official literature, safety of the manipulations and its pathogenetic aspects in causing lumbar radiculopathies are discussed.

The review of the publications concerning cervical spondylotic myelopathy (CSM) suggests that it has not been achieved a clear consensus about the treatment of this pathology. In this paper an algorithm of surveillance, conceived as an assistant tool to decide the best indications of treatment is presented. The algorithm permits a clear separation of the symptomatic patients on the base of the presence or the absence of neurologic damage resulting at the evoked potentials examination. The negativity of the evoked potentials, that means neurologic integrity, excludes any type of surgical treatment. In case of proved neurologic damage, the algorithm permits a further differentiation in subgroups according to the degree of clinical disability. If evoked potentials are positive, a surgical decompression should be always performed in patients affected by a severe clinical disability. The group of patients affected by a mild degree of clinical disability but with positive evoked potentials represents the most challenging for the spinal surgeons. Actually, several studies support either surgical and non surgical treatment for these patients. Although the Authors think that a surgical decompression has to be always performed in case of proved neurologic damage, only further randomized studies based on accurate algorithms could elucidate the outcome of the CSM and could permit to choose the best treatment according to the degree of the disease.