Aldo Moraci

Prognostic role of depression after lumbar disc surgery.

Abstract.A total of 73 patients underwent microdiscectomy for lumbar disc herniation between September 2001 and May 2002 at the Department of Neurosurgery of the Second University of Naples. Preoperatively and 3 and 6 months after surgery, patients were assessed on the Zung Self-rating Depression Scale (SDS) and on a visual analogue scale (VAS) for the subjective perception of pain. At 3 and 12 months, we found that patients with lower SDS scores (n=41) had a better outcome regarding pain than patients with relevant depressive symptoms (n=32). In agreement with the literature, our results confirm the negative role of depression in outcome after lumbar disc surgery. We emphasize the consideration of psychological factors in the management of lumbar disc herniation.

Spontaneous resolution of chronic subdural hematoma

BACKGROUND Spontaneous resolution of chronic subdural hematoma has rarely been reported in the literature, and its mechanism has not been fully investigated. Response to surgery has been very satisfactory; in fact, this is generally considered the treatment of choice. METHODS From a series of 24 cases of chronic subdural hematomas, we observed five patients between 1996 to 1998. These patients showed headache and decrease of cognitive level, 4-5 weeks after minor head injury. Neurologic evaluation revealed only worsening of mental function according to Mini Mental State Examination (MMSE). Computed tomography (CT) scans showed brain atrophy and chronic subdural hematoma without increased intracranial pressure. These patients were treated by clinical observation and serial cerebral CT scans. RESULTS After 7 to 10 days, all patients showed improvement of clinical signs. After 30 to 45 days, radiological disappearance or marked reduction in size of the hematoma and complete clinical recovery were obtained. No neurological deficits and no recurrences have been observed during follow-up (3 months to 2 years). CONCLUSIONS We believe that age greater than 70 years, decreased cognitive level (MMSE = 21), brain atrophy, and absence of increase of intracranial pressure are clinical and radiological signs that allow one to choose conservative treatment.

Positioning on surgical table

Positioning on the surgical table is one of the most important steps in any spinal surgical procedure. The “prone position” has traditionally been and remains the most common position used to access the dorsolumbar-sacral spine. Over the years, several authors have focused their attention on the anatomy and pathophysiology of both the vascular system and ventilation in order to reduce the amount of venous bleeding, as well as to prevent other complications and facilitate safe posterior approaches. The present paper reviews the pertinent literature with the aim of highlighting the advantages and disadvantages of various frames and positions currently used in posterior spinal surgery.

Management of benign craniovertebral junction tumors.

Summary. Background: We report our surgical experience in the treatment of fifteen consecutive patients with benign craniovertebral junction tumors, observed from 1993 to 2000 at our department. Method: We treated 7 meningiomas, 3 epidermoids, 3 C1 neurinomas and 2 neurinomas of the lower cranial nerves. Clinical results were evaluated by Karnofsky Performance Scale and all patients underwent preoperative neuroradiological evaluation with CT, MRI and MRA; angiography was not routinely performed and was considered for each individual case. Findings: 11 partial transcondilar and 4 retrocondilar approaches were performed. Total removal was achieved in 11 cases (73,3%) and subtotal removal in 4 patients (26,7%). None of the patients required occipitocervical fusion. Patients were followed for an average period of 24±31 months. Clinical and radiological follow-up showed no recurrence in cases with total removal. In all patients a statistically significant postoperative increase of KPS scores was recorded. The treatment of epidermoid tumors presented particular issues: debulking the lesion, we obtained a surgical window, avoiding a large removal of bone. In Nakasu grade 1 or 2 meningiomas, we carried out total removal by piecemeal resection and without complete condylectomy and bone fixation. Interpretation: The choice of these approaches and the extent of bone resection should be defined according to the tumors location and size. Moreover we emphasize that preoperative neuroradiological evaluations on presumptive tumor type could be helpful to the surgeon in order to tailor the technique to different lesions, providing the required exposure, without unnecessary surgical steps.

Cranial Reconstruction Using Bioabsorbable Calcified Triglyceride Bone Cement

Background: We report our experience on 6 cases of cranial reconstruction using bioabsorbable calcified triglyceride KRYPTONITE Bone Cement (Doctors Research Group). Methods: Six patients underwent cranial reconstruction during the surgical removal of a supratentorial tumor between September 2008 and November 2009 at our department. In 5 patients, we performed the cranial reconstruction using KRYPTONITE Bone Cement and cranial fixations; in the remaining patient, we avoided cranial fixation systems or other bone sutures to obtain good aesthetic results in the frontal supraorbital region. Preoperatively and 7 days and 12 months after surgery, patients were assessed using craniocerebral magnetic resonance imaging and computed tomography (CT). Results: We observed that this bone cement was an injectable liquid for up to 8 minutes after mixing, it became adhesive at 8 to 15 minutes, and it was then shaped for use. Brain and dural reconstructions were not protected when this bone cement was being poured into the craniotomy site because of the minimal exothermal reaction. After 8 minutes, additional expansion is limited to 10%; therefore, we took heightened awareness of the amount of cement needed to fill the bone defect. In all patients, postoperative craniocerebral CT scanning, at 7 days, showed perfect alignment of the craniotomical bone and optimal filling of bone defects. No complications occurred, and aesthetic result was good. Twelve months after surgery, craniocerebral CT scanning showed bioabsorbability and osteoconductivity of this cement. Conclusions: KRYPTONITE Bone Cement is a nonthermal conducting, radiopaque, nonmagnetic, lightweight, simple to prepare, and easily applicable and molded material. Moreover, it has adhesive, bioabsorbable, and osteoconductive properties. To our knowledge, we present the first case of cranial reconstruction using this cement without cranial fixation systems.

Surgery, radiotherapy and temozolomide in treating high-grade gliomas

Temozolomide (TMZ) a recent, oral, second generation alkylating agent is a chemotherapeutic with demonstrated efficacy for the treatment of high-grade gliomas. The efficacy of TMZ has been demonstrated in both pre-clinical and phase I and II studies. The goal of this study is to determine the activity and safety of temozolomide in improving overall survival (OS), progression-free survival (PFS) and health-related quality of life (HQL) in patient with malignant gliomas treated by surgery, radiotherapy and temozolomide. Twelve patients with newly diagnosed glioblastoma (GBM), and anaplastic astrocytoma (AA) were studied. The mean follow-up period was 12 months. The overall response rate for all histological groups was 33% (4 patients), 6 patients (50%) showed a stabilization of disease. The median progression-free survival (PFS) and overall survival (OS) was respectively 8.35 and 14.1 months; time to progression was 36 week ranging from 20 to 46 In all patients, treatment with temozolomide was associated with improvement of performance status including the patient showing disease progression; Karnofski score improved in all patients by a minimum of 10, with a median of 20 at 6 months. No patient stopped the treatment due to side-effects, no major adverse events were recorded. In two cases of glioblastoma, we observed complete response and after three years, the quality of life is optimal. Surgery allows to establish a histopathological diagnosis, to improve signs and symptoms which are attributable to intracranial hypertension or tumour topography, and to reduce the number of target cells for adjunctive therapies. Radiotherapy improves survival and TMZ chemotherapy that is given after radiotherapy adds survival benefit for patients. Because of its favourable pharmacokinetic and pharmacodynamic properties and improved tolerability. Temozolomide appears to be an ideal, first-line, single-agent, with a safe profile and demonstrated HQL benefits in patients with high-grade gliomas.

Trigeminal neuralgia and persistent trigeminal artery

We report a case of trigeminal neuralgia caused by persistent trigeminal artery (PTA) associated with asymptomatic left temporal cavernoma. Our patient presented unstable blood hypertension and the pain of typical trigeminal neuralgia over the second and third divisions of the nerve in the right side of the face. The attacks were often precipitated during physical exertion. MRI and Angio-MRI revealed the persistent carotid basilar anastomosis and occasionally left parietal cavernoma. After drug treatment of blood hypertension, spontaneous recovery of neuralgia was observed and we planned surgical treatment of left temporal cavernoma.

Traumatic Rupture into Frontal Sinus of a Frontal Intradiploic Epidermoid Cyst

The aim of this paper is to record a way of presentation of a frontal epidermoid tumour which has not been described before. Intradiploic epidermoid cysts are fairly uncommon benign tumours which arise between the two tables of cranial bones. These lesions grow slowly and do not involve the intracranial compartment. Some authors have reported the intracranial rupture of an epidermoid cyst producing complications such as pneumocephalus [4]. We present a case of a 24-years-old man with a frontal intradiploic epidermoid cyst which ruptured into the frontal sinus after head trauma producing fatty tissue vomiting.

Dural Reconstruction in Meningioma Surgery

After many cranial and spinal neurosurgical removal of meningiomas, reconstruction of the dura mater is needed. The dura has to be meticulously closed following craniotomy (Protasoni et al., 2011), but primary dural closure with sutures alone can be difficult in a loss of native dural tissue (i.e., convexity meningiomas), to enlarge the dural compartment (i.e., inoperable intramedullary tumors) and when the closure is difficult and not sufficiently watertight because dura mater edges have shrunken and they cannot be sutured directly.

Percutaneous thermocoagulation of the Gasserian ganglion in the treatment of trigeminal neuralgia

Abstract Objective: To validate the use of selective percutaneous thermocoagulation of the Gasserian ganglion in the treatment of trigeminal neuralgia. Methods: 1860 patients with trigeminal neuralgia (TN) were studied over a period of 26 years. Diagnosis was idiophatic (ITN) (97%), atypical (ATN) (2%) or symptomatic TN (STN) (1%). Patients underwent percutaneous thermocoagulation of the gasserian ganglion. Results: Immediate pain relief was observed in 1784 (98.9%) patients with ITN, in 13 (68.4%) patients with STN, and in 6 (16.2%) patients with ATN. Recurrence was observed in 25% of patients with ITN, 40% of with STN, and 67% of patients with ATN. Major side effects included transient dysesthesia (58%), and masseter weakness (14%). Patients with ITN treated at 75–80°C did not differ significantly from their cohort treated at 65–70°C in terms of immediate pain relief. Recurrence was more common in the group treated at the lower temperature. Facial hypoalgesia was more sustained in patients treated at th...