Antonio Bocchetti

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.

Ulcerative and mutilating variant of carpal tunnel syndrome.

SummaryCutaneous involvement in severe carpal tunnel syndrome is secondary to damage to sensory and autonomic fibers of the median nerve. We report the case of a 63 year old man who presented skin and bone lesions, confined to the sensory zones of both median nerves. The lesions consisted of dystrophic modifications of the fingernails, progressive sclerosis, skin thickening and ulcerations on the fingers, acro-osteolysis, and purulent inflammation with subsequent auto-amputation of the distal phalanx of the right index finger. Clinical, neurophysiological and surgical findings are reported. The recovery of the ulcerative lesions suggests the reversibility of autonomic disturbances after surgery.

Anaplastic oligodendroglioma presenting with drop metastases in the cauda equina

Metastatic involvement of the cerebro-spinal fluid (CSF) pathway in oligodendrogliomas is not uncommon; however, symptomatic involvement of the spinal cord is very rare: less of 10 cases have been published. To our knowledge, an intracranial oligodendroglioma presenting with symptoms of drop metastases in the cauda equina has never been reported. We report a case of 67-year-old woman who after 1 month of severe low back and legs pain developed symptoms of raised intracranial pressure. A spinal cord MRI showed multiple intradural nodular lesions at the level of the cauda equina, a MRI of the brain showed an intraventricular brain tumor. The histopathological diagnosis of both surgically treated lesions was anaplastic oligodendroglioma. The choices adopted in planning diagnostic and therapeutical procedures are discussed. The importance of the clinical and neuroradiological data in the diagnosis is stressed. Pathophysiology of the seeding of intracranial tumours via the cerebrospinal fluid is reviewed.

Post traumatic retropharyngeal pseudomeningocele

SummaryThe authors report a case of a 33-year-old man who presented, during recovery from coma due to severe head injury, dysphagia and respiratory failure. Magnetic resonance, retrograde radionuclide myelography and computerized tomographic myelography identified a pseudomeningocele in the retropharyngeal space due to a tear of the left C2 radicular sleeve. After failed medical management, the patient underwent lumbo peritoneal shunt. Magnetic resonance controls showed progressive collapse of the collection. After 3 months the patient was able to breathe spontaneously and to swallow. The authors describe pathogenesis, diagnostic strategy and principles of treatment of traumatic retropharyngeal pseudomeningoceles.

Spontaneous intracranial extradural haematoma associated with frontal sinusitis and orbital involvement

Intracranial extradural hematoma is usually traumatic. Rarely, it can occur spontaneously associated with coagulative disorders (spontaneous or iatrogenic), dural vascular malformation, cranio-facial tumors and infections. In these cases, spontaneous extradural hematoma (SEH) is a serious event that needs to be recognized and managed in time to avoid fatal outcome. The authors report a case of a 12-year-old young girl with a 3-year history of right frontal sinusitis treated urgently for a right frontal extradural hematoma involving the orbit. Diagnosis and management of this case is discussed reviewing the pertinent literature.

Versatility of sub-occipital approach for foramen magnum meningiomas: a single centre experience

BACKGROUND Foramen magnum meningiomas (FMM) represent a challenge for neurosurgeons. Multiple surgical strategies have been reported to treat these lesions in their variable location. Contemporary technical innovations allow the utilization of common sub-occipital craniotomy to treat ventrally, ventro-laterally and dorsally located FMMs. We present our technique and experience. METHODS From November 2004 to November 2015, we treated 14 patients with FMM at the Department of Neurosurgery of the Santa Maria delle Grazie Hospital in Pozzuoli, Naples, Italy. There were 10 females and 4 males, with a mean age of 64.5 years (range, 55-77 years). All patients had high field magnetic resonance imaging (MRI) with contrast enhancement preoperatively, which led to the radiological diagnosis. A sub-occipital craniotomy was performed in all patients as well as the removal of the posterior arch of C1. Partial removal of C2 was necessary in 2 patients. Neck pain was the most common symptom of presentation. Paraparesis was present in patients in 3 patients. Upper limbs dysesthesia or pain existed in 3 cases. RESULTS Thirty days after surgery neck pain and dysesthesia decreased in all patients affected. Neurological improvement was observed in 2 patients affected by weakness in lower limbs at 6 months follow up. Paraparesis was unchanged in 1 patient. Two patients presented transient worsening after surgery. Transient dysphagia occurred in one case and postoperative hemorrhage with subsequent surgery in another patient. We had no postoperative mortality. CONCLUSIONS FMM surgery should be tailored to the lesion at hand as in most instances it is possible to avoid the use of extensive skull base approaches.

Combined intra-extradural approach for posterolateral thoracic disk herniations. Preliminary study and technical note

Purpose Thoracic disk herniation is uncommon. It still represents a challenge for spinal surgeons. Multiple surgical strategies are available and, often, they are matter of debate. We describe a preliminary experience about a combined extra-intra dural approach for posterolateral disk herniation in patients affected by spinal cord compression.MethodsWe performed a combined extra-intra dural approach in two preliminary cases. We performed bilateral laminectomy of adjacent vertebrae and unilateral partial medial arthrectomy of the involved segment. After a lateral extradural diskectomy, we, subsequently, performed a median longitudinal durotomy. The conflict between disk herniation and spinal cord was identified. We removed disk herniation moving disk fragments in the extradural compartment without ventral spinal dura opening.ResultsWe solved spinal cord compression in both cases. Postoperative neurological improvement was observed in both cases. No major complications were observed.ConclusionOur preliminary results are probably insufficient to establish surgical criteria but offer another surgical perspective to especially treat patients with contraindication to anterior approaches.