Cristian Gragnaniello

Effect of Smoking Status on Successful Arthrodesis, Clinical Outcome and Complications After Anterior Lumbar Interbody Fusion (ALIF).

BACKGROUNDnAnterior lumbar interbody fusion (ALIF) is a surgical technique indicated for the treatment of several lumbar pathologies. Smoking has been suggested as a possible cause of reduced fusion rates after ALIF, although the literature regarding the impact of smoking status on lumbar spine surgery is not well established. This study aims to assess the impact of perioperative smoking status on the rates of perioperative complications, fusion, and adverse clinical outcomes in patients undergoing ALIF surgery.nnnMETHODSnA retrospective analysis was performed on a prospectively maintained database of 137 patients, all of whom underwent ALIF surgery by the same primary spine surgeon. Smoking status was defined by the presence of active smoking in the 2 weeks before the procedure. Outcome measures included fusion rates, surgical complications, Short-Form 12, and Oswestry Disability Index.nnnRESULTSnPatients were separated into nonsmokers (nxa0=xa0114) and smokers (nxa0= 23). Univariate analysis demonstrated that the percentage of patients with successful fusion differed significantly between the groups (69.6% vs. 85.1%, Pxa0= 0.006). Pseudarthrosis rates were shown to be significantly associated with perioperative smoking. Results for other postoperative complications and clinical outcomes were similar for both groups. On multivariate analysis, the rate of failed fusion was significantly greater for smokers than nonsmokers (odds ratio 37.10, Pxa0= 0.002).nnnCONCLUSIONSnThe rate of successful fusion after ALIF surgery was found to be significantly lower for smokers compared with nonsmokers. No significant association was found between smoking status and other perioperative complications or adverse clinical outcomes.

Bilateral Temporal Myofascial Flap for the Reconstruction of Frontal Sinus Defects

BACKGROUNDnA frontal sinus infection, following a transsinus skull base procedure, portends potentially life-threatening complications, making surgical revision mandatory in refractory infections. The authors describe the application of the bilateral temporal myofascial flap (BTMF) as a valuable option for frontal sinus reconstruction, when pericranial or galeal-frontalis myofascial flap (GFMF) is no longer available.nnnMETHODSnA microanatomic laboratory cadaver investigation was conducted to obtain anthropometric measurements. Surgical technique is described, and intraoperative images are provided.nnnRESULTSnThe surgical steps of this technique and the related intraoperative images are reported. One case illustration regarding frontal sinus reconstruction following a postoperative infection, as a complication after a transsinus procedure, is reported.nnnCONCLUSIONnThe BTMF should be considered as a valuable option for frontal sinus reconstruction after transsinus skull base procedures when GFMF is not available.

Navigation-Guided Endoscopic Intraventricular Injectable Tumor Model: Cadaveric Tumor Resection Model for Neurosurgical Training

BACKGROUNDnIntraventricular tumors present difficult challenges to the neurosurgeon. Neurosurgeons have begun to explore the possibilities of using the endoscope in the radical resection of solid intraventricular lesions. There is a steep learning curve when dealing with such lesions with an endoscope.nnnOBJECTIVEnThe aim of this study was to create a laboratory training model for neuroendoscopic surgery of intraventricular lesions guided by the navigation system. We believe this technique is more reliable than the traditional approach using contrast injection with C-arm x-ray guidance.nnnMATERIALS AND METHODSnFive formalin-fixated, latex-injected cadaveric heads were used. The arterial system was injected with red latex through the common carotid arteries, and the venous system was injected with blue latex through the internal jugular veins at the C6 vertebral level. The contrast-enhancing tumor polymer, Stratathane resin ST-504-derived polymer (SRSDP), was injected into the lateral ventricle via Fraziers point under direct endoscopic visualization and real-time neuronavigation guidance. When navigation was used for trajectory planning, the peel-away sheath was registered using a frameless navigational system (BrainLAB, Feldkirchen, Germany). A questionnaire was distributed to all participants in an endoscopic cadaveric course in which the models were used to evaluate the endoscopic tumor model.nnnRESULTSnNeurosurgeons participating in the course performed an endoscopic approach to resect the intraventricular tumor model through an ipsilateral frontal burr hole. The properties of the SRSDP mixture could be manipulated through varying concentrations of the materials used, in order to reach the desired consistency of a nodular solid lesion and possibility for piecemeal resection. The tumor model allowed participants to compare between normal and pathologic endoscopic anatomy in the same cadaveric head.nnnCONCLUSIONnThis injectable tumor model with the combination of neuroendoscopy and navigation can improve the accuracy of the endoscopic approach and minimize the risk of cadaveric brain specimen damage that in return augments the feeling of lifelike conditions. Using this endoscopic injectable tumor model technique can assist neurosurgeons preparation for the challenges associated with an endoscopic piecemeal resection of a solid lesion in the lateral or third ventricle.

Endoscope-Assisted Trans-Maxillo-Sphenoidal Approach to Sellar and Parasellar Regions: Anatomic Study.

BACKGROUNDnAnterolateral skull base surgery in the sellar and parasellar regions has always represented a technical challenge for neurosurgeons. The microscopic endoscope-assisted transmaxillosphenoidal approach (MEMSA) affords a direct surgical corridor free from critical skull base structures. Here we describe and critically evaluate the use of MEMSA to access the sellar and parasellar areas, in terms of surgical exposure and operability.nnnMETHODSnSix cadaveric heads were examined. A stepwise dissection using MEMSA was performed. Relevant anatomy and surgical technique were critically described and comparatively reviewed. The operability score was applied for quantitative analysis of surgical operability.nnnRESULTSnMEMSA provides wide bilateral surgical exposure and vascular control of the sellar, suprasellar, and parasellar regions, achieving the highest operability on the midline and in the parasellar region. The approach can be tailored to the lesion, with the surgical corridor easily widened toward the contralateral pterygopalatine fossa. Anatomic knowledge of maxillary sinus landmarks is key to the use of this approach. Favorable sphenoidal anatomy is the main limiting factor, making MEMSA a surgical alternative to endoscopic endonasal routes in situations where those routes are not feasible, and the approach of choice in selected cases of primarily sellar lesions widely extending contralaterally to the approached maxillary sinus.nnnCONCLUSIONSnMEMSA is a safe and effective technique that provides access to the sellar, suprasellar, and contralateral parasellar areas via a direct, minimally disruptive surgical corridor. The preservation of nasal anatomy ensures the availability of mucosal flaps for use in further reconstruction.

Endoscope-Assisted Transmaxillosphenoidal Approach to the Sellar and Parasellar Regions: An Anatomic Study

BACKGROUNDnAnterolateral skull base surgery in the sellar and parasellar regions has always represented a technical challenge for neurosurgeons. The microscopic endoscope-assisted transmaxillosphenoidal approach (MEMSA) affords a direct surgical corridor free from critical skull base structures. Here we describe and critically evaluate the use of MEMSA to access the sellar and parasellar areas, in terms of surgical exposure and operability.nnnMETHODSnSix cadaveric heads were examined. A stepwise dissection using MEMSA was performed. Relevant anatomy and surgical technique were critically described and comparatively reviewed. The operability score was applied for quantitative analysis of surgical operability.nnnRESULTSnMEMSA provides wide bilateral surgical exposure and vascular control of the sellar, suprasellar, and parasellar regions, achieving the highest operability on the midline and in the parasellar region. The approach can be tailored to the lesion, with the surgical corridor easily widened toward the contralateral pterygopalatine fossa. Anatomic knowledge of maxillary sinus landmarks is key to the use of this approach. Favorable sphenoidal anatomy is the main limiting factor, making MEMSA a surgical alternative to endoscopic endonasal routes in situations where those routes are not feasible, and the approach of choice in selected cases of primarily sellar lesions widely extending contralaterally to the approached maxillary sinus.nnnCONCLUSIONSnMEMSA is a safe and effective technique that provides access to the sellar, suprasellar, and contralateral parasellar areas via a direct, minimally disruptive surgical corridor. The preservation of nasal anatomy ensures the availability of mucosal flaps for use in further reconstruction.

Endoscopic Transnasal Transclival Approach to a Pontine Cavernoma with Associated Developmental Venous Anomaly

BACKGROUNDnBrainstem cavernous malformations represent around 8%-22% of all intracranial cavernous malformations but exhibit a higher annual incidence of hemorrhage (2%-3%) compared with other cavernous angiomas and tend to be more symptomatic given their proximity to critical nuclei and fiber tracts. Recently, endoscopic endonasal techniques have been used for the removal of ventral skull base lesions, with significant improvement in operative morbidity and mortality compared with open approaches. Here we demonstrate the utility and feasibility of the endoscopic transclival approach for ventrally located pontine cavernomas in carefully selected patients.nnnCASE DESCRIPTIONnConsent was provided by the patient before the writing of this report. Institutional review board approval was not necessary because there was no other patient data accessed. A 21-year-old man presented to the emergency department with right-sided hemiparesis. Magnetic resonance imaging demonstrated evidence of hemorrhage from a ventrally located pontine cavernoma. Given the ventral location of the lesion and the desire for early control of an associated developmental venous anomaly (DVA), an endoscopic endonasal transclival approach was chosen. Gross total resection was achieved, and the patient did well postoperatively with no new neurologic deficits or cerebrospinal fluid leak. He is currently routinely followed and is neurologically well.nnnCONCLUSIONSnThis approach provided direct visualization of the lesion and the associated DVA allowing for a gross total resection without injury to the DVA. The transclival approach may be considered as an alternative to open lateral and dorsolateral neurosurgical approaches for ventral brainstem cavernomas in carefully selected patients.

Natural history of incidental colloid cysts of the third ventricle: A systematic review

OBJECTIVEnClinical significance and management of asymptomatic colloid cysts of the third ventricle is not well defined. The aim of this study was to investigate the risk of cyst progression necessitating surgical intervention during a surveillance period.nnnMETHODSnA systematic pooled analysis of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search (conducted in December 2017) in MEDLINE and EMBASE databases, identified eligible studies. Data related to demographic (sex, age, size), clinical (surgical intervention, acute neurological deterioration, cyst related mortality) and radiological outcomes (cyst stability, progression, regression) were extrapolated and analysed.nnnRESULTSnOf the 134 manuscripts identified, only 4 retrospective studies (176 patients) met the inclusion criteria. The level of evidence provided by these studies was low. During a median follow up of 61.2u202fmonths (IQR 41.6-70.1), 11 patients (8.6%, 95% CI 4.7-14.9) required surgical intervention due to either clinical or radiological progression. One patient experienced an acute neurological decline (0.8%, 95% CI -0.3-4.7), which eventuated in death a few years later. There were no reported cases of sudden death during this period. On radiological follow up, 86.7% (95% CI 78.5-92.2) of cysts remained stable, 11.2% (95% CI 6.2-19.2) progressed, and 2.0% (95% CI 0.1-7.6) regressed in size.nnnCONCLUSIONnFor incidental colloid cysts deemed appropriate for conservative management, there is a 5-15% risk of future progression necessitating operative intervention in the 5u202fyears following diagnosis. The data presented supports the need for ongoing surveillance neuroimaging for asymptomatic colloid cysts.

Brainstem herniation into the internal acoustic canal secondary to hydrocephalus in context of spontaneous cerebrospinal fluid otorrhea: report of a novel entity

Introduction and clinical presentationThe authors report a case of a 5-year-old boy presenting with vision loss, right-sided hearing loss, and facial paralysis secondary to hydrocephalus causing brainstem herniation into the internal auditory canal (IAC) following cerebrospinal fluid (CSF) otorrhea.Management and outcomeAfter placement of a ventriculo-peritoneal shunt (VP shunt), the vision and facial palsy improved whilst hearing loss persisted. Imaging demonstrated partial reduction of the herniated brainstem and resolution of hydrocephalus. To our knowledge, this is the first case reported of brainstem herniation into the internal auditory canal.

Anterior to Psoas (ATP) Fusion of the Lumbar Spine

When fusing a lumbar spinal segment, certain facts are well established: the disc should be removed, the end plates prepared carefully, and then graft material placed against the end plates, contained or supported by a lordotic cage. The cage will help correct any deformity, resist subsidence, and improve stability. In an “ideal cage” competition, the large lateral cages are the obvious winners when compared to PLIF, TLIF, or ALIF cages. Spanning both lateral cortical rims while sparing the anterior longitudinal ligament, they provide the best support, most graft volume, and most stability for the anterior column even without supplemental fixation. The standard approach for their insertion and placement is also the most logical going through both lateral annuli without disrupting normal stabilizing structures. None of the above is in dispute. The question raised in this chapter is whether the best access to the lateral annulus is really transpsoas (i.e., through the psoas muscle).

The paramedian supracerebellar transtentorial approach to the posterior fusiform gyrus.

BackgroundThe posterior fusiform gyrus lies in a surgically challenging region. Several approaches have been described to access this anatomical area. The paramedian supracerebellar transtentorial (SCTT) approach benefits from minimal disruption of normal neurovascular tissue. The aim of this study was to demonstrate its application to access the posterior fusiform gyrus.MethodsThree brains and six cadaveric heads were examined. A stepwise dissection of the SCTT approach to the posterior fusiform gyrus was performed. Local cortical anatomy was studied. The operability score was applied for comparative analysis on surgical anatomy.ResultsThe major posterior landmark used to identify the fusiform gyrus with respect to the medial occipitotemporal gyrus was the collateral sulcus, which commonly bifurcated at its caudal extent. Compared with other surgical approaches addressed to access the region, SCTT demonstrated the best operability in terms of maneuverability arc. Favorable tentorial anatomy is the only limiting factor.ConclusionsThe supracerebellar transtentorial approach is able to provide access to the posterior fusiform gyrus via a minimally disruptive, anatomic, microsurgical corridor.