Cristina Mancarella

Basal ganglia stroke due to mild head trauma in pediatric age - clinical and therapeutic management: a case report and 10 year literature review

Ischemia of the basal ganglia as an immediate consequence of minor head injury in children is rare (< 2% of all ischemic stroke in childhood) and is due to vasospasm of the lenticulostriate arteries. The clinical history of these lesions is particularly favourable because they are usually small, and also because the facial-brachial-crural hemiparesis typical of this pathology usually regresses after a period ranging from several weeks to several months, despite the persistence of an ischemic area on MRI. This is due to the well known neuronal plasticity of the CNS, in particular, of the primary motor cortex. The most effective therapeutic approach appears to be the conservative one, although the best treatment regimen is still not well defined.Young patients should be closely monitored and treated conservatively with osmotic diuretics to reduce perilesional edema. At the same time, however, it is very important to exclude, by means of instrumental and laboratory studies, conditions that could favour the onset of ischemia, including emboligen heart disease, thrombophilia and acute traumatic arterial dissections. Generally speaking, the prognosis in these cases is good. The authors describe their experience treating a 10-month old baby girl, with a left lenticular nucleus ischemia and report a literature review.

Posterolateral arthrodesis in lumbar spine surgery using autologous platelet-rich plasma and cancellous bone substitute: an osteoinductive and osteoconductive effect.

Study Design Prospective cohort study. Objectives To analyze the effectiveness and practicality of using cancellous bone substitute with platelet-rich plasma (PRP) in posterolateral arthrodesis. Methods Twenty consecutive patients underwent posterolateral arthrodesis with implantation of cancellous bone substitute soaked with PRP obtained directly in the operating theater on the right hemifield and cancellous bone substitute soaked with saline solution on the right. Results Computed tomography scans at 6 and 12 months after surgery were performed in all patients. Bone density was investigated by comparative analysis of region of interest. The data were analyzed with repeated-measures variance analyses with value of density after 6 months and value of density after 12 months, using age, levels of arthrodesis, and platelet count as covariates. The data demonstrated increased bone density using PRP and heterologous cancellous block resulting in an enhanced fusion rate during the first 6 months after surgery. Conclusions PRP used with cancellous bone substitute increases the rate of fusion and bone density joining osteoinductive and osteoconductive effect.

Atlantoaxial rotatory dislocation (AARD) in pediatric age: MRI study on conservative treatment with Philadelphia collar—experience of nine consecutive cases

PurposeAtlantoaxial rotatory fixation and atlantoaxial rotatory subluxation are the most frequent manifestations of atlantoaxial rotatory dislocation (AARD) in pediatric population and are often treated conservatively. The objective of this study is to correlate the changes highlighted on MRI T2-weighted and STIR sequences with the duration of conservative treatment.MethodsWe analyzed nine consecutive patients treated surgically between 1 Jan 2006 and 1 Jan 2010 at the Policlinico Umberto I of Rome. All patients underwent cervical X-ray, computed tomography and magnetic resonance imaging (MRI) (T1 and T2-weighted, STIR, angio MRI). All patients were treated with bed rest, muscle relaxants and cervical collar, and radiological follow-up with MRI and cervical X-ray was performed.ResultsAccording to Fielding’s classification, we observed seven patients with a type 1 subluxation and two patients with a type II subluxation. In type 1, STIR and T2 sequences showed a hyperintensity in the alar and capsular ligaments and in the posterior ligamentous system, with integrity of the transverse ligament (LTA). In type 2, the hyperintensity also involved the LTA. During the follow-up, MRI showed a progressive reduction until the disappearance of the hyperintensity described, which was followed by a break with orthotic immobilization.ConclusionsMRI with STIR sequences appears to be useful in addressing the duration of conservative treatment in AARD.

Lumbar spinal degenerative “microinstability”: hype or hope? Proposal of a new classification to detect it and to assess surgical treatment

PurposeThe stage of unstable dysfunction, also defined as “active discopathy” by Nguyen in 2015 and configuring the first phase of the degenerative cascade described by Kirkaldy-Willis, has specific pathoanatomical and clinical characteristics (low back pain) in the interested vertebral segment, without the presence of spondylolisthesis in flexion–extension radiography. This clinical condition has been defined as “microinstability” (MI). The term has currently not been recognized by the scientific community and is subject of debate for its diagnostic challenge. MI indicates a clinical condition in which the patient has a degeneration of the lumbar spine, causing low back pain, and radiological examinations do not show a spondylolisthesis.MethodsWe elaborated a clinical score test based on preoperative radiological examinations (static and dynamic X-Rays, CT and MRI) to detect and assess MI. Then, we enrolled 74 patients, all the levels from L1 to S1 were analysed, for a total amount of 370 retrospectively analysed levels. We excluded patients with degenerative scoliosis, as it is related to an advanced stage of degeneration. The test has been developed with the aim of furnishing quantitative data on the basis of the aforementioned radiological examinations and of elaborating a diagnosis and a treatment for the degenerative pathology in dysfunctional phase, responsible for low back pain.ResultsWe performed a statistical analysis on the results obtained from the test in terms of significativity and predictive value with a 1-year follow-up, calculating the p value and the χ2 value.ConclusionsIn patients with low back pain and negative dynamic X-Rays, an accurate analysis of the radiological exams (CT, MRI, X-Rays) allows to formulate a diagnosis of suspect MI with a good predictive value. This situation opens many clinical and medicolegal scenarios. The preliminary results seem to validate the test with a good predictive value, especially towards ASD, but they need further studies. On the basis of the results obtained, the test seems to allow a good classification of the dysfunctional phase of the degenerative cascade, identifying and classifying MI as a pathologic entity, defining its pathoanatomical and clinical relevance and elaborating a treatment algorithm.

Spinal schwannomatosis in the absence of neurofibromatosis: A very rare condition

Schwannomatosis is defined as an extremely rare tumors syndrome characterized by the presence of multiple schwannomas in the absence of typical signs of NF1 and NF2 syndromes. The genetic and molecular analysis performed on these tumors makes it possible to name schwannomatosis as distinct clinical and genetic syndrome. The treatment in the case of symptomatic lesions is surgical removal; if the lesions are asymptomatic it is better to perform serial MRI studies. Given the high incidence of developing additional lesions in patients with schwannomatosis, it remains imperative to perform serial brain and spinal cord MRI studies during follow-up. The differential diagnosis is important including clinical and radiological criteria plus molecular genetic analysis of tumor cells and lymphocyte DNA. We report a rare case of spinal schwannomatosis in which genetic analysis performed on surgical samples showed two different mutations in the cells of the two lesions.

Spinal epidural hematomas: personal experience and literature review of more than 1000 cases

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patients clinical and neurological status at admission, age, and the craniocaudal site.

Post-traumatic Collet–Sicard syndrome: personal observation and review of the pertinent literature with clinical, radiologic and anatomic considerations

Study designThe lesion of the lower four cranial nerves, commonly called Collet–Sicard syndrome, can be caused by a blunt head and neck trauma. It may be associated to an isolated fracture of the occipital condyle or of the atlas.ObjectiveThe aim of this report is to assess the modality of the trauma, the type of fracture, the anatomic characteristics, the treatment and clinical results of this syndrome.Summary of background dataWe discuss 14 cases of fracture of occipital condyle and of atlas and 1 personal case.MethodsWe analyzed 14 cases collected from the literature between 1925 and 2013, reported a further personal case and performed an anatomical study of the paracondylar, atlas and styloid process region. The anatomical dissection was performed to assess the anatomic relationships in the site of transit in which the nerves IX, X, XI and XII are injured.ResultsA total of 14 cases of p-CSS were collected: 9 caused by a condyle fracture and 5 by an atlas fracture. The patients were 13 males and only 1 female, 10 of them had a blunt trauma due to the result of axial loading (force directed through the top of the head and through the spine) falling on the head. The nine cases with a condyle fracture were associated to the dislocation of part of it, while those with atlas fractures showed the fracture and/or disjunction of the articular mass. The anatomical evaluations reveal that the lower four cranial nerves, at their emergency, pass through a close osteo-ligamentous space in relationship to the condyle. Below they run through a little wider channel between the articular mass of C1 and the styloid process. Two cases underwent surgical procedure. All the other cases were treated conservatively with immobilization of the cervical spine. During follow-up three cases with condylar fractures were found to be clinically unchanged and six showed modest improvements while one case with atlas fracture had a complete recovery and four improved significantly.ConclusionsThe p-CSS is caused by force directed through the top of the head. We suppose that the nerve injuries are due to their laceration caused by a displacement of a condyle fragment or to their compression and stretching when they pass between the lateral mass of the atlas and the styloid process. These modalities of trauma explain the better clinical results in patients affected by C1 fractures. Conservative treatment is the option of choice. Surgical option, when choosed, is not considered to fix nerve damages.

Post laminoplasty cervical kyphosis—Case report

INTRODUCTION Cervical kyphosis is a progressive cervical sagittal plane deformity that may cause a reduction in the ability to look horizontally, breathing and swallowing difficulties, sense of thoracic oppression and social isolation. Moreover, cervical kyphosis can cause myelopathy due to a direct compression by osteo-articular structures on the spinal cord or to a transitory ischaemic injury. The treatment of choice is surgery. The goals of surgery are: nervous structures decompression, cervical and global sagittal balance correction and vertebral stabilization and fusion. PRESENTATION OF CASE In October 2008 a 35 years old woman underwent surgical removal of a cervical-bulbar ependymoma with C1–C5 laminectomy and a C2–C5 laminoplasty. Five months after surgery, the patient developed a kyphotic posture, with intense neck and scapular girdle pain. The patients had a flexible cervical kyphosis. Therefore, we decided to perform an anterior surgical approach. We performed a corpectomy C4–C5 in order to achieve the anterior decompression; we placed a titanium expansion mesh. DISCUSSION Cervical kyphosis can be flexible or fixed. Some authors have reported the use of anterior surgery only for flexible cervical kyphosis as discectomy and corpectomy. This approach is useful for anterior column load sharing however it is not required for deformity correction. CONCLUSION The anterior approach is a good surgical option in flexible cervical kyphosis. It is of primary importance the sagittal alignment of the cervical spine in order to decompress the nervous structures and to guarantee a long-term stability.

Twelfth nerve paresis induced by an unusual posterior fossa arachnoid cyst: Case report and literature review

Abstract There are only three cases of arachnoid cysts inducing twelfth nerve paresis described in English medical literature. We herein report one more instance. Six weeks after surgery, the patient has almost fully recovered. This case underlines the importance of considering the arachnoid cyst as a possible cause of twelfth nerve paresis.

Vincenzo Quercioli (1876-1939), researcher and pioneer of the atlas fracture.

A review of early 20th century literature regarding fractures of the atlas led the authors to discover a paper written in Italian by Professor Vincenzo Quercioli in 1908, at that time an assistant surgeon at the University of Siena. The work was published in the journal Il Policlinico, which at that time was directed by Professor Francesco Durante. The paper described the first case of a quadripartite fracture of the atlas, and it accurately reported the mechanism of injury, symptoms, neurological examination, treatment, complications, and cause of death of the patient. Quercioli performed an autopsy on the patient and gave a detailed description of anatomopathological features. In particular, he identified the 4 symmetrical fracture lines related to the arches of the atlas and the substantial integrity of the atlantoaxial ligaments, particularly the transverse ligament. Based on those findings, Quercioli concluded that the mechanism of trauma was an axial force. This force passed through the center of the vertebral ring and caused symmetrical displacement and compression of the articular masses. These concepts of dynamic physics led Quercioli to conclude that, because the atlas is wedge shaped, the masses of the atlas reacted to stress by moving away from the center. This reaction resulted in stretching the front and rear arches, which then fractured at their 4 points of weakness. The integrity of the spinal cord was intact, based on a negative neurological examination for CNS lesions. Thus, he concluded that these injuries were not fatal and could be cured by appropriate treatment with a Minerva cast and, in the presence of swallowing disorders, with a nasogastric tube. The case described by Quercioli was later mentioned in two classic works on atlas fractures by Sir Geoffrey Jefferson, published in 1920 and 1927. In those works, Jefferson proposed his classification of 5 different anatomopathological classes; this work is widely cited in the literature and should be considered a classic. The patterns and deductions that Jefferson reported on these fractures appeared to draw upon the scientific experience of Quercioli and his description of the quadripartite atlas fracture, which appeared to be unique, even in Jeffersons review. Therefore, the authors believe that they have identified another scientist and pioneer of the atlas fracture in Professor Vincenzo Quercioli. With his brilliant insights, which remain useful and valid, Quercioli led the way to further research on the subject.