Fabrizio Gregori

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.

Efficacy, Security, and Manageability of Gelified Hemostatic Matrix in Bleeding Control during Thoracic and Lumbar Spine Surgery: FloSeal versus Surgiflo

INTRODUCTION Accurate hemostasis in surgical practice is critical. The need for optimal atraumatic hemostasis has become compelling in neurosurgery. A simple and safe gelified hemostatic matrix is often used. This prospective study evaluates two different hemostatics, FloSeal (Baxter Healthcare, Deerfield, Illinois, United States) and Surgiflo (Ethicon, Somerville, New Jersey, United States), for bleeding control during spine surgery, considering their efficacy, safety, and ease of use. MATERIALS AND METHODS From January 2012 to December 2013, we recruited 149 patients. Inclusion criteria were age between 25 and 80 years, diagnosis of degenerative or traumatic pathology of the lumbar or thoracolumbar spine, and persistent bleeding not responding to standard hemostatic techniques. All patients underwent laminectomy or laminoarthrectomy, with exposure of the perivertebral venous plexus. Our aim was to stop the bleeding completely in the operative field by application of hemostatic gel. All patients were evaluated during the follow-up period with a clinical and neurologic examination. All patients underwent a computed tomography scan 3 months after the intervention. RESULTS We included 149 patients in our study: 98 men and 51 women. Overall, 92 patients were affected by a degenerative condition and 57 by traumatic pathology. A total of 42 patients had anticoagulant and/or antiaggregant therapy preoperatively. In all cases, massive bleeding originated from the epidural venous plexus. FloSeal was used in 86 cases and Surgiflo in 63. A complete hemostasis was achieved in all patients within 3 minutes, 30 seconds and 7 minutes (FloSeal, 5 minutes, 35 seconds ± 52 seconds; Surgiflo, 5 minutes, 32 seconds ± 54 seconds). Statistical analysis did not show any association between coagulation time and hemostatics, age, sex, and the pathology treated. Previous therapy with antiaggregants and/or anticoagulants determined a slight increase in the time of hemostasis without any statistical differences. The clinical and radiological follow-up showed no evidence of postsurgical hematomas. CONCLUSIONS Comparative analysis of the two products did not show any relevant differences in terms of efficacy and ease of use or their effectiveness in bleeding control. Their use was valid even in patients who used antiaggregant/anticoagulant drugs preoperatively. Both FloSeal and Surgiflo can be considered good choices for controlling bleeding in spinal surgery.

Isolated Pediatric Intramedullary Schwannoma: Case Report and Review of Literature

BACKGROUND Intramedullary (IM) schwannomas are rare entities representing 0.3%-1% of intramedullary tumors and 1.1% of spinal schwannomas. Beside many theories proposed, their rare occurrence might be related to the absence of Schwann cells in the spinal cord. Pediatric IM schwannomas are uncommon, and in the absence of neurofibromatosis they are extremely rare. To date, few cases have been reported in the literature. CASE DESCRIPTION We describe the case of an 8-year-old female affected by a progressive paraparesis. Neuroradiologic investigations showed an oval-shaped mass at the level of T10-T11. The patient underwent surgery, performed under neurophysiologic monitoring. The patient was operated on with complete removal of the lesion. The postoperative course was uneventful. CONCLUSIONS The clinical, neuroradiologic, and intraoperative findings are presented, along with a review of the literature. Despite the number of lesions potentially compressing the spinal cord, IM schwannoma is rare but should be taken into account in the differential diagnosis.

New Techniques and MIS: The Interspinous Fixation Devices

The treatment of vertebral instability has evolved over the years with the aim of searching and developing the most effective and less invasive procedure to reduce and to neutralize dynamically the metameric hypermobility; pedicle screw fixation (PSF) has been widely employed to reach vertebral fixation and fusion and still remains the “gold standard” technique [1, 2]. PSF is associated with well-known risks [3, 4] such as increased rates of cerebrospinal fluid leakage, fracture of the pedicles during screw insertion, transient/permanent injury to nervous structures, and deep wound infections. Furthermore, as a result of muscle dissection and long operative times, some disadvantages can be evident, such as postoperative back pain and long postoperative recovery time [5]. There are risks of exposure to ionizing radiations for the surgeon and the whole operating room staff, other than for the patient, due to the use of fluoroscopic guidance for the implantation of pedicle screws (PS) [4, 6]. The muscle dissection related to surgical exposure leaded to the development of minimally invasive procedures, at the cost of increased exposure to ionizing radiations. This has led to the development of a lot of different devices, some of them used indiscriminately in recent years but with questionable long-term results. In this context, a major role was played by interspinous devices, generally used in degenerative lumbar spine disease. Interspinous posterior device (IPD) is a term used to identify a relatively recent group of implants employed in the treatment of lumbar spinal degenerative disease. This kind of device is classified as part of the group of the dynamic stabilization systems of the spine. The concept of dynamic stabilization has been actually replaced by the principle of dynamic neutralization of the hypermobility, with the intention of clarifying that the primary aim of this kind of systems is not the preservation of the movement but the dynamic neutralization of the segmental hypermobility, which is at the base of the pathological condition. The surgical indications for the implantation of an IPD are the spinal stenosis and neurogenic claudication, assuming that its function is the enlargement of the neural foramen and the decompression of the roots forming the cauda equina in the central part of the vertebral canal. Recently, it has been noticed that those devices have significant problems in terms of clinical follow-up, since the action exercising on the vertebral body has an appreciable effect on the biomechanics of the lumbar spine. This is why in the last few years new devices have been introduced, the so-called interspinous anchors (IA) or interspinous fusion devices (IFD). Those differ from the IPD as their aim is the fusion of the spinous processes on which they are anchored, and therefore the target is spinal stabilization by arthrodesis and not the dynamic neutralization of the hypermovement. The question that requires response is: are those devices able to replace arthrodesis with plates and screws in lumbar instability?

Correlation Between Timing of Surgery and Outcome in ThoracoLumbar Fractures: Does Early Surgery Influence Neurological Recovery and Functional Restoration? A Multivariate Analysis of Results in Our Experience

BACKGROUND Treatment for spinal trauma is affected by both nonmodifiable and modifiable variables. The aim of this study was to compare early surgery with intermediate and late surgery to determine the benefits of spinal reconstruction in neurological recovery and functional restoration in patients with thoracolumbar fractures. METHODS In order to identify correlations between treatment timing, fracture site, neurological recovery, American Spinal Injury Association (ASIA) score restoration, and rehabilitation prognosis in patients with thoracic and lumbar fractures, we conducted a multivariate analysis of the results of surgery, at our institution, in 166 consecutive patients with unstable thoracolumbar fractures with or without neurological impairment. We conducted a literature review (1988-2012) and compared our results with those already published. RESULTS Regardless of the location and type of fracture, early surgery resulted in a reduction of median hospital and intensive care unit (ICU) length of stay, as well as a reduction of nosocomial complications. Regardless of the type of fracture and preoperative ASIA score, thoracic fractures had the worst outcome. Early treatment seemed to have better results, depending on the preoperative ASIA score. CONCLUSION Early surgery in patients with thoracolumbar fractures with incomplete neurological damage could positively affect neurological recovery, functional restoration, length of hospital and ICU stay, and associated comorbidity. Thoracic fractures had the worst outcome. Early surgery seemed to have better results if the initial ASIA score was good. The better the ASIA score on admission, the better was the outcome. Surgical timing did not affect the outcome when the ASIA score was A or E.

Spontaneous spinal discitis and spondylodiscitis: Clinicotherapeutic remarks

Introduction Spinal infections are rare (their incidence is estimated in about the 5% of all osteomyelitis) and severe pathologies. They are usually identified with different names, as disk space infection, spondylodiscitis, and vertebral osteomyelitis. Spondylodiscitis is the most frequent among spinal infections. The etiology might be due to bacteria, fungi, and parasites and might affect many anatomical structures. The reported incidence is increased in the last years.[1,2] The disease can be classified according to the involved anatomical structure: 1. Vertebral osteomyelitis 2. Discitis and spondylodiscitis 3. Spinal canal infections 4. Adjacent soft tissue infections.

Lumbar Dynamic Minimally Invasive Stabilization with Dynesys System Through Wiltse Far-Lateral Approach: A Surgical Alternative to the Open Surgery in Case of Failure of Interspinous Posterior Device

The dynamic stabilization, actually defined as dynamic neutralization of instability, represents a valid surgical choice in that condition defined as unstable dysfunction phase of the degenerative cascade of lumbar spine (or so called “microinstability”), provided that there is not a spondylolisthesis in the spinal segment involved. The pedicle dynamic stabilizations system DYNESYS is the one who respects the most the biomechanical characteristics of the spine. We describe our experience in a patient in which we used the DYNESYS system through a minimally invasive far lateral lumbar approach (Wiltse approach), as a rescue technique of the segmental motility after the failure of an interspinous posterior device, as an alternative to the classical open approach.

Current Status of Interspinous Posterior Devices in USA and Italy: Finally the Pandoras Vase has been Uncovered

Interspinous Posterior Devices (IPDs) are spinal implantable devices used to treat lumbar degenerative diseases, with lumbar stenosis as the main indication. They are defined as devices for dynamic stabilization, because their aim is to perform a decompression of the spinal canal in case of stenosis, while preserving biomechanical properties of the spinal metamere. Lumbar stenosis is considered as the last phase of the degenerative cascade, the process of degeneration of spinal motor unit described by Kirkaldy-Willis, which identified as primary cause the hypermobility of the vertebras.

Hidden Spondylolisthesis: Unrecognized Cause of Low Back Pain? Prospective Study about the use of Dynamic Projections in Standing and Recumbent Position for the Individuation of Lumbar Instability

Introduction The execution of dynamic X-rays is commonly used and widely recognized as an effective method to detect the presence of lumbar instability and to obtain qualitative and quantitative data regarding this condition. This examination is commonly executed while the patient is in a standing position. In our opinion, the standing position works as a limit to some micromovements of the lumbar segment affected by the spondylolisthesis, hiding its presence. According to us, the paravertebral muscles act as a stabilizer of the hypermovement (which generates instability) because of its antalgic contraction and augmented muscular tone. The aim of our study is to demonstrate that flexion and extension X-rays performed in recumbent position, with the patient lying along his/her side (in a patient with low back pain or sciatic pain), reduce the augmented muscular tone of the paravertebral muscles and might discover hypermovements hidden by antalgic contractions and not evidenced in dynamic studies executed in standing position. Materials and Methods In the period between January 2011 and January 2013, in the neurosurgery department of the Sapienza University of Rome, 200 consecutive patients with lumbar degenerative disease have been studied (males 117 and females 83). All the patients have been studied with lumbosacral MRI and dynamic X-rays performed in standing and recumbent positions. The aim of our study is to find a correlation between clinical symptom (low back pain or radicular pain) and the presence of a spondylolisthesis not shown by the dynamic X-rays in standing position, but shown by the dynamic X-rays executed in recumbent position, demonstrating how an unknown spondylolisthesis, not discovered by Rx in standing position, can cause low back pain. Results We analyzed 200 patients. A total of 133 were not pathologic in the Rx executed in standing position. Of the 133, 43 patients (32,3%) showed a hypermovement in the dynamic projections executed in recumbent position (p = 0.0001, McNemar test). The statistical analysis did not show any significant correlation between the hidden spondylolisthesis in standing position and age, sex, or level involved. The evidence of pathological hypermovement at the recumbent dynamic Rx has changed the surgical strategy, reducing the percentage of undertreatment of a degenerative and progressive clinical situation. Conclusion The aim of our study is to determine whether in the patients with lumbalgia with no evidence of pathological movements in the standing dynamic projections, the origin of the pain can be attributed to a faccettal syndrome or is linked to a spondylolisthesis not showed by the standing dynamic Rx. In our opinion, the spondylolisthesis can be identified as the pain generator. Consequence of the pain is an augmented muscular tone of the paravertebral musculature to prevent pain, which is at its major intensity in the standing position, when the intervertebral articulations are mostly solicited. The augmented muscular tone tries to inhibit the pain generator, attempting to limit the slippage of the involved segment. When the patient is examined in dynamic projections when recumbent on his/her side, the tone of the paravertebral musculature is reduced, showing, when present, the “hidden” spondylolisthesis.