Filippo Maria Polli

Intraparenchymal haemorrhage after evacuation of chronic subdural haematoma. Report of three cases and review of the literature

Three cases of intracerebral haemorrhage following removal of a chronic subdural haematoma are reported and the literature on this topic reviewed. The possibility of an increase in cerebral blood flow following removal of CSH, makes slow, gradual decompression mandatory in all patients submitted to cranial trapanation.

Neurocytoma of the spinal cord: report of three cases and review of the literature.

The spinal cord is a very rare location for extra-ventricular neurocytomas. Composed of small round cells with neuronal differentiation, neurocytoma has a particularly favourable prognosis. Long disease-free intervals have been observed in patients who received sub-total removal and radiotherapy. A careful intra-operative frozen section examination is helpful in avoiding excessive surgical tissue disturbance and to identify the best treatment option. To date, eight cases of neurocytoma of the spinal cord have been described. We report three more patients; one with very long survival, and review the published literature for this condition.

Ethylene oxide sterilization of autologous bone flaps following decompressive craniectomy.

Summary¶Introduction. In patients undergoing decompressive craniectomy, the bone flap is temporarily preserved either in the subcutaneous tissue of the patient or frozen. However, there are some drawbacks related to these methods. Material and methods. In 16 patients in whom the bone flap was removed for decompressive craniectomy, the bone was firstly washed in hydrogen peroxide and then placed in hermetically-sealed bags and sterilized using ethylene oxide. The bone was repositioned after an average period of 4.3 months. Results. One patient sustained an infection of the surgical wound which required permanent exclusion of the bone flap. In all the others, esthetic and functional results were good after an average follow-up of 20 months. Control CT-scan of the bone flap demonstrated preservation of its structural features with fusion of the bone margins and revitalization of the flap. On MRI a subdural space was again visible. Conclusions. Sterilization of the bone flap with ethylene oxide in patients undergoing decompressive craniectomy avoids some of the drawbacks related to the techniques currently used. The easiness, low cost, good aesthetic and functional results of this procedure make it a valid alternative to other techniques for preservation of autologous bone in decompressive craniectomies.

Glioblastoma in kidney transplant recipients. Report of five cases.

Five patients who developed an intracranial glioblastoma after a kidney transplant are described. All patients underwent surgical removal of the lesion and eventually radiation therapy, but none of them is still alive at follow-up. The possibility of tumours occurring in transplant recipients is a recognised entity and several series have been reported. Nevertheless, little consideration has been paid to post-transplant gliomas and a precise evaluation of this risk is still lacking. Several hypotheses have been proposed to explain a possible link. One possible factor may be the immunosuppressive state of recipients as a result of post-transplant administration of immunosuppressive drugs, as it is known that gliomas have an higher incidence in HIV-infected patients. However, it is not yet clear whether immunosuppressive drugs function as a direct transforming factor.

Magnetic resonance imaging flow void changes after cerebrospinal fluid shunt in post-traumatic hydrocephalus: clinical correlations and outcome

The assessment of the flow-void in the cerebral aqueduct of patients with post-traumatic hydrocephalus on magnetic resonance imaging (MRI) evaluation could concur the right diagnosis and have a prognostic value. We analysed prospectively 28 patients after a severe head injury (GCS≤8), with radiological or clinical suspicion of post-traumatic hydrocephalus and a fast flow-void signal in the cerebral acqueduct on T2-weighted and proton density MRI. Twenty-two patients were shunted (n=19) or revised (n=3). Six patients were followed-up without surgery. Twenty out of 22 shunted patients (91%) showed variable reduction of the fast flow-void. Eighteen of the operated patients (82%) presented a significant clinical improvement at 6-month follow-up. All patients (n=2) who had no change of the fast flow-void after surgery did not clinically improve. The six non-shunted patients did not present any clinical or radiological improvement. In head-injured patients, fast flow-void in the cerebral aqueduct is diagnostic for post-traumatic hydrocephalus and its reduction after ventriculo-peritoneal shunt is correlated with a neurological improvement. In already shunted patients, a persistent fast flow-void is associated with a lack of or very slow clinical improvement and it should be considered indicative of under-drainage.

Non-Posterior Subtraction Osteotomy Surgery to Restore Lumbar Lordosis in the Hidden Sagittal Imbalance of the Adult Degenerative Spine

Purpose: Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative kyphoscoliosis by a nonposterior subtraction osteotomy technique. Extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion were used to restore lumbar lordosis and mobilize the coronal curve, while grade 2 osteotomy (SPO) was useful to further decrease kyphosis. Methods: We operated 22 thoraco-lumbar and lumbar degenerative deformities, characterized by a sagittal compensated (hidden) imbalance (SVA<50 mm), with or without coronal deformity, and distinguished according to the SRS-Schwab classification. All patients were submitted to X-ray screening during pre, post-operative and follow-up periods. Results: Mean age was 65.3 (50-74; M/F 1: 4). Sixteen deformities were type L and 6 type N. Loss of LL was moderate (+) in 14 cases and marked (++) in 8. We performed 39 XLIFs, 8 TLIFs, 32 SPOs. Complication rate was minimal. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p<0.05), post-operative values were similar to those pre-operatively calculated in 90% of cases and clinical follow-up (mean 20.5; range 18- 24), scored using VAS and ODI, was satisfactory in all cases, except for two due to sacro-iliac pain. Conclusion: Current follow-up does not allow definitive conclusions. However, the surgical approach reported seems to be a viable choice usable in these compensated adult deformities, avoiding risks and complications of more aggressive pedicle subtraction osteotomies.

Atlantoaxial anterior transarticular screw fixation: a case series and reappraisal of the technique

BACKGROUND CONTEXT Atlantoaxial instability is commonly treated with C1-C2 fixation performed via posterior approaches. Although anterior transarticular screw (ATS) fixation, performed with a classic retropharyngeal approach, was described more than 10 years ago, the published literature still lacks a comprehensive analysis of the procedure and a real case series. PURPOSE We report a series of patients treated with atlantoaxial ATS, describing the surgical procedure in detail and discussing advantages and disadvantages of the technique. STUDY DESIGN The study design includes case series and technical report. METHODS We prospectively enrolled 15 patients affected by atlantoaxial instability secondary to trauma, degenerative diseases, or inflammatory diseases. Anterior transarticular screw fixation was performed with anteroposterior open-mouth and lateral intraoperative radiographs. All patients were evaluated radiologically at follow-up to identify bone fusion. RESULTS Anterior transarticular screw was performed successfully in 14 patients without complications. The procedure was aborted in a case of vertebral invagination, and one case required revision surgery owing to C2 articular bone fracture. Solid C1-C2 fusion was achieved in all cases (at 10- to 21-week follow-up) except in an elderly patient affected by severe osteoporosis. No complications occurred. CONCLUSIONS Although the procedure is still not widely known, ATS allows the effective and safe treatment of C1-C2 instability even in patients with systemic comorbidities. It offers several advantages over posterior approaches.

Real-time intraoperative contrast-enhanced ultrasound (CEUS) in vascularized spinal tumors: a technical note

BackgroundsIntra-operative ultrasound (ioUS), and the recently introduced contrast-enhanced ultrasound (CEUS) demonstrated to be an extremely valuable tool in oncological cerebral neurosurgery.MethodsThe authors applied ioUS/CEUS techniques to spinal oncological surgery as showed in the illustrative case of a dorsal hemangiopericytoma.Results and conclusionsioUS and CEUS provide real-time information that proved useful in identifying both vascular and parenchymatous tumoral patterns, anatomical relations with nervous structure, plan surgical strategy, and identify residuals. It allows to visualize unexposed anatomical and pathological structures within the parenchyma and is a valuable guide during resection.

Long-term Clinical Outcomes and Quality of Life in Elderly Patients Treated with Interspinous Devices for Lumbar Spinal Stenosis

Background and Objective Lumbar spinal stenosis (LSS) is a common degenerative condition that occurs in the spine with increasing age. Clinically, LSS causes a progressive reduction in walking autonomy, resulting in a poor quality of life and impaired functional capacity. The aim of this study was to evaluate the clinical outcome and quality of life of elderly patients presenting with LSS and associated comorbidities after a 5‐year follow‐up who were treated with an interspinous process device (IPD). Material and Methods Sixty patients > 75 years of age presenting with symptomatic degenerative LSS were included. All were treated with an IPD under local anesthesia. American Society of Anesthesiology score, Zurich Claudication Questionnaire, and Short Form 36 were evaluated pre‐ and postoperatively and at the follow‐up visit each year for 5 years. Results The mean surgery time while under local anesthesia was 20 minutes. Forty‐eight patients were followed for 5 years. Significant clinical improvements in all outcome scores (p < 0.05) both postoperatively or at follow‐up were found. Conclusions IPD seems to be an effective and safe treatment for LSS in elderly patients with general comorbidities. In our study, all followed up patients had a meaningful improvement of their quality of life even at 5 years after surgery.

Symptomatic ganglion cyst of ligamentum flavum as a late complication of lumbar fixation.

We report the case of a 72-year-old man who underwent surgery for a mobile spondylolisthesis L4-L5. Six months later, magnetic resonance imaging revealed an extradural cyst of the ligamentum flavum at L5-S1, which was then removed. Histological examination revealed a ganglion cyst of the ligamentum flavum. Cyst formation could be explained primarily according to the natural history of chronic degenerative disease of spine elements. Nevertheless, we could also consider the cyst formation as demonstrative of an adjacent segment syndrome: hypermobility of the L5-S1 segment just below three fixed vertebral segments would have triggered the mechanical stress necessary for L5-S1 ligamentum flavum degeneration.