Francesco Cacciola

Cerebellar Liponeurocytoma: Immunohistochemical and Ultrastructural Study of a Case

The clinical, histopathological, and ultrastructural features of a cerebellar liponeurocytoma are reported. The tumor, a 3-cm mass localized in the right cerebellar hemisphere, was resected from a 61-year-old man clinically presenting with symptoms of intracranial hypertension. The lesion was composed of small, in some areas closely packed, medulloblastoma-like cells with prominent areas of lipidization phenomena. Moreover, mitoses, cellular atypia, and numerous vascular structures were focally observed. Glial and neuronal differentiation was immunohistochemically noted (glial fibrillary acidic protein, synaptophysin, neurofilaments, and neuron-specific enolase positivity). The p53 oncoprotein was detected in the majority of neoplastic cells and a moderate proliferation activity, evaluated by Mib-1 antibody, was focally appreciated. Ultrastructural study did not show evident neuritic processes, synapses, or dense core neuroendocrine granules. This cerebellar tumor previously called lipidized medulloblastoma and recently renamed cerebellar liponeurocytoma is considered an adult neoplasm with excellent prognosis histologically presenting prominent lipidized areas and, at the immunohistochemical and ultrastructural level, both glial and neuronal differentiation. The present study providesthe first description of a less differentiated and histologically more aggressive form of this unusual tumor.The clinical, histopathological, and ultrastructural features of a cerebellar liponeurocytoma are reported. The tumor, a 3-cm mass localized in the right cerebellar hemisphere, was resected from a 61-year-old man clinically presenting with symptoms of intracranial hypertension. The lesion was composed of small, in some areas closely packed, medulloblastoma-like cells with prominent areas of lipidization phenomena. Moreover, mitoses, cellular atypia, and numerous vascular structures were focally observed. Glial and neuronal differentiation was immunohistochemically noted (glial fibrillary acidic protein, synaptophysin, neurofilaments, and neuron-specific enolase positivity). The p53 oncoprotein was detected in the majority of neoplastic cells and a moderate proliferation activity, evaluated by Mib-1 antibody, was focally appreciated. Ultrastructural study did not show evident neuritic processes, synapses, or dense core neuroendocrine granules. This cerebellar tumor previously called lipidized medulloblastoma and recently renamed cerebellar liponeurocytoma is considered an adult neoplasm with excellent prognosis histologically presenting prominent lipidized areas and, at the immunohistochemical and ultrastructural level, both glial and neuronal differentiation. The present study provides the first description of a less differentiated and histologically more aggressive form of this unusual tumor.

Antibiotic prophylaxis in clean neurosurgery.

Abstract Two regimens of antibiotic prophylaxis are in use at our institution. These protocols consist in perioperative administration of a single dose of amoxicillin-clavulanic acid of 2.2 g at induction and 8 h later and irrigation of the surgical wound with rifamycin before closure. In cases of dirty surgery, placement of external shunts or foreign bodies, we administer vancomycin 1.5 g/die and cef-tazidime 6 g/die for 72 h. A retrospective study of all the clean operations we performed in the last 2 years yielded a total of 793 consecutive procedures with three postoperative wound infections. These results are in agreement with the majority of series reported in literature, although different prophylactic protocols are applied and in some cases no prophylactic antibiotics are administered at all. The use of these agents in clean neurosurgery remains, as a matter of fact, controversial. In order to further investigate this issue we took three or more intraoperative samples for culture in 40 clean cases. Only in 2% of these samples were cultures positive. Although lacking statistical significance, these results are interesting indications of the appropriateness of antimicrobial prophylaxis in clean neurosurgery and invite further investigation in that direction.

Loss of cervical lordosis: What is the prognosis?

Neck pain is a diffuse problem with a high incidence and often leads to the more or less appropriate prescription of imaging studies of the cervical spine. In general, this is represented by a magnetic resonance imaging (MRI) scan. Frequently such studies reveal no other significant findings apart from a loss of cervical lordosis either under the form of a simple straightening of the spine or even an inversion of the normal curvature into a kyphosis. Faced with this entity, the clinician is put in front of a series of questions: to which extent such a finding plays a role in the patients symptoms? If it does what is the role of conservative or even invasive treatment? What are the implications for surgery either for decompressive procedures or corrective procedures? To shed some light on these questions, the authors present a narrative review of the most relevant literature on the topic. Papers examined span from the initial epidemiologic reports out of the pre-MRI and computerized tomography era up to the most recent discussions on cervical sagittal alignment and its implications both for the surgical and nonsurgical patient. In this process, it becomes increasingly clear that we are still far from making any definite statements.

Lateral Mass Screw Fixation of the Subaxial Cervical Spine

Lateral mass screw (LMS) fixation of the cervical spine is an important tool in the armamentarium of the spinal surgeon as it permits to associate a biomechanical sound instrumentation to a wide posterior decompression. Various techniques have been described by different authors. We describe the main procedures with an analysis of their safety and some technical hints that help to perform this surgery successfully.

Posterior fixation as the sole treatment for ossified posterior longitudinal ligament

The question that arises after reading this exquisite synthesis of ever‐increasing insight into the workings of the craniovertebral junction and subaxial cervical spine, that arises out of almost four decades of experience and does not seem to stop delivering ever more innovative concepts, is whether we might actually get to the stage where a simple atlantoaxial fixation done in timely fashion could alter or even altogether stop the consequences of spondylosis of the entire cervical spine in many affected patients.

Segmental spinal dysgenesis associated with occult dysraphism: Considerations on management strategies

Segmental spinal dysgenesis is a rare and challenging entity especially when associated with occult dysraphism. Experience with a female patient followed during a period of 10 years spanning from 5 to 15 years of age is reported. During that period the girl underwent three spinal operations consisting in one decompression and spinal cord untethering, one posterior instrumented fusion and a spinal cord re-untethering. Clinical and radiological features are discussed and considerations on optimization of management strategies are made.

Complications in the anterior approach to the cervical spine: Which factors matter?

We read with great interest the paper by Ba Z et al. “Do the complications increased in the antero-lateral right-side approach to treat the cervical degenerative disorders? A retrospective cohort stu-dy” [1]. The authors are to be congratulated for the very clear presentation of a large and well reported series that examines the complication rates in the anterolateral right-side approach to the cervical spine. Even though the study is only a retrospective cohort study the results are very positive and helpful showing a low complication rate in terms of incidence of vocal cord paralysis and dysphagia. The authors conclude that the right sided approach is safe and efficient. In particular they analyzed the relationship between the number of levels treated and the incidence of dysphagia and recurrent laryngeal nerve (RLN) palsy and found no statistical difference. We wanted to make the observation that this study has a very strong point and that is that the large number of surgeries has been carried out by a single surgeon and the beautiful postoperative x-rays show that there is no doubt on the technical skill. What would, however, have been very nice and helpful would have been the analysis of some more factors and their correlation with the incidence of RLN palsy and dysphagia. Considering that this is a single surgeon series, and therefore the important confounding variable of multiple surgeons is eliminated, it would have been interesting to know what type of retractors were used for the surgery and how they were applied as this has been shown to impact on complication rate [2]. Furthermore, the authors mention the time of exposure of the anterior cervical spine but then there is no mention on the overall operative time and the relationship to the incidence of complications. Considering that the exposure time reported is quick we can surely deduce that the surgeon performs his operations in short time but are there any differences between shorter and longer lasting procedures? Number of levels treated did not impact complication rate, but what about the level itself? It has been shown that high level anterior discectomy and fusion at C2-3 carries more complications than at lower levels [3]. Another piece of useful information would be whether

Post-traumatic acute-on-chronic subdural haematoma: an unusual presentation of skull metastasis from prostate carcinoma

The authors report on a case of an 80-year-old man operated on urgently for evacuation of an acute-on-chronic subdural haematoma after a minor blunt head trauma that had occurred the day before. The haematoma was revealed by a plain CT scan on arrival at the accident and emergency department. During operation, the calvarial bone and dura mater were found to be of pathological aspect and histology subsequently confirmed metastatic involvement from a known primary prostate cancer (PC). After an initial successful technical and clinical result, the patient worsened again due to a rebleed and succumbed soon after. The awareness of the possibility of osteodural metastatic involvement could have led to the adjunct of a contrast-enhanced CT study and altered the treatment strategy.

Odontoid Screw Fixation

Odontoid screw fixation is an efficient and rewarding procedure for both the patient and the surgeon. Correct patient selection is an important step in this procedure and appropriate corroboration of the guideline recommendations with the particular features and needs of the single patient can lead to a 90 % success rate with a minimal need for immobilization.