Lucia di Somma

Improving the endoscopic endonasal transclival approach: the importance of a precise layer by layer reconstruction

Abstract Background. The endoscopic endonasal transclival approach (EETCA) is a minimally-invasive technique allowing a direct route to the base of implant of clival lesions with reduced brain and neurovascular manipulation. On the other hand, it is associated with potentially severe complications related to the difficulties in reconstructing large skull base defects with a high risk of postoperative cerebrospinal fluid (CSF) leakage. The aim of this paper is to describe a precise layer by layer reconstruction in the EETCA including the suture of the mucosa as an additional reinforcing layer between cranial and nasal cavity in order to speed up the healing process and reduce the incidence of CSF leak. Methods. This closure technique was applied to the last six cases of EETCA used for clival meningiomas (2), clival chordomas (2), clival metastasis (1), and craniopharyngioma with clival extension (1). Results. After a mean follow-up of 6 months we had no one case of postoperative CSF leakage or infections. Seriated outpatient endoscopic endonasal controls showed a fast healing process of nasopharyngeal mucosa with less patient discomfort. Conclusions. Our preliminary experience confirms the importance of a precise reconstruction of all anatomical layers violated during the surgical approach, including the nasopharygeal mucosa.

Treatment of unstable thoracolumbar junction fractures: short-segment pedicle fixation with inclusion of the fracture level versus long-segment instrumentation.

BackgroundThe surgical management of thoracolumbar burst fractures frequently involves posterior pedicle screw fixation. However, the application of short- or long-segment instrumentation is still controversial. The aim of this study was to compare the outcome of the short-segment fixation with inclusion of the fracture level (SSFIFL) versus the traditional long-segment fixation (LSF) for the treatment of unstable thoracolumbar junction fractures.MethodsFrom December 2009 to February 2014, 60 patients with unstable thoracolumbar junction fractures (T11-L2) were divided into two groups according to the number of instrumented levels. Group 1 included 30 patients treated by SSFIFL (six-screw construct including the fracture level). Group 2 included 30 patients treated by LSF (eight-screw construct excluding the fracture level). Local kyphosis angle (LKA), anterior body height (ABH), posterior body height (PBH), ABH/PBH ratio of fractured vertebra, and Asia Scale Impairment Scale were evaluated.ResultsThe two groups were similar in regard to age, sex, trauma etiology, fracture level, fracture type, neurologic status, pre-operative LKA, ABH, PBH, and ABH/PBH ratio and follow-up (p > 0.05). Reduction of post-traumatic kyphosis (assessed with LKA) and restoration of fracture-induced wedge shape of the vertebral body (assessed with ABH, PBH, and ABH/PBH ratio) at post-operative period were not significantly different between group 1 and group 2 (p = 0.234; p = 0.754). There was no significant difference between the two groups in term of correction loss at the last follow-up too (LKA was 15.97° ± 5.62° for SSFIFL and 17.76° ± 11.22° for LSF [p = 0.427]). Neurological outcome was similar in both groups.ConclusionsInclusion of fracture level in a short-segment fixation for a thoracolumbar junction fractures results in a kyphosis correction and in a maintenance of the sagittal alignment similar to a long-segment instrumentation. Finally, this technique allowed us to save two or more segments of vertebral motion.

Combined endoscopic transforaminal-transchoroidal approach for the treatment of third ventricle colloid cysts.

Colloid cysts are histologically benign lesions whose primary goal of treatment should be complete resection to avoid recurrence and sudden death. Open surgery is traditionally considered the standard approach, but, recently, the endoscopic technique has been recognized as a viable and safe alternative to microsurgery. The endoscopic approach to colloid cysts of the third ventricle is usually performed through the foramen of Monro. However, this route does not provide adequate visualization of the cyst attachment on the tela choroidea. The combined endoscopic transforaminal-transchoroidal approach (ETTA), providing exposure of the entire cyst and a better visualization of the tela choroidea, could increase the chances of achieving a complete cyst resection. Between April 2005 and February 2011, 19 patients with symptomatic colloid cyst of the third ventricle underwent an endoscopic transfrontal-transforaminal approach. Five of these patients, harboring a cyst firmly adherent to the tela choroidea or attached to the middle/posterior roof of the third ventricle, required a combined ETTA. Postoperative MRI documented a gross-total resection in all 5 cases. There were no major complications and only 1 patient experienced a transient worsening of the memory deficit. To date, no cyst recurrence has been observed. An ETTA is a minimally invasive procedure that can allow for a safe and complete resection of third ventricle colloid cysts, even in cases in which the lesions are firmly attached to the tela choroidea or located in the middle/posterior roof of the third ventricle.

Posterior Titanium Screw Fixation without Debridement of Infected Tissue for the Treatment of Thoracolumbar Spontaneous Pyogenic Spondylodiscitis

Study Design Retrospective study. Purpose The aim of our study was to analyze the safety and effectiveness of posterior pedicle screw fixation for treatment of pyogenic spondylodiscitis (PSD) without formal debridement of the infected tissue. Overview of Literature Posterior titanium screw fixation without formal debridement of the infected tissue and anterior column reconstruction for the treatment of PSD is still controversial. Methods From March 2008 to June 2013, 18 patients with PSD underwent posterior titanium fixation with or without decompression, according to their neurological deficit. Postero-lateral fusion with allograft transplantation alone or bone graft with both the allogenic bone and the autologous bone was also performed. The outcome was assessed using the visual analogue scale (VAS) for pain and the Frankel grading system for neurological status. Normalization both of C-reactive protein (CRP) and erythrocyte sedimentation rate was adopted as criterion for discontinuation of antibiotic therapy and infection healing. Segmental instability and fusion were also analyzed. Results At the mean follow-up time of 30.16 months (range, 24–53 months), resolution of spinal infection was achieved in all patients. The mean CRP before surgery was 14.32±7.9 mg/dL, and at the final follow-up, the mean CRP decreased to 0.5±0.33 mg/dL (p <0.005). Follow-up computed tomography scan at 12 months after surgery revealed solid fusion in all patients. The VAS before surgery was 9.16±1.29 and at the final follow-up, it improved to 1.38±2.03, which was statistically significant (p <0.05). Eleven patients out of eighteen (61.11%) with initial neurological impairment had an average improvement of 1.27 grades at the final follow-up documented with the Frankel grading system. Conclusions Posterior screw fixation with titanium instrumentation was safe and effective in terms of stability and restoration of neurological impairment. Fixation also rapidly reduced back pain.

Piezosurgery as a further technical adjunct in minimally invasive supraorbital keyhole approach and lateral orbitotomy.

OBJECTIVE One of the problems in neurosurgery is how to perform rapid and effective craniotomies that minimize the risk of injury to underlying eloquent structures. The traditional high-powered pneumatic tools and saws are efficient in terms of speed and penetration, but they can provoke bone necrosis and sometimes damage neurovascular structures. As an alternative, we evaluated the piezoelectric bone scalpel (piezosurgery), a device that potentially allows thinner and more precise bone cutting without lesioning neighboring delicate structures, even in the case of accidental contact. MATERIAL AND METHODS From January 2009 to December 2011, 20 patients (8 men and 12 women), 19 to 72 years of age (mean: 49.3 years) were treated using piezosurgery. Surgery was performed for the removal of anterior cranial fossa meningiomas, orbital tumors, and sinonasal lesions with intracranial extension. RESULTS The time required to perform craniotomy using piezosurgery is a few minutes longer than with traditional drills. No damage was observed using the piezoelectric device. Follow-up clinical and neuroradiologic evaluation showed a faster and better ossification of the bone flap with good esthetic results. CONCLUSIONS Piezosurgery is a new promising technique for selective bone cutting with soft tissue preservation. This instrument seems suitable to perform precise thin osteotomies while limiting damage to the bone itself and to the underlying delicate structures even in the case of unintentional contact. These advantages make the piezoelectric bone scalpel a particularly attractive instrument in neurosurgery.

Calvarial bone cavernous hemangioma with intradural invasion: An unusual aggressive course—Case report and literature review

Highlights • Calvarial cavernous hemangiomas are benign tumors.• These tumors tend to involve the outer table of the skull.• More extensive involvement of the inner table and extradural space is very unusual.• We present a case of a huge frontal cavernoma with intradural extension.• Our case highlights the possibility of an aggressive course of this rare benign pathology.

Surgical treatment of cervical spine trauma: Our experience and results.

Objective and Background: The objective of this study is to evaluate how the neurological outcome in patients operated for cervical spinal cord injury (SCI) is influenced by surgical timing, admission American Spinal Injury Association (ASIA) grading system, and age. Materials and Methods: From January 2004 to December 2011, we operated 110 patients with cervical SCI. Fifty-seven of them (44 males and 13 females) with preoperative neurological deficit, were included in this study with a complete follow-up. Age, sex, associated comorbidities (evaluated with Charlson comorbidity index [CCI]), mechanism of trauma, preoperative and follow-up ASIA score, time elapsed from injury to surgical treatment, preoperative cervical computed tomography scan or magnetic resonance imaging, type of fractures, and surgical procedure were evaluated for each patient. The patient population was divided into two groups related to the timing of surgery: Ultra-early surgery group (within 12 h from the trauma, 27 patients) and early surgery (within 12–72 h from the trauma, 30 patients). Statistical Analysis Used: The univariate analysis of data was carried out by the Chi-square test for discrete variables, the t-test for the continuous ones. Logistic regression was used for the multivariate analysis. Results: Neurological outcome was statistically better in ultra-early surgery group (<12 h) than in patient underwent surgery within 12–72 h (82.14% vs. 31%, multivariate analysis P = 0.005). The neurological improvement was also correlated with the age and the ASIA grade at admission in the univariate analysis (P = 0.006 and P = 0.017 respectively) and in the multivariate 1 (P = 0.037 and P = 0.006 respectively) while the CCI was correlated with the improvement only in the univariate analysis (P = 0.007). Conclusion: Nowadays, in patients with cervical SCI early surgery could be associated with improved outcome, most in case of young people with mild neurological impairment.

Endoscopy-verified occult subependymal dissemination of glioblastoma and brain metastasis undetected by MRI: prognostic significance.

Although various prognostic indices exist for patients with malignant brain tumors, the prognostic significance of the subependymal spread of intracranial tumors is still a matter of debate. In this paper, we report the cases of two intraventricular lesions, a recurrent glioblastoma multiforme (GBM) and a brain metastasis, each successfully treated with a neuroendoscopic approach. Thanks to this minimally invasive approach, we achieved good therapeutic results: we obtained a histological diagnosis; we controlled intracranial hypertension by treating the associated hydrocephalus and, above all, compared with a microsurgical approach, we reduced the risks related to dissection and brain retraction. Moreover, in both cases, neuroendoscopy enabled us to identify an initial, precocious subependymal tumor spreading below the threshold of magnetic resonance imaging (MRI) detection. This finding, undetected in pre-operative MRI scans, was then evident during follow-up neuroimaging studies. In light of these data, a neuroendoscopic approach might play a leading role in better defining the prognosis and optimally tailored management protocols for GBM and brain metastasis.

Paradoxical Brain Herniation After Decompressive Craniectomy Provoked by Drainage of Subdural Hygroma

BACKGROUND Paradoxical brain herniation (PBH) is a rare and potentially life-threatening complication of decompressive craniectomy (DC) and results from the combined effects of brain gravity, atmospheric pressure and intracranial hypotension causing herniation in the direction opposite to the site of the DC with subsequent brainstem compression. To date, the cases of PBH reported in literature are spontaneous or provoked by a lumbar puncture, a cerebrospinal fluid (CSF) shunt, or ventriculostomy. CASE DESCRIPTION We present an uncommon case of PBH provoked by percutaneous drainage of a huge subdural hygroma (SH) ipsilateral to the decompressive craniectomy causing mass effect and neurologic deterioration. After percutaneous evacuation of SH, the patient became unresponsive with dilated and fixed left pupil. A brain computed tomography scan showed marked midline shift in the direction opposite to the craniectomy site with subfalcine herniation and effacement of the peripontine cisterns. Paradoxical brain herniation (PBH) was diagnosed. Conservative treatment failed, and the patient required an emergency cranioplasty for reverse PBH. CONCLUSIONS The present case highlights the possibility that all forms of CSF depletion, including percutaneous drainage of subdural CSF collection and not only CSF shunting and/or lumbar puncture, can be dangerous for patients with large craniotomies and result in PBH. Moreover, an emergency cranioplasty could represent a safe and effective procedure in patients not responding to conservative treatment.

Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance

BACKGROUND: During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora. OBJECTIVE: To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities. METHODS: Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case. RESULTS: A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far. CONCLUSION: The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.