Massimo Miscusi

An unusual case of orbito-frontal rod fence stab injury with a good outcome

BackgroundHigh-energy non-missile penetrating injuries (stab injuries) account for a small percentage of penetrating head injuries and they present a series of special features.Case presentationA 35-year-old man suffered orbito-frontal? and trans-cranial injuries after falling five meters from a terrace onto a rod iron fence. The removal of the metal rod was performed outside the operating room. The orbital roof was exposed and repaired through a bifrontal craniotomy and the frontal sinuses were cranialised. The orbital floor and zygoma were plated with micro-screws.ConclusionThe patient recovered without significant complications, apart from a slight paresis of the right superior rectus; the ocular globe remained intact.The positive outcome obtained in this very challenging case is attributable to the competency of the Neurotrauma Unit and to the use of a synergistic approach which involved the contribution of neurosurgeons, maxillo-facial surgeons, radiologists and anaesthesiologists.

Acute motor-sensory axonal neuropathy after cervical spine surgery.

The authors report the case of a 55-year-old man who presented with acute motor-sensory axonal neuropathy (AMSAN), a variant of Guillain-Barré syndrome with a poor prognosis, immediately after surgery for resection of a cervical chondroma. A misdiagnosis of spinal cord shock due to an acute surgical or vascular postoperative complication was initially made in this patient. Nevertheless, there was continuous transient improvement that was followed by progressive worsening, and further investigation was necessary. The diagnosis of AMSAN, associated with acute colitis caused by Helicobacter pylori, was made based on neurophysiological examinations and colonoscopy. Interestingly, the patient also developed nephrotic syndrome, which was thought to be a further complication of the autoimmune reaction. Delayed administration of immunoglobulins (400 mg/kg/day), mesalazine (800 mg 3×/day), and meropenem (3 g/day) was used to treat the Helicobacter infection and the autoimmune reaction, leading to restoration of renal function and slight neurological improvement. The patients general condition and neurological status improved slightly, but he remained seriously disabled (Frankel Grade C). This case demonstrates that a new onset of neurological symptoms in the early postoperative period after spine surgery could be related to causes other than iatrogenic myelopathy, and that an early diagnosis can reduce neurological sequelae, leading to a better outcome.

Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Remarks on 173 Cases

BACKGROUND Spinal meningiomas are common spinal tumors, in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring a less favorable prognosis. OBJECTIVE To correlate these data with clinical/functional outcome. METHODS Two hundred twenty-four consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these, 51 were excluded for incomplete clinical data or follow-up. The remaining 173 cases were classified in regards to sex, age, symptoms, axial location, Simpson grade resection, and functional pre-/postoperative status. RESULTS Most recurring onset symptoms were pain (32.9%) and motor deficit (31.8%); thoracic spine was the most severely affected (69.8%). Functional improvement on the follow-up was observed in 86.7% of cases; 6.4% of patients resulted stable and 6.9% worsened. A low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grades I and II) was conducted in 98.8%, and a macroscopically complete removal without dural resection or coagulation (Simpson grade III) was performed in 1.2%. Of the meningiomas, 98.3% were classified as WHO grade I. Recurrence rate was 2.3%, and 7 cases presented complications (4 of 7 required surgical procedure). CONCLUSION We can affirm that negative prognostic factors in our study were anterior or anterolateral axial location, prolonged presentation before diagnosis, WHO grade >I, Simpson grade resections II and III, sphincter involvement, and worse functional grade at onset.

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.

Surgical Treatment of Spinal Meningiomas

Spinal meningiomas are common spinal tumors; in most cases they are benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement, or spinal root involvement can bring to a less favorable progno‐ sis. We reviewed a series of 173 consecutive patients with spinal meningiomas treated from 1976 to 2011 in our institution, and data were stratified according to sex, age, symptoms, axial location, Simpson resection grade, and functional pre-/postoperative status. Particular attention was paid to description of those factors leading to a poor outcome. Functional improvement at follow-up was observed in 86.7% of cases, 6.4% of patients resulted stable, and 6.9% worsened; a low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42.2%); a gross total resection (Simpson grade I and II) was conducted in 98.8% and a macroscopically complete removal without dural resection or coagula‐ tion (Simpson grade III) was performed in 1.2%. According to data from our series, negative prognostic factors seem to be: anterior or anterolateral axial implant, longlasting symptoms before diagnosis, WHO grade > I, Simpson grade II and III resec‐ tion, sphincter involvement, and worse functional grade at onset.

A case of fatal late vasospasm in a patient with a recurrent, supratentorial rhabdoid primitive neuroectodermal tumor: possible molecular implications.

We report the case of a 44-year-old man who experienced a fatal and untreatable delayed vasospasm after resection of a recurrent temporal IV grade primitive neuroectodermal tumor (PNET). The histological analysis demonstrated a rare rhabdoid variant of the tumor with a diffuse myxoid degeneration; molecular investigations demonstrated an upregulation of IL-1β and IL-6 expression in the recurrence. We reviewed the pathophysiology of the vasospasm that occurs after tumors resection, and due to the rarity of case, we speculated on the possibility that specific histological and molecular features of the tumor could have contributed to the delayed and fatal complication.

Functional anatomy and biomechanics of the cervical spine

The head-neck system consists of seven cervical vertebrae and has a unique anatomy and motion to accommodate the needs of a highly mobile head-torso transitory zone. From a kinematical point of view, this system is very complex. Normally, the spine mainly functions as a coupled unit, and neck kinematics can be analyzed by studying head movement relative to the upper body. Cervical motion in every plane is checked by anatomic restraints that protect the spinal cord and accompanying vascular structures. The head can be regarded as a platform that houses the sensory apparatus for hearing, vision, smell, taste: the cervical spine constitutes a device that support this sensory platform, moving and orientating it in the three-dimensional space. Any disturbance of anatomy and mechanical properties can lead to clinical symptoms. Also age-related changes can modified cervical anatomy and alignment, drastically reducing range of motion [1, 2].

Minimally Invasive Surgery for Treatment of Patients with Advanced Cancer and Thoraco-lumbar Spine Metastases

Spinal metastases are common in patients with cancer. Spinal cord compression is the initial symptom of 5–10% of patients with diffuse cancer, and about 70% of lesions are found in the thoracic vertebrae. Patients with advanced cancer are generally excluded from major spine surgery, to reduce postoperative morbidity and mortality. Minimally invasive spine surgery (MISS) has recently been advocated as a useful approach for spinal metastases, especially in advanced cancer patients, seeking to decrease the morbidity of more traditional open spine surgery; furthermore, reducing the recovery time, MISS permits the post-operative chemotherapy and radiotherapy to begin sooner. A series of 29 cancer patients, with a short life expectancy, presenting acute myelopathy due to vertebral thoracic metastases, underwent MISS, with simple laminotomy and percutaneous stabilization; results from such series were compared to those retrospec‐ tively obtained from an homogenous series of patients operated with traditional open surgery. No significant differences between two groups were demonstrated in terms of surgical complications and neurological recovery. Nevertheless, patients operated with MISS appear to have an earlier recovery and better quality of life in the immediate postoperative period, which is a fundamental aim for patients who have a short life expectancy.

Adult Spinal Deformity in the Elderly. Preliminary Clinical and Radiological Results in 22 Patients Treated by a Two Times Minimally Invasive Spine Surgery

Introduction The adult spinal deformity (ASD) seems, in the last years, in a progressive increment. It should be in relation to the aging of the population. This trend leads to a progression of the disability and the reduction of the quality of life of these patients. The surgical correction of the ASD obtained by a traditional “open” surgery can often be incompatible with the co-morbidities of these patients. The minimally invasive surgery for correction of the deformities (MISDEF) can offer technical nuances, such as reduce of intraoperative blood loss and quickly recovery, which can lead the opportunities for these patients to approach the surgery. We present the preliminary results of our observational study on the radiological correction and clinical results of old patients affected by ASD treated by MISDEF. Methods Observational study with 20 months of follow-up. Twelve patients affected by low-back pain, sciatalgia and/cruralgia, neurological claudication were enrolled in this study. All the patients underwent to a MISDEF based on a percutaneous transpedicular stabilization plus a lateral or transforaminal interbody fusion. We collected all the radiological datas, such as sagittal vertical axis (SVA), sacral slope (SS), pervic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL) and coronal cob (CC) and the clinical status, oswestry disability index (ODI) and SF-36. Results The mean age was 70 years (65 – 78 years), 3 men and 9 women. 7 patients presented a lumbar left side convex scoliosis, while 5 patients presented a right side one. All the patients underwent to a 2 times surgery: the first time was a lateral access, the second time was the posterior access. The side for the lateral interbody fusion was the concave side of the scoliosis. L4L5 segment was always been approached for a transforaminal interbody fusion. The proximal strumental vertebra was T10. The mean intraoperative blood loss was 500 cc. All the patients were mobilized within 2 days. The ODI and SF36 evidenced a statistically improvement (p < 0,05). No evidence of infections, neurological deficit, failure of the implant and/or loosening of correction were documented in the follow up. Conclusions The MISDEF offers, even for elderly patients with co-morbidities, a valid and secure surgical solution for the correction of the ASD. From the results of our study appeared a good compliance of these techniques for all the patients, with a good result even at 20 months of follow-up. We considered that the opportunity to separate the surgical correction of the deformity in 2 times surgery seems to be a better and secure solution especially for elderly patients.

Intramedullary Spinal Cord Tumors: Long-Term Follow-Up After Surgery

We review a series of patients who underwent surgical removal of intramedullary spinal cord tumors, focusing on the long-term functional outcome, recurrence rates for the various tumors, and technical problems continually debated in neurosurgical practice. From December 1972 to December 2011, 202 patients underwent removal of intramedullary tumors. Lesions were located in the cervical spinal cord in 61 patients (30%), at a dorsal site in 60 (29%), at a cervicodorsal site in 51 (25%), and in the medullary cone in 30 (15%). The most frequent histological tumor types were astrocytomas (86 patients, 42%) and ependymomas (68 patients, 34%).