Maurizio Gladi

Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion

PurposeAnterior decompression of the craniovertebral junction is reserved to patients with irreducible ventral bulbo-medullary lesions and rapidly deteriorating neurological functions. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA).MethodsFour patients with irreducible, anterior bulbo-medullary compression due to rheumatoid pannus and basilar invagination were enrolled. The imaged-guided EEA was used to resect the odontoid process, trying to preserve the C1 anterior arch.ResultsNeurological improvement and adequate bulbo-medullary decompression were obtained in all patients. In two cases, anterior C1 ring was preserved. These patients did not required a posterior fusion.ConclusionsCompared with the standard transoral technique, the EEA provides the same good exposure but with potentially less complications. The preservation of the anterior C1 arch can contribute to avoid cranial settling and posterior fusion with its related risk of subaxial instability.

Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis

BACKGROUND CONTEXT Rheumatoid arthritis is the most common inflammatory disease involving the spine with predilection for the craniovertebral segment. Surgery is usually reserved to patients with symptomatic craniovertebral junction (CVJ) instability, basilar invagination, or upper spinal cord compression by rheumatoid pannus. Anterior approaches are indicated in cases of irreducible ventral bulbo-medullary compression. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA). PURPOSE The aim of this article is to demonstrate the feasibility of performing an odontoidectomy and a rheumatoid pannus removal by a minimally invasive EEA, preserving the anterior C1 arch continuity and avoiding a posterior fixation procedure. STUDY DESIGN Technical description and cohort report. METHODS We report three cases of elderly patients with a long history of rheumatoid arthritis and irreducible anterior bulbo-medullary compression secondary to basilar invagination and/or rheumatoid pannus. Anterior decompression was achieved by an endonasal image-guided fully endoscopic approach. RESULTS Neurological improvement and adequate bulbo-medullary decompression were obtained in all cases. The anterior C1 arch continuity was preserved, and none of the patients required a subsequent posterior fixation. CONCLUSIONS Anterior decompression by a minimally invasive EEA could represent an innovative option for the treatment of irreducible ventral CVJ lesions in elderly patients with rheumatoid arthritis. This approach permits the preservation of the anterior C1 arch and the avoidance of a posterior fixation, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.

Minimally invasive surgery for benign intradural extramedullary spinal meningiomas: experience of a single institution in a cohort of elderly patients and review of the literature.

Meningiomas of the spine are the most common benign intradural extramedullary lesions and account for 25%–46% of all spinal cord tumors in adults. The goal of treatment is complete surgical resection while preserving spinal stability. Usually, these lesions occur in the thoracic region and in middle-aged women. Clinical presentation is usually nonspecific and the symptoms could precede the diagnosis by several months to years, especially in older people, in whom associated age-related diseases can mask the tumor for a long time. We report a series of 30 patients, aged 70 years or more, harboring intradural extramedullary spinal meningiomas. No subjects had major contraindications to surgery. A minimally invasive approach ( hemilaminectomy and preservation of the outer dural layer) was used to remove the tumor, while preserving spinal stability and improving the watertight dural closure. We retrospectively compared the outcomes in these patients with those in a control group subjected to laminectomy or laminotomy with different dural management. In our experience, the minimally invasive approach allows the same chances of complete tumor removal, while providing a better postoperative course than in a control group.

Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture

Giant cell tumors (GCTs) are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches). The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.

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.

Minimally Invasive Supraorbital Key-hole Approach for the Treatment of Anterior Cranial Fossa Meningiomas

The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.

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.

A rare case of chordoma and craniopharyngioma treated by an endoscopic endonasal, transtubercular transclival approach.

Co-occurrence of different brain tumors is rarely observed, being more frequent in patients affected by genetic syndromes like phacomatoses. Different histological types of intracranial lesions may present at different times in the clinical history of the patient or, more rarely, they may occurr at the same moment. In these last cases, particularly for tumors located in adjacent areas of the brain, diagnostic difficulties may arise. Moreover, even when the correct diagnosis is established, treatment strategy becomes complex and a single staged approach could be ineffective in obtaining successful tumor removal. We report a case of simultaneous sellar-suprasellar craniopharyngioma and intradural clival chordoma, successfully treated by a single staged, extended, fully endoscopic endonasal approach, which required no following adjuvant therapy. We also discuss the potential etiopathogenesis of the two lesions, reviewing the literature.

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.