Mauro Dobran

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.

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.

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.

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.

Neurological outcome in a series of 58 patients operated for traumatic thoracolumbar spinal cord injuries.

Background: Traumatic thoracolumbar spinal fractures represent approximately 65% of all traumatic spinal fractures and are frequently associated to permanent disability with significant social and economic impact. These injuries create severe physical limitations depending on neurological status, level of fracture, severity of injury, patient age and comorbidities. Predicting neurological improvement in patients with traumatic spinal cord injuries (SCIs) is very difficult because it is related to different preoperative prognostic factors. We evaluated the neurological improvement related to the preoperative neurological conditions and the anatomic level of spinal cord injury. Methods: From January 2004 to June 2010, we operated 207 patients for unstable thoracolumbar spinal fractures. We carried out a retrospective analysis of 69 patients with traumatic SCIs operated on by a posterior fixation performed within 24 hours from the trauma. The preoperative neurological conditions (ASIA grade), the type of the fracture, the anatomic level of spinal cord injury and the postoperative neurological improvement were evaluated for each patient. Results: The ASIA grade at admission (P = 0,0005), the fracture type according to the AO spine classification (P = 0,0002), and the anatomic location of the injury (P = 0,0213) represented predictive factors of neurological improvement at univariate analysis. The preoperative neurological status (P = 0,0491) and the fracture type (P = 0,049) confirmed a positive predictive value also in the multivariate analysis. Conclusions: Our study confirms that the preoperative neurological status, the fracture type and the anatomic location of the fracture are predictive factors of the neurological outcome in patients with spinal cord injury.

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.

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.

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.