Nicola Marengo

Subarachnoid hemorrhage in elderly: Advantages of the endovascular treatment.

Aim:  Subarachnoid hemorrhage (SAH) from aneurysm rupture accounts for approximately 3% of all strokes. A significant improvement in surgery and endovascular procedures has reduced mortality and morbidity. Nowadays, endovascular treatment is a viable alternative to conservative treatment in elderly patients. We designed a retrospective observational study on all endovascular procedures carried out in our department in order to evaluate the outcome in elderly patients compared with a younger cohort.

C1 anterior arch preservation in transnasal odontoidectomy using three‑dimensional endoscope: A case report

Background: The transoral ventral corridor is the most common approach used to reach the craniovertebral junction (CVJ). Over the last decade, many case reports have demonstrated the transnasal corridor to the odontoid peg represents a practicable route to remove the tip of the odontoid process. The biomechanical consequences of the traditional odontoidectomy led to the necessity of a cervical spine stabilization. Preserving the inferior portion of the C1 anterior arch should prevent instability. Case Description: This is the first report in which the technique to remove the tip of the odontoid while preserving the C1 anterior arch is described by means of a three-dimensional (3D) endoscope. A 53-year-old man underwent a transnasal 3D endoscopic approach because of a complex CVJ malformation. The upper-medial portion of the C1 anterior arch was removed preserving its continuity, and the odontoidectomy was performed. After surgery, a dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative one. Conclusions: The stereoscopic perception augmented the precision of the surgical gesture in the deep field. The importance of a 3D view relates to the depth of field, which a two-dimensional endoscopy cannot provide. This affects the preservation of the C1 anterior arch because of the presence of critical structures that are exposed to potential damage if not displayed.

Maximal access surgery for posterior lumbar inter body fusion (PLIF) with divergent, cortical bone trajectory (CBT) pedicle-screws: a good option for minimize spine access and maximize the field for nerve decompression.

BACKGROUND First advocated by Santoni et al. in 2009, the cortical bone trajectory pedicle screw technique is an alternative to the traditional, convergent technique that shows comparable biomechanical features and potentially requires less aggressive tissue retraction. Aim of this therapy note is to describe this new technique focusing on main advantages and limitations. METHODS The authors provide a detailed description of the surgically relevant anatomy focusing on the positioning of the cortical trajectory screws. The surgical technique is then described in a precise step-by-step manner, stressing complication avoidance. RESULTS The maximal access surgery posterior lumbar interbody fusion approach is a safe, reproducible procedure allowing for a traditional lumbar spine approach with the benefits of minimal facet joint manipulation and potentially preserving part of their neural innervation and a large part of the paraspinous musculature. CONCLUSIONS A dedicated self-retaining retractor and directional neuromonitoring may guide surgeons during the procedure. Nevertheless, the surgeons knowledge of anatomical landmarks, response to visual and tactile cues and intraoperative decision-making skills remain of paramount importance.

Intraoperative neurophysiological monitoring during spinal surgery: technical review in open and minimally invasive approaches

Neurophysiological monitoring is of undoubted value for the intraoperative safety of neurosurgical procedures. Widely developed and used for cranial surgery, it is equally as effective, though perhaps less commonly employed, for spinal pathology. The most frequently used techniques for intraoperative monitoring during spinal surgery include somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs) and electromyography, which can either be spontaneous free-running (sEMG) or triggered (tEMG). The knowledge of the benefits and limitations of each modality is essential in optimising the value of intraoperative monitoring during spinal procedures. This review will analyse the single techniques, their anatomical and physiological basis, their use in spinal surgery as reliable indicators of functional injury, their limits and their application to specific procedures in minimally invasive surgery, such as the lateral transpsoas access for interbody fusion and the divergent trajectory for cortico-pedicular screws. In these particular techniques, because of reduced visual exposure, neuromonitoring is indeed essential to exploit the full potential of minimally invasive surgery, while avoiding damage to nervous structures.

Anterior Longitudinal Ligament Release From the Minimally Invasive Lateral Retroperitoneal Transpsoas Approach: Technical Note

BACKGROUND: The technique for minimally invasive anterior longitudinal ligament release is a major advancement in lateral access surgery. This method provides hypermobility of lumbar segments to allow for aggressive lordosis restoration while maintaining the benefits of indirect decompression and minimally invasive access. OBJECTIVE: To provide video demonstration of the lateral retroperitoneal transpsoas approach with anterior longitudinal ligament sectioning. METHODS: A detailed surgical technique of the minimally invasive anterior column release is described and illustrated in an elderly patient with adult spinal deformity and low back pain (visual analog scale, 8 of 10) refractory to conservative measures. The 3-foot standing radiographs demonstrated a lumbar lordosis of 54.4°, pelvic incidence of 63.7°, and pelvic tilt of 17.5°. Computed tomography and magnetic resonance imaging showed generalized lumbar spondylosis and degenerative disc changes from L2 to L5. RESULTS: The patient underwent a multilevel minimally invasive deformity correction with an anterior longitudinal ligament release at the L3/L4 level through the lateral retroperitoneal transpsoas approach. Lumbar lordosis increased from 54.4° to 77° with a global improvement in sagittal vertical axis from 4.37 cm to 0 cm. Total blood loss was less than 25 mL, and there were no major neurological or vascular complications. CONCLUSION: The anterior longitudinal ligament release using the minimally invasive lateral approach allows for deformity correction without the morbidity and blood loss encountered by traditional open posterior approaches. However, the risk of major vascular/visceral complication warrants only experts in minimally invasive lateral surgery to attempt this technique. ABBREVIATIONS: ACR, anterior column release ALL, anterior longitudinal ligament AP, anterior-posterior EMG, electromyogram MIS, minimally invasive surgery tEMG, triggered electromyogram

Maximal Access Surgery for Posterior Lumbar Interbody Fusion (PLIF) with Divergent, Cortical Bone Trajectory (CBT) Pedicle-screws: a Good Option for Minimizing Spine Access and Maximizing the Field for Nerve Decompression. Our Experience in a Case Series

Introduction First advocated by Santoni et al. in 2009, the cortical bone trajectory (CBT) pedicle screw technique is an alternative to the traditional, convergent technique that shows comparable biomechanical features and potentially requires less aggressive tissue retraction. Aim of this therapeutical note is to describe this new technique focusing on main advantages and limitations. Material and Methods The authors provide a detailed description of the surgically relevant anatomy focusing on the positioning of the cortical trajectory screws. The surgical technique is then described in a precise step-by-step manner, stressing complication avoidance. Results and Conclusion: The maximal access surgery PLIF approach is a safe, reproducible procedure allowing for a traditional lumbar spine approach with the benefits of minimal facet joint manipulation and potentially preserving part of their neural innervation and a large part of the paraspinous musculature. A dedicated self-retaining retractor and directional neuromonitoring may guide surgeons during the procedure. Nevertheless, the surgeons knowledge of anatomical landmarks, response to visual and tactile cues and intraoperative decision-making skills remain of paramount importance.