Pasquale Donnarumma

Posterolateral arthrodesis in lumbar spine surgery using autologous platelet-rich plasma and cancellous bone substitute: an osteoinductive and osteoconductive effect.

Study Design Prospective cohort study. Objectives To analyze the effectiveness and practicality of using cancellous bone substitute with platelet-rich plasma (PRP) in posterolateral arthrodesis. Methods Twenty consecutive patients underwent posterolateral arthrodesis with implantation of cancellous bone substitute soaked with PRP obtained directly in the operating theater on the right hemifield and cancellous bone substitute soaked with saline solution on the right. Results Computed tomography scans at 6 and 12 months after surgery were performed in all patients. Bone density was investigated by comparative analysis of region of interest. The data were analyzed with repeated-measures variance analyses with value of density after 6 months and value of density after 12 months, using age, levels of arthrodesis, and platelet count as covariates. The data demonstrated increased bone density using PRP and heterologous cancellous block resulting in an enhanced fusion rate during the first 6 months after surgery. Conclusions PRP used with cancellous bone substitute increases the rate of fusion and bone density joining osteoinductive and osteoconductive effect.

Surgery of intradural extramedullary tumors: Retrospective analysis of 107 cases

BACKGROUND Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits. OBJECTIVE To evaluate the effects of surgery for IDEMTs. METHODS This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software. RESULTS One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of -2.400 (P < .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (χ(2) = 27.6; P < .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4). CONCLUSION Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.

Pott's disease: medical and surgical treatment.

OBJECTIVES To evaluate the best treatment of Potts disease. MATERIALS AND METHODS 7 cases of Potts disease were treated in the department of Neurosurgery of Sapienza University of Rome (Italy) between 2004 to 2011. RESULTS All patients underwent surgical drainage of abscess and vertebral stabilization. In all cases culture exam showed positivity after 40 days of incubation. After surgery for a period of one year chemotherapy was administered. In all cases MRI scan with gd of the spinal column were performed 12 months after surgery and no recurrence of disease has been shown. DISCUSSION Potts disease is defined as vertebral involvement of extrapulmonary Tubercolosis (TB), involving mainly toraco-lumbar tract of the spine. MRI with gd represents the gold standard for the diagnosis. Treatment can be medical, surgical or usually both. The slippery course of the disease often causes a delay in getting to a diagnosis that is not made prior to rising signs, such as large abscess, neurological impairment or vertebral fractures. In these cases medical treatment alone did not show effective results, because no specific antibiotic drug can permeate the abscesss capsule, and an effective concentration is not achieved in the infections site. Therefore, surgical treatment is necessary to abscess draining and setting the correct medical treatment to mycobacterial eradication.

A case of cervical tuberculosis with severe kyphosis treated with a winged expandable cage after double corpectomy

In this case report, we demonstrate that the use of a winged expandable cage was able to obtain good clinical and radiological results in a case of cervical tuberculosis with severe kyphosis. However, case series will be necessary to affirm its validity as a stand-alone device for similar cases with high risk of instability.

Two Cystic Cavernous Angiomas after Radiotherapy for Atypical Meningioma in Adult Woman : Case Report and Literature Review

A correlation between radiation therapy and cavernoma has been suspected since 1994. Since then, only a few cases of radio-induced cavernomas have been reported in the literature (85 patients). Most of them were children, and the most frequent original tumour had been medulloblastoma. The authors report a case of two cystic cavernous angiomas after radiation therapy for atypical meningioma in adult woman. This is the first case of cavernous angioma after radiotherapy for low grade meningioma. A 39-year-old, Latin american woman was operated on for a frontal atypical meningioma with intradiploic component and adjuvant radiotherapy was delivered (6000 cGy local brain irradiation, fractionated over 6 weeks). Follow-up MR imaging showed no recurrences of the tumour and no other lesions. Ten years later, at the age of 49, she consulted for progressive drug-resistant headache. MR imaging revealed two new well defined areas of different signal intensity at the surface of each frontal pole. Both lesions were surgically removed; the histopathological diagnosis was cavernous angioma. This is the first case of cavernous angioma after radiation therapy for atypical meningioma : it confirms the development of these lesions after standard radiation therapy also in patients previously affected by non-malignant tumours.

Penetrating gunshot wound to the head: Transotic approach to remove the bullet and masseteric-facial nerve anastomosis for early facial reanimation

INTRODUCTION Gunshot wounds to the head (GSWH) account for the majority of penetrating brain injuries, and are the most lethal. Since they are rare in Europe, the number of neurosurgeons who have experienced this type of traumatic injury is decreasing, and fewer cases are reported in the literature. CASE We describe a case of gunshot to the temporal bone in which the bullet penetrated the skull resulting in the facial nerve paralysis. It was excised with the transotic approach. Microsurgical anastomosis among the masseteric nerve and the facial nerve was performed. CONCLUSION GSWH are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is very high. Survivors often have high rate of complications. When facial paralysis is present, masseteric-facial direct neurorraphy represent a good treatment.

Postoperative extradural hematomas.

Postoperative extradural hematoma (POEH) is a possible complication after head surgery, often neglected in the literature. In a single surgeon experience we found 13 cases of POEH (0.8%). We distinguished two subtypes: (1) larger hematomas (>40 cc) with typical features and overt clinical picture that always needed evacuation, and (2) smaller hematomas (<40 cc) with insidious clinical onset and different radiological features compared with traumatic and spontaneous extradural hematomas. On the basis of our experience, we propose that clinical picture and radiologic appearance lead the decision between conservative or interventional treatment of type II hematomas.

Delayed surgery in neurologically intact patients affected by thoraco-lumbar junction burst fractures: to reduce pain and improve quality of life

Background This is a retrospective study on 18 patients affected by thoraco-lumbar junction burst fractures (TLJBF) A3 or A4 at computed tomography (CT) scan who referred to our hospital. To assess the surgical results in terms of pain and quality of life in a series of neurologically intact patients affected by TLJBF who underwent surgery after 3-4 months from the injury. In literature there is controversy if pain could be an indication for surgery in TLJBF and series of patients conservatively managed with success have been reported. Methods A retrospective study on 18 patients is reported. Patients included in this series were neurologically intact and affected by a TLJBF A3 or A4 at CT scan, the height of the burst vertebral body was >50%, spinal canal invasion was <30% and kyphosis deformity <30 degrees. Pain and quality of life were evaluated using graphic rating scale (GRS) and EuroQol (EQ-5D) scores on admission, at the clinical follow-up and in post-surgical period. Results Comparing pre- and post-operative EQ-5D, the scores had a statistically significant decrease after the operation (P<0.001) [pre-surgery EQ-5D was 2.60 (SD =0.67), post-surgery EQ-5D was 1.37 (SD =0.41)]. Also analyzing the EQ5D-VAS scores, the t-test revealed that surgery (P<0.01) improved the quality of life with statistically significance (EQ5D-VAS pre =43.89, SD =12.43 and EQ5D-VAS post =73.33, SD =10.84). Analyzing pre- and post-surgical GRS scores, the pain decreased significantly with the maximum mean difference among the 2nd and 3rd month before surgery and at 12 months after surgery (respectively D =5.444, P<0.001 and D =5.167, P<0.001). Conclusions Conservatively managed patients affected by TLJBF require a strict clinical follow-up since pain sometimes is present in the following months and it affects the quality of life. Surgery should be considered for these cases.

The Manubriotomy is a safe option for the anterior approach to the cervico-thoracic junction

The cervicothoracic junction (CTJ) is defined as the area extending from vertebral segments C7 to T4. Because most pathological processes occur in the anterior segment of the vertebrae, the anterior approach is usually the best surgical option, allowing neural decompression, stabilization and restoration of anatomical spinal alignment. Nevertheless, it represents a big challenge for the spinal surgeon for the presence of important anatomical structures of the upper mediastinum: manubrium, thymus gland, left and right brachiocephalic veins (or innominate veins), right brachiocephalic artery, left common carotid artery, aortic arc, esophagus, trachea and thoracic duct. Varied approaches to the CTJ have been described in literature [low lateral anterior cervical approach (LACA), full sternotomy, lateral parascapular thoracotomy, clavicular dissection]. Among them, the low LACA combined with manubriotomy is the most used and safe (1).

Vertebral hemangiomas: common lesions with still many unknown aspects

Histologically VHs are not considered vascular neoplasms, but rather hamartomas or malformation of the microcirculation. Basing on the predominant type of vascular channel they are classified in: capillary, cavernous, arterio-venous and venous malformations. Most of spinal epidural hemangiomas belongs to the cavernous type (1). Numerous terms have been introduced and different classification systems. Unfortunately, none of these has been accepted due to the lack of accepted histological criteria and limited correlation with clinical outcome. Vascular tumours of bone originate from endothelial cells resulting in variable expression of endothelial markers, but none of these markers is useful to discriminate between benign and malignant lesions. Verbeke and Bovee (2) proposed the classification of vascular tumours of bone according to the WHO classification scheme for soft tissue tumours dividing entities into benign, intermediate and malignant category. Hemangioma is the most commonly recognized benign lesion. Epithelioid hemangioma was better defined over the past few years. Based on its locally aggressive behaviour and occurrence of lymph node metastases, its classification within the intermediate category could be considered. Angiosarcoma is the only accepted term for high-grade malignant vascular tumour of bone and epithelioid hemangioendothelioma is the only accepted low-grade malignant vascular tumour of bone. It is still unclear whether other low grade malignant vascular tumours of bone (e.g., hemangioendothelioma) truly exist. Molecular/genetic studies of vascular tumours of bone which might support the proposed classification are very sparse.