Roberto Gazzeri

Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma.

SummaryBackground. Chronic subdural haematoma is one of the most common entities encountered in daily practice. Many methods of treatment have been reported, each with its own advantages and disadvantages.Method. The authors present a novel technique for the management of chronic subdural haematoma which is a variation of a closed drainage system. After evacuation of the haematoma through a single burr hole, we inserted a Jackson Pratt drain into the subgaleal space, with suction facing the burr hole, allowing for continuous drainage of the remaining haematoma.Findings. We used the method for over 4 years to treat 224 patients. Seventeen patients (7.6%) needed a second operation for a recurrence of the haematoma no patient required a third operation. Postoperative complications developed in 3 patients. Two patients died while in the hospital, a mortality rate of 0.9%.Conclusions. The use of suction assisted evacuation, is followed by results that compare satisfactorily to reports of previous methods, with a low rate of recurrence and complications. It is relatively less invasive and can be used in high risk patients.

Delayed migration of a screw into the gastrointestinal tract after anterior cervical spine plating.

Study Design. Case report and clinical discussion. Objective. To describe a rare case of spinal cervical screw migration into the gastrointestinal tract 11 years after surgery. Summary of Background Data. Anterior cervical spine fusion and stabilization with plating is a well-established procedure for cervical myelopathy, cervical spinal trauma, and spinal infectious disease. Esophageal injury has been related to screw or plate extrusion. Methods. We present a 45-year-old white man suffering from severe quadriparesis and neck pain. Cervical spine magnetic resonance images showed spondylodiscitis and spinal fracture of C4 and C5 vertebral bodies. He underwent anterior surgical decompression consisting of C4 and C5 corpectomies and fusion with fibular allograft fixated with a cervical plate. The patients neurologic examination gradually improved during his follow-up. Results. The patient returned 11 years after cervical spine graft and plating, complaining of severe dysphagia and high fever. Radiographs of the cervical spine showed a screw back-out. Three days later, a new radiograph of the cervical spine revealed a progression of the screws extrusion. In a new cervical spine radiograph, obtained immediately before surgical intervention, the displaced screw was no more visible. Abdominal radiograph showed the missed screw in the right lower abdominal quadrant. Barium meal swallowing test showed no leakage on the cervical area. At 6 months follow-up, the patient is in good condition and symptom free. Conclusion. In this case, the delayed esophageal perforation occurred 11 years after initial surgery: the rapid progression of the screw extrusion after initial pull-out (6 days) was documented by several radiographs and spontaneous closure of the fistula was achieved.

Controversies about Interspinous Process Devices in the Treatment of Degenerative Lumbar Spine Diseases: Past, Present, and Future

A large number of interspinous process devices (IPD) have been recently introduced to the lumbar spine market as an alternative to conventional decompressive surgery in managing symptomatic lumbar spinal pathology, especially in the older population. Despite the fact that they are composed of a wide range of different materials including titanium, polyetheretherketone, and elastomeric compounds, the aim of these devices is to unload spine, restoring foraminal height, and stabilize the spine by distracting the spinous processes. Although the initial reports represented the IPD as a safe, effective, and minimally invasive surgical alternative for relief of neurological symptoms in patients with low back degenerative diseases, recent studies have demonstrated less impressive clinical results and higher rate of failure than initially reported. The purpose of this paper is to provide a comprehensive overview on interspinous implants, their mechanisms of action, safety, cost, and effectiveness in the treatment of lumbar stenosis and degenerative disc diseases.

Minimal craniotomy and matrix hemostatic sealant for the treatment of spontaneous supratentorial intracerebral hemorrhage.

The authors describe a minimally invasive technical note for the surgical treatment of primary intracerebral hematoma. Thirty-one patients with supratentorial intracerebral hematomas and no underlying vascular anomalies or bleeding disorders underwent treatment with a single linear skin incision followed by a 3-cm craniotomy. After evacuation of the hematoma, a matrix hemostatic sealant (FloSeal) was injected into the surgical cavity, and immediate hemostasis was achieved in all cases. A second operation was necessary in only 1 case. In this preliminary experience, a small craniotomy combined with FloSeal helped to control operative bleeding, reducing brain exposure and damage to the surrounding tissue while reducing the length of the surgery.

Fulminating septicemia secondary to oxygen-ozone therapy for lumbar disc herniation: case report

Study Design. A case report and clinical discussion. Objective. To describe a rare but fatal complication secondary to oxygen-ozone therapy for the treatment of herniated lumbar disc. Summary of Background Data. Previously reported complications secondary to oxygen-ozone therapy are rarely reported. Septic discitis and epidural abscesses have been reported after myelography, lumbar puncture, paravertebral injections, epidural anesthesia, acupuncture, and intradiscal therapy with chymopapain. We report the first case of a local infection with systemic fatal dissemination secondary to this treatment. Methods. A 57-year-old man previously treated with oxygen-ozone therapy presented low back and bilateral pain. The lumbar computed tomography revealed the presence of L4–L5 and L5–S1 herniated discs. Results. Three days after admission in the hospital, the patient developed a fulminant septicemia. An abdominal-pelvic and chest computed tomography and blood culture led to the diagnosis of pyogenic lumbar muscle involvement, accompanied with septic pulmonary embolism secondary to Escherichia coli infection. Conclusions. This case report identifies a rare and fatal complication of oxygen-ozone therapy in the treatment of a herniated lumbar disc. Acute fatal septicemia should be considered among the major complications of the oxygen-ozone therapy in the treatment of a herniated lumbar disc.

Interspinous spacer decompression (X-STOP) for lumbar spinal stenosis and degenerative disk disease: a multicenter study with a minimum 3-year follow-up.

Interspinous distraction devices provide an effective treatment for patients suffering from lumbar spinal stenosis and/or degenerative disk disease. The aim of this multicenter study was the prospective evaluation of patients treated for symptomatic lumbar spinal stenosis with interspinous process decompression (IPD) implants compared with a population of patients managed with conservative treatment. 542 patients affected by symptomatic lumbar spine degenerative disease were enrolled in a controlled trial. 422 patients underwent surgical treatment consisting of X-STOP device implantation, whereas 120 control cases were managed conservatively. Both patient groups underwent follow-up evaluations at 6, 12, 24, and 36 months using the Zurich Claudication Questionnaire, the Visual Analog Scale score and spinal lumbar X-rays, CT scans and MR imaging. One-year follow-up evaluation revealed positive good results in the 83.5% of patients treated with IPD with respect to 50% of the nonoperative group cases. During the first three years, in 38 out of the 120 control cases, a posterior decompression and/or spinal fixation was performed because of unsatisfactory results of the conservative therapy. In 24 of 422 patients, the IPD device had to be removed, and a decompression and/or pedicle screw fixation was performed because of the worsening of neurological symptoms. Our results support the effectiveness of surgery in patients with stenosis. IPD may offer an effective and less invasive alternative to classical microsurgical posterior decompression in selected patients with spinal stenosis and lumbar degenerative disk diseases.

Degenerative lumbar spinal stenosis with neurogenic intermittent claudication and treatment with the Aperius PercLID System: a preliminary report

OBJECT The aim of this study was to evaluate whether clinical improvement is noticeable after a minimally invasive procedure such as that used with the Aperius PercLID System in patients with degenerative lumbar spinal stenosis (DLSS) and neurogenic intermittent claudication (NIC). METHODS The patients were treated with the aforementioned system at 3 different centers. The initial requirement to be included in the study was a minimum follow-up of 12 months. The authors studied 40 cases of DLSS in patients with NIC (age 72.7 +/- 8.08 years). Symptom severity, physical function, quality of life, and self-rated pain were assessed preoperatively and at the 12-month follow-up using the Zurich Claudication Questionnaire (ZCQ) and a visual analog scale. The procedure was conducted under spinal (35 patients) or local (5 patients) anesthesia, using biplanar fluoroscopy for visualization. RESULTS Single-level treatment was performed in 28 patients and 2-level treatment was performed in 12 patients. Based on time recordings in 24 cases, the mean procedural time was 19.9 +/- 5.0 minutes. The mean pain visual analog scale score improved significantly from 8.1 +/- 2.19 at baseline to 3.44 +/- 2.89 at the 1-year follow-up. The ZCQ score for patient satisfaction showed 90% of the patients being satisfied with the procedure. The mean rates of improvement in ZCQ score for symptom severity and physical function at 1 year were 38.7 +/- 33.3% and 33.8 +/- 29.7%, respectively, and both proved to be statistically significant. Most improvement was seen in mobility, pain/discomfort, and ability for self-care. CONCLUSIONS In this preliminary study, the Aperius system provided clinically significant improvement after 1 year of follow-up in patients older than 65 years with DLSS and NIC.

Cervical cyst of the ligamentum flavum and C7-T1 subluxation: case report

A patient with progressive gait disturbance resulting from a cyst of the cervical ligamentum flavum associated with C7-T1 listhesis is reported. Surgical removal of the cyst improved the patient’s myelopathy. Intraspinal degenerative cysts are preferentially located in the lumbar region:unusual is the cervical localization. Differential diagnosis includes ligamentum flavum cyst, synovial and ganglion cysts. Association between degenerative intraspinal cysts and listhesis is discussed. To our knowledge, this is the first case of cyst of the ligamentum flavum associated with cervical subluxation.

Endoscopic supraorbital eyebrow approach for the surgical treatment of extraaxialand intraaxial tumors.

OBJECT The supraorbital eyebrow approach is a minimally invasive technique that offers wide access to the anterior skull base region and parasellar area through asubfrontal corridor. The use of neuroendoscopy allows one to extend the approach further to the pituitary fossa, the anterior third ventricle, the interpeduncular cistern, the anterior and medial temporal lobe, and the middle fossa. The supraorbital approach involves a limited skin incision, with minimal soft-tissue dissection and a small craniotomy, thus carrying relatively low approach-related morbidity. METHODS All consecutive patients who underwent the endoscopic supraorbital eyebrow approach were retrospectively analyzed for lesion location, pathology, length of stay, complications, and cosmetic results. RESULTS During a 56-month period, 97 patients (mean age 58.5 years) underwent an endoscopic eyebrow approach to resect extra- and intraaxial brain lesions. The most common pathologies treated were meningiomas (n = 41); craniopharyngiomas (n = 22); dermoid tumors (n = 7); metastases (n = 4); gliomas (n = 3); and other miscellaneous frontal, parasellar, and midbrain (n = 23) lesions. The median length of postoperative hospital stay was 2.7 days (range 1-8 days). In 82 patients a total removal of the lesion was performed, while in 15 patients a near-total or subtotal removal was achieved. There were no postoperative hematomas, cerebrospinal fluid leaks, or severe neurological deficits, with the exception of 2 cases of visual deterioration and 1 case each of meningitis, stroke, and third cranial nerve paresis. Other complications directly related to the approach included 2 cases of skin burn as a direct result of heat transmission from the microscope light, 1 case of right frontal palsy, 2 cases of frontal numbness, and 1 case of bone remodeling 1 year after surgery. CONCLUSIONS The endoscopic supraorbital eyebrow approach is a safe and effective minimally invasive approach to remove extra- and intraaxial anterior skull base, parasellar, and frontal lesions, promoting a rapid recovery and short hospital stay. The location of the eyebrow incision demands a meticulous cosmetic closure, but, with proper technique, cosmetic results are excellent.

Acute hemorrhagic cyst of the ligamentum flavum.

Study Design A case report and clinical discussion. Objective To describe a rare complication of a cyst of the ligamentum flavum, which bled spontaneously, provoking an acute lower limb monoparesis and lumbar sciatic pain. Summary of Backgrounds Data Cysts of the ligamentum flavum have been rarely reported. Intraspinal degenerative cysts described in literature are usually juxta-articular (synovial and ganglion) cysts and have a similar radiologic appearance. They are preferentially located in the lumbar spine, while the cervical localization is unusual. Hemorrhage into the cyst is an uncommon complication and an extremely rare cause of nerve root compression. Methods A 59-year-old woman presented with sudden severe radicular lumbar deficit and pain secondary to acute hemorrhage into a ligamentum flavum cyst. Magnetic resonance imaging showed at L3-L4 level a lobulated slightly hyperintense mass with a ventral area of marked hyperintensity in T1 images, hypointense on T2 images. Signal within the lesion was suggestive of intralesional hemorrhage. Results Complete resection of the lesion was performed, resulting in immediate recovery. The cyst was quite rounded, brownish, and contained rest of both partially fresh and coagulated hematoma. Histologic examination revealed myxoid degeneration of the ligamentum flavum with an hemorrage in the cystic cavity without a synovial layer. Conclusions This report identifies a rare case of radicular lumbar deficit and pain secondary to acute hemorrhage into a ligamentum flavum cyst. The pathogenesis and clinicopathologic characteristics of this lesion are described.