Stefano Forcato

Atlantoaxial anterior transarticular screw fixation: a case series and reappraisal of the technique

BACKGROUND CONTEXT Atlantoaxial instability is commonly treated with C1-C2 fixation performed via posterior approaches. Although anterior transarticular screw (ATS) fixation, performed with a classic retropharyngeal approach, was described more than 10 years ago, the published literature still lacks a comprehensive analysis of the procedure and a real case series. PURPOSE We report a series of patients treated with atlantoaxial ATS, describing the surgical procedure in detail and discussing advantages and disadvantages of the technique. STUDY DESIGN The study design includes case series and technical report. METHODS We prospectively enrolled 15 patients affected by atlantoaxial instability secondary to trauma, degenerative diseases, or inflammatory diseases. Anterior transarticular screw fixation was performed with anteroposterior open-mouth and lateral intraoperative radiographs. All patients were evaluated radiologically at follow-up to identify bone fusion. RESULTS Anterior transarticular screw was performed successfully in 14 patients without complications. The procedure was aborted in a case of vertebral invagination, and one case required revision surgery owing to C2 articular bone fracture. Solid C1-C2 fusion was achieved in all cases (at 10- to 21-week follow-up) except in an elderly patient affected by severe osteoporosis. No complications occurred. CONCLUSIONS Although the procedure is still not widely known, ATS allows the effective and safe treatment of C1-C2 instability even in patients with systemic comorbidities. It offers several advantages over posterior approaches.

Long-term Clinical Outcomes and Quality of Life in Elderly Patients Treated with Interspinous Devices for Lumbar Spinal Stenosis

Background and Objective Lumbar spinal stenosis (LSS) is a common degenerative condition that occurs in the spine with increasing age. Clinically, LSS causes a progressive reduction in walking autonomy, resulting in a poor quality of life and impaired functional capacity. The aim of this study was to evaluate the clinical outcome and quality of life of elderly patients presenting with LSS and associated comorbidities after a 5‐year follow‐up who were treated with an interspinous process device (IPD). Material and Methods Sixty patients > 75 years of age presenting with symptomatic degenerative LSS were included. All were treated with an IPD under local anesthesia. American Society of Anesthesiology score, Zurich Claudication Questionnaire, and Short Form 36 were evaluated pre‐ and postoperatively and at the follow‐up visit each year for 5 years. Results The mean surgery time while under local anesthesia was 20 minutes. Forty‐eight patients were followed for 5 years. Significant clinical improvements in all outcome scores (p < 0.05) both postoperatively or at follow‐up were found. Conclusions IPD seems to be an effective and safe treatment for LSS in elderly patients with general comorbidities. In our study, all followed up patients had a meaningful improvement of their quality of life even at 5 years after surgery.

Symptomatic ganglion cyst of ligamentum flavum as a late complication of lumbar fixation.

We report the case of a 72-year-old man who underwent surgery for a mobile spondylolisthesis L4-L5. Six months later, magnetic resonance imaging revealed an extradural cyst of the ligamentum flavum at L5-S1, which was then removed. Histological examination revealed a ganglion cyst of the ligamentum flavum. Cyst formation could be explained primarily according to the natural history of chronic degenerative disease of spine elements. Nevertheless, we could also consider the cyst formation as demonstrative of an adjacent segment syndrome: hypermobility of the L5-S1 segment just below three fixed vertebral segments would have triggered the mechanical stress necessary for L5-S1 ligamentum flavum degeneration.

A case of fatal late vasospasm in a patient with a recurrent, supratentorial rhabdoid primitive neuroectodermal tumor: possible molecular implications.

We report the case of a 44-year-old man who experienced a fatal and untreatable delayed vasospasm after resection of a recurrent temporal IV grade primitive neuroectodermal tumor (PNET). The histological analysis demonstrated a rare rhabdoid variant of the tumor with a diffuse myxoid degeneration; molecular investigations demonstrated an upregulation of IL-1β and IL-6 expression in the recurrence. We reviewed the pathophysiology of the vasospasm that occurs after tumors resection, and due to the rarity of case, we speculated on the possibility that specific histological and molecular features of the tumor could have contributed to the delayed and fatal complication.

Transfacet Screw Fixation for the Treatment of Lumbar Spinal Stenosis with Mild Instability: A Preliminary Study

Abstract Background Lumbar spinal stenosis (LSS) and low‐grade degenerative spondylolisthesis are frequently associated with facet joint degeneration, considered the main cause of low back pain. Surgery is the treatment of choice in patients affected by LSS unresponsive to conservative treatment. The aim of this study was to evaluate the clinical and radiologic outcome of patients treated with posterior decompression and transfacet fixation for single‐level LSS and facet joint degeneration. Methods A total of 25 patients between May 2015 and June 2016 affected by radiologically demonstrated one‐level LSS with facet joint degeneration and grade I spondylolisthesis were included in this prospective study. All the patients underwent laminectomy, foraminotomy, and one‐level facet fixation (Facet‐Link, Inc., Rockaway, New Jersey, United States). Pre‐ and postoperative clinical (Oswestry Disability Index [ODI], Short Form‐36 [SF‐36]) and radiologic (radiographs, magnetic resonance imaging, computed tomography) data were collected and analyzed. Results Mean follow‐up was 12 months. The L4‐L5 level was involved in 18 patients (72%) and L5‐S1 in 7 patients (28%); the average operative time was 80 minutes (range: 65‐148 minutes), and the mean blood loss was 160 mL (range: 90‐200 mL). ODI and SF‐36 showed a statistically significant (p < 0.05) improvement at last follow‐up. Conclusions Transfacet fixation is a safe and effective treatment option in patients with single‐level LSS, facet joint degeneration, and mild instability.

Completely Thrombosed Distal Middle Cerebral Artery Aneurysm Mimicking a Cavernous Angioma: Case Report and Review of the Literature

BACKGROUND Distal middle cerebral artery (MCA) aneurysms originate from branches of MCA distal to its main bifurcation or the peripheral branches. Distal MCA aneurysms are uncommon compared with saccular aneurysms, which develop along the proximal trunks of MCA. However, thrombotic aneurysms, characterized by organized intraluminal thrombus and solid mass, are frequently in the large and giant size range, whereas complete thrombosis of non-giant MCA aneurysms is very rare. CASE PRESENTATION We present the clinical case of a 53 years-old woman with a completely thrombosed medium distal MCA aneurysm mimicking a cavernous angioma. She came to our emergency department after the onset of tinnitus and persistent headache. Magnetic resonance imaging performed subsequently showed a nodular mass surrounded by edema located in the temporal lobe with a homogeneous peripheral contrast enhancement. Furthermore, angiography showed regular flow in the MCA and confirmed the diagnosis of cavernous angioma. The patient underwent surgery, and the lesion was found to be a thrombosed aneurysm originating from the distal temporal branch of the left MCA (M2 segment). CONCLUSIONS To our knowledge, this is the first report of a thrombosed distal medium MCA aneurysm that mimicked a cavernous angioma. The completely thrombosed aneurysm can be confused with intracranial lesions or cavernous malformations, which can have similar radiographic features without angiographic anomalies, so it is mandatory to consider the possibility of a thrombosed aneurysm for a correct differential diagnosis.

The Rehabilitation of Spinal Cord Injury Patients in Europe

In Western European countries there is an incidence of traumatic spinal cord injury (SCI) of 16 to 19.4 new cases per million inhabitants per year. Since World War II, European physicians have been fundamental in the development of SCI medicine, starting from Sir Ludwig Guttman, who developed the idea of the integrated treatment of these patients. More recently, scientists from Germany and Switzerland have developed a new rehabilitative approach, Body Weight Support Treadmill Training, based on the concept of activity-based therapy and aimed at restoring walking in SCI patients. This review highlights issues concerning different organizational systems and health policies within and outside Europe.

Atlantoaxial Joint Distraction with a New Expandable Device for the Treatment of Basilar Invagination with Preservation of the C2 Nerve Root: A Cadaveric Anatomical Study

BACKGROUND Atlantoaxial joint distraction has been advocated for the decompression of the brain stem in patients affected by basilar invagination, avoiding direct transoral decompression. This technique requires C2 ganglion resection and it is often impossible to perform due to the peculiar bony anatomy. We describe a cadaveric anatomical study supporting the feasibility of C1-C2 distraction performed with an expandable device, allowing easier insertion of the tool and preservation of the C2 nerve root. METHODS In five adult cadaveric specimens, posterior atlantoaxial surgical exposure was performed and an expandable system was inserted within the C1-C2 joint. The expansion of the device, leading to active distraction of the joint space, together with all the surgical steps of the technique was recorded with anatomical pictures and the final results were checked with a computed tomography (CT) scan. RESULTS Insertion of the device was easily performed in all cases without anatomical conflict with the C2 ganglion; CT scans confirmed the distraction of the C1-C2 joint. CONCLUSION This cadaveric anatomical study confirms the feasibility of the introduction of an expandable and flexible device within the C1-C2 joint, allowing its distraction and preservation of the C2 ganglion.

Minimally Invasive Surgery for Treatment of Patients with Advanced Cancer and Thoraco-lumbar Spine Metastases

Spinal metastases are common in patients with cancer. Spinal cord compression is the initial symptom of 5–10% of patients with diffuse cancer, and about 70% of lesions are found in the thoracic vertebrae. Patients with advanced cancer are generally excluded from major spine surgery, to reduce postoperative morbidity and mortality. Minimally invasive spine surgery (MISS) has recently been advocated as a useful approach for spinal metastases, especially in advanced cancer patients, seeking to decrease the morbidity of more traditional open spine surgery; furthermore, reducing the recovery time, MISS permits the post-operative chemotherapy and radiotherapy to begin sooner. A series of 29 cancer patients, with a short life expectancy, presenting acute myelopathy due to vertebral thoracic metastases, underwent MISS, with simple laminotomy and percutaneous stabilization; results from such series were compared to those retrospec‐ tively obtained from an homogenous series of patients operated with traditional open surgery. No significant differences between two groups were demonstrated in terms of surgical complications and neurological recovery. Nevertheless, patients operated with MISS appear to have an earlier recovery and better quality of life in the immediate postoperative period, which is a fundamental aim for patients who have a short life expectancy.

Adult Spinal Deformity in the Elderly. Preliminary Clinical and Radiological Results in 22 Patients Treated by a Two Times Minimally Invasive Spine Surgery

Introduction The adult spinal deformity (ASD) seems, in the last years, in a progressive increment. It should be in relation to the aging of the population. This trend leads to a progression of the disability and the reduction of the quality of life of these patients. The surgical correction of the ASD obtained by a traditional “open” surgery can often be incompatible with the co-morbidities of these patients. The minimally invasive surgery for correction of the deformities (MISDEF) can offer technical nuances, such as reduce of intraoperative blood loss and quickly recovery, which can lead the opportunities for these patients to approach the surgery. We present the preliminary results of our observational study on the radiological correction and clinical results of old patients affected by ASD treated by MISDEF. Methods Observational study with 20 months of follow-up. Twelve patients affected by low-back pain, sciatalgia and/cruralgia, neurological claudication were enrolled in this study. All the patients underwent to a MISDEF based on a percutaneous transpedicular stabilization plus a lateral or transforaminal interbody fusion. We collected all the radiological datas, such as sagittal vertical axis (SVA), sacral slope (SS), pervic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL) and coronal cob (CC) and the clinical status, oswestry disability index (ODI) and SF-36. Results The mean age was 70 years (65 – 78 years), 3 men and 9 women. 7 patients presented a lumbar left side convex scoliosis, while 5 patients presented a right side one. All the patients underwent to a 2 times surgery: the first time was a lateral access, the second time was the posterior access. The side for the lateral interbody fusion was the concave side of the scoliosis. L4L5 segment was always been approached for a transforaminal interbody fusion. The proximal strumental vertebra was T10. The mean intraoperative blood loss was 500 cc. All the patients were mobilized within 2 days. The ODI and SF36 evidenced a statistically improvement (p < 0,05). No evidence of infections, neurological deficit, failure of the implant and/or loosening of correction were documented in the follow up. Conclusions The MISDEF offers, even for elderly patients with co-morbidities, a valid and secure surgical solution for the correction of the ASD. From the results of our study appeared a good compliance of these techniques for all the patients, with a good result even at 20 months of follow-up. We considered that the opportunity to separate the surgical correction of the deformity in 2 times surgery seems to be a better and secure solution especially for elderly patients.