Vitaliano Francesco Muzii

Recruitment curve of the soleus H-reflex in chronic back pain and lumbosacral radiculopathy

BackgroundNeedle EMG may be negative in mild or predominantly sensory lumbosacral radiculopathies. In such cases, an increase in the latency of the soleus H-reflex is a useful diagnostic criterion for establishing sensory fiber compromise at the S1 root level. However, if clinical signs of radicular involvement are lacking, the latency of the H-reflex is normal. We therefore studied the recruitment curve of the soleus H-reflex to investigate whether a change in the electrical threshold for eliciting the H-reflex might be a more sensitive criterion for detecting subclinical S1 root dysfunction.MethodsClinical and electrophysiological findings from 26 patients with chronic back pain and radiculopathy were compared with data obtained from 40 healthy subjects.ResultsAn increase in the mean H-reflex threshold was the only abnormal electrophysiological finding in patients with no clinical sign of root injury (58%). A decrease in the mean H-reflex amplitude and a prolongation of H-reflex latency was observed in patients with radicular signs (42%). In both patients groups, F-wave and needle EMG studies were normal. No radiological evidence of S1 root compression was found.ConclusionsThe study of the recruitment curve of the soleus H-reflex may be usefully associated to F-wave and needle EMG studies to detect possible S1 root dysfunction in mild lumbosacral radiculopathies. An increase in H-threshold may be the earliest abnormality in the absence of focal neurological signs.

Microsurgery for recurrent lumbar disk herniation at the same level and side: do patients fare worse? Experience with 95 consecutive cases

BACKGROUND In reviewing our experience with reoperation of RLDH, our aim was mainly to determine whether patients fared worse than after primary surgery. We found no uniform answers to this question in the literature. METHODS The data of 95 patients (29 women and 66 men) who underwent reoperation for RLDH at the same level and side were analyzed retrospectively. Forty-two patients underwent the first operation in our clinic (recurrence rate, 2.6% of 1586 cases). Gadolinium-enhanced MRI was performed in all patients. Main clinical data of patients, pain-free interval, operation time, surgical complications, duration of hospital stay, and clinical improvement rate were recorded. RESULTS The mean pain-free interval was 55 months (range, 3-120 months). Levels of recurrent herniation were L4 through L5 and L5 through S1 (65% and 35% of cases, respectively). Revision surgery lasted longer on average than the previous diskectomy (P < .01) and was complicated by dural tear in 4 cases (4.2% vs 0.9% during primary diskectomy, P < .05). There were no significant differences between revision and previous surgery in terms of hospital stay. However, rates of excellent/good outcomes were significantly less for RLDH (89% vs 95%, P < .05); and the percentage of poor results was higher (2% vs 0.5%, P < .05). Age, sex, smoking, profession, trauma, level and degree of herniation, and pain-free interval were not correlated with clinical outcome. CONCLUSION Conventional microsurgery for RLDH showed lightly but significantly worse results than those of primary microdiskectomy. Patients contemplating reoperation should be informed of this fact and of the risk of dural tear and prolonged operation time.

Posterior retroextramarginal disc hernia (PREMDH): Definition, diagnosis, and treatment

BACKGROUND Detachment of the posterior part of the lumbar vertebral ring apophysis has been reported by many authors, associated or not with disc prolapse, and has been ascribed to various mechanisms, although the relationship between the two pathologies remains unclear. METHODS We studied 26 patients (17 males and 9 females; mean age, 34.3 years) suffering from a lumbar disc herniation with nontraumatic detachment of the ring apophysis. Investigations included standard X ray, computed tomography (CT), tridimensional CT, and magnetic resonance imaging. Nineteen patients were operated on by microsurgical discectomy and removal of bone fragments. RESULTS Clinical and neuroradiologic features of herniated disc associated with detachment of the ring apophysis have been recognized and have led to the definition of posterior retroextramarginal disc herniations. A further classification is suggested, considering two morphological types that imply clinically distinctive features and a different surgical approach. In all operated cases, removal of the bone fragments was necessary and the results were good. CONCLUSIONS Our observations led us to postulate a common mechanism in the pathogenesis of disc herniation with nontraumatic detachment of the ring apophysis. They should be distinguished from other calcifications of the disc because a proper surgical technique, including removal of apophyseal fragments, is required.

Abnormalities of the soleus H-reflex in lumbar spondylolisthesis: a possible early sign of bilateral S1 root dysfunction.

Using routine electrodiagnostic procedures, the authors searched for physiologic evidence of nerve root compromise in patients with chronic mechanical perturbation to the lumbar spine. They examined 37 patients with spondylolisthesis and various degrees of degenerative changes in the lumbar canal. Clinical and neurophysiologic findings were compared with data obtained from 36 healthy persons. The soleus H-reflex appeared to be a sensitive indicator of sensory fiber compromise at the S1 root level, because changes correlated well with the focal sensory signs and preceded clinical and electromyographic signs of motor root involvement. When these occurred, the clinical findings were consistent with a more severe nerve root deficit and with radiographic evidence of neural compression. The greater sensitivity of the soleus H-reflex may be related to the pathophysiologic events that occur at the lesion site.

Ganglion cyst of the ligamentum flavum: a rare cause of cervical spinal cord compression. A case report

Ganglion cysts of the ligamentum flavum are uncommon degenerative spinal lesions and are mostly encountered in the lumbar spine. Cervical localisation is rare and may cause severe myelopathy. They accompany degenerative changes of the spine and can be differentiated from synovial and other degenerative spinal cysts on the basis of location and histopathological features. Ganglion cysts of the ligamentum flavum are unusual extradural spinal lesions and most have been reported in the lumbar region. Cervical localisation is an extremely rare cause of myelopathy and, to our knowledge, only three cases have been reported.1 2 Differentiation of ganglion cysts of the ligamentum flavum from other degenerative spinal cysts is still debated.1–4 We report a case of ganglion cyst of the ligamentum flavum in the cervical spine, presenting as progressive tetraparesis due to severe spinal cord compression. A 60-year-old man presented with a 1-year history of progressive lower limb weakness and gait disturbance. Clinical examination revealed spastic tetraparesis with ataxic gait, positive Romberg test, diffuse tendon hyperreflexia, bilateral Achilles clonus, Babinski sign and proprioceptive sensory impairment. Electromyography showed a pattern of chronic denervation of the lower limbs, with indirect signs of motor pathway dysfunction. Magnetic resonance imaging (MRI) revealed a hypertrophic C4–C5 ligamentum flavum containing an oval cystic mass, 8 mm in …

Vasospasm and cerebral infarction from pituitary apoplexy. A case report.

Pituitary apoplexy is a potentially life-threatening acute or subacute clinical syndrome occurring from enlargement of the pituitary gland, and pituitary insufficiency, from hemorrhage or ischemia from an unknown pituitary lesion, most frequently being a non-functioning macroadenoma. A close, and multidisciplinary management is required. The purpose of this case report is to increase awareness to pituitary apoplexy presentation and management by reporting clinical features and neuroradiological findings observed in a 70-year-old patient with an unknown pituitary lesion. He presented with pituitary apoplexy and brain ischemia at magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. MR angiography (MRA) showed diffuse vasospasm of anterior and posterior circulation. Both MRI and cytochemical examination of the cerebrospinal fluid ruled out subarachnoid hemorrhage. Due to concomitant diseases, and absence of visual deficit, the management was conservative by medical and substitutive therapy, without surgery. Clinical follow-up showed clearcut improvement, and this was consistent with MRI and MRA evidence of vasospasm regression, and clearcut pituitary lesion shrinkage. Pituitary lesions with hemorrhagic infarction presenting with pituitary apoplexy may be associated with vasospasm and brain ischemia at diagnosis, also in the absence of subarachnoid hemorrhage. A correct MR evaluation of patients with PA should include DWI, ADC maps, and MRA. Notably, early diagnosis of PA-associated vasospasm and cerebral ischemia avoids the possibility of their detection only after neurosurgery

Wrist median nerve motor conduction after end range repeated flexion and extension passive movements in Carpal Tunnel Syndrome. Pilot study.

Carpal Tunnel Syndrome (CTS) can be due to a variety of different pathological conditions. These etiological and epidemiological differences may explain the non-homogeneous response to ordinary conservative therapeutical options observed in this syndrome. The aim of our study was to investigate on the possibility of identifying different sub-groups of patients among conservatively treatable CTS with different susceptibility to physiotherapeutic treatments. We decided to utilize an objective approach measuring some median motor nerve function parameters. Short term variations of Compound Motor Action Potential (CMAP) from the thenar eminence were compared in two groups of 55 hands (CTS patients and normal controls) after performance of two different types of end range passive movement. We found a different distribution of CMAP amplitude modifications within a sub-group of patients that suddenly improved more than the controls after two series of 10 end range passive flexions or after two series of ten end range passive extensions. Amplitude changes proved to be much more useful than latency variation studies in the provocative test neurophysiological approach. The method we propose appears to be useful for better surgical indication and/or for improvement of conservative therapeutic choice.

Is the short posterior stabilization by TLIF and cages a good way for a correct spinal alignment in the de novo scoliosis? A case report

De novo scoliosis is becoming one of the most prevalent findings in the aging spine, and this condition is associated not only with severe back or leg symptoms but also with complicated surgical outcomes. The most common surgery is a posterior spinal fusion with metal implants and bone graft (from the pelvis or the bone bank), with or without decompression of the nerve roots. Sometimes the surgery may need to be performed anteriorly (from the front of the spine) for better stability, correction, and healing. After 1 years of follow, up we presented a case report of a 74 year old man treated for De Novo Scoliosis with a spinal short posterior stabilization, TLIF and Cages.

An unruptured aneurysm of the posterior inferior cerebellar artery presenting with meningitis

We report a case of large, unruptured, partially thrombosed aneurysm of the left posterior inferior cerebellar artery (PICA), presenting with meningitis. Although a meningeal syndrome is common in aneurysmal subarachnoid hemorrhage (SAH), it is an unusual presentation of unruptured intracranial aneurysms, unless a mycotic aneurysm is being considered. On the basis of clinical, radiological, and histopathological findings, we speculated that a large berry aneurysm became secondarily infected. Aneurysms caused by arterial localization of an infection (so called mycotic aneurysms) are well known, whereas there is only one report of primary berry aneurysms with secondary infection [1, 2].

Complete loop of the posterior cerebral artery with ruptured aneurysm at the origin of the medial posterior choroidal artery. A case report

BACKGROUND Anatomical anomalies of the PCA are unusual and their association with an aneurysm is exceptional. A unique case of a complete loop of the posterior cerebral artery associated with a ruptured aneurysm is presented. CASE DESCRIPTION A 69-year-old woman with a subarachnoid hemorrhage in World Federation of Neurosurgical Societies grade IV was diagnosed with a loop of the right PCA with an aneurysm at the apex of the loop. At surgery, the aneurysm was found to arise at the origin of the MPChA and it was clipped. Three months later, after improving to Glasgow Outcome Scale 3, the patient died of unrelated cause. CONCLUSIONS To our knowledge, a complete loop of the PCA associated with an aneurysm at the origin of the MPChA has never been described. Microneurosurgical approach via subtemporal craniotomy was safe and effective in displaying the anomalous anatomy and allowing perfect clipping of the aneurysm.