Cranioplasty optimal timing in cases of decompressive craniectomy after severe head injury: a systematic literature review

AbstractObjectCranioplasty has been considered for several decades as a protective and cosmetic procedure. It has recently been postulated that cranioplasty may have a therapeutic role, and improve the patient’s functional outcome after decompressive craniectomy (DC). The appropriate timing for cranioplasty remains unknown. In our current study, we review the literature for evaluating the relationship of cranioplasty timing and its complication rate and outcome.MethodsThe PubMed database was searched to identify any relevant articles. The following terms were used as keywords: “cranioplasty”, “timing cranioplasty”, “early cranioplasty”, “late cranioplasty”, “delayed cranioplasty”, “early versus late cranioplasty”. Clinical studies with more than 10 participants, and closed head injury as the underlying cause for DC were included in our study. The study design, the timing performing cranioplasty, the complication rate, and the patients’ outcome were evaluated.ResultsTen clinical series met our inclusion criteria. The observed complication rate associated to cranioplasty after DC is not negligible. Several reports have demonstrated that late cranioplasty may minimize procedure-associated complications. Early cranioplasty has been associated with complications, but improves CSF dynamics, and regional cerebral perfusion and metabolism, minimizes the complications from a sunken scalp, reduces the overall length of hospitalization, and thus the overall cost of care.ConclusionsCranioplasty is a relatively simple procedure that is nevertheless burdened by considerable morbidity. However, an early cranioplasty procedure may improve the outcome in selected cases. Prospective, large-scale studies are necessary to outline the actual complication rate, the neurological outcome, and define the optimal timing for a cranioplasty

Intradural extramedullary Ewing's sarcoma: A case report and review of the literature

Introduction Extra-skeletal Ewing's sarcomas are very rare lesions to the spine surgeon, with the intradural, extramedullary lesions being even rarer. Herein we present a patient with an intradural, extramedullary form of Ewing's sarcoma and review the relevant literature. The medical records, operative reports, radiographical studies and histological examinations of a single patient are retrospectively reviewed. Case report A 31-year old male presented with back-pain, right-leg progressive paraparesis, and inability to walk. Both motor and sensory disturbances were revealed on the right leg at the clinical examination. Lumbar MRI showed two lesions. The first one was an intradural, extramedullary lesion at the L2-L3 level, while the second was smaller, located at the bottom of the dural sac. The patient underwent gross total resection of the L2-L3 lesion after a bilateral laminectomy. Histological examination was compatible with Ewing's sarcoma, and was verified by molecular analysis. No other extra-skeletal or skeletal lesion was found. A chemotherapy scheme was tailored to the patients’ histological diagnosis. The patient presented with local recurrence and bone metastasis 2 years after his initial diagnosis. A second operation was performed and the follow up of the patient showed no disease progression 18 months after revision surgery. Conclusion The spine surgeon should be aware of the existence of such rare entities, in order to timely fulfill the staging process and institute the proper therapy. The management of patients with extra-skeletal Ewing's sarcomas involves professionals as members of a multidisciplinary team, all of which should co-operate for the patient's optimal outcome

Anti-C1q Autoantibodies Are Frequently Detected in Patients With Systemic Sclerosis Associated With Pulmonary Fibrosis

BACKGROUND: Anti-C1q autoantibodies (autoAbs) are associated with systemic lupus erythematosus (SLE) but their presence in other rheumatic diseases has not been adequately investigated. OBJECTIVE: We aim to assessanti-C1q autoAbs and circulating immune complexes (CICs) in systemic sclerosis (SSc). METHODS: One hundred twenty four patients with SSc (106 females; median age 59.4 years, range 25-81.4; 75(60.5%) with limited cutaneous SSc[lcSSc], and 49(39.5%) with diffuse cutaneous SSc[dcSSc]), were studied. Twenty-five patients with Sjögren\u27s syndrome (SjS), 29 with rheumatoid arthritis (RA), and 38 patients with systemic lupus erythematosus (SLE) and 53 healthy controls (NC) were also included. ELISAs with high and low salt buffers the former allowing IgGFc binding to C1q, the latter not allowing IgGFc binding and anti-C1q Ab binding to C1q were used to measure anti-C1q Abs and CICs. RESULTS: Anti-C1q Abs were present in20/124 (16.1%) SSc patients [5 had high levels (\u3e80 RU/mL) and 10 patients (50%) had moderate levels (40-80 RU/mL)] compared to 1/25 (4%) SjS, 1/29 (3.4%) RA patients (p CONCLUSIONS: Anti-C1q autoAbs were frequently detected in patients with SSc and their high levels predict the co-occurrence of pulmonary fibrosis or pulmonary arterial hypertension

A cervical ligamentum flavum cyst in an 82-year-old woman presenting with spinal cord compression: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>We report on a very rare case of a cervical ligamentum flavum cyst, which presented with progressive myelopathy and radiculopathy. The cyst was radically extirpated and our patient showed significant recovery. A review of the relevant literature yielded seven cases.</p> <p>Case presentation</p> <p>An 82-year-old Greek woman presented with progressive bilateral weakness of her upper extremities and causalgia, cervical pain, episodes of upper extremity numbness and significant walking difficulties. Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Magnetic resonance imaging of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level, significantly compressing the spinal cord at this level, in close proximity to the yellow ligament and the C3 left lamina. The largest diameter of this lesion was 1.4 cm, and there was no lesion enhancement after the intravenous administration of a paramagnetic contrast. The lesion was surgically removed after a bilateral C3 laminectomy. The thick cystic wall was yellow and fibro-elastic in consistency, while its content was gelatinous and yellow-brownish. A postoperative cervical-spine magnetic resonance image was obtained before her discharge, demonstrating decompression of her spinal cord and dural expansion. Her six-month follow-up evaluation revealed complete resolution of her walking difficulties, improvement in the muscle strength of her arms (4+/5 in all the affected muscle groups), no causalgia and a significant decrease in her preoperative upper extremity numbness.</p> <p>Conclusion</p> <p>Cervical ligamentum flavum cysts are rare benign lesions, which should be included in the list of differential diagnosis of spinal cystic lesions. They can be differentiated from other intracanalicular lesions by their hypointense appearance on T₁-weighted and hyperintense appearance on T₂-weighted magnetic resonance images, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. The outcome of these cysts is excellent with no risk of recurrence.</p

Neurosurgical treatment for addiction:Lessons from an untold story in China and a path forward

Addiction is a major public-health crisis associated with significant disability and mortality. Although various pharmacological and behavioral treatments are currently available, the clinical efficacy of these treatments is limited. Given this situation, there is a growing interest in finding an effective neurosurgical treatment for addiction. First, we discuss the use of ablative surgery in treating addiction. We focus on the rise and fall of nucleus accumbens ablation for addiction in China. Subsequently, we review recent studies that have explored the efficacy and safety of deep-brain-stimulation treatment for addiction. We conclude that neurosurgical procedures, particularly deep-brain stimulation, have a potentially valuable role in the management of otherwise intractable addictive disorders. Larger well-controlled clinical trials, however, are needed to assess clinical efficacy and safety. We end by discussing several key issues involved in this clinical field and identifying some areas of progress

Cavernous Malformations of the Central Nervous System: An International Consensus Statement

Introduction: Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial. Research question: A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs. Material and methods: A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%. Results: A consensus for surgical intervention was reached on the importance of the patient’s age, symptomatology, and hemorrhagic recurrence; and the CM’s location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases. Discussion and conclusion: Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management

Study of the adjacent segment degeneration rate of the adjacent segments after a lumbar fusion and the impact on the clinical outcome

Study design: Descriptive, case series.Aim: To study the adjacent segment degeneration and disease in the patients of our population subjected to instrumented posterior lumbar fusion for degenerative conditions of the lumbar spine.Methods: In the period between January 2000 and December 2002, 46 patients had instrumented posterior lumbar fusion in all cases and posterior lumbar interrbody fusion in selected cases. All surgical procedures took place at our Hospital for the treatment of degenerative conditions of the lumbar spine. Five patients declined participating in our study, and one patient was not included due to material failure. The remaining 39 patients formed our study sample. We used questionnaires for the estimation of the pain intensity (VAS), back-related disability (Oswestry Disability Index), the return to work (Prolo scale), the depression status of our patients (Zung depression scale), and the satisfaction with the postoperative results. Fusion status was estimated by plain radiographs and graded according to Brantigan and Steffee. The patient’s follow-up included plain and dynamic radiographs, and magnetic resonance images. Plain radiographs took place preoperatively, at the immediate postoperative period, and at three, six, twelve, 18, 24, 48 months and 5 years. Magnetic resonance imaging took place preoperatively, along with the 1st and the third postoperative year. The minimum patient follow-up was five years. Statistical analysis was done by an independent statistician, using parametric and non-parametric statistics.Results: All patients included in our study developed solid fusions (Brantigan and Steffee, D and E) after the sixth postoperative month. Patient’s pain intensity decreased at a statistically significant level from the first postoperative trimester, and remained thus for at least five years (P<0,0001). Similarly, there was a statistically significant improvement in the back-related disability, return to work, and patient satisfaction with the postoperative results (P<0,0001). Nevertheless, there a worsening in the depression status of our patient sample (P<0,0001). Adjacent disc degeneration (36%) was the most common form of degeneration at a segment next to a fusion five years after the operation, followed by spondylosis (28%) and stenosis (15%). Six patients (15%) developed the adjacent segment disease. Stenosis was the main cause of the new symptomatology from the adjacent segment in all patients. In every case there was involvement of the superior adjacent segment and in two cases there also was participation of the inferior segment. Two patients were treated conservatively, and in other two we used epidural neuromodulation for the symptomatic pain treatment. Finally, in the remaining two patients we used minimally invasive lumbar fusion techniques with successful results.Conclusions: Lumbar fusion is an efficient solution for the treatment of degenerative conditions of the lumbar spine, decreasing the pain intensity and improving the back related disability. Nevertheless, the degenerative changes of the lumbar spine are characterized by recurrencies, remissions and many reoperations that affect the psychological condition of our patients. Adjacent segment disease appears in our series with a similar frequency to that reported in the literature. On the other hand, our sample is too small, to deduce valid results regarding the risk factors related to this pathological entity. Minimal invasive lumbar fusion techniques offer reliable solutions in the management of patients with adjacent segment degeneration.Σχεδιασμός της έρευνας: Περιγραφική μελέτη σειράς ασθενών.Στόχος: Να μελετήσουμε την νόσο του παρακείμενου διαστήματος σε ασθενείς του πληθυσμού μας, που υποβλήθηκαν σε οπίσθια οσφυϊκή σπονδυλοδεσία με σταθερά συστήματα για εκφυλιστικές παθήσεις της οσφυϊκής μοίρας.Μεθοδολογία: Στο χρονικό διάστημα μεταξύ Ιανουαρίου 2000 και Δεκεμβρίου 2002, 46 ασθενείς υποβλήθηκαν σε οσφυϊκή σπονδυλοδεσία με σταθερά συστήματα σε όλες τις περιπτώσεις και διασωματικούς κλωβούς σε επιλεγμένους ασθενείς. Όλες οι επεμβάσεις έλαβαν χώρα στο Πανεπιστημιακό Γενικό Νοσοκομείο Λάρισας για την αντιμετώπιση εκφυλιστικών παθήσεων της οσφυϊκής μοίρας. Πέντε ασθενείς δήλωσαν αδυναμία συμμετοχής στην έρευνα, ενώ άλλος ένας δεν συμπεριλήφθηκε εξαιτίας αστοχίας των υλικών σπονδυλοδεσίας. Οι 39 εναπομείναντες ασθενείς αποτέλεσαν το δείγμα της έρευνας μας. Παρακολουθήσαμε τους ασθενείς για χρονικό διάστημα τουλάχιστον πέντε ετών, με ερωτηματολόγια για την ένταση του πόνου (VAS), την λειτουργική ανεπάρκεια (Oswestry Disability Index), την ικανότητα για εργασία (Prolo), την ψυχολογική κατάσταση (Zung Questionairre) και την ικανοποίηση με τα μετεγχειρητικά αποτελέσματα. Η εκτίμηση της πώρωσης των εμπλεκόμενων στη σπονδυλοδεσία διαστημάτων έγινε με τη βοήθεια απλών ακτινογραφιών με την μέθοδο Brantigan και Steffee. Η παρακολούθηση των ασθενών μας ολοκληρώθηκε με απεικονιστικό έλεγχο που περιλάμβανε απλές και δυναμικές ακτινογραφίες, και μαγνητικές τομογραφίες. Ο έλεγχος πραγματοποιήθηκε προεγχειρητικά, άμεσα μετεγχειρητικά, στο τρίμηνο, εξάμηνο και μετά ανά έξι μήνες. Ο έλεγχος με μαγνητική τομογραφία έλαβε χώρα προεγχειρητικά, στο 1ο και στο 3ο μετεγχειρητικό έτος. Η στατιστική επεξεργασία έγινε από ανεξάρτητο στατιστικολόγο, με παραμετρικές και μη-παραμετρικές μεθόδους.Αποτελέσματα: Όλοι οι ασθενείς που συμπεριλήφθησαν στην έρευνά μας οδηγηθήκαν σε πώρωση της σπονδυλοδεσίας (Brantigan και Steffee D και E) μετά το πρώτο μετεγχειρητικό εξάμηνο. Η ένταση του πόνου μειώθηκε σε στατιστικά σημαντικό βαθμό από το πρώτο τρίμηνο και διατηρήθηκε για τουλάχιστον πέντε χρονιά μετά από την οσφυϊκή σπονδυλοδεσία (P<0,0001). Ομοίως, βελτιώθηκε η λειτουργική ανεπάρκεια των ασθενών (P<0,0001) και η ικανότητα τους για εργασία (P<0,0001), όπως και η ικανοποίηση τους με τα μετεγχειρητικά αποτελέσματα (P<0,0001). Παρόλα αυτά, παρατηρήθηκε επιδείνωση της ψυχολογικής τους κατάστασης (P<0.0001). Η εκφύλιση του παρακειμένου δίσκου (36%) ήταν η πιο συχνή μορφή της εκφύλισης σε παρακείμενο διάστημα στη σειρά μας, ακολουθουμένη από την εκφυλιστική σπονδύλωση (28%) και την σπονδυλική στένωση (15%), πέντε έτη μετά την σπονδυλοδεσία. Έξι ασθενείς (15%) παρουσίασαν τη νόσο του παρακειμένου διαστήματος. Η κύρια αιτία της νέας κλινικής συμπτωματολογίας ήταν η στένωση σπονδυλικού σωλήνα σε όλους τους ασθενείς. Και στους έξι ασθενείς εμπλεκόταν το υπερκείμενο διάστημα, ενώ σε δυο από αυτούς συμμετείχε το υποκείμενο διάστημα. Όλοι οι ασθενείς είχαν ένδειξη για χειρουργική αντιμετώπιση. Ωστόσο, δυο ασθενείς αντιμετωπίστηκαν συντηρητικά και άλλοι δύο υποβλήθηκαν σε επισκληρίδια νευροδιέγερση με εμφύτευση μόνιμου διεγέρτη για τη μείωση της έντασης του πόνου. Τέλος, άλλοι δύο ασθενείς αντιμετωπίστηκαν επιτυχώς χειρουργικά, με ελάχιστα επεμβατικές τεχνικές σπονδυλοδεσίας.Συμπεράσματα: Η οσφυϊκή σπονδυλοδεσία αποτελεί μια αποτελεσματική λύση στην αντιμετώπιση εκφυλιστικών αλλοιώσεων της οσφυϊκής μοίρας, μειώνοντας την ένταση του πόνου και βελτιώνοντας τη λειτουργική ανεπάρκεια. Παρόλα αυτά, οι εκφυλιστικές παθήσεις της οσφυϊκής μοίρας της σπονδυλικής στήλης χαρακτηρίζονται από υφέσεις και εξάρσεις και πιθανόν απαιτούν πολλαπλές επεμβάσεις, με αντίκτυπο στην ψυχοσύνθεση των ασθενών. Η συχνότητα εμφάνισης της νόσου του παρακειμένου διαστήματος στο δείγμα μας είναι αντίστοιχη με αυτήν της διεθνούς βιβλιογραφίας. Το μικρό δείγμα ασθενών με την νόσο του παρακειμένου διαστήματος, δεν μας επιτρέπει να διεξάγουμε ασφαλή συμπεράσματα για τους παράγοντες κινδύνου που αφορούν σε αυτή τη παθολογική οντότητα. Ελάχιστα επεμβατικές τεχνικές σπονδυλοδεσίας της οσφυϊκής μοίρας, προσφέρουν αξιόπιστες λύσεις στην αντιμετώπιση της νόσου του παρακείμενου διαστήματος

Letter to the Editor Regarding “Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries”

[No abstract available

Vitamin D serum levels in patients with migraine: A meta-analysis

Background/Purpose: Dietary habits and nutrients have been associated with migraine. The present study comprises a meta-analysis of observational studies evaluating serum levels of 25-hydroxyvitamin D (25(OH)D) in patients with migraine and healthy controls. Methods: MEDLINE and Cochrane databases were comprehensively searched. References from retrieved observational studies, reviews and meta-analyses were manually screened. Quality assessment was performed based on the Newcastle-Ottawa Scale. 25(OH)D concentrations were assessed by estimates of mean differences (MD) and their precision [95% confidence intervals (95% CIs)]. Random effects (RE) or fixed effects (FE) model was used based on heterogeneity among trials (homogeneity determined when PQ > 0.1 and I2 < 50%). Publication bias was assessed by funnel plots. Results: Eight studies were included in the primary analysis, while nine studies were involved overall (in primary and secondary analyses). Serum levels of 25(OH)D were determined significantly lower in migraine patients (n = 952) in comparison with healthy controls (n = 8013) [eight studies, PQ < 0.1, I2 = 94%, RE model MD = −4.11, 95% CI = (−6.48, −1.74)]. Secondary analysis revealed no difference between patients with migraine (n = 269) compared to patients with other primary headache disorders (n = 223) [three studies, PQ = 0.51, I2 = 0%, FE model MD = −0.15, 95% CI = (−1.57, 1.05)], as well as between patients with tension type headache (n = 295) in comparison with healthy controls (n = 267) [three studies, PQ < 0.1, I2 = 96%, RE model MD = −7.11, 95% CI = (−15.50, 1.27)]. Conclusions: 25(OH)D concentration is lower in patients with migraine than healthy individuals. In view of this finding, investigation of the effect of vitamin D supplementation in patients suffering from migraine is warranted. © 2020 Elsevier Masson SA