Navigazione spinale basata su immagini TC pre-operatorie: evoluzione della tecnica, applicazioni, vantaggi e limiti

Negli ultimi venti anni la tecnologia ha giocato un ruolo fondamentale nello sviluppo della chirurgia immagine-guidata, in particolare in chirurgia vertebrale. Nonostante questo, le tecniche di navigazione spinale non sono ancora diffusamente utilizzate. Durante le procedure strumentate di chirurgia vertebrale, la tecnologia più comunemente impiegata consiste nell’imaging intra-operatorio 2-D realizzato con l’impiego dell’amplificatore di brillanza senza il supporto di un sistema di navigazione. Meno frequenti risultano invece l’utilizzo dell’imaging 3-D fluoroscopico, l’impiego di scansioni TC preoperatorie ed infine il ricorso a procedure assistite da un sistema di navigazione. Cenni storici La navigazione spinale nacque con l’intento di rendere più sicure e meno invasive le procedure di chirurgia vertebrale strumentata. Risale a 20 anni fa l’introduzione di sistemi di navigazione chirurgica basati sull’acquisizione di immagini TC preoperatorie: rappresentò il primo tentativo, nell’ambito delle procedure strumentate di chirurgia vertebrale, finalizzato all’ottimizzazione del posizionamento delle viti peduncolari e alla riduzione dell’esposizione del paziente e del personale di sala operatoria alle radiazioni ionizzanti. Questa metodica risultò tuttavia eccessivamente complicata e non ottenne consenso su larga scala da parte della classe medica. L’indagine anatomica basata su immagini intra-operatorie 2-D ottenute mediante l’utilizzo dell’amplificatore di brillanza rimane ancora oggi la tecnica più comune, nonostante ne siano riconosciuti i limiti nel fornire informazioni relative alla terza dimensione, essenziali per un corretto e preciso posizionamento delle viti peduncolari. La prima applicazione clinica conclusa con successo risale al 1995 e consisteva nel posizionamento di viti peduncolari nelle vertebre lombari (1). Negli anni successivi la metodica è stata applicata nel trattamento chirurgico di numerose patologie degenerative, malformative, traumatiche e neoplastiche di tutto il rachide, non solo di quello lombare

First description of cervical intradural thymoma metastasis

Thymoma and thymic carcinoma are rare epithelial tumors, which originate from the thymus gland. According to the World Health Organization there are "organotypic" (types A, AB, B1, B2, and B3) and "non-organotypic" (thymic carcinomas) thymomas. Type B3 thymomas are aggressive tumors, which can metastasize. Due to the rarity of these lesions, only 7 cases of extradural metastasis are described in the literature. We report the first and unique case of a man with cervical intradural B3 thymoma metastasis. A 46-year-old man underwent thymoma surgical removal. The year after the procedure he was treated for a parietal pleura metastasis. In 2006 he underwent cervical-dorsal extradural metastasis removal and C5-Th1 stabilization. Seven years after he came to our observation complaining left cervicobrachialgia and a reduction of strength of the left arm. He underwent a cervical spine magnetic resonance imaging, which showed a new lesion at the C5-C7 level. The patient underwent a surgery for the intradural B3 thymoma metastasis. Neurological symptoms improved although the removal was subtotal. He went through postoperative radiation therapy with further mass reduction. Spinal metastases are extremely rare. To date, only 7 cases of spinal extradural metastasis have been described in the literature. This is the first case of spinal intradural metastasis. Early individuation of these tumors and surgical treatment improve neurological outcome in patients with spinal cord compression. A multimodal treatment including neoadjuvant chemotherapy, surgery and postoperative radiation therapy seems to improve survival in patients with metastatic thymoma

An Extremely Rare Case of Thoracic Intramedullary Melanocytoma: Case Report and Review of Literature

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Intramedullary non-specific inflammatory lesion of thoracic spine: A case report

<p>Abstract</p> <p>Background</p> <p>There are several non-neoplastic lesions which mimick intramedullary spinal cord neoplasm in their radiographic and clinical presentation. These can be classified as either infectious (TB, fungal, bacterial, parasytic, syphilis, CMV, HSV) and non-infectious (sarcoid, MS, myelitis, ADEM, SLE) inflammatory lesions, idiopathic necrotizing myelopathy, unusual vascular lesions and radiation myelopathy. Although biopsy may be indicated in many cases, an erroneous diagnosis of intramedullary neoplasm can often be eliminated pre-operatively.</p> <p>Case description</p> <p>the authors report a very rare case of intramedullary non-specific inflammatory lesion of unknown origin, without signs of infection or demyelinization, in a woman who showed no other evidence of systemic disease.</p> <p>Conclusions</p> <p>Intramedullary lesions that mimick a tumor can be various and difficult to interpret. Preoperative MRI does not allow a certain diagnosis because these lesions have a very similar signal intensity pattern. Specific tests for infective pathologies are useful for diagnosis, but histological examination is essential for establishing a certain diagnosis. In our case the final histological examination and the specific tests that we performed have not cleared our doubts regarding the nature of the lesion that remains controversial.</p

Management of calcified thoracic disc herniation using ultrasonic bone curette SONO-PET®: technical description.

This paper describes the surgical management of a post-traumatic calcified thoracic disc herniation treated using ultrasonic bone curette SONO-PET®. The case described concerns a young man with a symptomatic calcified thoracic disc herniation, who underwent posterolateral approach and transversoarthropediculectomy. Patient underwent posterolateral approach with excellent postoperative results. Neurophysiological monitoring somato-sensory evoked potential (SSEP) and muscle motor evoked potentials (MMEP), inclination of 30° toward the unaffected side of the operating table, the use of Ultrasonic Bone-Curette SONO-PET® and proper reconstruction of the three floors of the back muscles allows the removal of the disc herniation safer and risk's free, and less invasive for the patient

Post-traumatic Collet-Sicard syndrome: personal observation and review of the pertinent literature with clinical, radiologic and anatomic considerations

Study design The lesion of the lower four cranial nerves, commonly called Collet–Sicard syndrome, can be caused by a blunt head and neck trauma. It may be associated to an isolated fracture of the occipital condyle or of the atlas. Objective The aim of this report is to assess the modality of the trauma, the type of fracture, the anatomic characteristics, the treatment and clinical results of this syndrome. Summary of background data We discuss 14 cases of fracture of occipital condyle and of atlas and 1 personal case. Methods We analyzed 14 cases collected from the literature between 1925 and 2013, reported a further personal case and performed an anatomical study of the paracondylar, atlas and styloid process region. The anatomical dissection was performed to assess the anatomic relationships in the site of transit in which the nerves IX, X, XI and XII are injured. Results A total of 14 cases of p-CSS were collected: 9 caused by a condyle fracture and 5 by an atlas fracture. The patients were 13 males and only 1 female, 10 of them had a blunt trauma due to the result of axial loading (force directed through the top of the head and through the spine) falling on the head. The nine cases with a condyle fracture were associated to the dislocation of part of it, while those with atlas fractures showed the fracture and/or disjunction of the articular mass. The anatomical evaluations reveal that the lower four cranial nerves, at their emergency, pass through a close osteo-ligamentous space in relationship to the condyle. Below they run through a little wider channel between the articular mass of C1 and the styloid process. Two cases underwent surgical procedure. All the other cases were treated conservatively with immobilization of the cervical spine. During follow-up three cases with condylar fractures were found to be clinically unchanged and six showed modest improvements while one case with atlas fracture had a complete recovery and four improved significantly. Conclusions The p-CSS is caused by force directed through the top of the head.Wesuppose that the nerve injuries are due to their laceration caused by a displacement of a condyle fragment or to their compression and stretching when they pass between the lateral mass of the atlas and the styloid process. Thesemodalities of traumaexplain the better clinical results in patients affected by C1 fractures. Conservative treatment is the option of choice. Surgical option, when choosed, is not considered to fix nerve damages

Recurrent lumbar disc herniation: Is there a correlation with the surgical technique? A multivariate analysis

Purpose: The recurrence of a lumbar disc herniation (LDH) is a common cause of poor outcome following lumbar discectomy. The aim of this study was to assess a potential relationship between the incidence of recurrent LDH and the surgical technique used. Furthermore, we tried to define the best surgical technique for the treatment of recurrent LDH to limit subsequent recurrences. Materials and Methods: A retrospective study was conducted on 979 consecutive patients treated for LDH. A multivariate analysis tried to identify a possible correlation between (1) the surgical technique used to treat the primary LDH and its recurrence; (2) technique used to treat the recurrence of LDH and the second recurrence; and (3) incidence of recurrence and clinical outcome. Data were analyzed with the Pearson's Chi-square test for its significance. Results: In 582 cases (59.4%), a discectomy was performed, while in 381 (40.6%), a herniectomy was undertaken. In 16 cases, a procedure marked as “other” was performed. Among all patients, 110 (11.2%) had a recurrence. Recurrent LDH was observed in 55 patients following discectomy (9.45%), in 45 following herniectomy (11.8%), and in 10 (62.5%) following other surgery. Our data showed that 90.5% of discectomies and 88.2% of the herniectomies had a good clinical outcome, whereas other surgeries presented a recurrence rate of 62.5% (Pearson's χ2 0.05). A significant statistical correlation emerged between the use of other techniques and the incidence for the second recurrences (P < 0.05). Conclusions: The recurrence of an LDH is one of the most feared complications following surgery. Although the standard discectomy has been considered more protective toward the recurrence compared to herniectomy, our data suggest that there is no significant correlation between the surgical technique and the risk of LDH recurrence