Stand-alone oblique lumbar interbody fusion (OLIF) for the treatment of adjacent segment disease (ASD) after previous posterior lumbar fusion: clinical and radiological outcomes and comparison with posterior revision surgery

Background: Radiological evidence of adjacent segment disease (ASD) has been reported to have a prevalence of more than 30% and several risk factors have been reported. The aim of this study is to evaluate the clinical and radiological outcomes of patients with symptomatic ASD treated with stand-alone OLIF and compare results with a posterior revision surgery cohort. Methods: This is a retrospective case-control study. Clinical-patient-reported outcomes were obtained at preoperative, postoperative and final follow-up visits using the Short Form (SF-36) scale, the Oswestry Disability Index (ODI) and the visual analog scale (VAS). Radiological measures include lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental coronal Cobb angle and intervertebral disc height (DH). The data are compared with a retrospective series of patients that underwent a posterior revision surgery for ASD. Results: Twenty-eight patients in the OLIF group and 25 patients in the posterior group meet inclusion criteria. The mean ages at the time of the surgery are 65.1 years and 67.5, respectively. The mean follow-up time is 36.1 months (range of 14-56). The clinical outcomes significantly improve from preoperative values from the surgery in both groups. The radiological parameters are significantly improved postoperatively and were maintained at the last follow-up in both groups. A statistically significant difference is observed between the two groups for minor complication rate, length of surgery, blood loss and DH restoration. Conclusions: Stand-alone OLIF is an effective and safe technique with low morbidity and complication rates for the treatment of selected patients with symptomatic ASD following a previous lumbar fusion

Introductory Chapter: Spinal Cord Injury

The annual global incidence of traumatic spinal cord injury (SCI) was estimated by the Global Burden of Disease Study in 2016, and it resulted in as high as 0.93 million (0.78–1.16 million) per year, with an age-standardized incidence rate of 13 (11–16) per 100,000 population [1]. In the USA, the principal causes of SCI are represented by motor vehicle accidents (36–48%), violence (5–29%), falls (17–21%), and recreational activities (7–16%) [2]. The socioeconomic burden is extremely high due to the young age, the severity of acquired disabilities, and both direct and indirect health-related costs. In fact, the annual national cost in 2009 was as high as $1,7 billion [3], and for each patient ranged from$30,770 to $62,563 in 2016 [4]. The most significant cost derived from the severity of disability and complications developed during the hospitalization such as pressure ulcers and infections [5]. The SCI burden is extended also to the psychology of the younger patients, suddenly experiencing paraplegia or quadriplegia [6, 7]. It has been reported that people suffering from SCI are 2–5 times more likely to die prematurely compared to the healthy population [8, 9]. In SCI, the timing for intervention is crucial. Several studies have shown that early medical-surgical intervention could effectively improve functional outcomes. According to the Advanced Traumatic Life Support (ATLS) guidelines, any obstruction of upper airways should be restored while paying attention to neck and spine mobilization. The immobilization procedures should be fastidiously observed even in penetrating trauma without interfering with resuscitation efforts [10]. After immobilization, the patient should be quickly transferred to the closest trauma center hospital

Carmustine wafers implantation in patients with newly diagnosed high grade glioma: is it still an option?

Background: The implantation protocol for Carmustine Wafers (CWs) in high grade glioma (HGG) was developed to offer a bridge between surgical resection and adjuvant treatments, such as radio- and chemotherapy. In the last years, however, a widespread use of CWs has been limited due to uncertainties regarding efficacy, in addition to increased risk of infection and elevated costs of treatment. Objective: The aims of our study were to investigate the epidemiology of patients that underwent surgery for HGG with CW implantation, in addition to the assessment of related complications, long-term overall survival (OS), and associated prognostic factors. Methods: Three different medical databases were screened for conducting a systematic review of the literature, according to the PRISMA statement guidelines, evaluating the role of BCNU wafer implantation in patients with newly diagnosed HGG. The search query was based on a combination of medical subject headings (MeSH): "high grade glioma " [MeSH] AND "Carmustine " [MeSH] and free text terms: "surgery " OR "BCNU wafer " OR "Gliadel " OR "systemic treatment options " OR "overall survival. " Results: The analysis of the meta-data demonstrated that there was a significant advantage in using CWs in newly diagnosed GBM in terms of OS, and a very low heterogeneity among the included studies [mean difference 2.64 (95% CI 0.85, 4.44); p = 0.004; I2149 = 0%]. Conversely, no significant difference between the two treatment groups in terms of PFS wad detected (p = 0.55). The analysis of complications showed a relatively higher rate in Carmustine implanted patients, although this difference was not significant (p = 0.53). Conclusions: This meta-analysis seems to suggest that CWs implantation plays a significant role in improving the OS, when used in patients with newly diagnosed HGG. To minimize the risk of side effects, however, a carful patient selection based mainly on patient age and tumor volume should be desirable

Advancing Craniopharyngioma Management: A Systematic Review of Current Targeted Therapies and Future Perspectives

Craniopharyngiomas present unique challenges in surgical management due to their proximity to critical neurovascular structures. This systematic review investigates genetic and immunological markers as potential targets for therapy in craniopharyngiomas, assessing their involvement in tumorigenesis, and their influence on prognosis and treatment strategies. The systematic review adhered to PRISMA guidelines, with a thorough literature search conducted on PubMed, Ovid MED-LINE, and Ovid EMBASE. Employing MeSH terms and Boolean operators, the search focused on craniopharyngiomas, targeted or molecular therapy, and clinical outcomes or adverse events. Inclusion criteria encompassed English language studies, clinical trials (randomized or non-randomized), and investigations into adamantinomatous or papillary craniopharyngiomas. Targeted therapies, either standalone or combined with chemotherapy and/or radiotherapy, were examined if they included clinical outcomes or adverse event analysis. Primary outcomes assessed disease response through follow-up MRI scans, categorizing responses as follows: complete response (CR), near-complete response (NCR), partial response, and stable or progressive disease based on lesion regression percentages. Secondary outcomes included treatment type and duration, as well as adverse events. A total of 891 papers were initially identified, of which 26 studies spanning from 2000 to 2023 were finally included in the review. Two tables highlighted adamantinomatous and papillary craniopharyngiomas, encompassing 7 and 19 studies, respectively. For adamantinomatous craniopharyngiomas, Interferon-2α was the predominant targeted therapy (29%), whereas dabrafenib took precedence (70%) for papillary craniopharyngiomas. Treatment durations varied, ranging from 1.7 to 28 months. Positive responses, including CR or NCR, were observed in both types of craniopharyngiomas (29% CR for adamantinomatous; 32% CR for papillary). Adverse events, such as constitutional symptoms and skin changes, were reported, emphasizing the need for vigilant monitoring and personalized management to enhance treatment tolerability. Overall, the data highlighted a diverse landscape of targeted therapies with encouraging responses and manageable adverse events, underscoring the importance of ongoing research and individualized patient care in the exploration of treatment options for craniopharyngiomas. In the realm of targeted therapies for craniopharyngiomas, tocilizumab and dabrafenib emerged as prominent choices for adamantinomatous and papillary cases, respectively. While adverse events were common, their manageable nature underscored the importance of vigilant monitoring and personalized management. Acknowledging limitations, future research should prioritize larger, well-designed clinical trials and standardized treatment protocols to enhance our understanding of the impact of targeted therapies on craniopharyngioma patients

Role of stem cells-based in facial nerve reanimation: A meta-analysis of histological and neurophysiological outcomes

BACKGROUND Treatments involving stem cell (SC) usage represent novel and potentially interesting alternatives in facial nerve reanimation. Current literature includes the use of SC in animal model studies to promote graft survival by enhancing nerve fiber growth, spreading, myelinization, in addition to limiting fibrotic degeneration after surgery. However, the effectiveness of the clinical use of SC in facial nerve reanimation has not been clarified yet.AIMTo investigate the histological, neurophysiological, and functional outcomes in facial reanimation using SC, compared to autograft.METHODSOur study is a systematic review of the literature, consistently conducted according to the preferred reporting items for systematic reviews and meta-analyses statement guidelines. The review question was: In facial nerve reanimation on rats, has the use of stem cells revealed as effective when compared to autograft, in terms of histological, neurophysiological, and functional outcomes? Random-effect meta-analysis was conducted on histological and neurophysiological data from the included comparative studies.RESULTSAfter screening 148 manuscript, five papers were included in our study. 43 subjects were included in the SC group, while 40 in the autograft group. The meta-analysis showed no significative differences between the two groups in terms of myelin thickness [CI: -0.10 (-0.20, 0.00); I-2 = 29%; P = 0.06], nerve fibers diameter [CI: 0.72 (-0.93, 3.36); I-2 = 72%; P = 0.6], compound muscle action potential amplitude [CI: 1.59 (0.59, 3.77); I-2 = 89%; P = 0.15] and latency [CI: 0.66 (-1.01, 2.32); I-2 = 67%; P = 0.44]. The mean axonal diameter was higher in the autograft group [CI: 0.94 (0.60, 1.27); I-2 = 0%; P <= 0.001].CONCLUSIONThe role of stem cells in facial reanimation is still relatively poorly studied, in animal models, and available results should not discourage their use in future studies on human subjects

A Systematic Review of the Metabolism of High-Grade Gliomas: Current Targeted Therapies and Future Perspectives

High-grade glial tumors (HGGs) exhibit aggressive growth patterns and high recurrence rates. The prevailing treatment approach comprises radiation therapy (RT), chemotherapy (CMT), and surgical resection. Despite the progress made in traditional treatments, the outlook for patients with HGGs remains bleak. Tumor metabolism is emerging as a potential target for glioma therapies, a promising approach that harnesses the metabolism to target tumor cells. However, the efficacy of therapies targeting the metabolism of HGGs remains unclear, compelling a comprehensive review. This study aimed to assess the outcome of present trials on HGG therapies targeting metabolism. A comprehensive search of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted until November 2023. The search method used pertinent Medical Subject Heading (MeSH) terminologies and keywords referring to "high-grade gliomas", "metabolism", "target therapies", "monoclonal antibodies", "overall survival", and "progression-free survival". The review analyzed studies that focused on therapies targeting the metabolism of HGGs in human subjects. These studies included both randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs). Out of 284 articles identified, 23 trials met the inclusion criteria and were thoroughly analyzed. Phase II trials were the most numerous (62%). Targeted metabolic therapies were predominantly used for recurrent HGGs (67%). The most common targeted pathways were the vascular endothelial growth factor (VEGF, 43%), the human epidermal growth factor receptor (HER, 22%), the platelet-derived growth factor (PDGF, 17%), and the mammalian target of rapamycin (mTOR, 17%). In 39% of studies, the subject treatment was combined with CMT (22%), RT (4%), or both (13%). The median OS widely ranged from 4 to 26.3 months, while the median PFS ranged from 1.5 to 13 months. This systematic literature review offers a thorough exploration of the present state of metabolic therapies for HGGs. The multitude of targeted pathways underscores the intricate nature of addressing the metabolic aspects of these tumors. Despite existing challenges, these findings provide valuable insights, guiding future research endeavors. The results serve as a foundation for refining treatment strategies and enhancing patient outcomes within the complex landscape of HGGs

Two-Level Corpectomy and Fusion vs. Three-Level Anterior Cervical Discectomy and Fusion without Plating: Long-Term Clinical and Radiological Outcomes in a Multicentric Retrospective Analysis

Background: Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing. Methods: The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes. Results: Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction & GE; 1 & DEG; (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted. Conclusions: Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated

Two-level corpectomy and fusion vs. three-level anterior cervical discectomy and fusion without plating: long-term clinical and radiological outcomes in a multicentric retrospective analysis

Background: Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) represent effective alternatives in the management of multilevel cervical spondylotic myelopathy (CSM). A consensus on which of these techniques should be used is still missing. Methods: The databases of three centers were reviewed (January 2011-December 2018) for patients with three-level CSM, who underwent three-level ACDF without plating or two-level ACCF with expandable cage (VBRC) or mesh (VBRM). Demographic data, surgical strategy, complications, and implant failure were analyzed. The Neck Disability Index (NDI), the Visual Analog Scale (VAS), and the cervical lordosis were compared between the two techniques at 3 and 12 months. Logistic regression analyses investigated independent factors influencing clinical and radiological outcomes. Results: Twenty-one and twenty-two patients were included in the ACDF and ACCF groups, respectively. The median follow-up was 18 months. ACDFs were associated with better clinical outcomes at 12 months (NDI: 8.3% vs. 19.3%, p < 0.001; VAS: 1.3 vs. 2.6, p = 0.004), but with an increased risk of loss of lordosis correction & GE; 1 & DEG; (OR = 4.5; p = 0.05). A higher complication rate in the ACDF group (33.3% vs. 9.1%; p = 0.05) was recorded, but it negatively influenced only short-term clinical outcomes. ACCFs with VBRC were associated with a higher risk of major complications but ensured better 12-month lordosis correction (p = 0.002). No significant differences in intraoperative blood loss were noted. Conclusions: Three-level ACDF without plating was associated with better clinical outcomes than two-level ACCF despite worse losses in lordosis correction, which is ideal for fragile patients without retrovertebral compressions. In multilevel CSM, the relationship between the degree of lordosis correction and clinical outcome advantages still needs to be investigated

Comparison between intrasylvian and intracerebral hematoma associated with ruptured middle cerebral artery aneurysms: clinical implications, technical considerations, and outcome evaluation

Background: Subarachnoid hemorrhage (SAH) due to a middle cerebral artery (MCA) aneurysms rupture is often associated with intracerebral (ICH) or intrasylvian hematomas (ISH). Materials and methods: We reviewed 163 patients with ruptured MCA aneurysms associated with pure SAH or SAH+ICH/ISH. Patients were first dichotomized according to the presence of a hematoma (ICH/ISH). Then, we performed a subgroup analysis comparing ICH versus ISH in order to explore their relationship with the most relevant demographic, clinical, and angioarchitectural features. Results: Overall, 85 patients (52%) had a pure SAH, whereas 78 (48%) presented an associated ICH/ISH. No significant differences were observed in demographics and angioarchitectural features between the two groups, but Fisher grading and Hunt-Hess score were higher in patients with hematomas. A good outcome was observed in a higher percentage of patients with pure SAH compared with the others (76% Vs 44%), although mortality rates were comparable. Age, Hunt-Hess and treatment-related complications were the main outcome predictors at multivariate analysis. Patients with ICH appeared clinically worse than those with ISH. We also found that older age, higher Hunt-Hess, larger aneurysms, decompressive craniectomy and treatment-related complications were associated with poor outcome among patients with ISH, but not with ICH, which appeared per se as a more severe clinical condition. Conclusions: Our study confirm that age, Hunt-Hess and treatment-related complications influence the outcome of patients with ruptured MCA aneurysms. However, in the subgroup analysis of patients with SAH associated with ICH or ISH, only the Hunt-Hess at onset appeared as an independent predictor of outcome

Notas sobre a Carta de Veneza

This paper presents a critical reading of the Venice Charter, an Icomos key document, fruit of a conference held in 1964. The Charter is often quoted in Brazil but is not always properly understood. The conservation and restoration charters - especially those produced by international institutions - are documents that have an indicatory or, at the most, prescriptive character. They constitute the deontological foundation of many professionals involved in preservation, but they are not recipes for immediate use. In order to elaborate a well-founded reading of the document, its ideas must be understood in connection to the theoretical postulates of the time they were engendered and to the developments of the field. Thus this paper will examine these subjects, commenting and enlightening the Charter's articles and pointing out the origins of specific ideas. It also discusses how the Charter relates to previous documents and their theoretical foundations. This approach, based in a critical analysis, is necessary in order to reach a fuller interpretation of the Charter's indications so that they can be used in the present