Surgical anatomy of a neurenteric cyst anterior to the brainstem

Abstract The authors report on a sixteen-month old boy who presented a neurenteric cyst located in the cervicomedullary junction, anterior to the brain stem. Centred on the ventral aspect of the premedullary cistern, the cyst extended from the prepontine space to the cervicomedullary junction, causing important brain stem compression. The lesion was totally removed via a posterior approach with suboccipital craniotomy and laminectomy of C1. After surgery the patient recovered his neurological function and the postoperative MRI showed total resection of the cyst

Is the Thoracolumbar Injury Severity Score (TLISS) still a good base for the education of residents in Orthopaedics and Traumatology?

ABSTRACT Introduction. Thoracolumbar spinal injuries indicated for surgical intervention specify the necessity of intervention within 24 hours. The traumatologists working in a structure without a Spinal Unit must be able to evaluate such injury and set indications for surgical treatment, that is, nonoperative treatment. The purpose of this study is to evaluate if Thoracolumbar Injury Severity Score (TLISS) is still a good base for the classification of thoracolumbar spinal injuries and to give a correct indication for nonoperative, that is, surgical treatment. Patients and Methods. Six Orthopaedics and Traumatology residents from Siena (Italy), five Orthopaedics and Traumatology residents from the Clinical Centre of Banja Luka (Bosnia and Herzegovina) and five Orthopaedics and Traumatology residents from the Alta Val d’Elsa Hospital, Siena (Italy) were presented 24 clinical cases from professional literature where the following data were indicated: patient’s age, neurological conditions, description of the injury, mechanism of the injury and radiological findings (RTG, MR). The abovementioned 24 patients were chosen from the literature based on the injuries mostly seen by an orthopaedist with a lack of experience in the problems of spinal column trauma (low energy trauma, with partial or without neurological impairments, with the TLISS score of 4). The residents from the three groups had to classify all patients according to the TLISS score and to define the most appropriate method of treatment-conservative or surgical, and after that, all classifications, as well as the therapeutic decisions, were compared. The statistical methods used in this study include: statistical significance, reliability (P<0.05), the validity of the decision, the percentage of accuracy and Cohen’s kappa coefficient. The best results in evaluation of the mechanism of the injury were demonstrated by the group of doctors from the Orthopaedic Hospital with an accuracy of 78.8% (P<0.05) and with an average correlation (K = 0.598). The best description of the injury was presented by the doctors from Siena with 87% accuracy (P<0.05) and with correlation (K=0.749). The doctors from Siena responded best at evaluating the neurological status with 97.6% accuracy (P<0.05) and with correlation (K=0.936). The assessment of the injury of the PCL residents from Siena was 64.7% accurate (P<0.05) with correlation (K=0.426). The total TLISS score was best calculated by the residents of Siena with 82% accuracy (P<0.05) and correlation (K=0.718). The most appropriate therapeutic decision was made by the residents from Siena with 80.3% accuracy (P<0.05) and with correlation (K =0.707). Conclusion. Currently, the Denis classification and the AO classification are the most widely used classification algorithms for the fractures of thoracolumbar spine but some defects have also been identified in both of them. The value of TLISS evaluation is by the three groups of residents in presented 24 patients from the professional literature. Significant differences in accuracy were found in defining a real damage of the spinal cord at the level of the cauda equina. The evaluation of the integrity of the posterior longitudinal ligament by the radiography is of low accuracy

Dynamic corset versus three-point brace in the treatment of osteoporotic compression fractures of the thoracic and lumbar spine: a prospective, comparative study

Background: The three-point orthosis is the most commonly used brace in the conservative treatment of osteoporotic vertebral fractures. The Spinomed® dynamic orthosis represents an alternative. Aims: We compared efficacy and safety of these two types of brace in treating osteoporotic vertebral fractures. Methods: One hundred forty patients, aged 65–93 years, sustaining osteoporotic vertebral fracture were consecutively recruited and divided into two groups, and treated with either three-point orthosis or dynamic corset. Patients were evaluated with Visual Analogue Scale, Oswestry Low Back Pain Disability Questionnaire, and measurement of forced expiratory volume in the first second. Regional kyphosis angle, Delmas Index, and height of the fractured vertebral body were also measured on full-spine X-rays. Follow-up intervals were 1, 3, and 6 months after trauma. The complications encountered during the 6-month follow-up were recorded. Results: At the 3- and 6-month follow-ups, there was a significant difference (p 0.05) in all the radiological parameters between groups. Complications were reported for 28 patients in the three-point orthosis group, and for eight patients in the dynamic corset group (p < 0.05). Discussion: Biofeedback activation of back muscles is probably a key factor in improving functional outcome with dynamic orthosis. Conclusions: Compared to three-point orthosis, patients treated with dynamic orthosis had a greater reduction in pain and a greater improvement in quality of life and respiratory function, with equal effectiveness in stabilizing the fracture, and fewer complications

Symptomatic cerebral vasospasm after glioblastoma resection and carmustine wafers implantation. A case report

Local chemotherapy with carmustine-impregnated wafers showed safe and effective in the treatment of malignant glioma, with infrequent, though sometime serious, adverse effects. We report a rare case of cerebral vasospasm following glioblastoma removal with carmustine wafers implantation in a 57-years-old man. After surgery, the patient awoke with aphasia, due to vasospasm of the left middle cerebral artery. Intra-arterial infusion of nimodipine was performed, with rapid vasospasm resolution and quick recovery. Cerebral vasospasm is an extremely rare adverse effect after carmustine wafers implantation in glioma surgery, with only one case reported. In our case, intra-arterial nimodipine was rapidly effective. Although rare, such a potentially disastrous complication should be considered when a new neurological deficit unexpectedly occurs after carmustine wafers implantation, and vascular investigation should be undertaken

A rare association of ganglioglioma and cavernous malformation: Report of two cases and literature review

Background: Some glial tumors have been observed in association with different types of vascular malformations of the brain (angiogliomas). However, the association of ganglioglioma with other vascular malformations is extremely rare, with only few cases reported in the literature, one of which is referred to as “angioganglioglioma.” Case Description: Two patients presented with acute onset of neurological symptoms, with magnetic resonance imaging (MRI) nding of cavernoma of the left middle cerebellar penduncle, and small mass of the chiasmatic region, respectively. After microsurgical excision, histopathological examination revealed mixed ganglioglioma and cavernous malformation in both cases. Postoperative course was uneventful, and follow‐up MRI showed complete removal of the tumor with no recurrence after 4 years. Conclusions: Angiogliomas are very uncommon tumors. In literature, we found different interpretations of such lesions, although they should most probably be considered as distinct pathological entities. Although the association of ganglioglioma with cavernoma is extremely rare, it could be considered as a most peculiar form of angioglioma, and supports the existence of angioganglioglioma

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

Towards a functional treatment of lumbar vertebral instability. Restoration of the biomechanics with Dynesys

Vertebral instability is a clinical entity which can only be defined in terms of its many functional and morphological effects and anatomopathological and pathophysiological aspects. Because vertebral instability involves proteiform features and evolves in a cyclic way, it is difficult to treat and diagnose and its course is hard to predict. Furthermore, possible iatrogenic consequences should be considered. Spine fusion has been regarded as the gold standard in the surgical treatment of instability of the lumbar spine. However, new concepts are evolving in the direction of non-fusion techniques. In fact, there is evidence that pain in vertebral instability may be load-related rather than motion-related. Moreover, there is increasing evidence of accelerated degeneration of the adjacent segment of a fused spinal segment. Dynesys is a dynamic stabilization system that aims to limit excessive motion to a parphysiological range, while neutralizing anomalous load transfer within functional spinal unit. We based our practice and clinical use of Dynesys on functional evaluation of vertebral instability with an in vivo biomechanical study by axial-loaded computed tomography (ALCT) and Cine ALCT, as well as conventional dynamic X-rays, in 32 patients. Cine ALCT findings led us to define typical pathological motion patterns that guided targeted treatment in individual patients, with good clinical results in all cases. Postoperative ALCT was also performed in 14 cases, showing elimination of anonalous movement and restoration of biomechanincs akin to that observed in normal subjects. In selected cases, neutralizing pathological motion and load transfer with a non rigid system, and the least invasive technique, enables restoration of biomechanics with good clinical results. The use of ALCT led us to a functional approach to instability. We could reveal biomechanical anomalies and their translation into dynamic images with significant anatomical and functional information. Forthermore, we could find in most cases a correlation between altered motion and symptoms, for a targeted treatment

Porous tantalum cage for interbody fusion of the cervical spine: assessment of fusion in a long term study. Preliminary results

Introduction/Aim Porous tantalum cages (PTC) have been satisfactorily used for about 15 years for both anterior discectomy and fusion (ACDF), and corpectomy. However, assessment of fusion with PTC may be difficult due to total radio-opacity, with concern about radiolucency at the bone-cage interface, which might anticipate non-union. We assessed the long-term fusion rate with PTC cervical cages, and analysed the significance of lucency in predicting non-fusion. Materials and methods The authors retrospectively analyzed a consecutive series of 78 patients who underwent ADCF or corpectomy and fusion with PTCs from 2005 to 2014 for degenerative or traumatic disorders. There were 43 males and 35 females from 22 to 80 years of age (average 50.9). Patients underwent 1-, 2-, or 3-level ACDF with TM-100 or TM-S cages, or 1 or 2 corpectomies and fusion with VBR-11 cages (Zimmer Spine, Minneapolis, MN). Outcome was evaluated with Odom’s scale, and X-rays were obtained a few days to 2 years after surgery.Most patients were recalled for long-term follow-up up to 9 years after surgery. X-rays were evaluated for segmental lordosis, cage subsidence, bone-cage interface lucency, bony bridges, and residual motion at fused levels. Fusion was defined as bony bridging, and/or <3° variation of Cobb’s angle on functional X-rays, and/or absence of radiolucent line exceeding 50% of bone-cage interface. Results Clinical results were satisfactory overall. Long term fusion rate was 98%. Although radiolucency was seen in some cases in the first few weeks or months, it disappeared in most cases and it was not predictive of nonunion. There were no reoperations nor infections. Discussion A radiolucent rim around PTCs does not appear to predict nonunion. When present, it resolved with time and was not associated with patient discomfort or pseudoarthrosis. Although fusion may not be seen in the early stage after PTC implantation, almost all patients eventually show patent fusion with bony bridging and remodelling. Conclusion Although fusion is difficult to assess in some cases, PTCs are safe and effective in achieving interbody fusion of the cervical spine