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

External validation of a convolutional neural network for the automatic segmentation of intraprostatic tumor lesions on 68Ga-PSMA PET images

Introduction: State of the art artificial intelligence (AI) models have the potential to become a "one-stop shop " to improve diagnosis and prognosis in several oncological settings. The external validation of AI models on independent cohorts is essential to evaluate their generalization ability, hence their potential utility in clinical practice. In this study we tested on a large, separate cohort a recently proposed state-of-the-art convolutional neural network for the automatic segmentation of intraprostatic cancer lesions on PSMA PET images.Methods: Eighty-five biopsy proven prostate cancer patients who underwent Ga-68 PSMA PET for staging purposes were enrolled in this study. Images were acquired with either fully hybrid PET/MRI (N = 46) or PET/CT (N = 39); all participants showed at least one intraprostatic pathological finding on PET images that was independently segmented by two Nuclear Medicine physicians. The trained model was available at and data processing has been done in agreement with the reference work.Results: When compared to the manual contouring, the AI model yielded a median dice score = 0.74, therefore showing a moderately good performance. Results were robust to the modality used to acquire images (PET/CT or PET/MRI) and to the ground truth labels (no significant difference between the model's performance when compared to reader 1 or reader 2 manual contouring).Discussion: In conclusion, this AI model could be used to automatically segment intraprostatic cancer lesions for research purposes, as instance to define the volume of interest for radiomics or deep learning analysis. However, more robust performance is needed for the generation of AI-based decision support technologies to be proposed in clinical practice

Surgical treatment of metastatic pheochromocytomas of the spine: a systematic review

Metastatic pheochromocytoma of the spine (MPS) represents an extremely rare and challenging entity. While retrospective studies and case series make the body of the current literature and case reports, no systematic reviews have been conducted so far. This systematic review aims to perform a systematic review of the literature on this topic to clarify the status of the art regarding the surgical management of MPS. A systematic review according to PRISMA criteria has been performed, including all studies written in English and involving human participants. 15 papers for a total of 44 patients were finally included in the analysis. The median follow-up was 26.6 months. The most common localization was the thoracic spine (54%). In 30 out of 44 patients (68%), preoperative medications were administered. Open surgery was performed as the first step in 37 cases (84%). Neoadjuvant treatments, including preoperative embolization were reported in 18 (41%) cases, while adjuvant treatments were administered in 23 (52%) patients. Among those patients who underwent primary aggressive tumor removal and instrumentation, 16 out of 25 patients (64%) showed stable disease with no progression at the final follow-up. However, the outcome was not reported in 14 patients. Gross total resection of the tumor and spinal reconstruction appear to offer good long-term outcomes in selected patients. Preoperative alpha-blockers and embolization appear to be useful to enhance hemodynamic stability, avoiding potential detrimental complications

Spontaneous Repositioning of Isolated Blow-In Orbital Roof Fracture: Could Wait and See Be a Strategy in Asymptomatic Cases?

Treatment of isolated blow-in orbital roof fractures is still debated due to their anatomical complexity and the potential ocular and neurological related injuries. Surgery is advised in symptomatic cases while there is still controversy regarding the preferred treatment for those patients asymptomatic

Standard of care, controversies and innovations in the medical treatment of Severe Traumatic Brain Injury (STBI)

Severe traumatic brain injury (STBI) is characterized by a primary injury which cannot be reversed and a secondary injury that can be prevented or reversed. Management of STBI patients in intensive care mainly aims at preventing the secondary injury. Treatment aims to: reducing ICP pressure (that can result in an ischemic insult); avoiding hypotension, hyperthermia, or hypoxemia; maintaining a normal electrolytes homeostasis; treating the Autonomic dysfunction syndrome, coagulopathies, Acute Kidney Injury and maintaining an adequate nutrition. Many treatment protocols are already well established, while many others are still debated. Moreover, new frontiers in STBI management are represented by the neurovascular regeneration and neurorestoration which are showing very promising results even if most of them still need a clinical validation. In this paper we review standard of care, controversies and innovations in the medical treatment of STBI

A brain hidden in Ferrara cathedral: a novel interpretation of a Renaissance masterpiece

The aim of present report was to briefly review the history of the anatomical studies during the Italian Renaissance and to outline their relationship to the figurative arts, focusing, in particular, on neuroanatomical studies that have been at the center of the medical and philosophical debate from the 14th to 16th centuries. Therefore, we have presented the interpretation of different Renaissance masterpieces for which some references to brain anatomy have been previously reported. We propose a new interpretation, in neuroanatomical key, of the fresco of the universal judgment in the vault of San Giorgio's Cathedral in Ferrara, Italy, painted around the end of the 16th century

Chylothorax in spine fractures: a rarely reported complication? Literature review with an example case

Post-traumatic chylothorax may occur after blunt or penetrating trauma. We describe a case of chylothorax following a B3 fracture of the T12 vertebra, integrating our single-case experience into a focused literature review of this complication when it is directly associated with spine fractures.A PubMed search was performed by using the terms "chylothorax", "chyle leakage", "chylous leakage", "thoracic duct injury" combined with "spine", "fracture", "spine fracture", "spinal fracture", "vertebral fracture", "spine trauma", "spinal trauma", "spine injury" and "spinal injury". Nontraumatic chylothorax, iatrogenic chyle leakage, technical notes, purely descriptive papers, chylothorax as a consequence of chest and/or abdominal trauma, or studies on multiple thoracic and/or abdominal injuries were excluded. In addition to the 20 articles yielded by this search strategy, an example case of type B3 spine fracture, which caused a chylothorax, was discussed.The vast majority of chylothoraxes regarded spinal injuries from T9 to L1. A prevalence of type C fractures was noted. Pulmonary dysfunction usually developed 3-7 days after trauma, always requiring urgent thoracic drainage. Total parenteral nutrition and restrictive diet revealed insufficient with chyle leakage exceeding 1.5 litres/day, with prolonged drainage over 1 litre/day and with persisting chest tube outflow for more than 2 weeks or with deterioration in clinical status. Two dynamics of thoracic duct injury could be hypothesized: indirect lesion from an abrupt hyperextension of the spine overstressing the stretchability of the duct itself; and direct lesion likely depending from the thoracic duct overstretching and its concomitant impact against sharpened fracture margins or acuminated fracture fragments. Compared to vascular injuries sometimes complicating severely fragmented or dislocated spine fractures, chylothorax appears relatively underreported considering the greater anatomical fragility of the thoracic duct than an arterial vessel. LEVEL OF EVIDENCE: therapeutic

Transpars approach for L5-S1 foraminal and extra-foraminal lumbar disc herniations: technical note

BACKGROUND: The short pars and the narrowed surgical corridor for far lateral L5S1 herniation make the transpars approach challenging. The aim of this study is to determine the feasibility, efficacy and safety of the transpars microscopic approach for the treatment of L5-S1 foraminal and extraforaminal lumbar disc herniation. METHODS: From 2015 to 2019, patients with L5-S1 far lateral lumbar disc herniation were prospectively recruited. Drug intake, working days lost, NRS-leg, NRS-back, nerve-root palsy, Oswestry disability-index, Macnab criteria were recorded before surgery and at follow-up. Patients were seen at 1-6-12 months after surgery. Lumbar dynamic x-rays were performed at 6-12 months after surgery and again at 2-4 years after surgery. Key-steps of surgery are described. RESULTS: Fourteen patients were enrolled. NRS-leg and NRS-back scores significantly improved (from 7.93 to 1.43 and from 3.2 to 0.6, respectively-p\u3c0.0001). Oswestry score significantly decreased (from 63.14 to 19.36 at 12 months; p\u3c0.0001). L5 Root palsy improved in all cases (from 3.72/5 to 5/5; p\u3c0.0001). At 12-months, excellent or good outcome (Macnab criteria) was achieved in 12 (85.7%) and 2 (14.3%) patients, respectively. All patients who were not retired returned to work within 30 days after surgery. No recurrence, instability or re-operations occurred. CONCLUSIONS: The trans pars microscopic approach is feasible, safe and effective for L5-S1 foraminal and extraforaminal disc herniation. During surgery, the key-point is the oblique working angle, directed caudally, parallel to L5 pedicle. The iliac crest does not seem to constitute an obstacle

Chylothorax in spine fractures: A rarely reported complication? Literature review with an example case

Post-traumatic chylothorax may occur after blunt or penetrating trauma. We describe a case of chylothorax following a B3 fracture of the T12 vertebra, integrating our single-case experience into a focused literature review of this complication when it is directly associated with spine fractures.A PubMed search was performed by using the terms "chylothorax", "chyle leakage", "chylous leakage", "thoracic duct injury" combined with "spine", "fracture", "spine fracture", "spinal fracture", "vertebral fracture", "spine trauma", "spinal trauma", "spine injury" and "spinal injury". Nontraumatic chylothorax, iatrogenic chyle leakage, technical notes, purely descriptive papers, chylothorax as a consequence of chest and/or abdominal trauma, or studies on multiple thoracic and/or abdominal injuries were excluded. In addition to the 20 articles yielded by this search strategy, an example case of type B3 spine fracture, which caused a chylothorax, was discussed.The vast majority of chylothoraxes regarded spinal injuries from T9 to L1. A prevalence of type C fractures was noted. Pulmonary dysfunction usually developed 3-7 days after trauma, always requiring urgent thoracic drainage. Total parenteral nutrition and restrictive diet revealed insufficient with chyle leakage exceeding 1.5 litres/day, with prolonged drainage over 1 litre/day and with persisting chest tube outflow for more than 2 weeks or with deterioration in clinical status. Two dynamics of thoracic duct injury could be hypothesized: indirect lesion from an abrupt hyperextension of the spine overstressing the stretchability of the duct itself; and direct lesion likely depending from the thoracic duct overstretching and its concomitant impact against sharpened fracture margins or acuminated fracture fragments. Compared to vascular injuries sometimes complicating severely fragmented or dislocated spine fractures, chylothorax appears relatively underreported considering the greater anatomical fragility of the thoracic duct than an arterial vessel. LEVEL OF EVIDENCE: therapeutic