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Open access

Alba Scerrati, Pasquale De Bonis, Nicolò Norri and Michele Alessandro Cavallo

Most patients with spasticity, rigidity, and other symptoms of the upper motor neuron syndrome respond effectively to surgical treatment with an intrathecal baclofen pump when their symptoms become intractable to nonsurgical measures. Baclofen administered into the lumbar subarachnoid space produces a locally high concentration at the spinal level and a low concentration supraspinally, avoiding most of the central side effects associated with a high oral dose, such as drowsiness and confusion.

The aim of surgical treatment is to provide the appropriate volume and concentration of the drug in the subarachnoid space, avoiding the main surgical complications, that is, infections, skin erosion, and catheter displacement.

The video can be found here: https://youtu.be/HetelPwwwak

Open access

Stefano Ferraresi, Elisabetta Basso, Lorenzo Maistrello, Alba Scerrati and Piero Di Pasquale

The treatment of deafferentation pain is a primary goal of a referral center for peripheral nerve surgery. DREZ is an important asset in the neurosurgeon’s armamentarium. The surgical technique and long-term results are analyzed in two series, with or without intraoperative monitoring (IOM). DREZotomy is highly effective in lumbar root avulsive injuries but is ineffective in resolving pain due to spinal cord injuries. Cervical DREZotomy for cancer pain is not superior to intrathecal morphine. In brachial plexus avulsive injuries, the largest series shows a 74% success rate, but the efficacy of the procedure is lost over time. No relevant difference has been observed since the introduction of IOM.

The video can be found here: https://youtu.be/uG_kkQj5m1U

Full access

Serdar Ercan, Alba Scerrati, Phengfei Wu, Jun Zhang and Mario Ammirati

OBJECTIVE

The subtemporal approach is one of the surgical routes used to reach the interpeduncular fossa. Keyhole subtemporal approaches and zygomatic arch osteotomy have been proposed in an effort to decrease the amount of temporal lobe retraction. However, the effects of these modified subtemporal approaches on temporal lobe retraction have never been objectively validated.

METHODS

A keyhole and a classic subtemporal craniotomy were executed in 4 fresh-frozen silicone-injected cadaver heads. The target was defined as the area bordered by the superior cerebellar artery, the anterior clinoid process, supraclinoid internal carotid artery, and the posterior cerebral artery. Once the target was fully visualized, the authors evaluated the amount of temporal lobe retraction by measuring the distance between the base of the middle fossa and the temporal lobe. In addition, the volume of the surgical and anatomical corridors was assessed as well as the surgical maneuverability using navigation and 3D moldings. The same evaluation was conducted after a zygomatic osteotomy was added to the two approaches.

RESULTS

Temporal lobe retraction was the same in the two approaches evaluated while the surgical corridor and the maneuverability were all greater in the classic subtemporal approach.

CONCLUSIONS

The zygomatic arch osteotomy facilitates the maneuverability and the surgical volume in both approaches, but the temporal lobe retraction benefit is confined to the lateral part of the middle fossa skull base and does not result in the retraction necessary to expose the selected target.

Free access

Alba Scerrati, Jacopo Visani, Luca Ricciardi, Flavia Dones, Oriela Rustemi, Michele Alessandro Cavallo and Pasquale De Bonis

OBJECTIVE

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical pathologies, typically affecting the elderly. Its incidence is expected to grow along with the aging population. Surgical drainage represents the treatment of choice; however, postoperative complications and the rate of recurrence are not negligible. For this reason, nonsurgical alternatives (such as middle meningeal artery embolization, steroids, or tranexamic acid administration) are gaining popularity worldwide and need to be carefully evaluated, especially in the elderly population.

METHODS

The authors performed a systematic review according to PRISMA criteria of the studies analyzing the nonsurgical strategies for CSDHs. They collected all papers in the English language published between 1990 and 2019 by searching different medical databases. The chosen keywords were “chronic subdural hematoma,” “conservative treatment/management,” “pharmacological treatment,” “non-surgical,” “tranexamic acid,” “dexamethasone,” “corticosteroid,” “glucocorticoid,” “middle meningeal artery,” “endovascular treatment,” and “embolization.”

RESULTS

The authors ultimately collected 15 articles regarding the pharmacological management of CSDHs matching the criteria, and 14 papers included the endovascular treatment.

CONCLUSIONS

The results showed that surgery still represents the mainstay in cases of symptomatic patients with large CSDHs; however, adjuvant and alternative therapies can be effective and safe in a carefully selected population. Their inclusion in new guidelines is advisable.

Free access

Gianluca Trevisi, Carmelo Lucio Sturiale, Alba Scerrati, Oriela Rustemi, Luca Ricciardi, Fabio Raneri, Alberto Tomatis, Amedeo Piazza, Anna Maria Auricchio, Vito Stifano, Carmine Romano, Pasquale De Bonis and Annunziato Mangiola

OBJECTIVE

The objective of this study was to analyze the risk factors associated with the outcome of acute subdural hematoma (ASDH) in elderly patients treated either surgically or nonsurgically.

METHODS

The authors performed a retrospective multicentric analysis of clinical and radiological data on patients aged ≥ 70 years who had been consecutively admitted to the neurosurgical department of 5 Italian hospitals for the management of posttraumatic ASDH in a 3-year period. Outcome was measured according to the Glasgow Outcome Scale (GOS) at discharge and at 6 months’ follow-up. A GOS score of 1–3 was defined as a poor outcome and a GOS score of 4–5 as a good outcome. Univariate and multivariate statistics were used to determine outcome predictors in the entire study population and in the surgical group.

RESULTS

Overall, 213 patients were admitted during the 3-year study period. Outcome was poor in 135 (63%) patients, as 65 (31%) died during their admission, 33 (15%) were in a vegetative state, and 37 (17%) had severe disability at discharge. Surgical patients had worse clinical and radiological findings on arrival or during their admission than the patients undergoing conservative treatment. Surgery was performed in 147 (69%) patients, and 114 (78%) of them had a poor outcome. In stratifying patients by their Glasgow Coma Scale (GCS) score, the authors found that surgery reduced mortality but not the frequency of a poor outcome in the patients with a moderate to severe GCS score. The GCS score and midline shift were the most significant predictors of outcome. Antiplatelet drugs were associated with better outcomes; however, patients taking such medications had a better GCS score and better radiological findings, which could have influenced the former finding. Patients with fixed pupils never had a good outcome. Age and Charlson Comorbidity Index were not associated with outcome.

CONCLUSIONS

Traumatic ASDH in the elderly is a severe condition, with the GCS score and midline shift the stronger outcome predictors, while age per se and comorbidities were not associated with outcome. Antithrombotic drugs do not seem to negatively influence pretreatment status or posttreatment outcome. Surgery was performed in patients with a worse clinical and radiological status, reducing the rate of death but not the frequency of a poor outcome.

Restricted access

Luca Ricciardi, Sokol Trungu, Alba Scerrati, Pasquale De Bonis, Oriela Rustemi, Mauro Mazzetto, Giorgio Lofrese, Francesco Cultrera, Cédric Y. Barrey, Alessandro Di Bartolomeo, Amedeo Piazza, Massimo Miscusi and Antonino Raco

OBJECTIVE

Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

METHODS

The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

RESULTS

Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

CONCLUSIONS

Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.