✓ A two-step supraorbital approach to lesions of the orbital apex is described. This technique is easy and allows a satisfactory exposure of the region. In addition, the reconstruction resulting from the procedure is anatomically perfect. The authors report the operative results obtained in 20 patients and compare this two-step supraorbital procedure with similar surgical techniques described previously.
Roberto Delfini, Antonino Raco, Marco Aritco, Maurizio Salvati and Pasquale Ciappetta
Antonino Raco, Natale Russo, Alessandro Landi, Mauro Dazzi and Bruno Carlesimo
✓ The authors describe the unique case of a patient who had undergone posterior stabilization of the lumbar spine complicating the course of a lymphatic fistula. A lymphatic fistula is a rare complication of posterior lumbar surgery. Predisposing factors include individual anatomy, scarring adherences due to previous abdominal operations or surgical maneuvers deep in the plane of the transverse processes. Because the onset of lymphatic fistulas is subtle, and because they are associated with a high mortality rate and require multidisciplinary treatment, care is needed to avoid misdiagnosing these lesions as the more common cerebrospinal fluid fistula.
Massimo Miscusi, Maurizio Domenicucci, Filippo Maria Polli, Stefano Forcato, Fabio De Giorgio and Antonino Raco
The authors' aim was to conduct a surgical anatomy and feasibility study on the use of an extended posterolateral approach to the cervicothoracic junction (Fessler approach) in cadavers to facilitate en bloc removal of the second thoracic vertebra using the Tomita technique. To apply this technique, it is mandatory to approach both sides of the vertebra. But such a maneuver is very difficult in the region of the cervicothoracic junction because the scapula and its muscles represent an anatomical barrier to the paravertebral compartment and lateral aspects of the vertebrae.
To study the extended posterolateral Fessler approach to the cervicothoracic junction and the possible application of the Tomita technique on the second thoracic vertebra, 3 fresh-frozen cadavers were used in the Laboratory of Human Anatomy at the University of Nantes.
The proposed approach allows exposure of both the posterior arch and the body of the second thoracic vertebra without any significant resection or traction of the superficial and deep posterior thoracic muscles, enabling application of the Tomita technique and facilitating intraoperative spinal fixation.
The proposed surgical technique is technically feasible. Nevertheless, it should be an option reserved for selected patients for whom the surgical complexity can be justified by the characteristics of their malignancy and expected curative outcome.
Case report and review of the literature
Maurizio Domenicucci, Alessandro Ramieri, Maurizio Salvati, Christian Brogna and Antonino Raco
✓A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown–Séquard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patient's preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.
Andrea Pietrantonio, Sokol Trungu, Isabella Famà, Stefano Forcato, Massimo Miscusi and Antonino Raco
Lumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.
The authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.
Two hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58–77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).
Bilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients’ symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.
Massimo Miscusi, Sokol Trungu, Luca Ricciardi, Stefano Forcato, Alessandro Ramieri and Antonino Raco
Over the last few decades, many surgical techniques for lumbar interbody fusion have been reported. The anterior-to-psoas (ATP) approach is theoretically supposed to benefit from the advantages of both anterior and lateral approaches with similar complication rates, even in L5–S1. At this segment, the anterior lumbar interbody fusion (ALIF) requires retroperitoneal dissection and retraction of major vessels, whereas the iliac crest does not allow the lateral transpsoas approach. This study aimed to investigate clinical-radiological outcomes and complications of the ATP approach at the L5–S1 segment in a single cohort of patients.
This is a prospective single-center study, conducted from 2016 to 2019. Consecutive patients who underwent ATP at the L5–S1 segment for degenerative disc disease or revision surgery after previous posterior procedures were considered for eligibility. Complete clinical-radiological documentation and a minimum follow-up of 12 months were set as inclusion criteria. Clinical patient-reported outcomes, such as the visual analog scale for low-back pain, Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) scores, as well as spinopelvic parameters, were collected preoperatively, 6 weeks after surgery, and at the last follow-up visit. Intraoperative and perioperative complications were recorded. The fusion rate was evaluated on CT scans obtained at 12 months postoperatively.
Thirty-two patients met the inclusion criteria. The mean age at the time of surgery was 57.6 years (range 44–75 years). The mean follow-up was 33.1 months (range 13–48 months). The mean pre- and postoperative visual analog scale (7.9 ± 1.3 vs 2.4 ± 0.8, p < 0.05), Oswestry Disability Index (52.8 ± 14.4 vs 22.9 ± 6.0, p < 0.05), and SF-36 (37.3 ± 5.8 vs 69.8 ± 6.1, p < 0.05) scores significantly improved. The mean lumbar lordosis and L5–S1 segmental lordosis significantly increased after surgery. The mean pelvic incidence–lumbar lordosis mismatch and pelvic tilt significantly decreased. No intraoperative complications and a postoperative complication rate of 9.4% were recorded. The fusion rate was 96.9%. One patient needed a second posterior revision surgery for residual foraminal stenosis.
In the present case series, ATP fusion for the L5–S1 segment has resulted in valuable clinical-radiological outcomes and a relatively low complication rate. Properly designed clinical and comparative trials are needed to further investigate the role of ATP for different L5–S1 conditions.
High-grade intramedullary astrocytomas: what is the best surgical option?
Michael G. Fehlings and Sorin C. Craciunas
Alessandro Frati, Maurizio Salvati, Fabrizio Mainiero, Flora Ippoliti, Giovanni Rocchi, Antonino Raco, Emanuela Caroli, Giampaolo Cantore and Roberto Delfini
Object. To evaluate the role of local inflammation in the pathogenesis and postoperative recurrence of chronic subdural hematoma (CSDH), the authors conducted an investigation in a selected group of patients who could clearly recall a traumatic event and who did not have other risk factors for CSDH. Inflammation was analyzed by measuring the concentration of the proinflammatory and inflammatory cytokines interleukin (IL)-6 and IL-8. The authors also investigated the possible relationship between high levels of local inflammation that were measured and recurrence of the CSDH.
Methods. A prospective study was performed between 1999 and 2001. Thirty-five patients who could clearly recall a traumatic event that had occurred at least 3 weeks previously and who did not have risk factors for CSDH were enrolled. All patients were surgically treated by burr hole irrigation plus external drainage.
The concentration of inflammatory cytokines was very high in the lesion, whereas it was normal in serum. In five cases in which recurrence occurred, concentrations of both IL-6 and IL-8 were significantly increased (p < 0.01) in comparison with cases without a recurrence. In a layering hematoma, the IL-6 and IL-8 concentrations were significantly higher (p < 0.05). Layering CSDHs were also significantly correlated with recurrence. Trabecular hematoma had the lowest cytokine levels and the longest median interval between trauma and clinical onset. The interval from trauma did not significantly influence recurrence, although it did differ significantly between the trabecular and layering CSDH groups. Concentrations of IL-6 and IL-8 in the CSDHs did not differ significantly in relation to either the age of the hematoma (measured as the interval from trauma) or the age of the patient.
Conclusions. Brain trauma causes the onset of an inflammatory process within the dural border cell layer; high levels of inflammatory cytokines were significantly correlated with recurrence and layering CSDH. A prolonged postoperative antiinflammatory medicine given as prophylaxis may help prevent the recurrence of a CSDH.
Antonino Raco, Alessandro Frati, Antonio Santoro, Tommaso Vangelista, Maurizio Salvati, Roberto Delfini and Giampaolo Cantore
Because of the anatomical complexity of the paraclinoid region, the surgical treatment of aneurysms arising in the C6 segment of the internal carotid artery is extremely challenging. The authors' aim in this study was to describe the extended clinical follow-up and assess the short-term and long-term effectiveness of surgical treatment for these aneurysms, focusing on the clinical outcome and degree of aneurysm occlusion and recurrence.
The authors retrospectively analyzed the clinical records for patients treated surgically between 1973 and 2004 at the University of Rome, “La Sapienza.” Aneurysms were classified into the following 3 groups according to the site where they arose: the anteromedial, anterior or anterolateral, and posteromedial wall of the C6 segment.
Of the 108 aneurysms in 104 patients treated, 63 (58%) were large or giant. Eighty-eight aneurysms in 84 patients were clipped, 16 underwent a high-flow bypass, 2 were trapped, 1 was wrapped, and 1 was left untreated. The mean follow-up was 126 months; 47 patients had a follow-up of > 10 years. Of the 88 aneurysms that were clipped, 6 (6.8%) had an incomplete occlusion that required an immediate reoperation in 1 case and at 2 years in another. Overall 6 patients (5.8%) had surgery-related permanent complications.
Mortality and morbidity rates depend mainly on the patient's preoperative Hunt and Hess grade subarachnoid hemorrhage, whereas surgical morbidity principally reflects excessive manipulation of the optic nerve or ischemic problems due to excessive temporary trapping undertaken without adequate neuroprotection. In expert hands, surgery (clipping and bypass procedures) is a definitive treatment for C6 aneurysms and has an acceptable complication rate.
Sergio Paolini, Roberta Morace, Giancarlo Di Gennaro, Angelo Picardi, Liliana G. Grammaldo, Giulio Nicolò Meldolesi, Pier Paolo Quarato, Antonino Raco and Vincenzo Esposito
Supratentorial cavernous angiomas may be associated with drug-resistant focal epilepsy. Surgical removal of the malformation may result in seizure control in a number of patients, although in most studies a long history and high frequency of attacks have been recognized as indicators of unfavorable seizure outcome. In the literature, there are no clear indications regarding the optimal diagnostic presurgical workup and the surgical strategy for this particular subgroup of patients with symptomatic epilepsy. In this paper the authors focus on the preoperative workup and the surgical management of the disease in eight consecutive patients undergoing surgery for drug-resistant temporal lobe epilepsy (TLE) due to cavernous malformations (CMs), and the relevant literature on this issue is also reviewed.
Preoperatively, all patients were assessed using a noninvasive protocol aimed at localizing the epileptogenic zone on the basis of anatomical, electrical, and clinical criteria. The presurgical assessment yielded an indication for lesionectomy in two cases, lesionectomy plus anteromesial temporal lobectomy in four cases, and lesionectomy plus extended temporal lobectomy in two cases. At follow-up examinations, seizure, neuropsychological, and psychiatric outcomes were all evaluated. Seven patients were categorized in Engel Class IA (seizure free), and one was categorized in Engel Class IB (occasional auras only). No adverse effects on neuropsychological or psychosocial functioning were observed.
Epilepsy surgery can be performed with excellent results in patients with intractable TLE caused by CMs. Noninvasive presurgical evaluation of these patients may enable a tailored approach, providing complete seizure relief in most cases.