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Enrico Tessitore and Oliver P. Gautschi

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Enrico Tessitore, Karim Burkhardt, and Michael Payer

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Giorgio Iaconetta, Enrico Tessitore, and Madjid Samii

Object. The anatomy of the abducent nerve is well known; its duplication (ranging from 5 to 28.6%), however, has rarely been reported in the literature. The authors performed a microanatomical study in 100 cadaveric specimens (50 heads) to evaluate the prevalence of this phenomenon and to provide a clear anatomical description of the course and relationships of the nerve. The surgery-related implications of this rare anatomical variant will be highlighted.

Methods. The 50 human cadaveric heads (100 specimens) were embalmed in a 10% formalin solution for 3 weeks. Fifteen of them were injected with colored neoprene latex. A duplicated abducent nerve was found in eight specimens (8%). In two (25%) of these eight specimens the nerve originated at the pontomedullary sulcus as two independent trunks: in one case the superior trunk was thicker than the inferior and in the other it was thinner. In the other six cases (75%) the nerve originated as a single trunk, splitting in two trunks into the cisternal segment: in two of them the trunks ran below the Gruber ligament, whereas in four specimens one trunk ran below and one above it. In all the specimens, the duplicated nerves fused again into the cavernous sinus, just after the posterior genu of the internal carotid artery.

Conclusions. Although the presence of a duplicated abducent nerve is a rare finding, preoperative magnetic resonance imaging should be performed to rule out this possibility, thus tailoring the operation to avoid postoperative deficits.

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Oliver P. Gautschi, Bawarjan Schatlo, Karl Schaller, and Enrico Tessitore

Object

The technique of pedicle screw insertion is a mainstay of spinal instrumentation. Some of its potential complications are clinically relevant and may require reoperation or further postoperative care.

Methods

A literature search was performed using MEDLINE (between 1999 and June 2011) for studies on pedicle screw placement in thoracolumbar surgery. The authors included randomized controlled trials, case-control studies, and case series (≥ 20 patients) from the English-, German-, and French-language literature. The authors assessed study type, the number of patients, the anatomical area, the number of pedicle screws, duration of follow-up, type of pedicle screw placement, incidence of complications, and type of complication. The management of specific complications is discussed.

Results

Thirty-nine articles with 46 patient groups were reviewed with a total of 35,630 pedicle screws. One study was a randomized controlled trial, 8 were case-control studies, and the remaining articles were case series. Dural lesions and irritation of nerve roots were reported in a mean of 0.18% and 0.19% per pedicle screws, respectively. Thirty-two patients in 10 studies (of 5654 patients from all 39 studies) required further revision surgeries for misplaced pedicle screws causing neurological problems. None of the analyzed studies reported vascular complications, and only 2 studies reported visceral complications of clinical significance.

Conclusions

Pedicle screw placement in the thoracolumbar region is a safe procedure with an overall high accuracy and a very low rate of clinically relevant complications.

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Michael Y. Wang, Enrico Tessitore, Neil Berrington, and Andrew Dailey

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Michael Y. Wang, Tetsuya Goto, Enrico Tessitore, and Anand Veeravagu

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Michael Payer, Daniel May, Alain Reverdin, and Enrico Tessitore

Object. The authors sought to evaluate retrospectively the radiological and clinical outcome of anterior cervical discectomy followed by implantation of an empty carbon fiber composite frame cage (CFCF) in the treatment of patients with cervical disc herniation and monoradiculopathy.

Methods. Twenty-five consecutive patients (12 men, 13 women, mean age 45 years) with monoradiculopathy due to cervical disc herniation were treated by anterior cervical discectomy followed by implantation of an empty CFCF cage. On lateral flexion—extension radiographs segmental stability at a mean follow up of 14 months (range 5–31 months) was demonstrated in all 25 patients, and bone fusion was documented in 24 of 25 patients. The mean anterior intervertebral body height was 3.4 mm preoperatively and 3.8 mm at follow up in 20 patients. In these patients the mean segmental angle (angle between lower endplate of lower and upper vertebra) was 0.9° preoperatively and 3.1° at follow up. In the remaining five patients preoperative images were not retrievable.

Self-scored neck pain based on a visual analog scale (1, minimum; 10, maximum) changed from a preoperative average of 5.6 to an average of 2 at follow up; radicular pain was reduced from 7.7 to 2.1 postoperatively. Analysis of the SF12 questionnaires showed a significant improvement in both the physical capacity score (preoperative mean 32.4 points; follow up 46 points) and the mental capacity score (preoperative mean 45.8 points; follow up 57.5 points).

Conclusions. Implantation of an empty CFCF cage in the treatment of cervical disc herniation and monoradiculopathy avoids donor site morbidity associated with autologous bone grafting as well as the use of any supplementary material inside the cage. Restoration or maintenance of intervertebral height and thus segmental lordosis and a very high rate of segmental stability and fusion are achieved using this technique.

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Marco V. Corniola, Bertrand Debono, Holger Joswig, Jean-Michel Lemée, and Enrico Tessitore

The concept of Enhanced Recovery After Surgery (ERAS) entails recovery facilitation of patients who undergo surgery through the implementation of a multidisciplinary and multimodal perioperative care approach. By its application, ERAS improves the overall functional outcome after surgery while maintaining high standards of care. A review of the essential aspects of ERAS in spine surgery was undertaken. Special consideration was given to the risks and benefits for patients and caregivers, as well as the medical and economical aspects of this concept.

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Bertrand Debono, Marco V. Corniola, Raphael Pietton, Pascal Sabatier, Olivier Hamel, and Enrico Tessitore

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.

METHODS

The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.

RESULTS

The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.

CONCLUSIONS

The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

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Granit Molliqaj, Bawarjan Schatlo, Awad Alaid, Volodymyr Solomiichuk, Veit Rohde, Karl Schaller, and Enrico Tessitore

OBJECTIVE

The quest to improve the safety and accuracy and decrease the invasiveness of pedicle screw placement in spine surgery has led to a markedly increased interest in robotic technology. The SpineAssist from Mazor is one of the most widely distributed robotic systems. The aim of this study was to compare the accuracy of robot-guided and conventional freehand fluoroscopy-guided pedicle screw placement in thoracolumbar surgery.

METHODS

This study is a retrospective series of 169 patients (83 women [49%]) who underwent placement of pedicle screw instrumentation from 2007 to 2015 in 2 reference centers. Pathological entities included degenerative disorders, tumors, and traumatic cases. In the robot-assisted cohort (98 patients, 439 screws), pedicle screws were inserted with robotic assistance. In the freehand fluoroscopy-guided cohort (71 patients, 441 screws), screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. Patients treated before 2009 were included in the fluoroscopy cohort, whereas those treated since mid-2009 (when the robot was acquired) were included in the robot cohort. Since then, the decision to operate using robotic assistance or conventional freehand technique has been based on surgeon preference and logistics. The accuracy of screw placement was assessed based on the Gertzbein-Robbins scale by a neuroradiologist blinded to treatment group. The radiological slice with the largest visible deviation from the pedicle was chosen for grading. A pedicle breach of 2 mm or less was deemed acceptable (Grades A and B) while deviations greater than 2 mm (Grades C, D, and E) were classified as misplacements.

RESULTS

In the robot-assisted cohort, a perfect trajectory (Grade A) was observed for 366 screws (83.4%). The remaining screws were Grades B (n = 44 [10%]), C (n = 15 [3.4%]), D (n = 8 [1.8%]), and E (n = 6 [1.4%]). In the fluoroscopy-guided group, a completely intrapedicular course graded as A was found in 76% (n = 335). The remaining screws were Grades B (n = 57 [12.9%]), C (n = 29 [6.6%]), D (n = 12 [2.7%]), and E (n = 8 [1.8%]). The proportion of non-misplaced screws (corresponding to Gertzbein-Robbins Grades A and B) was higher in the robot-assisted group (93.4%) than the freehand fluoroscopy group (88.9%) (p = 0.005).

CONCLUSIONS

The authors’ retrospective case review found that robot-guided pedicle screw placement is a safe, useful, and potentially more accurate alternative to the conventional freehand technique for the placement of thoracolumbar spinal instrumentation.