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Roberto Assietti, Federica Beretta and Cesare Arienta


Anterior cervical discectomy (ACD) is an effective and safe treatment for nerve root or spinal cord compression caused by disc herniation or spondylosis. Cervical interbody fusion allows preservation of the physiological lordosis and stability of the cervical spine. Based on data reported in the literature, fusion rates decrease significantly when more than one level undergoes surgery, and some authors recommend the addition of a plate system to improve results. At the authors' institution cervical carbon fiber cages (CFCs) are routinely used after ACD. They describe their experience in the treatment of 24 patients with two-level disease treated with CFCs alone.


Twenty-one patients with cervical radiculopathy and three with radiculomyelopathy underwent ACD. Surgery was performed at C5–6 and C6–7 in 18, at C4–5 and C5–6 in four, and at C3–4 and C5–6 in two patients. All the patients underwent magnetic resonance imaging and 15 also underwent computerized tomography (CT) to assess the results of surgery.

Radiculopathy improved after surgery in all the cases, whereas myelopathy resolved in only one patient. At 1 year fusion was achieved in 96% of the surgically treated discs; this was verified on cervical spine x-ray films in all patients and on CT scans in three patients. Cervical lordosis was restored in eight of the nine patients in whom it was lost preoperatively. No complications related to cage extrusion and no cases of symptomatic pseudarthrosis were observed.


Interbody fusion cages have a load-sharing function and stabilize the spine to increase segmental stiffness, thus achieving fusion rates similar to those associated with bone grafts, even in multilevel disease.

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Manuela Caroli, Marco Locatelli, Francesco Prada, Federica Beretta, Filippo Martinelli-Boneschi, Rolando Campanella and Cesare Arienta

Object. A grading system, called the Clinical—Radiological Grading System (CRGS), has been developed to standardize surgical indications in elderly patients harboring intracranial meningiomas. Patients with a score lower than 10 had a bad prognosis regardless of surgical treatment, those with a score between 10 and 12 had a prognosis positively influenced by surgery, and those with a score higher than 12 had a good prognosis regardless of surgical treatment. The authors performed a prospective cross-sectional study to validate further the use of the CRGS as a clinical tool to orientate surgical decision making in elderly patients and to explore prognostic factors of survival.

Methods. From 1990 to 2000 the authors consecutively recruited and surgically treated 90 patients 70 years of age or older with neuroimaging findings of intracranial meningiomas and a preoperative evaluation based on the CRGS.

The surgical mortality rate, which covers deaths within 3 months after surgical intervention, was 7.8%, and the 1-year mortality rate was 15.6%.

Female sex and a higher CRGS score were associated with a higher probability of survival. Among the different subset items of the CRGS score, no peritumoral edema for surgical survival and no concomitant diseases for 1-year survival provide the strongest predictive contribution, even if not at a statistically significant level.

Conclusions. The CRGS score is a useful and practical tool for the selection of elderly patients affected by intracranial meningiomas as surgical candidates. A CRGS score higher than 10 and female sex are good prognostic factors of survival, whereas age is not a contraindication to surgery.

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Federica Beretta, Norberto Andaluz, Chiraz Chalaala, Claudio Bernucci, Leo Salud and Mario Zuccarello


Minimally invasive approaches have been proposed for the treatment of anterior cranial base pathology. Whereas earlier studies have quantified surgical exposure by referring to the opening on the surface, this cadaveric morphometric study redefines the concept of working area by examining the deep exposures afforded by several different approaches. Specifically, the authors systematically quantify and compare the operative exposure afforded by the pterional, supraorbital, and transorbital keyhole approaches to the sellar, suprasellar, and perisellar regions, including the anterior communicating artery complex.


Pterional, supraorbital, and transorbital approaches were sequentially performed in 5 embalmed cadaveric heads on both sides. Preoperative and postoperative CT scans were obtained for frameless stereotactic navigation and measurements. Using reproducible anatomical landmarks, 6 triangles were defined to systematically measure the working area, depth of the surgical window, and angle of observation for each approach. Areas of the triangles were calculated using the Heron mathematical formula based on stereotactic navigation measurements. Ten sets of data were analyzed.


The pterional, supraorbital, and transorbital keyhole approaches provided progressively increasing working areas. The transorbital approach was associated with significantly increased exposure when compared with the pterional approach (p < 0.01). The transorbital approach was associated with a shallower depth of the surgical window when compared with either the supraorbital (p < 0.05) or pterional (p < 0.01) approach. The angle of basal view increased 56.6% with the transorbital approach (p < 0.001) when compared with the supraorbital approach. The transorbital route provided greater exposure on deeply located midline and contralateral structures.


In refining the concept of working area as deep rather than superficial in the surgical field, the authors quantified the 6 triangles whose boundaries were relative to the target structures to be exposed in the approach. The authors' morphometric findings support the use of the supraorbital and transorbital approaches as a valid alternative to the pterional approach for the treatment of sellar and perisellar pathology. The transorbital approach combines the advantages of minimal invasiveness with those of cranial base techniques.