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Antonino Germanò, Claudia Imperatore, Domenico d'Avella, Giovanni Costa and Francesco Tomasello

Object. The radical scavenger (±)-N,N′-propylenedinicotinamide (AVS) was shown recently to ameliorate delayed neurological deficits resulting from ischemia in patients who have had an aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to evaluate the effect of AVS administration after experimental SAH on 1) behavioral deficits; 2) angiographically confirmed basilar artery (BA) spasm; and 3) blood-brain barrier (BBB) permeability changes.

Methods. These parameters were measured by 1) using a battery of well-characterized chronic assessment tasks over a 5-day observation period; 2) assessing in vivo the mean vessel diameter 2 days after SAH; and 3) evaluating the extravasation of protein-bound Evans Blue dye by using a spectrophotofluorimetric technique 2 days after SAH. Groups of eight to 10 rats received injections of 400 µl of autologous blood into the cisterna magna. Within 5 minutes after the surgical procedures were completed the rats were treated with an intravenously administered continuous infusion of saline (Group III) or AVS (1 mg/kg/minutes, Group IV). Results were compared with those in sham-operated animals treated with intravenously administered saline (Group I) or AVS (Group II). The AVS-treated rats had significantly improved balance beam scores on Days 1 to 2 (p < 0.05), shorter beam traverse times on Day 1 (p < 0.05), and better beam walking performance on Days 1 to 4 (p < 0.01), but no significant effect was seen in terms of SAH-related changes in body weight. Treatment with AVS also attenuated the SAH-induced BA spasm (p < 0.05) and decreased BBB permeability changes in frontal, temporal, parietal, occipital, and cerebellar cortices, and in the subcortical and cerebellar gray matter and brainstem (p < 0.01).

Conclusions. These results demonstrate useful antivasospastic and brain-protective actions of AVS after induction of experimental SAH and provide support for observations of beneficial effects of AVS made in the clinical setting.

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Francesco Costa, Marco Sassi, Andrea Cardia, Alessandro Ortolina, Antonio De Santis, Giovanni Luccarell and Maurizio Fornari

Object

Surgical decompression is the recommended treatment in patients with moderate to severe degenerative lumbar spinal stenosis (DLSS) in whom symptoms do not respond to conservative therapy. Multilevel disease, poor patient health, and advanced age are generally considered predictors of a poor outcome after surgery, essentially because of a surgical technique that has always been considered invasive and prone to causing postoperative instability. The authors present a minimally invasive surgical technique performed using a unilateral approach for lumbar decompression.

Methods

A retrospective study was conducted of data obtained in a consecutive series of 473 patients treated with unilateral microdecompression for DLSS over a 5-year period (2000–2004). Clinical outcome was measured using the Prolo Economic and Functional Scale and the visual analog scale (VAS). Radiological follow-up included dynamic x-ray films of the lumbar spine and, in some cases, computed tomography scans.

Results

Follow-up was completed in 374 (79.1%) of 473 patients—183 men and 191 women. A total of 520 levels were decompressed: 285 patients (76.2%) presented with single-level stenosis, 86 (22.9%) with two-level stenosis, and three (0.9%) with three-level stenosis.

Three hundred twenty-nine patients (87.9%) experienced a clinical benefit, which was defined as neurological improvement in VAS and Prolo Scale scores. Only three patients (0.8%) reported suffering segmental instability at a treated level, but none required surgical stabilization, and all were successfully treated conservatively.

Conclusions

Evaluation of the results indicates that unilateral microdecompression of the lumbar spine offers a significant improvement for patients with DLSS, with a lower rate of complications.

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Robert A. Beatty

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Yunus Aydın and Halit Çavuşoğlu

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Fabio Galbusera, Chiara M. Bellini, Francesco Costa, Roberto Assietti and Maurizio Fornari

Object

Cervical instrumented fusion is currently performed using several fixation methods. In the present paper, the authors compare the following 4 implantation methods: a stand-alone cage, a cage supplemented by an anterior locking plate, a cage supplemented by an anterior dynamic plate, and a dynamic combined plate–cage device.

Methods

Four finite element models of the C4–7 segments were built, each including a different instrumented fixation type at the C5–6 level. A compressive preload of 100 N combined with a pure moment of 2.5 Nm in flexion, extension, right lateral bending, and right axial rotation was applied to the 4 models. The segmental principal ranges of motion and the load shared by the interbody cage were obtained for each simulation.

Results

The stand-alone cage showed the lowest stabilization capability among the 4 configurations investigated, but it was still significant. The cage supplemented by the locking plate was very stiff in all directions. The 2 dynamic plate configurations reduced flexibility in all directions compared with the intact case, but they left significant mobility in the implanted segment. These configurations were able to share a significant part of the load (up to 40% for the combined plate–cage) through the posterior cage. The highest risk of subsidence was obtained with the model of the stand-alone cage.

Conclusions

Noticeable differences in the results were detected for the 4 configurations. The actual clinical relevance of these differences, currently considered not of critical importance, should be investigated by randomized clinical trials.

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Francesco Costa, Alessandro Ortolina, Luca Attuati, Andrea Cardia, Massimo Tomei, Marco Riva, Luca Balzarini and Maurizio Fornari

OBJECT

Fractures of C-1 and C-2 are complex and surgical management may be difficult and challenging due to the anatomical relationship sbetween the vertebrae and neurovascular structures. The aim of this study was to evaluate the role, reliability, and accuracy of cervical fixation using the O-arm intraoperative 3D image–based navigation system.

METHODS

The authors evaluated patients who underwent a navigation system–based surgery for stabilization of a fracture of C-1 and/or C-2 from August 2011 to August 2013. All of the fixation screws were intraoperatively checked and their position was graded.

RESULTS

The patient population comprised 17 patients whose median age was 47.6 years. The surgical procedures were as follows: anterior dens screw fixation in 2 cases, transarticular fixation of C-1 and C-2 in 1 case, fixation using the Harms technique in 12 cases, and occipitocervical fixation in 2 cases. A total of 67 screws were placed. The control intraoperative CT scan revealed 62 screws (92.6%) correctly placed, 4 (5.9%) with a minor cortical violation (< 2 mm), and only 1 screw (1.5%) that was judged to be incorrectly placed and that was immediately corrected. No vascular injury of the vertebral artery was observed either during exposition or during screw placement. No implant failure was observed.

CONCLUSIONS

The use of a navigation system based on an intraoperative CT allows a real-time visualization of the vertebrae, reducing the risks of screw misplacement and consequent complications.

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Francesco Costa, Giovanni Tosi, Luca Attuati, Andrea Cardia, Alessandro Ortolina, Marco Grimaldi, Fabio Galbusera and Maurizio Fornari

OBJECTIVE

The O-arm system in spine surgery allows greater accuracy, lower rate of screw misplacement, and reduced surgical time. Some concerns have been postulated regarding the radiation doses to patients and surgeons. To the best of the authors' knowledge, most of the studies in the literature were performed with the use of phantoms. The authors present data regarding radiation exposure of the surgeon and operating room (OR) staff in a consecutive series of patients undergoing spine surgery.

METHODS

Radiation exposure data were collected in a series of 107 patients who underwent spine surgery using the O-arm system. The doses received by the surgeon and the staff were collected using electronic dosimeters.

RESULTS

All patients underwent 1–3 scans. The mean radiation dose to the patients was 5.15 mSv (range 1.48–7.64 mSv). The mean dose registered for the scan operator was 0.005 μSv (range 0.00–0.03 μSv) while the other members of the surgical team positioned outside the OR received 0 μSv.

CONCLUSIONS

The O-arm system exposes patients to a higher radiation dose than standard fluoroscopy. However, considering the clear advantages of this system, this adjunctive dose can be considered acceptable. Moreover, the effective dose to the patient can be reduced using collimation or minimizing the parameters of the O-arm system used in this paper. The exposure to operators is essentially negligible when radioprotective garments and protocols are adopted as recommended by the International Commission on Radiological Protection.

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Chih-Chang Chang, Li-Yu Fay, Jau-Ching Wu, Peng-Yuan Chang, Tsung-Hsi Tu, Henrich Cheng and Wen-Cheng Huang