Complications of degenerative lumbar spondylolisthesis and stenosis surgery in patients over 80 s: comparative study with over 60 s and 70 s. Experience with 678 cases

Purpose

Degenerative spondylolisthesis (DS) is a debilitating condition that carries a high economic burden. As the global population ages, the number of patients over 80 years old demanding spinal fusion is constantly rising. Therefore, neurosurgeons often face the important decision as to whether to perform surgery or not in this age group, commonly perceived at high risk for complications.

Methods

Six hundred seventy-eight elder patients, who underwent posterolateral lumbar fusion for DS (performed in three different centers) from 2012 to 2020, were screened for medical, early and late surgical complications and for the presence of potential preoperative risk factors. Patients were divided in three categories based on their age: (1) 60–69 years, (2) 70–79 years, (3) 80 and over. Multiple logistic regression was used to determine the predictive power of age and of other risk factors (i.e., ASA score; BMI; sex; presence or absence of insulin-dependent and -independent diabetes, use of anticoagulants, use of antiaggregants and osteoporosis) for the development of postoperative complications.

Results

In univariate analysis, age was significantly and positively correlated with medical complications. However, when controls for other risk factors were added in the regressions, age never reached significance, with the only noticeable exception of cerebrovascular accidents. ASA score and BMI were the two risk factors that significantly correlated with the higher numbers of complication rates (especially medical).

Conclusion

Patients of different age but with comparable preoperative risk factors share similar postoperative morbidity rates. When considering octogenarians for lumbar arthrodesis, the importance of biological age overrides that of chronological.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-022-05118-9.

Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome-Experience with 1001 Patients

BACKGROUND

Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing.

METHODS

A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery.

RESULTS

Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome.

CONCLUSIONS

Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m², symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or 3.

Randomized Trial of Sacroiliac Joint Arthrodesis Compared with Conservative Management for Chronic Low Back Pain Attributed to the Sacroiliac Joint

BACKGROUND

Sacroiliac joint pain is increasingly recognized as a cause of low back pain. We compared the safety and effectiveness of minimally invasive sacroiliac joint arthrodesis using triangular titanium implants and conservative management in patients with chronic sacroiliac joint pain.

METHODS

This study was a prospective, multicenter randomized controlled trial of adults with chronic sacroiliac joint pain assigned to either conservative management or sacroiliac joint arthrodesis with triangular titanium implants. The study end points included self-rated low back pain (visual analog scale [VAS]), back dysfunction (Oswestry Disability Index [ODI]), and quality of life. Ninety percent of subjects in both groups completed the study.

RESULTS

Between June 6, 2013, and May 15, 2015, 103 subjects were randomly assigned to conservative management (n = 51) or sacroiliac joint arthrodesis (n = 52). At 2 years, the mean low back pain improved by 45 points (95% confidence interval [CI], 37 to 54 points) after sacroiliac joint arthrodesis and 11 points (95% CI, 2 to 20 points) after conservative management, with a mean difference between groups of 34 points (p < 0.0001). The mean ODI improved by 26 points (95% CI, 21 to 32 points) after sacroiliac joint arthrodesis and 8 points (95% CI, 2 to 14 points) after conservative management, with a mean difference between groups of 18 points (p < 0.0001). Parallel improvements were seen in quality of life. In the sacroiliac joint arthrodesis group, the prevalence of opioid use decreased from 56% at baseline to 33% at 2 years (p = 0.009), and no significant change was observed in the conservative management group (47.1% at baseline and 45.7% at 2 years). Subjects in the conservative management group, after crossover to the surgical procedure, showed improvements in all measures similar to those originally assigned to sacroiliac joint arthrodesis. In the first 6 months, the frequency of adverse events did not differ between groups (p = 0.664). By month 24, we observed 39 severe adverse events after sacroiliac joint arthrodesis, including 2 cases of sacroiliac joint pain, 1 case of a postoperative gluteal hematoma, and 1 case of postoperative nerve impingement. The analysis of computed tomographic (CT) imaging at 12 months after sacroiliac joint arthrodesis showed radiolucencies adjacent to 8 implants (4.0% of all implants).

CONCLUSIONS

For patients with chronic sacroiliac joint pain due to joint degeneration or disruption, minimally invasive sacroiliac joint arthrodesis with triangular titanium implants was safe and more effective throughout 2 years in improving pain, disability, and quality of life compared with conservative management.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clinical Significance of Extracellular Vesicles in Plasma from Glioblastoma Patients

PURPOSE

Glioblastoma (GBM) is the most common primary brain tumor. The identification of blood biomarkers reflecting the tumor status represents a major unmet need for optimal clinical management of patients with GBM. Their high number in body fluids, their stability, and the presence of many tumor-associated proteins and RNAs make extracellular vesicles potentially optimal biomarkers. Here, we investigated the potential role of plasma extracellular vesicles from patients with GBM for diagnosis and follow-up after treatment and as a prognostic tool.

EXPERIMENTAL DESIGN

Plasma from healthy controls (n = 33), patients with GBM (n = 43), and patients with different central nervous system malignancies (n = 25) were collected. Extracellular vesicles were isolated by ultracentrifugation and characterized in terms of morphology by transmission electron microscopy, concentration, and size by nanoparticle tracking analysis, and protein composition by mass spectrometry. An orthotopic mouse model of human GBM confirmed human plasma extracellular vesicle quantifications. Associations between plasma extracellular vesicle concentration and clinicopathologic features of patients with GBM were analyzed. All statistical tests were two-sided.

RESULTS

GBM releases heterogeneous extracellular vesicles detectable in plasma. Plasma extracellular vesicle concentration was higher in GBM compared with healthy controls (P < 0.001), brain metastases (P < 0.001), and extra-axial brain tumors (P < 0.001). After surgery, a significant drop in plasma extracellular vesicle concentration was measured (P < 0.001). Plasma extracellular vesicle concentration was also increased in GBM-bearing mice (P < 0.001). Proteomic profiling revealed a GBM-distinctive signature.

CONCLUSIONS

Higher extracellular vesicle plasma levels may assist in GBM clinical diagnosis: their reduction after GBM resection, their rise at recurrence, and their protein cargo might provide indications about tumor, therapy response, and monitoring.

In vitro efficacy of silk sericin microparticles and platelet lysate for intervertebral disk regeneration

Intervertebral disk degeneration is an oxidative and inflammatory pathological condition that induces viability and functionality reduction of Nucleus Pulposus cells (NPs). Cellular therapies were previously proposed to repair and substitute the herniated disk but low proliferative index and pathological conditions of NPs dramatically reduced the efficacy of this approach. To overcome these problems we proposed, for the first time, a therapeutic system based on the association of silk sericin microparticles and platelet-derived products. Silk sericin (SS) is a bioactive protein with marked antioxidant properties, while platelet lysate (PL) and platelet poor plasma (PPP) represent a source of growth factors able to support cell viability and to promote tissue regeneration. We demonstrated that the mixture PL + PPP promoted NPs proliferation with a significant reduction of cellular doubling time. SS microparticles, alone or in combination with PPP, presented the higher ROS-scavenging activity while, SS microparticles and PL resulted as the best association able to protect NPs against oxidative stress induce by hydroxide peroxide. Based on these results, the authors are confident that, with the ever increasing need of efficacious tools for regenerative medicine purposes, SS microparticles and PL + PPP association could represent an effective approach for the development of low impact and non-invasive therapies.

Cell Kinetics Aspects of Human Malignant Neuroepithelial Tumors: A Follow-Up Study

The prognostic value of proliferative activity and DNA distribution (ploidy), determined by flow cytometry (FCM), was evaluated in 38 cases of human malignant neuroepithelial tumors. No statistically significant correlation was found between flow cytometric data and clinical outcome. In particular, there was no significant difference between mean survival in cases with percentage of cells in S-phase lower and higher than 5%, respectively. In 21 cases with unimodal DNA distribution, the mean survival was 11.7 months; in 17 cases with bimodal DNA distribution, the mean survival was 12.5 months. The difference was not statistically significant. In our experience, proliferative activity and ploidy do not correlate well with the clinical course and survival of patients with malignant neuroepithelial tumors. However, application of FCM may provide, aside from histopathologic examination, additional biologic information that may be valuable in understanding the variation observed in the course of individual patients.

Usefulness of corset adoption after single-level lumbar discectomy: a randomized controlled trial

OBJECTIVE In this paper, the authors sought to verify whether corset adoption could improve the short-term and midterm outcome scores of patients after single-level lumbar discectomy. METHODS A monocentric, randomized controlled trial of 54 consecutive patients who underwent single-level lumbar discectomy at the authors' institution was performed from September 2014 to August 2015. Patients were randomly assigned to use or not use a lumbar corset in the upright position. Patients with previous interventions for disc herniation or with concomitant canal or foraminal stenosis were excluded. The visual analog scale, Oswestry Disability Index, and Roland Morris Disability Questionnaire were used to compare groups at the 1- and 6-month follow-up time points. RESULTS No significant differences between the 2 groups were reported at either time point for any given outcome irrespective of the scale used. CONCLUSIONS Corset adoption does not improve the short-term and midterm outcomes of patients after single-level lumbar discectomy.

Expression of the Transcription Factor HEY1 in Glioblastoma: A Preliminary Clinical Study

Aims and background

The hairy/enhancer of split (E(spl))-related family of transcription factors (HES and HEY) are established targets of the notch signaling pathway, which has been implicated in different developmental processes, tumor formation and the self-renewal of neural stem cells. We determined the expression of HEY1 in human malignant gliomas to investigate whether its expression might be related to prognosis.

Methods

The expression of HEY1 was studied by in situ hybridization on 62 cases of glioblastoma. Patients were treated with surgery followed by chemotherapy and radiotherapy. We considered as end points of the study the overall survival time and progression-free interval. Correlations between HEY1 expression and tumor grade/patient overall survival and free interval before recurrence were analyzed using univariate analysis.

Results

Based on the in situ hybridization results, HEY1 expression rate was reported as negative staining in 13 cases (20.6%), as weak staining in 11 cases (17.3%), as moderate staining in 21 cases (33.3%), and as strong staining in 17 cases. We considered in the analysis the cumulative expression of HEY1 at in situ hybridization (Hey Index) as negative in 13 cases and positive in 49 cases (77.78%). The overall survival (P = 0.002) and the free-interval (P = 0.012) were significantly longer in patients who were negative for HEY1 expression.

Conclusions

Our data suggest that expression of HEY1 might be used as a marker to distinguish glioblastoma patients with a relatively good prognosis from those at high-risk, and that, in the future, HEY1 might represent a therapeutic target.

1-Year Results of a Randomized Controlled Trial of Conservative Management vs. Minimally Invasive Surgical Treatment for Sacroiliac Joint Pain

BACKGROUND

Low back pain (LBP) emanating from the sacroiliac joint (SIJ) is a common finding. Devices to fuse the SIJ are now commercially available, but high-quality evidence supporting their effectiveness is limited.

OBJECTIVES

To compare the safety and effectiveness of conservative management (CM) to minimally invasive sacroiliac joint fusion (SIJF) in patients with chronic LBP originating from the SIJ.

STUDY DESIGN

Prospective, multicenter randomized controlled trial.

SETTING

One hundred three adults in spine clinics with chronic LBP originating from the SIJ.

METHODS

Patients were randomly assigned to CM (n = 51) or SIJF using triangular titanium implants (n = 52). CM consisted of optimization of medical therapy, individualized physiotherapy, and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated LBP at 6 months using a 0 - 100 visual analog scale (VAS). Other effectiveness and safety endpoints, including leg pain, disability using Oswestry Disability Index (ODI), quality of life using EQ-5D, and SIJ function using active straight leg raise test (ASLR), were assessed up to 12 months.

RESULTS

At 12 months, mean LBP improved by 41.6 VAS points in the SIJF group vs. 14.0 points in the CM group (treatment difference of 27.6 points, P < 0.0001). Mean ODI improved by 25.0 points in the SIJF group vs. 8.7 points in the CM group (P < 0.0001). Mean improvements in leg pain and EQ-5D scores were large after SIJF and superior to those after CM. CM patients were allowed to crossover to SIJF after 6 months. Patients who crossed to surgical treatment had no pre-crossover improvement in pain and ODI scores; after crossover, improvements were as large as those originally assigned to SIJF. One case of postoperative nerve impingement occurred in the surgical group. Two SIJF patients had recurrent pain attributed to possible device loosening and one had postoperative hematoma. In the CM group, one crossover surgery patient had recurrent pain requiring a revision surgery.

LIMITATIONS

The primary limitation was lack of blinding and the subjective nature of self-assessed outcomes.

CONCLUSIONS

For patients with chronic LBP originating from the SIJ, minimally invasive SIJF with triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, and improving patient function and quality of life. Our findings will help to inform decisions regarding its use as a treatment option in this patient population.Key words: Sacroiliac joint dysfunction, pelvic girdle pain, randomized controlled trial, quality of life, spine implants.

Intraregional differences of perioperative management strategy for lumbar disc herniation: is the Devil really in the details?

BACKGROUND

This study intends to evaluate whether regional common habits or differences in case-volume between surgeons are significative variables in the perioperative management of patients undergoing surgery for lumbar disc herniation.

METHODS

An e-mail survey was sent to all neurosurgeons working in Lombardy, Italy's most populated region. The survey consisted of 17 questions about the perioperative management of lumbar disc herniation.

RESULTS

Forty-seven percent (47%) out of 206 Lombard neurosurgeons answered the survey. Although in some respects there is clear evidence in current literature on which is the best practice to adopt for an optimal management strategy, we noticed substantial differences between respondents, not only between hospitals but also between surgeons from the same hospital. Still, no differences were evident in a high vs low case-volume comparison.

CONCLUSION

We identified no regional clusterization as for practical principles in the perioperative management of lumbar disc herniation and neither was case-volume a significative variable. Other causes may be relevant in the variability between the perioperative management and the outcomes achieved by different specialists.

Postoperative rehabilitation for chronic subdural hematoma in the elderly. An observational study focusing on balance, ambulation and discharge destination

BACKGROUND

Chronic subdural hematoma (CSDH) can have a negative impact on autonomy of the elderly. Ambulatory and functional status may remain limited despite successful surgical evacuation.

AIM

To evaluate the outcome of a postoperative assisted rehabilitation program.

DESIGN

Single-institution short-term observational study.

SETTING

Inpatient (Neurosurgery Unit of a University Hospital).

POPULATION

Thirty-five patients, aged 65 or older, who underwent burr-hole drainage for chronic subdural hematoma.

METHODS

Postoperatively all participants underwent a rehabilitation program, described in details, aimed at recovering standing position and gait as soon as possible. The program involved daily 30-minute individual sessions assisted by a physiotherapist, until discharge from hospital. The Markwalder's Grading Scale was used to assess the neurological status preoperatively and at discharge. The Trunk Control Test, the Standing Balance by Bohannon Scale and the Modified Rankin Scale were used to evaluate balance and general function (primary outcome) in the immediate postoperative and at discharge. We also recorded the rate of pre-CSDH walking patients who maintained ambulation at discharge and the discharge destination (secondary outcome).

RESULTS

Total scores of Markwalder's Grading Scale, Trunk Control Test, Standing Balance by Bohannon Scale and Modified Rankin Scale improved (P<0.05), indicating a global favorable outcome, especially for balance. Excluding the patients who were dependent pre-CSDH, the others maintained gait function in 74.2% of cases. Only 45.7% of the patients were discharged home, the others being divided between inpatient medical settings and rehabilitation.

CONCLUSIONS

The rehabilitation program was well tolerated by the patients. Our study showed a clear improvement in trunk control and standing balance and an overall favorable outcome for neurological and ambulatory status at discharge. Despite an assisted postoperative rehabilitation program, the residual impairment in general function was the main factor that prevents us to discharge more elderly patients home rather than to assisted settings.

CLINICAL REHABILITATION IMPACT

The results of this descriptive study suggest that an assisted rehabilitation program may be helpful in improving short-term postoperative balance and ambulatory status (more than functional status), but further studies, with a randomized controlled design, are certainly justified to understand the efficacy of rehabilitation in this context.

ACTH-dependent Cushing's Syndrome: Diagnostic Pitfalls in Concomitant Non-secreting Pituitary Adenomas

Objectives

To describe the possible pitfalls in correctly interpreting clinical, radiological and biochemical findings in ACTH-dependent Cushing’s syndrome.

Methods

We describe a case of a pituitary adenoma visualized at MRI not correlated with an ACTH-dependent Cushing’s syndrome.

Results

Radiological imaging and hormonal testing can be misleading in suspected pituitary ACTH-related Cushing’s syndrome.

Conclusion

Correct interpretation of the initial clinical presentation can help in the proper diagnosis and treatment of ACTH-dependent Cushing’s syndrome.

LEARNING POINTS

Low-Cost Fluorescein Detection System for High-Grade Glioma Surgery

BACKGROUND

Intraoperative fluorescein detection has been used in the fields of vascular and oncologic neurosurgery since 1948. Modifications of the optics in order to enhance the fluorescence contrast under microscopic view have been developed by many authors. The industries, during the past 10 years, provided commercial high-cost optimized apparatuses. Reviewing the literature, we found that the prototypical techniques were definitely inexpensive but lacked reliability, reproducibility, and standard legal norms.

METHODS

We describe the developing of a fluorescein detection system that could be economic, simple, effective, and law abiding.

RESULTS

We employed a commercial violet-blue filter designed for fluorescein excitation in endoscopic procedures and used commercial photographic yellow optical filters for fluorescence detection. All the instrumentation is cleared for clinical use, and its cost is up to 200 times lower than commercial apparatuses.

CONCLUSION

Our results show a good distinction of fluorescein-stained structures, with overall acceptable operating light conditions.

Endoscopic Management of Spontaneous Clival Cerebrospinal Fluid Leaks: Case Series and Literature Review

OBJECTIVE

Spontaneous cerebrospinal fluid leaks are most commonly located along the anterior skull base. Sphenoidal localization is less common, and clival localization is even rarer. We analyzed a group of patients with spontaneous leaks and selected patients with clival localization. This article discusses surgical management of these entities and provides a brief literature review regarding spontaneous clival leaks.

METHODS

Of a cohort of 67 patients who presented to our departments with a spontaneous leak during the period 2005-2014, a retrospective data analysis was performed on 6 patients with clival localization of the defect. A skull base repair with a multilayered reconstruction was performed in 3 patients, and a single-layered reconstruction using a pedicled nasoseptal flap was performed in 3 patients.

RESULTS

The patients included 6 women with a mean age of 60 years (range, 36-91 years). The mean length of the follow-up period was 69.5 months (range, 22-114 months). The overall success rate of the primary endoscopic repair was 83.3% (5 of 6 patients); this increased to 100% after revision surgery.

CONCLUSIONS

This series, although numerically limited, suggests that a minimally invasive endoscopic repair of idiopathic clival leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Moreover, the pedicled nasoseptal flap has been confirmed to be the "workhorse" for the reconstruction of clival defects.

Endovascular embolization of pial arteriovenous fistula fed from P1 segment of posterior cerebral artery in 12 years old girl: case report and review of literature

OBJECTIVE

Intracranial pial arteriovenous fistulas (PAVFs) are rare vascular lesions with peculiar epidemiological, morphological, and pathophysiological characteristics. Since there is no nidus, PAVF treatment has been performed by direct disconnection of the arteriovenous communication via a surgical, endovascular, or a combined approach. We aim to outline the relevant variables to consider in planning an endovascular treatment strategy.

METHODS

We present a case of a 12 year old girl with a single feeder PAVF originating from the first segment (P1) of the left posterior cerebral artery with a varicose venous drainage into the right cavernous sinus.

RESULTS

We report the successful endovascular exclusion of the fistula with the release of a total of 27 detachable platinum coils with no complications at follow-up. Treatment strategy and nuances are discussed along with a review of the literature.

CONCLUSIONS

Morphology, age, embolization strategies, and materials are the different variables to be analyzed in the endovascular treatment of such lesions.

Chordoid glioma: a rare radiologically, histologically, and clinically mystifying lesion

Chordoid glioma (CG) is a rare central nervous system neoplasm (WHO grade II) of uncertain origin whose typical localization is in the anterior part of the third ventricle. Its clinical, radiological, and histological features may vary and furthermore mimic other kind of benign lesions usually associated with a better outcome. We report a case of a 43-year-old female who underwent gross total removal of a lesion of the third ventricle causing hydrocephalus. The imaging studies and the intraoperative examination led at first to a hypothesis of meningioma. Early surgical and neurological outcomes were good. The patient underwent multiple complications related to hypothalamic dysfunctions and thrombohemorragic issues and eventually died because of systemic infections. Definitive examination was of chordoid glioma of the third ventricle. Reviewing literature, we evaluated possible pitfalls in radiological and histological diagnosis as well as in surgical and medical treatment of CGs. Despite their benign presentation, a high incidence of multiple possible severe complications is reported. Early alertness and combined treatment strategies could improve overall CGs treatment strategies.

Haemorrhagic presentation of a craniopharyngioma in a pregnant woman

Objective. Craniopharyngioma is a rare tumour, and, consequently, acute clinical presentation and diagnosis, during pregnancy, of this pathology are quite difficult to find. Only few cases are reported in the literature, and no one describes these two conditions in association. Methods. We report a particular case of craniopharyngioma presenting both of the above conditions. Results. The patient was successfully operated with endoscopic technique. Conclusions. Rare and difficult cases, created by the superposition of different clinical conditions, need multidisciplinary management, with collaboration, integration, and cooperation between different medical specialists.

Percutaneous arthrodesis of sacro-iliac joint: a pilot study

AIM

Between 15-30% of patients presenting with low back pain have some SI joint involvement. The diagnosis of SI joint involvement in low back pain is quite difficult and depends on a detailed combination of clinical manoeuvres and injection tests. In 5% of patients with SI joint pain, the joint is physically unstable (termed disruption) resulting in ineffective medical and conservative therapeutic options. In this study we present the results of the first 12 cases of SI joint disruption treated using a minimally invasive SI joint arthrodesis system in order to evaluate the safety and the efficacy of this system.

METHODS

Medical charts at a single center were reviewed for demographics, perioperative metrics, patient reported outcomes for pain, function and quality of life (NRS, ODI and RDQ respectively), as well as satisfaction with surgery (yes/no) and results of postoperative CT scan.

RESULTS

Mean age was 53 years (range 36-71) and all patients were female. Patient reported outcomes at follow up (range 8-18 months) improved clinically as well as statistically as evidenced by a mean improvement in pain on NRS of 4 points, back related function on ODI by 19.4 points, and in quality of life measured using RDQ of 13.6 points (all P=0.01). Local hematoma requiring drainage was apparent in 2 patients. Patient satisfaction was 100%. All 3 month CT scans showed initial fusion.

CONCLUSION

The results of this study confirm that MIS SI joint fusion using the iFuse Implant System is safe and effective method of treating patients with SI joint disruption.

Treatment of high-grade spondylolisthesis with Schanz recoil screws: our experience

PURPOSE

Spondylolisthesis surgical treatment is often difficult with higher degree of slip and related techniques still debated. We have taken into consideration double thread recoil Schanz screws. This system should allow the best reduction of the slip, treating only the affected vertebrae.

METHODS

We retrospectively analyzed 46 patients affected by grade II or higher spondylolisthesis, treated with circumferential arthrodesis using Schanz screws. Duration of surgery, complications, reduction, and rate of fusion have been recorded.

RESULTS

We found that duration of surgery and complications were similar or slightly lower if compared to our standard Posterior Lumbar Interbody Fusion procedures. However, radiological results and clinical outcome appear better in cases treated with Schanz screws.

CONCLUSIONS

Fixation system with Schanz screws seems to be effective in reducing the slip, treating only the affected level, in high grade of spondylolisthesis.

Immunohistohemical expression of the chemokine fractalkine and its receptor in the human brain cortex after severe traumatic brain injury and brain hemorrhage

AIM

Recent experimental studies have suggested that chemokines, a subclass of chemoattractant cytokines which play an important role in regulating leukocyte migration and intercellular communication, participate in brain responses of traumatic injury. Fractalkine (CX3CL1) is a peculiar chemokine, the only one with a CX3C motif, existing both as a soluble and a membrane-anchored molecule. In the brain, Fractalkine has been suggested to have a role in neuroprotection under experimental conditions of brain injury.

METHODS

Eighteen human brain samples were obtained during surgery of decompressive craniotomy for severe traumatic brain injury (TBI) or after spontaneous intracranial haemorrhage (ICH). Five normal brain samples were obtained during surgery for unruptured intracranial aneurysms (standard gyrectomy). Immunohistochemistry of formalin fixed and paraffin embedded tissues was performed in order to verify the expression of fractalkine and its receptor (CX3CR1). The values of chemokine and receptor expression were correlated with the clinical parameters of the patients.

RESULTS

The chemokine fractalkine was significantly upregulated in the neural compartment after brain injury, compared to normal brain samples. Intensity scores were significantly higher when the interval between injury and surgery was >5 h, (P=0.015). In the glial compartment, Fractalkine expression was significantly associated with less severe clinical conditions and lower intracranial pressure at surgery (P=0.014). Expression of the receptor CX3CR1 was detected, at low intensity, on both glial and neurons. Higher expression in neurons was associated with better clinical conditions (Glasgow score) of patients at admission (P=0.037).

CONCLUSION

The results of this study highlights for the first time that fractalkine and its receptor CX3CR1 are expressed in the human brain after TBI and ICH and may be involved in the limitation of tissue damage.

Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70

AIM

Mortality and morbidity due to brain injury in the elderly population is a growing clinical problem: among older patients, those >70 years have a considerably higher risk both in terms of mortality and morbidity. Thereafter, the reasons influencing outcome have not been clearly examined: in the present study we addressed these questions considering the main clinical characteristics exerting a significant impact on the outcome of patients aged > 70, with emphasis for the severity of brain injury and anticoagulant (CAW) treatments.

METHODS

We performed a retrospective analysis of 103 consecutive isolated head injury patients older than 70, admitted at our Department in the period November 2004-November 2009. The clinical variables considered were as follow: age, sex, type of TBI, GCS, pre-TBI use of anti-coagulants (aspirin, warfarin, clopidogrel), INR at admission (INR values were subdivided in values >1.25 as at risk for hemorrhagic events and <1.25 as normal), initial CT scan classification looking at the presence of subarachnoid hemorrhage (t-SAH) or mass lesions; the main outcome measure was the Glasgow Outcome Scale.

RESULTS

The most frequent cause of TBI was accidental fall (65%): 39 were in CAW therapies and in 36 cases the cause of falling down injury was recorded due to a sincopal event (arterial hypotension, atrial fibrillation); in the older patients an accidental fall is significantly related to the TBI, while in the patients aged 70-75 years, TBI is related to a traffic accident (P=0.002). Moreover the cause of TBI correlates with the CAW treatment, the accidental fall being significantly more frequent in patients in CAW treatment (P=0.003). Overall mortality rate is significantly related to an elevated INR class, to presence of t-SAH (16/50 patients) and subdural hematoma (26/46).

CONCLUSION

The results of the present study show that in a population of patients aged > 70, TBI is a high risk event if patient has concurrent treatment with CAW therapies and if an accidental fall is the cause of TBI. In these cases the finding of t-SAH represents a high-risk parameter for mortality but not for morbidity.

Syndrome of inappropriate secretion of antidiuretic hormone in traumatic brain injury: when tolvaptan becomes a life saving drug

OBJECTIVE

To outline the role of a new drug, tolvaptan, in treating severe and chronic hyponatraemia. Tolvaptan decreases aquaporin expression in renal collecting ducts, by inhibiting antidiuretic hormone (ADH)-V2 receptors, to promote free water clearance. Given its mechanism of action, this drug seems the ideal treatment for the syndrome of inappropriate antidiuretic hormone secretion (SIADH) when the osmotic imbalance leads to life threatening complications.

DATA SOURCES

A case is described of severe hyponatraemia deriving from SIADH secondary to meningoencephalitis in a patient admitted to hospital for traumatic brain injury.

DATA EXTRACTION

Clinical, laboratory and radiological data at presentation and for a 1 year of follow-up were analysed.

DATA SYNTHESIS

Tolvaptan ameliorated hyponatraemia, brain oedema and consciousness, and drug withdrawal led to recurrence of hyponatraemia and coma.

CONCLUSIONS

In patients with SIADH, which is not self-limited, and is associated with severe cognitive impairment, the use Tolvaptan may prove life saving and should be rigorously evaluated.

Berengario da Carpi: a pioneer in neurotraumatology

Berengario da Carpi was one of the most famous physicians of the 16th century, a recognized master of anatomy and surgery, an emblematic "Renaissance man" who combined his medical experience and engineering knowledge to design new surgical instruments, and effectively used the arts of writing and drawing to describe state-of-the-art medicine and provide illustrations of anatomical structures. His greatest contribution to medicine was to write the most important work on craniocerebral surgery of the 16th century, the Tractatus de Fractura Calvae sive Cranei (Treatise on Fractures of the Calvaria or Cranium), in which he described an entire set of surgical instruments to be used for cranial operations to treat head traumas that became a reference for later generations of physicians. This was a systematic treatise covering the mechanisms, classification, and medical and surgical treatment of head traumas, and can be considered a milestone in the history of neurotraumatology.

Nonexpanded mesenchymal stem cells for regenerative medicine: yield in stromal vascular fraction from adipose tissues

The adipose-derived stromal vascular fraction (SVF) represents a rich source of mesenchymal cells, potentially able to differentiate into adipocytes, chondrocytes, osteoblasts, myocytes, cardiomyocytes, hepatocytes, and neuronal, epithelial, and endothelial cells. These cells are ideal candidates for use in regenerative medicine, tissue engineering, including gene therapy, and cell replacement cancer therapies. In this work, we aimed to the optimization of the adipose SVF-based therapy, and the effect of the collection site, surgical procedure, and tissue processing techniques on SVF yield was evaluated in terms of cell recovery and live cells, taking into account the effect of gender, age, and body mass index. Adipose tissue samples were recovered from 125 informed subjects (37 males and 88 females; mean age: 51.31 years; range: 15-87 years), and digested in different condition with collagenase. A multivariate linear model put in evidence that in males the best collection site in terms of yield is located in the abdomen, whereas in females the biopsy region do not influence cell recovery; the collection technique, the age, and the body mass index of donor seem not to influence the cell yield. The tissue-processing procedures strongly modify the yield and the vitality of cells: a collagenase concentration of 0.2% and a digestion time of 1 h could be chosen as the best operating conditions.

The microvascular network of the pituitary gland: a model for the application of fractal geometry to the analysis of angioarchitecture and angiogenesis of brain tumors

In geometrical terms, tumor vascularity is an exemplary anatomical system that irregularly fills a three-dimensional Euclidean space. This physical characteristic, together with the highly variable vessel shapes and surfaces, leads to considerable spatial and temporal heterogeneity in the delivery of oxygen, nutrients and drugs, and the removal of metabolites. Although these biological features have now been well established, quantitative analyses of neovascularity in two-dimensional histological sections still fail to view tumor architecture in non-Euclidean terms, and this leads to errors in visually interpreting the same tumor, and discordant results from different laboratories. A review of the literature concerning the application of microvessel density (MVD) estimates, an Euclidean-based approach used to quantify vascularity in normal and neoplastic pituitary tissues, revealed some disagreements in the results and led us to discuss the limitations of the Euclidean quantification of vascularity. Consequently, we introduced fractal geometry as a better means of quantifying the microvasculature of normal pituitary glands and pituitary adenomas, and found that the use of the surface fractal dimension is more appropriate than MVD for analysing the vascular network of both. We propose extending the application of this model to the analysis of the angiogenesis and angioarchitecture of brain tumors.

Lumbar arachnoiditis and thecaloscopy: brief review and proposed treatment algorithm

The term arachnoiditis describes the inflammation of the meninges and subarachnoid spaces. Lumbar arachnoiditis is characterized by obliterated nerve root sleeves and the adherence of nerve roots to each other in the proximity of the cauda equina, and may be secondary to infectious diseases or tumors, iatrogenic (subsequent to spinal surgery) or idiopathic. It is not very clearly defined epidemiologically or clinically, and various theories regarding its pathophysiology have been proposed; furthermore, its treatment is difficult because there is a lack of evidence-based diagnostic and therapeutic gold standards. Thecaloscopy has been recently described as a novel technique for retrograde transcutaneous neuroendoscopic inspection of the subarachnoid structures of the lumbar thecal sac; it has also been suggested for the treatment of lumbar arachnoiditis. We here review the most modern techniques for the treatment of this disease such as thecaloscopy and neurostimulation.

Addition of temozolomide to radiotherapy for treatment of newly diagnosed anaplastic gliomas

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Background: Anaplastic astrocytoma (AA), oligodendroglioma (AOD), and oligoastrocytoma (AOA) are rare tumors showing variable outcome due to their histological heterogeneity and different chemo- and radio-sensitivity. The presence of an oligodendroglial component is associated with LOH 1p/19 and a prolonged survival. Currently, the addition of chemotherapy to radiotherapy (RT) for newly diagnosed anaplastic gliomas is not sustained by available data. We evaluated the addition of temozolomide (TMZ) to radiotherapy for newly diagnosed anaplastic gliomas in terms of tolerability, progression-free survival (PFS), and overall survival (OS). Methods: Since September 2004, following initial surgery, patients (pts) with histologically confirmed anaplastic glioma, Karnofsky Performance Status (KPS) ≥40, adequate organ function, no prior chemotherapy, were treated with RT to limited fields once daily at 2 Gy per fraction, 5 days a week, for a total of 60 Gy with concomitant TMZ (75 mg/m2 for 7 days a week) followed by 6 cycles of maintenance TMZ at 200 mg/m2 on days 1–5 every 28 days. LOH 1p/19q was assessed by fluorescence in situ hybridization (FISH). Results: Twenty-eight pts were treated, 20 males, 8 females, median age 51 (range, 22–75), median KPS 90 (range, 40–100). Eleven pts had AOD (39%), 10 AA (36%), 6 AOA (21%), 1 pt gliosarcoma (4%). Nine pts (32%) underwent tumor complete resection, 10 partial resection (36%), and 9 (32%) tumor biopsy. In 1 patient with AOD RT and concomitant TMZ were interrupted at 44 Gy because of cerebral oedema, while in 1 patient with AA maintenance TMZ was suspended due to cumulative myelosuppression. Other severe toxicities included one spondilodiscitis, and a cutaneous G3 rush. Frequent mild toxicities were grade 1–2 nausea/vomiting (17 pts-63%), and grade 1–2 asthenia (8 pts-30%). With a median follow-up of 18 months (range, 4–53), median PFS, and 1-year PFS were 14.8 months and 72.6%, respectively; 1-year OS was 84.3%, median OS was not reached yet. Data on LOH 1p-19q available on 16 pts will be presented. Conclusions: The addition of temozolomide to radiation therapy for newly diagnosed anaplastic gliomas is well tolerated and seems active; efficacy needs confirmation in a randomized clinical trial.

No significant financial relationships to disclose.

A role for the transcription factor HEY1 in glioblastoma

Abstract Glioblastoma multiforme (GBM), the highest-grade glioma, is the most frequent tumour of the brain with a very poor prognosis and limited therapeutic options. Although little is known about the molecular mechanisms that underlie glioblastoma formation, a number of signal transduction routes, such as the Notch and Ras signalling pathways, seem to play an important role in the formation of GBM. In the present study, we show by in situ hybridization on primary tumour material that the transcription factor HEY1, a target of the Notch signalling pathway, is specifically up-regulated in glioma and that expression of HEY1 in GBM correlates with tumour-grade and survival. In addition, we show by chromatin immunoprecipitations, luciferase assays and Northern blot experiments that HEY1 is a bona fide target of the E2F family of transcription factors, connecting the Ras and Notch signalling pathways. Finally, we show that ectopic expression of HEY1 induces cell proliferation in neural stem cells, while depletion of HEY1 by RNA interference reduces proliferation of glioblastoma cells in tissue culture. Together, these data imply a role for HEY1 in the progression of GBM, and therefore we propose that HEY1 may be a therapeutic target for glioblastoma patients. Moreover, HEY1 may represent a molecular marker to distinguish GBM patients with a longer survival prognosis from those at high risk.

The neuroanatomical plates of Guido da Vigevano

Guido da Vigevano was an Italian physician and engineer who lived in the 13th and 14th centuries. He was the first scientist who used pictures to illustrate his anatomical descriptions, developing for the first time a close relationship between anatomical studies and artistic drawings. This was further developed in the Renaissance. In his textbook Anathomia are displayed six plates showing for the first time neuroanatomical structures and techniques: dissection of the head by means of trephination, and depictions of the meninges, cerebrum, and spinal cord. On the surface of the brain painting it is possible to recognize a vague patterning of cortical convolutions. Ventricles are also described and shown. This book constituted the first attempt in the history of neuroscience to illustrate an anatomical description with schematic pictures to achieve a better understanding of such complex structures.

Fractal dimension as a quantitator of the microvasculature of normal and adenomatous pituitary tissue

It is well known that angiogenesis is a complex process that accompanies neoplastic growth, but pituitary tumours are less vascularized than normal pituitary glands. Several analytical methods aimed at quantifying the vascular system in two-dimensional histological sections have been proposed, with very discordant results. In this study we investigated the non-Euclidean geometrical complexity of the two-dimensional microvasculature of normal pituitary glands and pituitary adenomas by quantifying the surface fractal dimension that measures its space-filling property. We found a statistical significant difference between the mean vascular surface fractal dimension estimated in normal versus adenomatous tissues (P = 0.01), normal versus secreting adenomatous tissues (P = 0.0003), and normal versus non-secreting adenomatous tissues (P = 0.047), whereas the difference between the secreting and non-secreting adenomatous tissues was not statistically significant. This study provides the first demonstration that fractal dimension is an objective and valid quantitator of the two-dimensional geometrical complexity of the pituitary gland microvascular network in physiological and pathological states. Further studies are needed to compare the vascular surface fractal dimension estimates in different subtypes of pituitary tumours and correlate them with clinical parameters in order to evaluate whether the distribution pattern of vascular growth is related to a particular state of the pituitary gland.

The neuroanatomical plates of Guido da Vigevano

✓Guido da Vigevano was an Italian physician and engineer who lived in the 13th and 14th centuries. He was the first scientist who used pictures to illustrate his anatomical descriptions, developing for the first time a close relationship between anatomical studies and artistic drawings. This was further developed in the Renaissance.

In his textbook Anathomia are displayed six plates showing for the first time neuroanatomical structures and techniques: dissection of the head by means of trephination, and depictions of the meninges, cerebrum, and spinal cord. On the surface of the brain painting it is possible to recognize a vague patterning of cortical convolutions. Ventricles are also described and shown. This book constituted the first attempt in the history of neuroscience to illustrate an anatomical description with schematic pictures to achieve a better understanding of such complex structures.

Intramedullary astrocytoma with granular cell differentiation

Granular cell astrocytomas are uncommon tumors of the central nervous system (CNS) of which no cases have been documented in the spinal cord. This variant of glioma should not be confused with benign granular cell tumor which, although rare, has been well characterized in the spinal cord. We describe here the clinical, pathological, and radiological features of such an astrocytoma arising within the spinal cord at the dorsal level. A 48-year-old female was seen after about 1 year of dorsal pain and gradual spastic paraparesis. Magnetic resonance imaging (MRI) studies showed a 2-cm contrast-enhanced mass in the spinal cord at T6-T7, which had the appearance of an astrocytoma. At surgery, the tumor was found to be infiltrating a posterior column with no dural attachment. It was debulked and dissected. The histological diagnosis was astrocytoma with granular cell differentiation. In addition to documenting a unique example of intramedullary granular cell astrocytoma, we review the literature to investigate differences from other tumors with granular changes described in the spinal cord.