Publications by authors named "Antonino Raco"

109 Publications

The Lone Star Retractor System in Neurosurgery.

World Neurosurg 2021 Sep 26;153:36-40. Epub 2021 Jun 26.

Operative Unit of Neurosurgery, AOSA, Department of NESMOS, Sapienza, Rome, Italy.

Background: We investigated the role of a self-retaining retractor system, commonly used in ear, abdominal, vascular, urologic and gynecologic surgeries: the Lone Star retractor system. We report our experience in using the Lone Star retractor in different brain surgeries, at a single neurosurgical department.

Methods: In 2019, patients who underwent brain surgery and in which the Lone Star Retractor System was used were considered for inclusion. Clinical and surgical data of included patients were prospectively collected. Postoperative VAS for local pain, and a properly designed intraoperative retractor stability score, were collected.

Results: Over 2019, the Lone Stare Retractor was used in 20 neurosurgical procedures: 9 high-grade glioma, 2 low-grade glioma, 4 cerebral metastases, and 5 meningiomas. Postoperative mean VAS score was 3.5 (range: 2-4). Intraoperative retractor stability score mean was 2 in frontal, 2 in pterional, 1.75 in subtemporal, 2 in interhemispheric, and 0.5 in suboccipital approaches. The Stony Brook Scar Evaluation Scale mean value was 4.4 (range: 3-5).

Conclusions: In our institutional experience, the Lone Star retractor showed many advantages in different brain procedures, when compared with standard fishhooks and other retractors.
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http://dx.doi.org/10.1016/j.wneu.2021.06.097DOI Listing
September 2021

Long-term Radiologic and Clinical Outcomes after Three-level Contiguous Anterior Cervical Diskectomy and Fusion without Plating: A Multicentric Retrospective Study.

J Neurol Surg A Cent Eur Neurosurg 2021 May 19. Epub 2021 May 19.

UOC di Neurochirurgia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UCSC, Roma, Italy.

Background:  Anterior cervical diskectomy and fusion (ACDF) has been providing good surgical, clinical, and radiologic outcomes in patients suffering from cervical degenerative disk disease (DDD). However, the role of anterior plating is still debated, especially in three-level procedures. This study aimed to investigate long-term clinical and radiologic outcomes and complications after three-level contiguous ACDF without plating for cervical DDD.

Methods:  Two institutional databases were retrieved (January 2009-December 2014) for patients treated with three-level contiguous ACDF without plating. Minimum follow-up (FU) was 5 years. Demographical data, smoking status, implant types, Neck Disability Index (NDI), visual analog scale (VAS) for neck pain, complications, fusion rate, adjacent segment degeneration (ASD), cervical lordosis (CL), and residual segmental mobility were evaluated.

Results:  We enrolled 21 patients. Tantalum and carbon fiber cages were implanted, respectively, in 13 and 8 patients. The mean FU length was 5.76 ± 0.87 years. Mean NDI score was 78.29 ± 9.98% preoperatively and 8.29 ± 1.67% at last FU ( < 0.01), whereas mean VAS score decreased from 7.43 ± 1.14 preoperatively to 0.95 ± 0.95 at last FU ( < 0.01). Complications were one postoperative hematoma, one superficial wound infection, and five cases of postoperative dysphagia (recovered within 3 days). The fusion rate was 90% and ASD was reported in three (14%) cases. The mean CL was 6.33 ± 2.70 degrees preoperatively, 8.19 ± 1.97 degrees 3 months after surgery ( = 0.02), and 7.62 ± 1.96 degrees at latest FU. There was no residual mobility on every operated segment at last FU. The smoking status was an independent risk factor for nonfusion in this case series ( = 0.02).

Conclusions:  Three-level contiguous ACDF without plating seems to be an effective treatment for cervical DDD. Properly designed comparative clinical trials are needed to further investigate this topic.
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http://dx.doi.org/10.1055/s-0041-1726112DOI Listing
May 2021

Percutaneous Carbon-PEEK instrumentation for spine tumors: a prospective observational study.

J Neurosurg Sci 2021 Apr 16. Epub 2021 Apr 16.

N.E.S.M.O.S. Department, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.

Background: Minimally invasive spine surgery (MISS) has been progressively accepted as a useful approach for spine tumors. Recently released carbon-PEEK implants have been already reported as effective in open surgeries for spine tumors. This study aimed to evaluate the feasibility, surgical, clinical and radiological outcomes of a new percutaneous carbon-PEEK instrumentations for spine tumors.

Methods: This is a prospective case-control observational study. Demographical, clinical, surgical, and radiological data were collected from May 2018 to August 2019. Visual analogue scale for back pain (VAS), the Oswestry Disability Index (ODI) questionnaire, EORTC QLQ-C30 questionnaire for quality of life, and ASIA impairment scale (AIS) were collected before surgery and at 6 weeks and follow-up visits. Data were compared with the control group, a retrospective series of 23 metastatic patients that underwent titanium pedicle screw fixation.

Results: Twenty-one patients met inclusion criteria. Mean age was 59.2 years (range, 35-78) and mean follow-up was 14.2 months (7-22). Thoracic spine was involved in 14 (66.7%) cases, lumbar spine in 7 (33.3%). The mean length of surgery was 75 (42-185) minutes, mean blood loss was 90ml (50-215) and every patient was mobilized within 24 hours after surgery. The VAS (8.3±1.1 to 2.9±1.0, p<0.05) and ODI (54.6±11.7 to 25.1±5.4, p<0.05) scores significantly improved over follow-up. AIS improved in 7 (33.3%) patients and remained unchanged in 14 (66.7%). The EORTC QLQ-C30 global health/QoL, functional and symptomatic scales significantly improved postoperatively and at the last follow-up. Only two minor complications (9.5%) were recorded. No statistically significant difference was observed between the two groups related to clinical, radiological outcomes, complications rate and implant failure.

Conclusions: Percutaneous Carbon/PEEK implants could be considered as alternative to standard titanium implants in oncological patients, according to their lower rate of MRI artifacts, facilitating radiological follow-up and adjuvant radiotherapy. Further clinical trials and biomechanical evaluations are needed to confirm our preliminary results.
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http://dx.doi.org/10.23736/S0390-5616.21.05153-5DOI Listing
April 2021

Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Involving the Cervical Spine: Technical Nuances and Outcome of a Multicenter Experience.

Global Spine J 2021 Feb 16:2192568220988272. Epub 2021 Feb 16.

Department of Neurosurgery, S. Anna University Hospital, Ferrara, Italy.

Study Design: Retrospective multicenter.

Objectives: diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH.

Methods: Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA.

Results: 24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel ( = 0.12) to the burr ( = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level ( = 0.15). Use of curved chisel reduced the surgical times ( = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more ( = 0.04) and shorter waiting times for surgery ( < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery.

Conclusion: The "age of DISH" counts more than patients' age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.
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http://dx.doi.org/10.1177/2192568220988272DOI Listing
February 2021

Surgical treatment of intracranial blister aneurysms: A systematic review.

Clin Neurol Neurosurg 2021 Mar 6;202:106550. Epub 2021 Feb 6.

Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Background: Intracranial blister aneurysms (BAs) are challenging vascular lesions related to high morbidity and mortality rates. Different surgical and endovascular techniques have been proposed to treat BAs; however, there is no consensus on a preferred treatment.

Objective: To systematically review the pertinent literature on clinical and radiological outcomes of different surgical treatments for BAs management, to meta-analyze their clinical and radiological outcomes, and compare these results with those from recent meta-analyses on endovascular treatments for BAs.

Methods: The present study was consistently conducted according to the PRISMA guidelines. Five different online medical databases (PubMed, Medline, EMBASE, Scopus, and Web-of-Science) were screened from 2010 through 2020. Papers reporting clinical and radiological outcomes of different surgical treatments for BAs were considered. Event rates were pooled across studies using random-effects meta-analysis.

Results: A total of 35 studies reporting on 514 patients (534 aneurysms) were included. Aneurysm clipping in 223 patients (45.4%; 95% CI 21.9-53.8), bypass and trapping in 87 (17.7%; 95% CI 1.89-21.6), clipping and wrapping in 82 (16.7%; 95% CI 3.71-19.0), and wrapping in 33 (6.7%; 95% CI 0.0-4.87) were the mostly common performed treatments. Complete occlusion rate was reported in 90.7% of patients. The complication rate was as high as 61.1%, the mortality rate was 7.4%, and the mean mRS at follow-up was 2.5.

Conclusions: Our meta-analysis suggests that surgical treatments for BAs are related to higher occlusion, complications and mortality rate than endovascular strategies. However, there is a high-heterogeneity among the included studies and data are poorly reported; so comparing the two type of treatments is unreliable in order to establish which one is better.
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http://dx.doi.org/10.1016/j.clineuro.2021.106550DOI Listing
March 2021

Incidence of hemorrhagic cerebrovascular disease due to vascular malformations during the COVID-19 national quarantine in Italy.

Clin Neurol Neurosurg 2021 03 19;202:106503. Epub 2021 Jan 19.

Neurosurgery Department, S. Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.

Background: hemorrhagic cerebrovascular disease due to vascular malformations represents an emergency for neurosurgery and neuro-interventional departments. During the COVID-19 pandemic, a dramatic reduction in the number of hospitalizations for acute myocardial infarction or stroke and a larger time interval from symptom onset to first medical contact have been reported. This study aims to verify the hypothesis that there would also have been a reduction of admissions for hemorrhagic cerebrovascular disease during the Italian lockdown.

Material And Method: s A multicenter, observational survey was conducted to collect data on hospital admissions for hemorrhagic cerebrovascular disease due to vascular malformations throughout two-months (March 15th to May 15th); the years 2020 (COVID-19 Italian lockdown), 2019 and 2018 were compared. Cases were identified by ICD-9 codes 430, 431, 432.1, 432.9, 747.81 of each hospital database. The statistical significance of the difference between the event rate of one year versus the others was evaluated using Poisson Means test, assuming a constant population.

Results: During the 2020 lockdown, the total number of admissions for hemorrhagic cerebrovascular disease was 92 compared with 116 in 2019 and 95 in 2018. This difference was not significant. GCS upon admission was 3-8 in 44 % of cases in 2020 (41 patients), 39.7 % in 2019 (46 patients) and 28 % in 2018 (27 patients).

Conclusion: Reduction of admissions for hemorrhagic cerebrovascular disease due to vascular malformations during the COVID-19 lockdown was not confirmed. Nevertheless, some patients reached the emergency rooms only several days after symptoms onset, resulting in a worse clinical condition at admission.
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http://dx.doi.org/10.1016/j.clineuro.2021.106503DOI Listing
March 2021

Letter: Internal Auditory Canal Variability: Anatomic Variation Affects Cisternal Facial Nerve Visualization.

Oper Neurosurg (Hagerstown) 2021 02;20(3):E252-E253

Department of Neurosurgery AOSA, NESMOS Sapienza University of Rome Rome, Italy.

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http://dx.doi.org/10.1093/ons/opaa431DOI Listing
February 2021

Perioperative interruption of antiplatelet medications for elective extradural non-instrumented spine surgery: it is really necessary?

J Neurosurg Sci 2020 Dec 15. Epub 2020 Dec 15.

UOC di Neurochirurgia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

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http://dx.doi.org/10.23736/S0390-5616.20.05251-0DOI Listing
December 2020

Fenestration of Peritoneal Catheter to Avoid Abdominal Pseudocyst Formation after Ventriculoperitoneal Shunts: A Technical Note.

J Neurol Surg A Cent Eur Neurosurg 2021 Mar 1;82(2):166-168. Epub 2020 Dec 1.

Department of NESMOS, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Sant'Andrea Hospital, Rome, Italy.

Ventriculoperitoneal shunt (VPS) is a well-known procedure in the neurosurgical field. However, it has high complication and reoperation rates. Abdominal pseudocyst (APC) formation is a rare complication of VPS with reports in the literature varying from 4 to 10%. In this article, we report a simple and effective technique, with no additional cost, to avoid APC formation by making small multiple slits along the length of the peritoneal catheter.
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http://dx.doi.org/10.1055/s-0040-1712532DOI Listing
March 2021

Epidural bleeding secondary to a synovial cyst rupture: a case report and review of literature.

Br J Neurosurg 2020 Nov 26:1-3. Epub 2020 Nov 26.

NESMOS, Department of Neuroradiology, S. Andrea Hospital, University Sapienza, Rome, Italy.

Hemorrhage into a juxtafacet cyst is rare and cyst rupture with hemorrhagic extension into the epidural space is even less commonly seen. We describe the case of a patient with a hemorrhagic synovial cyst with rupture associated to abundant bleeding in the epidural space. A 61-year-old man had a 5-month history of worsening low back pain radiating into the right leg with associated weakness and numbness. A magnetic resonance imaging scan showed the presence of a mild anterior spondylolisthesis of L5 on S1 with increased synovial fluid into both facet joints. A suspected synovial cyst of the right facet joint at level L5-S1, with signal characteristics consistent with hemorrhage was seen. Caudally, epidural blood was evident from S1 to S2 that involved spinal canal and right S1 and S2 foramens. These findings were confirmed at surgery.
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http://dx.doi.org/10.1080/02688697.2020.1849547DOI Listing
November 2020

Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study.

J Neurosurg Spine 2020 Oct 2:1-5. Epub 2020 Oct 2.

6Hôpital Pierre Wertheimer, Lyon, France.

Objective: Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

Methods: The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

Results: Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

Conclusions: Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.
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http://dx.doi.org/10.3171/2020.6.SPINE20318DOI Listing
October 2020

The anterior-to-psoas approach for interbody fusion at the L5-S1 segment: clinical and radiological outcomes.

Neurosurg Focus 2020 09;49(3):E14

1Department of Neuroscience, Mental Health, and Sense Organs, "Sapienza" University of Rome, Sant'Andrea Hospital, Rome.

Objective: 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.

Methods: 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.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.3171/2020.6.FOCUS20335DOI Listing
September 2020

Neurosurgery at the time of COVID-19: how this pandemic infectious disease is influencing neurosurgical activities and patient management.

J Neurosurg Sci 2021 Apr 29;65(2):216-217. Epub 2020 Apr 29.

Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy.

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http://dx.doi.org/10.23736/S0390-5616.20.04976-0DOI Listing
April 2021

Histomorphology and immunohistochemical patterns in degenerative disc disease and clinical-radiological correlations: a prospective study.

Eur Spine J 2020 06 16;29(6):1410-1415. Epub 2020 Apr 16.

UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Sapienza, Roma, Italy.

Purpose: Degenerative disc disease (DDD) is a common condition causing low-back pain, disability and, eventually, neurological symptoms. This investigation aimed to investigate intervertebral disc DDD-related changes, evaluating histomorphology and cytokines secretion, and their clinical-radiological correlations.

Methods: This is a monocentric prospective observational study. A cohort of patients who underwent microdiscectomy for DDD, from June 2018 to January 2019, were enrolled. Discs samples were examined for histomorphology, chondrons count, immunohistochemistry for Hif-1α, Nf200 and Egr-1. Demographical and clinical data were also collected.

Results: Twenty patients were finally included. MRI evaluation showed a Modic I alteration in nine patients and a Modic II in 11. The disability grade was low-moderate (ODI score was ≤ 40%) in eight patients and high (ODI score > 40%) in 12. The Modic I was associated with a low-moderate disability in two (22%) patients and to a high disability in seven (88%) (p < 0.01). In Modic I group and in ODI > 40% groups, there were a significative higher mean disability grade 48.4 (± 8.3)%, number of chondrons per section, cells per chondron, Nf200+ nerve fibers and Hif-1α expression, compared with Modic II and ODI ≤ 40% groups, respectively. There were no differences in terms of Egr-1 expression.

Conclusions: The discs with Modic I MRI signal could represent potential targets for medical treatments, whereas Modic II seems to be a more likely point of no return in a degenerative process. Therefore, further investigations are to better investigate inflammatory pathways and degenerative mechanisms in DDD.
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http://dx.doi.org/10.1007/s00586-020-06412-9DOI Listing
June 2020

Impact of early surgery of ruptured cerebral aneurysms on vasospasm and hydrocephalus after SAH: Our preliminary results.

Clin Neurol Neurosurg 2020 05 3;192:105714. Epub 2020 Feb 3.

S. Andrea Hospital, Neurosurgery, University of Rome "La Sapienza", Roma, Italy.

Objective: Timing of surgical treatment of ruptured intracranial aneurysms has undergone a drastic change in the last few decades with preference for early surgery Our paper focuses specifically on the prognostic importance of timing of surgery, since early surgery of ruptured aneurysms provides immediately good clinical results. We present a series of cases operated in early and ultra early surgery, evaluating the technical aspects, the efficacy, the safety and the clinical results.

Patients And Methods: We retrospectively reviewed the clinical records and radiological imaging of patients treated for ruptured intracranial aneurysms who underwent early and ultra early clipping between January 2011 and April 2017 at our Institution. We included patients treated within the first 12 h and subsequently we divided our series in two subgroups based on the timing of surgery comparing the "early surgery" group (within 12 h) with the "ultra early surgery" group (within 6 h).

Results: Seventy-six (76) patients undergoing either early or ultra-early surgery for ruptured intracranial aneurysms have been reported Either early or ultra-early surgery showed a statistically favorable impact on reducing the incidence of both postoperative vasospasm and hydrocephalus. Ultra-early surgery group had the best outcome at the statistical analyses. (good postoperative 1Y GOSE.) CONCLUSIONS: We strongly believe that patients affected by ruptured intracranial aneurysms excluding Hunt and Hess grade V patients) should be treated as soon as possible and hence it should be considered as an emergency surgery. This approach prevents immediately a second bleeding of the aneurysm, allows to treat any associated condition of intracranial hypertension including hematomas and hydrocephalus and to use safely aggressive medical therapy such as hypertension.
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http://dx.doi.org/10.1016/j.clineuro.2020.105714DOI Listing
May 2020

Aggressive Vertebral Hemangioma Causing Acute Spinal Cord Compression.

J Neurosci Rural Pract 2019 Oct 23;10(4):672-674. Epub 2019 Oct 23.

Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy.

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http://dx.doi.org/10.1055/s-0039-1700611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6906107PMC
October 2019

Radiation-Induced Brain Aneurysms: Institutional Experience and State of the Art in the Contemporary Literature.

World Neurosurg 2020 Mar 9;135:339-351. Epub 2019 Oct 9.

IRCCS "Neuromed", Pozzilli, Isernia, Italy. Electronic address:

Background: Brain aneurysms (BAs) are the most common intracranial vascular condition, with an overall incidence of 1%-2%. Among the common causes of their initial formation and growth, the role of radiation therapy (RT) has been reported in some studies. The aim of the present study is to report the most relevant features of BA related to a previous cranial RT.

Methods: Data deriving from 1 patient treated for RT-induced BA in our institution were added to reports of another 66 BAs retrieved from the literature. The following parameters were evaluated: age, sex, location, primary lesion, clinical presentation, dosage/amount of radiation delivered, type of treatment for the BA, dimension, morphology, chemotherapy, comorbidities, risk factors, and number of BAs.

Results: The most commonly involved vessel was the internal carotid artery (34%). In general, the anterior circulation showed higher vulnerability compared with the posterior circulation and middle cerebral artery (56.7%). The average latency between RT and the first imaging showing the BA was 9.01 ± 6.85 years. Vessels coursing in the posterior cranial fossa showed a significant univariate association with lower X-ray dosages (P = 0.014) compared with the other locations. No statistically significant correlation between the continuous variables age, latency of BA appearance, RT delivered dose, and dimension of the BA was shown.

Conclusions: The apparent higher fragility of the vascular structures of the posterior cranial fossa was statistically outlined, and the X-ray dosage, the primary condition target of the RT, the age of the patients, and no statistically significant correlation were outlined. Biological factors could play a significant role.
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http://dx.doi.org/10.1016/j.wneu.2019.09.157DOI Listing
March 2020

Microsurgical Treatment of Anterior Communicating Artery Aneurysms: A 20-year Single-institution Experience.

J Neurol Surg A Cent Eur Neurosurg 2020 Jan 23;81(1):33-43. Epub 2019 Sep 23.

NESMOS Department, "Sapienza" University of Rome, Rome, Italy.

Background:  Anterior communicating artery (AComA) aneurysms are the most frequent intracranial aneurysms. They have a high risk of rupture, morbidity, and mortality following rupture. Surgical treatment is complex because of their deep location, proximity to the perforators, and their different projections and relations with the parent vessels. This retrospective study reports our experience in the surgical management of AComA aneurysms, describing how the microsurgical strategy is influenced by their projection and size, the orientation of the AComA complex, and the location and caliber of the parent vessels.

Methods:  We reviewed all the patients treated surgically at our institution from September 1995 to March 2015 for ruptured and unruptured AComA aneurysms. Operative reports, neuroimages, and intraoperative videos were analyzed, and the surgical technique was examined. Illustrative cases are also included.

Results:  A complete documentation was available for 223 (75.3%) of the 296 treated patients. Medium-size (55.1%) and superiorly projecting (31.8%) aneurysms were the most represented; 158 patients (70.9%) had different A1 diameters. A left- or right-sided pterional approach was performed in 85 patients (38.1%) and 138 patients (61.9%), respectively. A complete occlusion was documented in 185 patients (83%).

Conclusions:  Posterior and superior projections are the most complex to deal with because of the difficult dissection of the perforators and the contralateral A2, respectively. Approaching from the side of the dominant A1 ensures a prompt proximal control. Searching preoperatively for an eventual rotation of the AComA complex and for the location of the A2s can be very helpful for intraoperative orientation.
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http://dx.doi.org/10.1055/s-0039-1685507DOI Listing
January 2020

Corrigendum to "Spinal dural tenting sutures in intradural tumor surgery: A technical insight" [J Clin Neurosci 61 (2019) 322-323].

J Clin Neurosci 2020 04 6;74:274. Epub 2019 Aug 6.

A.O.U. "Sant'Andrea", Neurosurgery Division, Sapienza University, Rome, NESMOS Department, Via di Grottarossa, 1035-1039, 00189 Roma, Italy.

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http://dx.doi.org/10.1016/j.jocn.2019.06.002DOI Listing
April 2020

Spinal cordectomy for the management of thoracic malignant intraspinal tumors in paraplegic or irreversibly, severely paraparetic patients: A technical remark.

J Clin Neurosci 2019 Oct 18;68:308-311. Epub 2019 Jul 18.

IRCCS, "Neuromed", Via Atinense 18, 86077 Pozzilli, IS, Italy.

Background: Malignant Intramedullary Spinal Cord Tumor are a relatively uncommon entity affecting patients whose prognosis is quickly and relentlessly dismal. Since the '50s Spinal Cordectomy' has been advocated for the surgical management of these conditions, but to date, no standard operative protocol has been reported yet.

Objective: Although apparently "easy", burdened by virtually no further risk for the neurological function in paraplegic or severely paraparetic patients, SCt conceals notable pitfalls and surgical problems that are to date not yet completely discussed. The objective of the present paper is therefore to report a detailed stepwise description of the surgical technique.

Methods And Results: SCt addresses the problem of reaching a surgical radicality in patients whom neurological preoperative conditions have already irreversibly declined to a deep nonfunctional motor impairment and whose preoperative Brain MRI scan rules out intracranial seeding. The dural sac along with the radicular pouches must be considered as possible seeding and recurrence locations therefore such structure should be "en-bloc" removed. The cranial medullary end of the resection should be identified on the ground of the preoperative MRI and intraoperatively confirmed with fresh histological examinations ruling out the presence of tumor cells above the cordectomy. Due to the topographic and functional medullary arterial anatomy, no SCt should be performed above T3. The risk of postoperative sagittal imbalance is high and therefore a concurrent posterior vertebral stabilization is required.

Conclusion: Spinal Cordectomy is a safe and feasible "last chance" treatment to prolong survival in paraplegic or severely paraparetic patients.
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http://dx.doi.org/10.1016/j.jocn.2019.07.041DOI Listing
October 2019

Spatial and temporal characteristics of the spine muscles activation during walking in patients with lumbar instability due to degenerative lumbar disk disease: Evaluation in pre-surgical setting.

Hum Mov Sci 2019 May 29;66:371-382. Epub 2019 May 29.

Department of NESMOS, Sapienza University, Rome, Italy.

Our purpose was to investigate the spatial and temporal profile of the paraspinal muscle activation during gait in a group of 13 patients with lumbar instability (LI) in a pre-surgical setting compared to the results with those from both 13 healthy controls (HC) and a sample of 7 patients with failed back surgery syndrome (FBSS), which represents a chronic untreatable condition, in which the spine muscles function is expected to be widely impaired. Spatiotemporal gait parameters, trunk kinematics, and muscle activation were measured through a motion analysis system integrated with a surface EMG device. The bilateral paraspinal muscles (longissimus) at L3-L4, L4-L5, and L5-S1 levels and lumbar iliocostalis muscles were evaluated. Statistical analysis revealed significant differences between groups in the step length, step width, and trunk bending and rotation. As regard the EMG analysis, significant differences were found in the cross-correlation, full-width percentage and center of activation values between groups, for all muscles investigated. Patients with LI, showed preserved trunk movements compared to HC but a series of EMG abnormalities of the spinal muscles, in terms of left-right symmetry, top-down synchronization, and spatiotemporal activation and modulation compared to the HC group. In patients with LI some of such EMG abnormalities regarded mainly the segment involved by the instability and were strictly correlated to the pain perception. Conversely, in patients with FBSS the EMG abnormalities regarded all the spinal muscles, irrespective to the segment involved, and were correlated to the disease's severity. Furthermore, patients with FBSS showed reduced lateral bending and rotation of the trunk and a reduced gait performance and balance. Our methodological approach to analyze the functional status of patients with LI due to spine disease with surgical indications, even in more complex conditions such as deformities, could allow to evaluate the biomechanics of the spine in the preoperative conditions and, in the future, to verify whether and which surgical procedure may either preserve or improve the spine muscle function during gait.
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http://dx.doi.org/10.1016/j.humov.2019.05.013DOI Listing
May 2019

Spinal Myxopapillary Ependymoma: The Sapienza University Experience and Comprehensive Literature Review Concerning the Clinical Course of 1602 Patients.

World Neurosurg 2019 Sep 29;129:245-253. Epub 2019 May 29.

Neurosurgery Division, NESMOS Department, A.O.U. "Sant'Andrea", Sapienza University - Rome, Rome, Italy.

Background: Spinal myxopapillary ependymoma (sMPE) is an uncommon primary spinal neoplasm infiltrating the spinal cord, conus medullaris (CM), and nerve roots. It is associated with low resection and high recurrence rates. The purpose of this literature review is to evaluate the exact impact of the involvement of the CM and the role played by gross total resection (GTR) on overall survival (OS).

Methods: The English literature was systematically investigated using MEDLINE, the NIH Library, PubMed, and Google Scholar search engines with relevant queries. Case series reporting details concerning OS, GTR, and CM involvement rate were included, with a differential statistical weight given by the number of patients enrolled. A final cohort of 1602 clinical records was analyzed according to the 3 selected end point variables.

Results: The average age was 36.44 ± 3.41 years, and the CM was involved in 28.4% ± 28.2% of cases. The average GTR rate was 53.94% ± 22.20%. Five- and 10-year OS rates were respectively available in 1170 and 1167 cases, with an average 5- and 10-year OS rate of 94.99% ± 3.87% and 92.31% ± 5.73%. By means of analyses performed both on aggregated and disaggregated data a strong positive statistical connection between GTR and increased OS was demonstrated despite the real clinical advantage could range as low as around 1% of increased OS rate.

Conclusions: Given the indolent sMPE behavior, it is difficult to evaluate the exact impact of GTR and CM involvement on OS; however, GTR could be associated with a limited survival advantage, whereas CM involvement could be associated with a survival disadvantage.
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http://dx.doi.org/10.1016/j.wneu.2019.05.206DOI Listing
September 2019

Minimally Invasive Surgery for the Treatment of Traumatic Monosegmental Thoracolumbar Burst Fractures: Clinical and Radiologic Outcomes of 144 Patients With a 6-year Follow-Up Comparing Two Groups With or Without Intermediate Screw.

Clin Spine Surg 2019 05;32(4):E171-E176

N.E.S.M.O.S Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome.

Study Design: This was a retrospective study of the clinical and radiologic outcomes of traumatic thoracolumbar (TL) burst fractures.

Objectives: We aimed to evaluate the clinical and radiologic outcomes after 6 years of follow-up of 144 patients with monosegmental TL burst fractures treated with percutaneous short-segment pedicle screw fixation, comparing two groups with versus without placement of an intermediate screw at the fractured vertebra.

Summary Of Background Data: Traumatic TL fractures are the most common vertebral fractures, especially at the TL junction (T10-L2). Minimally invasive surgery (MIS) is a valuable treatment option for traumatic TL burst fractures.

Materials And Methods: The clinical outcomes and radiologic parameters (Cobb angle, midsagittal index, and sagittal index) of 144 patients with traumatic monosegmental TL fractures treated with MIS were evaluated preoperatively, postoperatively, and after 3 and 6 years of follow-up. Patients were categorized into a nonintermediate screw group (nISG) and an intermediate screw group (ISG), and the groups were compared.

Results: There were 71 patients (49.3%) in the nISG and 73 patients (50.7%) in the ISG. The radiologic parameters improved significantly more from the preoperative evaluation to the 6-year follow-up in the ISG than in the nISG (P<0.025). There were no significant differences in the mean Oswestry Disability Index (ODI) and Visual Analog Scale scores at the 6-year follow-up between the ISG and the nISG: 15.6% (ISG) versus 16.8% (nISG) for ODI (P<0.1) and 2.2 (ISG) versus 2.4 (nISG) for Visual Analog Scale score (P<0.85) (P<0.73).

Conclusions: MIS showed good clinical outcomes 6 years after surgery in both the ISG and the nISG. The additional intermediate screw significantly improved radiologic parameters but not clinical outcomes.
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http://dx.doi.org/10.1097/BSD.0000000000000791DOI Listing
May 2019

Long-term clinical outcomes after bilateral laminotomy or total laminectomy for lumbar spinal stenosis: a single-institution experience.

Neurosurg Focus 2019 05;46(5):E2

1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ''Sapienza" University of Rome, Sant'Andrea Hospital, Rome.

OBJECTIVELumbar 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.METHODSThe 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.RESULTSTwo 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).CONCLUSIONSBilateral 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.
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http://dx.doi.org/10.3171/2019.2.FOCUS18651DOI Listing
May 2019

Spinal Epidural Lipomatosis: Weight Loss Cure.

World Neurosurg 2019 05 26;125:368-370. Epub 2019 Feb 26.

N.E.S.M.O.S. Department, Faculty of Medicine and Psychology, ''Sapienza,'' University of Rome, Sant'Andrea Hospital, Rome, Italy.

A 47-year-old male patient presented at our neurosurgery unit with neurogenic claudication symptoms. The patient had a history of low back pain and lower extremity pain for 2 years. He had a body mass index of 38. Magnetic resonance imaging of the lumbar spine demonstrated severe stenosis due to spinal epidural lipomatosis. The patient was treated conservatively, and after weight loss in 13 months (body mass index of 29) he had full recovery of neurologic symptoms. A follow-up magnetic resonance image obtained 14 months after showed complete resolution of spinal epidural lipomatosis.
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http://dx.doi.org/10.1016/j.wneu.2019.02.051DOI Listing
May 2019

Spinal dural tenting sutures in intradural tumor surgery: A technical insight.

J Clin Neurosci 2019 Mar 28;61:322-323. Epub 2018 Oct 28.

A.O.U. "Sant'Andrea", Neurosurgery Division, Sapienza University, Rome, NESMOS Department, Via di Grottarossa, 1035-1039, 00189 Roma, Italy.

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http://dx.doi.org/10.1016/j.jocn.2018.10.085DOI Listing
March 2019

Trigonal and Peritrigonal Lesions of the Lateral Ventricle: Presurgical Tractographic Planning and Clinic Outcome Evaluation.

World Neurosurg 2018 Dec 30. Epub 2018 Dec 30.

NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Rome, Italy.

Background: Surgery of lesions within the atrium of the lateral ventricle remains a challenging procedure because of the deep location and the relationship to vascular structures. The aim of this study was to determine the usefulness of tractography to evaluate the position of white matter tracts located along the course of the surgical access to trigonal and peritrigonal lesions.

Methods: Diffusion tensor imaging (DTI) was acquired in 19 patients. All patients underwent surgical resection of brain tumors. Pre- and postoperative clinical conditions were evaluated by a neurosurgeon, using the Karnofsky Performance Status Scale. The corticospinal tract, optic radiation, and arcuate fasciculum were reconstructed because of their location close to the trigonal region. Two neurosurgeons were asked to assess the surgical approach with and without tractography.

Results: According to the tractographic reconstructions, the surgical access was chosen from the middle temporal gyrus in 12 patients (63%) and the posterior parietal gyrus in 7 patients (37%), leading to an a priori change in the surgical approach in 14 patients (73%). Six patients (31%) showed new postsurgical transient symptoms, whereas in 2 patients (10%) the deficits were permanent. After 30 days, the Karnofsky Performance Status Scale evaluation showed an improvement or a substantial stability of symptoms in 90% of cases. In 2 patients, a worsening of 30% of clinical performance was appreciable.

Conclusions: The use of DTI in preoperative planning of trigonal and peritrigonal lesions may help in description of the best surgical approach for patient; this technique allows to reach the tumors, saving the white matter tracts, when it is possible.
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http://dx.doi.org/10.1016/j.wneu.2018.12.086DOI Listing
December 2018

Pneumoventricle of Unknown Origin: A Personal Experience and Literature Review of a Clinical Enigma.

World Neurosurg 2019 Feb 15;122:661-664. Epub 2018 Nov 15.

A.U.O. "Sant'Andrea", Neurosurgery Division, NESMOS Department, Sapienza University, Rome, Italy.

Background: Pneumocephalus is an uncommon and life-threatening neurologic condition. Air within the ventricular system of the brain is also known as pneumoventricle (PV). It requires emergency treatments to prevent catastrophic neurologic outcomes. Head injury is the most common cause of PV, but there are other well-recognized etiologies in case there is no clear radiological evidence of skull discontinuity.

Case Description: Although this clinical entity has been well described in the literature, our report presents the unique feature of describing a purely ventricular pneumocephalus without evidence of skull base or cranial vault fracture. Therefore, this case presentation explores mysterious causes of fistulous connections with the atmosphere that may lead to air trapped in and around the cranial vault.

Conclusions: The aim of the present paper is to report a case of post-traumatic PV without radiological signs of skull base or convexity fracture in a 72-year-old man, underlining the diagnostic and clinical features, and review the relevant literature.
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http://dx.doi.org/10.1016/j.wneu.2018.11.050DOI Listing
February 2019
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