Posterior spinal fusion in patients with spinal muscular atrophy: a surgical technique to allow intrathecally inject nusinersen.

BACKGROUND: Nusinersen, the recently approved medical therapy in the treatment of spinal muscular atrophy (SMA), has revolutionized the natural history of this disease. Until now, surgical treatment of scoliosis in SMA patients was an exclusion criterion for drug therapy. In fact, the bone graft positioned posteriorly during surgery, in order to obtain a solid fusion, prevented the lumbar puncture necessary for the intrathecal administration of the drug. The aim is to describe a surgical technique that allows for safe and easy intrathecal administration of nusinersen. METHODS: We present a single-center, single-surgeon case series descriptive study. From 2019 to 2021 seven consecutive patients affected by genetically confirmed SMA suitable for treatment with nusinersen and suffered from neuromuscular scoliosis needing posterior spinal fusion surgery were included in the present study. During posterior spinal fusion surgery a L3-L4 or L2-L3 laminectomy was performed to provide safer access to intrathecal injection. The drainage scar was used as a skin landmark so as to facilitate future procedures. RESULTS: The median of operative time was 250 min (range: 200-370 min). The median correction rate was 57% (range: 43.5-68). The median of intraoperative blood loss was 650 mL (range 320-940 mL). The median value of the correction loss at the last follow-up was 10% (range: 4.5-15%). CONCLUSIONS: The surgical procedure allowed all patients to receive nusinersen therapy without complications. The procedure described is simple and effective in providing safe intrathecal access to make these patients suitable for undertaking or continuing the protocol of treatment with nusinersen.

Arthrodesis versus dynamic neutralization: A short/mid- and long-term retrospective evaluation in degenerative disk disease treatment.

Study Design: This was a retrospective comparative study. Objectives: The aim of this study was to perform a clinical and radiological retrospective evaluation of the most used techniques for the lumbar degenerative disk disease (DDD) treatment: arthrodesis versus dynamic neutralization (DN)-Dynesys dynamic stabilization system. Methods: The study included 58 consecutive patients affected by lumbar DDD, 28 treated with rigid stabilization and 30 with DN at our department between 2003 and 2013. The clinical evaluation was performed through the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). The radiographic evaluation was performed through standard and dynamic X-ray projections and magnetic resonance imaging. Results: Both techniques determined a clinical improvement in the postoperative period compared to the preoperative one. There were no significant differences between the postoperative VAS of the two techniques. The DN group postoperative ODI percentage showed a significant improvement (P = 0.026) compared to the arthrodesis group. During the follow-up, no clinically significant differences were highlighted between the two techniques. At a long term follow up period, radiographic results showed, in both groups, a L3-L4 disk mean height reduction and an increase of segmental and lumbar lordosis without significant differences between the two techniques. During an average of 96-month follow-up period, 5 (18%) patients developed an adjacent segment disease in the arthrodesis group and 6 (20%) patients developed this syndrome in the DN group. Conclusions: We are confident in recommending arthrodesis and DN as effective techniques for lumbar DDD treatment. Both techniques are potentially burdened, with similar frequency, by the development of long-term adjacent segment disease.

Surgical approach to single-level symptomatic thoracic disc herniations through costotransversectomy: A report of ten case series.

Study Design: This was an observational study. Objectives: The treatment of symptomatic thoracic disc herniation (TDH) remains a matter of debate. We report our experience with ten patients affected by symptomatic TDH, surgically treated through costotransversectomy. Methods: A total of ten patients (four men and six women) with single-level symptomatic TDH were surgically treated by two senior spine surgeons at our institution between 2009 and 2021. The most common type was a soft hernia. TDHs were classified as lateral (5) or paracentral (5). Preoperative clinical symptoms were varied. The diagnosis was confirmed by computed tomography (CT) and magnetic resonance imaging of the thoracic spine. The mean follow-up period was 38 months (range: 12-67 months). The Oswestry Disability Index (ODI), the Frankel grading system, and the modified Japanese Orthopedic Association (mJOA) scoring system were used as outcome scores. Results: Postoperative CT study documented satisfactory decompression either on the nerve root or the spinal cord. All patients experienced a reduction of disability with an improved mean ODI score by 60%. Six patients reported total recovery of neurological function (Frankel Grade E) and four patients improved by 1 Grade (40%). The overall recovery rate estimated with the mJOA score was 43.5%. We reported the absence of significant difference in outcome compared to either calcified and noncalcified discs or paramedian and lateral location. Four patients had minor complications. No revision surgery was required. Conclusion: Costotransversectomy represents a valuable tool for spine surgeons. The major limit of this technique is the possibility to approach the anterior spinal cord.

Case series of four complex spinal deformities: new frontiers in pre-operative planning.

BACKGROUND AND AIM: Osseous and medullar anomalies constitute a hard challenge for interpretation of complex vertebral deformities anatomy. To better frame these deformities three-Dimensional (3D) printing represents a new frontier in this field. The aim of this brief report is describing the use of 3D printed models for surgical planning in four complex vertebral deformity cases treatment. METHODS: Four cases of severe scoliosis were treated between December 2017 and January 2019; patients' mean age was 12,25 years. Two patients underwent neurosurgical intervention for myelomeningocele at the time of birth. Standard and dynamics X-Ray, Computed Tomography (CT) and Magnetic Resonance (MR) of the column were performed pre-operatively. CT files were implemented to build the 3D model of each spine and selected ribs. The models were 3D printed in thermoplastic material, then used to study the deformities and for surgical planning. A survey proposal about 3D models' utility and accuracy has been made to 15 residents and 6 main surgeons. RESULTS: Preparation of each 3D models required about 316.5 minutes and printing time was about 108 hours each. The average cost was 183.16 € to produce one 3D printed model, which resulted useful in surgical planning and educational. CONCLUSIONS: The manufacture of 3D models requires time, resources and multidisciplinary approach, it must be justified by complexity of the case. In this study 3D Printing allowed surgeons to carefully plan and simulate the surgery, ensuring for a better sizing of the implant.

Non-specific spondylodiscitis: a new perspective for surgical treatment.

PURPOSE: Pyogenic spondylodiscitis is a relatively rare spinal disease; non-specific spondylodiscitis (NSS) cases are increasing. This study aims to identify if changes of inflammatory markers under antibiotic therapy can be used to determine which NSS patients can benefit from surgical indication earlier than others. METHODS: Two groups of patients with NSS were examined. Group A underwent surgery, while Group B was treated conservatively. Group B was also subdivided in patients undergoing antibiotic therapy for > 6 weeks (B1) and < 6 weeks (B2). Groups were compared for age, gender, BMI, blood levels of ESR and CRP and VAS scale. RESULTS: There were no differences (P = 0.06) in reduction in ESR at 4 weeks between two main groups. A reduction in CRP, with < 2.7 mg/dl at 4 weeks, was observed in Group A (P = 0.01). Comparing Group B1 to B2, a reduction (P = 0.0001) in VAS, ESR and CRP at 4 weeks was observed in Group B2. It was possible to isolate the pathogen in 52.8% of Group B, without any differences on VAS, ESR and CRP values and on length of the antibiotic therapy. CONCLUSIONS: The surgical treatment should be considered for patients who, after 4 weeks of conservative therapy, do not show a reduction in the ESR < 50 mm/h and of the CRP < 2.7 g/dl. The comparison between groups underwent surgically and those treated conservatively showed a reduction in the CRP at 4 weeks and better VAS for pain at 3 months in Group A.

A New Single Volar Approach for Both-Bone Fractures of the Forearm: The Mediolateral Windows Approach Extended.

Fractures of the forearm are common injuries in adults. Particularly, both-bone fractures of the radius and ulna are frequently encountered by orthopedic surgeons. To date, these fractures are typically treated with open reduction and internal fixation, because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. We propose a modification of the classic double approach for both-bone fractures of the distal radius and ulna. Indeed, we described a minimal and anatomic approach to prevent complications such as the heterotopic ossification of the interosseus membrane and vascular-nervous lesions. By a single anterior incision, we utilize 2 windows to expose the medial and lateral compartments of the forearm. In this way, we avoid the handling of the interosseous membrane, and we protect the ulnar, median, and radial nerves from the surgical approach. This technique is indicated for complex distal radius and ulna fractures. We exclude open fractures, and Monteggia, Galeazzi, or Essex-Lopresti lesions. In this report, we describe the surgical anatomy, surgical approach, and complications regarding this approach.

Pediatric intervertebral disc calcification: case series and systematic review of the literature.

Pediatric intervertebral disc calcification (PIDC) is an uncommon disease with an unclear etiology. The clinical picture may suggest a severe spinal disease, thus involving an extensive differential diagnosis. The aim of this study was to find a diagnostic and treatment approach for PIDC on the basis of the literature. The Medline, Embase, Web of Science, and Cochrane Systematic Review databases were searched for relevant studies, whose reference lists were checked manually for additional articles. For each study, year of publication, study design, demographics, onset type, history of trauma, clinical and neurological signs and symptoms, imaging studies performed, blood test results, treatment strategies, and outcomes were recorded. The charts of eight patients with symptomatic PIDC treated at our institution from 2000 to 2016 were reviewed. Of 1522 articles identified by the search, 51 level IV studies involving 91 patients fulfilled the inclusion criteria. Most patients were treated conservatively and achieved complete recovery. Of the 13 patients who were treated surgically, one had a persistent myelopathy at the final follow-up. All the patients of our case series were treated conservatively and achieved complete symptom resolution at the final follow-up. PIDC is predominantly a benign and self-limiting condition. Surgery should be considered only in case of failure of conservative treatment in the presence of severe neurological impairment and myelopathy. Level of Evidence: IV (case series and systematic review of level IV studies).

Mesenchymal Stem Cells from Nucleus Pulposus and Neural Differentiation Potential: a Continuous Challenge.

Mesenchymal stem cells (MSCs) are well-characterized adult stem cells, recently isolated from human nucleus pulposus of degenerate and non-degenerate intervertebral disc. The attention to this source is linked to its embryologic history and cells may conserve a stronger aptitude to neuronal differentiation than other MSCs. Here, MSCs from nucleus pulposus (NP-MSCs) were successfully isolated and characterized for morphology, proliferation, and expression of selected genes. Subsequently, the neuronal differentiation was induced by 10 days of culture with a neuronal medium. NP-MSCs subjected to neural differentiation media (NP-MSCs-N) showed a morphological and biochemical modifications. NP-MSCs-N displayed elongated shape with protrusion, intermediate filaments, microtubules, and electron dense granules and the ability to form neurospheres. Even if they expressed neural markers such as NESTIN, ß-TUBULIN III, MAP-2, GAP-43, and ENOLASE-2, the neural differentiated cells did not show neither spontaneous nor evoked intracellular calcium variations compared to the undifferentiated cells, suggesting that cells do not have electric functional properties. Further studies are required in order to get a better understanding and characterization of NP-MSCs and analyzed the molecular mechanisms that regulate their neural differentiation potential.

Is posterior fixation alone effective to prevent the late kyphosis after T-L fracture?

INTRODUCTION: The posterior transpedicular fixation technique is a standard procedure for stabilizing the injured thoracolumbar spine but the long-term results of this approach are controversial. Clear guidelines are missing and the literature shows complete disagreement regarding indications, approaches, surgical techniques, and type of fixation. MATERIAL AND METHOD: The objective of this study is to investigate if the surgical treatment by posterior approach alone is always enough to prevent the late kyphotic deformity through the retrospective analysis of 219 patients affected with a thoracolumbar injury. Follow-up examinations included radiographic measurements of the sagittal index (SI) and the sagittal plane kyphosis (SPK). RESULT: Results show that, at the follow-up, the SI remains almost stable after the surgical correction, while the SPK (which describes the eventual injury of the affected intervertebral disc) decreases indicating a progressive regional kyphotic deformity. Thus, in some cases posterior fixation alone is not sufficient for long-term spinal stabilization and often can be not effective to prevent the late kyphotic deformity.

"In situ" fusion or reduction in high-grade high dysplastic developmental spondylolisthesis (HDSS).

PURPOSE: To assess if the evaluation of the spino-pelvic balance can be effective in the surgical decision making of the high-grade high dysplastic developmental spondylolisthesis (HDDS). METHODS: Sixteen patients affected with high-grade HDDS (6 treated with "in situ" fusion, and 10 with reduction and fusion) were retrospectively evaluated. A clinical and radiological assessment of the deformity correction was carried out, with a minimum follow-up of 2 years. The differences between the pre- and postoperative measures were statistically analyzed using a two-tailed, paired t test. RESULTS: The six patients treated with "in situ" fusion showed no statistically significant change at the last follow-up relative to pelvic tilt (PT), sacral slope (SS), and grade, while the 10 patients treated with reduction showed significant changes: PT significantly decreased following surgery, while SS and grade significantly increased. CONCLUSIONS: The analysis of the spino-pelvic sagittal balance allows to identify two types of HDDS: the balanced deformities, which do not need reduction, and the unbalanced deformities, in which correction is needed.