Implementation of Robotic Exoscope in Minimally Invasive Corpectomy at Thoracolumbar Junction for the Treatment of Traumatic Spinal Cord Compression.

The development and diffusion of minimally invasive (MI) approaches have coincided with improvements in magnification systems. The exoscope will probably open a new era in new technologies in spinal surgery. This study reports a retrospective series of 19 thoracolumbar (T11-L2) burst fractures with anterior column failure and cord compression, treated with MI corpectomy and spinal decompression assisted by a three-dimensional high-definition exoscope (Video 1). Exclusion criteria were pathologic or osteoporotic fractures, multilevel fractures, and previous surgery at the site of the fracture. Three key indicators were recorded: surgical time, blood loss, and intraoperative complications. A questionnaire was administered to assess the users' exoscope experience with ergonomics, preparation, magnification, image definition, illumination, and user-friendliness, compared with the operative microscope. To the best of our knowledge, this is the first study reporting on exoscope-assisted MI corpectomy. This procedure permitted low blood loss and less surgical time without intraoperative complications. The exoscope offers clear advantages in terms of ergonomics, definition, and user-friendliness. Moreover, it is a suitable instrument for training and education, providing an opportunity for better interaction with other members of the surgical staff.

Integrated spine trauma team protocol: Combined neurosurgical and orthopedic experience for the management of traumatic spinal injuries.

Objectives: During the last decades, spine surgery has grown exponentially. In spite of that, it remains a surgical specialty without a well-defined own certification. It is usually carried out, separately, by neurosurgeons and orthopedic surgeons, even if there is an overlapping of competence and skills. Materials and Methods: In our hospital, from January 2019, a systematic protocol called integrated spine trauma team protocol (ISTTP) was implemented to improve the management of traumatic spinal injuries in a multidisciplinary way. It is characterized by a specific algorithm from diagnosis to postoperative care. According to the new protocol, orthopedic spinal surgeons and neurosurgeons work together as an integrated spine trauma team. The authors analyzed, retrospectively, the results obtained by comparing patients treated before and after the application of the ISTTP. Results: The new protocol allowed a statistically significant reduction in waiting time before surgery and complication rate. Moreover, early discharge of patients was recorded. To the best of our knowledge, this is the first study that described a specific algorithm for a standardized multidisciplinary management of the spinal trauma with combined orthopedic and neurosurgeon expertise. Conclusion: Our preliminary results suggest that the application of our ISTTP leads to better results for treating traumatic spinal injury (TSI).

Spinal injury in major trauma: Epidemiology of 1104 cases from an Italian first level trauma center.

INTRODUCTION: Traumatic spinal injuries are frequent and their management is debated, especially in major trauma patients. This study aims to describe a large population of major trauma patients with vertebral fractures to improve prevention measures and fracture management. PATIENTS AND METHODS: Retrospective analysis of 6274 trauma patients prospectively collected between October 2010 and October 2020. Collected data include demographics, mechanism of trauma, type of imaging, fracture morphology, associated injuries, injury severity score (ISS), survival, and death timing. The statistical analysis focused on mechanism of trauma and the search of predictive factors for critical fractures. RESULTS: Patients showed a mean age of 47 years and 72.5% were males. Trauma included 59.9% of road accidents and 35.1% of falls. 30.7% patients had at least a severe fracture, while 17.2% had fractures in multiple spinal regions. 13.7% fractures were complicated by spinal cord injury (SCI). The mean ISS of the total population was 26.4 (SD 16.3), with 70.7% patients having an ISS≥16. There is a higher rate of severe fractures in fall cases (40.1%) compared to RA (21.9% to 26.3%). The probability of a severe fracture increased by 164% in the case of fall and by 77% in presence of AIS≥3 associated injury of head/neck while reduced by 34% in presence of extremities associated injuries. Multiple level injuries increased with ISS rise and in the case of extremities associated injuries. The probability of a severe upper cervical fracture increased by 5.95 times in the presence of facial associated injuries. The mean length of stay was 24.7 days and 9.6% of patients died. CONCLUSIONS: In Italy, road accidents are still the most frequent trauma mechanism and cause more cervico-thoracic fractures, while falls cause more lumbar fractures. Spinal cord injuries represent an indicator of more severe trauma. In motorcyclists or fallers/jumpers, there is a higher risk of severe fractures. When a spinal injury is diagnosed, the probability of a second vertebral fracture is consistent. These data could help the decisional workflow in the management of major trauma patients with vertebral injury.

Giant calcified thoracic disk herniations: ossification of PLL or autonomous entity?

BACKGROUND: Giant calcified thoracic disk herniation (GCTD) is an uncommon event, which requires surgical treatment in less than 1% of patients. GCDTs are a specific subgroup of herniated thoracic disks occupying more than 40% of the spinal canal showing calcifications associated with a certain degree of ossification. In this paper, we are reporting our whole experience in the surgical management of GCTDs through anterior approaches. We believe that they present characteristics that associate them to the circumscribed type of Ossified Posterior Longitudinal Ligament (OPLL) with a possible common pathophysiology consisting in the dural violation. METHODS: Twenty-three consecutive patients with GCDTs were managed through anterior approaches during the period 1996-2019 at the Niguarda Hospital - Milan, Italy. Clinical data, radiological features, surgical reports, histological findings, and outcomes were reviewed. RESULTS: There was no mortality, whereas permanent morbidity consisted of 1 cases of worsened paraparesis due to accidental spinal cord contusion. One patient required reoperation to repair a postoperative cerebrospinal fluid (CSF) leakage. All patients underwent postoperative MRI which showed excellent decompression of cord and dural sac in all cases. Histological study of en-bloc removed GCTD showed typical calcification patterns of the PLL. CONCLUSIONS: GCDTs may be assimilated to the so-called "circumscribed type" of OPLL. The GCDTs may show the same radiological CT and MRI pattern of OPLL. The anterior accesses now represent the standard of care for GCTDs. The use of operative microscope and intraoperative monitoring is mandatory. The risk of CSF leakage can be markedly reduced by meticulous reconstruction of the dura and the placement of spinal drainage. Adequate exposition may sometimes require one or two levels of corpectomy with consequent vertebral body reconstruction and fixation of anterior column of the spine.

Complications of Halo Placement.

BACKGROUND: The halo vest is widely used throughout the world to manage craniovertebral and cervical instabilities. It can be used for postoperative immobilization or as an alternative to surgical fixation. METHOD: In this paper we present some cases of severe complications from our own practice and review the literature on halo complications. RESULTS: Like any therapeutic manoeuvre, halo placement may be followed by various complications. In the meantime, modern techniques of fixation offer safe and immediate stabilization. CONCLUSION: The halo vest remains a formidable method for cervical immobilization. However, it should not be used a priori instead of surgery.

A new model to predict the influence of surface temperature on contact angle.

The measurement of the equilibrium contact angle (ECA) of a weakly evaporating sessile drop becomes very challenging when the temperatures are higher than ambient temperature. Since the ECA is a critical input parameter for numerical simulations of diabatic processes, it is relevant to know the variation of the ECA with the fluid and wall temperatures. Several research groups have studied the effect of temperature on ECA either experimentally, with direct measures, or numerically, using molecular dynamic simulations. However, there is some disagreement between the authors. In this paper two possible theoretical models are presented, describing how the ECA varies with the surface temperature. These two models (called Decreasing Trend Model and Unsymmetrical Trend Model, respectively) are compared with experimental measurements. Within the experimental errors, the equilibrium contact angle shows a decrease with increasing surface temperatures on the hydrophilic surface. Conversely the ECA appears approximately constant on hydrophobic surfaces for increasing wall temperatures. The two conclusions for practical applications for weakly evaporating conditions are that (i) the higher the ECA, the smaller is the effect of the surface temperature, (ii) a good evaluation of the decrease of the ECA with the surface temperature can be obtained by the proposed DTM approach.

The Typical Presentation Spectrum of Deep Vein Thrombosis Associated with Inferior Vena Cava Malformations.

Congenital malformations of the inferior vena cava (IVC) are rare and underreported. They can be a risk factor for deep venous thrombosis (DVT) as a result of inadequate venous drainage of the lower extremities through collateral circulation. The significant number of cases reported in the literature highlights their importance, warranting investigating their existence in younger individuals with idiopathic DVT of the lower extremities and pelvic veins. In this systematic review, we depict the typical presentation of IVC malformations, their management, and the management of their associated DVT.

Strong nonlinear terahertz response induced by Dirac surface states in Bi2Se3 topological insulator.

Electrons with a linear energy/momentum dispersion are called massless Dirac electrons and represent the low-energy excitations in exotic materials such as graphene and topological insulators. Dirac electrons are characterized by notable properties such as a high mobility, a tunable density and, in topological insulators, a protection against backscattering through the spin-momentum locking mechanism. All those properties make graphene and topological insulators appealing for plasmonics applications. However, Dirac electrons are expected to present also a strong nonlinear optical behaviour. This should mirror in phenomena such as electromagnetic-induced transparency and harmonic generation. Here we demonstrate that in Bi2Se3 topological insulator, an electromagnetic-induced transparency is achieved under the application of a strong terahertz electric field. This effect, concomitantly determined by harmonic generation and charge-mobility reduction, is exclusively related to the presence of Dirac electron at the surface of Bi2Se3, and opens the road towards tunable terahertz nonlinear optical devices based on topological insulator materials.

Is robot-assisted laparoscopic right colectomy more effective than the conventional laparoscopic procedure? A meta-analysis of short-term outcomes.

AIM: The use of robotic technology procedures has proved to be safe and effective, arising as a helpful alternative to standard laparoscopic surgery in a variety of colorectal procedures. However, the role of robotic assistance in laparoscopic right colectomy is still not demonstrated. METHODS: A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library and Google Scholar up to 30th August 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the currently available data regarding the incidence of anastomotic leakage, operative time, intra-operative blood loss, conversion rate, retrieved lymphnodes, post-operative hemorrhage, intra-abdominal abscess, time to 1st flatus, post-operative ileus, wound infection, incisional hernia, not-surgical complications, total complications, hospital stay, post-operative mortality, surgery-related costs and total costs, in conventional laparoscopic right colectomy (LRC) compared to robot-assisted laparoscopic right colectomy (RRC). RESULTS: Overall 8 studies were included, thus resulting in 616 patients. The meta-analysis showed that the RRC decreases the intra-operative blood loss and the time to the 1st flatus, if compared to the LRC. On the other hand, the robotic assistance increases the operative time and the surgery-related costs. No statistically significant differences were found about the other post-operative outcomes. CONCLUSION: RRC may ensure limited improvements in post-operative outcome, thus increasing procedural costs and without a proved enhanced oncological accuracy to date, if compared to the LRC.

The craniovertebral junction area and the role of the ligaments and membranes.

Traumatic injuries of the craniovertebral junction (CVJ) area are common and frequently the outcome of motor vehicle accidents, falls, and diving accidents. To define and characterize CVJ traumatic injuries, some international classifications are currently in use, and they are thought and focused on junction bone fracture. However, recent data point out a major important role of the CVJ ligaments and membranes in traumatic injuries with a secondary function of the osseous structures. Emphasizing the correct role of the ligaments and membranes is extremely important for determining appropriate medical or surgical planning for patients and also to design new CVJ injury classifications. We reviewed every recent major publication on the ligaments and membranes of the CVJ area. We divided the information into sections concerning anatomy, embryology, biomechanics, trauma, and CVJ bone fractures. A role of the ligaments and membranes in the traumatic injuries of the CVJ area has often been recognized; but only recently, with the increase in the knowledge of the anatomic and biomechanical junction area, supported by neuroradiological tools (magnetic resonance imaging) and a more detailed traumatic injuries assessment, has the role of the ligaments and membranes been highlighted. Ligaments and membranes have a pivotal role in each junctional ability and are the key to orienting any medical or surgical indications in this unique area of the spine.

Traumatic injuries to the craniovertebral junction: a review of rare events.

The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns. Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare. In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries. In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability. Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management. We provide a guide for correctly identifying "rare" craniovertebral junction traumatic injuries.

Mapping the transverse coherence of the self amplified spontaneous emission of a free-electron laser with the heterodyne speckle method.

The two-dimensional single shot transverse coherence of the Self-Amplified Spontaneous Emission of the SPARC_LAB Free-Electron Laser was measured through the statistical analysis of a speckle field produced by heterodyning the radiation beam with a huge number of reference waves, scattered by a suspension of particles. In this paper we report the measurements and the evaluation of the transverse coherence along the SPARC_LAB undulator modules. The measure method was demonstrated to be precise and robust, it does not require any a priori assumptions and can be implemented over a wide range of wavelengths, from the optical radiation to the x-rays.

Great saphenous vein surgery without high ligation of the saphenofemoral junction.

OBJECTIVE: The aim of this study was to evaluate whether great saphenous vein (GSV) surgery without high ligation of the saphenofemoral junction (SFJ) is beneficial in terms of varicose vein recurrence. METHODS: This was a prospective randomized trial set in a private practice. From December 2000 to May 2004, 120 patients were enrolled. Patients were randomly allocated preoperatively to two groups undergoing GSV surgery with (group A, n = 60) or without (group B, n = 60) high ligation of the SFJ. In four patients (two in each group), both limbs were operated on. Inclusion criteria were primary varicose veins with SFJ incompetence resulting in GSV reflux. Exclusion criteria were age <18 years, inability to give informed consent, associated small saphenous vein incompetence, and prior GSV surgery. Mean follow-up was 8 years and was complete in all but one patient (99.2%). The primary end point was varicose vein recurrence, defined as treated lower limbs with new thigh varices at clinical evaluation (CEAP ≥ 2) or venous reflux at the thigh or groin level, as assessed by duplex ultrasound imaging. RESULTS: The follow-up included 123 limbs. The combined clinical and ultrasound-determined recurrence rate was 24.4% (30 of 123): 32.2% (20 of 62) in group A vs 16.4% (10 of 61) in group B (P = .045). Postoperatively, recurrence of even minimal varices was observed in 24 limbs (19.5%): 18 of 62 (29.0%) in group A vs six of 61 (9.8%) in group B (P = .014). The ultrasound-detected recurrence rate was 22% (27 of 123): 32.2% (20 of 62) in group A vs 11.4% (7 of 61) in group B (P = .010). The average time to recurrence was 3.5 ± 1.2 years in group A and 4.1 ± 1.6 years in group B (P = .258). CONCLUSIONS: GSV surgery without high ligation of the SFJ is associated with low rates of clinical and ultrasound-determined recurrence of varicose veins.

Traumatic (type II) odontoid fracture with transverse atlantal ligament injury: a controversial event.

OBJECTIVE: Traumatic (Type II) odontoid fractures are very common injuries. Nevertheless, their connection with transverse atlantal ligament injury is controversial and poorly defined. The aim of this study is to report a single case of traumatic (type II) odontoid fracture with transverse atlantal ligament injury and to critically analyze the role of ligaments and membranes together with neuroradiological tools in the management of craniovertebral junction-traumatized patients. METHODS: We report 27 consecutive cases of traumatic (type II) odontoid fractures who underwent magnetic resonance imaging (MRI) in the acute phase injury (<72 hours), focusing our attention on the transverse atlantal ligament. RESULTS: One patient (3.7%) demonstrated a transverse atlantal ligament injury on MRI. The patient underwent surgery. CONCLUSIONS: Traumatic (type II) odontoid fracture with transverse atlantal ligament avulsion can be considered an unusual event. It is our opinion that the routine use of MRI for all patients with type II odontoid fracture could be unjustified in clinical practice. Strict clinical surveillance of all patients managed conservatively and the use of MRI in selected cases could be a reasonable management option.

Single fracture in the atlas vertebral arch: analysis of an unusual event.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study is to show that a single traumatic fracture of the atlas is unusual but not rare and requires specific management strategies, which can be highlighted by the study of the junctional ligaments and membranes. SUMMARY OF BACKGROUND DATA: A single traumatic fracture of the atlas arch is considered a rare event and has been analyzed in few case reports. Ligaments and membranes play a primary role in providing stability to the craniovertebral junction area. METHODS: Here, we report 10 cases of a single traumatic fracture of the atlas arch: 4 cases were part of our series of spine injuries and were studied by magnetic resonance imaging during the acute phase to assess the junctional ligaments. The remaining 6 cases were obtained from the Literature. RESULTS: Indirect signs of a traumatic ligamentous injury were found only in 1 patient. However, in all cases, these fractures were considered biomechanically stable and all patients were discharged with a rigid collar. During the follow-up, all patients reported an improvement in their neck pain and tenderness, with radiologic signs of bone healing. CONCLUSIONS: A single fracture of the atlas arch is an unusual traumatic event that results from slow-force impact. Medical experience in treating this specific fracture subtype is nowadays poor because of the paucity of the literature; thus, this unusual condition may either be underestimated or even overstudied and overtreated. Nowadays, it seems reasonable to assume that the management should be conservative in all cases and that magnetic resonance imaging often plays only a marginal role.

The anterior stand-alone approach (ASAA) during the acute phase of spondylodiscitis: results in 40 consecutively treated patients.

PURPOSE: Spondylodiscitis mainly affects the anterior part of the spine. In this paper, we retrospectively analyze our experience with the anterior stand-alone approach (ASAA) in the treatment of spinal infections. METHODS: Forty consecutive patients with severe spondylodiscitis underwent the ASAA during the acute infective phase. Treatment consisted of disease debridement, vertebral body reconstruction using titanium expandable prostheses and anterior fixation. RESULTS: There was neither mortality nor major morbidity. Successful arthrodesis was achieved in 39 out of 40 patients who remained disease free throughout the follow-up period. Six months after treatment, one patient experienced pseudarthrosis and required supplemented posterior spinal fixation for vertebral instability. However, adequate arthrodesis was eventually obtained even in this patient. CONCLUSIONS: ASAA with spine reconstruction using synthetic materials during the acute infection phase was safe and effective. The infections were rapidly defeated, the patients were allowed to stand up early after the procedure and the length of hospital stay was significantly reduced.

The craniovertebral junction area and the role of the ligaments and membranes.

Traumatic injuries of the craniovertebral junction (CVJ) area are common and frequently the outcome of motor vehicle accidents, falls, and diving accidents. To define and characterize CVJ traumatic injuries, some international classifications are currently in use, and they are thought and focused on junction bone fracture. However, recent data point out a major important role of the CVJ ligaments and membranes in traumatic injuries with a secondary function of the osseous structures. Emphasizing the correct role of the ligaments and membranes is extremely important for determining appropriate medical or surgical planning for patients and also to design new CVJ injury classifications. We reviewed every recent major publication on the ligaments and membranes of the CVJ area. We divided the information into sections concerning anatomy, embryology, biomechanics, trauma, and CVJ bone fractures. A role of the ligaments and membranes in the traumatic injuries of the CVJ area has often been recognized; but only recently, with the increase in the knowledge of the anatomic and biomechanical junction area, supported by neuroradiological tools (magnetic resonance imaging) and a more detailed traumatic injuries assessment, has the role of the ligaments and membranes been highlighted. Ligaments and membranes have a pivotal role in each junctional ability and are the key to orienting any medical or surgical indications in this unique area of the spine.

Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases.

OBJECT: The authors report on a series of 145 consecutive patients with different types of spine lesions surgically treated via an anterior approach (AA) at the thoracic and lumbar levels during the past 10 years. Indications, techniques, and surgical results are described. METHODS: This series included 92 patients with fractures, 30 with neoplasms, 13 with thoracic disc hernias, and 10 with spinal infections. Based on the lesion to be addressed, the AA was used for lesion excision, corpectomy, vertebral body reconstruction with cages, realignment, and/or plating or screwing. The approach was extracavitary in 55 patients and intracavitary in 90. In 126 patients (86.8%), neural decompression and spine stabilization were achieved via a stand-alone AA (SA-AA), whereas 19 patients (13.1%) were treated using a 2-stage anteroposterior approach. This circumferential approach was reserved for select cases of severe traumatic dislocation, particular types of tumors, or specific anatomical locations. The authors developed a simple neuronavigation-based method of identifying the severely injured patients who were eligible for the SA-AA by evaluating the angle of lateral dislocation. RESULTS: There were no deaths and no instances of major surgery-related morbidity. Minor morbidity was almost always transitory and was reported in 13 patients (8.9%). Neurological improvement was reported in 20% of injured patients with a preoperative incomplete lesion. Postoperatively, all patients were able to stand or at least sit without load pain. During the follow-up (mean +/- standard deviation 3.8 +/- 2.4 years), there were no cases of failure, fracture, dislocation, or bending of the anterior instrumentation, and the rate of pseudarthrosis was 0%. CONCLUSION: The anterior route provides direct access to most spine diseases and allows optimal neural decompression and the possibility of adequate realignment and strong reconstruction/fixation. Stability of the vertebral column is achieved, resolution of clinical pain is rapid and almost complete, and the rate of surgical complications is very low. The authors assert that the SA-AA offers so many advantages and has such good results that the 2-stage anteroposterior approach can be reserved for a minority of select cases and that the time for using the posterior approach alone is over.