A Benefit/Risk Assessment of Intrathecal Ziconotide in Chronic Pain: A Narrative Review.

BACKGROUND: Ziconotide is an intrathecal drug administered for the treatment of chronic pain. The current literature lacks an exhaustive benefit/risk assessment on this drug. We herein focus on Ziconotide's pharmacology and clinical applications. METHODS: Literature research was conducted to identify studies on Ziconotide administration for the treatment of chronic pain, published between January 1990 and March 2023 and located via PubMed, Embase, Medline, Cinahl, and Web of Science, using the following keywords: Ziconotide, Omega conotoxin, Prialt, SNX-111, intrathecal therapy, and neuropathic pain. Only publications written in English were selected. RESULTS: Among the 86 selected studies, we found 4 Randomized Controlled Trials (RCTs) and 3 prospective long-term studies concerning the intrathecal use of Ziconotide as a monotherapy in chronic pain. Other studies described the intrathecal infusion of Ziconotide combined with other drugs. Overall, Ziconotide has been proved to have strong efficacy for relieving chronic pain, although patients with co-morbid psychiatric disorders require a careful monitoring when treated with Ziconotide. CONCLUSIONS: Overall, the use of Ziconotide, as a monotherapy or in conjunction with other therapies for the treatment of chronic pain, was reported to be efficacious. Overall, its use in patients with chronic pain refractory to other pharmacologic agents outweighs the possible adverse consequences, thus resulting in a favorable benefit/risk assessment.

The Role of the Transorbital Superior Eyelid Approach in the Management of Selected Spheno-orbital Meningiomas: In-Depth Analysis of Indications, Technique, and Outcomes from the Study of a Cohort of 35 Patients.

Objective Primary goal in spheno-orbital meningioma (SOM) surgery still remains complete resection. Nevertheless, given their highly infiltrative nature, a growing body of literature suggests to shift toward function-sparing surgeries. We here present our experience in the management of SOMs through the endoscopic superior eyelid approach (SEA). Methods Surgical database from our multidisciplinary work group was retrospectively reviewed to identify patients treated for SOMs in the last 10 years by our senior authors, analyzing and correlating clinical, radiological, and outcome variables among the different approaches used. Results There were 35 patients (mean age of 57.3 ± 12.86 years), with a mean follow-up of 31.5 months (range: 6-84 months). The most common preoperative complaint was proptosis (62.9%) followed by diplopia and visual deficit. Greater and lesser sphenoid wings were the areas mainly involved by the pathology (91.4% and 88.6%, respectively), whereas orbital invasion was evidenced in one-third of cases. Patients were operated on through craniotomic (48.6%), endoscopic superior eyelid (37.1%), and combined cranioendoscopic (14.3%) approaches. Simpson grades 0 to II were accomplished in 46.2% of SEA and 76.5% of craniotomies. All patients with a preoperative visual deficit improved in the postoperative period, independently from the approach used. On patients who underwent endoscopic SEA, there was improved their short-/long-term postoperative Karnofsky Performance Status. Conclusions Endoscopic SEA is a safe and effective alternative to transcranial approaches in very selected cases of SOMs, where the planned primary objective was to obtain a maximally safe resection, aimed at symptom relief, rather than a gross total resection at any cost.

Endoscopic Endonasal Odontoidectomy Preserving Atlantoaxial Stability: a Pediatric Case.

Objectives We illustrate endoscopic endonasal odontoidectomy for the Chiari-I malformation respecting craniovertebral junction (CVJ) stability. Design Case report of a 12-year-old girl affected by the Chiari-I malformation. Magnetic resonance imaging (MRI) showed tonsillar herniation, basilar invagination, and dental retroversion, causing angulation and compression of the bulbomedullary junction. Patient underwent endoscopic third ventriculostomy (ETV) with reduction of ventricular size and resolution of gait disturbances, but she complained the Valsalva-induced headaches, hiccup, and dysesthesias in the lower limbs. Endoscopic endonasal odontoidectomy was chosen to decompress the cervicomedullary junction. Setting The research was conducted at University Hospital "Ospedale di Circolo," Department of Neurosurgery at Varese in Italy. Participants Patients were from neurosurgical and ENT (ear, nose, and throat) skull base team. Main Outcome Measures A bilateral paraseptal approach was performed, using a four-hand technique. After resection of posterior edge of the nasal septum, the choana is entered and a rhinopharynx muscle-mucosal flap is dissected subperiosteal and transposed in oral cavity. The CVJ is exposed and, using neuronavigation and neuromonitoring, odontoidectomy is fulfilled until dura is reached, preserving the anterior arch of C1. Reconstruction is obtained suturing the flap previously harvested. Results Postoperative course was unremarkable and the patient experienced improvement of symptoms. Postoperative MRI documented the appearance of tight cerebrospinal fluid (CSF) film anterior to bulbomedullary junction and in retrotonsillar spaces, opening of the bulbomedullary angle, and slight tonsils reduction. No CVJ instability was occurred with any need of posterior fixation. Conclusion Endoscopic endonasal odontoidectomy is a feasible approach for CVJ malformation. In this case, bulbar decompression was achieved preserving CVJ stability and avoiding posterior fixation. The link to the video can be found at: https://youtu.be/VIobocHfCuc .

Lower Grade Gliomas: Relationships Between Metabolic and Structural Imaging with Grading and Molecular Factors.

BACKGROUND: Positron emission tomography (PET) is a valuable tool for the characterization of brain tumors in vivo. However, few studies have investigated the correlation between carbon-11-methionine (11C-METH) PET metrics and the clinical, radiological, histological, and molecular features of patients affected by lower grade gliomas (LGGs). The present observational study evaluated the relationships between 11C-METH PET metrics and structural magnetic resonance imaging (MRI) findings with the histomolecular biomarkers in patients with LGGs who were candidates for surgery. METHODS: We enrolled 96 patients with pathologically proven LGG (51 men, 45 women; age 44.1 ± 13.7 years; 45 with grade II, 51 with grade III), who had been referred from March 2012 to January 2015 for tumor resection and had undergone preoperative 11C-METH PET. The semiquantitative metrics for 11C-METH PET included maximum standardized uptake value (SUVmax), SUV ratio to normal brain, and metabolic tumor burden (MTB). The PET semiquantitative metrics were analyzed and compared with the MRI features, histological diagnosis, isocitrate dehydrogenase-1/2 status, and 1p/19q codeletion. RESULTS: Histological grade was associated with SUVmax (P = 0.002), SUV ratio (P = 0.011), and MTB (P = 0.001), with grade III lesions showing higher values. Among the nonenhancing lesions on MRI, SUVmax (P = 0.001), SUV ratio (P = 0.003) and MTB (P < 0.001) were significantly different statistically for grade II versus grade III. The MRI lesion volume correlated poorly with MTB (r2 = 0.13). The SUVmax and SUV ratio were greater (P < 0.05) in isocitrate dehydrogenase-1/2 wild-type lesions, and the SUV ratio was associated with the presence of the 1p19q codeletion. CONCLUSIONS: The 11C-METH PET metrics correlated significantly with histological grade and the molecular profile. Semiquantitative PET metrics can improve the preoperative evaluation of LGGs and thus support clinical decision-making.

Minimally Invasive Transforaminal Lumbar Interbody Fusion with Percutaneous Bilateral Pedicle Screw Fixation for Lumbosacral Spine Degenerative Diseases. A Retrospective Database of 40 Consecutive Cases and Literature Review.

AIM: To report our results about minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) with bilateral pedicle screw fixation, in patients with degenerative lumbosacral spine disease. To describe the indications, surgical technique and results of a consecutive series of 40 patients who had undergone MI-TLIF. Despite the limited number of clinical studies, published data suggest tremendous potential advantages of this technique. MATERIAL AND METHODS: Forty patients with radiological findings of degenerative lumbosacral spine disease had undergone MI-TLIF between July 2012 and January 2015. Clinical outcomes were assessed by means of Oswestry Disability Index (ODI) and Health Survey Scoring (SF36) before surgery and at first year follow-up. Furthermore, the following parameters were retrospectively reviewed: age, sex, working activity, body mass index (BMI), type of degenerative disease, number of levels of fusion, operative time, blood loss, length of hospital stay. RESULTS: Average operative time was 230 minutes, mean estimated blood loss 170 mL, average length of hospital stay 5 days. The ODI improved from a score of 59, preoperatively, to post-operative score of 20 at first year follow-up. Average SF36 score increased from 36 to 54 (Physical Health) and from 29 to 50 (Mental Health) at first year outcome evaluation. CONCLUSION: MI-TLIF with bilateral pedicle screw fixation is an excellent choice for selected patients suffering from symptomatic degenerative lumbosacral spine disease, especially secondary to recurrent disc herniations.

Monopolar high-frequency language mapping: can it help in the surgical management of gliomas? A comparative clinical study.

OBJECT Intraoperative language mapping is traditionally performed with low-frequency bipolar stimulation (LFBS). High-frequency train-of-five stimulation delivered by a monopolar probe (HFMS) is an alternative technique for motor mapping, with a lower reported seizure incidence. The application of HFMS in language mapping is still limited. Authors of this study assessed the efficacy and safety of HFMS for language mapping during awake surgery, exploring its clinical impact compared with that of LFBS. METHODS Fifty-nine patients underwent awake surgery with neuropsychological testing, and LFBS and HFMS were compared. Frequency, type, and site of evoked interference were recorded. Language was scored preoperatively and 1 week and 3 months after surgery. Extent of resection was calculated as well. RESULTS High-frequency monopolar stimulation induced a language disturbance when the repetition rate was set at 3 Hz. Interference with counting (p = 0.17) and naming (p = 0.228) did not vary between HFMS and LFBS. These results held true when preoperative tumor volume, lesion site, histology, and recurrent surgery were considered. Intraoperative responses (1603) in all patients were compared. The error rate for both modalities differed from baseline values (p < 0.001) but not with one another (p = 0.06). Low-frequency bipolar stimulation sensitivity (0.458) and precision (0.665) were slightly higher than the HFMS counterparts (0.367 and 0.582, respectively). The error rate across the 3 types of language errors (articulatory, anomia, paraphasia) did not differ between the 2 stimulation methods (p = 0.279). CONCLUSIONS With proper setting adjustments, HFMS is a safe and effective technique for language mapping.