Treatment of remote type ii axis fractures in the elderly: feasibility of anterior odontoid screw fixation.

OBJECTIVE: This preliminary study considers the feasibility and the results of anterior screw fixation in elderly patients with remote Type II axis fractures. Odontoid fractures are the most common fractures of the cervical spine in people 70 years of age or older. In developing countries, direct anterior fracture fixation is replacing posterior fusion in many cases. Recently, it has been demonstrated that patient age does not influence the outcome in terms of fusion after odontoid screw fixation. There is considerable disagreement about correct treatment in the case of remote fractures. In the literature, there have been no studies considering the feasibility and results of anterior screw fixation in elderly patients with remote Type II axis fractures. METHODS: From 1989 to 2005, we observed 9 patients over the age of 65 years with isolated Type II remote fractures of the dens. All fractures were considered to be inveterate, as the traumatic events had occurred 6 to 12 months earlier. All fractures were treated with anterior infibulation of the dens with single 3.5-mm cannulated screws. RESULTS: A bony fusion was radiologically documented in 7 patients (77%) 4 to 16 months after the intervention. In 1 patient, a fibrous union was observed. The neurological status remained unchanged in all patients, and no patients showed any neurological impairment at the time of follow-up. CONCLUSION: According to our preliminary study, the technique appears to be feasible for remote axis fractures within 12 months of trauma, and it seems to be safe for elderly patients. Further data from additional studies are needed.

Brain metastasis from non-seminomatous germ cell tumors of the testis: indications for aggressive treatment.

Brain metastases from non-seminomatous germ cell tumors (NSGCTs) are rare and mainly occur in young men whose clinical condition is unimpaired. The records of 15 patients with brain metastasis from non-seminomatous germ cell tumors of the testis, who had been surgically treated between 1984 and 1998, were retrospectively reviewed. All of the patients had undergone surgery plus whole-brain radiotherapy (WBRT), and chemotherapy based on cisplatin. On admission they had a median age of 33 years and their mean Karnofsky performance scale (KPS) score was >70. Mean survival was 37.7 months. Eight patients had a survival period longer than 5 years. Five patients belonged to radiation therapy oncology group (RTOG) class I; all of them survived. There was a significant difference in survival time between patients in whom the brain metastasis was present at diagnosis (six survivors at 5 years; mean survival 53 months) and patients in whom the brain metastasis occurred during or after chemotherapy (two survivors at 5 years; mean survival 24 months) (P = 0.04). The presence of a trophoblastic component at histopathological analysis of the metastasis negatively influenced survival at univariate analysis. Multiple brain metastasis proved to be a significant risk factor at both univariate and multivariate analysis, while a metastatic residue with a diameter less than 2 cm after surgery did not negatively affect survival in our series. Prognosis is worst in patients with multiple brain metastases, in whom brain involvement occurred during or after cisplatin-based chemotherapy. Considering that these metastases are often both radiosensitive and chemosensitive, and mainly affect young men that are in very good clinical condition, we advocate aggressive treatment with surgery plus adjuvant radiotherapy and chemotherapy. This is mandatory in patients with large metastases (diameter >3 cm).

Use of carbon fiber cages for treatment of cervical myeloradiculopathies.

BACKGROUND: Different types of intersomatic fixation systems are available for use in the treatment of cervical disc pathologies. In this paper, we report our experience using carbon fiber cages (Brantigan I/F cage, De Puy Acromed, Raynham, MA; Mikai distrib.) for acute and chronic cervical disc pathologies. METHODS: Between 1997 and 2001, 97 patients underwent surgical treatment for cervical disc pathologies. Follow-up ranged from 1 to 60 months. In all cases a microdiscectomy according to Caspar was performed; anterior stabilization was performed in cases with evidence of instability and in post-traumatic disc herniations. RESULTS: A total number of 119 carbon fiber cages, ranging in height from 4 to 8 mm, were employed as well as 10 anterior plates with screws. The type of material used to fill the cages was homologous bone (50.5%), heterologous bone (22.3%), hydroxyapatite (21.1%), and autologous bone (6%). In all cases, follow-up radiograms performed after at least 6 months demonstrated bone fusion. None of the patients had either spontaneous displacement of the implant or symptoms from nerve compression. CONCLUSIONS: These preliminary results suggest that anterior cervical fusion with carbon fiber cages are valid to restore intervertebral disc height and to promote bone fusion with low complications rate.

Surgical options in the management of falcotentorial meningiomas: report of 13 cases.

BACKGROUND: The primary aim of surgical treatment for falcotentorial meningiomas is gross total excision. The vital surrounding brain structures make this a complex task. Seeking elements that might facilitate presurgical planning we reviewed our surgical records of falcotentorial meningiomas treated during the past 20 years. METHODS: Between 1975 and 1996, in the Neurosurgical Unit at the University of Rome, "La Sapienza," 13 consecutive patients underwent surgery for falcotentorial meningiomas that had been localized on preoperative imaging and confirmed by histology. The surgical approach varied according to the site of the tumor. RESULTS: Nine meningiomas were totally removed and 4 subtotally. Three patients (23.0%), all treated early in the series, died after the operation. Ten patients (76.9%) survived: 3 (23.0%) had postoperative neurologic complications necessitating reintervention, and 7 patients (53.8%) had an uneventful postoperative course. Two of the 4 patients who had subtotal resections had regrowth at 1 year that responded to radiosurgery. CONCLUSIONS: The ideal surgical approach to falcotentorial meningiomas should allow gross total removal and minimum brain retraction while safeguarding the galenic system and other vital neighboring structures. Toward achieving this aim we propose detailed preoperative imaging studies to classify falcotentorial meningiomas according to their site and direction of growth-craniocaudal or anteroposterior-in relation to the cerebellar tentorium.