Degenerative L4-L5 spondylolisthesis and stenosis surgery: does over-level flavectomy technique influence clinical outcomes and rates of cranial adjacent segment disease?

BACKGROUND: One of the most dreaded long-term complications related to L4-L5 lumbar arthrodesis is the onset of adjacent segment disease, which most frequently occurs at the cranial level. Few studies have compared the rates of cranial adjacent segment disease (CASD) in patients undergoing lumbar fusion associated with total laminectomy at the same level with those undergoing partial laminectomy. No study has examined the role of selective over-level flavectomy (OLF; i.e., L3-L4). METHODS: A total of 299 patients undergoing posterolateral arthrodesis (PLA) for L4-L5 degenerative spondylolisthesis were retrospectively analyzed with a 5-year follow-up. 148 patients underwent PLA + L4-L5 flavectomy + L4 partial laminectomy (control group), while 151 underwent PLA + L4-L5 flavectomy + total L4 laminectomy + L3-L4 flavectomy (OLF group). Rates of reoperations due to CASD were examined utilizing Cox proportional hazard models, while clinical improvement at follow-up (measured in ODI) was analyzed using generalized linear models (GLMs). Adjustments for potential confounders were made (grade of lumbar lordosis, age, sex, BMI, intervertebral disc degeneration, and presurgical cranial spinal stenosis). RESULTS: At 5 years from the operation, 16 patients (10.8%) in the control group had undergone revision surgery for CASD compared to 5 patients (3.3%) in the OLF group (p = 0.013). Survival analysis and GLM demonstrated that the OLF group had a significantly lower incidence of CASD and presented more favorable clinical outcome. There were no differences in the rate of discal degeneration or the onset of Meyerding's grade I degenerative spondylolisthesis at the adjacent segment. BMI was the only other significant predictor of ODI improvement and of the incidence of CASD. CONCLUSIONS: In patients with L4-L5 degenerative spondylolisthesis and stenosis, the OLF technique may lower rates of CASD and improve clinical outcomes by preventing cranial spinal stenosis without increasing iatrogenic instability or accelerating intervertebral disc degenerative changes.

Fluorescein sodium-guided resection of a cerebellar lymphoma: case report and literature review.

We report on a patient, who underwent the resection of a cerebellar primary central nervous system lymphoma and was administered intraoperative fluorescein sodium to improve the visualization of the tumor and guide surgery. Low-dosage fluorescein was administered prior to opening the dura so to distinguish contrast-enhanced lymphomatous tissue from the surrounding unenhanced brain cerebellar parenchyma. Intraoperatively, the tumor was indistinguishable from cerebellar parenchyma under the white light, however, after the administration of low-dose intravenous fluorescein, it appeared brightly fluorescent under yellow light, and was safely resected. Our protocol of administration allowed for the sampling of the pathological tissue while at the same time avoiding neurological damage. The fluorescein-guided technique for the resection of primary central nervous system lymphomas has only been rarely described, as surgical excision of such tumors is rarely indicated. Starting from our case, we review and discuss the pertinent literature. Furthermore, an intraoperative video detail is provided.

A cervical solitary fibrous tumor with intramedullary invasion.

Solitary fibrous tumor is a tumor originating from the mesenchymal cells, which occurrence in the central nervous system is extremely rare and was described in few patients as to yet. We report on a 53-years old male patient presenting with right upper limb radicular pain and ipsilateral limbs paresis, who was diagnosed with a cervical spinal lesion which, after surgical resection, resulted to be a solitary fibrous tumor (SFT). We discuss imaging, clinical and histopathological findings to allow considering this tumor early in the differential diagnosis.

Pros of the contralateral (over-the-top) approach to intra/extraforaminal lumbar disc herniations at the L5-S1 level.

Background: Minimally invasive approaches to intra/extraforaminal lumbar disc herniations offer the benefit of less bone removal and reduced nerve root manipulation at the L5-S1 level. Moreover, the potential to better preserve stability. Methods: Here, we summarized the efficacy of the contralateral approach to intraforaminal/extraforaminal lumbar disc herniations particularly focusing on the L5-S1 level. Variables studied included the level of these disc herniations, their locations within the foramina, and the anatomy of the facet joints. Results: A major "pro" for the contralateral interlaminar procedure at the L5-S1 level is that it does not require facet joint removal, or with a spondylotic facet, <30% joint excision, to directly visualize the intraforaminal/ extraforaminal nerve root. It, therefore, reduces the risk of creating iatrogenic instability, while offering a higher certitude of adequate nerve root visualization, decompression, and safer disc removal. Conclusion: The contralateral interlaminar approach is more suitable for all types of intra/extraforaminal disc herniations at the L5/S1 level. The most specific benefit of this approach is its avoidance of disruption/significant removal (i.e., <30%) of the facet joint to adequately expose the foraminal L5 nerve root, and more safely remove the intra/extraforaminal disc herniation.

Cervical Spondylotic Myelopathy with Ossification of Posterior Longitudinal Ligament: Which Is the Most Suitable Surgical Procedure? A Technical Note.

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are widely performed to resolve anterior cervical spine compression. The main purpose of the different surgical techniques is to obtain an adequate decompression of the spinal cord and nerve roots, preserving spinal stability like in oblique corpectomy or leading to a final solid construct to achieve arthrodesis. TECHNICAL NOTE: We describe a surgical procedure for treating cervical spondylotic myelopathy(CSM) with ossification of the posterior longitudinal ligament (OPLL) at the level of C3-C4 and C4-C5. A double level discectomy C3-C4 and C4-C5 and selective posterior wedge corpectomy of C3, C4, and C5 were performed. Two cages (Zero-P VA) at C3-C4 and C4-C5 were positioned to obtain segmental stability and arthrodesis. An extended anterior cervical canal decompression was obtained and confirmed by postsurgical CT scan. At 15 months, dynamic X-ray showed fusion, and cervical magnetic resonance imaging (MRI) showed evidence of spinal canal decompression. CONCLUSIONS: Anterior cervical discectomy followed by selective wedge corpectomy appears to be a safe and effective technique for anterior spinal cord compression extending above and below the intervertebral disc space.

In Situ Side-to-Side Pericallosal-Pericallosal Artery and Callosomarginal-Callosomarginal Artery Bypasses for Complex Distal Anterior Cerebral Artery Aneurysms: A Technical Note.

BACKGROUND: Despite surgical and endovascular technical improvements over the last decades, the treatment of complex aneurysms of the distal anterior cerebral artery (ACA) is very challenging for both vascular neurosurgeons and interventional neuroradiologists. Furthermore, the interpersonal anatomic variability requires, most of the time, a tailored planning. OBJECTIVE: To describe a novel technique of bypasses in the territory of ACA to protect the brain territory distal to the aneurysm. METHODS: A 53-yr-old male with a large complex fusiform aneurysm of the left distal A2 segment of the ACA, involving the origin of the callosomarginal and pericallosal arteries, was judged not suitable for a single procedure (endovascular or neurosurgical). Two side-to-side bypasses were performed in a single surgery to connect the pericallosal and callosomarginal arteries of both sides, distally to the aneurysm. Subsequently, an endovascular embolization of the aneurysm was achieved with coils. RESULTS: The patency of the microanastomoses, performed in the anterior interhemispheric fissure, was positively evaluated intraoperatively with indocyanine green and fluorescein videoangiography. The aneurysm sac, together with proximal A2 segment, was completely occluded with platinum coils. At the last follow-up, computed tomography angiography confirmed the patency of both bypasses, without any sign of aneurysm recanalization. The patients never complained of any focal neurological deficits or worsening of clinical status. CONCLUSION: We present an elegant and innovative solution to completely protect the distal ACA territory in cases of complex aneurysm involving the origin of both callosomarginal and pericallosal arteries.

Venous Infarct after Sacrifice of Single Cortical Vein during Deep-Brain Stimulation Surgery.

Intracerebral hemorrhage (ICH) is the most feared and dreadful complication related to deep-brain stimulation (DBS). Bleeding may originate from arterial or venous damage. Commonly, hemorrhage is detected by postoperative imaging performed to assess lead positioning in asymptomatic patients. Rarely, hemorrhage leads to stroke, coma, or even death. We present the case of a patient who suffered a severe ICH of venous origins after bilateral DBS. Deep-brain hemorrhages are the most difficult to be predicted and to be prevented because they are caused by small vessels. As superficial hemorrhages are secondary to venous coagulation or sulcal hemorrhage, neurosurgeons must drive all efforts to minimize their occurrence.