Vertebrobasilar Dolichoectasia, Hypoplastic Third Ventricle, and Related Biventricular Hydrocephalus: Case Report and Review of the Literature.

BACKGROUND: Vertebrobasilar dolichoectasia (VBDE) is defined as a symptomatic dilatation and tortuosity of the vertebrobasilar arteries. The risk of hydrocephalus development is due to direct compression of the third ventricle outflow or brainstem compression and related aqueduct stenosis. We present an uncommon case of a patient with symptomatic VBDE with the uniqueness of a hypoplastic third ventricle associated with biventricular hydrocephalus. A literature review concerning diagnosis and management of patients affected by biventricular hydrocephalus caused by VBDE was also performed. CASE ILLUSTRATION: We report a case of a 54-year-old man who presented with headache, ideomotor apraxia, and gait disorder. A head computed tomography (CT) scan showed a biventricular hydrocephalus and a subsequent CT angiography documented the presence of a VBDE compressing the anterior part of the third ventricle that also appeared hypoplastic. The patient also presented a clinical history of arterial hypertension for which he was given a proper pharmacologic treatment with symptom relief. A surgical treatment of ventriculoperitoneal shunt along with endoscopic septostomy was proposed, but the patient refused, probably due to the slightly positive response to medical treatment. CONCLUSIONS: The natural clinical history of patients affected by VBDE is unfavorable with 7.8 years of median survival. The therapeutic strategy is usually conservative and the role of antiplatelets or oral anticoagulants is still debated. In selected patients, ventriculoperitoneal shunt to resolve intracranial hypertension caused by biventricular hydrocephalus is the most effective treatment. In our opinion, chronic third ventricle compression could lead to anatomic-pathologic alterations like the third ventricle hypoplasia documented in our report.

A Review of Remote Intracerebral Hemorrhage after Chronic Subdural Hematoma Evacuation.

BACKGROUND: Remote intracerebral hemorrhage (RICH) is a severe complication following chronic subdural hematoma (cSDH) drainage, and only case reports and small case series have been reported to date. The authors present an emblematic patient affected by RICH following cSDH drainage. A systematic review of the literature on diagnosis and management of patients affected by RICH following cSDH evacuation has also been performed. METHODS: A literature search according to the PRISMA statement was conducted using PubMed and Scopus databases with the following Mesh terms: [(remote) AND (intracerebral hemorrhage or cerebral hematoma or cerebral infarction or cerebellar hemorrhage or cerebellar hematoma or cerebellar infarction) AND (chronic subdural hematoma)]. RESULTS: The literature search yielded 35 results, and 25 articles met our inclusion criteria: 22 articles were case reports and 3 were case series including three to six patients. Overall, 37 patients were included in the study. Age was reported in all 37 patients, 26 males (70.3%) and 11 females (29.7%), with a male-to-female ratio of 2.4:1. The mean age at diagnosis was 64.6 years (range: 0.25-86 years). Only in 5 cases (13.5%) did the ICH occur contralaterally to the previously drained cSDH. The rapidity of drainage can lead to several types of intracranial hemorrhages, caused by a too rapid change in the cerebral blood flow (CBF) and/or tears of bridging veins. The average time interval between cSDH drainage and neurologic deterioration was 71.05 hours (range: 0-192 hours). CONCLUSIONS: RICH following cSDH represents a rare occurrence and a serious complication, associated with elevated morbidity. Careful monitoring of drain speed after cSDH evacuation surgery is recommended, and minimally invasive techniques such as twist drill craniostomy are suggested, especially for massive cSDHs.

The "sandwich phenomenon": a rare complication in adjacent, double-level X-stop surgery: report of three cases and review of the literature.

STUDY DESIGN: Case reports. OBJECTIVE: To report the atraumatic fracture of the intervening (L4) spinous process (SP) in patients treated with X-Stop at 2 adjacent levels and discuss the potential underlying causes. SUMMARY OF BACKGROUND DATA: Limited evidence on complications in double-level X-Stop surgery is available. METHODS: Three men, 47, 63, and 75 years old, respectively, underwent surgery with insertion of X-Stop at L3-L4 and L4-L5 because of low back pain and neurogenic claudication due to degenerative lumbar spine conditions. Two 10 mm devices were implanted in the first patient and two 16 mm distractors in the second man. One 10 mm X-Stop at L3-L4 and one 12 mm at L4-L5, respectively, were implanted in the third patient. No intraoperative complications occurred and the postoperative course was uneventful, with symptoms relief. RESULTS: The first 2 patients presented because of recurrent symptoms 4 and 6 months after surgery, respectively. Imaging revealed "spontaneous" fracture of the L4 SP in both of them. Revision surgery was required, with removal of the interspinous devices, decompression and fixation. In the third patient the L4 SP fracture was detected when the patient presented because of recurrent back pain 18 months after the index surgery, but revision surgery was not consented. CONCLUSION: To our knowledge this is the first report describing the "sandwich phenomenon," i.e., the atraumatic fracture of the intervening SP in patients with adjacent, double-level X-Stop. Possible underlying theories and anatomic peculiarities which may predispose to this rare event are discussed.

Heterotopic ossification in cervical disc arthroplasty: Is it clinically relevant?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the presence and clinical relevance of heterotopic ossification (HO) at 3 years mean follow-up. METHODS: Thirty patients suffering from cervical radiculopathy and/or myelopathy treated with anterior disc replacement (ADR) were studied. HO was classified using the McAfee grading system. Range of motion was measured from flexion and extension x-rays. Short-form 36 and neck disability index (NDI) assessed functional outcome. RESULTS: Forty-five prostheses were implanted in 30 patients with cervical radiculopathy and/or myelopathy, mean age 40.9 years. Nineteen patients received 1 level and 11 patients received multilevel disc replacement. The incidence rate of HO was 42.2% (19 levels). Segmental range of motion was ≥3° in 93.8% of patients with HO. There was no significant difference in functional scores between those who did and those who did not develop HO. Males tended to develop HO more frequently than females, though this was not statistically significant. The indication for surgery (soft disc hernia or spondylosis) was not associated with the formation of HO. CONCLUSIONS: Functional improvement is maintained despite the presence of HO following cervical disc arthroplasty. Indications for arthroplasty should not be halted by the risk of HO. [Table: see text] The definiton of the different classes of evidence is available on page 83.

Anatomic midline marking during cervical arthroplasty with ProDisc-C: an alternative, simple, and reliable method: technical note.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report the results of a different, and previously undescribed, technique to anatomically mark the midline during cervical arthroplasty. SUMMARY OF BACKGROUND DATA: The ProDisc-C prosthesis should be implanted in the vertebral body midline. Current standard technique for midline marking usually relies on intraoperative fluoroscopy to locate on anteroposterior (AP) x-rays a midpoint between the uncinate processes and superimposed to the intervening spinous process. Nevertheless, uncinate process can be used as anatomic landmarks to size the proper width of the prosthesis and implant a suitable device well centered in the midline. METHODS: Two groups of ProDisc-C prostheses were analyzed and compared for midline alignment. Group 1: 68 prostheses were implanted using a different technique to identify the anatomic midline. Soft disc hernia and/or spondylotic disease (whose degree was not a contraindication for arthroplasty), either at single or multiple levels, were the underlying diseases. Group 2: 19 ProDisc-C implanted using the standard fluoroscopic technique to mark the midline. RESULTS: Postoperative analysis of AP digital x-rays revealed in group 1a mean difference of -0.35 mm between the 2 halves of the prosthesis' inferior plate in respect to the defined midline. Sixty prostheses (88.2%) had an eccentric position ranging between 0.1 and 2.2 mm. Five prostheses (7.3%) were in a more significantly eccentric position by 4 to 5.5 mm. In 3 cases (4.4%), the eccentric positioning was between 2.5 and 4 mm. SD was + or - 2.18. In group 2, the mean difference was -0.07 mm. Only 1 prosthesis (5.2%) was in eccentric position by 6.14 mm. Five devices (26.3%) were in eccentric position by > or = 2 mm. The remaining 13 prostheses (68.4%) showed an eccentric position ranging between 0.36 and 1.82 mm. SD was + or - 2.02. Statistical analysis was performed using the Student t test. CONCLUSIONS: This study confirms that in cases of soft disc hernia or moderate spondylosis, the anatomic midline marking technique is a safe, reliable, and effective option. It is as accurate as the current fluoroscopic-guided technique and gives the opportunity either to reduce patient's and surgeons' exposure to radiations or to shorten the operation time by reducing the overall fluoroscopy and avoiding performing AP x-rays.

Analysis of complications in patients treated with the X-Stop Interspinous Process Decompression System: proposal for a novel anatomic scoring system for patient selection and review of the literature.

OBJECTIVE: The X-Stop Interspinous Process Decompression System (St. Francis Medical Technologies, Concord, CA) is an interspinous device used with increasing frequency in the treatment of degenerative lumbar spine conditions. To date, limited data are available on complications observed in association with X-Stop procedures, and even less information exists on their underlying causes. The aim of this study was to analyze a series of complications occurring at a single institution and their potential causes and propose an anatomic scoring system that may help to classify patients and prevent complications. METHODS: Sixty-nine patients were treated with the X-Stop. Forty-six single-level and 23 double-level operations (92 devices) were performed according to recommended indications. The mean follow-up duration was 23 months. RESULTS: Eight complications were recorded: 4 device dislocations and 4 spinous process (SP) fractures, including 2 spontaneous fractures of the L4 SP in patients treated at L3-L4 and L4-L5. The following anatomic variants were demonstrated: markedly decreased interspinous distance (kissing spine-like), with concomitant facet joint hypertrophy, a posterior V-shaped interspinous area, limited accessibility of the space between the base and the tip of the SP because of facet joint hypertrophy and variations in the shape of the inferior surface of the cranial SP. CONCLUSION: This is the first study focusing on interspinous distractor complications and the anatomic features of the SP and interspinous areas of the patients, which could potentially be the underlying causes for those complications. The X-Stop can be an effective treatment option, but it is not a panacea for all patients with degenerative lumbar spine conditions. Not only do the clinical indications deserve attention, but also, and most importantly, the patient's anatomic characteristics.

Early results and review of the literature of a novel hybrid surgical technique combining cervical arthrodesis and disc arthroplasty for treating multilevel degenerative disc disease: opposite or complementary techniques?

We report the clinical and radiological results on the safety and efficacy of an unusual surgical strategy coupling anterior cervical discectomy and fusion and total disc replacement in a single-stage procedure, in patients with symptomatic, multilevel cervical degenerative disc disease (DDD). The proposed hybrid, single-stage, fusion-nonfusion technique aims either at restoring or maintaining motion where appropriate or favouring bony fusion when indicated by degenerative changes. Twenty-four patients (mean age 46.7 years) with symptomatic, multilevel DDD, either soft disc hernia or different stage spondylosis per single level, with predominant anterior myeloradicular compression and absence of severe alterations of cervical spine sagittal alignment, have been operated using such hybrid technique. Fifteen patients underwent a two-level surgery, seven patients received a three-level surgery and two a four-level procedure, for a total of 59 implanted devices (27 disc prostheses and 32 cages). Follow-up ranged between 12 and 40 months (mean 23.8 months). In all but one patient clinical follow-up (neurological examination, Nurick scale, NDI, SF-36) demonstrated significant improvement; radiological evaluation showed functioning disc prostheses (total range of motion 3-15 degrees ) and fusion through cages. None of the patients needed revision surgery for persisting or recurring symptoms, procedure-related complications or devices dislocations. To the authors' best knowledge, this is the first study with the longest available follow-up describing a different concept in the management of cervical multilevel DDD. Although larger series with longer follow-up are needed, in selected cases of symptomatic multilevel DDD, the proposed surgical strategy appears to be a safe and reliable application of combined arthroplasty and arthrodesis during a single surgical procedure.