The role of neurosurgeon in the multidisciplinary approach to ectopic or bifocal intracranial germinoma: A systematic review and report of two illustrative cases.

BACKGROUND: Pure germinoma typically originates from the midline and is usually found in the pineal and suprasellar regions in 76-90 % of cases. When it is in both regions, it is considered bifocal (10 % at diagnosis). If pure germinoma is located outside of the midline, it is considered ectopic, with a global incidence of about 0.7 %. The study aims to describe the clinical and surgical approach to patients with atypical intracranial ectopic germinoma (IEG) and bifocal germinoma (BG) through a literature review with the goal to delineate the correct diagnostic and therapeutic pathway, to reduce the diagnostic delay and improve the prognosis of these patients. METHODS: A systematic review of the literature in most common electronic database (PubMed, Ovid MEDLINE and Ovid EMBASE) on IEG and BG, in according with the "PRISMA statement" criteria, from January 1990 to September 2022 was done. In addition, two rare cases of IEG and BG were reported. RESULTS: This systematic review included 16 papers (20 patients) with a final diagnosis of IEG and 30 papers (121 patients) with a final diagnosis of BG. IEGs seems to involve primary basal ganglia (40 %) and corpus callosum (40 %). For IEGs, biopsy (70 %, 14 cases out of 20) was the most common surgical approach: open approach (35 %), stereotactic minimally invasive approach (30 %) or endoscopic trans-sphenoidal approach (5 %). Partial resection was performed in 10 % of cases, whereas a total resection was performed in 20 % of cases. Also for BGs, biopsy was the most common surgical approach in 80 % of patients, whereas surgical resection (partial or total) was performed in 5.3 % of patients. CONCLUSION: IEG and BG are rare type of primary intracranial germ cell tumor, whose unusual location often can cause delays in diagnosis, which can have a significant impact on the patient's prognosis and requiring a multidisciplinary and timely approach.

Case report of Kummell's disease with delayed onset myelopathy and the literature review.

INTRODUCTION: Kummell's disease is an avascular necrosis of the vertebral body, secondary to a vertebral compression fracture. This entity is characterised by the gradual development in time of a vertebral body collapse following a trivial spinal trauma, involving a worsening back pain associated with a progressive kyphosis. PURPOSES: The aim of this article is to carry out an international literature review regarding Kummell's disease, addressing its physiopathology, histopathology, clinical presentation, radiological characteristics and treatment modalities; at the same time, the literature is updated through the description of a new and interesting case, symbol of the pathology long-term potential complications, if not diagnosed and therefore not suitably treated. CASE REPORT: A patient with osteoporosis, following a slight spinal trauma, suffered a progressive necrosis of the D11 body; although the radiological exams showed a constant worsening of the thoracic-lumbar kyphosis and a restriction of the spinal canal, in another medical centre he was only treated with a corset and painkillers. A year after the injury, motor deficits concerning the lower limbs appeared. He was then sent to us and indication for posterior internal fixation was given. On the basis of both his medical history and radiological and histological findings, Kummell's disease was diagnosed. CONCLUSION: It is necessary to have a complete knowledge of the clinical, pathological and radiological characteristics of Kummell's disease, so as to follow a correct diagnostic course enabling to prepare the most suitable therapy.

Cervicothoracic postarachnoiditic hydrosyringomyelia secondary to pedicular hook dislocation: case report.

BACKGROUND: Pedicular hook dislocation is a rare complication of spinal instrumentation. We report on the first case of hydrosyringomyelia secondary to intracanalar hook displacement after scoliosis surgery. CASE DESCRIPTION: A 15-year-old girl presented to our institution with a 7-month history of persistent neck and occipital pain as well as numbness of the lower extremities and previous dorsolumbar instrumentation with dorsal pedicular hooks and lumbar screws. Magnetic resonance imaging showed intramedullary cystic cavity from C5 to T7, isointense to cerebrospinal fluid (CSF) on T1- and T2-weighted images. Computed tomographic scan showed intracanalar displacement of the left hook. On admission, the patient presented with mild weakness of the lower extremities, hypalgesia below the level of T4, and urinary disturbance. The patient underwent surgical hook removal, T4 laminectomy, and midline dural opening: the arachnoid membrane was found to be thick and adhered to the dura and dorsolateral spinal cord. The arachnoid scarring was dissected, and the cord was untethered. A small posterior-median myelotomy was performed, and a syringosubarachnoid catheter was placed into the subarachnoid space to restore CSF flow. CONCLUSIONS: Late intracanalar displacement of spinal devices is an event that may complicate spinal instrumentation for scoliosis. This case highlights the importance of correct spinal device positioning and that of careful follow-up after instrumentation to detect complications early. We also discuss the pathogenetic pathway of the postarachnoiditic syringomyelia in this case.

[GPs' self-perception of their own role compared with hospital, ambulatory, academic, and health organisation physicians]. / Auto-percezione del ruolo professionale in medicina generale nel confronto con il medico specialista.

Aim of the present study was to explore how the 76 general practitioners (GPs) - serving Carpi district (90,000 residents) - value their own role compared with the hospital, ambulatory, academic, and health organisation physicians'. GPs had a positive self-image only in comparison with health organisation doctors (7 vs 7 grades). GPs disappointed with themselves when comparing their role with ambulatory (-1.6 grades), academic (-1.9 grades) and hospital doctors (-2.2 grades). Secondarily, GPs perceived patients' valuing their professional role mostly 'subordinate' to the other physicians', except health organisation colleagues'.