The Lone Star Retractor System in Neurosurgery.

BACKGROUND: We investigated the role of a self-retaining retractor system, commonly used in ear, abdominal, vascular, urologic and gynecologic surgeries: the Lone Star retractor system. We report our experience in using the Lone Star retractor in different brain surgeries, at a single neurosurgical department. METHODS: In 2019, patients who underwent brain surgery and in which the Lone Star Retractor System was used were considered for inclusion. Clinical and surgical data of included patients were prospectively collected. Postoperative VAS for local pain, and a properly designed intraoperative retractor stability score, were collected. RESULTS: Over 2019, the Lone Stare Retractor was used in 20 neurosurgical procedures: 9 high-grade glioma, 2 low-grade glioma, 4 cerebral metastases, and 5 meningiomas. Postoperative mean VAS score was 3.5 (range: 2-4). Intraoperative retractor stability score mean was 2 in frontal, 2 in pterional, 1.75 in subtemporal, 2 in interhemispheric, and 0.5 in suboccipital approaches. The Stony Brook Scar Evaluation Scale mean value was 4.4 (range: 3-5). CONCLUSIONS: In our institutional experience, the Lone Star retractor showed many advantages in different brain procedures, when compared with standard fishhooks and other retractors.

Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases.

Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.

Entrapment of the temporal horn: case series and systematic review of literature.

INTRODUCTION: Entrapment of the temporal horn (ETH) is a form of focal, obstructive hydrocephalus. Etiology and clinical presentation are diversified. Though known since 1947, standard treatment has not yet been defined. The objective of our study was to perform a systematic review on ETH. EVIDENCE ACQUISITION: Data from patients treated at our Institution from 2008 to 2019 were retrospectively collected and analyzed. A systematic PRISMA review of literature was also performed using PubMed and Google Scholar. The following search terms were used: "temporal horn entrapment" [All Fields] OR "trapped temporal horn" [All Fields]. EVIDENCE SYNTHESIS: One hundred and twenty-one cases (mean age 41 years; M/F ratio: 1/1) were analyzed. In 65 (vs. 56) cases (53.7% vs. 46.3%), ETH was not surgery related. Headache was the most common symptom (42%). "Major" treatments were ventriculoperitoneal/ventriculoatrial shunt (42 cases, 34.7%), and endoscopic ventriculocisternostomy (12 cases, 9.9%). In the first group, no perioperative complications were found, 39 patients (92.9%) had a favorable outcome, three patients (7.1%) died for the underlying disease, four cases (9.5%) went through revision; also considering the cases in which another procedure was performed as definitive treatment, there were six shunt failures (13.6%). In the second group, one case (8.3%) developed a deep intracerebral hemorrhage, 11 cases (91.6%) had a favorable long-term outcome, one case (8.3%) had a favorable short-term outcome; also considering the cases in which another procedure was performed as definitive treatment, there were six endoscopic ventriculocisternostomy failures (37.5%). CONCLUSIONS: Described as uncommon, ETH is probably underestimated. Early diagnosis and appropriate treatment are critical. VP shunt is still the most commonly performed treatment. Further randomized clinical trials are, however, needed to establish the gold standard.

Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study.

OBJECTIVE: Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures. METHODS: The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma. RESULTS: Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not. CONCLUSIONS: Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.

Multidisciplinary management of spontaneous spinal infections: is there a correlation between timing, type of treatment and outcome?

BACKGROUND: Spontaneous spinal infections (SSIs) represent a rare and serious pathological entity. We tried to study a correlation between type of treatment, timing of treatment and clinical outcome through a multivariate analysis of an observational cohort study with the aim to define what is the optimal clinico-therapeutic management. METHODS: We performed a retrospective observational cohort study on all consecutive patients observed in our Institute in a period of 13 years; from 2001 to 2014 we enrolled 50 consecutive patients with symptomatic spontaneous spinal infections (no previous surgery or recent infection in other site), confirmed with diagnostic imaging. The inclusion parameters were: diagnostic imaging, signs and symptoms positive for SSI, no history of recent infection or surgery. Of each parameter analyzed, we calculated mean and standard deviation and when necessary correlation (ρ), covariance (σ) and relation coefficient between type of treatment, timing of treatment and clinical outcome. RESULTS: Our results suggest that an increase of one day from the onset of symptoms and the start of therapy leads to an increase in the Oswestry Disability Index Scale both at 6 months than at 1 year, with a statistical relevance, so our experience shows a statistically significant correlation and a positive co-variance between timing and outcome at 6 months and 1 year. CONCLUSIONS: SSI are rare, very difficult to diagnose and represent a significant clinical problem. If not properly managed, they may lead to significant impact in the quality of life. The most relevant problem is not the treatment, conservative or surgical, but early diagnosis, so a careful physical, laboratory and imaging examination is fundamental, with an important help provided by isolation of the pathogen and histology. In our experience early diagnosis has a fundamental role. In the light of this, current treatment protocols may require a prompt and multidisciplinary management including infectivologists, neuroradiologists and spine surgeons.