Prognostic MRI parameters in acute traumatic cervical spinal cord injury.

PURPOSE: The aim of this study is to estimate the prognostic value of some features documented on preoperative MRI study in patients with acute cervical spinal cord injury. METHODS: The study was conducted in patients operated for cervical spinal cord injury (cSCI) from April 2014 to October 2020. The quantitative analysis on preoperative MRI scans included: length of the spinal cord intramedullary lesion (IMLL the canal diameter at the level of maximal spinal cord compression (MSCC) and the presence of intramedullary hemorrhage. The canal diameter at the MSCC was measured on the middle sagittal FSE-T2W images at the maximum level of injury. The America Spinal Injury Association (ASIA) motor score was used for neurological assessment at hospital admission. At 12-month follow-up all patients were examined with the SCIM questionnaire. RESULTS: At linear regression analysis, the length of the spinal cord lesion [ß coefficient -10.35, 95% confidence interval (CI)-13.71 to-6.99; p < 0.001], the diameter of the canal at the level of the MSCC (ß coefficient 6.99, 95% CI 0.65 to 13.33; p = 0.032), and the intramedullary hemorrhage (ß coefficient - 20.76, 95% CI - 38.70 to - 2.82; p = 0.025), were significantly associated with the score at the SCIM questionnaire at one year follow-up: shorter spinal cord lesion, greater diameter of the canal at the level of the MSCC, and absence of intramedullary hemorrhage were predictors of better outcome. CONCLUSION: According to the findings of our study, the spinal length lesion, canal diameter at the level of spinal cord compression and intramedullary hematoma documented by the preoperative MRI study were associated with the prognosis of patients with cSCI.

Primary Dural Lymphoma: Clinical Cases and Literature Review.

Primary dural lymphoma (PDL) is an extranodal non-Hodgkin lymphoma that accounts for less than 1% of all central nervous system lymphomas. Primary dural lymphoma grows from the dura mater, and it is often diagnosed as meningioma or acute subdural hematoma due to its radiological characteristics. Surgery is the gold standard of therapy; in many patients, PDL is relatively benign with good outcome. Authors report their experience in three patients affected by extranodal non-Hodgkin lymphoma (PDL) mimicking a meningioma.

Analysis of risk factors and postoperative predictors for recurrent lumbar disc herniation.

BACKGROUND: This study identified risk factors and postoperative indicators for recurrent lumbar disc herniations (rLDH) following microdiscectomy. METHODS: We retrospectively reviewed the 1-year recurrence rate for LDH in 209 consecutive patients undergoing microdiscectomy (2013-2018). RESULTS: Utilizing a multivariate analysis, higher body mass index (BMI) and postsurgery Oswestry disability index (ODI) were significantly associated with an increased risk of rLDH. CONCLUSION: Elevated postsurgery ODI and higher BMI were significantly associated with increased risk of rLDH.

Cervical lordosis after subaxial spinal trauma surgery: relationship with neck pain and stiffness.

BACKGROUND: The objective of this retrospective study is to evaluate how neck pain is influenced by post-operative cervical alignment in patients operated for cervical spinal trauma. PATIENTS AND METHODS: From January 2013 to June 2017, at our department we operated 34 patients with cervical spinal trauma, 22 males and 12 females. Age, sex, level and type of fractures, surgical approach, fixation levels (cervical or cervico-dorsal), preoperative and postoperative CT scan, cervical (C2-C7) Cobb angle (lordotic > +10°, straight 0 /+10°, kyphotic < 0°) at X-rays on sitting position 3 months after surgery, postoperative self-reported neck stiffness scale, preoperative and follow-up ASIA score, pre and postoperative VAS value were evaluated for each patient. Statistical analysis was performed according to the Mann-Whitney and T-test. RESULTS: In this series, 22 patients were operated by anterior approach, 7 patients by posterior approach and 5 by combined approach. Postoperative chronic cervical pain was not correlated with cervical sagittal alignment after surgery, fracture type, surgical approach, fixation level and postoperative ASIA score but is correlated with the presence of neck stiffness (P=0,001). Patients treated with posterior approach (P=0,022) and fracture type C (P=0,026) had higher significantly neck stiffness compared to patients who underwent anterior approach for type B fractures. CONCLUSIONS: The presence of abnormal cervical lordosis after surgery for cervical spinal trauma does not correlate with neck pain. Patients treated with posterior fixation had higher neck stiffness and related chronic pain.

Ventriculoperitoneal shunt malfunction: analysis of abdominal causes.

BACKGROUND: Ventriculoperitoneal (VP) shunt is the most common neurosurgical procedure to treat obstructive and communicating hydrocephalus in children and adults but failure are frequent. The knowledge of risk factors related to abdominal shunt failure is useful to avoid complications. PATIENTS AND METHODS: We analyze retrospectively 86 adults patients affected by obstructive and communicating hydrocephalus operated for VP shunt at our Institution. Statistical analysis was performed in order to correlate shunt malfunctioning with type of abdominal approach (trocar vs mini-laparotomy), perioperative infective status, sex, bowel distention and length of surgical time. RESULTS: Factors statistically significant for surgical shunt revision were the use of trocar (univariate analisys p=0,029 and multivariate p= 0,035) and high infective risk (univariate analisys p=0,028 and multivariate p= 0,038). No statistical significant association was observed between shunt revision and sex, bowel distension and operative length time. CONCLUSIONS: To avoid postoperative shunt malfunctions especially in peritoneum the mini-laparotomy is the approach of choice. Surgery must be performed when infective status is healed.

Surgical treatment of aggressive vertebral hemangioma causing progressive paraparesis.

Vertebral hemangioma is a benign vascular lesion that may onset with neurologic symptoms due to spinal cord compression by epidural extension. Surgical procedure, embolization and radiotherapy are the gold standard for the treatment of this disease. We present a case of a 84 years old woman admitted at our department with worsening paraparesis and urinary retention. Her magnetic resonance images (MRI) showed a lesion involving both anterior and posterior vertebral element of D5, with extension into epidural space and spinal cord compression. The patient was operated for laminectomy and epidural lesion removal. Histological examination confirmed the diagnosis of cavernous hemangioma.

Deep spinal infection in instrumented spinal surgery: diagnostic factors and therapy.

AIM: Postoperative surgical site infections (SSI) are complication of spinal surgery. These complications may lead to a poor outcome with neurological deficits, spinal deformity and chronic pain. The purpose of this study is to explore the statistical value of diagnostic parameters and the proper therapy. METHOD: We retrospectively reviewed 550 patients who underwent spinal instrumentation at our department from January 2011 to December 2015. The SSI was present in 16 patients out of 550 operated. Diagnostic criteria of SSI were the positivity of the surgical wound swab or blood culture, the clinical findings, positivity of laboratory tests and radiological elements. All patients had peri-operative antibiotic prophylaxis. Diagnostic laboratory findings were compared with a homogeneous control group of 16 patients and analyzed by univariate statistical analysis with Chi-square test for the discrete variables. P<0,05 was considered statistically significant. RESULTS: Matching the SSI patients with a group of control, fever was not statistically significant for diagnosis as number of leukocytes, neutrophils and lymphocytes. On the contrary values of ESR and CRP were statistically significant with p <0, 01. The hardware was removed only in 3 patients (18%) out of 16 SSI patients. CONCLUSION: In this study the statistically significant parameters to diagnose SSI are ESR and CRP values. The leucocytes count, number of lymphocytes and presence of fever integrates the data of ESR and CRP with no statistical significance. Most patients with SSI reach clinical healing with favorable outcome by means of target antibiotic therapy without hardware removal.

Risk factors of surgical site infections in instrumented spine surgery.

BACKGROUND: The incidence of wound infections associated with instrumented spine surgery ranges from 2 to 20%. These complications may lead to poor outcomes. Knowing the risk factors associated with surgical site infections (SSI) after utilizing spinal implants is essential to avoid these complications, including hardware removal. METHODS: We reviewed retrospectively 550 patients who underwent spinal fusion surgery from 2011 to 2015; 16 developed SSI after spinal instrumentation. The diagnosis of SSI was established based on positive wound swab or blood cultures, and various clinical, laboratory, and radiological findings. Additional preoperative and intraoperative risk factors were analyzed. RESULTS: The incidence of SSI after spinal instrumentation surgery was 2.9%. Obesity was a statistically significant parameter (P = 0.013) that contributed to SSI along with the alcoholism and/or drug abuse (P = 0.034); use of a Foley catheter nearly reached significance levels. CONCLUSIONS: There is an increased risk of SSI in patients who are obese or use drugs and/or alcohol. Clear preoperative identification of these risk factors prior to implanting spinal instrumentation should help prevent SSI in the future.

Epidural scarring after lumbar disc surgery: Equivalent scarring with/without free autologous fat grafts.

BACKGROUND: To limit epidural fibrosis and prevent scar formation/nerve tethering that may contribute to chronic postoperative pain; some surgeons have utilized epidural autologous fat grafts following lumbar microdiscectomy. METHODS: We investigated the correlation between post-microdiscectomy epidural scarring [including select magnetic resonance imaging (MRI) studies] and clinical outcomes in 36 patients operated for symptomatic. MRI documented L4-L5 and L5-S1 disk herniations with (18 patients) and without (18 patient) the application of free fat grafts. In addition, histological evaluation of the original fat grafts was performed in 4 patients requiring additional surgery. RESULTS: We found no clear association between the use of autologous graft fats and the clinical outcomes in this study. CONCLUSION: In this preliminary study involving only 36 patients, the prospective randomized use of free autologous fat grafts did not appear to influence outcomes following microdiscectomy.

Spontaneous chronic subdural hematoma in young adult: the role of missing coagulation facto.

AIM: Chronic subdural hematoma (CSDH) is typically in elderly and rarely in young people. To prevent complications and re-bleeding after surgical treatment of CSDH it is important to assess the risk factors as coagulation disorders especially in young patients (below 65 years) with no history of head trauma, alcohol abuse or anticoagulant therapy. PATIENTS AND METHODS: This study consists of 16 patients (12 males, 4 females) with age ranging from 27 to 59 years (median 48,25 years) operated for CSDH. All patients are submitted to routine coagulation parameters pre-operatively and complete screening for unknown coagulation deficit in the follow-up. RESULTS: Factor VII was altered in 6 out of 16 patients and one patient had the alteration of the Von Willebrand factor. Recurrence occurred in 4 out of 16 patients and all of these patients were positive for factor VII deficiency. Three pts were in therapy with ASA. No patients were alcoholists or suffered from hematological disease. CONCLUSION: In this study we documented that the decreased activity of VII factor may play a role in the pathophysiology and recurrence of spontaneous CSDH in young adults. We suggest that for young patients aged under 65 y.o. suffered from CSDH the screening of coagulation factors is useful to planning a safely and correct surgical therapy.

Delayed diagnosed intermuscular lipoma causing a posterior interosseous nerve palsy in a patient with cervical spondylosis: the "priceless" value of the clinical examination in the technological era.

BACKGROUND: Posterior interosseous nerve (PIN) palsy may present with various symptoms, and may resemble cervical spondylosis. CASE REPORT: We report about a 59-year-old patient with cervical spondylosis which delayed the diagnosis of posterior interosseous nerve (PIN) palsy due to an intermuscular lipoma. Initial right hand paraesthesias and clumsiness, together with MR findings of right C5-C6 and C6-C7 foraminal stenosis, misled the diagnostic investigation. The progressive loss of extension of all right hand fingers brought to detect a painless mass compressing the PIN. Electrophysiological studies confirmed a right radial motor neuropathy at the level of the forearm. RESULTS: Surgical tumor removal and nerve decompression resulted in a gradual motor deficits recovery. CONCLUSIONS: A thorough clinical examination is paramount, and electrophysiology may differentiate between cervical and peripheral nerve lesions. Ultrasonography and MR offer an effective evaluation of lipomas, which represent a rare cause of PIN palsy. Surgical decompression and lipoma removal generally determine excellent prognoses, with very few recurrences.

Tuberculous spondylitis: a retrospective study on a series of 12 patients operated on in a 25-year period.

BACKGROUND: The incidence of tuberculous spondylitis, which had declined steadily for over 40 years in our countries, started increasing again in the eighties, paralleling the resurgence of pulmonary tuberculosis. Therefore it has become a matter of discussion in contemporary literature, because it can be a diagnostic challenge and, in spite of its severe neurological complications, it is a potentially curable illness. METHODS: In this retrospective study the authors report their experience concerning 12 patients operated on in a 25-year period because of serious cord compression from thoracic (9 cases) and cervical (1 case) tuberculous spondylitis or from thoracic tubercular epidural lesion (2 cases). Surgical techniques were selected on the basis of the cause of cord compression. Fusion with autologous bone and metallic osteosynthesis was performed in the cervical case (1986); no other patient received spinal instrumentation, and this can be explained with the consideration that all but one cases of Pott's paraplegia were treated in the years 1968-1977. In all of these cases fusion was achieved by means of plaster jackets and prolonged bed rest. Prolonged chemotherapy was systematically administered. RESULTS: Follow-up data collected in 1995 show good and long-lasting results. CONCLUSIONS: They conclude that surgical treatment is required in case of cord compression and results can be excellent even in presence of severe neurological impairment; spinal instrumentation available in our era should be now considered in order to make rehabilitation earlier and morphologic results more satisfactory.

Bilateral traumatic abducens nerve palsy. Case report.

Bilateral traumatic abducens nerve palsy after head injury is a rare event. We present a case associated with skull fractures and intracranial hematoma, with complete recovery of abducens nerve palsy after six months. The mechanism of the lesion, the clinical conditions and the radiological findings are presented.

Investigations on the presence of viral and chlamydial antigens in cells exfoliated in the vagina of women with common and malignant gynecopathies.

A high proportion of parainfluenza, herpes, adenovirus and chlamydial antigens (10.7-36%) was detected by indirect immunofluorescence in cells exfoliated in the vagina of women with genital neoplasia and with uterine cervix ectopia and dysplasia. Much lower proportions of the same antigens were found in patients with common gynecopathies or recurrent genital herpes and in pregnant women. The possible relationships between chronic virus infections and genital neoplasia in women are discussed.