Interspinous spacers in the treatment of degenerative lumbar spinal disease: our experience with DIAM and Aperius devices.

Insertion of an interspinous devices has became a common procedure for the treatment of different clinical picture of degenerative spinal disease. We present our experience in 1,575 patients with the use of two different interspinous spacers: Device for Intervertebral Assisted Motion (DIAM) and Aperius PercLID system. From 2000 through 2008, 1,315 consecutive patients underwent DIAM implantation and 260 had an Aperius PercLID procedure. The main surgical indications included: degenerative disc disease (478 patients), canal and/or foraminal stenosis (347 patients), disc herniation (283 patients), black disc and facet syndrome (143) and topping-off (64 patients). 1,100 patients underwent a single level implant and 475 had a multiple level implant. Mean operating time was 35 min for DIAM and 7 min for Aperius. Complications were detected in 20 patients (10 cases of infections, 10 fractures of the posterior spinous processes). 40 patients were subsequently treated with posterior arthrodesis (n = 30) or total disc replacement (n = 10). Patient's postoperative clinical status was rated according to the modified Macnab criteria: symptoms resolution or improvement was achieved in 1,505 patients; and unchanged or unsatisfactory results in 70. Both techniques are safe, simple and less technically demanding. These approaches appear to be an effective alternative in selected cases, although conventional posterior lumbar decompression and fusion still may be required.

Degenerative lumbar spinal stenosis with neurogenic intermittent claudication and treatment with the Aperius PercLID System: a preliminary report.

OBJECT: The aim of this study was to evaluate whether clinical improvement is noticeable after a minimally invasive procedure such as that used with the Aperius PercLID System in patients with degenerative lumbar spinal stenosis (DLSS) and neurogenic intermittent claudication (NIC). METHODS: The patients were treated with the aforementioned system at 3 different centers. The initial requirement to be included in the study was a minimum follow-up of 12 months. The authors studied 40 cases of DLSS in patients with NIC (age 72.7 +/- 8.08 years). Symptom severity, physical function, quality of life, and self-rated pain were assessed preoperatively and at the 12-month follow-up using the Zurich Claudication Questionnaire (ZCQ) and a visual analog scale. The procedure was conducted under spinal (35 patients) or local (5 patients) anesthesia, using biplanar fluoroscopy for visualization. RESULTS: Single-level treatment was performed in 28 patients and 2-level treatment was performed in 12 patients. Based on time recordings in 24 cases, the mean procedural time was 19.9 +/- 5.0 minutes. The mean pain visual analog scale score improved significantly from 8.1 +/- 2.19 at baseline to 3.44 +/- 2.89 at the 1-year follow-up. The ZCQ score for patient satisfaction showed 90% of the patients being satisfied with the procedure. The mean rates of improvement in ZCQ score for symptom severity and physical function at 1 year were 38.7 +/- 33.3% and 33.8 +/- 29.7%, respectively, and both proved to be statistically significant. Most improvement was seen in mobility, pain/discomfort, and ability for self-care. CONCLUSIONS: In this preliminary study, the Aperius system provided clinically significant improvement after 1 year of follow-up in patients older than 65 years with DLSS and NIC.

The middle cranial fossa: morphometric study and surgical considerations.

The anatomical features of the temporal bone can vary significantly among different individuals. These variations affect the operative view in middle cranial fossa surgery. We performed 18 middle fossa approaches in 9 cadaveric heads, with detailed morphological analysis, to identify unfavorable situations and reliable systems to avoid complications during surgery. We recorded linear, angular measurements and calculated areas. We performed a computed tomography (CT) scan with analysis of the amount of bone to remove in two temporal bones. We found that the location of the internal auditory canal (IAC) is the keystone of bone removal. We also found accuracy in the system suggested by E. and J. L. Garcia-Ibanez for its identification and that there is a smaller surgical window in female patients (statistically significant) that can be predicted on preoperative imaging studies. Our study also confirms significant individual variability in the mutual relationships of different surgical landmarks. We concluded that surgery of the middle fossa requires detailed understanding of the complex temporal bone anatomy. The surgeon has to be aware of extreme variability of the more commonly used anatomical landmarks. The method to identify the position of the IAC described by E. and J. L. Garcia-Ibanez seems to be the simplest and most reliable. When the surgical strategy includes an anterior petrosectomy, interindividual variability can critically affect the working area, particularly in females. The working area can be estimated on preoperative CT scans through the petrous bone.

Extradural motor cortex stimulation in advanced Parkinson's disease: the Turin experience: technical case report.

OBJECTIVE AND IMPORTANCE: At our institution, extradural motor cortex stimulation (EMCS) has recently been applied for treating Parkinson's disease symptoms. We report our results and review the literature supporting this application of EMCS. CLINICAL PRESENTATION: Since 1998, six patients affected by advanced Parkinson's disease and not fulfilling inclusion criteria for deep brain stimulation underwent EMCS. INTERVENTION: A quadripolar electrode was introduced in the extradural space over the motor cortex, opposite to the side on which parkinsonian symptoms had begun. Bipolar chronic electrostimulation was delivered at 2.5 to 6 V, 150 to 180 microseconds, and 25 to 40 Hz. Preoperative and postoperative clinical status was assessed by the Unified Parkinson's Disease Rating Scale (UPDRS) and recorded on videotapes. The follow-up of this series varied from 4 months to 2.5 years. After EMCS, the overall UPDRS score decreased by 42 to 62%; Section III UPDRS score (motility evaluation) by 32 to 83%; and Section IV UPDRS score (therapy complications) by 100% in two patients, by 50 to 67% in four patients, and by 33% in one patient. L-Dopa therapy was reduced by 11 to 33% in three patients and by 70 to 73% in the other two patients. No postoperative complications or negative side effects of electrostimulation were recorded, except for a misplacement of the electrodes in one patient. CONCLUSION: Unilateral EMCS relieves, at least partially, but sometimes dramatically, the whole spectrum of symptoms in advanced Parkinson's disease. L-Dopa may be reduced up to 70%. The symptoms of long-term L-dopa syndrome are usually markedly improved. The neurophysiological mechanisms involved are still under debate. Our clinical experience adds favorable data to enlarge the series of parkinsonian patients treated by EMCS.

Therapeutic extradural cortical stimulation for movement disorders: a review.

Extradural motor cortex stimulation was introduced in 1989 for control of central pain. In recent years this has been found useful in several patients with movement disorders. This paper attempts to bring together all the relevant literature, discuss mechanisms and lay out guidelines for future research and clinical applications.