Surgical management of giant calcified thoracic disc herniation and the role of neuromonitoring. The outcome of large mono centric series.

PURPOSE: Giant thoracic disc herniations (GTDH) are considered a subgroup of TDHs with worse functional outcomes, a high calcification rate, and a considerable risk of complications. We aimed to determine whether there is a relationship between the extent of calcification of GTDH and outcomes concerning the risk of complications, the surgical technique, and changes in neuromonitoring signals. METHODS: We present a retrospective analysis of 76 patients undergoing surgery for calcific GTDH. We introduced and defined a radiological definition of the calcified disc into"fully calcified" and "partially calcified." We performed a statistical analysis between clinical and radiological variables, type of surgical procedure, the extent of excision, neuro-monitoring signals, and outcome, comparing a group of 58 "fully-calcified TDH" patients and 18 "partially-calcified TDH" patients. RESULTS: Fully calcified TDHs, compared with partially calcified TDHs, do not have significant differences in outcome (worse outcome 4/58-6.9% versus 0/18, p = 0.25) and complications (10/58-17.24% versus 4/18-22.2%, p = 0.63); Fully calcified TDH is associated with a higher risk of alterations in neurophysiological potentials (14/58-24.1% versus 0/18, p = 0.02) and subtotal excision (18/58-31% versus 2/18-11%, p = 0.15), without significant differences between the approaches used. CONCLUSION: Fully calcified TDH group has a similar outcome and complication rate as the partially calcified TDH group, but they are associated with higher intraoperative neuromonitoring signal changes. We introduced a new classificationsystem that guides the approach and helps tocounsel the patients.

Spinal Nerves Schwannomas: Experience on 367 Cases-Historic Overview on How Clinical, Radiological, and Surgical Practices Have Changed over a Course of 60 Years.

BACKGROUND: Spinal schwannomas are common benign spinal tumors. Their treatment has significantly evolved over the years, and preserving neurological functions has become one of the main treatment goals together with tumor resection. STUDY DESIGN AND AIMS: Retrospective review focused on clinical assessment, treatment techniques, and outcomes. METHODS: A retrospective study on our surgical series was performed. Clinical and operative data were analyzed. In regard to neurophysiologic monitoring, patients were retrospectively divided into two groups comparing the outcomes before and after introduction of routine intraoperative neurophysiology tests. RESULTS: From 1951 to 2010, 367 patients overall were treated. Diagnosis was obtained using angiography and/or myelography (pre-CT era), MRI, or CT scan. A posterior spinal approach was used for most patients; complex approaches were adopted for treatment of giant/dumbbell tumors. A trend of neurophysiology monitoring decreasing the rate of post-op neurological deficits was observed but was not statistically significant enough to draft evidence-based conclusions. CONCLUSIONS: Clinical and radiological assessment of spinal schwannomas has markedly changed over the course of 50 years. Diagnostic tools have improved, and detection of recurrence has become way more sensitive. Neurophysiologic monitoring has become a useful intraoperative tool to guide resection and prevent post-op neurological impairment.

Awake craniotomy for trapping a giant fusiform aneurysm of the middle cerebral artery.

BACKGROUND: Giant fusiform aneurysms of the distal middle cerebral artery (MCA) are rare lesions that, because of the absence of an aneurysm neck and the presence of calcified walls and partial thrombosis, can be difficult to clip without sacrificing the parent vessel. Moreover, when the aneurysm is located in the dominant hemisphere, it is not possible to test language and cognitive functions during surgical intervention, making the closure of the parent vessel extremely dangerous. CASE DESCRIPTION: A 46-year-old woman presented with a one-year history of frontal headache without neurological deficit. A magnetic resonance imaging and an angiography showed a giant fusiform aneurysm of the left M2 tract. Because of the location and the absence of a neck, the aneurysm was considered difficult to coil and not amenable to preoperative balloon occlusion; thus, the patient was a candidate for surgical treatment. After a preoperative psychological evaluation, patient underwent awake craniotomy with the asleep-awake-asleep technique. A standard left pterional approach was performed to expose the internal carotid artery, the MCA and the aneurysm originating from the frontal branch of the MCA. Neurological examination responses remained unchanged during temporary parent artery occlusion, and trapping was successfully performed. CONCLUSIONS: Awake craniotomy is a useful option in intracranial aneurysm surgery because it permits neurological testing before vessels are permanently clipped or sacrificed. With the asleep-awake-asleep technique, it is possible to perform a standard pterional craniotomy, which allows good exposure of the vascular structures without cerebral retraction.