In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.

BACKGROUNDTo discuss the rare event of spontaneous resolution of a lumbar ganglion cyst, a personal case report and 25 cases culled from the literature were described in detail.We focused on demographic, classification, clinical and radiological findings, treatment, outcome and radiological resolution. CASE SUMMARYA 51-year-old man presented to our observation with complaints of low back and right leg pain.Lumbar magnetic resonance imaging (MRI).showed a L4-L5 ganglion cyst.The patient was referred to medical therapy and bracing.After 4 wk, he showed a complete resolution of pain.The complete spontaneous resolution of the cyst was demonstrated by the followed-up MRI. CONCLUSIONSpontaneous resolution of lumbar ganglion is very rare and only 26 cases, including ours, were reported in literature.Different degrees of biomechanical impairment seem to play a fundamental role in the pathogenesis.Related symptoms are essentially represented by low back and/or radicular pain, without significant neurological disorders.Anti-inflammatory drugs, light unloading exercises and brace could be recommended to administrated pain and decrease facet loads.Mean time for clinical improvement was 7 mo, while MRI disappearance occurred in an average time of 11 mo.Therefore, surgery should be applied when conservative treatment, prolonged at least 6 mo, fails.

Arachnoid cysts (ACs) are congenital intracranial benign cavities originating from the meninges during embryological development. Several studies have shown the existence of a relationship between AC and a higher risk to develop ipsilateral chronic subdural hematoma (CSH) especially in a young population. In the presence of an AC, the practice of sport activities may expose young patients to minor head trauma and to an increased risk of developing CSH. We describe three cases of young soccer players with AC associated with CSH. Then, we performed a literature review of all the reported cases in the literature of patients younger than 18 years with AC-associated CSH related to sport practice. A total of 33 cases, including the three cases reported by us, are analyzed. Soccer is the most represented sport activity in this association (39% of cases). The treatment of choice is surgical in all patients, with burr hole or craniotomy in similar proportions. In one-third of patients, the AC has been fenestrated. Outcome is good in all the reported cases. We reviewed the main pathogenic theories, the main surgical strategies described in literature, as well as recurrence rate of CSH, the association of AC and cranial deformities, and the clinical outcome. AC might be associated with skull deformities, but their real incidence remains unclear. The clinical detection of such anomalies should suggest performing further radiological investigations. If the presence of AC is confirmed, the practice of sport activities should not be avoided, as the real incidence of AC-associated CSH is not clear yet and the reported outcomes in literature are good. Surgical treatment of AC-associated CSH should be hematoma removal through burr hole, reserving AC fenestration only for cases with intracystic bleeding or recurrences. The surgeon should adequately advise and inform the young patients and their families that they could have an increased risk of developing CSH given by the presence of the AC, and that they should be referred to a neurosurgical center if they become symptomatic.

Objectives: Few studies have described retrograde migration of the atrial catheter tip in ventriculoatrial shunt to treat adult hydrocephalus. Methods: We placed ventriculoatrial shunts in 25 selected adult patients with a previous complicated abdominal surgery or concurrent bowel disease and in patients with persistent symptoms after a ventriculoperitoneal, potentially due to conflicting internal abdominal pressure. Clinical and radiological follow-ups were performed at least 18 months postoperatively. Results: No mortality or early or late infection occurred in the series of patients. At the long-term clinical and radiological follow-up (mean 4.5 years), eight patients died due to causes unrelated to shunt surgery. All other patients were able to live independently but some experienced neurological decline related to their neurodegenerative disease. In five patients (20%), atrial catheter migration was detected on a control chest x-ray; in four patients, it was associated with worsening of their clinical condition. These patients underwent surgical substitution of the atrial catheter. The remaining asymptomatic patient was managed conservatively. Conclusions: The ventriculoatrial shunt was a safe, effective procedure for treating hydrocephalus in adult patients. Retrograde migration of the atrial catheter tip in symptomatic patients required surgical substitution of the atrial catheter.

Intracranial pseudoaneurysm (IPA) is a rare but likely underdiagnosed cause of intracranial hemorrhage, which accounts for just 1–6% of all intracranial aneurysms. Spontaneous IPAs are exceptionally rare, and their etiology and features are not well defined. Herein, we report a case of a pediatric patient who died from massive intracranial bleeding due to the rupture of a spontaneous IPA after undergoing multiple radiological studies and neurosurgical operations. At the postmortem examination of the brain, a giant size pseudoaneurysm of the right middle cerebral artery was observed. Microscopic examination demonstrated variable wall thickness and dense fibrosis focally in the vessel wall with disruption of the media structure together with a loss and fragmentation of the elastic laminae, loss of organization of smooth muscle cells in the media, and multifocal areas of hemorrhage throughout the vessel wall, as well as direct evidence of wall dissection. Since IPAs without any traumatic or infective history are extremely uncommon, further pathologic studies should be performed to clarify spontaneous pseudoaneurysm etiology.

BACKGROUND: Sacral fractures are a challenge regarding treatment and classification. Surgical techniques using spinal navigation systems can improve treatment, especially if used in collaboration among different specialists. METHODS: Between 2015 and 2017, we treated 25 consecutive cases of sacral fracture. Twelve patients (48%) underwent mechanical ventilation due to hypovolemic shock for severe thoracoabdominal trauma; bleeding was blocked with pelvic packing in 9 cases (36%) and trans-catheter embolization in 2 cases (8%). External fixation was used in 7 cases (28%). In 20 cases (80%) spinal fractures were associated. All patients were operated on using spinal navigation by a team of neurosurgeons and ortho-pedic surgeons. RESULTS: The mean time from first observation to surgery was 18 days (range 8-31). Surgical treatment consisted of iliosacral fixation in 19 cases (76%) and spinopelvic fixation in 6 cases (24%). The mean number of screws for spinopelvic fixation was 9.67 (range 6-17) with a mean operation time of 323.67 minutes (range 247-471); in iliosacral osteosynthesis the mean screw number was 1.37 (range 1-3) and mean surgical time was 78.93 minutes (range 61-130). Postoperative computed tomography showed the correct screw placement. Wound infection occurred in 2 cases (8%), managed with vacuum-assisted closure therapy; in 1 case (4%) a sacral screw was removed for decubitus. CONCLUSIONS: Navigation systems in instrumented spinopelvic and sacropelvic reconstruction provide greater safety, reducing learning times and malpositioning. Multi-disciplinary management allows us to achieve optimal results, especially when the sacral fracture is combined with spinal and pelvic lesions. The use of navigation systems could represent an important advancement.

Traumatic thoraco-lumbar spine fracture spine with a concomitant blunt aortic injury is uncommon but potentially a fatal association. Our aim was to clarify: morphology of spinal fractures related to vascular damages and vice versa, diagnostic procedures and decision-making process for the best treatment options for spine and vessels.

The formation of a post-traumatic delayed epidural hematoma (DEDH) is a rare but well-described complication in the literature. It is defined as an extradural bleeding not evident at the first computed tomography (CT) scan performed after trauma, but evidenced by further radiological evaluations. The most supported hypothesis about the mechanism responsible for the formation of a DEDH concerns above all the loss of a tamponade effect given by the reduction of intracranial pressure with medical or surgical treatment. A 30-year-old man was admitted to the emergency department with an epidural hematoma (EDH) associated with a linear calvarial bitemporal coronal fracture. A few hours after the surgical procedure for hematoma evacuation, the patient developed a DEDH contralateral to the site of surgical procedure. The literature review identified other 27 analogue cases. The presence of a calvarial fracture contralateral to the site of a craniotomy and the intraoperative brain swelling during EDH removal are suspicious for the development of DEDH. A CT scan has to be urgently performed in this situation. The timing of postoperative radiological examinations after EDH removal has to consider possible complications and has to be balanced on the basis of patient’s clinical condition and neuroradiological data, such as skull fractures or intraoperative anomalies. The development of a DEDH after the surgical removal of an EDH is a rare event, characterized by a high mortality rate. DEDH develops preferentially on the contralateral side and with a concomitant skull fracture.

BACKGROUND:In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient's survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics.METHOD:Herein, we report the patient's selection and technique to execute the TES for cases of thoracic metastasis.CONCLUSION:This surgery is technically demanding so the patient's selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor's progression is "limited" by local barriers as demonstrated by histological studies.

BACKGROUND:Removing the posterior longitudinal ligament in cervical corpectomy is a controversial issue. It is unclear whether the risks are counterbalanced by clinical benefits. Another unexplored topic is whether the width of the corpectomy affects outcome. METHODS:This cross-sectional retrospective study included consecutive patients who underwent cervical corpectomy for spondylosis by 6 different neurosurgeons. We compared 2 groups, where the posterior longitudinal ligament was either removed (N = 15 patients) or preserved (N = 21 patients). The posterior width of the corpectomy was assessed postoperatively with computed tomography and magnetic resonance imaging. Clinical results were evaluated with the visual analog scale (VAS), Modified Japanese Orthopedic Association scale (MJOAS), Cooper scale, and neck disability index (NDI), in the long-term follow-up. RESULTS:Compared to preservation, removal of the posterior longitudinal ligament produced more favorable clinical results (but not statistically significant), based on the VAS (+41%, P = 0.48), MJOAS (+26.5%, P = 0.62), Cooper scale (+19%, P = 0.75), and NDI (+62%, P = 0.22). Magnetic resonance imagings showed that removing the posterior longitudinal ligament produced greater evagination of the dural sac into the space left by the corpectomy. Improvements in clinical outcome were associated with more posterior bone wall removal in the corpectomy (corpectomy width ≥15.6 mm; P < 0.05), based on the VAS, NDI, and MJOAS. CONCLUSIONS:Removing the posterior longitudinal ligament in cervical corpectomy may produce a better outcome, particularly when associated with more posterior bone wall removal in the corpectomy.

Spinal infections are rare (their incidence is estimated in about the 5% of all osteomyelitis) and severe pathologies. They are usually identified with different names, as disk space infection, spondylodiscitis, and vertebral osteomyelitis. Spondylodiscitis is the most frequent among spinal infections. The etiology might be due to bacteria, fungi, and parasites and might affect many anatomical structures. The reported incidence is increased in the last years.[[1] [2]] The disease can be classified according to the involved anatomical structure:

BACKGROUND:Spinal intradural meningiomas that arise purely from a nerve root without dural attachments are extremely rare. Spinal meningiomas arise from arachnoidal cap cells in the spinal canal, and growth of these tumors exerts pressure on the spinal cord and nerve roots.CASE DESCRIPTION:A patient presented with a lesion at the T3-T4 level that resembled a schwannoma on magnetic resonance imaging. During surgery, the tumor originated from a spinal nerve root. Pathologically, it was an angiomatous meningioma (AM).CONCLUSIONS:In a review of the literature, we discuss the pathogenesis and surgical strategy for diagnosing and treating these extremely rare AM lesions.

Spinal epidural arteriovenous fistulas (SEDAVFs) are peculiar and poorly understood lesions with a poorly understood natural history. They usually are subclassified into 2 types according to their drainage components. This study aimed to describe a new type of SEDAVFs that is featured with a unique drainage pattern and present our natural history hypothesis of SEDAVFs.Five SEDAVF cases of the new type were reviewed retrospectively from a high case-volume spinal vascular malformation database. The clinical manifestations, neuroradiologic findings, angioarchitecture, treatment strategies, and clinical outcomes were assessed.All patients presented with spontaneous spinal epidural hematoma, and 2 of them exhibited rebleeding. The median age at the initial episode was 20 years. Spinal digital subtraction angiography revealed slow-flow epidural fistulas drained by spinal epidural venous plexus without intradural drainage or engorged venous pouches in all 5 patients. Three patients underwent microsurgical treatment. The outcomes of all of the patients were favorable.Our study reported a special type of hemorrhagic SEDAVF without an intradural drainage component or epidural mass effect. The key diagnostic clue was early opacification of spinal epidural venous plexus on spinal angiogram. We believe SEDAVFs may form at an early age and gradually develop with time. Different types of SEDAVFs may represent different developing stages of one disease, and our type may represent the early stage of SEDAVFs.

Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative thoracolumbar and lumbar kyphoscoliosis by a non posterior subtraction osteotomy technique.

BACKGROUND: Spinal acupuncture is a relatively safe and common analgesic treatment, but it may be complicated by serious adverse effects, such as direct spinal cord and nerve root injury, subdural empyema, and epidural abscesses. In this report we compare our case of an extremely uncommon spinal epidural hematoma, which appeared after treatment by acupuncture, with other similar documented cases. CASE DESCRIPTION: This is the case of a 64-year-old man who presented a left hemiparesis associated with paraesthesia. This appeared several hours after acupuncture treatment for left lumbosciatic pain. The cervicothoracic spine magnetic resonance imaging (MRI) scan showed a cervicothoracic spinal epidural hematoma from C2 to T12. The rapid improvement of the patient's neurologic symptoms justified the adoption of a conservative treatment strategy. This gave excellent long-term results. CONCLUSIONS: Although a post-acupuncture spinal epidural hematoma (paSEH) is very rare, there are only 6 documented cases, it is a possible complication from acupuncture on the back. The use of very thin needles can produce bleeding, probably venous, in the epidural space. In general, this evolves more slowly than other kinds of epidural hematomas. The symptoms are also less severe, warranting less frequent surgical intervention, and in general there is a good outcome. The possibility of hematoma makes acupuncture contraindicated in patients who have coagulation disorders. The onset of severe spinal pain after spinal or paraspinal acupuncture treatment should lead to the suspicion of a paSEH, and a spinal MRI should be carried out.

OBJECTIVE The goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma (SEH) by correlating etiology, age, site, clinical status, and treatment with immediate results and long-term outcomes. METHODS The authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012. In addition, the authors reviewed the relevant international literature from 1869 (when SEH was first described) to 2012, collecting a total of 1010 cases. Statistical analysis was performed in 959 (95%) cases that were considered valid for assessing the incidence of age, sex, site, and clinical status at admission, correlating each of these parameters with the treatment results. Statistical analysis was also performed in 720 (71.3%) cases to study the incidence of etiological factors that favor SEH formation: coagulopathy, trauma, spinal puncture, pregnancy, and multifactorial disorders. The clinical status at admission and long-term outcome were studied for each group. Clinical status was assessed using the Neuro-Grade (NG) scale. RESULTS The mean patient age was 47.97 years (range 0-91 years), and a significant proportion of patients were male (60%, p < 0.001). A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life. The cause of the SEH was not reported in 42% of cases. The etiology concerned mainly iatrogenic factors (18%), such as coagulopathy or spinal puncture, rather than noniatrogenic factors (29%), such as genetic or metabolic coagulopathy, trauma, and pregnancy. The etiology was multifactorial in 11.1% of cases. The most common sites for SEH were C-6 (n = 293, 31%) and T-12 (n = 208, 22%), with maximum extension of 6 vertebral bodies in 720 cases (75%). At admission, 806 (84%) cases had moderate neurological impairment (NG 2 or 3), and only lumbar hematoma was associated with a good initial clinical neurological status (NG 0 or 1). Surgery was performed in 767 (80%) cases. Mortality was greater in patients older than 40 years of age (9%; p < 0.01). Sex did not influence any of these data (p > 0.05). CONCLUSIONS Factors that contribute to the formation of acute SEH are iatrogenic, not iatrogenic, or multifactorial. The treatment of choice is surgery, and the results of treatment are influenced by the patient's clinical and neurological status at admission, age, and the craniocaudal site.

Dural sinus thrombosis following a head trauma is a rare condition, described in literature along with the lack of consensus regarding diagnosis and management. We present a case of a fifty-year-old man with a head injury and combined supratentorial-subtentorial epidural hematoma who was treated conservatively through the administration of low molecular weight heparin. The diagnosis and management of this condition are discussed based on a literature review. The early diagnosis may prevent potentially treatable poor out-comes.