Introduction:Spine surgery requires precise visualization to ensure safety in anatomically complex regions. Traditional microscopes, though effective, have ergonomic and communication limitations. High-definition three-dimensional (3D) exoscopes address these challenges by providing superior image quality, depth perception, ergonomics, collaboration, and teaching opportunities, while supporting minimally invasive techniques. This study reports the experience of two Italian centers adopting the exoscope as a primary visualization tool, integrating surgeons' and staff perspectives through structured questionnaires. Methods:This retrospective, observational, dual-center study evaluated spinal procedures performed with the exoscope between January 2022 and June 2025 at two Italian institutions. Procedures included cervical, thoracic, and lumbar surgeries performed through anterior, posterior, and lateral approaches, and encompassed intradural and extradural pathologies. Clinical experience was complemented by two structured questionnaires, one for surgeons and one for non-surgeon team members, addressing image quality and visualization, ergonomics and fatigue, intraoperative communication and workflow, learning curve and implementation, and educational value. Results:A total of 880 spinal procedures were performed. Surgeons reported excellent visualization, illumination, magnification, depth perception, and ergonomics, with reduced fatigue and improved workflow. Competency was typically achieved within three cases. Non-surgeons confirmed improved image quality, intraoperative communication, awareness of surgical actions, and educational engagement. Both groups consistently endorsed the exoscope as a transformative surgical and teaching tool. Conclusions:The exoscope enhances visualization and ergonomics while fostering collaboration and education in the operating room. It offers significant advantages over traditional microscopes, improving precision, efficiency, and training across diverse spinal procedures, and represents a valuable tool for routine clinical practice.

STUDY DESIGN:Prospective, nationwide, multicenter observational cohort registry with first-year implementation data. OBJECTIVES:To describe the design and rationale of the Italian Spine Trauma Registry (TVMit) and assess the feasibility of standardized nationwide recruitment and longitudinal data collection in surgically treated spinal trauma. SETTING:Forty-eight neurosurgical centers across Italy. METHODS:Adults aged ≥ 16 years undergoing surgery for traumatic spinal column and/or spinal cord injury are prospectively enrolled from 2025 to 2034. Standardized data include demographics, injury characteristics, neurological status, surgical timing and technique, perioperative management, complications, rehabilitation, and Patient-Reported Outcome Spine Trauma (PROST), with follow-up at 3, 12, and 24 months. RESULTS:During the first year, 673 participants were enrolled. Lumbar injuries were most frequent (46.2%), followed by thoracic (30.6%), subaxial cervical (15.0%), and upper cervical injuries (8.0%). Surgery within 48 h was more frequent for subaxial cervical injuries (46.5%), and posterior approaches predominated at upper cervical, thoracic, and lumbar levels. CONCLUSIONS:TVMit has established a feasible national prospective platform for standardized real-world data collection in surgically managed spinal trauma. Longitudinal neurological and patient-reported outcomes will support benchmarking, comparative effectiveness research, and future predictive modeling.

Introduction: Metastatic spinal cord compression (MSCC) is a life-threatening complication caused by the involvement of the spinal cord or nerve roots. It can result in severe neurological deficits, including paralysis, sensory loss, and bladder or bowel dysfunction, significantly affecting patients' quality of life. Prompt diagnosis and intervention are critical to minimizing these outcomes and improving neurological recovery. This study evaluates the efficacy of a diagnostic and therapeutic protocol introduced at our institution in 2022, designed to enhance early detection, optimize management, and improve outcomes for patients with MSCC. Materials and Methods: The protocol was developed through a multidisciplinary collaboration involving emergency physicians, oncologists, spine surgeons, neuroradiologists, and radiation oncologists. Each specialty contributed its expertise to create a streamlined approach emphasizing early symptom recognition, rapid diagnostic imaging, and timely therapeutic interventions, such as surgical decompression and radiotherapy. To assess the protocol's effectiveness, a retrospective analysis was conducted. Clinical data from the pre-implementation period (years 2019-2021) were compared to the post-implementation period (2022-2024). Results: The implementation of the algorithm significantly improved MSCC management, increasing outpatient consultations from 671 to 828 (+23%). Comparing the pre- to post-implementation periods, emergency consultations rose from 14% to 23%, while intrahospital consultations decreased from 20% to 16%. Surgical procedures increased slightly, from 60 to 66 (+10%), including 26 emergency surgeries (+4%) and 40 elective delayed surgeries (+14%). Conclusions: The introduction of a multidisciplinary diagnostic and therapeutic protocol significantly improved outpatient management of patients with metastatic spine disease, demonstrated by a significant increase in urgent outpatient consultations and a reduction in intrahospital consultations. The number of surgical interventions for metastatic spinal cord compression slightly increased after the protocol's adoption, although the proportion of elective surgeries remained unchanged. Neurological presentation at the time of surgery did not show a statistically significant difference between the pre- and post-implementation periods. These findings highlight the protocol's effectiveness in optimizing patient flow and triaging, while further research is needed to evaluate its long-term clinical impact.

The sparse representation of women in neurosurgery, compared to other medical fields, has driven debates about causes and remedies. This study explores gender disparities through a survey of female members of the Italian Society of Neurosurgery (SINch). Comprising 49 questions, the survey focused on career trajectories, work-life balance, mentorship, and perceptions of gender-related challenges. The respondents numbered 119, with 51% from 31 to 40 years old. Personal motivation emerged as the dominant driver for choosing neurosurgery. Mentorship was identified as a critical factor, with 69% perceiving benefits from having female mentors. Over half of respondents reported experiencing gender bias during residency and in the workplace. Many reported facing discouragement from peers and professors. A substantial proportion reported difficulty reconciling family responsibilities with professional duties, with 84% attributing lack of commitment to a relationship, and 49% attributing delayed motherhood, to professional demands. Respondents also expressed dissatisfaction with their visibility in scientific societies and conferences. As a remedy to hindrances of career progression, the majority of respondents do not envision female-centered initiatives (e.g., quotas in scientific societies, “women sections” or “pink rooms” at conferences). Instead, the respondents seek recognition based on merit. Rather than being categorized by their gender, the women surveyed advocate for a fair system where all individuals work on equal footing. Discussing these findings in the context of initiatives entailing quotas and enforced diversity, we argue that identity-based programs undermine core principles. Addressing underrepresentation in neurosurgery requires solutions that promote access and recognition for contributions irrespective of gender. Scientific associations have a fundamental responsibility in combating prejudice and enforcing measures to ensure the elimination of all forms of bias within neurosurgery.

BACKGROUND:Atlantoaxial injuries pose a significant threat to morbidity and mortality. This retrospective study aims to analyze clinical and radiologic results, failure rates, and complications in a series of patients treated with a halo vest, validating the effectiveness of this device through long-term follow-up. METHODS:This study reviewed adult patients with acute upper cervical spine injuries treated with halo vest immobilization from 1994 to 2022. Fracture types were classified based on computed tomography characteristics. Clinical and radiologic follow-up was performed at the end of treatment and 3 months after the removal of the system. RESULTS:Most treated patients were male (70%), with a mean age of 38 years. Car accidents were the primary cause of injury (63%). Among 161 patients, 134 had a C2 fracture, 20 had a C1 fracture, 5 had a C1-C2 rotational dislocation, and 2 had other unclassified combined C1/C2 fractures. Patients without additional injuries or neurologic deficits had significantly shorter hospitalization (8 vs. 16 days and 12 vs. 22 days, respectively) compared with those with additional injuries (P < 0.00001) or neurologic deficits (P = 0.00164). At 6 months follow-up, radiologic and clinical outcomes were available for 147 patients. Radiography in 139 cases showed fracture fusion (94.6%). Clinical follow-up showed a normal or slightly reduced range of motion in 144 cases (98%). Pain was absent or episodic in all the patients except one. In 131 patients (89%), an excellent or good clinical result was achieved. Complications did not affect treatment. CONCLUSIONS:Based on our results, the halo vest is a valid treatment for atlantoaxial injuries in selected patients. These patients include young and middle-aged individuals (up to 65 years old) with C1 and/or C2 fractures. Halo vest treatment is associated with minor complications and yields a high percentage of excellent/good clinical results.

PurposeNeurological complications are among the most frightening risks in spine surgery. Intraoperative neuromonitoring (IONM) aims to quickly detect changes in the patient's neurology, allowing for actions that can reverse neurological deficits before they become irreversible. A checklist was proposed in 2014 in response to changes in neuromonitoring for correcting deformities in spine surgery; however, it was designed specifically for procedures on stable spines, which are different from oncological and degenerative spine surgery. The goal of this project is to provide a checklist for oncological and degenerative spine surgery to improve the quality of surgical treatment and patient's safety.MethodsTo revise and implement the existing checklist a study group of 27 people was created, including: 8 surgeons from five hospitals, 7 anesthetists, 7 IONM operators and 5 operating room nurses. To achieve consensus the Delphi method was used with 2 surveys and 3 consensus rounds, which occurred from February 2022 to February 2023, when the new checklist was approved.ResultsInitial survey and Round I: 22 items of the existing checklist considered appropriate. Thirty new items proposed, focusing particularly on unstable spine procedures. Second survey and Round II: 28 items considered suitable; 24 items deemed as unnecessary. Round III and final survey: discussion about the participants' experience with the new checklist. One item was added: "Evaluate D-Wave response (if applicable)" and the final version of the checklist was approved.ConclusionA new checklist based on IONM changes during oncological and degenerative spine surgery was created. Its implementation can potentially improve surgical results and patient's safety in spine surgery.

Background/Objectives: Desmoid tumors (DTs) are rare benign soft tissue neoplasms characterized by local aggressiveness and high rate of recurrence. Spinal localization is only anecdotally reported in the literature. When presenting in a dumbbell-shaped configuration, they can mimic neurogenic tumors. Methods: We report a rare case of a spinal intracanalar–intrathoracic DT, initially suspected to be a schwannoma, and review the literature. Results: A 24-year-old asymptomatic man was incidentally found to have a mediastinal mass on chest X-ray. CT and MRI revealed a left thoracic paravertebral mass (T9–T12), with intracanalar extension through the T10–T11 foramen, suggestive of a dumbbell-shaped neurogenic tumor. After embolization, the patient underwent surgery via a posterior combined intracanalar and endothoracic approach. Histology and immunohistochemistry analysis identified the tumor as a desmoid type fibromatosis (β catenin positive; S100, CD34, SMA negative). Follow-up MRI at 8, 12, and 18 months showed stable residual intrathoracic mass. Conclusions: To date, only 36 cases of spinal DTs have been reported in the literature, of which only 6 exhibited dumbbell morphology. Immunohistochemical and molecular pathological testing is essential for diagnosis. Although wide resection is preferred, anatomical limitations often necessitate marginal or subtotal surgery, which increases the risk of recurrence (24–77%). Our review showed a 29% overall recurrence rate (50% after subtotal, 29% marginal, 20% wide resection). Adjuvant radiotherapy or systemic therapies may help improve outcomes. Spinal DTs pose significant diagnostic and therapeutic challenges. In the absence of established guidelines, management should be individualized and multidisciplinary. Lifelong follow-up is essential due to the high risk of recurrence.

The craniovertebral junction (CVJ) is an anatomically complex and surgically challenging region, where critical neurovascular structures converge. Traditional surgical approaches to this area have involved high risks of morbidity due to the intricate anatomy and limited surgical corridors. Recent advancements in minimally invasive techniques, imaging, robotic assistance, and artificial intelligence are revolutionizing CVJ surgery. This article reviews current innovations shaping the future of CVJ surgery, emphasizing improved safety, precision, and patient outcomes.

The craniovertebral junction (CVJ) is an anatomically complex and surgically challenging region, where critical neurovascular structures converge. Traditional surgical approaches to this area have involved high risks of morbidity due to the intricate anatomy and limited surgical corridors. Recent advancements in minimally invasive techniques, imaging, robotic assistance, and artificial intelligence are revolutionizing CVJ surgery. This article reviews current innovations shaping the future of CVJ surgery, emphasizing improved safety, precision, and patient outcomes.

BACKGROUND: Long segment fixation has been frequently used to treat thoracolumbar burst fractures. In our study we want to compare the long and short segment with intermediate screw fixation of thoracolumbar junction burst fractures in relation to radiological and clinical outcomes.METHODS: We collected the data of 115 patients, with thoracolumbar junction (T11-L2) burst fracture A3 or A4, according to AO classification. Patients were divided into two groups. Group A was treated by long segment fixation. Group B was treated by short segment fixation. At admission, after surgery, and at 12-month follow-up the patients were radiographically assessed for local kyphotic angle using the Cobb method. Patients were clinically evaluated with the Visual Analogue Scale (VAS) for back pain.RESULTS: The mean difference of the preoperative, immediate postoperative, and 12-month follow-up Cobb angle was significant in both groups (p = 0.018). The mean difference of the preoperative and immediate postoperative Cobb angle, Δ1, was significantly greater in group A than in group B (p = 0.038), indicating that the Cobb angle correction immediately postoperative was better in patients with double level fixation. The mean difference of the immediate postoperative and 12-month follow-up Cobb angle, Δ2, was significantly greater in group A than in group B (p = 0.007), indicating that the maintenance of local Cobb angle correction was better in patients with double level, long fixation. There was no difference in VAS values between Group B (single) and Group A (double) segment fixation immediately post operatively (p = 0.356) or after 12 months (p = 0.147).CONCLUSIONS: In A3 and A4 thoracolumbar junction fractures, long segment fixation can correct the local kyphosis Cobb angle and maintain the correction at 12-month follow-up better than short segment fixation with intermediate screws in the fractured vertebra. The radiological difference, however, was not predictive of clinical results.

Pregnancy and lactation-associated osteoporosis is a rare form of osteoporosis occurring during late pregnancy and early lactation, featuring fragility fractures, primarily involving the vertebral bodies and leading to back pain. Its management involves osteoporosis treatment, complicated by potential drug-related dangerous effects on the fetus. Nevertheless, many controversies remain regarding diagnosis, prognosis, and treatment options. Herein, we propose a multicentric case series to provide a comprehensive neurosurgical, gynecological, and endocrinological perspective on the management of pregnancy and lactation-associated osteoporotic vertebral fractures. A multicenter retrospective study was conducted at the Neurosurgical Department of Università degli Studi di Napoli Federico II, the Neurosurgical Unit of Hopitaux Universitaires de Genève, and the Spine and Spinal Cord Surgery Unit of the University Hospital of Udine, collecting data from January 2014 to December 2022. The study has been approved by the ethical committee of each hospital. N = 11 patients with an overall number of 31 fractures were eligible, with a mean age of 36. N = 5 (16

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic–therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

BACKGROUND:Over the past 10 years, intraoperative neurophysiological monitoring (IONM) has been widely performed during surgery for treating spondylotic cervical myelopathy. Our study considers the predictive value of IONM during laminoplasty, regarding, first, the adequacy of spinal cord decompression and, second, the long-term neuro-functional outcome. METHODS:We considered 38 patients with the diagnosis of degenerative cervical myelopathy who underwent an open-door laminoplasty. All patients were evaluated preoperatively, and at three and 12 months postoperatively, with the Japanese Orthopedic Association (JOA) point scale. Upper and lower limb somatosensory and motor evoked potentials (SSEPs and MEPs) were recorded preoperatively and intraoperatively. RESULTS:During surgery, three of 38 patients showed a deterioration of SSEPs and MEPs compared to baseline values. Surgery was then converted from laminoplasty to laminectomy, resulting in the gradual restoration of the evoked potentials. The neurophysiological parameter significantly associated with a better clinical outcome was the latency of lower limbs MEPs. The 12 patients who had a more prominent reduction of the MEPs latency at the end of surgery showed a higher post-surgical JOA score, increasing ≥30% compared to baseline values at the 3- and 12-month follow-up. CONCLUSIONS:Though not a predictor of clinical outcome, the IONM was essential to evaluate the effectiveness of spinal cord decompression. Reduced latency of lower limbs MEPs may predict a better clinical outcome. We suggest that IONM in patients with degenerative cervical myelopathy should be routine. It is necessary to conduct larger studies to clarify the predictive value of IONM.

INTRODUCTION:The three-dimensional elaboration of morphological data derived from computed tomography (CT) and magnetic resonance imaging (MRI) scans generates virtual anatomical reconstructions. Here, we propose a novel protocol to analyze the postoperative results of open-door laminoplasty to evaluate differences in the volume of the spinal canal. The protocol uses geometric models in patients with cervical degenerative myelopathy before versus after cervical laminoplasty.MATERIALS AND METHODS:Mimics and 3-Matic software (Materialise, Leuven, BE) programs were used to segment anatomical structures and create polygon meshes of spines. Patients with cervical spondylotic myelopathy were enrolled. The models obtained before and after laminoplasty were superimposed by using a global registration function. The magnitude of divergence was quantified by using the root-mean-square error (RMSE).RESULTS:Using this novel protocol, we were able to map the differences in the volume of the spinal canal before laminoplasty and after laminoplasty and to quantify its magnitude and calculate the volumes.DISCUSSION AND CONCLUSIONS:The development of a procedure to measure the space within the cervical bone walls using geometric parameters represents a new, powerful method to verify the results obtained by cervical laminoplasty. Further research horizons may include the routine use of virtual models in surgical planning for this procedure.

The gradual rise of women in medical schools and residencies, surpassing men in medical school applications, contrasts with the male dominance in surgical fields, including neurosurgery (only 18% women). Reasons include concerns about work-life balance, traditional childcare roles, and gender biases. In response, Women in Neurosurgery (WINs) was founded in 1989 to address gender disparities. However, WINs sessions at conferences evolved into segregated scientific sessions, deviating from their original purpose. This contradicts the ideal of a unified neurosurgical community. While some support segregated spaces, many advocate against gender-based divisions. Today WINs' existence is deemed outdated, with a call for integration, inclusivity, and equality in the modern era of neurosurgery.