ReAbility: Complex External Prosthesis Systems to Rehabilitate Movement

The ReAbility Project is a solution that provides an alternative to wheelchair mobility for people with serious disabilities of the lower limbs, such as paraplegics, allowing them to stand and walk once again. This solution is achieved by utilizing an instrument called an "exoskeleton".The ReAbility device is a robotic-assisted system designed to improve the quality of life of people with a movement disability and/or reduced movement; it is meant both for daily domestic use and for rehabilitation therapy in hospitals and rehabilitation centers.The principal characteristics of the device are its modularity, manageability, and wearability for the patient, who is actively involved and has full control of all the movement functions. Its light weight (16 kg) renders it easy to wear for the patient and competitive on the market. From an esthetic perspective it can be worn under clothes, with obvious and important psychological and social advantages. Its cost is also well contained.With the use of this device, there is also a very real positive effect on healthcare costs.

The Significance of Abnormal Muscle Response Monitoring During Microvascular Decompression for Hemifacial Spasm

BACKGROUND

Despite the wide adoption of the abnormal muscle response (AMR) to electrical stimulation of the facial nerve during microvascular decompression (MVD) surgery, the value of AMR in the prognosis of the postoperative outcome is still controversial. In order to better use this intraoperative electrophysiology, it is necessary to further address the relationship between AMR and postoperative results.

METHODS

Three hundred and thirty-two patients with hemifacial spasm (HFS) in whom MVD surgery was performed and in whom AMR was available were finally enrolled in this study. The intraoperative AMR changes were classified as amplitude ≥ 50 %, <50 %, and disappearance. These changes were retrospectively analyzed in association with intraoperative findings and postoperative outcomes. The follow-up period ranged from 11 to 62 months, with an average of 34.1 months.

RESULTS

Among the 332 patients with a typical AMR wave recorded at the beginning of the operation, the AMR disappeared in 305, and amplitude was <50 % in 11 and ≥50 % in 16. Of those with AMR disappearance plus those with amplitude < 50 %, 98.4 % achieved relief on the first postoperative day and at the latest follow-up, while of those with amplitude ≥50 %, 18.8 % and 25 %, respectively, achieved relief on the first postoperative day and at the latest follow-up (P < 0.01). Accordingly, a more than 50 % decrease of AMR amplitude may predict a good prognosis. The accuracy, sensitivity, and specificity of AMR monitoring were 97.5 %, 99 %, and 72.2 %, respectively.

CONCLUSIONS

AMR could be a good tool for successful MVD in patients with HFS when a rational analysis is conducted in association with the intraoperative findings. Persistence of AMR may imply that the real offending vessel was missed. If the entire facial nerve root is cleared of any vessel, a remaining AMR amplitude of less than 50 % might be acceptable. Otherwise, neurocombing is suggested before finishing the operation.

Combination of Magnetic Resonance Imaging and Electrophysiological Studies in Lumbar Disc Herniation

Objective We aimed to study the clinical value of magnetic resonance imaging (MRI) and electrophysiological studies in the diagnosis of lumbar disc herniation and in the evaluation of the therapeutic effect of discectomy. Methods In this study, 265 patients with LDH were treated with discectomy after assessment by the Japanese Orthopedic Association (JOA) score, MRI, and electrophysiological studies. All the patients were followed-up for 6 years. The effects of the operation were assessed by determining the angle between the nerve root canal and disc protrusion (AN value), the stenotic ratio of the spinal canal, the width of the lateral recess, motor conduction velocity (MCV), sensory conduction velocity (SCV), and nerve action potential (NAP) before and after operation. Results The AN value, stenotic ratio of the spinal canal, and the width of the lateral recess of protruding intervertebral discs showed significant differences from these values for the patients' unaffected intervertebral discs (P < 0.05). The MCV, SCV, and NAP of the affected limb showed significant differences from these values for the patients' unaffected limbs (P < 0.05). In all the patients the values for these indicators showed significant differences before and after operation (P < 0.05). Conclusion MRI and electrophysiological studies can be used in the diagnosis of lumbar disc herniation, and in the evaluation of the effect of surgery.

Recovery from Chronic Diseases of Consciousness: State of the Art in Neuromodulation for Persistent Vegetative State and Minimally Conscious State

Chronic diseases of consciousness (CDC) can still be considered a challenging frontier for modern medicine, probably because of their not completely understood physiopathological mechanisms. Following encouraging evidence on cerebral hemodynamics, some authors have hypothesized a role for neuromodulation in the treatment of CDC patients. In the past 40 years, spinal cord stimulation (SCS) and deep brain stimulation (DBS) have been used experimentally for the treatment of patients in a severe altered state of consciousness, with some interesting but not conclusive results. The present review summarizes the data currently available in the literature on this particular and debated topic. On these grounds, further clinical studies are needed to better understand the altered dynamics of neuronal network circuits in CDC patients as a step towards novel therapeutic strategies.

One-Pot Aqueous Synthesization of Near-Infrared Quantum Dots for Bioimaging and Photodynamic Therapy of Gliomas

BACKGROUND

As the early detection and total destruction of gliomas are essential for longer survival, we attempted to synthesize a quantum dot (QD) that is capable of recognizing glioma cells for imaging and photodynamic therapy.

METHODS

Using a one-pot aqueous approach, near infrared-emitting CdTe was produced. After detection of its physicochemical characteriistics, it was conjugated with RGD. The emission images were observed with confocal microscopy. To test its toxicity, CdTe-RGD at various concentrations was separately added to a human glioma cell line (U251) and a mouse embryo fibroblast cell line (3T3) (control) for incubation in dark conditions. To test its photodynamic effect, the U251 and 3T3 cells were then irradiated for 5-60 min, using a 632.8-nm laser.

RESULTS

This QD (Φ = 3.75 nm, photoluminescence (PL) peak wavelength = 700 nm, photoluminescence quantum yield (PLQY) = 20 %), was a spherical crystal with excellent monodispersity. Under a confocal microscope, U251 cells were visualized, but not the 3T3 cells. In dark conditions, the survival rates of both U251 and 3T3 cells were above 85 %. After laser irradiation, the survival rate of U251 cells decreased to 37 ± 1.6 % as the irradiation time and the CdTe-RGD concentration were increased.

CONCLUSIONS

With good physicochemical characteriistics and low toxicity, this QD-RGD has broad prospects for use in the biomedical imaging and photodynamic therapy of gliomas.

Giant Basilar Artery Aneurysm Involving the Origin of Bilateral Posterior Cerebral and Superior Cerebellar Arteries: Neck Reconstruction with pCONus-Assisted Coiling

Giant aneurysms of the basilar artery are rare and are frequently associated with obstructive hydrocephalus and brainstem compression. Treatment still remains a challenge both for neurosurgeons and for interventional neuroradiologists. Cases reported in the literature are anecdotal and, overall, their outcomes are poor. We present the case of a patient with a giant aneurysm of the basilar artery tip, involving the origin of both the posterior cerebral and superior cerebellar arteries, who underwent coiling and ventriculoperitoneal shunting for associated obstructive hydrocephalus. A pCONus ® stent (Phenox; Bochum, Germany) was detached with its petals opened over the ostia of the parent vessels, with the aim being to reconstruct the neck of the aneurysm and to preserve the flow in the parent vessel. Moreover, the presence of the stent was useful to maintain the coils within the dome of the aneurysm. The pCONus is a new neurovascular device that is also useful for treating cases of complex basilar artery aneurysms when the ostia of the parent vessel origin is at the level of the aneurysm neck.

Minipterional Craniotomy for Treatment of Unruptured Middle Cerebral Artery Aneurysms. A Single-Center Comparative Analysis with Standard Pterional Approach as Regard to Safety and Efficacy of Aneurysm Clipping and the Advantages of Reconstruction

Pterional craniotomy (PT) has long been the standard approach for the treatment of middle cerebral artery (MCA) aneurysms, even though it may cause temporalis muscle atrophy, facial nerve injury, and masticatory difficulties. Minipterional craniotomy (MPT) is an alternative approach that may provide the same surgical corridor, limiting the risk of postoperative esthetic and functional complications. From January 2011 to December 2014 we consecutively performed 68 craniotomies for surgical treatment of unruptured MCA aneuryms: 37 were standard PT and 31 were MPT. There were no significant differences in mean age, sex, and aneurysm topography between the two groups. The mean skin incision length was 14 cm in the PT group and 6 cm in the MPT group. According to the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), there were no significant differences in clinical outcome at discharge or follow-up between the two groups. Also, the rates of complete aneurysm exclusion were comparable. However, the number of patients complaining of masticatory disorders was higher among those treated with PT. Finally, the number of complications observed in the PT group was higher than that in the MPT group, but only the differences in mean hospitalization length and necessity for a dural patch for reconstruction were statistically significant. In conclusion, the MPT approach is a safe and effective alternative to the standard PT for the treatment of unruptured MCA aneurysms.

Focus on Functional Delayed Central Sleep Apnea Following Cervical Laminectomy. An Example of Respiratory Dysfunction in Restorative Neurosurgical Procedures

In sleep-related breathing disorders, sleep apnea is a clinical symptom that can be categorized as obstructive sleep apnea (OSA) or mixed apnea by analysis using polysomnography. The occurrence of delayed central sleep apnea (CSA) is an extremely rare complication of cervical laminectomy for spondylotic myelopathy. So far only three studies concerning such an event have been reported in the literature. Naim-ur-Rahman, in 1994, reported a case of postoperative CSA following C3-C6 laminectomy, and Visocchi and colleagues, in 2014, in two studies, stressed the lack of association with any other neurological sign of spinal cord damage. No definitive mechanism has been recognized so far for delayed CSA after cervical laminectomy. A transient dysfunction of the reticulo-spinal fibers directed to the nucleus of the phrenic nerve can be speculated, although neither emi-diaphragm paralysis, nor any prominent nocturnal sleep-related disorders are associated with this delayed CSA.

Spinal Cord Stimulation: An Alternative Concept of Rehabilitation?

BACKGROUND

Chronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery.

METHODS

We report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric instability and persistent or ingravescent disabling low back and leg pain, with a mean duration of symptoms of at least 18 months. A visual analog scale (VAS) was employed for back and leg pain, and the Oswestry Disability Index (ODI) score was determined, and findings were analyzed after 6 months.

FINDINGS

No intra- or postoperative complication was recorded. The mean VAS score for back pain decreased from 7.5 to 2.9, while leg VAS decreased from 8.2 to 3.0. Analysis of ODI values showed evident improvement in daily life activities, ranging from a median value of 75.7% to 32.7 % after the stimulation.

CONCLUSION

Spinal cord stimulation has a recognized impact on the pain and on the quality of life of patients with failed back surgery syndrome.

Out-of-third ventricle colloid cysts: review of the literature on pathophysiology, diagnosis and treatment of an uncommon condition, with a focus on headache

INTRODUCTION

Colloid cysts are rare benign intracranial lesions classically described as "third ventricle colloid cysts" because of their location within the third ventricle. These lesions' clinical and diagnostic features are mainly related to intermittent or persistent obstruction of foramina of Monro causing cerebrospinal fluid (CSF) circulation impairment and symptoms of raised intracranial pressure. Few reports on colloid cysts located outside the third ventricle have been published over the years. This paper aims to review the existing literature on out-of-third ventricle colloid cysts, and introduces a new illustrative case of lateral ventricle colloid cyst surgically managed with endoscopic technique.

EVIDENCE ACQUISITION

A literature review was performed through a Medline web-search, using "colloid cysts," "lateral ventricle colloid cysts," "fourth ventricle colloid cysts," "brain colloid cyst," "spinal colloid cysts" as keywords. All retrieved abstracts were screened and full-length text of papers suitable for inclusion were examined. An illustrative case has been added to the existing literature. A 45-year-old man complaining of recurrent headache underwent conservative treatment for 4 years. The unusual headache features as well as the uncommon onset and association with episodic mental impairment led to an initial diagnosis of anxiety disorder triggering the headache. A further worsening of headache and the lack of significant clinical benefit prompted further investigation. Computed-tomography (CT) of the brain showed asymmetrical dilatation of the right lateral ventricle, due to the presence of a cystic mass obstructing the foramen of Monroe. Patient underwent endoscopic resection of the cyst.

EVIDENCE SYNTHESIS

The literature review revealed 16 papers reported between 1952 and 2016. In all cases included histological diagnosis of colloid cyst had been obtained. Clinical and radiological features, as well as surgical management in each case have been analyzed. In the case here reported, histological examination documented a colloid cyst. The postoperative course was uneventful, with progressive resolution of headache.

CONCLUSIONS

Despite third ventricle colloid cysts are related to typical clinical and diagnostic features, non-third ventricle colloid cysts may be responsible for unusual clinical presentation, so making a correct diagnostic approach challenging. We submit that in cases of recurrent headache with unusual features and lacking signs of neurological deficits, a rare neurosurgical condition as an "ectopic" colloid cyst should be included in the differential diagnosis.

Anterior cervical discectomy and fusion with a compressive staple of C-JAWS

OBJECTIVE

To evaluate the clinical value of C-JAWS in anterior cervical discectomy and fusion (ACDF) surgery.

METHODS

Between January 2012 and December 2013, nine consecutive patients with cervical spondylopathy underwent ACDF process using a polyetheretherketone cervical spacer prefilled with bone substitute and secured by a cervical compressive staple in our department. The Neck Disability Index (NDI) score and visual analogy scale (VAS) of neck or arm pain as well as radiographic examination were adopted to assess the postoperative outcome and fusion.

RESULTS

Bony fusion was observed in all of the nine patients, and no serious surgery-related or implant-related complications were observed during the operation or postoperative period. The average operative time was 60.3 ± 11.6 min. The average hospital stay was 3.2 ± 0.8 days. The average skin incision length was about 3.0 ± 0.3 cm. The average of the follow-up days was 18.4 ± 4.3 months. At the last follow-up, the NDI changed from the baseline of 23.4 ± 10.3 to 7.1 ± 4.8, the VAS of neck or arm pain from 6.1 ± 1.0 and 4.6 ± 1.6 to 2.3 ± 1.7 and 2.4 ± 1.1, respectively. The patients' subjective satisfaction was excellent in 6 and good in 3.

CONCLUSIONS

Without screws, this low-profile designed compressive staple C-JAWS performed well in the ACDF surgeries.

Delayed chronic intracranial subdural hematoma complicating resection of a tanycytic thoracic ependymoma

Background:

To demonstrate that the diagnosis of an intracranial subdural hematoma should be considered for patients presenting with acute or delayed symptoms of intracranial pathology following resection of a spinal tumor.

Case Description:

We present a case of a 57-year-old woman found to have a chronic subdural hematoma 1 month following resection of a thoracic extramedullary ependymoma. Evacuation of the hematoma through a burr hole relieved the presenting symptoms and signs. Resolution of the hematoma was confirmed with a computed tomography (CT) scan.

Conclusion:

Headache and other symptoms not referable to spinal pathology should be regarded as a warning sign of an intracranial subdural hematoma, and a CT scan of the head should be obtained. The mechanism of the development of the hematoma may be related to the leakage of cerebrospinal fluid with subsequent intracranial hypotension leading to an expanding subdural space and hemorrhage.

Videoassisted anterior surgical approaches to the craniocervical junction: rationale and clinical results

PURPOSE

In this narrative review, we aim to give an update on the anatomic fundamentals of endoscopic assisted surgery to the craniocervical junction (transnasal, transoral and transcervical), and to report on the available clinical results.

METHODS

A non-systematic review and reporting on the anatomical and clinical results of endoscopic assisted approaches to the craniocervical junction (CVJ) is performed.

RESULTS

Pure endonasal and cervical endoscopic approaches still have some disadvantages, including the learning curve and the lack of 3-dimensional perception of the surgical field. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging alternative to standard microsurgical techniques for transoral approaches to the anterior CVJ. Used in conjunction with traditional microsurgery and intraoperative fluoroscopy, it provides a safe and improved method for anterior decompression with or without a reduced need for extensive soft palate splitting, hard palate resection, or extended maxillotomy.

CONCLUSIONS

Transoral (microsurgical or video-assisted) approach with sparing of the soft palate still remains the gold standard compared to the "pure" transnasal and transcervical approaches due to the wider working channel provided by the former technique. Transnasal endoscopic approach alone appears to be superior when the CVJ lesion exceeds the upper limit of the inferior third of the clivus. Combined transnasal and transoral procedures can be tailored according to the specific pathological and radiological findings.

Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature

Patient: Male, 30

Final Diagnosis: Acute epidural hematoma

Symptoms: —

Medication: —

Clinical Procedure: Observation

Specialty: Neurosurgery

Portable Intraoperative Computed Tomography Scan in Image-Guided Surgery for Brain High-grade Gliomas: Analysis of Technical Feasibility and Impact on Extent of Tumor Resection

BACKGROUND

Intraoperative magnetic resonance imaging is the gold standard among image-guided techniques for glioma surgery. Scant data are available on the role of intraoperative computed tomography (i-CT) in high-grade glioma (HGG) surgery.

OBJECTIVE

To verify the technical feasibility and usefulness of portable i-CT in image-guided surgical resection of HGGs.

METHODS

This is a retrospective series control analysis of prospectively collected data. Twenty-five patients (Group A) with HGGs underwent surgery using i-CT and 5-aminolevulinic acid (5-ALA) fluorescence. A second cohort of 25 patients (Group B) underwent 5-ALA fluorescence-guided surgery but without i-CT. We used a portable 8-slice CT scanner and, in both groups, neuronavigation. Extent of tumor resection (ETOR) and pre- and postoperative Karnofsky performance status (KPS) scores were measured; the impact of i-CT on overall survival (OS) and progression-free survival (PFS) was also analyzed.

RESULTS

In 8 patients (32%) in Group A, i-CT revealed residual tumor, and in 4 of them it helped to also resect pathological tissue detached from the main tumor. EOTR in these 8 patients was 97.3% (96%-98.6%). In Group B, residual tumor was found in 6 patients, whose tumor's mean resection was 98% (93.5-99.7). The Student t test did not show statistically significant differences in EOTR in the 2 groups. The KPS score decreased from 67 to 69 after surgery in Group A and from 74 to 77 in Group B (P = .07 according to the Student t test). Groups A and B did not show statistically significant differences in OS and PFS (P = .61 and .46, respectively, by the log-rank test).

CONCLUSION

No statistically significant differences in EOTR, KPS, PFS, and OS were observed in the 2 groups. However, i-CT helped to verify EOTR and to update the neuronavigator with real-time images, as well as to identify and resect pathological tissue in multifocal tumors. i-CT is a feasible and effective alternative to intraoperative magnetic resonance imaging. Portable i-CT can provide useful real-time information during brain surgery and can be easily introduced in neurosurgical theaters in daily practice.

Role of intraoperative indocyanine green video-angiography to identify small, posterior fossa arteriovenous malformations mimicking cavernous angiomas. Technical report and review of the literature on common features of these cerebral vascular malformations

OBJECTIVE

To illustrate the usefulness of intraoperative indocyanine green videoangiography (ICG-VA) to identify the nidus and feeders of a small cerebellar AVM resembling a cavernous hemangioma. To review the unique features regarding the overlay between these two vascular malformations and to highlight the importance to identify with ICG-VA, and treat accordingly, the arterial and venous vessels of the AVM.

METHODS

A 36-year old man presented with bilateral cerebellar hemorrhage. MRI was equivocal in showing an underlying vascular malformation but angiography demonstrated a small, Spetzler-Martin grade I AVM. Surgical resection of the AVM with the aid of intraoperative ICG-VA was performed. After hematoma evacuation, pre-resection ICG-VA did not reveal tortuous arterial and venous vessels in keeping with a typical AVM but rather an unusual blackberry-like image resembling a cavernous hemangioma, with tiny surrounding vessels. Such intraoperative appearance, which could also be the consequence of a "leakage" of fluorescent dye from the nidal pathological vessels, with absent blood-brain barrier, into the surrounding parenchymal pathological capillary network, is important to be recognized as an unusual AVM appearance.

RESULTS

Post-resection ICG-VA confirmed the AVM removal, as also shown by postoperative and 3-month follow-up DSAs.

CONCLUSIONS

Despite technical limitations associated with ICG-VA in post-hemorrhage AVMs, this case together with the intraoperative video, demonstrates the useful role of ICG-VA in identifying small AVMs with peculiar features.

10 Levels thoracic no-intrumented laminectomy for huge spontaneous spinal subdural hematoma removal. Report of the first case and literature review

•

In this article, reporting on the case of a huge 10 levels spontaneous spinal subdural hematoma treated with decompressive thoracic no-instrumented laminectomy in a 45-year-old woman with good neurological recovery, we would like to underline the importance of a timely surgical decompression as the mainstay option in the management of strongly symptomatic spontaneous idiopathic acute spinal subdural hematomas.

•

To our knowledge, 10 levels thoracic laminectomy for a SSDH removal have never been described. We performed “conservative” laminectomy by sparing of articular processes with no need to posterior fixation also considering the intrinsic stability of thoracic chest.

Introduction

Spontaneous idiopathic acute spinal subdural hematoma (SSDH) is a rare cause of acute back pain followed by signs and symptoms of nerve root and/or spinal cord compression, frequently associated with coagulopathies, blood dyscrasias and arterio-venous malformations. Standard management includes non-operative treatment and timely (within 24 h) surgical decompression.

Presentation of case

We report on the case of a huge 10 levels SSDH treated with decompressive thoracic no-instrumented laminectomy in a 45-year-old woman with good neurological recovery (from ASIA A to D).

Discussion

Spontaneous SSDHs without detectable structural lesion or anticoagulant therapy are very rare. Among 26 cases documented the literature harbouring SSDHs, the thoracic spine was found to be the preferred site, and the compression was usually extending over several vertebral levels. Nonoperative treatment for SSDH may be justified in presence of minimal neurologic deficits, otherwise, early decompressive laminectomy along with evacuation of hematoma are considered the treatment of choice in presence of major deficits.

Conclusion

To our knowledge, the present case is the most extensive laminectomy for a SSDH removal never described before. No postoperative instability occurs in 10 levels thoracic laminectomy in case the articular processes are spared. When major neurological deficits are documented, early decompressive laminectomy with evacuation of hematoma should be considered the best treatment for SSDH.