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Lei M, Zheng W, Cao Y, Cao X, Shi X, Su X, Liu Y. Treatment of patients with metastatic epidural spinal cord compression using an enhanced recovery after surgery program. Front Cell Dev Biol 2023; 11:1183913. [PMID: 37250907 PMCID: PMC10213636 DOI: 10.3389/fcell.2023.1183913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/04/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose: The aims of this study were to introduce a new medical, pathway based on the concept of "enhanced recovery after surgery" (ERAS) for patients with metastatic epidural spinal cord compression (MESCC), and to test whether the ERAS program could improve clinical metrics among such patients. Methods: Data from patients with MESCC (n = 98), collected between December 2016 and December 2019 (Non-ERAS cohort), and from 86 patients with metastatic epidural spinal cord compression collected between January 2020 and December 2022 (ERAS cohort), were retrospectively analyzed. Patients were treated by decompressive surgery combined with transpedicular screw implantation and internal fixation. Patient baseline clinical characteristics were collected and compared between the two cohorts. Surgical outcomes analyzed included operation time; intraoperative blood loss; postoperative length of hospital stay; time to ambulation, regular diet, urinary catheter removal, and radiation therapy; perioperative complications; anxiety; depression; and satisfaction with treatment. Results: No significant differences in clinical characteristics were found between the non-ERAS and enhanced recovery after surgery cohorts (all p > 0.050), indicating that the two cohorts were comparable. Regarding surgical outcomes, the enhanced recovery after surgery cohort had significantly less intraoperative blood loss (p < 0.001); shorter length of postoperative hospital stay (p < 0.001); shorter time to ambulation (p < 0.001), regular diet (p < 0.001), urinary catheter removal (p < 0.001), radiation administration (p < 0.001), and systemic internal therapy (p < 0.001); lower perioperative complication rate (p = 0.024); less postoperative anxiety (p = 0.041); and higher score for satisfaction with treatment (p < 0.001); whereas operation time (p = 0.524) and postoperative depression (p = 0.415) were similar between the two cohorts. Compliance analysis demonstrated that ERAS interventions were successfully conducted in the vast majority of patients. Conclusion: The enhanced recovery after surgery intervention is beneficial to patients with metastatic epidural spinal cord compression, according to data on intraoperative blood loss; length of hospital stay; time to ambulation, regular diet, urinary catheter removal, radiation exposure, and systemic internal therapy; perioperative complication; alleviation of anxiety; and improvement of satisfaction. However, clinical trials to investigate the effect of enhanced recovery after surgery are needed in the future.
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Affiliation(s)
- Mingxing Lei
- Senior Department of Orthopedic Surgery, The Fourth Medical Center of PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Hainan Hospital of PLA General Hospital, Beijing, China
| | - Wenjing Zheng
- Department of Chemical Poisoning Treatment, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yuncen Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xuyong Cao
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xiaolin Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiuyun Su
- Intelligent Medical Innovation institute, Southern University of Science and Technology Hospital, Shenzhen, China
| | - Yaosheng Liu
- Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, PLA General Hospital, Beijing, China
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Cardia A, Cannizzaro D, Stefini R, Chibbaro S, Ganau M, Zaed I. The efficacy of laser interstitial thermal therapy in the management of spinal metastases: a systematic review of the literature. Neurol Sci 2023; 44:519-528. [PMID: 36181543 DOI: 10.1007/s10072-022-06432-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In the last years, laser interstitial thermal therapy (LITT) has started to be used also in neurosurgical setting. Its efficacy for intracranial pathologies, namely, tumors and epilepsy, has been widely demonstrated. However, the literature evidences about the use of LITT for spinal lesions are recent, and it is still a topic of discussion regarding its efficacy. Here, the authors sought to present a systematic review of the literature investigating the utility of LITT for spinal lesions. METHODS Using PubMed, Scopus, and the Cochrane Library, the authors performed a systematic review of the literature focused on the use of spinal laser interstitial thermal therapy (sLITT). Included in the search were randomized controlled trials, cohort studies, and clinical series. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies. RESULTS Out of the initial 134 studies, 6 met the inclusion criteria for the systematic review, resulting in a total of 206 patients. All the patients have been treated with sLITT for compressive spinal metastases. Most of the lesions were thoracic (88.8%). All the studies reported an effective local control of the disease with a reduction of epidural compression at 30 days. Complication rate was 12.6%, but most of them were transient conditions, and only 3.4% patients needed a revision surgery. CONCLUSION sLITT is safe and provides effective local control for epidural compression from metastases, particularly in the thoracic spine. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.
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Affiliation(s)
- Andrea Cardia
- Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland
| | - Delia Cannizzaro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Roberto Stefini
- Department of Neurosurgery, Azienda Socio Sanitaria Territoriale (ASST) Ovest Milanese - Legnano Hospital, Milan, Italy
| | - Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland. .,Department of Neurosurgery, Legnano Hospital, Legnano, Italy.
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Shao X, Wu J, Zhou Z, Lv N, Chen K, He S, Sun Z, Qian Z. Bone Cement and Pedicle Screw for the Treatment of Spinal Tumors with Spinal Cord Compression and Posterior Wall Defects. Orthop Surg 2022; 14:1827-1835. [PMID: 35794856 PMCID: PMC9363719 DOI: 10.1111/os.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To compare the safety and efficacy of posterior internal fixation with open vertebroplasty (VP) and posterior internal fixation with open kyphoplasty (KP) in the treatment of metastatic epidural spinal cord compression (MESCC) with posterior wall destruction. METHODS This retrospective study, conducted between January 2016 and May 2019, equally divided 60 patients with MESCC and posterior wall destruction into two groups based on the surgical method: open vertebroplasty with pedicle screw fixation (VP group) and open kyphoplasty with pedicle screw fixation (KP group). Visual analogue scale (VAS), SF-36 scores, middle vertebral height (MVH), and posterior vertebral height (PVH) were evaluated for the two groups preoperatively, postoperatively, and 1 year after surgery. Spinal Instability Neoplastic Score, Frankel grades and complications were recorded and evaluated. RESULTS Five patients were excluded from the analysis, and our study cohort consisted of 55 adult patients who met the inclusion criteria. The VAS and SF-36 scores of these two groups of patients significantly improved, when compared with those before the surgery (P < 0.05). There were significant differences in total cost (8835 ± 1468 vs 9540 ± 053 USD) and cement volume (4.51 ± 0.96 ml vs 6.35 ± 1.09 ml) between two groups (P < 0.05). The MVH and PVH of these two groups of patients significantly improved, when compared with those before the surgery (P < 0.05). The MVH was significantly larger in the KP group than in the VP group postoperatively (20.15 ± 4.86 vs 17.70 ± 3.78, P < 0.05) and at the final follow-up (20.42 ± 5.59 vs 17.28 ± 3.23, P < 0.05). However, the PVH of the two groups did not significantly differ at the two postoperative follow-ups (P > 0.05). No significant differences were found in surgery time, time from surgery to discharge, blood loss and complications between both groups postoperatively (P > 0.05). CONCLUSION In the short term, both approaches are effective and safe in patients with MESCC and posterior wall destruction. The posterior internal fixation with open VP may be a good choice of surgical method in patients with MESCC and posterior wall defects.
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Affiliation(s)
- Xiaofeng Shao
- The Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Wu
- The Department of Orthopaedic Surgery, Changsu No.2. People's Hospital, Suzhou, China
| | - Zhangzhe Zhou
- The Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Nanning Lv
- Department of Orthopaedic Surgery, The Second People's Hospital of Lianyungang, Lianyungang, China
| | - Kangwu Chen
- The Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuangjun He
- Department of Orthopaedic Surgery, Affiliated Danyang Hospital of Nantong University, Danyang, China
| | - Zhiyong Sun
- The Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhonglai Qian
- The Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Flynn SC, Eli IM, Ghogawala Z, Yew AY. Minimally Invasive Surgery for Spinal Metastasis: A Review. World Neurosurg 2021; 159:e32-e39. [PMID: 34861449 DOI: 10.1016/j.wneu.2021.11.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) techniques have advanced the treatment of metastatic diseases to the spine. The objective of this review is to describe clinical outcomes, benefits, and complications of these techniques. METHODS All relevant clinical studies describing the role of MIS, computer-assisted navigation (CAN), robot-assisted (RA) procedures, and laser interstitial thermal therapy (LITT) in the treatment of metastatic spine diseases were identified from PubMed, MEDLINE, and relevant article bibliographies. RESULTS For MIS articles, we filtered 1480 results and identified 26 studies. For CAN, we searched 464 articles to identify 18 articles for review. For RA, we searched 321 results to identify 7 studies for review. For LITT, we identified 21 articles for review. CONCLUSIONS MIS for the treatment of spine metastasis has significant potential benefits in reducing surgical site infections, hospital stay, and blood loss without compromising instrument accuracy or overall outcomes. Overall, MIS and its adjuncts have the potential to reduce the risks involved in the treatment of patients with metastatic disease to the spinal column without compromising the benefits of decompression and stabilization of the spine.
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Affiliation(s)
- Scott C Flynn
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ilyas M Eli
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA; Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA
| | - Andrew Y Yew
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA.
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Orenday-Barraza JM, Cavagnaro MJ, Avila MJ, Strouse IM, Dowell A, Kisana H, Khan N, Ravinsky R, Baaj AA. 10-Year Trends in the Surgical Management of Patients with Spinal Metastases: A Scoping Review. World Neurosurg 2021; 157:170-186.e3. [PMID: 34655822 DOI: 10.1016/j.wneu.2021.10.086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spinal metastases are present in approximately 20% of patients with cancer, giving a risk for neurologic dysfunction and instability. In already frail patients, surgeons strive to improve quality of life. Our goal was to review a 10-year trend in the surgical management of spinal metastases. METHODS A scoping review was performed systematically using PubMed to assess trends in surgical treatment for spinal metastases. The search terms used were: metastas∗, "neoplasm metastasis"[Mesh], "Spine"[Mesh], spine, spinal, "vertebral column," "vertebral body," laser, robot, radiofrequency, screws, fixation, "separation surgery," corpectomy, vertebrectomy, spondylectomy, vertebroplasty, kyphoplasty, surgery, "open surgery," "mini open surgery," "minimally invasive surgery," endoscopy, thoracoscopy, corpectom∗, vertebrectom∗, spondylectom∗, "en bloc," and MIS. The variables of interest were neurologic improvement, tumor recurrence, reoperation, and overall survival. RESULTS A total of 2132 articles were found within the primary query. Fifty-six studies were selected for final review. The results were organized into main surgical practices: decompression, mechanical stabilization, and pain management. For separation surgery, clinical outcomes were overall 1-year survival, 40.7%-78.4%; recurrence rate, 4.3%-22%; reoperation, 5%; and complications, 5.4%-14%. For corpectomy, clinical outcomes were overall 1-year survival, 30%-92%; reoperation, 1.1%-50%; and recurrence rate, of 1.1%-28%. Complications and reoperations with spinal instrumentation were 0%-13.6% and 0%-15%, respectively. Cement augmentation achieved pain reduction rates of 56%-100%, neurologic improvement/stability 84%-100%, and complication rates 6%-56%. Laser achieved local tumor control rate of 71%-82% at 1 year follow-up, reoperation rate of 15%-31%, and complication rate of 5%-26%. CONCLUSIONS Minimally invasive techniques for decompression and stabilization seem to be the preferred method to surgically treat metastatic spine disease, with good outcomes. More research with high level of evidence is required to support the long-term outcomes of these approaches.
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Affiliation(s)
| | - María José Cavagnaro
- Department of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mauricio J Avila
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Isabel M Strouse
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Aaron Dowell
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Haroon Kisana
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Naushaba Khan
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Robert Ravinsky
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Ali A Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
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Bastos DCA, Vega RA, Traylor JI, Ghia AJ, Li J, Oro M, Bishop AJ, Yeboa DN, Amini B, Kumar VA, Rao G, Rhines LD, Tatsui CE. Spinal laser interstitial thermal therapy: single-center experience and outcomes in the first 120 cases. J Neurosurg Spine 2021; 34:354-363. [PMID: 33307530 DOI: 10.3171/2020.7.spine20661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to present the results of a consecutive series of 120 cases treated with spinal laser interstitial thermal therapy (sLITT) to manage epidural spinal cord compression (ESCC) from metastatic tumors. METHODS The electronic records of patients treated from 2013 to 2019 were analyzed retrospectively. Data collected included demographic, pathology, clinical, operative, and imaging findings; degree of epidural compression before and after sLITT; length of hospital stay; complications; and duration before subsequent oncological treatment. Independent-sample t-tests were used to compare means between pre- and post-sLITT treatments. Survival was estimated by the Kaplan-Meier method. Multivariate logistic regression was used to analyze predictive factors for local recurrence and neurological complications. RESULTS There were 110 patients who underwent 120 sLITT procedures. Spinal levels treated included 5 cervical, 8 lumbar, and 107 thoracic. The pre-sLITT Frankel grades were E (91.7%), D (6.7%), and C (1.7%). The preoperative ESCC grade was 1c or higher in 92% of cases. Metastases were most common from renal cell carcinoma (39%), followed by non-small cell lung carcinoma (10.8%) and other tumors (35%). The most common location of ESCC was in the vertebral body (88.3%), followed by paraspinal/foraminal (7.5%) and posterior elements (4.2%). Adjuvant radiotherapy (spinal stereotactic radiosurgery or conventional external beam radiation therapy) was performed in 87 cases (72.5%), whereas 33 procedures (27.5%) were performed as salvage after radiotherapy options were exhausted. sLITT was performed without need for spinal stabilization in 87 cases (72.5%). Post-sLITT Frankel grades were E (85%), D (10%), C (4.2%), and B (0.8%); treatment was associated with a median decrease of 2 ESCC grades. The local control rate at 1 year was 81.7%. Local control failure occurred in 25 cases (20.8%). The median progression-free survival was not reached, and overall survival was 14 months. Tumor location in the paraspinal region and salvage treatment were independent predictors of local recurrence, with hazard ratios of 6.3 and 3.3, respectively (p = 0.01). Complications were observed in 22 cases (18.3%). sLITT procedures performed in the lumbar and cervical spine had hazard ratios for neurological complications of 15.4 and 17.1 (p < 0.01), respectively, relative to the thoracic spine. CONCLUSIONS sLITT is safe and provides effective local control for high-grade ESCC from vertebral metastases in the thoracic spine, particularly when combined with adjuvant radiotherapy. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.
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Affiliation(s)
| | - Rafael A Vega
- 4Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Behrang Amini
- 3Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Vinodh A Kumar
- 3Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
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Di Perna G, Cofano F, Mantovani C, Badellino S, Marengo N, Ajello M, Comite LM, Palmieri G, Tartara F, Zenga F, Ricardi U, Garbossa D. Separation surgery for metastatic epidural spinal cord compression: A qualitative review. J Bone Oncol 2020; 25:100320. [PMID: 33088700 PMCID: PMC7559860 DOI: 10.1016/j.jbo.2020.100320] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Separation surgery is a new concept for metastatic spinal cord compression treatment. Stereotactic radiosurgery increased local control, overcoming radio-resistance’s idea. The surgery goal shifted towards creating targets for radiations avoiding cord damages. Minimal invasive strategies could allow quick return to systemic therapies.
Introduction The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease’s local control. Discussion In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration. Conclusion Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.
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Key Words
- CTV, Clinical tumor volume
- Carbon fiber/PEEK cement
- ECOG PS, Eastern Cooperative Oncology Group Performance Status Scale
- ESCC, Epidural Spinal Cord Compression
- Epidural spinal cord compression
- GTV, Gross tumor volume
- KPS, Karnofsky Performance Status
- LC, Local Control
- LITT, Laser Interstitial Thermal Therapy
- MAS, Minimal Access Spine
- MESCC, Metastatic Epidural Spinal Cord Compression
- MIS techniques
- MIS, Minimally Invasive Surgical
- NSCLC, Non-Small Cell Lung Cancer
- NSE, Neurologic Stability Epidural compression
- PEEK, Polyetheretherketone
- PLL, Posterior Longitudinal Ligament
- PMMA, Poly-Methyl-Methacrylate
- PRV, Spinal cord planning risk volume
- PTV, Planning target volume
- SBRT, Stereotactic Body Radiation Therapy
- SINS, Spinal Instability Neoplastic Score
- SRS, Stereotactic Radiosurgery
- SS, Separation Surgery
- Separation surgery
- Spinal metastases
- Stereotactic body radiation therapy
- cEBRT, conventional External Beam Radiation Therapy
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Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
- Spine Surgery, Humanitas Gradenigo, Turin, Italy
- Corresponding author at: Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Via Cherasco 15, 10126 Turin, Italy.
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Serena Badellino
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Nicola Marengo
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Ludovico Maria Comite
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Palmieri
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fulvio Tartara
- Neurosurgery Unit, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
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