Intraforaminal disc herniations at the L5-S1 level are extremely surgically challenging lesions. ... more Intraforaminal disc herniations at the L5-S1 level are extremely surgically challenging lesions. Intracanal approaches frequently require partial or total facetectomy, which may lead to instability. Solely extraforaminal approaches may offer limited visualization of the more medial superiorly exiting and inferiorly exiting nerve roots; this approach is also more complicated at L5-S1 due to the often large L5 transverse process and the iliac wing. Nine patients with intraforaminal L5-S1 disc herniations, foraminal stenosis, or synovial cysts underwent contralateral interlaminar approaches for lesion resection. Preoperative and postoperative visual analog scale scores were evaluated, and complications were reviewed. All 9 patients demonstrated immediate postoperative clinical improvement. None of the patients exhibited complications and none developed instability or neuropathic disorders. Although the number of cases in our sample was very small (9 in total), the contralateral interlaminar approach appeared to effectively address multiple degenerative L5-S1 foraminal pathologies. Large studies are needed to further evaluate the pros and cons of this approach.
Deep brain stimulation (DBS) is an established therapy for movement disorders, such as Parkinson&... more Deep brain stimulation (DBS) is an established therapy for movement disorders, such as Parkinson's disease (PD), dystonia, and tremor. The efficacy of DBS depends on the correct lead positioning. The commonly adopted postoperative radiological evaluation is performed with computed tomography (CT) scan and/or magnetic resonance imaging (MRI). We conducted a retrospective study on 202 patients who underwent DBS from January 2009 to October 2013. DBS indications were PD, progressive supranuclear palsy, tremor, dystonia, Tourette syndrome, obsessive compulsive disorder, depression, and Huntington's disease. Preoperatively, all patients underwent brain MRI and brain CT scan with the stereotactic frame positioned. The lead location was confirmed intraoperatively with CT. The CT images were subsequently transferred to the Stealth Station Medtronic and merged with the preoperative planning. On the first or second day after, implantation we performed a brain MRI to confirm the correc...
A rare cause of spinal cord compression is spinal arachnoid cysts. Symptoms are caused by spinal ... more A rare cause of spinal cord compression is spinal arachnoid cysts. Symptoms are caused by spinal cord compression, however, asymptomatic patients have been also reported. Treatment options depend upon symptom severity and clinical course. We report the case of a 47-year-old patient who developed an intramedullary arachnoid cyst after removal of an intradural extramedullary cyst. Surgery should be considered early in a symptomatic disease course. Longstanding medullary compression may reduce the possibility of neurological recovery as well as secondary complications such as intramedullary cyst formation.
Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of ex... more Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of extension cable damage or IPG pocket infection, it can dramatically affect a patient's quality of life. Higher risk of infection has been reported after IPG replacement procedures rather than after primary deep brain stimulation lead implantation, and some authors suggested that the IPG pocket capsule could play a pivotal role in causing it. In this technical note we present a capsulectomy technique adopted in IPG replacement procedures. Between July and October 2015, we carried out ten outpatient IPG replacement procedures at the chest and abdomen under local anesthesia for battery depletion using the PEAK PlasmaBlade(TM). All patients were followed for at least 2 months to rule out any hardware malfunction and infection. All ten procedures were uneventful. No extension cable damage occurred. No IPG pocket infection occurred, also not in the follow-up. Mean surgical time was 30 min. Complete capsulectomy is not feasible with basic surgical instruments, and the PEAK PlasmaBlade(TM) pencil appears to be a helpful tool in carrying out the procedure.
Tourette's syndrome (TS) is a neurodevelopmental disorder... more Tourette's syndrome (TS) is a neurodevelopmental disorder typically defined by multiple motor tics and at least one sound tic, beginning in childhood or in adolescence. Handwriting is one of the most impaired school activities for TS patients because of the presence of tics that hamper learning processes. In this paper, we present a case of handwriting tics in a TS patient highlighting the main features.
The aim of this paper was to perform a critical and systematic review of the published papers on ... more The aim of this paper was to perform a critical and systematic review of the published papers on deep brain stimulation (DBS) for Tourette's Syndrome (TS). A PubMed search on DBS in TS was conducted selecting papers that reported on the clinical outcome of DBS. The majority of papers were case reports or small series. The thalamus and the globus pallidus internus appear to be the most promising targets. However, in light of the great methodological diversity a balanced comparison of clinical outcome and understanding of the role of DBS in TS remains difficult. Despite 16 years of experience with DBS in GTS a consensus on many issues, foremost on target selection and age inclusion continue to be missing. Class I evidence and international collaborations, to increase the number of included patients, are urgently needed to evaluate further the role of DBS in TS.
Gilles de la Tourette syndrome (GTS) is a severe neuropsychiatric disorder with childhood onset, ... more Gilles de la Tourette syndrome (GTS) is a severe neuropsychiatric disorder with childhood onset, characterized by disabling motor and vocal tics lasting for more than 1 year and associated with a wide range of psychiatric comorbidities. Pharmacological treatment is indicated for moderate to severe GTS patients. However, when GTS is refractory to conventional medical and behavioral treatments, deep brain stimulation (DBS) can be considered as a last resort therapeutic avenue. To evaluate the efficacy of DBS and its comorbidities in the largest pool of GTS patients to date. Our cohort study was based on 48 patients' refractory to conventional treatment who underwent DBS for GTS at Galeazzi Institute, Milan, Italy. An exhaustive preoperative and a follow-up battery of tests was performed including the Yale Global Tic Severity Rating Scale, the Yale-Brown Obsessive Compulsive Scale, the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Subjective Social Impairmen...
Gilles de la Tourette Syndrome (GTS) is a complex neuropsychiatric disorder, characterized by chr... more Gilles de la Tourette Syndrome (GTS) is a complex neuropsychiatric disorder, characterized by chronic motor and vocal tics, associated in 50-90% of cases with psychiatric comorbidities. Patients with moderate and severe clinical picture are treated with psychotherapy and pharmacological therapy. Deep brain stimulation (DBS) is reserved for pharmacological refractory GTS patients. As GTS tends to improve with time and potentially resolves in the second decade of life, the major concern of DBS in GTS is the age at which the patient undergoes surgical procedure. Some authors suggest performing DBS after 18 years, others after 25 years of age. We present a 25-year-old patient with GTS, who was aged 17 years and was treated with thalamic DBS. DBS resulted in progressive and sustained improvement of tics and co-morbidities. After 6 years of DBS treatment, it was noted that the clinical improvement was maintained also in OFF stimulation setting, so it was decided to keep it off. After 2 years in off-setting and stable clinical picture the entire DBS device was removed. Six months after DBS device removal the patient remained symptom-free. DBS is a therapeutic option reserved for severe and refractory GTS cases. In our opinion DBS might be considered as a temporary application in GTS.
... Clinical Neuropsychiatry (2009) 6, 6 precise neurophysiological characterization of the thala... more ... Clinical Neuropsychiatry (2009) 6, 6 precise neurophysiological characterization of the thalamic targets. Acknowledgements We would like to acknowledge Mrs Olga Lee Rachello for English supervision and translation. References Ackermans LY, Temel et al. (2006). ...
Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neu... more Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neuropathic pain refractory to any conservative treatment. The aim of this data collection is to enforce evidence of SCS effectiveness on neuropathic chronic pain reported in the literature and to speculate on the usefulness of the trial period in determining the long-term efficacy. Moreover, the very low percentage of undesired side effects and complications reported in our case series suggests that all implants should be performed by similarly well-trained and experienced professionals. A multicentric data collection on a common database from 11 Italian neurosurgical departments started 3 years ago. Two different types of electrodes (paddle or percutaneous leads) were used. Of 122 patients, 73 % (N = 89) were submitted to a trial period, while the remaining patients underwent the immediate permanent implant (N = 33). Statistical comparisons of continuous variables between groups were performed. Most of the patients (80 %) had predominant pain to their lower limbs, while only 17 % of patients had prevalent axial pain. Significant reduction in pain, as measured by variation in visual analogue scale (VAS) score, was observed at least 1 year after implantation in 63.8 % of the cases, 59.5 % of patients who underwent a test trial and 71.4 % of patients who underwent permanent implant at once. No statistical differences were found between the lower-limb pain group and the axial pain group. No relevant differences in long-term outcomes were observed in previously tested patients compared with patients implanted at once. Through this analysis we hope to recruit new centres, to give more scientific value to our results.
We read the article by Talacchi et al 1 entitled Surgical Approaches to Tumors of the Anterior G... more We read the article by Talacchi et al 1 entitled Surgical Approaches to Tumors of the Anterior Gyrus Cinguli with great interest. To their credit, the authors have successfully focused attention on a surgical site that rarely receives the attention it deserves, and we applaud them for ...
Intraforaminal disc herniations at the L5-S1 level are extremely surgically challenging lesions. ... more Intraforaminal disc herniations at the L5-S1 level are extremely surgically challenging lesions. Intracanal approaches frequently require partial or total facetectomy, which may lead to instability. Solely extraforaminal approaches may offer limited visualization of the more medial superiorly exiting and inferiorly exiting nerve roots; this approach is also more complicated at L5-S1 due to the often large L5 transverse process and the iliac wing. Nine patients with intraforaminal L5-S1 disc herniations, foraminal stenosis, or synovial cysts underwent contralateral interlaminar approaches for lesion resection. Preoperative and postoperative visual analog scale scores were evaluated, and complications were reviewed. All 9 patients demonstrated immediate postoperative clinical improvement. None of the patients exhibited complications and none developed instability or neuropathic disorders. Although the number of cases in our sample was very small (9 in total), the contralateral interlaminar approach appeared to effectively address multiple degenerative L5-S1 foraminal pathologies. Large studies are needed to further evaluate the pros and cons of this approach.
Deep brain stimulation (DBS) is an established therapy for movement disorders, such as Parkinson&... more Deep brain stimulation (DBS) is an established therapy for movement disorders, such as Parkinson's disease (PD), dystonia, and tremor. The efficacy of DBS depends on the correct lead positioning. The commonly adopted postoperative radiological evaluation is performed with computed tomography (CT) scan and/or magnetic resonance imaging (MRI). We conducted a retrospective study on 202 patients who underwent DBS from January 2009 to October 2013. DBS indications were PD, progressive supranuclear palsy, tremor, dystonia, Tourette syndrome, obsessive compulsive disorder, depression, and Huntington's disease. Preoperatively, all patients underwent brain MRI and brain CT scan with the stereotactic frame positioned. The lead location was confirmed intraoperatively with CT. The CT images were subsequently transferred to the Stealth Station Medtronic and merged with the preoperative planning. On the first or second day after, implantation we performed a brain MRI to confirm the correc...
A rare cause of spinal cord compression is spinal arachnoid cysts. Symptoms are caused by spinal ... more A rare cause of spinal cord compression is spinal arachnoid cysts. Symptoms are caused by spinal cord compression, however, asymptomatic patients have been also reported. Treatment options depend upon symptom severity and clinical course. We report the case of a 47-year-old patient who developed an intramedullary arachnoid cyst after removal of an intradural extramedullary cyst. Surgery should be considered early in a symptomatic disease course. Longstanding medullary compression may reduce the possibility of neurological recovery as well as secondary complications such as intramedullary cyst formation.
Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of ex... more Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of extension cable damage or IPG pocket infection, it can dramatically affect a patient's quality of life. Higher risk of infection has been reported after IPG replacement procedures rather than after primary deep brain stimulation lead implantation, and some authors suggested that the IPG pocket capsule could play a pivotal role in causing it. In this technical note we present a capsulectomy technique adopted in IPG replacement procedures. Between July and October 2015, we carried out ten outpatient IPG replacement procedures at the chest and abdomen under local anesthesia for battery depletion using the PEAK PlasmaBlade(TM). All patients were followed for at least 2 months to rule out any hardware malfunction and infection. All ten procedures were uneventful. No extension cable damage occurred. No IPG pocket infection occurred, also not in the follow-up. Mean surgical time was 30 min. Complete capsulectomy is not feasible with basic surgical instruments, and the PEAK PlasmaBlade(TM) pencil appears to be a helpful tool in carrying out the procedure.
Tourette's syndrome (TS) is a neurodevelopmental disorder... more Tourette's syndrome (TS) is a neurodevelopmental disorder typically defined by multiple motor tics and at least one sound tic, beginning in childhood or in adolescence. Handwriting is one of the most impaired school activities for TS patients because of the presence of tics that hamper learning processes. In this paper, we present a case of handwriting tics in a TS patient highlighting the main features.
The aim of this paper was to perform a critical and systematic review of the published papers on ... more The aim of this paper was to perform a critical and systematic review of the published papers on deep brain stimulation (DBS) for Tourette's Syndrome (TS). A PubMed search on DBS in TS was conducted selecting papers that reported on the clinical outcome of DBS. The majority of papers were case reports or small series. The thalamus and the globus pallidus internus appear to be the most promising targets. However, in light of the great methodological diversity a balanced comparison of clinical outcome and understanding of the role of DBS in TS remains difficult. Despite 16 years of experience with DBS in GTS a consensus on many issues, foremost on target selection and age inclusion continue to be missing. Class I evidence and international collaborations, to increase the number of included patients, are urgently needed to evaluate further the role of DBS in TS.
Gilles de la Tourette syndrome (GTS) is a severe neuropsychiatric disorder with childhood onset, ... more Gilles de la Tourette syndrome (GTS) is a severe neuropsychiatric disorder with childhood onset, characterized by disabling motor and vocal tics lasting for more than 1 year and associated with a wide range of psychiatric comorbidities. Pharmacological treatment is indicated for moderate to severe GTS patients. However, when GTS is refractory to conventional medical and behavioral treatments, deep brain stimulation (DBS) can be considered as a last resort therapeutic avenue. To evaluate the efficacy of DBS and its comorbidities in the largest pool of GTS patients to date. Our cohort study was based on 48 patients' refractory to conventional treatment who underwent DBS for GTS at Galeazzi Institute, Milan, Italy. An exhaustive preoperative and a follow-up battery of tests was performed including the Yale Global Tic Severity Rating Scale, the Yale-Brown Obsessive Compulsive Scale, the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Subjective Social Impairmen...
Gilles de la Tourette Syndrome (GTS) is a complex neuropsychiatric disorder, characterized by chr... more Gilles de la Tourette Syndrome (GTS) is a complex neuropsychiatric disorder, characterized by chronic motor and vocal tics, associated in 50-90% of cases with psychiatric comorbidities. Patients with moderate and severe clinical picture are treated with psychotherapy and pharmacological therapy. Deep brain stimulation (DBS) is reserved for pharmacological refractory GTS patients. As GTS tends to improve with time and potentially resolves in the second decade of life, the major concern of DBS in GTS is the age at which the patient undergoes surgical procedure. Some authors suggest performing DBS after 18 years, others after 25 years of age. We present a 25-year-old patient with GTS, who was aged 17 years and was treated with thalamic DBS. DBS resulted in progressive and sustained improvement of tics and co-morbidities. After 6 years of DBS treatment, it was noted that the clinical improvement was maintained also in OFF stimulation setting, so it was decided to keep it off. After 2 years in off-setting and stable clinical picture the entire DBS device was removed. Six months after DBS device removal the patient remained symptom-free. DBS is a therapeutic option reserved for severe and refractory GTS cases. In our opinion DBS might be considered as a temporary application in GTS.
... Clinical Neuropsychiatry (2009) 6, 6 precise neurophysiological characterization of the thala... more ... Clinical Neuropsychiatry (2009) 6, 6 precise neurophysiological characterization of the thalamic targets. Acknowledgements We would like to acknowledge Mrs Olga Lee Rachello for English supervision and translation. References Ackermans LY, Temel et al. (2006). ...
Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neu... more Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neuropathic pain refractory to any conservative treatment. The aim of this data collection is to enforce evidence of SCS effectiveness on neuropathic chronic pain reported in the literature and to speculate on the usefulness of the trial period in determining the long-term efficacy. Moreover, the very low percentage of undesired side effects and complications reported in our case series suggests that all implants should be performed by similarly well-trained and experienced professionals. A multicentric data collection on a common database from 11 Italian neurosurgical departments started 3 years ago. Two different types of electrodes (paddle or percutaneous leads) were used. Of 122 patients, 73 % (N = 89) were submitted to a trial period, while the remaining patients underwent the immediate permanent implant (N = 33). Statistical comparisons of continuous variables between groups were performed. Most of the patients (80 %) had predominant pain to their lower limbs, while only 17 % of patients had prevalent axial pain. Significant reduction in pain, as measured by variation in visual analogue scale (VAS) score, was observed at least 1 year after implantation in 63.8 % of the cases, 59.5 % of patients who underwent a test trial and 71.4 % of patients who underwent permanent implant at once. No statistical differences were found between the lower-limb pain group and the axial pain group. No relevant differences in long-term outcomes were observed in previously tested patients compared with patients implanted at once. Through this analysis we hope to recruit new centres, to give more scientific value to our results.
We read the article by Talacchi et al 1 entitled Surgical Approaches to Tumors of the Anterior G... more We read the article by Talacchi et al 1 entitled Surgical Approaches to Tumors of the Anterior Gyrus Cinguli with great interest. To their credit, the authors have successfully focused attention on a surgical site that rarely receives the attention it deserves, and we applaud them for ...
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Papers by Edvin Zekaj