The need for spinal fixation in patients who cannot tolerate classical open surgery has led in re... more The need for spinal fixation in patients who cannot tolerate classical open surgery has led in recent years to the development of minimally invasive approaches. The use of percutaneous pedicle screw fixation offers several advantages, such as less blood loss and postoperative pain due to blunt separation of the muscles with reduction of soft tissue dissection. Medical records and demographic information, diagnosis, and preoperative pain levels of 63 patients who underwent percutaneous minimally invasive thoracolumbar spine stabilization using the Illico® Fixation System (Alphatec Spine, Carlsbad, California) were analysed: a total of 344 screws were implanted. Preoperative and postoperative clinical assessment of the patients were based on a visual analogue scale. Because percutaneous techniques do not allow gross visualization of the vertebra and erroneous placement of the screw may be high in the initial cases, we discuss the techniques for a safe implantation of pedicle screws using a single or double intraoperative fluoroscopy. We report tips and tricks for technical challenges including fixation in osteoporotic patients, percutaneous insertion of long rods, compression/distraction using multiaxial screws turning into monoaxial, and use of minimally invasive retractror for interbody fusion. Recently, indications for minimally invasive percutaneous fixation have expanded and my results support that it may be considered a safe and effective option for the treatment of degenerative and traumatic thoracolumbar spinal diseases.
Diaphragma sellae meningiomas are very rare and often manifest themselves with aspecific symptoms... more Diaphragma sellae meningiomas are very rare and often manifest themselves with aspecific symptoms. Before the advent of MR, the diagnosis was very difficult or even impossible. For this reason they were often included in the broader category of suprasellar meningiomas. We describe two cases of diaphragma sellae meningiomas anterior to the pituitary stalk, manifesting with visual disturbances. We present the clinic and diagnostic data and we compare our experience with that reported in the literature. The tumor were removed by pterional (case 1) and subfrontal approach (case 2) with a recover of vision. Our experience support a clear demarcation of the diaphragma sellae meningioma among the wither group of suprasellar meningiomas. It is mandatory to define its position relative to the pituitary stalk and to the diaphragma sellae to chose the best surgical approach.
Subdural hematomas may affect 0.4-5 p. 100 of patients with cancer, because of predisposing risk ... more Subdural hematomas may affect 0.4-5 p. 100 of patients with cancer, because of predisposing risk factors or because of the cancer itself. The most likely association is with hematological cancer with coagulative disorders. An association with pachymeningitis carcinomatosa is less likely. In this instance the subdural hematoma is due to a neoplastic obstruction of dural vein with subdural engorgement and hemorrhage or subdural effusion. We report a case in which an acute neurological deterioration due to a subdural hematoma disclosed a dural metastasis from a breast cancer operated four years earlier and present a literature review.
Osteoporosis is a major global health problem, with over 10 million people currently diagnosed wi... more Osteoporosis is a major global health problem, with over 10 million people currently diagnosed with the disease. Although 80% of osteoporotic patients are women, a considerable number of men are also affected. Also, due to increasing life expectancy, the number of elderly patients with osteoporosis affected by degenerative and traumatic spinal diseases will increase further. Osteoporosis reduces bone quality through negative bone remodelling. Low bone quality can reduce the pull-out strength of pedicle screw, and negative bone remodelling can cause delayed bone fusion. However, pedicle screw instrumentation of the osteoporotic spine carries an increased risk of screw loosening, pull-out, and fixation failure. Our preliminary study aims to investigate the efficiency of expandable pedicle screws (OsseoScrew-Spinal Fixation System, Alphatec Spine Inc., Carlsbad, CA) in osteoporotic spinal patients. All osteoporotic patients with degenerative and traumatic spinal diseases admitted in our department underwent a pre-operative spinal x-Ray and MRI or CT. Pre-operative clinical assesment of patients was based on the visual analog scale (VAS) and Owestry Disability (ODI) questionnaire-a disease-specific outcome measure. Ten osteoporotic patients were treated with expandable pedicle screws (OsseoScrew). Post-operative clinical assessment of patients was based on the VAS and ODI questionnaire at 3 months and 1 year of follow-up. Post-operative radiologic follow-up was performed after 3 days (CT, x-ray); 3 months (x-ray); 6 months (spinal CT); and 1 year (spinal CT). Expandable pedicle screws improved pull-out strength as compared to standard pedicle screws in osteoporotic patients with degenerative and traumatic spinal diseases.
The role of surgical management in the setting of multiple brain metastases is controversial. Alt... more The role of surgical management in the setting of multiple brain metastases is controversial. Although the role of surgical resection in single brain metastases is well stated, in multiple brain metastases whole brain radiation therapy remains a mainstay of treatment. In this series, the authors evaluate the efficacy of minimally invasive neurosurgical techniques in the resection of brain metastases with a particular focus on multiple metastases. 57 patients who underwent surgical resection of brain metastases with a key-hole approach, were analyzed for surgical success, complications, neurological deficits, functional outcome and overall survival. 187 brain metastases were detected. The majority of patients improved in KPS postoperatively at 6 weeks (80.6%) and 3 months follow up (62.5%). Mean overall survival was 14.2 months with a 1 year survival rate of 44%. According to univariate analysis, poor systemic control of cancer, tumor extending to both lobar and deep brain, lower extent of resection and symptomatic tumor resection were found to be associated with poorer survival. With the use of minimally invasive neurosurgery, aggressive management of multiple metastases leads to minimal postoperative stay, improvement in quality of life and overall survival. Patient overall survival is dependent on recursive partitioning analysis (RPA) class, and should be used to guide management.
Infections of the spine have been a constant throughout history. At present there are infections ... more Infections of the spine have been a constant throughout history. At present there are infections in the spine fostered in part by the same advances in medicine: there are a lot of immunocompromised patients, the life expectancy of patients with chronic diseases is augmented and the increasing number of complex spinal surgeries can result in secondary infection. In this review the main types of infection of the spine and its treatment highlighting techniques in minimally invasive surgery are discussed. Spontaneous pyogenic and nonpyogenic spine infections as well as iatrogenic infections can be treated in a different manner depending on its extension, location and microorganism involved. We will review the use and the indication of percutaneous image-guided techniques, endoscopic and microsurgical techniques with or without use of tubular retractors. We conclude that techniques in minimally invasive surgery in spine infections are safe, effective and have benefits in morbidity of the approach and subsequent patient recovery.
The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positio... more The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positioning exist. Here, we report a simple, safe, and quick positioning technique which maximizes patient safety, surgeon comfort, and intraoperative view. We reviewed the senior author's prospective surgical database for retrosigmoid approaches to the posterior fossa and noted any complications or difficult exposures. Over 970 retrosigmoid operations were performed over the course of 19 years. There were no positioning-related complications and no aborted surgeries due to inadequate exposure. No normal cerebellum was ever resected to increase exposure and no retractor was ever used in the posterior fossa. Supine positioning for the retrosigmoid approach is an excellent and safe positioning alternative.
Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the n... more Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the neural foramen and the extraforaminal compartment in the paraspinal region. We report a case of a 20-year-old man who presented with back pain radiating to his left lower limb mostly when in a supine position. Magnetic resonance imaging of the lumbar spine showed a dumbbell lesion at the L5-S1 neural foramen, with enlargement of the foramen and extension into the left paraspinal compartment. Although MR imaging studies were strongly suggestive of a dumbbell radicular schwannoma, the histological diagnosis was an osteoblastoma of the lumbar spine originating from the left L5 pedicle with intracanalicular, intraforaminal and extracanalicular extension. The presentation, imaging studies, intervention, pathology and differential diagnosis are described.
Lumbar disc herniation is a common cause of back and radicular leg pain. A bulging annulus and co... more Lumbar disc herniation is a common cause of back and radicular leg pain. A bulging annulus and contained herniated disc can compress a nearby exiting root as it enters the neuroforamen and may cause pain and neurological symptoms. Percutaneous laser disc decompression (PLDD) has been regarded as an effective alternative to microdiscectomy for the treatment of contained lumbar disc herniations. However, there is no consensus regarding the type of laser to use, the ideal wavelength, or the energy applied. The ideal laser irradiation should have a high water absorption coefficient and low tissue pervasion, to limit thermal injury. The 1470 nm wavelength of the diode laser is absorbed by water 40 times more effectively than the 980 nm wavelength. We conducted this study to evaluate the efficacy and safety of PLDD using a 1470 nm diode laser. We retrospectively reviewed the clinical data of 27 patients with radicular pain who underwent PLDD for the treatment of contained lumbar disc hern...
To clarify outcomes and develop a novel classification according to CSF fistula in a selective co... more To clarify outcomes and develop a novel classification according to CSF fistula in a selective cohort with intraoperative spinal dural tear, we examined 72 consecutive patients who underwent spinal dural repair after microdiscectomy (n=42) or lumbar spinal decompression (n=30). Group 1 consisted of 25 patients with Type I (mild) dural tear who were treated with either tissue-glue-coated collagen sponge or fibrin glue. Group 2 consisted of 26 patients with Type II (moderate) dural tear who were treated with both tissue-glue-coated collagen sponge and fibrin glue. Group 3 consisted of 21 patients with Type III (severe) dural tear who were treated with polypropylene suture along with tissue-glue-coated collagen sponge and/or fibrin glue. Evident postoperative internal or external CSF leak was used to determine the patient's postoperative result. Postoperative internal or external CSF leak was not evident during a minimum 1-year follow-up in Group 1. In contrast, internal CSF leak was evident in both Groups 2 (n=3) and 3 (n=3) during the same follow-up. No external CSF leak was noted in any of the patients. Three patients underwent re-do spinal surgery for CSF leak repair. Patients in all groups satisfactorily avoided CSF leak. According to the intraoperative findings of a distinct dural tear, patients can be treated adequately with a specific surgical technique.
The need for spinal fixation in patients who cannot tolerate classical open surgery has led in re... more The need for spinal fixation in patients who cannot tolerate classical open surgery has led in recent years to the development of minimally invasive approaches. The use of percutaneous pedicle screw fixation offers several advantages, such as less blood loss and postoperative pain due to blunt separation of the muscles with reduction of soft tissue dissection. Medical records and demographic information, diagnosis, and preoperative pain levels of 63 patients who underwent percutaneous minimally invasive thoracolumbar spine stabilization using the Illico® Fixation System (Alphatec Spine, Carlsbad, California) were analysed: a total of 344 screws were implanted. Preoperative and postoperative clinical assessment of the patients were based on a visual analogue scale. Because percutaneous techniques do not allow gross visualization of the vertebra and erroneous placement of the screw may be high in the initial cases, we discuss the techniques for a safe implantation of pedicle screws using a single or double intraoperative fluoroscopy. We report tips and tricks for technical challenges including fixation in osteoporotic patients, percutaneous insertion of long rods, compression/distraction using multiaxial screws turning into monoaxial, and use of minimally invasive retractror for interbody fusion. Recently, indications for minimally invasive percutaneous fixation have expanded and my results support that it may be considered a safe and effective option for the treatment of degenerative and traumatic thoracolumbar spinal diseases.
Diaphragma sellae meningiomas are very rare and often manifest themselves with aspecific symptoms... more Diaphragma sellae meningiomas are very rare and often manifest themselves with aspecific symptoms. Before the advent of MR, the diagnosis was very difficult or even impossible. For this reason they were often included in the broader category of suprasellar meningiomas. We describe two cases of diaphragma sellae meningiomas anterior to the pituitary stalk, manifesting with visual disturbances. We present the clinic and diagnostic data and we compare our experience with that reported in the literature. The tumor were removed by pterional (case 1) and subfrontal approach (case 2) with a recover of vision. Our experience support a clear demarcation of the diaphragma sellae meningioma among the wither group of suprasellar meningiomas. It is mandatory to define its position relative to the pituitary stalk and to the diaphragma sellae to chose the best surgical approach.
Subdural hematomas may affect 0.4-5 p. 100 of patients with cancer, because of predisposing risk ... more Subdural hematomas may affect 0.4-5 p. 100 of patients with cancer, because of predisposing risk factors or because of the cancer itself. The most likely association is with hematological cancer with coagulative disorders. An association with pachymeningitis carcinomatosa is less likely. In this instance the subdural hematoma is due to a neoplastic obstruction of dural vein with subdural engorgement and hemorrhage or subdural effusion. We report a case in which an acute neurological deterioration due to a subdural hematoma disclosed a dural metastasis from a breast cancer operated four years earlier and present a literature review.
Osteoporosis is a major global health problem, with over 10 million people currently diagnosed wi... more Osteoporosis is a major global health problem, with over 10 million people currently diagnosed with the disease. Although 80% of osteoporotic patients are women, a considerable number of men are also affected. Also, due to increasing life expectancy, the number of elderly patients with osteoporosis affected by degenerative and traumatic spinal diseases will increase further. Osteoporosis reduces bone quality through negative bone remodelling. Low bone quality can reduce the pull-out strength of pedicle screw, and negative bone remodelling can cause delayed bone fusion. However, pedicle screw instrumentation of the osteoporotic spine carries an increased risk of screw loosening, pull-out, and fixation failure. Our preliminary study aims to investigate the efficiency of expandable pedicle screws (OsseoScrew-Spinal Fixation System, Alphatec Spine Inc., Carlsbad, CA) in osteoporotic spinal patients. All osteoporotic patients with degenerative and traumatic spinal diseases admitted in our department underwent a pre-operative spinal x-Ray and MRI or CT. Pre-operative clinical assesment of patients was based on the visual analog scale (VAS) and Owestry Disability (ODI) questionnaire-a disease-specific outcome measure. Ten osteoporotic patients were treated with expandable pedicle screws (OsseoScrew). Post-operative clinical assessment of patients was based on the VAS and ODI questionnaire at 3 months and 1 year of follow-up. Post-operative radiologic follow-up was performed after 3 days (CT, x-ray); 3 months (x-ray); 6 months (spinal CT); and 1 year (spinal CT). Expandable pedicle screws improved pull-out strength as compared to standard pedicle screws in osteoporotic patients with degenerative and traumatic spinal diseases.
The role of surgical management in the setting of multiple brain metastases is controversial. Alt... more The role of surgical management in the setting of multiple brain metastases is controversial. Although the role of surgical resection in single brain metastases is well stated, in multiple brain metastases whole brain radiation therapy remains a mainstay of treatment. In this series, the authors evaluate the efficacy of minimally invasive neurosurgical techniques in the resection of brain metastases with a particular focus on multiple metastases. 57 patients who underwent surgical resection of brain metastases with a key-hole approach, were analyzed for surgical success, complications, neurological deficits, functional outcome and overall survival. 187 brain metastases were detected. The majority of patients improved in KPS postoperatively at 6 weeks (80.6%) and 3 months follow up (62.5%). Mean overall survival was 14.2 months with a 1 year survival rate of 44%. According to univariate analysis, poor systemic control of cancer, tumor extending to both lobar and deep brain, lower extent of resection and symptomatic tumor resection were found to be associated with poorer survival. With the use of minimally invasive neurosurgery, aggressive management of multiple metastases leads to minimal postoperative stay, improvement in quality of life and overall survival. Patient overall survival is dependent on recursive partitioning analysis (RPA) class, and should be used to guide management.
Infections of the spine have been a constant throughout history. At present there are infections ... more Infections of the spine have been a constant throughout history. At present there are infections in the spine fostered in part by the same advances in medicine: there are a lot of immunocompromised patients, the life expectancy of patients with chronic diseases is augmented and the increasing number of complex spinal surgeries can result in secondary infection. In this review the main types of infection of the spine and its treatment highlighting techniques in minimally invasive surgery are discussed. Spontaneous pyogenic and nonpyogenic spine infections as well as iatrogenic infections can be treated in a different manner depending on its extension, location and microorganism involved. We will review the use and the indication of percutaneous image-guided techniques, endoscopic and microsurgical techniques with or without use of tubular retractors. We conclude that techniques in minimally invasive surgery in spine infections are safe, effective and have benefits in morbidity of the approach and subsequent patient recovery.
The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positio... more The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positioning exist. Here, we report a simple, safe, and quick positioning technique which maximizes patient safety, surgeon comfort, and intraoperative view. We reviewed the senior author's prospective surgical database for retrosigmoid approaches to the posterior fossa and noted any complications or difficult exposures. Over 970 retrosigmoid operations were performed over the course of 19 years. There were no positioning-related complications and no aborted surgeries due to inadequate exposure. No normal cerebellum was ever resected to increase exposure and no retractor was ever used in the posterior fossa. Supine positioning for the retrosigmoid approach is an excellent and safe positioning alternative.
Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the n... more Spinal dumbbell tumors originate from nerve roots, usually growing within the spinal canal, the neural foramen and the extraforaminal compartment in the paraspinal region. We report a case of a 20-year-old man who presented with back pain radiating to his left lower limb mostly when in a supine position. Magnetic resonance imaging of the lumbar spine showed a dumbbell lesion at the L5-S1 neural foramen, with enlargement of the foramen and extension into the left paraspinal compartment. Although MR imaging studies were strongly suggestive of a dumbbell radicular schwannoma, the histological diagnosis was an osteoblastoma of the lumbar spine originating from the left L5 pedicle with intracanalicular, intraforaminal and extracanalicular extension. The presentation, imaging studies, intervention, pathology and differential diagnosis are described.
Lumbar disc herniation is a common cause of back and radicular leg pain. A bulging annulus and co... more Lumbar disc herniation is a common cause of back and radicular leg pain. A bulging annulus and contained herniated disc can compress a nearby exiting root as it enters the neuroforamen and may cause pain and neurological symptoms. Percutaneous laser disc decompression (PLDD) has been regarded as an effective alternative to microdiscectomy for the treatment of contained lumbar disc herniations. However, there is no consensus regarding the type of laser to use, the ideal wavelength, or the energy applied. The ideal laser irradiation should have a high water absorption coefficient and low tissue pervasion, to limit thermal injury. The 1470 nm wavelength of the diode laser is absorbed by water 40 times more effectively than the 980 nm wavelength. We conducted this study to evaluate the efficacy and safety of PLDD using a 1470 nm diode laser. We retrospectively reviewed the clinical data of 27 patients with radicular pain who underwent PLDD for the treatment of contained lumbar disc hern...
To clarify outcomes and develop a novel classification according to CSF fistula in a selective co... more To clarify outcomes and develop a novel classification according to CSF fistula in a selective cohort with intraoperative spinal dural tear, we examined 72 consecutive patients who underwent spinal dural repair after microdiscectomy (n=42) or lumbar spinal decompression (n=30). Group 1 consisted of 25 patients with Type I (mild) dural tear who were treated with either tissue-glue-coated collagen sponge or fibrin glue. Group 2 consisted of 26 patients with Type II (moderate) dural tear who were treated with both tissue-glue-coated collagen sponge and fibrin glue. Group 3 consisted of 21 patients with Type III (severe) dural tear who were treated with polypropylene suture along with tissue-glue-coated collagen sponge and/or fibrin glue. Evident postoperative internal or external CSF leak was used to determine the patient's postoperative result. Postoperative internal or external CSF leak was not evident during a minimum 1-year follow-up in Group 1. In contrast, internal CSF leak was evident in both Groups 2 (n=3) and 3 (n=3) during the same follow-up. No external CSF leak was noted in any of the patients. Three patients underwent re-do spinal surgery for CSF leak repair. Patients in all groups satisfactorily avoided CSF leak. According to the intraoperative findings of a distinct dural tear, patients can be treated adequately with a specific surgical technique.
Uploads
Papers by Roberto Gazzeri