Spine metastases affect more than 70% of terminal cancer patients that eventually suffer from severe pain and neurological symptoms. Nevertheless, in the overwhelming majority of the cases, a spinal metastasis represents just one location of a diffuse systemic disease. Therefore, the best practice for treatment of spinal metastases depends on many different aspects of an oncological disease, including the assessment of neurological status, pain, location, and dissemination of the disease as well as the ability to predict the risk of disease progression with neurological worsening, benefits and risks associated to treatment and, eventually, expected survival. To address this need for a framework and algorithm that takes all aspects of care into consideration, we reviewed available evidence on the multidisciplinary management of spinal metastases. According to the latest evidence, the use of stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT) for spinal metastatic disease is rapidly increasing. Indeed, aggressive surgical resection may provide the best results in terms of local control, but carries a significant rate of post-surgical morbidity whose incidence and severity appears to be correlated to the extent of resection. The multidisciplinary management represents, according to current evidence, the best option for the treatment of spinal metastases. Noteworthy, according to the recent literature evidence, cases that once required radical surgical resection followed by low-dose conventional radiotherapy, can now be more effectively treated by minimally invasive spinal surgery (MISS) followed by spine SRS with decreased morbidity, improved local control, and more durable pain control. This combination allows also extending this standard of care to patients that would be too sick for an aggressive surgical treatment.

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Background:The list of complications reported after decompressive craniectomy (DC) and cranioplasty is progressively increasing. Nonetheless, the exact incidence of these events is still ill-defined. Problems affecting skin flaps after DC and cranioplasty have never been accurately analyzed in papers and their impact on patients’ prognosis is largely underestimated.Methods:In a 10-year time, we treated by DC 450 patients, 344 of whom underwent cranioplasty, either with autologous bone or artificial implants (hydroxyapatite, polyetheretherketone, titanium, polymethylmethacrylate). Complications involving skin flaps and requiring re-surgery were observed and treated in 38 cases. We classified three main types of lesions: (1) dehiscence, (2) ulcer, and (3) necrosis. In all cases surgical decision making was performed in cooperation with plastic surgeons, to select the best treatment option.Results:Dehiscence was reported in 28 cases, ulcer in 6, and necrosis in 4. Surgeries included flap re-opening and re-suturing, Z-plasty, rotational, advancement, or free flaps. Treatment complications required further surgical procedures in six patients.Conclusions:In our experience, complications involving skin flaps after DC and post-DC cranioplasty cannot be considered a minor event because of their potential to further compromise the yet fragile conditions of these patients. Their management is complex and requires a multidisciplinary approach to get the better results.

Image-guided radiosurgery holds the dose distributions and precision of frame-based techniques with the remarkable advantage of multiple-session treatments that are better tolerated by sensitive peritumoral structures, such as the optic pathway and hypothalamus. This, together with the comfort of a frameless technique, candidates frameless image-guided radiosurgery to be the first option for the adjuvant post-operative treatment of craniopharyngiomas in children and young adults when total resection cannot be achieved, in particular those with hypothalamic involvement, and when the residual tumor is mostly solid.

Background: Although anterior cervical discectomy and fusion (ACDF) represents a standardized procedure for surgical treatment of a cervical herniated disc, several variables could affect patients' clinical and radiological outcome. We evaluated the impact of sex, age, body mass index (BMI), myelopathy, one- or two-level ACDF, and the use of postoperative collars on functional and radiological outcomes in a large series of patients operated for ACDF. Materials and Methods: Databases of three institutions were searched, resulting in the enrollment of 234 patients submitted to one- or two-level ACDF from January 2013 to December 2017 and followed as outpatients at 6- and 12-month follow-up. The impact of variables on functional and radiological outcomes was evaluated using univariate and multivariate logistic regression analysis. Results: At univariate analysis, female sex, higher BMI, two-level ACDF, and postoperative collar correlated with a significantly worse early and late Neck Disability Index (NDI). Multivariate analysis showed that male patients had a lower risk of worse early ( P = 0.01) and late NDIs ( P = 0.009). Patients with myelopathy showed better early NDI ( P = 0.004). Cervical collar negatively influenced both early and late NDIs ( P < 0.0001), with a higher risk of early nonfusion ( P = 0.001) but a lower risk of late nonfusion ( P = 0.01). Patients operated for two-level ACDF have a worse early NDI ( P = 0.005), a worse late NDI ( P = 0.01), and a higher risk of early nonfusion ( P = 0.048). BMI and age did not influence outcome. Conclusions: Female sex, two-level surgery, and the use of postoperative collars significantly correlate with worse functional outcomes after one- or two-level ACDF.