Intraoperative radiotherapy after neurosurgical resection of brain metastases as institutional standard treatment- update of the oncological outcome form a single center cohort after 117 procedures.

PURPOSE: Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice. METHODS: We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA). RESULTS: We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%. CONCLUSION: After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.

Focal cavity radiotherapy after neurosurgical resection of brain metastases: sparing neurotoxicity without compromising locoregional control.

PURPOSE: Does focal cavity radiotherapy after resection of brain metastasis "spare" whole-brain radiotherapy, which is associated with toxicity for patients, through the complete course of their disease without compromising long-term local control of the brain? METHODS: We retrospectively analyzed outcomes of patients who underwent adjuvant focal cavity radiotherapy between 2014 and 2021 at our center. RESULTS: A total of 83 patients with 86 resected brain metastases were analyzed. 64% had singular, 36% two to four brain metastases. In cases with multiple metastases, omitted lesions were treated with radiosurgery. Median follow-up was 7.3 months (range 0-71.2 months), 1­year overall survival rate was 57.8% (95% CI 44.9-68.8%). Radiotherapy was administered with a median biologically effective dose (α/ß 10) surrounding the planning target volume of 48 Gy (range 23.4-60 Gy). Estimated 1­year local control rate was 82.7% (95% CI 67.7-91.2%), estimated 1­year distant brain control rate was 55.7% (95% CI 40.5-68.4%), estimated 1­year leptomeningeal disease rate was 16.0% (95% CI 7.3-32.9%). Eleven distant brain recurrences could be salvaged with radiosurgery. In the further course of disease, 14 patients (17%) developed disseminated metastatic disease in the brain. Estimated 1­year free of whole-brain radiotherapy rate was 72.3% (95% CI 57.1-82.9%). All applied treatments led to an estimated 1­year neuro-control rate of 79.1% (95% CI 65.0-88.0%), estimated 1­year radionecrosis rate was 23% (95% CI 12.4-40.5%). CONCLUSION: In our single-center study, focal cavity radiotherapy was associated with high local control. In three out of four patients, whole-brain radiotherapy could be avoided in the complete course of disease, using radiosurgery as salvage approach without compromising neuro-control.

Hydrocephalus, cerebral vasospasm, and delayed cerebral ischemia following non-aneurysmatic spontaneous subarachnoid hemorrhages: an underestimated problem.

Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27-84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications.

Intraoperative radiotherapy with low-energy x-rays after neurosurgical resection of brain metastases-an Augsburg University Medical Center experience.

PURPOSE: External-beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50-kV x­rays is an alternative way to focally irradiate the resection cavity after BM surgery, with the option of shortening the overall treatment time and limiting normal tissue irradiation. METHODS: We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50-kV x­ray IORT between 2013 and 2020 at Augsburg University Medical Center. RESULTS: We identified 40 patients with 44 resected BM treated with 50-kV x­ray IORT. Median diameter of the resected metastases was 2.8 cm (range 1.5-5.9 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including 3­monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for alive patients of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1­year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1­year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1­year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%. CONCLUSION: IORT with 50-kV x­rays is a safe and appealing way to apply LBRT after neurosurgical resection of BM, with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.

High-frequency spinal cord stimulation in failed back surgery syndrome patients with predominant low back pain-single-center experience.

Treatment of patients with failed back surgery syndrome (FBSS) with predominant low back pain (LBP) remains challenging. High-frequency spinal cord stimulation (HF10 SCS) is believed to achieve significant pain reduction. We aimed to evaluate the real-life efficacy of HF-10 SCS in a tertiary spine center. A prospective observational study of all patients with FBSS and predominant LBP who underwent HF-10 SCS surgery was performed between 2016 and 2018. Patients > 18 years with Visual Analogue Scale (VAS) scores of ≥ 5 for LBP and pain duration > 6 months under stable medication were implanted percutaneous under general anesthesia and a trial phase of 7-14 days was accomplished. Primary end point was a successful trial defined as ≥ 50% VAS score reduction for LBP. Thirty-four of 39 (85%) subjects had a successful trial. Fifty-three percent were female and the mean age was 69 years. Median follow-up lasted for 10 months. Devices were removed after a median of 10 months in 5 cases. Remaining 29 patients stated significant VAS score reduction for LBP from 8.1 to 2.9 and VAS for leg pain from 4.9 to 2.2. Twenty-four percent of all patients were able to discontinue their opioids. Eight of 9 patients (89%) with signs of adjacent disc disease and 7 of 10 (70%) patients with hardware failure were successfully implanted with significant VAS reduction for LBP. HF-10 SCS achieves significant pain reduction in most patients with FBSS and predominant LBP. It might be an efficient alternative to revision surgery.

Craniocervical trauma above the age of 90: are current prognostic scores sufficient?

Clinical data following head or spine trauma in patients over 90 years is rare. The aim of this study was to analyze this patient cohort, assessing clinical characteristics, outcomes, and survival rates and to identify variables that may predict early mortality. A retrospective analysis of all patients over the age of 90 that were treated between January 2006 and December 2016 at our department was performed. Patient characteristics, type of injury, and comorbidities were analyzed with regard to the 30-day mortality rate as the primary outcome. One hundred seventy-nine patients were identified. Mean age was 93 (range 90-102); 105 (59%) patients were female. One hundred thirty-two (74%) and 34 (19%) of patients presented with head and spinal trauma, respectively. Fourteen patients (8%) had a combined head and spine injury. One hundred (56%) patients were treated operatively. Mean Charlson comorbidity index was 4.1 (range 0-18), mean diagnosis count was 6.2 (range 0-12), mean geriatric index of comorbidity (GIC) was 3.3 (range 1-4), and mean Barthel index was 28 (range 0-100). The 30-day mortality rate was 31%. Multivariate cox regression analysis showed that head trauma had a 1.66 hazard ratio (p = 0.036) of dying within 30 days of admission, whereas a higher Glasgow coma score and surgical treatment had a hazard ratio of 0.88 (p = 0.0001) and 0.72 (p = 0.05) to reach the primary outcome. None of the standard geriatric scores reached any significant correlation with the primary outcome. Standard geriatric prognostic scores seem less reliable to predict mortality for patients above the age of 90. Higher Glasgow coma score and surgical treatment were associated with a higher survival probability.

Cranioplasty following decompressive craniectomy: minor surgical complexity but still high periprocedural complication rates.

Cranioplasty following decompressive craniectomy is of low surgical complexity, so much so that it has become the "beginners" cranial case. However, these "simple" procedures may have high complication rates. Identification of specific risk factors would allow targeted intervention to lower the complication rates. The aim of this study was to assess the rate of complications and to evaluate potential risk factors. We conducted a review of all patients who underwent cranioplasty in our center following decompressive craniectomy for stroke or brain trauma between 2009 and 2016. One hundred fifty-two patients were identified. Fifty-three percent were male. Mean age was 48 (range 11-78). Median time from craniectomy until cranioplasty was 102 days (range 14-378). The overall rate of complications, such as postoperative bleeding, seizures, postoperative infection, and hydrocephalus, was 30%. The mortality rate was 1%. None of the following potential risk factors was associated with significantly increased risk of periprocedural complications: gender (p = 0.34), age (p = 0.39), cause of initial surgery (p = 0.08), duration of surgery (p = 0.59), time of surgery (0.24), surgical experience (p = 0.17), and time from craniectomy until cranioplasty (p = 0.27). The 30-day complication rate following cranioplasty is high, but serious permanent deficits from these complications were rare. We found no clear predictor for these 30-day complications, which renders its prevention difficult.

Inaccuracy of standard geriatric scores in nonagenarians following hospitalization for various spinal pathologies.

Demographic trends make it incumbent on spine surgeons to recognize the special challenges involved in caring for older patients. The aim of this study was to identify variables that may predict early mortality in geriatric patients over the age of 90 following elective hospitalization for various spinal pathologies. Retrospective analyses of all patients over the age of 90 years, which were electively treated between 2006 and 2016 at out department for various spinal conditions, were performed. Patient characteristics, type of treatment, and comorbidities were analyzed with regard to the 30-day mortality rate. Twenty-six patients were identified. Mean age was 93 years (range 91-97), 19 (73%) were female. Eighteen (69%) patients were treated operatively. Mean hospital stay was 13 days (range 2-51). Seventeen (65%) patients were on anticoagulation therapy. Mean Charlson Comorbidity Index (CCI) was 5.3 (range 1-11); mean diagnosis count (DC) was 8.3 (range 2-17); mean Geriatric Index of Comorbidity (GIC) was 2.8 (range 1-4); and mean comorbidity-polypharmacy score (GPS) was 13.3 (range 5-23). The 30-day mortality rate was 16.7% in the surgically treated group compared with 12.5% in the conservatively treated group (p = 0.9), anticoagulation therapy (p = 0.91), gender (p = 0.49), length of hospital stay (p = 0.33), GIC (p = 0.54), CCI (p = 0.74), GPS (p = 0.82), and DC (p = 0.65) did not correlate with the 30-day mortality rate. Cause of death was pulmonary embolism in two cases and unknown in one case. Thirty-day mortality rate in patients over 90 years old with degenerative spinal diseases is relatively high regardless of the treatment modality. Standard geriatric prognostic scores seem less reliable for these patients.

Completeness and accuracy of data in spine registries: an independent audit-based study.

PURPOSE: Clinical registries are used for quality management and clinical research. Due to the importance and implications of both aims, completeness and high quality of data are of paramount importance. However, this remains uncertain, as none of these registries have implemented independent monitoring. The aim of this study was to determine the accuracy and completeness of registry data o the example of the German Spine Society (DWG) registry. METHODS: In a prospective study, audits by a board-certified neurosurgeon were conducted at certified spine centers with mandatory registry input, a setting comparable to most existing registries worldwide. A 2-week period was analyzed, and any discrepancy between patients' charts and the registry entry was evaluated. A median of 31 items per patient was evaluated including completeness and accuracy of data. RESULTS: Out of 17 centers willing to participate, 4 were still lacking any data entries. Even in the remaining 13 centers eligible for audits, 28.50% (95%-CI = [22.46-34.55]) of entries were finalized only after the audits were announced. Only 82.55% (95%-CI = [79.12-85.98]) of surgeries were documented, and on average 14.95% (95%-CI = [10.93-19.00]) of entries were not accurate with a wide variation (range; 6.21-27.44%) between centers. Aspects for improvement of the situation were identified. CONCLUSION: Due to the high inaccuracy, the high number of centers lacking mandatory entries at all and the number of false entries, these data alert us to advocate unannounced audits and further measures to improve the situation. Data should not be used for the time being, since wrong conclusion will be drawn. These slides can be retrieved under Electronic Supplementary Material.

Psychological predictors of quality of life and functional outcome in patients undergoing elective surgery for degenerative lumbar spine disease.

OBJECTIVE: To quantify the correlation between patients' psychopathological predisposition, disability and health-related quality of life (QOL) after surgery for degenerative lumbar spine disease. METHODS: We prospectively included patients undergoing decompression for degenerative lumbar spinal stenosis, spondylolisthesis or disc herniation with additional fusion of up to two segments. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and State Trait Anxiety Inventory-Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol 5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores. RESULTS: In total, 245 patients between March 2013 and November 2017 received surgery, of which 180 (73.5%) fully completed follow-up after 3 months and 12 months. QOL scores significantly increased by 3 months (EQ: +0.2; p < 0.001; SF-36 PCS: +7.0; p < 0.001; SF-36 MCS: +3.3; p = 0.018), a benefit which was retained at 12 months, without statistically significant difference between fused and non-fused patients. Depressed patients exhibited impaired mean scores of EQ (0.58 vs. 0.36; p < 0.001) and ODI mean scores (35.5 vs. 51.9; p < 0.001) at baseline, which significantly improved and converged with scores of non-depressed patients after 12 months. Linear regression analysis identified statistically significant predictors in age, STAI-T and SF-36 MCS for post-operative QOL and disability. CONCLUSION: Despite exhibiting pronounced psychological distress preoperatively, patients may significantly benefit from surgery with an outcome equal to psychologically healthy patients after 12 months. These slides can be retrieved under Electronic Supplementary Material.

Radiographic measurements of cervical alignment, fusion and subsidence after ACDF surgery and their impact on clinical outcome.

BACKGROUND: Some recent studies indicate correlations between cervical alignment and clinical outcome after anterior cervical discectomy and fusion (ACDF) surgery. However, there still are no established criteria for the interpretation of alignment, fusion and subsidence in relation to clinical outcome. METHODS: A retrospective analysis of 208 radiographs of patients following ACDF with stand-alone PEEK cage implantation was performed. The measurements were obtained on plain radiographs in lateral and anteroposterior projections as well as flexion/extension radiographs. Cervical alignment was measured using the Gore, Laing and Cobb methods; fusion was evaluated by an assortment of radiographic hallmarks: the presence of bridging bone, the Cobb angle and the distances between the tips and bases of the spinous processes of the operated segments, respectively. For assessment of subsidence, we used the Mochida method in addition to ventral and dorsal segmental height reduction. Correlation analysis between the different radiological characteristics and clinical outcome at a minimum follow-up of 12 months was conducted. RESULTS: Two hundred and eight patients were evaluated for alignment, fusion and subsidence. Cervical alignment using the Gore and Cobb methods correlated among each other, but failed to exhibit significant correlation with clinical outcome. Interpretation of fusion rates varied greatly (43.9 to 89.4%) depending on the criteria used. Pearson coefficients between radiographic presence of pseudarthrosis and the measurements of the spinous process distances (0.595; p < 0.001), the Cobb angles (0.187; p = 0.007) and the presence of bridging bone (0.224; p < 0.001) each exhibited statistical significance. None of the methods employed significantly correlated with clinical outcome. Regarding subsidence, we found rates of 62%, 48% and 27% using the Mochida, ventral and dorsal segmental height reduction assessment methods, respectively. Pearson correlations between pairs of Mochida/ventral (r = 0.39; p = 0.66) and Mochida/dorsal (r = 0.007; p = 0.921) height reduction assessment methods were weak and no significant correlation between subsidence rates and clinical outcome was shown. CONCLUSION: All measured parameters varied depending in the measurement method used. This was most pronounced for fusion. There was a moderate positive correlation between neck pain and subsidence as measured by the Mochida method.

Treatment considerations for cervical and cervicothoracic spondylodiscitis associated with esophageal fistula due to cancer history or accidental injury: a 9-patient case series.

BACKGROUND: The combination of cervical spondylodiscitis and esophageal fistula is rare but life-threatening. Due to both the rarity of these conditions' coincidence and the complexity and heterogeneity of individual cases, there is no optimal treatment or management approach. The aims of this study are to obtain an overview of patients' outcomes and to discuss treatment options. METHOD: This study is a retrospective analysis of patients who presented with cervical spondylodiscitis and associated esophageal fistula between January 2010 and November 2018. We examined reports of 59 patients who suffered from cervical spondylodiscitis and included nine patients (15.25%) who had an esophageal fistula as the underlying cause. We assessed clinical findings, treatment, and outcome. RESULTS: Three of the nine patients were female, and the mean age of the sample was 64.56 years. Six of the patients had a history of esophagopharyngeal cancer and had undergone tumor resection followed by radiotherapy. Two of the remaining patients' fistulas were caused by an iatrogenic injury during cervical spine surgery and a swallowed toothpick; in the final case, the origin remained unclear. Five patients presented with tetraparesis or tetraplegia, and the other four patients were neurologically intact. In seven cases, dorsal instrumentation was initially performed. Three patients secondarily received a ventral approach for debridement, and one received explantation of the ventral implants. Two patients died during the hospital stay, and three were transferred to a palliative care unit. Thus, the spondylodiscitis and esophageal fistula were cured in only four patients. At discharge, two patients were neurologically intact, two others remained in tetraparesis. CONCLUSIONS: Cervical spondylodiscitis in association with an esophageal fistula carries high morbidity and high mortality. Because patients whose infections are not cured have high morbidity, we recommend using interdisciplinary and individual management, including definite surgical treatment of the discitis and fistula, in every case.

Quality of life and emotional burden after transnasal and transcranial anterior skull base surgery.

OBJECTIVE: To analyze psychopathological outcome and health-related quality of life (QOL) for cohorts of patients undergoing transcranial or transnasal anterior skull base surgery. METHODS: A prospective study of patients undergoing elective surgery for various entities of the anterior skull base was performed. Evaluation for depression (ADS-K score) and anxiety (PTSS, STAI-S, STAI-T, and ASI-3 scores) was done before surgery, at 3 and 12 months after surgery. The correlation between preoperative psychological burden and postoperative quality of life as measured by the SF-36 and EuroQol questionnaires was analyzed. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined and compared between transnasal and transcranial subgroups. RESULTS: We included 54 patients scheduled for surgery of a pituitary adenoma or meningioma of the anterior skull base between January 2013 and July 2017. Of these, a cohort of 40 (74.1%) completed follow-up interviews after 3 and 12 months. There were 60.0% female patients, median age was 57 years. 57.5% of patients had a meningioma and were operated transcranially, while 42.5% of patients received transnasal surgery for pituitary adenoma. The proportion of pathological anxiety scores significantly decreased from 75.0 to 45.0% (p = 0.002), without difference between transnasal and transcranial subgroups. After 3 months, mean EuroQol VAS score non-significantly increased by 0.07 (p = 0.236) across the entire cohort without significant difference between transcranial and transnasal subgroups (p = 0.478). The transnasal cohort tended to score higher in anxiety scores, whereas the transcranial cohort demonstrated higher depression scores without significant difference, respectively. The individually declared emotional burden significantly decreased from 6.7 to 4.0 on the ten-point Likert scale (p < 0.001) equally for both subgroups (transnasal, - 2.3; transcranial, - 3.0; p = 0.174). On last examination, about half of the patients in each subgroup (41.2% vs. 52.2%; p = 0.491) expressed a considerable recovery of preoperative bodily complaints such as headaches, dizziness, and unrest defined as a score of at least 8 on the Likert scaled item. CONCLUSION: Both transnasal and transcranial approaches yield favorable postoperative QOL and psychopathological outcomes. The postoperative increase in QOL is partly influenced by preoperative expression of mental distress, which tends to resolve postoperatively.

Autistic-like behaviours and hyperactivity in mice lacking ProSAP1/Shank2.

Autism spectrum disorders comprise a range of neurodevelopmental disorders characterized by deficits in social interaction and communication, and by repetitive behaviour. Mutations in synaptic proteins such as neuroligins, neurexins, GKAPs/SAPAPs and ProSAPs/Shanks were identified in patients with autism spectrum disorder, but the causative mechanisms remain largely unknown. ProSAPs/Shanks build large homo- and heteromeric protein complexes at excitatory synapses and organize the complex protein machinery of the postsynaptic density in a laminar fashion. Here we demonstrate that genetic deletion of ProSAP1/Shank2 results in an early, brain-region-specific upregulation of ionotropic glutamate receptors at the synapse and increased levels of ProSAP2/Shank3. Moreover, ProSAP1/Shank2(-/-) mutants exhibit fewer dendritic spines and show reduced basal synaptic transmission, a reduced frequency of miniature excitatory postsynaptic currents and enhanced N-methyl-d-aspartate receptor-mediated excitatory currents at the physiological level. Mutants are extremely hyperactive and display profound autistic-like behavioural alterations including repetitive grooming as well as abnormalities in vocal and social behaviours. By comparing the data on ProSAP1/Shank2(-/-) mutants with ProSAP2/Shank3αß(-/-) mice, we show that different abnormalities in synaptic glutamate receptor expression can cause alterations in social interactions and communication. Accordingly, we propose that appropriate therapies for autism spectrum disorders are to be carefully matched to the underlying synaptopathic phenotype.

Traumatic vertebral artery rupture causing intraspinal hematoma and progressive neurological symptoms.

Traumatic vertebral artery rupture is extremely rare. Herein, we report a case of traumatic vertebral artery rupture causing extensive intraspinal hematoma and progressive neurological symptoms.

Symptomatic annulus-repair-device loosening due to a low-grade infection.

We report the unusual case of a young patient with reoperation after annuloplasty using the Barricaid® (Intrinsic Therapeutics, Woburn, MA, USA) closure device. Our patient, a 32-year-old man underwent lumbar discectomy and annuloplasty of the level L5-S1. Five years later, the patient presented with a new onset of low-back pain radiating into the right leg. Imaging revealed loosening of the annulus repair device. The device was removed surgically and the patient was pain free thereafter. Annular closure devices such as the Barricaid system aim to improve outcome after lumbar discectomy by reducing the risk of recurrent disc herniation of the same level. Data on long-term follow-up are missing. Here we present, to our knowledge, the first case of symptomatic device loosening.

Working ability and use of healthcare resources for patients with trigeminal neuralgia treated via microvascular decompression.

BACKGROUND: Trigeminal neuralgia (TN) is defined as sudden, usually unilateral, severe, brief, stabbing and recurrent episodes of pain in one or more branches of the trigeminal nerve. In patients with TN refractory to medical therapy, microvascular decompression (MVD) is considered. TN interferes with daily functioning and is associated with depression and anxiety. Direct costs of MVD are high, but the procedure is believed to improve working ability and reduce the use of medical resources. This study aims to analyse MVD's effects on TN patients regarding work capacity, healthcare utilisation and health-related quality of life (hrQoL). METHODS: We conducted a cross-sectional survey of patients who underwent MVD for TN between 2007 and 2016 (n = 46). The patients' outcome, work capacity and use of medical resources were assessed via the Barrow Neurological Institute Pain Intensity Score (BNI Score), with questions regarding patients' employment status, restrictions in work capacity, healthcare utilisation and completion of the EQ5D questionnaire. RESULTS: The response rate was 28/46 (61%). The majority of the participants (20/28) reported feeling strongly/quite handicapped in productivity due to TN preoperatively, which was also indicated by a few participants (3/28) postoperatively (p = < 0.01). Pain-related days off work were reduced postoperatively from 21 to 4 (p = 0.059) on average. Postoperative hrQoL did not differ from the general German population. Further reductions in healthcare utilisation and private costs were shown. CONCLUSION: In TN, MVD alleviates patient burden, especially concerning productivity and the consumption of health resources.

The impact of nTMS mapping on treatment of brain AVMs.

BACKGROUND: The treatment of brain arteriovenous malformations (BAVMs) is still contrarily discussed. Despite the debatable results of the ARUBA trial, most BAVMs still require treatment depending on the Spetzler-Martin (SM) grading. Since size is measurable and venous drainage is visible, the determination of eloquence is comparably crucial but not fully objective. The present bicentric cohort study aims to examine the influence of preoperative navigated transcranial magnetic stimulation (nTMS) motor and language mapping data on decision-making for or against surgical treatment of BAVMs. METHODS: The influence of data from nTMS on decision-making for or against treatment of BAVMs was examined by confirming/falsifying presumed motor or language eloquence. RESULTS: The results of nTMS mappings changed the SM grading in nine cases. In six cases, the SM grading changed to a lower grade (= falsified eloquence); in three cases, the SM grading changed to a higher grade due to nTMS mappings (= unexpected eloquence). Out of all 34 cases, indication for surgery was supported by nTMS mappings in 15 cases (7 motors, 8 languages). In six cases, the decision against surgery was made based on nTMS mappings (three motors, three languages). CONCLUSION: In 21 of 34 cases (62%), nTMS was a supportive argument. We could show that nTMS motor and language data can be used for a more objective decision-making regarding the treatment of BAVMs and for a more detailed SM grading regarding the rating of eloquence.

The implementation of an infection prevention bundle reduces surgical site infections following cranial surgery.

BACKGROUND: The benefit of an infection prevention bundle made up of five basic procedures to avoid surgical site infections (SSIs) following cranial surgery was evaluated. METHODS: Data from all patients with first time elective brain surgery from March 2014 till May 2016 were analyzed. In April 2015, an infection prevention bundle was implemented. The rate of SSIs after first time elective cranial surgery of patients operated 1 year before and 1 year after the implementation was compared. RESULTS: Of the 321 cases operated before the implementation of the infection prevention bundle, 13 cases (4%) developed a SSI. After the implementation, only 6 patients out of 288 were re-operated due to a SSI (2%). The most frequent etiological germ cultivated was Staphylococcus aureus. CONCLUSION: The implementation of a bundle of 5 basic infection prevention steps leads to a clinical relevant reduction of SSIs.

No correlation between radiological and clinical outcome 1 year following cervical arthrodesis.

AIM: To correlate clinical and radiological outcome following one- and two-level anterior cervical discectomy and fusion (ACDF) with stand-alone polyetheretherketone (PEEK) cages filled with demineralized bone matrix (DBM). METHODS: We performed a retrospective review of a consecutive patient cohort with degenerative disc disease that underwent ACDF with stand-alone PEEK cages filled with demineralized bone matrix (DBM) between 2010 and 2013 with a minimum follow-up of 12 months. Changes in the operated segments were measured and compared to radiographs directly after surgery. Clinical outcome was evaluated by a physical examination, pain by visual analog scale (VAS) for arm and neck. Health-related quality of life was measured using the EuroQOL questionnaire (EQ-5D). RESULTS: Of 282 consecutive cases, follow-up data were obtained from 194 (69%) cases. The median age at presentation was 54 years and 91 patients were male (46%). Ninety-eight and 96 patients had one- and two-level surgeries, respectively. Mean VAS pain was reduced from 5.2 ± 3.6 to 2.6 ± 2.4 (p < 0.001) and from 5.8 ± 3.3 to 2.1 ± 2.7 (p < 0.001) in the myelopathy and radiculopathy group, respectively. Fusion was achieved in 79 and 82% of segments in one- and two-level surgeries, respectively. Cervical alignment was better in 10 and 1%, similar in 68 and 76%, worse in 23 and 23% in one- and two-level surgeries, respectively. Subsidence was observed in 44 and 34% of segments in one- and two-level surgeries, respectively. Follow-up operations due to symptomatic adjacent disc disease or implant failure were needed in 13 (7%) and 15 (8%) of cases, respectively. Subsidence, adjacent disc disease, and cervical alignment all had no influence on the clinical outcome. CONCLUSIONS: The clinical outcome after ACDF with PEEK cages filled with demineralized bone matrix is highly satisfactory. Radiological signs of non-fusion, subsidence, and cervical alignment have no influence on clinical outcome.