Extreme Lateral Interbody Fusion (XLIF) with Lateral Modular Plate Fixation: Preliminary Report on Clinical and Radiological Outcomes.

The lateral transpsoas approach (extreme lateral interbody fusion, or XLIF) allows surgeons to use various lordotic cage sizes to help restore intervertebral disk height, correct sagittal alignment, and improve fusion rates. The use of standalone devices has consistently raised doubts due to the high risk of complications and inadequate functional recovery that a circumferential arthrodesis can support. The recent introduction of a novel XLIF cage with adapted lateral plate fixation (XLPF) may further enhance the structural rigidity, consolidating the cage and plate into a singular modular entity. Nine patients from our surgical centers underwent a procedure of 1-level XLIF with XLPF in selected cases. We observed that XLPF does not extend the intraoperative footprint and provides immediate rigidity to the anterior column without any additional risk of complications and with minimal increased time compared to the traditional cage implant procedure. Although it has been shown that the use of interbody fusion cages with supplemental posterior fixation improves stabilization in all directions, the technique of standalone lateral cages may also have a place in spine surgery in that the stability may be sufficient in selected cases, such as junctional syndrome and in some forms of degenerative scoliosis.

Complex Regional Pain Syndrome after Spine Surgery: A Rare Complication in Mini-Invasive Lumbar Spine Surgery: An Updated Comprehensive Review.

BACKGROUND: Complex regional pain syndrome (CRPS) is a postoperative, misdiagnosed condition highlighted only by pain therapists after numerous failed attempts at pain control by the treating surgeon in the case of prolonged pain after surgery. It only occurs rarely after spine surgery, causing the neurosurgeon's inappropriate decision to resort to a second surgical treatment. METHODS: We performed a systematic review of the literature reporting and analyzing all recognized and reported cases of CRPS in patients undergoing spinal surgery to identify the best diagnostic and therapeutic strategies for this unusual condition. We compare our experience with the cases reported through a review of the literature. RESULTS: We retrieve 20 articles. Most of the papers are clinical cases showing the disorder's rarity after spine surgery. Most of the time, the syndrome followed uncomplicated lumbar spine surgery involving one segment. The most proposed therapy was chemical sympathectomy and spinal cord stimulation. CONCLUSION: CRPS is a rare pathology and is rarer after spine surgery. However, it is quite an invalidating disorder. Early therapy and resolution, however, require a rapid diagnosis of the syndrome. In our opinion, since CRPS occurs relatively rarely following spinal surgery, it should not have a substantial impact on the indications for and timing of these operations. Therefore, it is essential to diagnose this rare occurrence and treat it promptly and appropriately.

Peritumoral Brain Edema in Relation to Tumor Size Is a Variable That Influences the Risk of Recurrence in Intracranial Meningiomas.

Peritumoral brain edema (PBE) is common in intracranial meningiomas (IM) and can increase their morbidity. It is not uncommon for a neurosurgeon to confront meningiomas with a large proportion of PBE independently from the site and size of the contrast-enhancing lesion with increased surgical risks. We performed a retrospective review of 216 surgically-treated patients suffering from IM. We recorded clinical, biological, and radiological data based on the rate of tumor and edema volume and divided the patients into a group with high Edema/Tumor ratio and a group with a low ratio. We investigated how the ratio of edema/lesion may affect the outcome. Multivariate analysis was performed for the two groups. Smokers were found to be more likely to belong to the high-rate group. The edema/tumor ratio did not affect the surgical radicality; however, independently of the biological sub-type, WHO grading, and EOR, a higher frequency of recurrence is shown in patients with a high edema/tumor ratio (70.5% vs. 8.4%. p < 0.01). There is evidence to suggest that the blood-brain barrier (BBB) damage from smoke could play a role in an increased volume of PBE. The present study demonstrates that IMs showing a high PBE ratio to tumor volume at diagnosis are associated with a smoking habit and a higher incidence of recurrence independently of their biological type and grading.

The Surgical Risk Factors of Giant Intracranial Meningiomas: A Multi-Centric Retrospective Analysis of Large Case Serie.

Giant intracranial meningiomas (GIMs) are a subgroup of meningiomas with huge dimensions with a maximum diameter of more than 5 cm. The mechanisms by which a meningioma can grow to be defined as a "giant" are unknown, and the biological, radiological profile and the different outcomes are poorly investigated. We performed a multi-centric retrospective study of a series of surgically treated patients suffering from intracranial meningioma. All the patients were assigned on the grounds of the preoperative imaging to giant and medium/large meningioma groups with a cut-off of 5 cm. We investigated whether the presence of large diameter and peritumoral brain edema (PBE) on radiological diagnosis indicates different mortality rates, grading, characteristics, and outcomes in a multi-variate analysis. We found a higher risk of developing complications for GIMs (29.9% versus 14.8%; p < 0.01). The direct proportional relationship between PBE volume and tumor volume was present only in the medium/large group (Pearson correlation with p < 0.01) and not in the GIM group (p = 0.47). In conclusion, GIMs have a higher risk of developing complications in the postoperative phase than medium/large meningioma without higher risk of mortality and recurrence.

Intracranial Meningioma in Elderly Patients. Retrospective Multicentric Risk and Surgical Factors Study of Morbidity and Mortality.

With the increasing life expectancy, a large number of intracranial meningiomas (IM) have been identified in elderly patients. There is no general consensus regarding the management for IMs nor studies regarding the outcome of older patients undergoing meningioma surgery. We aimed to determine whether preoperative variables and postoperative clinical outcomes differ between age groups after meningioma surgery. We analyzed data from all patients who had undergone IM surgery from our departments. The final cohort consisted of 340 patients affected by IM with ASA class I-II: 188 in the young group (<65) and 152 in the elderly. The two subgroups did not present significant differences concerning biological characteristics of tumor, localization, diameters, lesion and edema volumes and surgical radicality. Despite these comparable data, elderly presented with a significantly lower Karnofsky Performance status value on admission and remained consistently lower during the follow-up. We establish instead that there is no intrinsic correlation to the presence of IM and no significant increased risk of complications or recurrence in elderly patients, but rather only an increased risk of reduced performance status with mortality related to the comorbidity of the patient, primarily cardiovascular disease, and an intrinsic frailty of the aged population.

Preserving Visual Functions During Gliomas Resection: Feasibility and Efficacy of a Novel Intraoperative Task for Awake Brain Surgery.

Objective: The intraoperative identification and preservation of optic radiations (OR) during tumor resection requires the patient to be awake. Different tasks are used. However, they do not grant the maintenance of foveal vision during all testing, limiting the ability to constantly monitor the peripheral vision and to inform about the portion of the peripheral field that is encountered. Although hemianopia can be prevented, quadrantanopia cannot be properly avoided. To overcome these limitations, we developed an intra-operative Visual field Task (iVT) to monitor the foveal vision, alerting about the likelihood of injuring the OR during task administration, and to inform about the portion of the peripheral field that is explored. Data on feasibility and efficacy in preventing visual field deficits are reported, comparing the outcome with the standard available task (Double-Picture-Naming-Task, DPNT). Methods: Patients with a temporal and/or parietal lobe tumor in close morphological relationship with the OR, or where the resection can involve the OR at any extent, without pre-operative visual-field deficits (Humphrey) were enrolled. Fifty-four patients were submitted to iVT, 38 to DPNT during awake surgery with brain mapping neurophysiological techniques. Feasibility was assessed as ease of administration, training and mapping time, and ability to alert about the loss of foveal vision. Type and location of evoked interferences were registered. Functional outcome was evaluated by manual and Humphrey test; extent of resection was recorded. Tractography was performed in a sample of patients to compare patient anatomy with intraoperative stimulation site(s). Results: The test was easy to administer and detected the loss of foveal vision in all cases. Stimulation induced visual-field interferences, detected in all patients, classified as detection or discrimination errors. Detection was mostly observed in temporal tumors, discrimination in temporo-parietal ones. Immediate visual disturbances in DPNT group were registered in 84 vs. 24% of iVT group. At 1-month Humphrey evaluation, 26% of iVT vs. 63% of DPNT had quadrantanopia (32% symptomatic); 10% of DPNT had hemianopia. EOR was similar. Detection errors were induced for stimulation of OR; discrimination also for other visual processing tract (ILF). Conclusion: iVT was feasible and sensitive to preserve the functional integrity of the OR.