Natural history of spinal cord metastasis from brain glioblastomas.

BACKGROUND AND OBJECTIVES: Spinal cord metastasis arising from an intracranial glioblastoma is a rare and late event during the natural course of the disease. These pathological entities remain poorly characterized. This study aimed to identify and investigate the timeline, clinical and imaging findings, and prognostic factors of spinal cord metastasis from a glioblastoma. METHODS: Consecutive histopathological cases of spinal cord metastasis from glioblastomas in adults entered in the French nationwide database between January 2004 and 2016 were screened. RESULTS: Overall, 14 adult patients with a brain glioblastoma (median age 55.2 years) and harboring a spinal cord metastasis were included. The median overall survival as 16.0 months (range, 9.8-22.2). The median spinal cord Metastasis Free Survival (time interval between the glioblastoma diagnosis and the spinal cord metastasis diagnosis) was 13.6 months (range, 0.0-27.9). The occurrence of a spinal cord metastasis diagnosis greatly impacted neurological status: 57.2% of patients were not ambulatory, which contributed to dramatically decreased Karnofsky Performance Status (KPS) scores (12/14, 85.7% with a KPS score ≤ 70). The median overall survival following spinal cord metastasis was 3.3 months (range, 1.3-5.3). Patients with a cerebral ventricle effraction during the initial brain surgery had a shorter spinal cord Metastasis Free Survival (6.6 vs 18.3 months, p = 0.023). Out of the 14 patients, eleven (78.6%) had a brain IDH-wildtype glioblastoma. CONCLUSIONS: Spinal cord metastasis from a brain IDH-wildtype glioblastoma has a poor prognosis. Spinal MRI can be proposed during the follow-up of glioblastoma patients especially those who have benefited from cerebral surgical resection with opening of the cerebral ventricles.

Anatomical study of the carotid-trigeminal interface: The missing link in the trigeminovascular system?

The trigeminal system is considered a prominent actor in brain nociceptive innervation. The trigeminovascular system is mainly composed of pseudounipolar neurons located within the trigeminal ganglion, whose dendrites originate in cerebral blood vessels. Anatomical studies demonstrating anatomical continuity between perivascular fibers and the trigeminal system are lacking. This issue is addressed in this study. Eleven cadaveric heads obtained from a body donation program were fixed in formalin. We performed a microanatomical study of the cavernous carotid-trigeminal interface and a histological examination of the tissue bridges crossing the virtual space between the medial aspect of the trigeminal ganglion and ophthalmic nerve and the lateral aspect of the cavernous segment of the internal carotid artery. Very strong adhesion was observed between the horizontal segment of the artery and the ophthalmic nerve in all specimens. The virtual space in this interface was crossed by a web of delicate filaments. Histological examination demonstrated the presence of nerve fibers in all samples. In this study, the carotid-trigeminal interface has been described in greater detail than ever before and could provide insight into disorders related to the trigeminovascular system. As the present results do not allow the exact nature of the axons to be affirmed, further investigation is necessary.

Chronic low back pain during COVID-19 lockdown: is there a paradox effect?

PURPOSE: The coronavirus 2019 (COVID-19) pandemic led to a compulsory lockdown of 3 months with strict restrictions. The impact of the COVID-19 pandemic has shown broad repercussions on patients with chronic pain; especially for conditions that present a significant emotional participation such as chronic low back pain (cLBP). METHODS: We performed a prospective study on 50 patients. Pre- and 1-month post-lockdown questionnaires such as: the Impact of Event Scale (IES), the Oswestry Disability Index (ODI), the Roland-Morris questionnaire (RMQ) and the visual analogue scale (VAS) for back and leg pain intensity were collected. RESULTS: The mean time of the evolution of cLBP was 33.04 months (range 5-120 months). Eighteen (36%) patients improved their cLBP (i-cLBP), whereas for 14 (28%) it was worse (w-cLBP). Cox multivariate proportional hazard model identified that MODIC 1 disc disease [OR 19.93, IC95% (2.81-102.13), p = 0.015] and at-home workouts [OR 18.854, IC95% (1.151-204.9), p = 0.040] were good prognosis factors of the improvement of cLBP while subclinical/mild Covid-19 anxiety (IES score < 26) was a poor prognosis factor in improving cLBP [OR 0.21, IC95% (0.001-0.384), p = 0.009]. Furthermore, pre-lockdown benzodiazepine medication [OR 2.554, IC95% (1.20-9.9), p = 0.002] was a prognosis factor of worse cLBP. In contrast, patients with severe Covid-19 anxiety (IES score > 26) significantly improved their cLBP [OR 0.58, IC95% (0.025-0.834), p = 0.01]. CONCLUSION: Lockdown affected the somatic component of cLBP by decreasing activities and physical measures, whereas the SARS-CoV-2 pandemic spectrum paradoxically improved the psychic and emotional component of cLBP.

Spine metastasis in patients with prostate cancer: Survival prognosis assessment.

BACKGROUND: Patients presenting spine metastasis (SpM) from prostate cancer (PC) form a heterogeneous population, through this study, we aimed to clarify and update their prognostic assessment. METHODS: The patient data used in this study was obtained from a French national multicenter database of patients treated for PC with SpM between 2014 and 2017. A total of 72 patients and 365 SpM cases were diagnosed. RESULTS: The median overall survival time for all patients following the event of SpM was 28.8 months. First, we identified three significant survival prognostic factors of PC patients with SpM: good Eastern Cooperative Oncology Group/World Health Organization personnel status (Status 0 hazard ratio [HR]: 0.031, 95% confidence interval [CI]: 0.008-0.127; p < .0001) or (Status 1 HR: 0.163, 95% CI: 0.068-0.393; p < .0001) and SpM radiotherapy (HR: 2.923, 95% CI: 1.059-8.069; p < .0001). Secondly, the presence of osteolytic lesions of the spine (vs. osteoblastic) was found to represent an independent prognosis factor for longer survival [HR: 0.424, 95% CI: 0.216-0.830; p = .01]. Other factors including the number of SpM, surgery, extraspinal metastasis, synchrone metastasis, metastasis-free survival, and SpM recurrence were not identified as being prognostically relevant to the survival of patients with PC. CONCLUSION: Survival and our ability to estimate it in patients presenting PC with SpM have improved significantly. Therefore, we advocate the relevance of updating SpM prognostic scoring algorithms by incorporating data regarding the timeline of PC as well as the presence of osteolytic SpM to conceive treatments that are adapted to each patient.

The trigeminal system: The meningovascular complex- A review.

Supratentorial sensory perception, including pain, is subserved by the trigeminal nerve, in particular, by the branches of its ophthalmic division, which provide an extensive innervation of the dura mater and of the major brain blood vessels. In addition, contrary to previous assumptions, studies on awake patients during surgery have demonstrated that the mechanical stimulation of the pia mater and small cerebral vessels can also produce pain. The trigeminovascular system, located at the interface between the nervous and vascular systems, is therefore perfectly positioned to detect sensory inputs and influence blood flow regulation. Despite the fact that it remains only partially understood, the trigeminovascular system is most probably involved in several pathologies, including very frequent ones such as migraine, or other severe conditions, such as subarachnoid haemorrhage. The incomplete knowledge about the exact roles of the trigeminal system in headache, blood flow regulation, blood barrier permeability and trigemino-cardiac reflex warrants for an increased investigation of the anatomy and physiology of the trigeminal system. This translational review aims at presenting comprehensive information about the dural and brain afferents of the trigeminovascular system, in order to improve the understanding of trigeminal cranial sensory perception and to spark a new field of exploration for headache and other brain diseases.

Arcuate foramen: "Anatomical variation shape or adaptation legacy?"

PURPOSE: The groove of the vertebral artery on the posterior arch of the atlas (sulcus arteriae vertebralis) may become a complete or partial osseous foramen: the arcuate foramen. The presence of a complete or partial arcuate foramen is a rare anatomical variant described in a minority of patients and it seems to be associated with vertigo, vertebro-basilar insufficiency, posterior circulation strokes, and musculoskeletal pain. As the number and morphology of cervical vertebrae is highly preserved, we questioned about its significance from an evolutionary point of view. We thus investigated through an extensive literature review if the arcuate foramen is a pure anatomical variation shape or if it might represent an adaptation legacy. METHODS: We observed five atlas of an extinct species, the Late Pleistocene Mammoths (M. primigenius), and we compared them with five atlas of a closely related existent species, the African elephant (L. africana). RESULTS: All the mammoths' atlas had an arcuate foramen through which the vertebral artery passed before turning anteriorly and becoming intradural. This foramen was not present in elephants' atlas, where only a groove was observed, such as in the majority of patients. CONCLUSION: We would like to raise the hypothesis that this peculiar morphology of mammoths' atlas might have contributed, in association with other factors, to their precocious extinction and that the arcuate foramen might represent a disadvantage in the evolutionary process, with a low prevalence in humans being the result of a natural selection.

Predictive factors of neurological recovery after chronic craniovertebral brainstem compression.

BACKGROUND: Neurologic manifestations of craniovertebral junction (CVJ) disease may generate dramatic brainstem damage, which could evolve to paralysis. In most cases, patients are referred with advanced neurological symptoms such as tetraplegia/paresis. The aim of this study was to identify predictive factors of favorable neurological evolution after non-traumatic brainstem compression. METHODS: A prospective study evaluated 143 consecutive patients who had undergone CVJ anterior brainstem decompression. The mean age was 45.1 ± 19.1 years. The study analyzed clinical, surgical, and imagery characters to determine predictive factors of neurological improvement. RESULTS: The mean follow-up of our series was 10.2 years (range 0.5-23.9). Seventy-one (49.6%) presented initial tetrapalsies resulting from spinal cord compression. Multivariable analysis revealed that Frankel score [odds ratio (OR) 5.7, CI 95% 1.01-31.8; p < 0.04] and preoperative symptoms < 6 months [OR 0.33, CI 95% 0.125-0.9; p < 0.025] were independently associated with partial neurological improvement, while the only independent factor associated with total neurologic recovery was the preoperative symptom evolution <6 months [odd ratio (OR) 4.3, CI 95% 1.6-11.4; p < 0.003]. None of the following were identified as predictive factors: demographic characteristics, medical history, the etiology of compression, or initial spinal cord MRI. CONCLUSION: The earlier the decompression is performed, the better the neurological improvement. Whatever the initial Frankel score, if neurological palsy or disorders evolved for less than 6 months, complete recovery is possible.

Distally Based Medial Hemisoleus Muscle Flap: Anatomic and Angiographic Study of 18 Lower Limbs.

BACKGROUND: The distally based medial hemisoleus (MHS) flap was found useful for repairing soft-tissue defects of the lower third of the leg; however, its reliability is controversial. We used a combination of static and dynamic techniques to investigate the vascular supply of distally based MHS muscle flaps to better establish their use in repair of lower-third leg defects. METHODS: We performed an anatomic study of 18 cadaver legs. For 6 legs, we performed dynamic angiography, which allowed for obtaining MHS muscle radiographs after pulsed injection of contrast medium in distal pedicles. RESULTS: The mean length of MHS muscle was 25.4 cm, the mean width was 6.9 cm, and the mean surface area was 87.5 cm. A mean of 3 distal posterior tibial vascular pedicles was directly connected to this medial subunit. These pedicles were present in all 18 cadaver legs. We observed complete opacification of the 6 MHS muscles through distal pedicles. Radiography revealed opacification of a vascular path from 1 distal pedicle to 1 proximal vascular pedicle of the MHS muscle. The mean level of this main distal pedicle was 14.5 cm to the tip of the medial malleolus. The level was at 38.2%, on average, from the bottom of the entire tibia. CONCLUSIONS: The distally based MHS muscle flap has constant blood supply, so it could be a useful flap to repair soft-tissue defects of the lower third of the leg. Moreover, knowledge of the average location of the main distal pedicle can help in increasing the use of the distally based MHS flap.

Are There Still Any Benefits to Drainage for Anterior Cervical Arthrodesis/Arthroplasty by Cervicotomy?

STUDY DESIGN: A retrospective single-center study between January 2019 and January 2023. OBJECTIVE: The role and contribution of drainage in the anterior approach to the cervical spine (cervicotomy) is much debated, motivated primarily by the prevention of retropharyngeal hematoma, so are there still any benefits to drainage? BACKGROUND: The anterior approach to the cervical spine is a widespread and common procedure performed in almost all spine surgery departments for the replacement of cervical intervertebral discs and medullar or radicular decompression. The primary endpoint was the occurrence of symptomatic postoperative cervical hematoma. PATIENTS AND METHODS: Four hundred thirty-one patients who had undergone cervical spine surgery by anterior cervicotomy for cervicarthrosis or cervical disc herniation (anterior cervical discectomy and fusion and anterior cervical disc replacement) were consecutively included. Patients were separated into 2 groups: (1) Group A, 140 patients (with postoperative drainage) and (2) Group B, 291 patients (without drainage). RESULTS: The mean follow-up was 2.8 months. The 2 groups were comparable on all criteria, but there was a predominance of arthroplasty ( P < 0.0001), use of anticoagulants/antiaggregants ( P < 0.0001) and a greater number of stages ( P < 0.0001) in group A. There were a total of 4/431 symptomatic postoperative hematomas (0.92%) in this study. Two hematomas occurred in group A (2/140, 1.4%) and 2 in group B (2/291, 0.68%; P < 0.0001). One patient in group A (0.71%) required surgical drainage for cavity hematoma revealed by marked dyspnea, swallowing, and neurological disorders. One case of hematoma diagnosed by dysphonia and neurological deficit was reported in group B (0.34%; P < 0.0001). CONCLUSIONS: The placement of a drain during anterior cervicotomy (anterior cervical discectomy and fusion/anterior cervical disc replacement) did not limit the occurrence of symptomatic postoperative hematoma.

Surgical management of herniated intervertebral disc in children: Running title: Pediatric disc herniation.

STUDY DESIGN: Retrospective literature review analysis OBJECTIVE: Analyze the risk factors, characteristics, outcome, and follow up of surgical management of disc herniation in children ≤15 years old (y.o) through a review of the literature. BACKGROUND: Disc herniation is a rare disease in the pediatric population. While conservative treatment if very often tried, some cases require surgical treatment. METHODS: A literature search was conducted using PubMed data base using the terms 'pediatric/children/adolescent disc herniation' and 'surgical management' as key words. Significant manuscripts i.e: case reports, case series, reviews were identified and analyzed. The exclusion criteria were: series and cases with patients >15 y.o, results non-individualizable and medical management. RESULTS: 49 studies were identified, 28 were retained. 69 children <15 y.o were identified with a median age of 13 y.o (SD 1-15). The mean FU was 3.3 years. Trauma and repeated micro traumatism were identified as the main causes of disc herniation in this population. It is mostly a lumbar disease, with very anecdotic cases of thoracic or cervical herniation described. In the absence of neurological deficit, conservative treatment should be tried. Different types of surgery exist (open, endoscopic, tubular), with no difference in outcome or complications. The post-operative outcome was very satisfactory, with no neurological sequalae described with excellent recovery. CONCLUSIONS: Pediatric disc herniation is often caused by precipitating factors such as trauma. In the absence of resolution with conservative treatment, surgical options yield favorable short term clinical outcomes with minimal complications and no neurological sequalae.

Impact of metastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fracture (pVCF) in neurological and survival prognosis.

BACKGROUND: Metastatic epidural spinal cord compression (MESCC) and pathological vertebral compression fractures (pVCF) are the most serious debilitating morbidities of spine metastases (SpMs) causing devastating neurological damages. The respective impact of these two metastasis-spreading entities on survival and on neurological damage is debated. METHODS: A French prospective cohort study collected 279 consecutive patients presenting with SpMs between January 2017 and 2021. We compared 174 patients with MESCC and 105 patients with pVCF. RESULTS: The median Overall Survival (OS) for the MESCC group was 13.4 months (SD 1.5) vs 19.2 months (SD 2.3) for pVCF patients (p = 0.085). Sixty-five patients (23.3 %) were operated on: 49/65 (75.4 %) in the MESCC group and 16/65 (15.2 %) in the pVCF group, p < 0.0001. At 6 months FU, in the MESCC group, 21/44 (45.4 %) of non-ambulatory patients at onset improved to ambulatory status (Frankel D-E) vs 10/13 (76.9 %) in the pVCF group (p = 0.007). In multivariable analysis with the Cox proportional hazard model, good ECOG-PS and SINS Score 7-12 [HR: 6.755, 95 % CI 2.40-19.00; p = 0.001] were good prognostic factors for preserved ambulatory neurological status. However, SpMs diagnosed synchronously with the primary tumor [HR: 0.397, 95 % CI 0.185-0.853; p = 0.018] and MESCC [HR: 0.058, 95 % CI 0.107-0.456; p = 0.007] were independent risk factors for impaired neurological function. CONCLUSION: Contrary to pVCF, MESCC causes neurological damage. Nevertheless, neurological recovery remains possible. MESCC and pVCF have no impact on survival. The management of MESCC remains to be clarified and optimized to reduce neurological damage.

Bilateral spheno-orbital meningiomas: surgical management, progression, and recurrence.

OBJECTIVE: Bilateral spheno-orbital meningiomas (bSOMs) are a rare entity among meningiomas. These tumors are benign and predominantly affect women. They represent 4% of spheno-orbital meningiomas (SOMs) and are poorly described in the literature. This study aimed to describe the characteristics, risk factors, evolution, and management of bSOMs. METHODS: Twenty patients with bSOMs were enrolled in a multicentric descriptive study including 15 neurosurgical departments. RESULTS: In this study, the authors found that bSOMs affected exclusively women, with a mean age of 50 years. Approximately 65% of patients were on progestin therapy. The mean follow-up in this series was 55 months. Clinically, visual symptoms were predominant: proptosis was present in 17 of 20 patients (85%; 7 unilateral, 10 bilateral), and a decrease in visual acuity was observed in 11 of 20 patients (55%; 6/10 to 9/10 in 6 patients, 3/10 to 5/10 in 1 patient, and < 3/10 in 4 patients). Contrary to unilateral SOMs, the authors identified that intracranial hypertension was a common presentation (25%) of bSOMs. Surgical management with gross-total resection was the gold standard treatment. Recurrences only occurred following subtotal resection in 36% to 60% of patients, with a median time of 50 to 54 months after surgery. Visual improvement or stability was observed in 75% of cases postoperatively. Progesterone receptor expression levels were 70% to 100% in 10 of 11 (91%) cases. CONCLUSIONS: Bilateral SOMs are usually found in female patients and are strongly associated with hormone replacement therapy. Early surgical management with gross-total resection is the most effective treatment in terms of recurrence and improves visual acuity. Given the slow progressive nature of bSOMs and their time to recurrence, which can be up to 10 years, long-term follow-up of patients is essential.

Internal carotid artery dissection after anterior cervical disc replacement: first case report and literature review of vascular complications of the approach.

We report the case of a 41-year-old woman who underwent cervical total disc replacement at C4C5 and C5C6 levels and fusion at C6C7 level through an anterior right-side approach. After anesthesia recovery, the patient presented left hemiparesia and facial palsy due to large right hemispheric stroke. Diffusion-weighted magnetic resonance imaging was performed as soon as the patient developed neurologic symptoms of stroke and revealed a right internal carotid artery dissection. Digital substraction angiography, endovascular stenting, angioplasty and thrombectomy were performed. Six months after treatment, clinical examination showed mild left-arm spasticity. To the best of our knowledge, only two cases of internal carotid artery stroke without dissection or thrombosis are reported. In conclusion, although vascular complications are rare after anterior cervical spine procedure, internal carotid artery dissection can occur. Suspected risk factors are prolonged retraction of the carotid artery and neck extension.

Spine Metastasis: Patients With Poor Performance Status (ECOG) Could benefit From Palliative Surgical Care! A Prospective Cohort Study.

STUDY DESIGN: This study used a French prospective national multi-center database of patients with spine metastasis (SpM). OBJECTIVE: The main challenge was to clarify if SpM patients presenting poor ECOG-PS could benefit from a surgical intervention. BACKGROUND: Spine metastases (SpM) are debilitating lesions commonly found in the evolution of cancer. At present, patients with poor ECOG-PS do not benefit from surgical care. MATERIALS AND METHODS: Between 2014 and 2017, 176 SpM patients with poor initial ECOG-PS (3 or 4) were identified. RESULTS: The median overall survival of patients was 2.1 months (SD 0.2). Seventy-one patients (40.3%) underwent surgery: for 49 patients (27.8%) the intervention consisted of a simple decompression and for 22 patients (12.5%) the previous was associated with an osteosynthesis. Patients who underwent surgery demonstrated significantly longer median overall survival than those who did not: 3.5 months (SD 0.4) versus 1.6 (SD 0.2) ( P <0.0001). No significant differences between operated/nonoperated patients were noted concerning median age (66.4 vs. 64.2 y, P =0.897), the median number of SpM (4.1 vs. 4.2, P =0.374), ECOG-PS 4 ratio (41.6 vs. 39.3%, P =0.616), or for primary tumors ( P =0.103). Patients who underwent surgery statistically improved their neurological impairment according to the Frankel score: 5/11 (45.4%) from A to C, 5/17 (29.4%) from B to C or D, 6/11 (54.5%) from C to D and 2/4 (50%). Twelve patients (16.9%) presented a postoperative complication. CONCLUSION: Patients with poor ECOG-PS could benefit from surgery. Even though survival gain is small, it permits the preservation of their neurological function. By making ambulation possible, pain is decreased during the last months of their lives.

Spinal lesions in multiple myeloma: Primary bone tumors with distinct prognostic factors.

PURPOSE: Although prognostic factors of spinal multiple myeloma (MM) seem to differ from those of other spine metastases (SpM), the data in the literature remains scarce. METHODS: A prospective population of 361 patients treated for spine MM lesions between January 2014 and 2017. RESULTS: OS for our series was 59.6 months (SD 6.0 months; CI 95%: 47.7-71.3). Cox multivariate proportional-hazards analysis showed that bone marrow transplant [HR: 0.390, 95% CI 0.264-0.577; p < 0.0001] and light-chain isotype [HR: 0.748, 95% CI 0.318-1.759; p = 0.005] were independent predictors of longer survival. In contrast, age >80 years [HR: 2.7, 95% CI 1.6-4.3; p < 0.0001], ISS III [HR: 2.510, 95% CI 2.01-3.124; p = 0.001], IgA isotype [HR: 1.475, 95% CI 1.031-2.11; p = 0.034] and IgD/M isotype [HR: 2.753, 95% CI 1.230-6.130; p = 0.013] were independent poor prognostic factors. However, ECOG (p = 0.486), spine surgery (p = 0.391), spine radiotherapy (p = 0.260), epidural involvement (p = 0.259), the number of vertebra lesions (p = 0.222), and synchronous/metachronous timeline (p = 0.412) were not significantly associated with improved OS. CONCLUSIONS: Spinal involvement in the context of MM does not influence OS. The main prognostic factors to consider before spinal surgery are the characteristics of the primary MM disease (ISS score, IgG isotype and systemic treatment).

Multiple Myeloma Spinal Lesion Care: Management of a Primary Bone Malignancy Rather Than a Spinal Metastasis.

OBJECTIVE: Multiple myeloma (MM) is too often wrongly categorized as a spinal metastasis (SpM), although it is distinguishable from SpM in many aspects, such as its earlier natural history at the time of diagnosis, its increased overall survival (OS), and its response to therapeutic modalities. The characterization of these 2 different spine lesions remains a main challenge. METHODS: This study compares 2 consecutive prospective oncologic populations of patients with spine lesions: 361 patients treated for MM spine lesions and 660 patients treated for SpM between January 2014 and 2017. RESULTS: The mean time between the tumor/MM diagnosis and spine lesions was respectively 0.3 (standard deviation [SD] 4.1) and 35.1 months (SD 21.2) for the MM and SpM groups. The median OS for the MM group was 59.6 months (SD 6.0) versus 13.5 months (SD 1.3) for the SpM group (P < 0.0001). Regardless of Eastern Cooperative Oncology Group (ECOG) performance status, patients with MM always have a significantly better median OS than do patients with SpM: ECOG 0, 75.3 versus 38.7 months; ECOG 1, 74.3 versus 24.7 months; ECOG 2, 34.6 versus 8.1 months; ECOG 3, 13.5 versus 3.2 months and ECOG 4, 7.3 versus 1.3 months (P < 0.0001). The patients with MM had more diffuse spinal involvement (mean, 7.8 lesions; SD 4.7) than did patients with SpM (mean, 3.9; SD 3.5) (P < 0.0001). CONCLUSIONS: MM must be considered as a primary bone tumor, not as SpM. The strategic position of the spine in the natural course of cancer (i.e., nurturing cradle of birth for MM vs. systemic metastases spreading for SpM) explains the differences in OS and outcome.

Natural Course and Prognosis of Primary Spinal Glioblastoma: A Nationwide Study.

BACKGROUND AND OBJECTIVES: Primary spinal glioblastoma (PsGBM) is extremely rare. The dramatic neurologic deterioration and unresectability of PsGBM makes it a particularly disabling malignant neoplasm. Because it is a rare and heterogeneous disease, the assessment of prognostic factors remains limited. METHODS: PsGBMs were identified from the French Brain Tumor Database and the Club de Neuro-Oncologie of the Société Française de Neurochirurgie retrospectively. Inclusion criteria were age 18 years or older at diagnosis, spinal location, histopathologic diagnosis of newly glioblastoma according to the 2016 World Health Organization classification, and surgical management between 2004 and 2016. Diagnosis was confirmed by a centralized neuropathologic review. The primary outcome was overall survival (OS). Therapeutic interventions and neurologic outcomes were also collected. RESULTS: Thirty-three patients with a histopathologically confirmed PsGBM (median age 50.9 years) were included (27 centers). The median OS was 13.1 months (range 2.5-23.7), and the median progression-free survival was 5.9 months (range 1.6-10.2). In multivariable analyses using Cox model, Eastern Cooperative Oncology Group (ECOG) performance status at 0-1 was the only independent predictor of longer OS (hazard ratio [HR] 0.13, 95% CI 0.02-0.801; p = 0.02), whereas a Karnofsky performance status (KPS) score <60 (HR 2.89, 95% CI 1.05-7.92; p = 0.03) and a cervical anatomical location (HR 4.14, 95% CI 1.32-12.98; p = 0.01) were independent predictors of shorter OS. The ambulatory status (Frankel D-E) (HR 0.38, 95% CI 0.07-1.985; p = 0.250) was not an independent prognostic factor, while the concomitant standard radiochemotherapy with temozolomide (Stupp protocol) (HR 0.35, 95% CI 0.118-1.05; p = 0.06) was at the limit of significance. DISCUSSION: Preoperative ECOG performance status, KPS score, and the location are independent predictors of OS of PsGBMs in adults. Further analyses are required to capture the survival benefit of concomitant standard radiochemotherapy with temozolomide.

The trigeminal pathways.

The role of the trigeminal system in facial and dural sensitivity has been recognized for a long time. More recently, the trigeminal system has also been considered a prominent actor in brain nociceptive innervation. It is the anatomical substrate of several frequent conditions, such as primary or secondary headaches, trigeminal neuralgia, and other orofacial pains. Appreciation of the delicate anatomical arrangement of the trigeminal pathway is one of the keys to understanding these conditions' pathophysiology and to proposing innovative treatments. This review provides a structured presentation of existing knowledge about the trigeminal system, from classical anatomical data to the most recent literature. First, we present the organization of the trigeminal pathway from the trigeminal divisions, nerve, and nuclei to the thalamus and somatosensory cortex. We describe the neurons and fibers' repartition at each level, depending on the location (somatotopic organization) and the type of receptors (modal organization). Such a dual somatotopic-modal arrangement of the trigeminal fibers is especially clear for the juxtapontine segment of the trigeminal nerve and the trigeminal nuclei of the brainstem. It has significant clinical consequences both for diagnosis and treatment. Second, we explore how the trigeminal system is modulated and involved in reflexes, for instance the trigemino-cardiac and the trigemino-autonomic reflexes, which could play an essential role in the autonomic symptoms observed in cluster headache. Finally, we present how to interact with this complex system to relieve pain mediated by the trigeminal system. This section covers both neuromodulatory and lesional approaches.