From data to practice: brain meningioma treatment in elderly patients - a survey of the Italian Society of Neurosurgery (SINch®) and systematic review and meta-analysis.

The management of meningioma in elderly patients (MEP) presents a complex and evolving challenge. Data available offer conflicting information on treatment options and complications. This survey aimed to examine the current approach to MEP, comparing the national profile to data in the current literature. A survey addressing the treatments options and management of meningioma in elderly was designed on behalf of SINch® (Società Italiana di Neurochirurgia) and sent via email to all Chiefs of Neurosurgical Departments. The survey remained open for responses from May 5th, 2022, until November 21st, 2022. A search of the literature published between January 2000 and March 2023, in accordance to PRISMA guidelines, was included. A total of 51 Neurosurgical centers participated in the survey. The caseload profile of each center influences the choice of treatment selection (Stereotactic Radiosurgery versus open surgery) (p = 0.01) and the consolidated practice of discussing cases within a multidisciplinary group (p = 0.02). The pooled meta-analysis demonstrated a significant increased risk in the elderly group for permanent deficits (p < 0.00001), postoperative infections (p = 0.0004) and hemorrhage (p = 0.0001), perioperative mortality (p < 0.00001), and medical complications (p < 0.00001) as compared to the young population. This study presents the initial comprehensive analysis of the existing trends in the surgical management of MEP in Italy. The significant variation in practices primarily stems from the absence of standardized guidelines. While most centers have adopted an integrated approach, there is a need to promote a multidisciplinary care model. Prospective studies are needed to gather robust evidence in this clinical setting.

Predictive Factors of Long-Term Neurologic Outcome and Progression-Free Survival in Intramedullary Spinal Cord Tumors: A 10-year Single-Center Cohort Study and Review of the Literature.

BACKGROUND: Intramedullary spinal cord tumors (IMSCTs) are a rare subgroup of neoplasms, encompassing both benign, slow-growing masses, and malignant lesions; radical surgical excision represents the cornerstone of treatment for such pathologies regardless of histopathology, which, on the other hand, is a known predictor of survival and neurologic outcome postsurgery. The present study aims to investigate the relevance of other factors in predicting survival and long-term functional outcomes. METHODS: We conducted a review of current literature on functional outcomes of IMSCTs, as well as a 10-years prospective analysis of a wide cohort of patients with diagnosis of IMSCTs who underwent surgical resection at our institution. RESULTS: Our series encompasses 60 patients with IMSCTS, among which 36 ependymomas, 6 cavernous angiomas, 5 hemangioblastomas, 6 WHO Grade I-IV astrocytomas, 3 intramedullary spinal metastases and 4 miscellaneous tumors. GTR was achieved in 76,67% of patients, with high preoperative McCormick grade, syringomyelia and changes at neurophysiologic monitoring being the strongest predictors at multivariate analysis (P = 0.0027, P = 0.0017 and P = 0.001 respectively). CONCLUSIONS: Consistently with literature, preoperative neurologic function is the most important factor predicting long-term functional outcome (0.17, CI 0.069-0.57 with P = 0.0018), advocating for early surgery in the management of IMSCTs, whereas late complications such as myelopathy and neuropathic pain were present regardless of preoperative function.

Proposal of a new score system (Cervical Surgical Score) for management of degenerative cervical myelopathy.

BACKGROUND: To date, no shared algorithms with the aim of guiding surgical strategy in complex cases of degenerative cervical myelopathy (DCM) exist. Our purpose is to present the Cervical Surgical Score (CSS) which could help in identifying complex DCM cases, suggesting a surgical strategy. METHODS: We created the CSS based on multidisciplinary and literature-focused discussions, based on eight parameters including number of levels of cervical pathology and myelopathy, type and predominance of compression and grade of clinical myelopathy. We prospectively enrolled surgical DCM patients in a 15-months period, collecting clinical and radiological data. During outpatient clinic a specific surgical indication was offered to DCM patients. To validate the score, each outpatient clinic surgical indication was compared a posteriori to the one that resulted from multidisciplinary CSS scoring, focusing on patients for which both an anterior and posterior approach were considered suitable. RESULTS: A total of 100 patients operated on for DCM at our Institution between December 2021 and February 2023 were prospectively enrolled. In 53% of patients the pathology was present at more than two levels. According to CSS calculation, 14% of patients resulted in the "grey zone", where both an anterior and posterior approach were deemed feasible. Among them, in 42.8% of cases the CSS allowed a modification of the originally planned surgery. Looking at outcome, an improvement of m-JOA score in 62% of patients was disclosed. CONCLUSIONS: This preliminary study showed the reliability and usefulness of CSS in detecting complex DCM cases, requiring further analysis by expert spine surgeons, suggesting a surgical strategy.

Aggressive giant dumbell-shaped thoracic vertebral hemangioma: illustrative case.

BACKGROUND: Vertebral hemangioma is the most common benign tumor of the spine, diagnosed incidentally in most cases. In 0.4% of patients, the lesion is considered aggressive, causing neurological deficits. This subtype of hemangioma is characterized by strong postcontrast enhancement, cortical lysis, and epidural extension causing myelopathy and/or radiculopathy. OBSERVATIONS: A 52-year-old man presented with myelopathy symptoms, namely lower-limb hypoesthesia up to the T4-5 sensory level, right leg hyposthenia, and urinary incontinence. Imaging studies revealed a giant dumbbell-shaped lesion causing spinal cord compression, associated with signal alteration of the T3 vertebral body. The diagnosis of schwannoma was not certain given the radiological features, so a biopsy was planned and confirmed the diagnosis of vertebral hemangioma. Preoperative embolization, spinal fusion, and gross-total resection of the extravertebral component of the lesion were performed. LESSONS: This report should raise awareness of the differential diagnosis of dumbbell-shaped spinal tumors and the therapeutic strategies available for aggressive vertebral hemangiomas, a rare lesion that should be managed in a multidisciplinary setting. https://thejns.org/doi/10.3171/CASE24190.

Monocentric Retrospective Analysis of Clinical Outcomes, Complications, and Adjacent Segment Disease in 507 Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Myelopathy.

BACKGROUND: Degenerative cervical myelopathy (DCM) is a leading cause of nontraumatic spinal cord injury. Surgery aims to arrest neurological decline and improve conditions, but controversies surround risks and benefits in elderly patients, outcomes in mild myelopathy, and the risk of adjacent segment disease (ASD). METHODS: Retrospective data of patients who underwent anterior cervical discectomy and fusion for DCM in our hospital were collected. Patients were stratified by preoperative modified Japanese Orthopaedic Association (mJOA) (mild, moderate, severe) and age (under 70, over 70). Clinical outcomes, complications, and ASD rate were analyzed. We evaluated the relationship between mJOA recovery rate and the risk of complications and various preoperative parameters. RESULTS: Five hundred seven consecutive patients were included in the study, with a mean follow-up of 43.52 months (12-71). Improvement in all outcome variables was observed in mild, moderate, and severe myelopathy categories, with elderly patients showing a lower improvement. Except for age, no other variable correlated with mJOA recovery rate. We observed 45 complications (11.1% of patients), with 14 in the U70 group and 31 in the O70 group (P value < 0.001). Age, Charlson comorbidity index, and ASA score were found to be predictors of complications. Fourteen patients (2.8% of total), mean age 54.2, developed radiological and clinical ASD. Most had cranial-level ASD with Pfirmann grade ≥ 2 before index surgery. CONCLUSIONS: Most myelopathic patients improve after anterior cervical discectomy and fusion. Elderly patients show a lower improvement and higher complication rates than their younger counterparts. ASD rates are low, and younger patients with preexisting cranial level alterations are more susceptible.

Multimodal Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumors: A 10-Year Single Center Experience.

OBJECTIVE: The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. METHODS: Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. RESULTS: Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). CONCLUSION: The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.

Vertebroplastia e cifoplastia: técnicas complementares para o tratamento da fratura vertebral osteoporótica dolorosa tipo compressão / Vertebroplastia y cifoplastia: técnicas complementarias para el tratamiento de la fractura vertebral osteoporótica dolorosa tipo compresión / Vertebroplasty and kyphoplasty: complementary tecniques for the treatment of painful osteoporotic vertebral compression fractures

In a prospective study, we aimed to evaluate the potential use of kyphoplasty (KP) and vertebroplasty (VP) as complementary techniques in the treatment of painful osteoporotic vertebral compression fractures (VCFs). METHODS: after one month of conservative treatment for VCFs, patients with intractable pain were offered treatment with KP or VP according to a treatment algorithm that considers time from fracture (Ãt) and amount of Vertebral Body Collapse (VBC). Bone biopsy was obtained intraoperatively to exclude patients affected by malignancy or osteomalacia. RESULTS: hundred and sixty-four patients were included according to the above criteria. Mean age was 67.6 years. Mean followup was 33 months. Ten patients (6.1 percent) were lost to follow-up and 154 reached the minimum two years follow-up. 118 (69.5 percent) underwent VP and 36 (30.5 percent) underwent KP. Complications affected five patients treated with VP, whose one suffered a transient intercostal neuropathy and four a subsequent VCF (two at adjacent level). Results in terms of VAS and Oswestry scores were not different among treatment groups. CONCLUSION: in conclusion, at an average follow-up of almost 3 years from surgical treatment of osteoporotic VCFs, VP and KP show similar good clinical outcomes and appear to be complementary techniques with specific different indications.

Estudo prospectivo para avaliar a utilização da cifoplastia e vertebroplastia como técnicas complementares para o tratamento das fraturas osteoporóticas tipo compressão. MÉTODOS: após um mês de tratamento conservador, os pacientes com fratura osteoporótica do tipo compressão e com dor intratável, foram submetidos à cifoplastia ou vertebroplastia de acordo com algoritmo que considera o tempo da fratura e a quantidade do colapso do corpo vertebral. Biópsia óssea foi obtida no intra-operatório para excluir os pacientes com tumor ou osteomalácia. RESULTADOS: cento e trinta e quatro pacientes foram incluídos de acordo com os critérios do estudo. A média de idade foi 67,7 anos. O seguimento médio foi 33 meses. Dez pacientes não foram seguidos e 154 atingiram um seguimento mínimo de dois; 118 pacientes (69,5 por cento) foram submetidos à vertebroplastia e 36 (30,5 por cento) à cifoplastia. Ocorreram complicações em cinco pacientse tratados por verebroplastia, sendo que um paciente apresentou neuropatia intercostal transitória e quatro pacientes fratura por compressão, tendo ocorrido na vértebra adjacente em dois pacientes. Não foi observada diferença nos escores da avaliação da dor e do questionário de Oswestry. CONCLUSÃO: após um seguimento médio de três anos foram observados resultados satisfatórios com a utilização da vertebroplastia ou cifoplastia para o tratamento das fraturas osteoporóticas por compressão. Ambas as técnicas mostraram bons resultados, de acordo com a sua indicação específica.

Estudio prospectivo para evaluar la utilización de la cifoplastia y vertebroplastia como técnicas complementarias para el tratamiento de las fracturas osteoporóticas tipo compresión. MÉTODOS: después de 1 mes de tratamiento conservador, los pacientes con fractura osteoporótica del tipo compresión y de haber presentado un dolor intratable, los pacientes fueron sometidos a la cifoplastia o vertebroplastia de acuerdo con el algoritmo que considera el tiempo de la fractura y la cantidad del colapso del cuerpo vertebral. Biopsia ósea fue obtenida en el intraoperatorio para excluir los pacientes con tumor u osteomalacia. RESULTADOS: ciento treinta y cuatro pacientes fueron incluidos de acuerdo con los criterios del estudio. El promedio de edad fue 67.7 años. El seguimiento promedio fue de 33 meses. Diez pacientes no fueron seguidos y 154 llegaron a un seguimiento mínimo de dos. 118 pacientes (69.5 por ciento) fueron sometidos a la vertebroplastia y 36 (30.5 por ciento) a la cifoplastia. Complicaciones ocurrieron en cinco pacientes tratados por vertebroplastia, siendo que un paciente presentó neuropatía intercostal transitoria y cuatro pacientes una fractura por compresión en la vértebra adyacente. No fue observada diferencia entre los índices de la evaluación del dolor y del cuestionario de Oswestry. CONCLUSIÓN: después del seguimiento promedio de tres años fueron observados resultados satisfactorios con la utilización de la vertebroplastia o cifoplastia para el tratamiento de las fracturas osteoporóticas por compresión. Ambas técnicas mostraron buenos resultados de acuerdo con su indicación específica.