Synchronous versus metachronous spinal metastasis: a comparative study of survival outcomes following neurosurgical treatment.

PURPOSE: Patients with spinal metastases (SM) from solid neoplasms typically exhibit progression to an advanced cancer stage. Such metastases can either develop concurrently with an existing cancer diagnosis (termed metachronous SM) or emerge as the initial indication of an undiagnosed malignancy (referred to as synchronous SM). The present study investigates the prognostic implications of synchronous compared to metachronous SM following surgical resection. METHODS: From 2015 to 2020, a total of 211 individuals underwent surgical intervention for SM at our neuro-oncology facility. We conducted a survival analysis starting from the date of the neurosurgical procedure, comparing those diagnosed with synchronous SM against those with metachronous SM. RESULTS: The predominant primary tumor types included lung cancer (23%), prostate cancer (21%), and breast cancer (11.3%). Of the participants, 97 (46%) had synchronous SM, while 114 (54%) had metachronous SM. The median overall survival post-surgery for those with synchronous SM was 13.5 months (95% confidence interval (CI) 6.1-15.8) compared to 13 months (95% CI 7.7-14.2) for those with metachronous SM (p = 0.74). CONCLUSIONS: Our findings suggest that the timing of SM diagnosis (synchronous versus metachronous) does not significantly affect survival outcomes following neurosurgical treatment for SM. These results support the consideration of neurosurgical procedures regardless of the temporal pattern of SM manifestation.

Image Guided Intraoperative Radiation Therapy After Surgical Resection of Brain Metastases: A First In-Human Feasibility Report.

Purpose: A correct placement of the applicator during intraoperative radiation therapy for brain metastasis is of paramount importance, to deliver a precise and safe treatment. The applicator-to-surface contact assessment cannot be performed under direct observation because the applicator itself limits the visual range. No image guided verification is currently performed intracranially. We hypothesize that image guided intraoperative radiation therapy would assure a more precise delivery in the target area. We describe our workflow in a first in-human experience. Methods and Materials: Phantom-based measurements were performed to reach the best cone beam computed tomography imaging quality possible. Once defined, a clinical feasibility study was initiated. An in-room cone beam computed tomography device is used to acquire intraoperative images after placing the applicator. Repositioning the applicator is thereafter discussed with the surgeon, according to the imaging outcomes, if required. Results: An optimal image quality was achieved with 120-kV voltage, 20-mA current, and a tube current time product of 150 mAs. An additional 0.51 mSv patient exposure was calculated for the entire procedure. The wide dynamic range (-600 HU to +600 HU) of cone beam computed tomography and a 27 HU mean computed tomography values difference between brain tissue and spherical applicator allows distinguishing both structures. In this first in-human experience, the applicator was repositioned after evidencing air gaps, assuring full applicator-to-surface contact. Conclusions: This first in-human procedure confirmed the feasibility of kilovoltage image guided intraoperative radiation therapy in a neurosurgical setting. A prospective study has been initiated and will provide further dosimetric details.

Functional outcome after late cranioplasty after decompressive craniectomy: a single-center retrospective study.

OBJECTIVE: The best time for cranioplasty (CP) after decompressive craniectomy (DC) is controversial, and there are no authoritative guidelines yet. Both complications as well as outcome may depend on the timing of CP. The aim of this single-center study was to evaluate the impact of late CP on procedural safety as well as on patient outcome. METHODS: All patients receiving CP at a tertiary university medical center between 01/2015 and 12/2022 were included retrospectively. Patients' conditions were assessed according to the modified Rankin Scale (mRS) prior to CP and 6 months after. Baseline characteristics, indication for DC, time from DC to CP, and postoperative complications according to the Landriel Ibañez Classification were analyzed. RESULTS: CP was performed in 271 patients who previously underwent DC due to traumatic brain injury (25.5%), ischemic stroke (29.5%), aneurysmal subarachnoid hemorrhage (26.9%), or intracerebral hemorrhage (18.1%). The median interval between DC and CP was 143 days (interquartile range 112-184 days). Receiver operating characteristic analysis revealed a cut-off of 149 days, where CP performed within 149 days after DC led to an improvement on mRS after CP (p = 0.001). In multivariate analysis, additional rehabilitation after and better mRS before CP were independently associated with improvement of outcome. The rate of complications was similar between early and late CP (24.8% and 25.4%, respectively, p = 0.562). CONCLUSIONS: Late cranioplasty is a safe procedure. The outcome was improved when additional rehabilitation was performed after cranioplasty and was not associated with the timing of cranioplasty.

Correlation between Blood Type 0 and Risk of Chronic Subdural Hematoma Recurrence: A Single Center Retrospective Cohort Study.

Chronic subdural hematoma (cSDH) is a common disease in the neurological and neurosurgical world. The recommended treatment for cSDH patients with moderate or severe neurological symptoms is surgical evacuation, but cSDH frequently recurs. The patient's ABO blood type may influence the outcome. This study aims to evaluate the correlation between cSDH recurrence and blood type O. We performed a retrospective analysis of the data of patients with cSDH who were surgically treated. Recurrence was defined as the need for re-operation within the first 12 weeks after the initial surgery. We analyzed standard demographic data, duration and type of surgery, ABO blood types, and the re-operation rate. Univariate and multivariate analyses were conducted. A total of 229 patients were included. The recurrence of hematoma was identified in 20.5% of patients. Blood type O was found to be significantly associated with cSDH recurrence leading to re-operation within 12 weeks (p = 0.02, OR 1.9, 95% CI 1.1-3.5). Thrombocyte aggregation inhibition and oral anticoagulants were not predictors of cSDH recurrence. Patients with blood type O in our cohort were identified to be at higher risk of cSDH recurrence and may, therefore, be a more vulnerable patient group. This finding needs further evaluation in larger cohorts.

Postoperative prolonged mechanical ventilation in patients with surgically treated pyogenic spondylodiscitis: a surrogate endpoint for early postoperative mortality.

Surgical procedures with spinal instrumentation constitute a prevalent and occasionally highly indicated treatment modality in patients with pyogenic spondylodiscitis (PSD). However, surgical therapy might be associated with the need of prolonged postoperative intensive care medicine which in turn might impair intended operative benefit. Therefore, we analyzed prolonged mechanical ventilation (PMV) as an indicator variable for such intensive care treatment with regard to potential correlations with mortality in this vulnerable patient cohort. Between 2012 and 2018, 177 consecutive patients received stabilization surgery for PSD at the authors' neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 h. A multivariable analysis was performed to identify independent predictors for 30-day mortality. Twenty-three out of 177 patients (13%) with PSD suffered from postoperative PMV. Thirty-day mortality rate was 5%. Multivariable analysis identified "spinal empyema" (p = 0.02, odds ratio (OR) 6.2, 95% confidence interval (CI) 1.3-30.2), "Charlson comorbidity index (CCI) > 2" (p = 0.04, OR 4.0, 95% CI 1.0-15.5), "early postoperative complications (PSIs)" (p = 0.001, OR 17.1, 95% CI 3.1-96.0) and "PMV > 24 hrs" (p = 0.002, OR 13.0, 95% CI 2.7-63.8) as significant and independent predictors for early postoperative mortality. The present study indicates PMV to significantly correlate to elevated early postoperative mortality rates following stabilization surgery for PSD. These results might entail further scientific efforts to investigate PMV as a so far underestimated negative prognostic factor in the surgical treatment of PSD.

Early fusion outcome after surgical treatment of single-level and multi-level pyogenic spondylodiscitis: experience at a level 1 center for spinal surgery-a single center cohort study.

STUDY DESIGN: Retrospective single center cohort study. PURPOSE: Spinal instrumentation in combination with antibiotic therapy is a treatment option for acute or chronic pyogenic spondylodiscitis (PSD). This study compares the early fusion outcome for multi-level and single-level PSD after urgent surgical treatment with interbody fusion in combination with fixation. METHODS: This is a retrospective cohort study. Over a 10 year period at a single institution, all surgically treated patients received surgical debridement, fusion und fixation of the spine to treat PSD. Multi-level cases were either adjacent to each other on the spine or distant. Fusion rates were assessed at 3 and 12 months after surgery. We analyzed demographic data, ASA status, duration of surgery, location and length of spine affected, Charlson comorbidity index (CCI), and early complications. RESULTS: A total of 172 patients were included. Of these, 114 patients suffered from single-level and 58 from multi-level PSD. The most frequent location was the lumbar spine (54.0%) followed by the thoracic spine (18.0%). The PSD was adjacent in 19.0% and distant in 81.0% of multi-level cases. Fusion rates at the 3 month follow-up did not differ among the multi-level group (p = 0.27 for both adjacent and distant sites). In the single-level group, sufficient fusion was achieved in 70.2% of cases. Pathogen identification was possible 58.5% of the time. CONCLUSIONS: Surgical treatment of multi-level PSD is a safe option. Our study demonstrates that there was no significant difference in early fusion outcomes between single-level and multi-level PSD, whether adjacent or distant.

Pain management with epidural catheter and epidural analgesia after spinal dorsal instrumentation of lumbar spine.

Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery (P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.

Bipolar Lumbar Radiofrequency Medial Branch Neurotomy in a Patient with Deep Brain Stimulation Implant.

Chronic axial lower back pain is one of the most common conditions that patients seek medical attention for in pain practices. About 15 to 40% of axial lower back pain is due to facet-mediated pain. Diagnostic blocks of the medial branch reliably identify the facet joint as the pain generator and offer a prognostic factor for response to radiofrequency neurotomy of the identified facet joints resulting in profound pain relief. However, deep brain stimulation implants have been considered a contraindication for neurotomy. We present an illustrative case of a patient with deep brain stimulation system treated with bipolar medial branch neurotomy using a two-needle technique.

Impact of patient nationality on the severity of early side effects after radiotherapy.

BACKGROUND: Major demographical changes in Germany commenced in the 1960s. Ongoing humanitarian crises in the Ukraine with subsequent immigration will have also long-range effects on national provision of cancer treatment. Ensuring the best possible outcomes for each cancer patient undergoing radiotherapy requires the prediction and prevention of unfavorable side effects. Given that recent research has primarily focused on clinical outcome indicators solely, less is known regarding sociodemographic predictors of therapeutic outcomes, such as patient nationality. Here, we investigated whether the severity of early side effects after radiotherapy are associated with patient nationality and other sociodemographic and clinical characteristics. METHODS: Out of 9187 patients treated at a German university medical center between 2017 and 2021, 178 German and 178 non-German patients were selected for matched-pair analysis based on diagnostic and demographic criteria. For all 356 patients, data on side effects from follow-up care after radiotherapy were collected. RESULTS: Non-German patients were more likely to have severe side effects than German patients. Side effect severity was also associated with tumor entity, concomitant therapy, body mass index, and age. CONCLUSION: Foreign cancer patients are at higher risk of experiencing severe side effects of radiotherapy, suggesting a need to develop and implement targeted preventive measures for these patients. Further research investigating factors predicting the occurrence of radiotherapy side effects, including other sociodemographic characteristics, is needed to better personalize therapy regimens for cancer.

Postoperative prolonged mechanical ventilation correlates to poor survival in patients with surgically treated spinal metastasis.

Objective: Patients with spinal metastasis (SM) are at advanced stages of systemic cancer disease. Surgical therapy for SM is a common treatment modality enabling histopathological diagnosis and the prevention of severe neurological deficits. However, surgery for SM in this vulnerable patient cohort may require prolonged postoperative intensive care treatment, which could adversely affect the anticipated benefit of the surgery. We therefore assessed postoperative prolonged mechanical ventilation (PMV) as an indicator for intensive care treatment with regard to potential correlations with early postoperative mortality and overall survival (OS). Methods: Between 2015 and 2019, 198 patients were surgically treated for SM at the author´s neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 hours. A multivariate analysis was performed to identify pre- and perioperative collectable predictors for 30 days mortality. Results: Twenty out of 198 patients (10%) with SM suffered from postoperative PMV. Patients with PMV exhibited a median OS rate of 1 month compared to 12 months for patients without PMV (p < 0.0001). The 30 days mortality was 70% and after one year 100%. The multivariate analysis identified "PMV > 24 hrs" (p < 0.001, OR 0.3, 95% CI 0.02-0.4) as the only significant and independent predictor for 30 days mortality (Nagelkerke's R2 0.38). Conclusions: Our data indicate postoperative PMV to significantly correlate to high early postoperative mortality rates as well as to poor OS in patients with surgically treated SM. These findings might encourage the initiation of further multicenter studies to comprehensively investigate PMV as a so far underestimated negative prognostic factor in the course of surgical treatment for SM.

Patient Safety Comparison of Frameless and Frame-Based Stereotactic Navigation for Brain Biopsy-A Single Center Cohort Study.

Leksell stereotactic system-based aspiration biopsy is a common procedure in the neurosurgical treatment of deep-seated or multiple brain lesions. This study aimed to evaluate the benefit of frameless biopsy using VarioGuide compared to frame-based biopsy using the Leksell stereotactic system (LSS). We analyzed all brain biopsies using VarioGuide or LSS at our neurooncological Department of Neurosurgery in the University Hospital of Bonn between January 2018 and August 2020. We analyzed demographic data, duration of surgery, size of lesion, localization, and early complications. Uni-variable analyses were carried out on data from both groups. In total, 109 biopsies were compared (40 VarioGuide vs. 69 LSS). Patients with VarioGuide were significant older (74 (62−80) years vs. 67 (57−76) years; p = 0.03) and had a shorter duration of general anesthesia (163 (138−194) min vs. 193 (167−215) min, p < 0.001). We found no significant differences in surgery duration (VarioGuide median 28 min (IQR 20−38); LSS: median 30 min (IQR 25−39); p = 0.1352) or in early complication rates (5% vs. 7%; p = 0.644). A slightly higher false negative biopsy rate was registered in the LSS group (3 vs. 1; p = 0.1347). The size of the lesions also did not differ significantly between the two groups (18.31 ± 26.35 cm3 vs. 12.63 ± 14.62; p = 0.15). Our data showed that biopsies performed using VarioGuide took significantly less time than LSS biopsies and did not differ in complication rates. Both systems offered a high degree of patient safety.

Safety Evaluation of Cervical Dorsal Instrumentation in Geriatric Patients: Experience at a Level 1 Center for Spinal Surgery-A Single Center Cohort Study.

Objective: Dorsal instrumentation of the cervical spine is an established treatment in spine surgery. However, careful planning is required, particularly in elderly patients. This study evaluates early clinical outcomes in geriatric patients undergoing complex spine surgery. Methods: In this retrospective, single center cohort study, we included all geriatric patients (aged ≥65 years) who underwent dorsal instrumentation between January 2013 and December 2020. We analyzed postoperative complications and the 30-day in-hospital mortality rate. Furthermore, the Charlson comorbidity index (CCI) and Clavien-Dindo grading system (CDG) were used to assess the patients' comorbidity burden. Results: In total, 153 patients were identified and included. The mean age of patients was 78 years (SD ± 7). Traumatic injury (53.6%) was the most common reason for surgery. 60.8% of the patients underwent dorsal instrumentation with 3 or more levels. The most common comorbidities were arterial hypertension (64%), diabetes mellitus (22.2%), coronary heart disease and atrial fibrillation (19.6%). The most common adverse event (AE) was pneumonia (4%) and the most common surgery-related complication was wound infection (5.2%). Among patients categorized as high risk for AE (CCI > 5), 14.6% suffered a postoperative AE. In our univariate analysis, we found no risk factors for high rates of complications or mortality. Conclusion: Our data demonstrates that older patients were at no significant risk of postoperative complications. The CCI/CDG scores may identify patients at higher risk for adverse events after dorsal instrumentation, and these assessments should become an essential component of stratification in this older patient population.

Predictors of postoperative long-term seizure outcome in pediatric patients with focal cortical dysplasia type II at a German tertiary epilepsy center.

OBJECTIVE: Focal cortical dysplasia (FCD) is a common cause of early-onset intractable epilepsy, and resection is a highly sufficient treatment option. In this study, the authors aimed to provide a retrospective analysis of pre- and postoperative factors and their impact on postoperative long-term seizure outcome. METHODS: The postoperative seizure outcomes of 50 patients with a mean age of 8 ± 4.49 years and histologically proven FCD type II were retrospectively analyzed. Furthermore, pre- and postoperative predictors of long-term seizure freedom were assessed. The seizure outcome was evaluated based on the International League Against Epilepsy (ILAE) classification. RESULTS: Complete resection of FCD according to MRI criteria was achieved in 74% (n = 37) of patients. ILAE class 1 at the last follow-up was achieved in 76% (n = 38) of patients. A reduction of antiepileptic drugs (AEDs) to monotherapy or complete withdrawal was achieved in 60% (n = 30) of patients. Twelve patients (24%) had a late seizure recurrence, 50% (n = 6) of which occurred after reduction of AEDs. A lower number of AEDs prior to surgery significantly predicted a favorable seizure outcome (p = 0.013, HR 7.63). Furthermore, younger age at the time of surgery, shorter duration of epilepsy prior to surgery, and complete resection were positive predictors for long-term seizure freedom. CONCLUSIONS: The duration of epilepsy, completeness of resection, number of AEDs prior to surgery, and younger age at the time of surgery served as predictors of postoperative long-term seizure outcome, and, as such, may improve clinical practice when selecting and counseling appropriate candidates for resective epilepsy surgery. The study results also underscored that epilepsy surgery should be considered early in the disease course of pediatric patients with FCD type II.

Use of halo fixation therapy for traumatic cranio-cervical instability in children: a systematic review.

PURPOSE: Traumatic cranio-cervical instability in childhood is rare and constitutes a challenge for the treating surgeon. The aim of therapy is to restore cervical stability without limiting the range of motion. The goal of this systematic review was to find out whether, over the last 10 years, halo fixation (HF) could still be considered a successful treatment option without major risks or complications. METHODS: We analyzed studies describing the use of HF in traumatic injuries of the cranio-cervical junction in children under the age of 17. Searches were performed in PubMed, MEDLINE and Embase databases for the years from 2010 to 2020. The general success rate, the success rate related to underlying pathologies, and complication rates were evaluated. RESULTS: The main indications for HF range from pre-surgical correction to postoperative fusion support. C2 is the most frequently injured vertebra in children. The overall success rate of HF was very high. Evaluation according to the underlying pathology showed that, except for atlanto-occipital dislocation, HF generates high fusion rates among different patient cohorts, mainly in C2 vertebra injuries and atlantoaxial rotatory subluxation. Only minor complications were reported, such as pin infections. CONCLUSION: The current data show that, when used according to the appropriate indication, HF is an effective conservative treatment option for cranio-cervical instability, associated with only minor complications.

Indications for early revision surgery for material failure in spinal instrumentation: experience at a level 1 center for spinal surgery - a single-center study.

ABSTRACT: Posterior instrumentation is an established treatment for a range of spinal disorders. Material failure is not uncommon, and the indications for a revision are very heterogeneous. This study aimed to evaluate the indications and timing for early revision spinal surgery due to material failure.In this retrospective, single-center cohort study, patients underwent spinal posterior instrumentation between January 2017 and July 2019. They were followed up at 3, 12, and 18 months postoperatively. The time of onset of material failure which led to revision surgery was analyzed. In addition, the relationship between the indications for revision surgery and independent variables was examined using a multivariate logistic regression model.A total of one hundred thirty-five patients were enrolled. Radiolucent zones were found in 30 patients (20%) after 3 months, whereas 48 patients (31%) had radiolucent zones after 12 months. Revision surgery was performed in 13 patients (8.5%). The peak time for revision due to instability was within the first four months of the primary surgery. Multivariate analysis revealed that location, pathology, ASA score, and smoking had no significant impact on the indication for revision surgery, and neither did BMI (P = .042). Non-fusion (P = .007) and radiolucent zones (P = .004), in combination with increased pain (P = .006), were predictors for revision.Our data show that the peak time for early revision of material failure after posterior instrumentation was within the first 4 months of primary surgery. The abnormalities (e.g., radiolucent zones) surrounding the screws without fusion, including persistence of pain, were predictors for revision surgery.

Can Postoperative CT Imaging in Spine Surgery Be Replaced by Intraoperative 3D Rotation With the C-Arm?: Results of a Prospective Single Center Cohort Study.

Objective: Dorsal instrumentation of the spine is an established treatment option for a range of spinal pathologies. Intraoperative fluoroscopy connected with navigation minimize the risk of incorrect screws placement. In several cases, post-operative CT scans are needed to verify possible mismatches. In this study, we evaluated the efficacy of 3D intraoperative fluoroscopy as compared to post-operative CT and the need of post-operative CT. Methods: We conducted a prospective single-center cohort study, 94 patients were included. The screws were implanted using 3D rotation with C-arm and navigation system. The definitive position of the screws was verified by a post-operative CT scan. Finally, we compared the discrepance between intraoperative imaging and post-operative CT scan using Rampersaud-grade (A-D). Results: 607 screws in 94 patients were included. Some 3% of the screws had to be replaced immediately intraoperative due to inadequate position with lateral or medial trajectory. An A-score was achieved for 85.5% of the 3D controlled screws and 87% of the post-operative CT. A B-score was found in 11.5% of either groups. In the 3D group a C-score was achieved for 2.5% and in the CT group for 0.8%. A D-score was found in 0.5% of the screws in both groups, p = 0.45. Only a mismatch of 3% could be detected for the intraoperative and post-operative imaging results. Conclusion: Our study data shows that the placement of screws using the 3D rotation and navigation tool is safe and accurate. There were no relevant mismatches between intraoperative images and the post-operative CT.

Age at Diagnosis and Baseline Myelomalacia Sign Predict Functional Outcome After Spinal Meningioma Surgery.

Objective: Spinal meningioma (SM) accounts for 12% of all meningiomas. Clinical and immunohistochemical factors were analyzed with regard to functional outcome, surgical adverse events, and tumor recurrence. Methods: One-hundred and twenty-three consecutive SM patients underwent surgery and were retrospectively reviewed with regard to demographic parameters, imaging features, neurological function, and immunohistochemical items. Neurological function was graded according to the Modified McCormick Scale (MMS) and dichotomized as "good (grade I + II)" and "poor (grade III-V)" function. Results: One-hundred and fourteen (92.7%) WHO grade I and 9 (7.3%) WHO grade II SM were included in this study. Univariate analysis identified a baseline T2 hyperintensity of the spinal cord, baseline symptom duration ≥4 weeks, age ≥66 years, and dural tail sign as predictors of poor MMS. Baseline T2 hyperintensity of the spinal cord [Odds ratio (OR) = 13.3, 95% CI = 3.4-52.1, p < 0.001] and age ≥66 years (OR = 10.3, 95% CI = 2.6-41.1, p = 0.001) were independent predictors of a poor MMS grade at discharge after SM surgery in the multivariate binary logistic regression analysis. The 12- and 24-month recurrence-free survival rates were 98.7 % (1/80) and 94.7% (2/38), respectively. In those patients with tumor recurrence of the SM, highly increased MIB-1 (≥5%) labeling indices were observed. Conclusion: Baseline T2 hyperintensity, especially in the elderly patients, is a strong predictor of poorer recovery after spinal meningioma surgery. SMs with high proliferative activity should be followed-up closely despite maximal safe resection.

The Role of Intraoperative Image Guidance Systems (Three-Dimensional C-arm versus O-arm) in Spinal Surgery: Results of a Single-Center Study.

OBJECTIVE: Spinal dorsal instrumentation is an established treatment option for a range of spinal disorders. In combination with navigation, intraoperative fluoroscopy reduces the risk of incorrectly placing screws. This study aimed to evaluate the efficacy and validity of fluoroscopy (intraoperative navigation with three-dimensional rotation of C-arm vs. O-arm). METHODS: In this retrospective single-center study, 240 patients were included between July 2017 and April 2020. Intraoperative images were acquired using a Siemens-Arcadis Orbic 3D C-arm with a navigation system (Brainlab, AG, Munich, Germany) or using O-arm (Medtronic, Minneapolis, Minnesota, USA) with a navigation system (S7 StealthStation). Finally, we compared mismatches between intraoperative and postoperative computed tomography imaging results using Rampersaud-grade (A-D). RESULTS: A total of 1614 screws were included: 94 patients in the C-arm group (cAG) and 146 in the O-arm group (oAG). In cAG, 3% (n = 20) of the screws had to be replaced directly due to inadequate positioning with median or lateral breaches, and 3.5 % of screws in oAG (n = 35). An A-score was achieved for 85.7% in the cAG and 87.4% in the oAG. A B-score was found in 11.5% in the cAG and 11.9% in the oAG. In the cAG, a C-score was achieved for 2.5% and in oAG for 0.7%. For 0.3% of the screws, a D-score was found in cAG and for none in oAG. CONCLUSIONS: Our study shows that placement of screws using intraoperative imaging in combination with a navigation tool is accurate. Furthermore, navigation coupled with the O-arm had significant advantages in accuracy over navigation with 3D C-arm fluoroscopy. However, both systems offer a high level of accuracy.

Antithrombotic Therapy in Spinal Surgery Does Not Impact Patient Safety-A Single Center Cohort Study.

OBJECTIVE: Antithrombotic therapy is common in older patients to avoid thromboembolic events. Careful planning is required, particularly in the perioperative environment. There are no clearly date guidelines on the best timing for interrupting the use of anticoagulation in the case of spinal surgery. This study evaluates early per procedural clinical outcomes in patients whose antithrombotic therapy was interrupted for spinal surgery. METHODS: This is a retrospective cohort study. All patients who underwent dorsal instrumentation from January 1, 2019 to December 31, 2020 were included. In group A, vitamin K antagonists (VKA) were suspended for 5 days and direct oral anticoagulants (DOAC) for 3 days. In group B, antiplatelet agents (APA) were paused for at least 7 days before surgery to prevent perioperative bleeding. Patients not taking anticoagulation medication were gathered into control group C. We analyzed demographic data, ASA status, blood loss, comorbidities, duration of surgery, blood transfusion, length of hospital stay, complications, thromboembolism, and 30 day in-hospital mortality. Multivariate analyses from the three groups were further analyzed and conducted. RESULTS: A total of 217 patients were operated and included. Twenty-eight patients taking VKA/DOAC (group A), 37 patients using APA (group B), and 152 patients without anticoagulation (group C) underwent spinal surgery. Those using anticoagulants were significantly older and often with multimorbidity, but did not differ significantly in procedural bleeding, time of surgery, length of hospital stay, complication rate, thromboembolism, or 30 day in-hospital mortality (p > 0.05). CONCLUSION: Our data show that dorsal instrumentation safely took place in patients whose antithrombotic therapy was interrupted.

The earlier the better? Bevacizumab in the treatment of recurrent MGMT-non-methylated glioblastoma.

PURPOSE: The adequate second-line therapy of patients with glioblastoma (GBM) is a matter of ongoing debate. This particularly applies to patients with a non-methylated MGMT promotor who are known to have a poor response to alkylating chemotherapy. In some countries, antiangiogenic therapy with BEV is applied as second-line therapy, and in others nitrosourea therapy is second-line choice. It is an open question whether the delay of BEV to third-line therapy has a negative impact on survival. METHODS: A total of 61 adult patients (median age 56.9 years) with MGMT-non-methylated relapsed GBM treated with BEV (n = 45) or nitrosourea (n = 16) as second-line therapy were analyzed retrospectively and compared regarding progression-free survival (PFS) and overall survival (OS). RESULTS: Patients treated with second-line BEV had longer median PFS (107 days, 95 % CI 80.7-133.2 days) than patients with second-line nitrosourea (52 days, 95 % CI 36.3-67.7 days, P = 0.011, logrank test). However, there was no significant difference in overall survival (BEV median 170 days, 95 % CI 87.2-252.8 days; nitrosourea median 256 days, 95 % CI 159.9-352.0 days, P = 0.468). PFS was similar after BEV third-line therapy (median 117 days, 95 % CI 23.6-210.4 days) as compared to second-line BEV therapy (median 107 days, 95 % CI 80.7-133.3 days, P = 0.584). CONCLUSION: Our findings suggest that early treatment with BEV in patients with MGMT-non-methylated relapsed GBM is associated with a better PFS, but not with superior OS, possibly implicating that the early, i.e., second-line, use of BEV is not mandatory and BEV treatment may safely be delayed to third-line therapy in this subgroup of patients.