Spinal Intradural Tumor Resection via Long-Segment Approaches and Clinical Long-Term Follow-Up.

INTRODUCTION: Spinal intradural tumors account for 15% of all CNS tumors. Typical tumor entities include ependymomas, astrocytomas, meningiomas, and neurinomas. In cases of multiple affected segments, extensive approaches may be necessary to achieve the gold standard of complete tumor resection. METHODS: We performed a bicentric, retrospective cohort study of all patients equal to or older than 14 years who underwent multi-segment surgical treatment for spinal intradural tumors between 2007 and 2023 with approaches longer than four segments without instrumentation. We assessed the surgical technique and the clinical outcome regarding signs of symptomatic spinal instability. Children were excluded from our cohort. RESULTS: In total, we analyzed 33 patients with a median age of 44 years and interquartile range IQR of 30-56 years, including the following tumors: 21 ependymomas, one subependymoma-ependymoma mixed tumor, two meningiomas, two astrocytomas, and seven patients with other entities. The median length of the approach was five spinal segments with a range of 4-14 and with the foremost localization in the cervical or thoracic spine. Laminoplasty was the most chosen approach (72.2%). The median time to follow-up was 13 months IQR (4-56 months). Comparing pre- and post-surgery outcomes, 72.2% of the patients (n = 24) reported pain improvement after surgery. The median modified McCormick scores pre- and post surgery were equal to II IQR (I-II) and II IQR (I-III), respectively. DISCUSSION: We achieved satisfying results with long-segment approaches. In general, patients reported pain improvement after surgery and received similar low modified McCormick scores pre- and post surgery and did not undergo secondary dorsal fixation. Thus, we conclude that intradural tumor resection via extensive approaches does not seem to impair long-term spinal stability in our cohort.

Sex-dependent characteristics and outcomes after clipping of unruptured intracranial aneurysms: a multicenter propensity score-matched study.

OBJECTIVE: Disparities in the epidemiology and growth rates of aneurysms between the sexes are known. However, little is known about sex-dependent outcomes after microsurgical clipping of unruptured intracranial aneurysms (UIAs). The aim of this study was to examine sex differences in characteristics and outcomes after microsurgical clipping of UIAs and to perform a propensity score-matched analysis using an international multicenter cohort. METHODS: This retrospective cohort study involved the participation of 15 centers spanning four continents. It included adult patients who underwent clipping of UIAs between January 2016 and December 2020. Patients were stratified according to their sex and analyzed for differences in morbidities and aneurysm characteristics. Based on this stratification, female patients were matched to male patients in a 1:1 ratio with a caliper width of 0.1 using propensity score matching. Endpoints included postoperative complications, neurological performance, and aneurysm occlusion at discharge and 24 months after clip placement. RESULTS: A total of 2245 patients with a mean age of 57.3 (range 20-87) years were included. Of these patients, 1675 (74.6%) were female. Female patients were significantly older (mean 57.6 vs 56.4 years, p = 0.03) but had fewer comorbidities. Aneurysms of the internal carotid artery (7.1% vs 4.2%), posterior communicating artery (6.9% vs 1.9%), and ophthalmic artery (6.0% vs 2.8%) were more commonly treated surgically in females, while clipping of aneurysms of the anterior communicating artery was more frequent in males (17.0% vs 25.3%; all p < 0.001). After propensity score matching, female patients were found to have had significantly fewer pulmonary complications (1.4% vs 4.2%, p = 0.01). However, general morbidity (24.5% vs 25.2%, p = 0.72) and mortality (0.5% vs 1.1%, p = 0.34), as well as neurological performance (p = 0.58), were comparable at discharge in both sexes. Lastly, rates of aneurysm occlusion at the time of discharge (95.5% vs 94.9%, p = 0.71) and 24 months after surgery (93.8% vs 96.1%, p = 0.22) did not significantly differ between male and female patients. CONCLUSIONS: Despite overall differences between male and female patients in demographics, comorbidities, and treated aneurysm location, sex did not relevantly affect surgical performance or perioperative complication rates.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes.

BACKGROUND AND OBJECTIVES: Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. METHODS: Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. RESULTS: Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. CONCLUSION: Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases.

BACKGROUND AND OBJECTIVES: Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS: A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS: Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION: This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.

Evaluating a cutting-edge augmented reality-supported navigation system for spinal instrumentation.

OBJECTIVE: Dorsal instrumentation using pedicle screws is a standard treatment for multiple spinal pathologies, such as trauma, infection, or degenerative indications. Intraoperative three-dimensional (3D) imaging and navigated pedicle screw placement are used at multiple centers. For the present study, we evaluated a new navigation system enabling augmented reality (AR)-supported pedicle screw placement while integrating navigation cameras into the reference array and drill guide. The present study aimed to evaluate its clinical application regarding safety, efficacy, and accuracy. METHODS: A total of 20 patients were operated on between 06/2021 and 01/2022 using the new technique for intraoperative navigation. Intraoperative data with a focus on accuracy and patient safety, including patient outcome, were analyzed. The accuracy of pedicle screw placement was evaluated by intraoperative CT imaging. RESULTS: A median of 8 (4-18) pedicle screws were placed in each case. Percutaneous instrumentation was performed in 14 patients (70%). The duration of pedicle screw placement (duration scan-scan) was 56 ± 26 (30-107) min. Intraoperative screw revision was necessary for 3 of 180 pedicle screws (1.7%). Intraoperatively, no major complications occurred-one case of delay due to software issues and one case of difficult screw placement were reported. CONCLUSION: The current study's results could confirm the use of the present AR-supported system for navigated pedicle screw placement for dorsal instrumentation in clinical routine. It provides a reliable and safe tool for 3D imaging-based pedicle screw placement, only requires a minimal intraoperative setup, and provides new opportunities by integrating AR.

In-Hospital Mortality from Spondylodiscitis: Insights from a Single-Center Retrospective Study.

(1) Background: There is a marked proportion of spondylodiscitis patients who die during the early stage of the disease despite the applied therapy. This study investigates this early mortality and explores the associated risk factors. (2) Methods: We conducted a retrospective analysis of spondylodiscitis patients treated at our Level I spine center between 1 January 2018 and 31 December 2022. (3) Results: Among 430 patients, 32 (7.4%) died during their hospital stay, with a median time of 28.5 days (range: 2.0-84.0 days). Six of these patients (18.75%) did not undergo surgery due to dire clinical conditions or death prior to scheduled surgery. Identified causes of in-hospital death included multiorgan failure (n = 15), acute bone marrow failure (2), cardiac failure (4), liver failure (2), acute respiratory failure (2), acute renal failure (1), and concomitant oncological disease (1). In a simple logistic regression analysis, advanced age (p = 0.0006), diabetes mellitus (p = 0.0002), previous steroid medication (p = 0.0279), Charlson Comorbidity Index (p < 0.0001), and GFR level at admission (p = 0.0008) were significant risk factors for in-hospital death. In a multiple logistic regression analysis, advanced age (p = 0.0038), diabetes mellitus (p = 0.0002), and previous steroid medication (p = 0.0281) remained significant. (4) Conclusions: Despite immediate treatment, a subset of spondylodiscitis patients experience early mortality. Particular attention should be given to elderly patients and those with diabetes or a history of steroid medication, as they face an elevated risk of a rapidly progressing and fatal disease.

Risk identification for the development of large-artery vasospasm after aneurysmatic subarachnoid hemorrhage - a multivariate, risk-, and location-adjusted prediction model.

BACKGROUND: Vasospasm of the large cerebral arteries (CVS) after aneurysmatic subarachnoid hemorrhage (aSAH) reduces cerebral perfusion and causes delayed cerebral ischemia. Although endovascular spasmolysis shows convincing angiographic results, patients often do not improve in outcome. Delayed recognition of CVS contributes substantially to this effect. Therefore, this study aimed to confirm established and to identify unknown risk factors for CVS, which can be used for risk stratification. METHODS: In this monocentric, retrospective cohort study of 853 patients with aSAH, we compared demographics, clinical, and radiographic parameters at the time of aneurysm occlusion between patients who developed CVS and those who did not. Significant cohort differences were included as predictors in a multivariate analysis to address confounding. Logistic regression models were used to determine odds ratios (ORs) for the presence of CVS for each predictor. RESULTS: Of the 853 patients treated with aSAH, 304 (32%) developed CVS. In the univariable analysis, CVS was significantly associated with young age, female sex, aneurysm location, modified Fisher score, Barrow Neurological Institute (BNI) score, and surgical interventions. In the multivariable regression analysis, we identified BNI score (OR 1.33, 95% CI 1.11 to 1.58, p=0.002), decompressive craniectomy (OR 1.93, 95% CI 1.22 to 3.04, p=0.005), and aneurysm clipping (OR 2.22, 95% CI 1.50 to 3.29, p<0.001), as independent risk factors. CONCLUSIONS: Young female patients with high BNI scores who undergo surgical interventions are more likely to develop CVS and should therefore be monitored most intensively after aneurysm occlusion.

Improving tractography in brainstem cavernoma patients by distortion correction.

Introduction: The resection of brainstem cerebral cavernous malformations (CCM) harbors the risk of damaging the corticospinal tract (CST) and other major tracts. Hence, visualization of eloquent fiber tracts supports pre- and intraoperative planning. However, diffusion tensor imaging fiber tracking at brainstem level suffers from distortion due to field inhomogeneities and eddy currents by steep diffusion gradients. Research question: This study aims to analyze the effect of distortion correction for CST tractography in brainstem CCM patients. Material and methods: 25 patients who underwent resection of brainstem CCM were enrolled, 24 suffered from hemorrhage. We performed an anatomically based tractography of the CST with a mean minimal fractional anisotropy of 0.22 ± 0.04 before and after cranial distortion correction (CDC). Accuracy was measured by anatomical plausibility and aberrant fibers. Results: CDC led to a more precise CST tractography, further approximating its assumed anatomical localization in all cases. CDC resulted in a significantly more ventral location of the CST of 1.5 ± 0.6 mm (6.1 ± 2.7 mm before CDC vs. 4.6 ± 2.1 mm after CDC; p < .0001) as measured by the distance to the basilar artery and of 1.7 ± 0.6 mm (8.9 ± 2.7 mm vs. 7.2 ± 2.1 mm; p < .0001) in relation to the clivus. Aberrant fibers were reduced by CDC in 44% of cases. We found a mean difference in CST volume of 0.6 ± 0.8 ccm. We could not detect motor deficits after resection of irregular fibers. Discussion and conclusion: CDC effectively corrects tractography for distortion at brainstem level, especially in patients suffering from brainstem CCM, further approximating its actual anatomical localization.

Neurological Outcome and Respiratory Insufficiency in Intramedullary Tumors of the Upper Cervical Spine.

Background and Objectives: Intramedullary spinal cord tumors (IMSCT) are rare entities. A location in the upper cervical spine as a highly eloquent region carries the risk of postoperative neurological deficits, such as tetraparesis or respiratory dysfunction. Evidence for respiratory dysfunction is scarce. This study aimed to describe these highly eloquent tumors' early and late postoperative clinical course. Materials and Methods: This is a single-center retrospective cohort study. We included 35 patients with IMSCT at levels of the craniocervical junction to C4 who underwent surgical treatment between 2008 and 2022. The authors analyzed the patients' preoperative status, tumor- and surgery-specific characteristics, and follow-up functional status. Results: The study cohort included twenty-two patients with grade II ependymoma (62.9%), two low-grade astrocytomas (5.7%), two glioblastomas (5.7%), six hemangioblastomas (17.1%), two metastases (5.7%), and one patient with partially intramedullary schwannoma (2.9%). Gross total resection was achieved in 76% of patients. Early dorsal column-related symptoms (gait ataxia and sensory loss) and motor deterioration occurred in 64% and 44% of patients. At a follow-up of 3.27 ± 3.83 years, 43% and 33% of patients still exhibited postoperative sensory and motor deterioration, respectively. The median McCormick Scale grade was 2 in the preoperative and late postoperative periods, respectively. Only three patients (8.6%) developed respiratory dysfunction, of whom, two patients, both with malignant IMSCT, required prolonged invasive ventilation. Conclusions: More than 60% of the patients with IMSCT in the upper cervical cord developed new neurological deficits in the immediate postoperative period, and more than 40% are permanent. However, these deficits are not disabling in most cases since most patients maintain functional independence as observed by unchanged low McCormick scores. The rate of respiratory insufficiency is relatively low and seems to be influenced by the rapid neurological deterioration in high-grade tumors.

Cost-effectiveness of opportunistic QCT-based osteoporosis screening for the prediction of incident vertebral fractures.

Objectives: Opportunistic quantitative computed tomography (oQCT) derived from non-dedicated routine CT has demonstrated high accuracy in diagnosing osteoporosis and predicting incident vertebral fractures (VFs). We aimed to investigate the cost-effectiveness of oQCT screening compared to dual-energy X-ray absorptiometry (DXA) as the standard of care for osteoporosis screening. Methods: Three screening strategies ("no osteoporosis screening", "oQCT screening", and "DXA screening") after routine CT were simulated in a state-transition model for hypothetical cohorts of 1,000 patients (women and men aged 65 years) over a follow-up period of 5 years (base case). The primary outcomes were the cumulative costs and the quality-adjusted life years (QALYs) estimated from a U.S. health care perspective for the year 2022. Cost-effectiveness was assessed based on a willingness-to-pay (WTP) threshold of $70,249 per QALY. The secondary outcome was the number of prevented VFs. Deterministic and probabilistic sensitivity analyses were conducted to test the models' robustness. Results: Compared to DXA screening, oQCT screening increased QALYs in both sexes (additional 2.40 per 1,000 women and 1.44 per 1,000 men) and resulted in total costs of $3,199,016 and $950,359 vs. $3,262,934 and $933,077 for women and men, respectively. As a secondary outcome, oQCT screening prevented 2.6 and 2.0 additional VFs per 1,000 women and men, respectively. In the probabilistic sensitivity analysis, oQCT screening remained cost-effective in 88.3% (women) and 90.0% (men) of iterations. Conclusion: oQCT screening is a cost-effective ancillary approach for osteoporosis screening and has the potential to prevent a substantial number of VFs if considered in daily clinical practice.

The role of extended coagulation screening in adult cranial neurosurgery.

Introduction: Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality. Research question: We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage. Methods: A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage. Results: The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p â€‹= â€‹.546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p â€‹= â€‹.023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p â€‹= â€‹.034). Differences in mean intraoperative blood loss were not significant with 528 â€‹ml in the study cohort and 486 â€‹ml in the control cohort (p â€‹= â€‹.376). Conclusion: Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.

Predictive value of IOM in clipping of unruptured intracranial aneurysms - A prospective study from the surgeon's point of view.

Introduction: Intraoperative neuromonitoring (IOM) of motor/somatosensory evoked potentials is a well-established approach for reducing ischemic complications after aneurysm clipping. Research question: To determine the predictive validity of IOM for postoperative functional outcome and its perceived added value for intraoperative real-time feedback of functional impairment in the surgical treatment of unruptured intracranial aneurysms (UIAs). Material and methods: Prospective study of patients scheduled for elective clipping of UIAs between 02/2019-02/2021. Transcranial motor evoked potentials (tcMEP) were used in all cases, a significant decline was defined as loss of ≥50% in amplitude or 50% latency increase. Clinical data were correlated to postoperative deficits. A surgeon's questionnaire was conceived. Results: 47 patients were included, median age 57 years (range 26-76). IOM was successful in all cases. In 87.2%, IOM was stable throughout surgery, although 1 patient (2.4%) demonstrated a permanent postoperative neurological deficit. All patients with an intraoperatively reversible tcMEP-decline (12.7%) showed no surgery-related deficit, regardless of the decline duration (range 0.5-40.0 â€‹min; mean: 13.8). Temporary clipping (TC) was performed in 12 cases (25.5%), with a decline in amplitude in 4 patients. After clip-removal, all amplitudes returned to baseline. IOM provided the surgeon with a higher sense of security in 63.8%. Discussion and conclusion: IOM remains invaluable during elective microsurgical clipping, particularly during TC of MCA and AcomA-aneurysms. It alerts the surgeon of impending ischemic injury and offers a way of maximizing the time frame for TC. IOM has highly increased surgeons' subjective feeling of security during the procedure.

Preoperative angiographic considerations and neurological outcome after surgical treatment of intradural spinal hemangioblastoma: a multicenter retrospective case series.

PURPOSE: Intradural spinal hemangioblastomas are rare highly hypervascularized benign neoplasms. Surgical resection remains the treatment of choice, with a significant risk of postoperative neurological deterioration. Due to the tumor infrequency, scientific evidence is scarce and limited to case reports and small case series. METHODS: We performed a retrospective multicenter study including five high-volume neurosurgical centers analyzing patients surgically treated for spinal hemangioblastomas between 2006 and 2021. We assessed clinical status, surgical data, preoperative angiograms, and embolization when available. Follow-up records were analyzed, and logistic regression performed to assess possible risk factors for neurological deterioration. RESULTS: We included 60 patients in Germany and Austria. Preoperative angiography was performed in 30% of the cases; 10% of the patients underwent preoperative embolization. Posterior tumor location and presence of a syrinx favored gross total tumor resection (93.8% vs. 83.3% and 97.1% vs. 84%). Preoperative embolization was not associated with postoperative worsening. The clinical outcome revealed a transient postoperative neurological deterioration in 38.3%, depending on symptom duration and preoperative modified McCormick grading, but patients recovered in most cases until follow-up. CONCLUSION: Spinal hemangioblastoma patients significantly benefit from early surgical treatment with only transient postoperative deterioration and complete recovery until follow-up. The performance of preoperative angiograms remains subject to center disparities.

CFR-PEEK Pedicle Screw Instrumentation for Spinal Neoplasms: A Single Center Experience on Safety and Efficacy.

(1) Background: Surgery for spinal metastases has gained a decisive role in modern oncological treatment. Recently, carbon-fiber-reinforced (CFR) polyethyl-ether-ether-ketone (PEEK) pedicle screw systems were introduced, reducing artifacts on imaging and showing less perturbation effects on photon radiation. Preliminary clinical experience with CFR-PEEK implants for spinal metastases exists. The aim of this monocentric study is to report on the safety and efficacy of CFR-PEEK pedicle screw systems for spinal neoplasms in a large cohort of consecutive patients. (2) Methods: We retrospectively analyzed prospectively the collected data of consecutive patients being operated on from 1 August 2015 to 31 October 2021 using a CFR-PEEK pedicle screw system for posterior stabilization because of spinal metastases or primary bone tumors of the spine. (3) Results: We included 321 patients of a mean age of 65 ± 13 years. On average, 5 ± 2 levels were instrumented. Anterior reconstruction was performed in 121 (37.7%) patients. Intraoperative complications were documented in 30 (9.3%) patients. Revision surgery for postoperative complications was necessary in 55 (17.1%) patients. Implant-related complications, such as intraoperative screw breakage (3.4%) and screw loosening (2.2%), were rare. (4) Conclusions: CFR-PEEK is a safe and efficient alternative to titanium for oncological spinal instrumentation, with low complication and revision rates in routine use and with the advantage of its radiolucency.

Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation.

Introduction: Adverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error. Research question: To determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error. Material and methods: Prospective observation of all adverse events occurring at an academic neurosurgery referral center focusing on neuro-oncology, cerebrovascular and spinal surgery. All 4176 inpatients treated between September 2019 and September 2020 were included. Adverse events were recorded daily and their nature, severity and a potential contribution of human error were evaluated weekly by all senior neurosurgeons of the department. Results: 25.0% of patients had at least one adverse event. In 25.9% of these cases, the major adverse event was associated with human error, mostly with execution (18.3%) or planning (5.6%) deficiencies. 48.8% of cases with adverse events were severe (≥SAVES-v2 grade 3). Patients with multiple adverse events (8.6%) had more severe adverse events (67.6%). Adverse events were more severe in cranial than in spinal neurosurgery (57.6 vs. 39.4%). Discussion and conclusion: Adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms.The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm.

Level-Specific Volumetric BMD Threshold Values for the Prediction of Incident Vertebral Fractures Using Opportunistic QCT: A Case-Control Study.

Purpose: To establish and evaluate the diagnostic accuracy of volumetric bone mineral density (vBMD) threshold values at different spinal levels, derived from opportunistic quantitative computed tomography (QCT), for the prediction of incident vertebral fractures (VF). Materials and Methods: In this case-control study, 35 incident VF cases (23 women, 12 men; mean age: 67 years) and 70 sex- and age-matched controls were included, based on routine multi detector CT (MDCT) scans of the thoracolumbar spine. Trabecular vBMD was measured from routine baseline CT scans of the thoracolumbar spine using an automated pipeline including vertebral segmentation, asynchronous calibration for HU-to-vBMD conversion, and correction of intravenous contrast medium (https://anduin.bonescreen.de). Threshold values at T1-L5 were calculated for the optimal operating point according to the Youden index and for fixed sensitivities (60 - 85%) in receiver operating characteristic (ROC) curves. Results: vBMD at each single level of the thoracolumbar spine was significantly associated with incident VFs (odds ratio per SD decrease [OR], 95% confidence interval [CI] at T1-T4: 3.28, 1.66-6.49; at T5-T8: 3.28, 1.72-6.26; at T9-T12: 3.37, 1.78-6.36; and at L1-L4: 3.98, 1.97-8.06), independent of adjustment for age, sex, and prevalent VF. AUC showed no significant difference between vertebral levels and was highest at the thoracolumbar junction (AUC = 0.75, 95%-CI = 0.63 - 0.85 for T11-L2). Optimal threshold values increased from lumbar (L1-L4: 52.0 mg/cm³) to upper thoracic spine (T1-T4: 69.3 mg/cm³). At T11-L2, T12-L3 and L1-L4, a threshold of 80.0 mg/cm³ showed sensitivities of 85 - 88%, and specificities of 41 - 49%. To achieve comparable sensitivity (85%) at more superior spinal levels, resulting thresholds were higher: 114.1 mg/cm³ (T1-T4), 92.0 mg/cm³ (T5-T8), 88.2 mg/cm³ (T9-T12). Conclusions: At all levels of the thoracolumbar spine, lower vBMD was associated with incident VFs in an elderly, predominantly oncologic patient population. Automated opportunistic osteoporosis screening of vBMD along the entire thoracolumbar spine allows for risk assessment of imminent VFs. We propose level-specific vBMD threshold at the thoracolumbar spine to identify individuals at high fracture risk.

Quality of life and return to work and sports after spinal ependymoma resection.

Adult spinal ependymoma presents a rare low-grade tumor entity. Due to its incidence peak in the fourth decade of life, it mostly affects patients during a professionally and physically active time of life. We performed a retrospective monocentric study, including all patients operated upon for spinal ependymoma between 2009 and 2020. We prospectively collected data on professional reintegration, physical activities and quality-of-life parameters using EQ-5D and SF-36. Issues encountered were assessed using existing spinal-cord-specific questionnaires and free-text questions. In total, 65 of 114 patients agreed to participate. Most patients suffered from only mild pre- and postoperative impairment on the modified McCormick scale, but 67% confirmed difficulties performing physical activities in which they previously engaged due to pain, coordination problems and fear of injuries after a median follow-up of 5.4 years. We observed a shift from full- to part-time employment and patients unable to work, independently from tumor dignity, age and neurological function. Despite its benign nature and occurrence of formal only mild neurological deficits, patients described severe difficulties returning to their preoperative physical activity and profession. Clinical scores such as the McCormick grade and muscle strength may not reflect the entire self-perceived impairment appropriately.

Neuropathic pain after spinal intradural benign tumor surgery: an underestimated complication?

Neuropathic pain presents a burdening and impairing condition which may occasionally occur after spinal tumor surgery. While it has been described in peripheral nerve sheath tumors, data on other intradural tumor patients is sparse. We hereby present a large cohort population undergoing different intradural spinal tumor surgery with assessment of early postoperative and follow-up outcomes, focusing on the occurrence of neuropathic pain. We performed a retrospective monocentric study including all patients treated for intradural spinal tumors between 2009 and 2020. We extracted surgical aspects as well as pre- and postoperative clinical courses from the records. Statistical analysis of potential contributing prognostic factors was performed including matched pair analysis. In total, 360 patients were included for analysis. At a median follow-up of 2 years, 26/360 patients complained of a neuropathic pain syndrome (7.2%) requiring continuous medication. Of these patients only 50% complained preoperatively of pain. Tumor entity did not significantly influence the incidence of postoperative neuropathic pain (p = 0.91). Sacrifice of the tumor carrying nerve root and tumor recurrence also did not increase the risk for this condition. Persistent neuropathic pain requiring continuous treatment occurred in 7.2% of patients undergoing intradural spinal surgery in our cohort. This frequently underestimated postoperative adverse event represents a disabling condition leading to a substantial impairment in the quality of life among the affected patients.

Impacting the Treatment of Highly Eloquent Supratentorial Cerebral Cavernous Malformations by Noninvasive Functional Mapping-An Observational Cohort Study.

BACKGROUND: Cerebral cavernous malformations (CCM) may cause cavernoma-related epilepsy (CRE) and intracranial hemorrhage (ICH). Functional mapping has shown its usefulness during the resection of eloquent lesions including the treatment of brain arteriovenous malformations. OBJECTIVE: To evaluate the impact of noninvasive functional mapping on decision-making and resection of eloquently located CCM. METHODS: Of 126 patients with intracranial cavernomas, we prospectively included 40 consecutive patients (31.7%) with highly eloquent CCM between 2012 and 2020. We performed functional mapping via navigated transcranial magnetic stimulation (nTMS) motor mapping in 30 cases and nTMS language mapping in 20 cases. Twenty patients suffered from CRE. CCM caused ICH in 18 cases. RESULTS: We used functional mapping data including function-based tractography in all cases. Indication toward (31 cases) or against (9 cases) CCM resection was influenced by noninvasive functional mapping in 36 cases (90%). We resected CCMs in 24 cases, and 7 patients refused the recommendation for surgery. In 19 and 4 cases, we used additional intraoperative neuromonitoring and awake craniotomy, respectively. Patients suffered from transient postoperative motor or language deficits in 2 and 2 cases, respectively. No patient suffered from permanent deficits. After 1 yr of follow-up, anti-epileptic drugs could be discontinued in all patients who underwent surgery but 1 patient. CONCLUSION: Surgery-related deficit rates are low even for highly eloquent CCM and seizure outcome is excellent. The present results show that noninvasive functional mapping and function-based tractography is a useful tool for the decision-making process and during microsurgical resection of eloquently located CCM.

Cement-Augmented Carbon Fiber-Reinforced Pedicle Screw Instrumentation for Spinal Metastases: Safety and Efficacy.

OBJECTIVE: To investigate the complication rates and long-term implant failure rates in a monocentric study of a consecutive cohort of patients with thoracolumbar spinal metastases after posterior instrumentation with a fenestrated carbon fiber-reinforced poly-ether-ether-ketone (CFRP) pedicle screw system. METHODS: We retrospectively reviewed demographics, Karnofsky Performance Status Scale scores, complications, and implant failure rates. RESULTS: Between June 2016 and November 2019, 51 consecutive patients underwent cement-augmented CFRP pedicle screw instrumentation at our institution. Mean age was 68 years (standard deviation 10.5), the median preoperative Karnofsky Performance Status Scale of 80 increased to 90 postoperatively (P = 0.471). Most common primary entities were breast (25.5%), lung (15.7%), and prostate (13.7%) cancers. Of 428 placed screws, 293 (68.5%) were augmented with polymethylmethacrylate, a mean 6 per patient (standard deviation ±2). Screws were inserted via a minimally invasive system technique in 54.9% of cases. In total, 11.8% of patients had immediate postoperative sequelae related to the cement. Pulmonary cement embolisms were noted in 3 patients, 2 had paravertebral extravasation, and 1 had an embolism into a segmental artery. Of these 6, 2 patients with pulmonary embolisms reported related symptoms. Follow-up was available for 80.4%. After a mean 9.8 months, screw loosening was noted in 11.8% of cases on computed tomography, although it was asymptomatic in all but 1 patient. Screw pull-out did not occur. Neither cement-related (P = 0.353) nor general complication rates (P = 0.507) differed significantly between open and minimally invasive system techniques. CONCLUSIONS: Percutaneous cement-augmented CFRP pedicle screw instrumentation facilitates artifact-reduced postoperative imaging, while maintaining a risk profile and implant failure rates comparable to conventional metallic instrumentation.