A shared neoantigen vaccine combined with immune checkpoint blockade for advanced metastatic solid tumors: phase 1 trial interim results.

Therapeutic vaccines that elicit cytotoxic T cell responses targeting tumor-specific neoantigens hold promise for providing long-term clinical benefit to patients with cancer. Here we evaluated safety and tolerability of a therapeutic vaccine encoding 20 shared neoantigens derived from selected common oncogenic driver mutations as primary endpoints in an ongoing phase 1/2 study in patients with advanced/metastatic solid tumors. Secondary endpoints included immunogenicity, overall response rate, progression-free survival and overall survival. Eligible patients were selected if their tumors expressed one of the human leukocyte antigen-matched tumor mutations included in the vaccine, with the majority of patients (18/19) harboring a mutation in KRAS. The vaccine regimen, consisting of a chimp adenovirus (ChAd68) and self-amplifying mRNA (samRNA) in combination with the immune checkpoint inhibitors ipilimumab and nivolumab, was shown to be well tolerated, with observed treatment-related adverse events consistent with acute inflammation expected with viral vector-based vaccines and immune checkpoint blockade, the majority grade 1/2. Two patients experienced grade 3/4 serious treatment-related adverse events that were also dose-limiting toxicities. The overall response rate was 0%, and median progression-free survival and overall survival were 1.9 months and 7.9 months, respectively. T cell responses were biased toward human leukocyte antigen-matched TP53 neoantigens encoded in the vaccine relative to KRAS neoantigens expressed by the patients' tumors, indicating a previously unknown hierarchy of neoantigen immunodominance that may impact the therapeutic efficacy of multiepitope shared neoantigen vaccines. These data led to the development of an optimized vaccine exclusively targeting KRAS-derived neoantigens that is being evaluated in a subset of patients in phase 2 of the clinical study. ClinicalTrials.gov registration: NCT03953235 .

The MetaInvert soil invertebrate genome resource provides insights into below-ground biodiversity and evolution.

Soil invertebrates are among the least understood metazoans on Earth. Thus far, the lack of taxonomically broad and dense genomic resources has made it hard to thoroughly investigate their evolution and ecology. With MetaInvert we provide draft genome assemblies for 232 soil invertebrate species, representing 14 common groups and 94 families. We show that this data substantially extends the taxonomic scope of DNA- or RNA-based taxonomic identification. Moreover, we confirm that theories of genome evolution cannot be generalised across evolutionarily distinct invertebrate groups. The soil invertebrate genomes presented here will support the management of soil biodiversity through molecular monitoring of community composition and function, and the discovery of evolutionary adaptations to the challenges of soil conditions.

[Techniques and indications of neurosurgical treatment of oligometastatic renal cell carcinomas in case of spinal metastases]. / Oligometasztatikus vesesejtes karcinóma idegsebészi ellátásának technikái és indikációi gerincáttétek esetén.

The treatment of spinal metastases is a huge challenge, but both oncological and surgical treatment have improved significantly. Spine surgeons use the experience of spine surgeries performed for an increased number of degenerative causes during spine surgeries performed for an increased number of tumors. Establishing an indication for surgery is at least as much of a challenge as the surgery itself, for which there are many objective point systems available. Renal cell carcinoma metastases are less sensitive to radiation, which is why careful surgery is even more important. In our short summary, we review the symptoms, the examination, the grading systems used and the surgical options.

Low-dose self-amplifying mRNA COVID-19 vaccine drives strong protective immunity in non-human primates against SARS-CoV-2 infection.

The coronavirus disease 2019 (COVID-19) pandemic continues to spread globally, highlighting the urgent need for safe and effective vaccines that could be rapidly mobilized to immunize large populations. We report the preclinical development of a self-amplifying mRNA (SAM) vaccine encoding a prefusion stabilized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike glycoprotein and demonstrate strong cellular and humoral immune responses at low doses in mice and rhesus macaques. The homologous prime-boost vaccination regimen of SAM at 3, 10 and 30 µg induced potent neutralizing antibody (nAb) titers in rhesus macaques following two SAM vaccinations at all dose levels, with the 10 µg dose generating geometric mean titers (GMT) 48-fold greater than the GMT of a panel of SARS-CoV-2 convalescent human sera. Spike-specific T cell responses were observed with all tested vaccine regimens. SAM vaccination provided protective efficacy against SARS-CoV-2 challenge as both a homologous prime-boost and as a single boost following ChAd prime, demonstrating reduction of viral replication in both the upper and lower airways. The SAM vaccine is currently being evaluated in clinical trials as both a homologous prime-boost regimen at low doses and as a boost following heterologous prime.

[Early experience with minimal invasive treatment of thirty-one thoracolumbar injury cases]. / Korai tapasztalataink thoracolumbalis gerincsérülések minimálinvazív mutéti kezelésével.

The authors report on their experience with minimal invasive treatment of thirtyone thoracolumbar injury cases. The medical charts, radiological documentation (preop CT and MRI scans, postop CT scans at 3 and 6 months) were analysed retrospectively. All pedicle screws were inserted appropriately, there was no neurological deterioration or surgical site infection postoperatively. There were three cases of radiological loss of correction, however, these were clinically irrelevant. There were no screw loosening or implant failure observed. According to our experience, which coincedes with literature data, this minimally invasive percutaneous pedicle screw technique can be recommended for the treatment of thoracolumbar injury.

Initial experience with the treatment of concomitant aortic pseudoaneurysm and thoracolumbar spinal fracture: Case report.

One blunt abdominal aortic disruption (BAAD) and one blunt thoracic aortic injury (BTAI) case are presented. Both aortic injuries were combined with spinal fractures. In the BAAD case the aortic pseudoaneurysm manifested just above the lumbar fracture while in the BTAI case the aortic injury appeared several vertebras below the thoracal fracture site, suggesting different mechanisms in the aortic wall damage. In both cases the aortic wall first was sealed, successfully, by endovascularly-placed stents, meaning the risks of open aortic reconstructive surgery could be avoided. The adjacent crucial vessel's preservation, despite the stent covering the left subclavian artery and the left common carotid artery in one of the cases was verified by post-operative computed tomography angiography (CTA) examination. In second stage those spinal fractures which were deemed unstable were stabilized by the fixateur interne (a transpedicular screw-rod system). With this treatment sequence we wanted to avoid the unnecessary risk of a possible rupture of the unsealed aortic wall during positioning for the spinal procedure and during the spinal surgery. Both patients recovered from their aortic and spinal injuries.

[Treatment of osteoporotic vertebral compression fractures with PMMA-augmented pedicle screw fixation]. / Osteoporoticus kompressziós csigolyatörések kezelése PMMA-augmentált csavaros transpedicularis rögzítéssel.

BACKGROUND: Over the last few decades many innovative operation technique were developed due to the increase of porotic vertebral fractures. These new techniques aim to reach the required stability of the vertebral column. In case of significant instability, spinal canal stenosis or neural compression, decompressive intervention may be necessary, which results in further weakening of the column of the spine, the minimal invasive percutan vertebroplasty is not an adequate method to reach the required stability, that is why insertion of complementary pedicular screws is needed. Considering the limited screw-fixing ability of the porotic bone structure, with this new technique we are able to reach the appropriate stability of cement-augmented pedicle screws by dosing cement carefully through the screws into the vertebral body. We used this technique in our Institute in case of 12 patients and followed up the required stability and the severity of complications. METHODS: Fifteen vertebral compression fractures of 12 patients were treated in our Institute. Using the classification proposed by Genant et al. we found that the severity of the vertebral compression was grade 3 in case of 13, while grade 2 in case of two fractures. The average follow up time of the patients was 22 months (12-39), during this period X-ray, CT and clinical control examinations were taken. During the surgery the involved segments were localised by using X-ray and after the exploration the canulated screws were put through the pedicles of the spine and the vertebral body was filled through the transpedicular screws with bone cement. Depending on the grade of the spinal canal stenosis, we made the decompression, vertebroplasty or corpectomy of the fractured vertebral body, and the replacement of the body. Finally the concerned segments were fixed by titanium rods. RESULTS: In all cases the stenosis of spinal canal was resolved and the bone cement injected into the corpus resulted in adequated stability of the spine. In case of six patients we observed cement extravasation without any clinical signs, and by one patient--as a serious complication--pulmonary embolism. Neurological progression or screw loosening were not detected during the follow up period. Part of the patients had residual disability after the surgery due to their older ages and the problem of their rehabilitation process. CONCLUSION: After the right consideration of indications, age, general health condition and the chance of successful rehabilitation, the technique appears to be safe for the patients. With the use of this surgical method, the stability of the spine can be improved compared to the preoperative condition, the spinal canal stenosis can be solved and the neural structures can be decompressed. The severity of complications can be reduced by a precise surgical technique and the careful use of the injected cement. The indication of the surgical method needs to be considered in the light of the expected outcome and the rehabilitation.

Minimally invasive spine surgery: systematic review.

Minimally invasive procedures in spine surgery have undergone significant development in recent times. These procedures have the common aim of avoiding biomechanical complications associated with some traditional destructive methods and improving efficacy. These new techniques prevent damage to crucial posterior stabilizers and preserve the structural integrity and stability of the spine. The wide variety of reported minimally invasive methods for different pathologies necessitates a systematic classification. In the present review, authors first provide a classification system of minimally invasive techniques based on the location of the pathologic lesion to be treated, to help the surgeon in selecting the appropriate procedure. Minimally invasive techniques are then described in detail, including technical features, advantages, complications, and clinical outcomes, based on available literature.

Modified surgical approach to cervical neurinomas with intraforaminal components: minimal invasive facet joint sparing "open-tunnel" technique.

BACKGROUND: The conventional posterior approaches, which may involve multilevel laminectomies and facetectomies, may lead to spinal deformities, instability, or subluxation. Our objective was to develop a minimally invasive approach suitable for exploring neuromas with an intraforaminal component in the cervical spine, with the aim of preserving mechanically relevant bone structures and the facet joints as much as possible. METHODS: The authors used the hemi-semi-laminectomy combined with partial lateral facetectomy "open-tunnel" technique in nine adult patients with neuromas of the cervical spine extending into the foramen. RESULTS: The operating field under the operating microscope was sufficient for tumor removal according to the keyhole concept. The approach did not affect the extent of tumor resection or neurological outcome. Complete removal was achieved in all patients, as confirmed by magnetic resonance imaging (MRI). The affected nerve roots included C3 in three cases, C2 and C4 in two, and C5 and C6 in one case. Average follow-up was 12 months, with a range from 8 to 18 months. Histological results were as follows: six schwannomas and three neurofibromas. Computed tomographic scans demonstrated the extension of the keyhole approaches and the moderately affected bony structures and facet joints. Instability was detected in none of the patients on the flexion or extension lateral radiographs during the follow-up period. CONCLUSION: This modified surgical approach fulfills the requirements of other minimally invasive techniques and lowers the risk of damage to the crucial posterior stabilizers of the spine; furthermore, disintegration of vertebral arches and facet joints is reduced. The approach is suitable for exploring and removing neuromas located in the spinal canal and in the neuroforamen.

Novel surgical approach in the management of longitudinal pathologies within the spinal canal: the split laminotomy and "archbone" technique: alternative to multilevel laminectomy or laminotomy.

Multilevel laminectomy to open the spinal canal carries the risk of spinal deformities and instability. With the aim of preserving and reconstructing the posterior structures the authors developed a novel, minimally invasive, multilevel spinous process splitting and distracting laminotomy approach with or without complementary corticocancellous iliac crest or PEEK cage "archbone" grafting. The technique allows exploration of the spinal canal and the removal of intramedullary pathologies. Moderate enlargement of the spinal canal with preservation of the majority of posterior structures is also possible, so that muscle attachments remain intact and postoperative complications are substantially reduced.This surgical approach, while fulfilling the requirements of previous laminotomy techniques, helps to prevent damage to the crucial posterior stabilizers of the spine. In contrast to conventional spinal canal approaches, preservation of the majority of posterior structures is possible, leaving muscle attachments on the spinous processes and laminae completely intact.Furthermore, the procedure for exposure and decompression of the spinal canal is a suitable method for all spinal segments, the cervical, thoracic, and the lumbar spine in all age groups.

[New minimally invasive surgical techniques in spinal surgery]. / Új mutéttechnikai eljárások a gerincsebészetben, különös tekintettel a minimálinvazivitásra.

The last decade has brought significant development in spine surgery. As in all field of surgery, introduction of the minimal invasive, atraumatic procedures characterized our activities. The number of short and long-time complications were significantly reduced and the effectiveness of operations were markedly improved by the new technical conditions, for example by the use of neuronavigation, surgical microscope, intraoperative fluoroscopy, high speed drill and the widespread of keyhole concept. The applied multislice CT imaging and the high resolution MRI enabled to improve the accuracy of the planned surgical procedures and to reduce the mortality and morbidity of operations. In our studies technical methods were investigated and new developments were established in the field of minimal invasive spine surgery. The National Institute of Neurosurgery's spinal surgical team pioneers further development and application of novel minimal invasive procedures. Applied methods of vanguard surgical procedures include split laminotomy, the "archbone" technique, the "over the top" decompression, the multilevel hemi-semi laminectomy, the supraforaminal "burr hole", the facet joint sparing "open tunnel" techniques or parasplit minimal invasive approaches. The new innovative surgical techniques are applied in our daily routine and meet international trends by utilizing benefits of minimal invasive spinal surgery. Using our newly developed innovative techniques allow to decompress neural elements in case of spinal canal stenosis and to remove the intramedullary and extramedullary space-occupying lesions located in the spinal canal and spreading extraspinally through the neuroforamen. These techniques are specially tailored to preserve structural integrity and stability of the spinal column, and allow at the same time to minimize resection of and injury to tissues not directly involved in the pathologic processes. In our studies a classification system of spatial localization of pathological lesions and processes in spinal canal was developed by us. Using this classification system enables the surgeon to select and apply the appropriate minimal invasive technique from dorsal direction and to remove the space-occupying lesions located in the spinal canal. The minimal invasive techniques were characterized and summarized. This overview of the minimal invasive techniques can be applied and recommended in the daily routine of spine surgery. We proudly employ novel surgical techniques having been developed in our institution. These techniques are internationally recognized and applied in our practice on daily basis as well.

Rare angioproliferative tumors mimicking aggressive spinal hemangioma with epidural expansion.

BACKGROUND AND PURPOSE: We present two cases of angio-proliferative tumors that were misdiagnosed and treated as typical hemangiomas with epidural expansion. MATERIALS AND METHODS: Two middle-aged women presented with symptoms and radiological signs characteristic for aggressive hemangioma with epidural expansion. In the first case preoperative embolization and decompressive surgery with open transpedicular vertebroplasty was performed. Within less than a year, epidural recurrence of the tumor prompted for radical excision and corpectomy. The diagnosis after the histological studies and the further clinical evolution was metastasizing leiomyomatosis. No further recurrence occured during the next 6 years. In the second case percutaneous vertebroplasty was performed and complicated by epidural polymethyl-methacrylcate (PMMA) leakage, requiring urgent decompressive surgery. Histological study of the lesion raised the possibility of myopericytoma. This was confirmed 16 months later when complete vertebrectomy was performed due to severe epidural propagation of the recurring tumor. No further recurrence occurred in next the two years. CONCLUSIONS: Rare angio-proliferative tumors, like benign metastasizing leiomyoma and myopericytoma radiologically may resemble aggressive vertebral hemangiomas of the spine. Unlike hemangiomas, such tumors require radical removal due to their likely recurrence. As imaging studies may not be able to completely exclude such pathologies, bone biopsy and thorough histopathological studies are warranted prior to the therapeutic decision.

[New surgical technique for atlanto-axial instability: C1-2 dorsal fixation with the screw-rod system]. / Az atlantoaxialis instabilitás mutéti kezelésének újabb módszere: CI-II. Dorsalis rögzítés csavaros-rudas rendszerrel.

OBJECTIVE: It is still challenging to perform the operation for the instability of the C1-C2 junction because of the limited cases, unique anatomical landmarks, the potential or real injury of the neurological elements, the serious clinical state and the special technical and human background is demanding. With the aim of minimalize the risk the following method provide sufficient stability, successful and simple. METHOD: The authors used the dorsally implanted screw-rod systems for operating 34 patient with C1-2 instability resulting clinically signs and symptoms. Depending the anatomical landmarks and the technical possibilities, the screw insertion method and the reinforced wire cable use was selected. Meaning the indication of the surgical treatment, the neurological signs, compromise of the spinal canal and pain resisting the conservative treatment was presented. RESULT: The C1-2 dorsally fixation was performed to 34 patients. Both sided lateral mass screw was inserted in 30 cases (88.3%). Because of the anatomical landmarks in four cases (11.7%) the one sided screwing was made by the Magerl technique. Pure bone quality detecting intraoperatively demand reinforcement with titanium cables for three cases (8.8%). Pain resulted of instability was recovered. The clinical and neurorariological follow-up present perfect result for 26 patients (76%), good result for six patients, there was respectable result for two patients. Most of the patients, 31 cases (91%) were satisfied, and three patients (9%) consider their condition acceptable. CONCLUSION: Performing the represened techique, the risk and the time of the operation was decreased reducing the rate of the complications. The method providing full stability resulted immediate axial painless, no outer support and early mobilization is possibile. Summarizing this technique is safe, reliable and cost effective.

[Frequency of adjacent vertebral fractures following percutaneous vertebroplasty]. / Szomszédos csigolyatörések elofordulása percutan vertebroplastica után.

INTRODUCTION AND AIMS: Percutaneous vertebroplasty (PVP) proved to be very effective in the treatment of pain caused by osteoporotic vertebral compression fractures. A certain proportion of patients, however, suffer a new fracture after treatment. Our purpose was to analyze the frequency of new fractures, and to estimate the causative role of PVP in the treated population. METHODS: The retrospective study reviewed all consecutive patients treated with PVP for osteoporotic compression fractures during a 5.5 years period. The study group comprised those patients, who suffered a new fracture during the follow up. The primary endpoint was the frequency of new fractures. The secondary endpoint was the occurrence of new fractures in a timeframe of 90 days after treatment that were adjacent to the previously treated segments. The causative role of PVP was estimated to be the highest in this subgroup. RESULTS: Altogether 396 consecutive patients were treated with PVP for osteoporotic compression fractures. Mean age was 68+11 years, and 23% of the population was male. The study group comprised 73 patients (18.4%). In this subgroup the patients had an average of 3.8 vertebral fractures. After PVP, adjacent fractures were significantly more likely, than distal fractures. Altogether 44 patients (11% of the entire population) suffered an adjacent fracture in 90 days after PVP. In this group there were significantly less male patients as compared to the entire population. CONCLUSIONS: After PVP almost every fifth patient is at risk for developing a new fracture, however, it is likely to be related to the vertebral augmentation in every tenth subject only. Female patients with severe osteoporosis are probably facing the highest risk for developing new fractures.

Cervical juxtafacet cyst combined with spinal dysraphism.

Juxtafacet cysts of the cervical and thoracic spine are rare and often cause radiculopathy or myelopathy. We present a case of a patient with radicular pain and early onset myelopathy. A juxtafacet cyst at the cervico-thoracic junction combined with discal herniation and spina bifida occulta was diagnosed with computed tomography (CT) and magnetic resonance imaging (MRI). Laminectomy with removal of the cyst was the treatment and the patient recovered rapidly.

Exploration and decompression of the spinal canal using split laminotomy and its modification, the "archbone" technique.

OBJECTIVE: To develop a novel minimally invasive approach suitable for exploring different pathologies located in the spinal canal, allowing moderate enlargement of the canal with preservation of the majority of posterior structures so muscle attachments remain intact and postoperative complications are reduced. METHODS: The authors developed a multilevel spinous process splitting and distracting laminotomy technique with or without complementary corticocancellous iliac crest "archbone" autografting. Technical details are discussed. The multilevel spinous process splitting and distracting laminotomy technique with or without complementary iliac bone grafting was used in 19 patients with different pathologies of the spinal canal. RESULTS: Satisfactory surgery of the lesions located within the spinal canal, especially intramedullary, was achieved in all patients using this new approach. The affected area of the spine was cervical in seven patients, cervicothoracic in four patients, thoracic in five patients, and thoracolumbar in three patients. The average number of split laminae was three (range, 2-6). Histological results were as follows: seven intramedullary astrocytomas, eight ependymomas, two cavernous hemangiomas, one dural arteriovenous malformation, and one hemangioblastoma. Of the eight ependymomas, 75% were removed completely and 25% were partially removed. Of the seven astrocytomas, 28.7% were removed completely, 14.3% were removed subtotally, and 57% were partially removed. The cavernous hemangiomas and the hemangioblastoma were completely removed. The approach used did not affect the extent of resection or neurological outcome. The spinous processes were closed directly in 13; in six cases, a tricortical iliac bone graft was placed between the facing bony parts of the spinous processes. The mean duration of splitting and distracting the spinous process was 16 minutes (range, 11-28 min) for the first process and 8 minutes (range, 5-14 min) for each additional spinous process. The mean duration of the whole surgical procedure, including intraspinal surgery, was 159 minutes (range, 90-290 min). The mean blood loss was 158 ml (range, 48-442 ml). The average length of hospital stay was 7.2 days. The average follow-up period was 15.4 months. Fifty-one of the 57 (89.5%) spinous process computed tomographic scans demonstrated bony healing with or without a graft between the osteotomized faces. Of the 57 spinous process computed tomographic scans, fracture of the spinous process was seen in nine (15.8%) and traumatic bony changes of the body of the vertebra in the midline in three (5.2%); these were without clinical significance and they later showed complete healing. CONCLUSION: This surgical approach fulfills the requirements of other laminotomy techniques and helps prevent damage to the crucial posterior stabilizers of the spine. In contrast to conventional spinal canal approaches, preservation of the majority of posterior structures leaves muscle attachments on the spinous processes and laminae completely intact. Furthermore, the technique for exposure and decompression of the spinal canal is a suitable method for all spinal segments, the cervical, thoracic, and the lumbar spine in all age groups.

[Removal of intraspinal space-occupying lesions through unilateral partial approach, the "hemi-semi laminectomy"]. / A gerinccsatornában elhelyezkedo térfoglaló folyamatok eltávolítása féloldali parciális feltárásból, a "hemi-semi laminectomia".

OBJECTIVE: The conventional dorsal surgical approaches used in removal of intraspinal space-occupying lesions by unroofing the spinal canal, often result the destruction of dorsal bony structures, sacrifice the interspinosus/supraspinosus ligament complexes and stripping of the paraspinal muscles causing a pathologic biomechanical milieu may lead to spinal deformities, instability. Various less invasive techniques exist to save the integrity and to prevent the instability of the spinal column and allow removal of intraspinally located space-occupying lesions at the same time. The authors discuss the experiences with unilateral partial laminectomy approach in removal of intraspinally, mainly lateral, intra- or extradurally located pathologic lesions. METHODS: The unilateral partial laminectomy, in which the laminas were preserved (hemi-semi laminectomy) was performed in 86 symptomatic patients to remove space-occupying intra- or extradurally located lesions of the cervical, thoracic and lumbar spinal canal. Symptoms were local or radicular pain, motor, sensory and vegetative disturbances. RESULTS: Adequate surgery of the lesions located within the spinal canal was achieved in all patients using this approach. The hemi-semi laminectomy was performed at one spinal level in 68 patients, two levels in 15 and three levels in 3. The affected spine was the cervical in 16, the cervico-thoracic in 6, the thoracic in 35, the thoraco-lumbar in 10 and lumbar region in 19 cases. Histological results were as follows: 32 intradural meningiomas, 27 neurinomas, 10 ependymomas, 3 arachnoid cysts, 2 cavernomas and extradurally 4 epidural haemorrhage, 5 epidural abscesses and 3 dural vascular malformations. CONCLUSION: The unilateral partial laminectomy (named hemi-semi laminectomy) approach for the mainly laterally located intra- or extradural lesions, confined to one side, allow to minimize resection of and injury to tissues not directly involved in the pathologic process, while affording a safe and thorough removal of space-occupying pathologies and decompression of neural structures located in a spinal canal. Two additional advantages come from this technique in cases of misjudged level or at re-operation.

Occipitoatlantoaxial instability and congenital thoracic vertebral deformity in Pierre Robin sequence: a case report.

STUDY DESIGN: Case report of a patient with Pierre Robin sequence who presented with occipitoatlantoaxial instability and congenital thoracic deformity. OBJECTIVE: As there are lack of similar cases in the literature, we would like to introduce a case of a patient with associated malformations, the consultations that we consider that are obligatory, and our decision-making process. We would also like to demonstrate the follow-up plan and the further key points about either the conservative or the surgical solution of the problem. SUMMARY OF BACKGROUND DATA: The occurrences of 2 malformations (Pierre Robin sequence and occipitoatlantoaxial instability) together are very rare. We have found only 1 publication in the related literature about this topic. We consider that this rare appearance is due to the difficulty in diagnosing this problem. There is no clinical evidence that musculoskeletal examinations are indicated in a patient with Pierre Robin sequence, and it is difficult to check for all the possible deformities. METHOD: As congenital scoliosis appeared only at 6 years of age in the case of this child with Pierre Robin syndrome, we promptly began to investigate for other musculoskeletal defects. We would like to demonstrate the investigation process and emphasize the necessity of conventional and functional radiographs, computed tomography, and magnetic resonance images. RESULTS: We have not found similar cases to refer to, so we made our decision about conservative treatment of the craniocervical instability knowing that we will have to follow up the progression of both the congenital thoracic scoliotic deformity and the occipitoatlantoaxial instability later. CONCLUSION: To recognize a rare case is a big challenge indeed due to the lack of the investigational protocol, the key points of the decision process, the prognostic classification system, and the progression of the disease. We recommend that one should individualize and follow up the patient frequently.

[Bilateral "over the top" decompression through unilateral laminotomy for lumbar and thoracic spinal canal stenosis]. / A gerinccsatorna kétoldali "over the top" rekalibrációja féloldali feltáráson keresztül degeneratív háti es agyéki gerinccsatorna- szukület esetén.

OBJECTIVE: The standard surgical procedures used in degenerative thoracic and lumbar spinal canal stenosis allows decompression of the neural structures by unroofing the spinal canal, often resulted in destruction or insufficiency of facet joints, sacrifice the interspinosus/supraspinosus ligament complexes and stripping of the paraspinal muscles altering an already pathologic biomechanical milieu causing segmental instability. Various less invasive techniques exists to save the integrity and prevent the instability of the spine and allow decompression of neural structures located in the spinal canal. The authors discusses the experiences with technique of unilateral laminotomy for bilateral decompression. METHODS: The unilateral laminotomy for bilateral decompression technique was performed at 60 levels in 51 patients to decompress the symptomatic degenerative stenosis of the thoracic and lumbar spinal canal. The inclusion criteria were used as follows: symptoms of neurogenic claudication and/or radiculopathy, myelopathy, neuroimaging evidence of degenerative stenosis and absence of instability. Symptoms were considered refractory to nonsurgical conservative management or myelopathy was detected. RESULTS: The distribution of mostly affected segments were the L 4-5 (45%) and L3-4 (28.4%). Neurogenic claudication and walking distance improved during the follow up period in all patients. Seven patients (13.73%) reported excellent, 32 (62.74%) good, 12 (23.53%) fair outcome and no patient a poor overall outcome. The low back pain was the major residual postoperative complaint. 25 (49%) patients were very satisfied with their outcome, 23 (45.1%) were fairly satisfied, 2 (3.9%) were not very satisfied and 1 (2%) patients was dissatisfied. CONCLUSION: The unilateral laminotomy for bilateral microdecompression technique minimizes resection of and injury to tissues not directly involved in the pathologic process, while affording a safe and through decompression of neural structures located in a degeneratively stenotic spinal canal.