Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients With Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort. METHODS: We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version-the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4-6). RESULTS: Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, P<0.001) whereas the sensitivity decreased from 0.88 to 0.37 (P<0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, P<0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, P<0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, P<0.001). CONCLUSIONS: The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification-presence of brain stem signs is required for grade V-should be added to the WFNS classification. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.

How I do it: minimally invasive resection of a sub-ependymoma of the fourth ventricle.

BACKGROUND: A 54-year-old female was referred to our clinic with a lesion of the lower fourth ventricle extending to the median aperture. Here, we report the use a minimally invasive sub-occipital approach (MISA) as a safe and effective surgical management. METHOD: We performed a MISA using a short midline incision and a 1-cm sub-occipital craniectomy. Dissection of the lesion was performed, and "en bloc" resection could be achieved. The lesion was confirmed to be a grade I sub-ependymoma. CONCLUSION: MISA can be safely used when confronted to a lesion of the lower fourth ventricle.

Functional outcome and quality of life after meningioma surgery: a systematic review.

Assessment of long-term functional outcomes after meningioma surgery is important. We systematically reviewed the literature on health-related quality of life (HrQoL) and functional disability (FD) of patients after surgery for intracranial meningiomas. Using PRISMA 2015 guidelines, we screened 289 abstracts and 43 titles were retained for full-paper screening. 15 articles did not present enough data to meet the inclusion criteria and 7 articles failed to assess functional assessment and HrQoL. Twenty-two articles were included in our review. HrQol was assessed in N = 18 publications, most frequently using SF-36 (N = 10), followed by EQ5D-5L (N = 4), EORTC-QLQ (N = 4), and the FACT questionnaire (N = 2). The assessment of FD was reported in N = 11 publications, mostly using the KPS (N = 8). The Barthel index was used in N = 2 publications. Follow-up was reported in N = 12 publications, ranging from 6 months to 9 years. Scientific publications assessing long-term postoperative HrQol and FD in patients undergoing meningioma surgery are scarce and the data are heterogeneously reported, using various scales and follow-up protocols. Efforts should be undertaken to uniformly assess long-term post-operative functional outcomes in meningioma patients.

How I do it: the trans-laminar, facet-joint sparing minimal invasive approach for ventral dural repair in spontaneous intracranial hypotension-a 2-dimensional operative video.

BACKGROUND: We describe the minimally invasive, facet-sparing postero-lateral approach to the thoracic spine for a ventral dural repair in a patient with intracranial hypotension secondary to a spontaneous dural breach. METHODS: We performed a minimally invasive approach using a short paramedian posterior skin incision followed by a 10 × 10 mm targeted trans-laminar approach, to achieve a microsurgical repair of a symptomatic ventral dural defect causing severe disability. CONCLUSION: The facet-sparing postero-lateral approach is safe and effective in the surgical management of thoracic dural tears, even in the most anterior ones, and avoids the traditional costotransversectomy.

Visual field restoration after Simpson grade I resection of symptomatic occipital lobe meningioma: illustrative case and review of the literature.

Intracranial meningiomas mostly affect patients in their fifth decade and beyond, raising pertinent questions regarding the risk of surgery, particularly in the elderly. Here, we describe the case of a septuagenarian patient with occipital meningioma causing severe visual field cuts that experienced full recovery of the visual function after a Simpson I resection of the lesion. This case illustrates the potential of recovery of the brain, even in the case of severely impaired function in elderly patients. To complete the picture, we review the literature on occipital meningiomas, advocating for systematic reports and increase data collection on post-operative neurological recovery in the elderly.

Acute Stenting and Concomitant Tirofiban Administration for the Endovascular Treatment of Acute Ischemic Stroke Related to Intracranial Artery Dissections: A Single Center Experience and Systematic Review of the Literature.

BACKGROUND: Intracranial artery dissection is an uncommon cause of acute ischemic stroke. Although acute stenting of the dissected arterial segment is a therapeutic option, the associated antiplatelet regimen remains a matter of debate. OBJECTIVES: To evaluate the efficacy and safety of acute intracranial stenting together with concomitant intravenous administration of tirofiban and to perform a systematic review of the literature. MATERIALS AND METHODS: A single-center, retrospective study of the clinical and radiological records of all patients treated at our center by intracranial stenting in the setting of acute ischemic stroke between January 2010 and December 2020. A systematic review of the literature was conducted according to the PRISMA-P guidelines for relevant publications from January 1976 to December 2020 on intracranial artery dissection treated by stent. RESULTS: Seven patients with intracranial artery dissections underwent acute stenting with concomitant tirofiban during the study period. Mid-term follow-up showed parent artery patency in 6/7 cases (85.7%). The modified Rankin Score was ≤ 0-2 at 3 months in 5/7 cases (71.4%). The literature review identified 22 patients with intracranial artery dissection treated with acute stenting in association with different antithrombotic therapies. Complete revascularization was obtained in 86.3% of cases with a modified Rankin Score of ≤ 0-2 in 68% of patients at 3-month follow-up. CONCLUSIONS: Acute intracranial stenting together with intravenous tirofiban administration could be a therapeutic option in patients with intracranial artery dissection and a small ischemic core.

Lateral sphenoid wing meningiomas without bone invasion-still skull base surgery?

Sphenoid wing meningiomas are generally considered as skull base meningiomas (SBMs). However, given their surgical similarities with non-skull base meningiomas (NSBMs), we hypothesized that lateral sphenoid wing meningiomas (LSWMs) without bone invasion (BI) should be considered as NSBMs. N = 65 LSWMs without BI operated between 1990 to 2010 at a single-center were compared to N = 352 NSBMs, represented by convexity meningiomas (CMs), and to N = 23 SBMs, represented by spheno-orbital meningiomas (SOMs), with respect to baseline demographics, clinical presentations, Simpson grades, complications, adjuvant therapies, as well as overall survival (OS) and progression-free survival (PFS). Only WHO grade I meningiomas were included. No significant differences in baseline demographics, clinical presentation, or pre-operative KPS were found between the three groups. Simpson grade 1-3 was achieved in 90.1% of LSWMs, 97.1% in CMs (p = 0.05), and 82.6% in SOMs (p = 0.23). There were no significant differences in postoperative infection, hematoma, neurological worsening, 30-day mortality, or OS between the three groups. Lower re-treatment rates were observed in LSWMs and CMs compared to SOMs (p = 0.06). With respect to PFS, there was no significant difference between LSWMs and CMs (89.1% and 88.5% at 5 years, respectively), whereas PFS was significantly higher in LSWMs than in SOMs (79% at 5 years) (p = 0.05). LSWMs without BI should be considered as an intermediate entity between NSBMs and SBMs. LSWMs are similar to SOMs with respect to extent of resection, but more similar to CMs with respect to re-treatment rates and PFS.

Thoracic aggressive vertebral hemangiomas: multidisciplinary management in a hybrid room.

PURPOSE: Vertebral hemangiomas (VH) account for 2-3% of all spinal tumors. The majority is incidentally found on radiographic studies: 1% present with pain and/or neurologic deficits. We report our experience with the multidisciplinary management of aggressive symptomatic thoracic VH by concomitant intraoperative sclerotization with sodium tetradecyl sulfate (STS), vertebroplasty, posterior decompression (with/without fusion) and surgical resection in a hybrid operating room (HR) equipped with a rotational scanner and a radiolucent operating table. METHODS: Patients admitted with aggressive spinal VH between 2007 and 2018 were included. Data regarding demographics, presenting symptoms, location of the lesion, preoperative embolization, length of the surgery, estimated blood loss (EBL) as well as follow-up (FU) were retrieved. RESULTS: Five patients were included (three females, mean age 65 years; range 59-75). Three patients presented with a myelopathy and two mechanical thoracic pain. All patients underwent a single-stage percutaneous sclerotization and vertebroplasty followed by a surgical decompression associated with epidural intralesional injection of STS and subtotal resection of the epidural lesion. Two patients had preoperative embolization. Mean procedural duration was 338 min (range 210-480 min). Four patients had marginal EBL, one patient had 500 ml EBL. Patients had no evidence of lesion recurrence or progression at the end of the follow-up. CONCLUSIONS: The single-stage multimodal management of aggressive symptomatic VH is safe and effective. It allows for a direct intraoperative sclerotherapy combined with maximal tumor resection, resulting in reduced blood loss. The use of STS as a direct intraoperative sclerotizing agent is safe and reliable.

Resection of meningiomas in octogenarians: a comparison with a younger geriatric population.

OBJECTIVE: Intracranial meningiomas (ICMs) may be diagnosed in octogenarians. Since the lesions are rarely life-threatening, surgery is a questionable choice in this age group. The authors' aim in this study was to analyze factors associated with the extent of resection (EOR), overall survival (OS), and postoperative complications in octogenarians undergoing ICM surgery, by using a cohort of septuagenarians as a reference. METHODS: All patients ≥ 70 years of age who underwent surgery at Oslo University Hospital for an ICM between 1990 and 2010 were included in this study. Data on these cases were retrospectively (1990-2002) and prospectively (2003-2010) acquired from a databank belonging to Oslo University Hospital. All related preoperative imaging studies or reports (earlier cases) were reviewed to confirm tumor location, the presence of bone invasion, and the postoperative EOR. RESULTS: In this study, 49 octogenarians (29 females [59.2%], mean age 83.3 ± 2.5 years) were compared with 272 septuagenarians (173 females [63.6%], mean age 74.3 ± 2.7 years). Forty octogenarians (81.6%) and 217 septuagenarians (79.8%) underwent gross-total resection. Simpson grade IV resection was achieved in 9 octogenarians (18.4%) and 4 septuagenarians (1.4%), while Simpson grade V resection was obtained in 4 septuagenarians (1.4%). Postoperative complications were similar in both groups, and 4 octogenarians (8.2%) and 11 septuagenarians (4.1%) died within 30 days after surgery (p = 0.25). No octogenarian underwent adjuvant radiotherapy. The OS was 4.2 ± 2.8 years in the octogenarians and 5.8 ± 4.4 years in the septuagenarians (p < 0.001). Female sex (OR 0.36, 95% CI 0.14-0.93; p = 0.03) and a preoperative Karnofsky Performance Scale score ≥ 70 (OR 0.27, 95% CI 0.10-0.72; p = 0.009) were correlated to the OS. CONCLUSIONS: Octogenarians undergoing surgery for ICMs had an overall reduced OS compared to septuagenarians. However, the clinical relevance of this difference in OS is debatable and has to be put in perspective with expected survival without surgery. Data on symptoms upon admission, EOR, invasive tumor features, and postoperative complications in octogenarians are similar to those observed in septuagenarians. Therefore, the decision concerning whether surgery should be performed must be based on a case-by-case discussion, and surgery should not be immediately dismissed when it comes to ICMs in octogenarians.

Enhanced recovery after spine surgery-a multinational survey assessing surgeons' perspectives.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is the object of numerous publications in various surgical fields. Still, its value in spine surgery is not as recognized as it is in other surgical domains. Our aim was to report neurosurgeons' opinions about ERAS in spine surgery. METHODS: From December 2019 to January 2020, members of the European Association of Neurosurgical Societies were asked to complete an online questionnaire regarding ERAS in spine surgery. RESULTS: N = 234 participants responded to the survey (60% spine neurosurgeons; 22.6% working in private practice). Thirty-two percent reported to have more than 20 years of experience, followed by surgeons having between 5 and 10 (27.4%), 10-15 (17.9%), 15-20 (12%), and 0-5 years (10.7%). Gender distribution (12% vs 27% female gender, p = 0.04), private practice activity (28% vs 14%, p = 0.01), familiarity with the ERAS concept (57.4% vs 27%, p < 0.0001), and its implementation in the daily clinical practice (47.5% vs 18.3%, p < 0.0001) were statistically different between spine and general neurosurgeons. 54.7% of the surgeons were unfamiliar with ERAS in spine surgery. 63.7% considered ERAS as a progress; 36% declared to implement ERAS in their daily clinical practice. 1.7% reported ERAS as a decrease in the quality of management. 6.8% considered ERAS as not having an impact on patient care; 27.8% had no opinion. There were no differences in opinion on ERAS and its implementation between surgeons working in private and public hospitals. 69.5% of the spine surgeons considered ERAS having a positive impact on patient management, versus 55% of non-spine surgeons (p = 0.02). CONCLUSIONS: Efforts are necessary to promote minimal invasive pre-, intra-, and postoperative workflow to improve patient management and reduce complications or side effects particularly adapted to spinal surgery. Specificities of spine patients, in terms of chronic pain, pre- and postoperative pain management, and psychological issues have to be considered.

[Intra-cranial meningiomas - Management of the patients in the microsurgery era]. / Méningiomes intracrâniens†: prise en charge des patients à l'ère microchirurgicale.

Intracranial meningiomas account for 30 to 40 % of the primary lesions of the central nervous system. In most of the cases, the diagnosis of an intracranial meningioma requires a neurosurgical management, in a multi-disciplinary perspective involving radiation therapists, pathologists and, in some cases, oncologists. The variety of clinical presentations and localizations, as well as the varying degrees of aggressiveness, make intracranial meningiomas a protean surgical entity, requiring a case-by-case management tailored to each patient.

Les méningiomes intracrâniens représentent 30 à 40 % des lésions primaires du système nerveux central. La découverte d'un méningiome intracrânien nécessite, dans la plupart des cas, une prise en charge neurochirurgicale, dans une perspective multidisciplinaire impliquant radiothérapeutes, pathologues et, dans certains cas, oncologues. La variété des présentations cliniques et de localisations, ainsi que les degrés d'agressivité variables des lésions font des méningiomes intracrâniens une entité chirurgicale protéiforme, imposant une prise en charge discutée au cas par cas, adaptée à chaque patient.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction.

OBJECTIVEEnhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.METHODSThe authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012-2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016-2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.RESULTSThe pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.CONCLUSIONSThe introduction of the ERAS approach at the authors' institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

Objective functional assessment using the "Timed Up and Go" test in patients with lumbar spinal stenosis.

OBJECTIVEPatient-reported outcome measures (PROMs) are standard of care for the assessment of functional impairment. Subjective outcome measures are increasingly complemented by objective ones, such as the "Timed Up and Go" (TUG) test. Currently, only a few studies report pre- and postoperative TUG test assessments in patients with lumbar spinal stenosis (LSS).METHODSA prospective two-center database was reviewed to identify patients with LSS who underwent lumbar decompression with or without fusion. The subjective functional status was estimated using PROMs for pain (visual analog scale [VAS]), disability (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQoL; 12-Item Short-Form Physical Component Summary [SF-12 PCS] and the EQ-5D) preoperatively, as well as on postoperative day 3 (D3) and week 6 (W6). Objective functional impairment (OFI) was measured using age- and sex-standardized TUG test results.RESULTSSixty-four patients (n = 32 [50%] male, mean age 66.8 ± 11.7 years) were included. Preoperatively, they reported a mean VAS back pain score of 4.1 ± 2.7, VAS leg pain score of 5.4 ± 2.7, RMDI of 10.4 ± 5.3, ODI of 41.9 ± 16.2, SF-12 PCS score of 32.7 ± 8.3, and an EQ-5D index of 0.517 ± 0.226. The preoperative rates of severe, moderate, and mild OFI were 4.7% (n = 3), 12.5% (n = 8), and 7.8% (n = 5), respectively, and the mean OFI T-score was 116.3 ± 23.7. At W6, 60 (93.8%) of 64 patients had a TUG test result within the normal population range (no OFI); 3 patients (4.7%) had mild and 1 patient (1.6%) severe OFI. The mean W6 OFI T-score was significantly decreased (103.1 ± 13.6; p < 0.001). Correspondingly, the PROMs showed a decrease in subjective VAS back pain (1.6 ± 1.7, p < 0.001) and leg pain (1.0 ± 1.8, p < 0.001) scores, disability (RMDI 5.3 ± 4.7, p < 0.001; ODI 21.3 ± 16.1, p < 0.001), and increase in HRQoL (SF-12 PCS 40.1 ± 8.3, p < 0.001; EQ-5D 0.737 ± 0.192, p < 0.001) at W6. The W6 responder status (clinically meaningful improvement) ranged between 81.3% (VAS leg pain) and 29.7% (EQ-5D index) of patients.CONCLUSIONSThe TUG test is a quick and easily applicable tool that reliably measures OFI in patients with LSS. Objective tests incorporating longer walking time should be considered if OFI is suspected but fails to be proven by the TUG test, taking into account that neurogenic claudication may not clinically manifest during the brief TUG examination. Objective tests do not replace the subjective PROM-based assessment, but add valuable information to a comprehensive patient evaluation.

Posterior fossa meningiomas: perioperative predictors of extent of resection, overall survival and progression-free survival.

BACKGROUND: Posterior fossa meningiomas (PFMs) often represent surgical challenges due to their proximity to neurovascular structures. Factors predicting the extent of resection (EOR), overall survival (OS), and progression-free survival (PFS) were identified and integrated in a prediction tool to offer evidence-based personalized therapeutic strategies. METHODS: All meningiomas managed surgically from 1990 to 2010 from a single-center were reviewed. A classification tree was created using the classification and regression tree recursive partitioning analysis that incorporated patient and tumor data available before surgery in order to predict the rates of gross total resection (GTR). RESULTS: A total of 198 patients were identified (female-to-male ratio, 2.7; mean age, 59.1 years) and compared with 1271 supratentorial meningiomas (STMs) operated in the same institution during the same time period. GTR was achieved less often (59.6% versus 81.9%; p < 0.01) in PFMs than STMs. Preoperative neurological symptoms were predictive of higher Simpson grades (OR, 2.19 [1.05; 4.58]; p = 0.04). Age was associated with reduced OS (OR, 1.08 [1.04;1.12]; p < 0.001). A KPS ≥ 70 was associated with higher survival rates (OR, 2.70 [2.19;2.92]; p = 0.02). Higher WHO grades were associated with reduced OS (OR, 3.56 [1.02;12.47]; p = 0.05). The GTR rate varies from 80% in patients without a preoperative deficit to 40% patients with a preoperative deficit, younger than 60 years old, and with adjacent bone invasion. CONCLUSIONS: This study provides a classification tree of the predictors of EOR in PFMs, based upon preoperative demographic, clinical, and radiological variables. An evidence-based management protocol with estimated EORs may guide the decision-making process in PFMs.

Factors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage.

Grading scales yield objective measure of the severity of aneurysmal subarachnoid hemorrhage and serve as to guide treatment decisions and for prognostication. The purpose of this cohort study was to determine what factors govern a patient's disease-specific admission scores in a representative Central European cohort. The Swiss Study of Subarachnoid Hemorrhage includes anonymized data from all tertiary referral centers serving subarachnoid hemorrhage patients in Switzerland. The 2009-2014 dataset was used to evaluate the impact of patient and aneurysm characteristics on the patients' status at admission using descriptive and multivariate regression analysis. The primary/co-primary endpoints were the GCS and the WFNS grade. The secondary endpoints were the Fisher grade, the presence of a thick cisternal or ventricular clot, the presence of a new focal neurological deficit or cranial nerve palsy, and the patient's intubation status. In our cohort of 1787 consecutive patients, increasing patient age by 10 years and low pre-ictal functional status (mRS 3-5) were inversely correlated with "high" GCS score (GCS ≥ 13) (OR 0.91, 95% CI 0.84-0.97 and OR 0.67, 95% CI 0.31-1.46), "low" WFNS grade (grade VI-V) (OR 1.21, 95% CI 1.04-1.20 and OR 1.47, 95% CI 0.66-3.27), and high Fisher grade (grade III-IV) (OR 1.08, 95% CI 1.00-1.17 and OR 1.54, 95% CI 0.55-4.32). Other independent predictors for the patients' clinical and radiological condition at admission were the ruptured aneurysms' location and its size. In sum, chronological age and pre-ictal functional status, as well as the ruptured aneurysm's location and size, determine the patients' clinical and radiological condition at admission to the tertiary referral hospital.

The usefulness of radiological grading scales to predict pain intensity, functional impairment, and health-related quality of life after surgery for lumbar degenerative disc disease.

PURPOSE: The goal of this study is to determine the relationship of radiological grading scales of lumbar degenerative disc disease (DDD) with postoperative pain intensity, functional impairment, and health-related quality of life (HRQoL). METHODS: Response to surgical treatment at 6 weeks (W6) on the visual analogue scale (VAS) for back and leg pain, Oswestry-Disability (ODI) and Roland-Morris Disability Index (RMDI), Timed Up and Go (TUG) test, EuroQol (EQ) 5D, and Short-Form Health-Survey (SF-12) physical component summary (PCS) was compared between patients with different Modic (MOD) and Pfirrmann (PFI) grades. Longitudinal outcomes at day 3 (D3), W6, 6 months (M6), and 1 year (Y1) were compared. RESULTS: The study included 338 patients (mean age, 58.6 years), of which n = 202 (59.8%) had MOD 1-3 and n = 217 (64.2%) PFI 4-5 changes. Patients with MOD 1-3 were as likely as patients without MOD changes to be treatment-responders at W6 in terms of VAS leg pain, ODI, RMDI, TUG, EQ5D, and SF-12 PCS. Similarly, patients with PFI 4-5 were as likely as patients with PFI 1-3 changes to be treatment-responders at W6. Longitudinal outcomes were similar at D3, W6, M6, and Y1 between patients with and without MOD changes. Patients with PFI 4-5 fared similar to those with PFI 1-3 except for inferior HRQoL on the SF-12 PCS metric at Y1. CONCLUSIONS: There was no distinct relationship between commonly used radiological grading scales of lumbar DDD with clinical outcome. Therefore, no prognosis should be made on the grounds of preoperative PFI and MOD classifications for patients undergoing spine surgery for lumbar DDD.

Pre- and postoperative correlation of patient-reported outcome measures with standardized Timed Up and Go (TUG) test results in lumbar degenerative disc disease.

BACKGROUND: The Timed Up and Go (TUG) test is a reliable tool for evaluating objective functional impairment (OFI) in patients with degenerative disc disease before a surgical intervention. The aim of this study is to assess the validity of the TUG test to measure change in function postoperatively. METHODS: In a prospective two-center study, OFI was assessed by the TUG test in patients scheduled for lumbar spine surgery, as well as 3 days (D3) and 6 weeks (W6) postoperatively. At each time point, the TUG test results were correlated with established subjective measures of pain intensity (visual analogue scale (VAS) for back and leg pain), functional impairment (Oswestry Disability Index (ODI)) and health-related quality of life (HRQoL; Short Form-12 (SF12)). RESULTS: The patient cohort comprised 136 patients with a mean age of 57.7 years; 76 were males, 54 had a microdiscectomy for lumbar disc herniation, 58 a decompression for a lumbar spinal stenosis, 24 had a surgical fusion procedure. The mean OFI t-score was 125.1 before surgery, and as patients improved on the subjective measures in the postoperative interval, the OFI t-score likewise decreased to 118.8 (D3) and 103.4 (W6). The Pearson correlation coefficient (PCC) between the OFI t-score and VAS leg pain was 0.187 preoperatively (p = 0.029) and 0.252 at W6 (p = 0.003). The PCC between OFI t-score and the ODI was 0.324 preoperatively (p < 0.001) and 0.413 at W6 (p < 0.001). The PCC between OFI t-score and physical HRQoL (SF12) was -0.091 preoperatively (p = 0.293) and -0.330 at W6 (p < 0.001). CONCLUSIONS: The TUG test is sensitive to change, and reflects the postoperative functional outcome even more exact than preoperatively, as indicated by better correlation coefficients of the OFI t-score with subjective measures of pain intensity, functional impairment and HRQoL.

Incidental durotomy in lumbar spine surgery--a three-nation survey to evaluate its management.

BACKGROUND: Although it is generally accepted that incidental durotomies (ID) should be primarily repaired, the current literature shows no consensus regarding the peri- and postoperative management in case of ID during lumbar spine surgery. Because ID is a rather frequent complication and may be associated with significant disability, we were interested to analyze the current handling of ID in three European countries. METHODS: In March 2014, members of the Swiss, German, and Austrian neurosurgical and spine societies were asked to complete an online questionnaire regarding the management of ID during and after lumbar spine surgery. Two, respectively 4 weeks after the first invitation, reminder requests were sent to all invitees, who had not already responded at that time. RESULTS: There were 175 responses from 397 requests (44.1 %). Responders were predominantly neurosurgeons (89.7 %; 10.3 % were orthopedic surgeons), of which 45.7, 40.0, and 17.8 % work in a non-university hospital, university hospital, and private clinic, respectively. As for the perioperative management of ID, 19.4 % of the responders suggest only bed rest, while, depending on the extent of the ID, 84.0 % suggest additional actions, TachoSil/Spongostan with fibrin glue or a similar product and single suture repair being the most mentioned. Concerning epidural wound drainage in case of ID, 37.2 % desist from placing an epidural wound drainage with or without aspiration, 30.9 % place it sometimes, and 33.7 % place it regularly, but only without aspiration. Most responders prescribe bed rest for 24 (34.9 %) or 48 h (28.0 %), with much fewer prescribing bed rest for 72 h (6.3 %) and none more than 72 h, and 14.9 % of participants never prescribe bed rest. The vast majority of physicians (82.9 %, n = 145) always inform their patients after the operation in case of ID. CONCLUSIONS: There is substantial heterogeneity in the management of incidental durotomies. The majority of spine surgeons today aim at complete/sufficient primary repair of the ID with varying recommendations concerning postoperative bed rest. Still, there is a trend towards early mobilization if the incidental durotomy has been closed completely/sufficiently with no participant favoring bed rest for more than 72 h.