Three-Dimensional Volumetric Magnetic Resonance Imaging Analysis of Syringomyelia Evolution After Posterior Fossa Decompression for Chiari Malformation Type1.

OBJECTIVE: This study aims to introduce a method of three-dimensional (3D) volume magnetic resonance imaging (MRI) measurements to evaluate the evolution of syringomyelia (SM) in adults with Chiari malformation type 1 (CM-1) after posterior fossa decompression (PFD), to provide reproducible and accurate measurements. METHODS: Radiologic and clinical data were obtained for 28 patients. MRI 3D syrinx volumes were evaluated by 2 observers using Philips Healthcare Tumor Tracking tool. RESULTS: The mean SM preoperative volume was 9.1 ± 15.3 cm3 versus 4.6 ± 8.7 cm3 postoperatively, corresponding to a volume variation reduced by -50% ± 33.4%. A total of 21 patients (75%) showed >25% reduction in SM volume postoperatively and 25 patients (89.2%) showed good to excellent postoperative clinical outcomes. Very high interobserver and intraobserver agreement was noted for 3D volumetric analysis with Cohen weighted κ coefficients (0.899-0.991). A negative correlation was found between the number of involved metameres and the postoperative SM volume reduction (Pearson correlation coefficient = 0.378; P = 0.047). Patients with better clinical outcomes had fewer syrinx septae (F = 8.830; P = 0.001). Similarly, better syrinx volume reduction was associated with fewer septae (F = 1.554; P = 0.233). A positive relationship was observed between clinical outcomes and postoperative syrinx volume reduction (F = 1.554; P= 0.233), with data similar to the reported literature. CONCLUSIONS: This study shows that 3D volume measurement of the syrinx cavity on MRI is a reproducible and accurate method to assess the postoperative evolution of SM in CM-1 after PFD. Most patients (75%) showed a reduction of SM volume, with a mean volume decrease of 50%. The reliability is yet to be validated in further larger studies.

Surgical Treatment of Spinal Meningiomas in the Elderly (≥75 Years): Which Factors Affect the Neurological Outcome? An International Multicentric Study of 72 Cases.

(1) Background: With the increasing life expectancy in the Western world, an increasing number of old patients presents with spinal meningioma. Considering the benign nature of these tumors, the functional outcome remains of great importance, since more people reach old age in general conditions of well-being and satisfactory autonomy. (2) Methods: We conducted an international multicenter retrospective study to investigate demographic, clinical and radiological data in a population of elderly patients (≥75 years of age) undergoing surgery for SM from January 2000 to December 2020 in four European referral centers. The aim was to identify prognostic and predictive factors for a good postoperative functional outcome. (3) Results: 72 patients were included in the study. Complete tumor resection (Simpson I or II) was achieved in 67 (95.7%) cases. Intraoperative complications were reported in 7 (9.9%) patients while postoperative complications were found in 12 (16.7%). An excellent general postoperative status (McCormick I and II) was achieved in 65.3%. Overall, surgical resection had a good impact on patients' functional outcome (86.1% either showing an improvement or maintaining a good preoperative status). Uni- and multivariate analyses found that both age and preoperative modified McCormick independently correlated with relative outcome (coeff = −0.058, p = 0.0251; coeff = 0.597, p < 0.0001) and with postoperative status (coeff = 0.058, p = 0.02507; coeff = 0.402, p = 0.00027), respectively. (4) Conclusions: Age and preoperative modified McCormick were found to be independent prognostic factors. Nevertheless, advanced age (≥75), per se, did not seem to contraindicate surgery, even in those with severe preoperative neurological deficits. The functional results sustain the need for surgical resection of SM in the elderly.

Chronic low back pain: Relevance of a new classification based on the injury pattern.

BACKGROUND: The objectives of this study were to define the role for surgery in the treatment of chronic low back pain (cLBP) and to develop a new classification of cLBP based on the pattern of injury. HYPOTHESIS: Surgery may benefit patients with cLBP, and a new classification based on the injury pattern may be of interest. METHOD: A systematic literature review was performed by searching Medline, the Cochrane Library, the French public health database (Banque de Données en Santé Publique), Science Direct, and the National Guideline Clearinghouse. The main search terms were "back pain" OR "lumbar" OR "intervertebral disc replacement" OR "vertebrae" OR "spinal" AND "surgery" OR "surgical" OR "fusion" OR "laminectomy" OR "discectomy". RESULTS: Surgical techniques available for treating cLBP consist of fusion, disc replacement, dynamic stabilisation, and inter-spinous posterior devices. Compared to non-operative management including intensive rehabilitation therapy and cognitive behavioural therapy, fusion is not better in terms of either function (evaluated using the Oswestry Disability Index [ODI]) or pain (level 2). Fusion is better than non-operative management without intensive rehabilitation therapy (level 2). There is no evidence to date that one fusion technique is superior over the others regarding the clinical outcomes (assessed using the ODI). Compared to fusion or multidisciplinary rehabilitation therapy, disc replacement can produce better function and less pain, although the differences are not clinically significant (level 2). The available evidence does not support the use of dynamic stabilisation or interspinous posterior devices to treat cLBP due to degenerative disease (professional consensus within the French Society for Spinal Surgery). The following recommendations can be made: non-operative treatment must be provided for at least 1 year before considering surgery in patients with cLBP due to degenerative disease; patients must be fully informed about alternative treatment options and the risks associated with surgery; standing radiographs must be obtained to assess sagittal spinal alignment and a magnetic resonance imaging scan to determine the mechanism of injury; and, if fusion is performed, the lumbar lordotic curvature must be restored. DISCUSSION: This work establishes the need for a new classification of cLBP based on the presumptive mechanism responsible for the pain. Three categories should be distinguished: non-degenerative cLBP (previously known as symptomatic cLBP), in which the cause of pain is a trauma, spondylolysis, a tumour, an infection, or an inflammatory process; degenerative cLBP (previously known as non-specific cLBP) characterised by variable combinations of degenerative alterations in one or more discs, facet joints, and/or ligaments, with or without regional and/or global alterations in spinal alignment (which must be assessed using specific parameters); and cLBP of unknown mechanism, in which the pain seems to bear no relation to the anatomical abnormalities (and the Fear-Avoidance Beliefs Questionnaire and Hospital Anxiety and Depression Scale may be helpful in this situation). This classification should prove useful in the future for constituting well-defined patient groups, thereby improving the assessment of treatment options. LEVEL OF EVIDENCE: II, systematic review of level II studies.