Surgical versus conservative treatment for odontoid fractures in older people: an international prospective comparative study.

BACKGROUND: The optimal treatment for odontoid fractures in older people remains debated. Odontoid fractures are increasingly relevant to clinical practice due to ageing of the population. METHODS: An international prospective comparative study was conducted in fifteen European centres, involving patients aged ≥55 years with type II/III odontoid fractures. The surgeon and patient jointly decided on the applied treatment. Surgical and conservative treatments were compared. Primary outcomes were Neck Disability Index (NDI) improvement, fracture union and stability at 52 weeks. Secondary outcomes were Visual Analogue Scale neck pain, Likert patient-perceived recovery and EuroQol-5D-3L at 52 weeks. Subgroup analyses considered age, type II and displaced fractures. Multivariable regression analyses adjusted for age, gender and fracture characteristics. RESULTS: The study included 276 patients, of which 144 (52%) were treated surgically and 132 (48%) conservatively (mean (SD) age 77.3 (9.1) vs. 76.6 (9.7), P = 0.56). NDI improvement was largely similar between surgical and conservative treatments (mean (SE) -11 (2.4) vs. -14 (1.8), P = 0.08), as were union (86% vs. 78%, aOR 2.3, 95% CI 0.97-5.7) and stability (99% vs. 98%, aOR NA). NDI improvement did not differ between patients with union and persistent non-union (mean (SE) -13 (2.0) vs. -12 (2.8), P = 0.78). There was no difference for any of the secondary outcomes or subgroups. CONCLUSIONS: Clinical outcome and fracture healing at 52 weeks were similar between treatments. Clinical outcome and fracture union were not associated. Treatments should prioritize favourable clinical over radiological outcomes.

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.

Spontaneous spinal hematomas: A case series.

PURPOSE: Spontaneous spinal hematoma (SSH), a rare neurological disorder, demands immediate diagnostic evaluation and intervention to prevent lasting deficits. This case series analyzes instances, particularly highlighting cases where vascular causes were identified despite inconclusive initial imaging. METHODS: In a retrospective study of 20 patients treated for SSH at a Level I spine center from 01/01/2017 to 11/15/2023, we examined demographics, clinical presentation, imaging, and treatment details. Excluding traumatic cases, we present 4 instances of SSH associated with diverse vascular pathologies. RESULTS: Patient ages ranged from 39 to 85 years, with a median age of 66 years. 45% were male, and 55% were female. Among 20 cases, 14 were epidural hematomas, 4 subdural, 1 combined epidural and subdural, and 1 subarachnoid hemorrhage. 85% presented with neurological deficits, while 3 solely had pain-related symptoms. 55% were under anticoagulant medication, and vascular anomalies were found in 25% of cases. The cause of SSH remained unclear in 20% of cases. MRI was performed for all patients, and DSA was conducted in 25% of cases. The 4 highlighted cases involved individuals with distinct vascular pathologies managed surgically. CONCLUSION: Urgent attention is crucial for SSH due to possible lasting neurological consequences. The study emphasizes comprehensive diagnostics and surgical exploration, especially in cases with unclear etiology, to identify and address vascular causes, preventing hematoma progression or recurrence. Despite their rarity, vascular malformations contributing to spinal hematomas warrant particular attention.

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.

The Role of Gut and Oral Microbiota in the Formation and Rupture of Intracranial Aneurysms: A Literature Review.

In recent years, there has been a growing interest in the role of the microbiome in cardiovascular and cerebrovascular diseases. Emerging research highlights the potential role of the microbiome in intracranial aneurysm (IA) formation and rupture, particularly in relation to inflammation. In this review, we aim to explore the existing literature regarding the influence of the gut and oral microbiome on IA formation and rupture. In the first section, we provide background information, elucidating the connection between inflammation and aneurysm formation and presenting potential mechanisms of gut-brain interaction. Additionally, we explain the methods for microbiome analysis. The second section reviews existing studies that investigate the relationship between the gut and oral microbiome and IAs. We conclude with a prospective overview, highlighting the extent to which the microbiome is already therapeutically utilized in other fields. Furthermore, we address the challenges associated with the context of IAs that still need to be overcome.

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.

Proposed diagnostic volumetric bone mineral density thresholds for osteoporosis and osteopenia at the cervicothoracic spine in correlation to the lumbar spine.

OBJECTIVES: To determine the correlation between cervicothoracic and lumbar volumetric bone mineral density (vBMD) in an average cohort of adults and to identify specific diagnostic thresholds for the cervicothoracic spine on the individual subject level. METHODS: In this HIPPA-compliant study, we retrospectively included 260 patients (59.7 ± 18.3 years, 105 women), who received a contrast-enhanced or non-contrast-enhanced CT scan. vBMD was extracted using an automated pipeline ( https://anduin.bonescreen.de ). The association of vBMD between each vertebra spanning C2-T12 and the averaged values at the lumbar spine (L1-L3) was analyzed before and after semiquantitative assessment of fracture status and degeneration, and respective vertebra-specific cut-off values for osteoporosis were calculated using linear regression. RESULTS: In both women and men, trabecular vBMD decreased with age in the cervical, thoracic, and lumbar regions. vBMD values of cervicothoracic vertebrae showed strong correlations with lumbar vertebrae (L1-L3), with a median Pearson value of r = 0.87 (range: rC2 = 0.76 to rT12 = 0.96). The correlation coefficients were significantly lower (p < 0.0001) without excluding fractured and degenerated vertebrae, median r = 0.82 (range: rC2 = 0.69 to rT12 = 0.93). Respective cut-off values for osteoporosis peaked at C4 (209.2 mg/ml) and decreased to 83.8 mg/ml at T12. CONCLUSION: Our data show a high correlation between clinically used mean L1-L3 values and vBMD values elsewhere in the spine, independent of age. The proposed cut-off values for the cervicothoracic spine therefore may allow the determination of low bone mass even in clinical cases where only parts of the spine are imaged. KEY POINTS: vBMD of all cervicothoracic vertebrae showed strong correlation with lumbar vertebrae (L1-L3), with a median Pearson's correlation coefficient of r = 0.87 (range: rC2 = 0.76 to rT12 = 0.96). The correlation coefficients were significantly lower (p < 0.0001) without excluding fractured and moderate to severely degenerated vertebrae, median r = 0.82 (range: rC2 = 0.69 to rT12 = 0.93). We postulate that trabecular vBMD < 200 mg/ml for the cervical spine and < 100 mg/ml for the thoracic spine are strong indicators of osteoporosis, similar to < 80 mg/ml at the lumbar spine.

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.

Concentrations of estradiol, progesterone and testosterone in sefrum and cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage correlate weakly with transcranial Doppler flow velocities.

BACKGROUND: The implication of the steroids estradiol, progesterone and testosterone in cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) has not been comprehensively assessed. In rodents, studies suggested beneficial effects of steroids on cerebral vasospasm after experimental SAH. Studies in humans are warranted, however, a general dilemma of human studies on neuroactive substances is that the brain is not directly accessible and that concentrations in the periphery may not adequately parallel concentrations in the central compartments. In the present study, concentrations of estradiol, progesterone and testosterone in serum and cerebrospinal fluid (CSF) of patients with aSAH were determined. Blood flow velocities in cerebral arteries were measured by transcranial Doppler sonography (TCD). The aim of this study was to evaluate the correlations between the cerebral blood flow velocities and levels of estradiol, progesterone and testosterone in CSF and serum. RESULTS: Samples of serum and CSF of 42 patients with aSAH were collected concomitantly daily or every other day via the arterial line and the external ventricular drainage for two weeks after the hemorrhage. Blood flow velocities in the cerebral arteries were determined by TCD. Total estradiol, progesterone and testosterone concentrations were measured by electro-chemiluminescence immunoassay. The strength of correlation was assessed by Spearman's rank correlation coefficient. The correlation analysis revealed very weak correlations between cerebral blood flow velocities and concentrations of estradiol, progesterone and testosterone levels in both compartments with correlation coefficients below 0.2. CONCLUSIONS: In humans with aSAH, merely very weak correlations between flow velocities in cerebral arteries and concentrations of estradiol, progesterone and testosterone in serum and CSF were demonstrated. These results suggest a limited influence of the respective steroids on cerebral vascular tone although vasodilatory effects were described in rodent studies. Thus, the implication of steroids in processes of neurological deterioration warrants further clarification.

Surgical treatment and neurological outcome of infiltrating intramedullary astrocytoma WHO II-IV: a multicenter retrospective case series.

INTRODUCTION: Primary malignant spinal astrocytomas present rare oncological entities with limited median survival and rapid neurological deterioration. Evidence on surgical therapy, adjuvant treatment, and neurological outcome is sparse. We aim to describe the treatment algorithm and clinical features on patients with infiltrating intramedullary astrocytomas graded WHO II-IV. METHODS: The following is a multicentered retrospective study of patients treated for spinal malignant glioma WHO II-IV in five high-volume neurosurgical departments from 2008 to 2019. Pilocytic astrocytomas were excluded. We assessed data on surgical technique, perioperative neurological status, adjuvant oncological therapy, and clinical outcome. RESULTS: 40 patients were included (diffuse astrocytoma WHO II n = 11, anaplastic astrocytoma WHO III n = 12, WHO IV n = 17). Only 40% were functionally independent before surgery, most patients presented with moderate disability (47.5%). Most patients underwent a biopsy (n = 18, 45%) or subtotal tumor resection (n = 15, 37.5%), and 49% of the patients deteriorated after surgery. Patients with WHO III and IV tumors were treated with combined radiochemotherapy. Median overall survival (OS) was 46.5 months in WHO II, 25.7 months in WHO III, and 7.4 months in WHO IV astrocytomas. Preoperative clinical status and WHO significantly influenced the OS, and the extent of resection did not. CONCLUSION: Infiltrating intramedullary astrocytomas WHO II-IV present rare entities with dismal prognosis. Due to the high incidence of surgery-related neurological impairment, the aim of the surgical approach should be limited to obtaining the histological tissue via a biopsy or, tumor debulking in cases with rapidly progressive severe preoperative deficits.

Spine surgery in pregnant women: a multicenter case series and proposition of treatment algorithm.

PURPOSE: Spinal diseases requiring urgent surgical treatment are rare during pregnancy. Evidence is sparse and data are only available in the form of case reports. Our aim is to provide a comprehensive guide for spinal surgery on pregnant patients and highlight diagnostic and therapeutic aspects. METHODS: The study included a cohort of consecutive pregnant patients who underwent spinal surgery at five high-volume neurosurgical centers between 2010 and 2017. Perioperative and perinatal clinical data were derived from medical records. RESULTS: Twenty-four pregnant patients were included. Three underwent a preoperative cesarean section. Twenty-one patients underwent surgery during pregnancy. Median maternal age was 33 years, and median gestational age was 13 completed weeks. Indications were: lumbar disk prolapse (n = 14; including cauda equina, severe motor deficits or acute pain), unstable spine injuries (n = 4); intramedullary tumor with paraparesis (n = 1), infection (n = 1) and Schwann cell nerve root tumor presenting with high-grade paresis (n = 1). Two patients suffered transient gestational diabetes and 1 patient presented with vaginal bleeding without any signs of fetal complications. No miscarriages, stillbirths, or severe obstetric complications occurred until delivery. All patients improved neurologically after the surgery. CONCLUSION: Spinal surgical procedures during pregnancy seem to be safe. The indication for surgery has to be very strict and surgical procedures during pregnancy should be reserved for emergency cases. For pregnant patients, the surgical strategy should be individually tailored to the mother and the fetus.

Minimally invasive posterior pedicle screw fixation versus open instrumentation in patients with thoracolumbar spondylodiscitis.

BACKGROUND: Due to the aging society, the incidence of pyogenic spondylodiscitis is still rising. Although surgical treatment for spondylodiscitis in general is increasingly accepted, an optimal surgical strategy for treatment of pyogenic spinal infection has not yet been established. The aim of this study was to investigate the suitability of percutaneous posterior pedicle screw fixation for surgical treatment in patients with spondylodiscitis of the thoracolumbar spine. METHODS: We conducted a retrospective review of a consecutive cohort of patients undergoing surgical treatment for spondylodiscitis of the thoracolumbar spine between January 2017 and December 2019. We assessed intraoperative and clinical data, comparing for the classic open and the percutaneous approach. In total, we analyzed 125 cases (39 female, 86 male). The mean age was 69.49 years ± 12.63 years. RESULTS: Forty-seven (37.6%) patients were operated on by a percutaneous approach for pedicle screw fixation, and 78 (62.4%) received open surgery. There was no significant difference in the mean age of patients between both groups (p= 0.57). The time of surgery for percutaneous fixation was statistically significantly shorter (p= 0.03). Furthermore, the estimated intraoperative blood loss was significantly lower in the minimally invasive group (p < 0.001). No significant difference could be observed regarding the recurrence rate of spondylodiscitis and the occurrence of surgical site infections (p= 0.2 and 0.5, respectively). CONCLUSION: Percutaneous posterior pedicle screw fixation appears to be a feasible option for the surgical treatment of a selected patient group with spondylodiscitis of the thoracic and lumbar spine.

Frequency and risk factors for postoperative aneurysm residual after microsurgical clipping.

OBJECTIVE: Aneurysm residuals after clipping are a well-known problem, but the course of aneurysm remnants in follow-up is not well studied. No standards or follow-up guidelines exist for treatment of aneurysm remnants. The aim of this study was to evaluate the risk factors for postoperative aneurysm remnants and their changes during follow-up. METHODS: We performed a retrospective analysis of 666 aneurysms treated via clipping in our hospital from 2006 to 2016. Postoperative and follow-up angiographic data were analyzed for aneurysm remnants and regrowth. Clinical parameters and aneurysm-specific characteristics were correlated with radiological results. RESULTS: The frequency of aneurysm residuals was 12% (78/666). Aneurysms located in the middle cerebral artery (p = 0.02) showed a significantly lower risk for incomplete aneurysm occlusion. Larger aneurysms with a diameter of 11-25 mm (p = 0.005) showed a significantly higher risk for incomplete aneurysm occlusion. Five patients underwent re-clipping during the same hospital stay. Remnants were stratified based on morphological characteristics into "dog ears" (n = 60) and "broad based" (n = 13). The majority of the "dog ears" stayed stable, decreased in size, or vanished during follow-up. Broad-based remnants showed a higher risk of regrowth. CONCLUSIONS: A middle cerebral artery location seems to lower the risk for the incomplete clip occlusion of an aneurysm. Greater aneurysm size (11-25 mm) is associated with a postoperative aneurysm remnant. The majority of "dog-ear" remnants appear to remain stable during follow-up. In these cases, unnecessarily frequent angiographic checks could be avoided. By contrast, broad-based residuals show a higher risk of regrowth that requires close imaging controls if retreatment cannot be performed immediately.

Impact of Goal-Directed Therapy on Delayed Ischemia After Aneurysmal Subarachnoid Hemorrhage: Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is the most important cause for a poor clinical outcome after a subarachnoid hemorrhage. The aim of this study was to assess whether goal-directed hemodynamic therapy (GDHT), as compared to standard clinical care, reduces the rate of DCI after subarachnoid hemorrhage. METHODS: We conducted a prospective randomized controlled trial. Patients >18 years of age with an aneurysmal subarachnoid hemorrhage were enrolled and randomly assigned to standard therapy or GDHT. Advanced hemodynamic monitoring and predefined GDHT algorithms were applied in the GDHT group. The primary end point was the occurrence of DCI. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) 3 months after discharge. RESULTS: In total, 108 patients were randomized to the control (n=54) or GDHT group (n=54). The primary outcome (DCI) occurred in 13% of the GDHT group and in 32% of the control group patients (odds ratio, 0.324 [95% CI, 0.11-0.86]; P=0.021). Even after adjustment for confounding parameters, GDHT was found to be superior to standard therapy (hazard ratio, 2.84 [95% CI, 1.18-6.86]; P=0.02). The GOS was assessed 3 months after discharge in 107 patients; it showed more patients with a low disability (GOS 5, minor or no deficits) than patients with higher deficits (GOS 1-4) in the GDHT group compared with the control group (GOS 5, 66% versus 44%; GOS 1-4, 34% versus 56%; P=0.025). There was no significant difference in mortality between the groups. CONCLUSIONS: GDHT reduced the rate of DCI after subarachnoid hemorrhage with a better functional outcome (GOS=5) 3 months after discharge. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01832389.

Fusiform aneurysms of the vertebrobasilar complex: a single-center series.

BACKGROUND: Fusiform vertebrobasilar aneurysms (FVBAs) may exhibit a disastrous clinical course. Due to their rare occurrence, evidence concerning optimal management is lackluster. OBJECTIVE: To describe the epidemiology, clinical features and treatment outcomes of a consecutive series of patients admitted to our institution. METHODS: We retrospectively evaluated patient charts with respect to clinical presentation, treatment procedures, and the outcomes of all patients diagnosed with an FVBA, which were seen at our institution between March 2006 and February 2017. RESULTS: Forty-five consecutive patients were analyzed. Follow-up was available for 39 patients (86.7%) with a median duration of 28.8 months. Seventeen patients (37.7%) were asymptomatic, 14 patients (31.1%) presented with brainstem ischemia, 8 patients (17.8%) with supratentorial ischemia, and 3 (6.7%) patients with brain stem compression. Aneurysm rupture occurred in 3 patients upon presentation (6.7%). Initially, 19 patients (42.2%) were significantly disabled with Modified Rankin Scale (mRS) scores ≥ 3. Twelve patients (26.7%) underwent invasive treatment: endovascular therapy in 9 cases and surgical treatment in 3 cases. Thirty-three patients received conservative treatment. During follow-up, 6 events (66.7%) of severe disability or death (mRS 4-6) occurred in the endovascular group versus 1 event (33%) in the surgical group versus 19 events (63.3%) among conservatively treated aneurysms. Deterioration was significantly more frequent in patients with symptomatic aneurysms (p = 0.030). CONCLUSION: Patients harboring an FVBA frequently present with disabling symptoms caused by various pathomechanisms. The natural history is aggressive, mostly for initially symptomatic aneurysms, and periprocedural morbidity of surgical or endovascular treatment remains substantial.

Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis.

INTRODUCTION: Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction (CVJ) abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective. In turn, C1-2 fusion is proposed as a single solution for all CVJ abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead relying on the intraoperative assessment of the atlantoaxial joints to confirm instability. METHODS: The authors conducted a comprehensive narrative review of literature and evidence covering this recently emerged hypothesis. The proposed pathomechanisms are discussed and contextualized with published literature. CONCLUSION: The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with CVJ abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression, occipitocervical fusion, and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor for CVJ abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.

Diagnostic reliability of the Berlin classification for complex MCA aneurysms-usability in a series of only giant aneurysms.

BACKGROUND AND OBJECTIVE: The main challenge of bypass surgery of complex MCA aneurysms is not the selection of the bypass type but the initial decision-making of how to exclude the affected vessel segment from circulation. To this end, we have previously proposed a classification for complex MCA aneurysms based on the preoperative angiography. The current study aimed to validate this new classification and assess its diagnostic reliability using the giant aneurysm registry as an independent data set. METHODS: We reviewed the pretreatment neuroimaging of 51 patients with giant (> 2.5 cm) MCA aneurysms from 18 centers, prospectively entered into the international giant aneurysm registry. We classified the aneurysms according to our previously proposed Berlin classification for complex MCA aneurysms. To test for interrater diagnostic reliability, the data set was reviewed by four independent observers. RESULTS: We were able to classify all 51 aneurysms according to the Berlin classification for complex MCA aneurysms. Eight percent of the aneurysm were classified as type 1a, 14% as type 1b, 14% as type 2a, 24% as type 2b, 33% as type 2c, and 8% as type 3. The interrater reliability was moderate with Fleiss's Kappa of 0.419. CONCLUSION: The recently published Berlin classification for complex MCA aneurysms showed diagnostic reliability, independent of the observer when applied to the MCA aneurysms of the international giant aneurysm registry.

Clinical and radiological outcome after anterior cervical discectomy and fusion with stand-alone empty polyetheretherketone (PEEK) cages.

OBJECTIVE: To evaluate long-term results after one-, two-, and three-level anterior cervical discectomy and fusion (ACDF) with stand-alone empty polyetheretherketone (PEEK) cages. METHODS: We performed a retrospective review of a consecutive patient cohort that underwent ACDF with stand-alone empty PEEK cages between 2007 and 2010 with a minimum follow-up of 12 months. Radiographic follow-up included static and flexion/extension radiographs. Changes in the operated segments were measured and compared to radiographs directly after surgery. Clinical outcome was evaluated by a physical examination, pain visual analog scale (VAS), and health-related quality of life (HRQL) using the EuroQOL questionnaire (EQ-5D). Analysis of associations between fusion, subsidence, cervical alignment, and clinical outcome parameters were performed. RESULTS: Of 407 consecutive cases, 318 met all inclusion criteria. Follow-up data were obtained from 265 (83 %) cases. The mean age at presentation was 55 years and 139 patients were male (52 %). In the sample, 127, 125, and 13 patients had one-, two-, and three-level surgeries, respectively; 132 (49 %) presented with spondylotic cervical myelopathy and 133 (50 %) with cervical radiculopathy. Fusion was achieved in 85, 95, and 94 % of segments in one-, two-, and three-level surgeries, respectively. Non-fusion was associated with higher VAS pain levels. Radiographic adjacent segment disease (ASD) was observed in 20, 29, and 15 % in one-, two-, and three-level surgeries, respectively. ASD was associated with lower HRQL. Subsidence was observed in 25, 27, and 15 % of segments in one-, two-, and three-level surgeries, respectively. However, this had no influence on clinical outcome. Follow-up operations for symptomatic adjacent disc disease and implant failure at index level were needed in 16 (6 %) and four (1.5 %) cases, respectively. Younger age was associated with better clinical outcome. Multilevel surgery favored better myelopathy outcomes and fusion reduced overall pain. ASD worsened EuroQOL-Index values. Worsening of the cervical alignment induced arm pain. CONCLUSIONS: One- and two-level ACDF with stand-alone empty PEEK cages achieved very high fusion rates and a low rate of follow-up operations. The rate of good clinical outcome is highly satisfactory. Younger age was the single most influential factor associated with better clinical outcome.

Interobserver variability in the characterization of giant intracranial aneurysms with special emphasis on aneurysm diameter and shape.

BACKGROUND: The Giant Intracranial Aneurysm Registry is a multicenter observational trial exclusively focusing on giant intracranial aneurysms (GIA). As no data exist on the interobserver variability in the radiological description of GIA, there is some uncertainty concerning the reliability of the GIA characteristics included in the registry. We have therefore designed a study to test the interobserver variability in the description of the specific GIA characteristics that are examined in the GIA registry. METHODS: Six different raters analyzed imaging of five GIA concerning GIA location, GIA size, GIA shape, GIA thrombosis, and the presence of perianeurysmal edema. Interobserver variability was examined using intraclass correlation and Fleiss' kappa analysis. RESULTS: The intraclass correlation coefficient was 0.99 (95 % CI 0.97-1.0) for the largest GIA diameter and 0.98 (95 % CI 0.94-1.0) for the largest GIA diameter in an axial imaging slice. We found perfect interobserver agreement (Fleiss' kappa 1.00) in the characterization of GIA location and the presence of perianeurysmal edema and almost perfect interobserver agreement for GIA thrombosis (Fleiss' kappa 0.86, 95 % CI 0.63-1.00). Only moderate interobserver agreement was found in the description of GIA shape (Fleiss' kappa 0.50, 95 % CI 0.27-0.73). CONCLUSIONS: While GIA size, location, thrombosis, and the presence of perianeurysmal edema showed excellent interobserver agreement, the description of GIA shape was achieved with only moderate agreement. Data on GIA shape in multicenter studies, like the GIA registry, should therefore be discussed with caution and potentially reassessed in a centralized fashion.

Vertebral artery injury during foraminal decompression in "low-risk" cervical spine surgery: incidence and management.

OBJECTIVES: Vertebral artery injury (VAI) during foraminal decompression in cervical spine surgery in the absence of repositioning or screw stabilization is rare. Without immediate recognition and treatment, it may have disastrous consequences. We aimed to describe the incidence and management of iatrogenic VAI in low-risk cervical spine surgery. MATERIALS AND METHODS: The records of all patients who underwent surgical procedures of the cervical spine between January 2007 and May 2012 were retrospectively consecutively evaluated. Anterior cervical discectomy and fusion or arthroplasty as well as dorsal foraminal decompression through the Frykholm approach in degenerative diseases were defined as low-risk surgeries (n = 992). RESULTS: VAI occurred in 0.3 % (n = 3) of 992 procedures: in one case during a dorsal foraminal decompression, and in two cases during the anterior cervical discectomy and fusion (ACDF) of two or four levels, respectively. In the first case, the VAI was intraoperatively misdiagnosed. Despite an initially uneventful course, the patient suffered hemorrhage from a pseudoaneurysm of the injured VA 1 month after surgery. The aneurysm was successfully occluded by endovascular coiling. In both ACDF cases, angiography and endovascular stenting of the lacerated segment proceeded immediately after the surgery. All three patients suffered no permanent deterioration. CONCLUSIONS: In a high-volume surgical center, the incidence of VAI during low-risk cervical spine surgery is extremely low, comprising 0.3 % of all cases. The major risks are delayed sequels of the vessel wall laceration. In cases of VAI, immediate angiographic diagnostics and generous indications for endovascular treatment are obligatory.