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

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

Postoperative Communicating Hydrocephalus Following Grade 2/3 Glioma Resection: Incidence, Timing and Risk Factors.

BACKGROUND: In diffusely infiltrating gliomas, the maximum extent of tumor resection is an important predictor of overall survival, irrespective of histological or molecular subtype or tumor grade. For glioblastoma WHO grade 4 (GBM), it has been shown that resection-related events, such as ventricular opening and ventriculitis, increase the risk for development of communicating hydrocephalus (CH) requiring cerebrospinal fluid (CSF) diversion surgery. Risk factors for the development and the incidence of hydrocephalus following resection of other types of infiltrating gliomas are less well established. In this study, we evaluated the incidence and timing of occurrence of different types of hydrocephalus and potential risk factors for the development of CH following resection of grade 2 and 3 gliomas. METHODS: 346 patients who underwent tumor resection (WHO grade 2: 42.2%; 3: 57.8%) at our department between 2006 and 2019 were analyzed retrospectively. For each patient, age, sex, WHO grade, histological type, IDH mutation and 1p/19q codeletion status, tumor localization, number of resections, rebleeding, ventriculitis, ventricular opening during resection and postoperative CSF leak were determined. Uni- as well as multivariate analyses were performed to identify associations with CH and independent risk factors. RESULTS: 24 out of 346 (6.9%) patients needed CSF diversion surgery (implantation of a ventriculoperitoneal or ventriculoatrial shunt) following resection. Nineteen patients (5.5%) had CH, on median, 44 days after the last resection (interquartile range: 18-89 days). Two patients had obstructive hydrocephalus (OH), and three patients had other CSF circulation disorders. CH was more frequent in grade 3 compared to grade 2 gliomas (8.5 vs. 1.4%). WHO grade 3 (odds ratio (OR) 7.5, p = 0.00468), rebleeding (OR 5.0, p = 0.00984), ventriculitis (OR 4.1, p = 0.00463) and infratentorial tumor localization (OR 6.6, p = 0.00300) were identified as significant independent risk factors for the development of post-resection CH. Ventricular opening was significantly associated with CH, but it was not an independent risk factor. CONCLUSION: Physicians treating brain tumor patients should be aware that postoperative CH requiring CSF shunting occurs not only in GBM but also after resection of lower-grade gliomas, especially in grade 3 tumors. It usually occurs several weeks after resection. Rebleeding and postoperative ventriculitis are independent risk factors.

VPS dependency after aneurysmal subarachnoid haemorrhage and influence of admission hyperglycaemia.

Introduction: Hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH) is a common complication which may lead to insertion of a ventriculoperitoneal shunt (VPS). Our aim is to evaluate a possible influence of specific clinical and biochemical factors on VPS dependency with special emphasis on hyperglycaemia on admission. Patients and methods: Retrospective analysis of a monocentric database of aSAH patients. Using univariable and multivariable logistic regression analysis we evaluated factors influencing VPS dependency, with a special focus on hyperglycaemia on blood sample within 24 h of admission, dichotomised at 126 mg/dl. Factors evaluated in the univariable analysis were age, sex, known diabetes, Hunt and Hess grade, Barrow Neurological Institute scale, treatment modality, extra-ventricular drain (EVD) insertion, complications (rebleeding, vasospasm, infarction, decompressive craniectomy, ventriculitis), outcome variables and laboratory parameters (glucose, C-reactive protein, procalcitonin). Results: We included 510 consecutive patients treated with acute aSAH requiring a VPS (mean age 58.2 years, 66% were female). An EVD was inserted in 387 (75.9%) patients. In the univariable analysis, VPS dependency was associated with hyperglycaemia on admission (OR 2.56, 95%CI 1.58-4.14, p < 0.001). In the multivariable regression analysis after stepwise backward regression, factors associated with VPS dependency were hyperglycaemia >126 mg/dl on admission (OR 1.93, 95%CI 1.13-3.30, p = 0.02), ventriculitis (OR 2.33, 95%CI 1.33-4.04, p = 0.003), Hunt and Hess grade (overall p-value 0.02) and decompressive craniectomy (OR 2.68, 95%CI 1.55-4.64, p < 0.001). Conclusion: Hyperglycaemia on admission was associated with an increased probability of VPS placement. If confirmed, this finding might facilitate treatment of these patients by accelerating insertion of a permanent draining system.

Duration between aneurysm rupture and treatment and its association with outcome in aneurysmal subarachnoid haemorrhage.

Timely treatment of aneurysmal subarachnoid haemorrhage (aSAH) is key to prevent further rupture and poor outcome. We evaluated complications and outcome adjusting for time from haemorrhage to treatment. Retrospective analysis of aSAH patients admitted between 2006 and 2020. Data was collected using standardized case report forms. We compared risk factors using multivariable logistic regression. We included 853 patients, 698 (81.8%) were treated within 24 h. Patients with higher Hunt and Hess grades were admitted and treated significantly faster than those with lower grades (overall p-value < 0.001). Fifteen patients (1.8%) rebled before intervention. In the multivariable logistic analysis adjusting for timing, Barrow Neurological Institute score and intracerebral haemorrhage were significantly associated with rebleeding (overall p-value 0.006; OR 3.12, 95%CI 1.09-8.92, p = 0.03, respectively) but timing was not. Treatment > 24 h was associated with higher mortality and cerebral infarction in only the subgroup of lower grades aSAH (OR 3.13, 1.02-9.58 95%CI, p-value = 0.05; OR 7.69, 2.44-25.00, p-value < 0.001, respectively). Therefore treatment > 24 h after rupture is associated with higher mortality and cerebral infarction rates in lower grades aSAH. Delay in treatment primarily affects lower grade aSAH patients. Patients with lower grade aSAH ought to be treated with the same urgency as higher-grade aSAH.

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

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

Primary Bone Tumors of the Spine-Proposal for Treatment Based on a Single Centre Experience.

This study reports a large single-center series of primary bone tumors of the spine (PBTs). We aimed to review the concepts for management, as this kind of tumor represents a very rare entity, and also propose a new treatment algorithm. Retrospective analysis revealed 92 patients receiving surgery for PBTs from 2007 to 2019 at our center. They were analyzed based on surgical management and the course of the disease. A total of 145 surgical procedures were performed (50 cervical, 46 thoracic, 28 lumbar, and 21 sacral). Complete tumor resection was achieved in 65%, of which 22% showed tumor recurrence during follow-up (mean time to recurrence 334 days). The five-year mortality rate was significantly lower after complete resection (3% versus 25% after subtotal resection). Most of the patients improved in their symptoms through surgery. Regarding the tumor entity, the most common PBTs were vertebral hemangiomas (20%), osteoid osteomas (15%), and chordomas (16%). The Enneking graduation system showed a good correlation with the risk of recurrence and mortality. Complete resection in PBTs increased survival rates and remains the method of choice. Thus, quality of life-especially with a higher extent of resection-should be considered.

Postoperative communicating hydrocephalus following glioblastoma resection: Incidence, timing and risk factors.

Introduction: Glioblastoma (GBM) is the most common malignant primary brain tumor. Treatment includes maximally safe surgical resection followed by radiation and/or chemotherapy. However, resection can lead to ventricular opening, potentially increasing the risk for development of communicating hydrocephalus (CH). Complications such as rebleeding and infection may also lead to CH and, eventually, the need for cerebrospinal fluid (CSF) diversion surgery. In this study, we evaluated the incidence of different types of hydrocephalus and potential risk factors for the development of CH following glioblastoma resection. Methods: 726 GBM patients who underwent tumor resection at our department between 2006 and 2019 were analyzed retrospectively. Potential risk factors that were determined for each patient were age, sex, tumor location, the number of resection surgeries, ventricular opening during resection, postoperative CSF leak, ventriculitis, and rebleeding. Uni- as well as multivariate analyses were performed to identify associations with CH and independent risk factors. Results: 55 patients (7.6%) needed CSF diversion surgery (implantation of a ventriculoperitoneal or ventriculoatrial shunt) following resection surgery. 47 patients (6.5%) had CH, on median, 24 days after the last resection (interquartile range: 17-52 days). 3 patients had obstructive hydrocephalus (OH) and 5 patients had other CSF circulation disorders. Ventricular opening (odds ratio (OR): 7.9; p=0.000807), ventriculitis (OR 3.3; p=0.000754), and CSF leak (OR 2.3; p=0.028938) were identified as significant independent risk factors for the development of post-resection CH. Having more than one resection surgery was associated with CH as well (OR 2.1; p=0.0128), and frontal tumors were more likely to develop CH (OR 2.4; p=0.00275), while temporal tumors were less likely (OR 0.41; p=0.0158); However, none of those were independent risk factors. Age, sex, or rebleeding were not associated with postoperative CH. Conclusion: Postoperative CH requiring CSF shunting is not infrequent following GBM resection and is influenced by surgery-related factors. It typically occurs several weeks after resection. If multiple risk factors are present, one should discuss the possibility of postoperative CH with the patient and maybe even consider pre-emptive shunt implantation to avoid interruption of adjuvant tumor therapy. The incidence of CH requiring shunting in GBM patients could rise in the future.

Anterior Pituitary Hormones in Blood and Cerebrospinal Fluid of Patients in Neurocritical Care.

BACKGROUND: Anterior pituitary hormones in blood follow a circadian rhythm, which may be influenced by various factors such as intracranial pathologies. In cerebrospinal fluid (CSF), pituitary hormones have been collected only selectively and circadian rhythm has not yet been investigated. This pilot study analysed diurnal variations of anterior pituitary hormones in patients in neurocritical care to determine whether circadian rhythmicity exists in these patients. Possible influences of intracranial pathologies were also investigated. Blood and CSF concentrations were assessed simultaneously to explore the value of blood concentrations as a surrogate parameter for CSF levels. METHODS: Blood and CSF samples of 20 non-sedated patients were collected at 06:00, noon, 18:00 and midnight, and analysed for adrenocorticotropic hormone (ACTH), cortisol, thyroid-stimulating hormone (TSH) and insulin-like growth factor-1 (IGF-1) concentrations at each of the four time points. ACTH and IGF-1 were measured by sandwich chemiluminescence immunoassay. Cortisol and TSH were measured by electrochemiluminescence immunoassay. RESULTS: Results showed inconsistent circadian rhythms. Less than 50% of the patients showed a circadian rhythmicity of ACTH, cortisol, TSH or IGF-1. Significance of diurnal variations was only present for blood concentrations of TSH. Correlations between blood and CSF concentrations were strong for cortisol and TSH. CONCLUSIONS: CSF concentrations were only in the measurable range in some of the patients. No clear circadian rhythmicity could be identified, except for TSH in blood. Absence of significant diurnal variations could be explained by the underlying pathologies or disturbing influences of the intensive care unit. Blood concentrations of cortisol and TSH may be suitable surrogate parameters for CSF.

Analysis of risk factors for perioperative complications in spine surgery.

Complications in spine surgery can arise in the intraoperative or the immediate postoperative period or in a delayed manner. These complications may lead to severe or even permanent morbidity if left undiagnosed and untreated. We prospectively interviewed 526 patients out of 1140 patients who consecutively underwent spinal surgery in our department between November 2017 and November 2018 and analysed the outcome and complication rates. A 12 months follow-up period was also adopted. We analysed the patients' clinical characteristics, comorbidities, surgical management, survival rates, and outcomes. Risk factor analyses for the development of complications were also performed. Patients' median age was 67 years (range: 13-96). The main diagnoses were as follows: degenerative in 50%, tumour in 22%, traumatic fractures in 13%, infections in 10%, reoperations in 3%, and others in 2%. Surgeries were emergency procedures (within 24 h) in 12%. Furthermore, 59% required instrumentation. The overall postoperative complication rate was 26%. Revision surgery was required in 12% of cases within 30 postoperative days (median time to revision 11 days [IQR 5-15 days]). The most frequent complications included wound healing disorders, re-bleeding, and CSF leakage. Thereby, the risk factor analysis revealed age-adjusted CCI (p = 0.01), metastatic tumour (p = 0.01), and atrial fibrillation (p = 0.02) as significant risk factors for postoperative complications. Additionally, postoperative KPS (p = 0.004), postoperative anaemia (p = 0.001), the length of hospital stay (p = 0.02), and duration of surgery (p = 00.002) were also identified as associated factors. Complication rates after spinal surgeries are still high, especially in patients with metastatic tumour disease and poor clinical status (KPS), requiring revision surgeries in several cases. Therefore, specific risk factors should be determined to carefully select surgery groups.

Treatment during cerebral vasospasm phase-complication association and outcome in aneurysmal subarachnoid haemorrhage.

BACKGROUND: Aneurysm treatment during cerebral vasospasm (CVS) phase is frequently considered as particularly dangerous, mainly because of the risk of cerebral infarct. OBJECTIVE: We aimed to evaluate the risk of aneurysmal subarachnoid haemorrhage (aSAH)-specific complications and functional outcome in patients treated during CVS phase. METHODS: We retrospectively analysed a large, retro- and prospectively collected database of aSAH patients admitted to our department between March 2006 and March 2020. We conducted a uni- and multivariable logistic regression analysis to evaluate influencing factors on rebleeding, cerebral infarct, Glasgow Outcome Score (GOS) at discharge and mortality and assessed the rate of angiographic vasospasm on admission. RESULTS: We included 853 patients. The majority of patients were female (66.6%), mean age was 57.3 years. Out of 853 included patients, 92 (10.8%) were treated during CVS phase, 312 (36.6%) underwent clipping and 541 (63.4%) endovascular treatment. Treatment during CVS phase was significantly associated with cerebral infarct in the multivariable logistic regression analysis, unrelated to the nature of intervention (OR 2.42, 1.29-4.54 95% CI p-value = 0.006). However, patients treated during CVS phase did not have increased risk of unfavourable outcome by GOS on discharge. In addition, they did not have a higher rate of rebleeding or mortality. CONCLUSIONS: Treatment during CVS phase was significantly associated with a higher rate of cerebral infarct as confirmed by imaging. This did not reflect on GOS on discharge, rebleeding, or mortality. Aneurysm treatment during CVS phase is relatively safe and should not be postponed due to the risk of rebleeding and subsequent devastating deterioration.

The Impact of Postoperative Tumor Burden on Patients With Brain Metastases.

Background: Brain metastases were considered to be well-defined lesions, but recent research points to infiltrating behavior. Impact of postoperative residual tumor burden (RTB) and extent of resection are still not defined enough. Patients and Methods: Adult patients with surgery of brain metastases between April 2007 and January 2020 were analyzed. Early postoperative MRI (<72 h) was used to segment RTB. Survival analysis was performed and cutoff values for RTB were revealed. Separate (subgroup) analyses regarding postoperative radiotherapy, age, and histopathological entities were performed. Results: A total of 704 patients were included. Complete cytoreduction was achieved in 487/704 (69.2%) patients, median preoperative tumor burden was 12.4 cm3 (IQR 5.2-25.8 cm3), median RTB was 0.14 cm3 (IQR 0.0-2.05 cm3), and median postoperative tumor volume of the targeted BM was 0.0 cm3 (IQR 0.0-0.1 cm3). Median overall survival was 6 months (IQR 2-18). In multivariate analysis, preoperative KPSS (HR 0.981982, 95% CI, 0.9761-0.9873, p < 0.001), age (HR 1.012363; 95% CI, 1.0043-1.0205, p = 0.0026), and preoperative (HR 1.004906; 95% CI, 1.0003-1.0095, p = 0.00362) and postoperative tumor burden (HR 1.017983; 95% CI; 1.0058-1.0303, p = 0.0036) were significant. Maximally selected log rank statistics showed a significant cutoff for RTB of 1.78 cm3 (p = 0.0022) for all and 0.28 cm3 (p = 0.0047) for targeted metastasis and cutoff for the age of 67 years (p < 0.001). (Stereotactic) Radiotherapy had a significant impact on survival (p < 0.001). Conclusions: RTB is a strong predictor for survival. Maximal cytoreduction, as confirmed by postoperative MRI, should be achieved whenever possible, regardless of type of postoperative radiotherapy.

Navigation for surgical treatment of disorders of the cervical spine - A systematic review.

INTRODUCTION: Computer-assisted navigation (CAN) is a well-established tool in spinal instrumentation surgery. Different techniques - each with specific advantages and disadvantages - are used in the cervical spine. METHODS: A structured summary of different spinal navigation techniques and a review of the literature were done to discuss the advantages and disadvantages of specific navigation tools in the cervical spine. RESULTS: In cervical spine surgery, CAN increases the accuracy of pedicle screw placement, reduces screw mispositioning and leads to fewer revision surgeries. Due to the mobility of the cervical spine, preoperative CT followed by region matching or intraoperative CT are recommended. CONCLUSIONS: CAN increases pedicle screw placement accuracy and should be used in spinal instrumentation for the cervical spine whenever possible.

Surgical management of spinal metastases involving the cervicothoracic junction: results of a multicenter, European observational study.

OBJECTIVE: Surgical management of spinal metastases at the cervicothoracic junction (CTJ) is highly complex and relies on case-based decision-making. The aim of this multicentric study was to describe surgical procedures for metastases at the CTJ and provide guidance for clinical and surgical management. METHODS: Patients eligible for this study were those with metastases at the CTJ (C7-T2) who had been consecutively treated in 2005-2019 at 7 academic institutions across Europe. The Spine Instability Neoplastic Score, neurological function, clinical status, medical history, and surgical data for each patient were retrospectively assessed. Patients were divided into four surgical groups: 1) posterior decompression only, 2) posterior decompression and fusion, 3) anterior corpectomy and fusion, and 4) anterior corpectomy and 360° fusion. Endpoints were complications, surgical revision rate, and survival. RESULTS: Among the 238 patients eligible for inclusion this study, 37 were included in group 1 (15%), 127 in group 2 (53%), 18 in group 3 (8%), and 56 in group 4 (24%). Mechanical pain was the predominant symptom (79%, 189 patients). Surgical complications occurred in 16% (group 1), 20% (group 2), 11% (group 3), and 18% (group 4). Of these, hardware failure (HwF) occurred in 18% and led to surgical revision in 7 of 8 cases. The overall complication rate was 34%. In-hospital mortality was 5%. CONCLUSIONS: Posterior fusion and decompression was the most frequently used technique. Care should be taken to choose instrumentation techniques that offer the highest possible biomechanical load-bearing capacity to avoid HwF. Since the overall complication rate is high, the prevention of in-hospital complications seems crucial to reduce in-hospital mortality.

Surgical Outcome of Trigeminal Schwannomas.

(1) Background: As resection of trigeminal schwannomas is challenging, due to anatomical involvement of the anterior, middle and posterior fossa, the appropriate approach is important. We report our experience with surgical resection of trigeminal schwannomas by simple and classic skull-base approaches. (2) Methods: We performed a retrospective single-center study including patients who underwent surgery for trigeminal schwannoma tumors between June 2007 and May 2020, concentrating on surgical technique, extent of resection, postoperative outcome and complications. (3) Results: We included 13 patients (median age 57.5 with range of 36-83 years, 53.8% (7/13) female. The most common preoperative clinical presentations were facial pain in six (46.2%), hypoacusis in four (30.8%), trigeminal nerve hypesthesia in 11 (V1 46.2% (6/13), V2 (61.5% (8/13), V3 46.2% (6/13)) and headache in three (23.1%) patients. In three cases, the tumor was resected in a two-stage technique. The intradural subtemporal approach was performed in six cases, the extradural technique in two cases, the retrosigmoid approach in five cases, a Kawase approach in two cases and the transnasal endoscopic approach in one case. The gross total resection rate was 76.9% (10/13) and the median follow-up time 24.0 (0-136) months. Three (23.1%) patients developed postoperative anesthesia in at least one branch of the trigeminal nerve. Trigeminal motor function was preserved in 11 (84.6%) patients. Ten of the 11 patients (76.9%) who reported decreased gustation, cerebellar ataxia, visual impairment, or headache improved postoperatively. Two (15.4%) patients exhibited minimal facial palsy (House and Brackmann II-III), which resolved during the follow-up. The total adverse event rate requiring surgical intervention during follow-up was 7.7%. Surgery-related mortality was 0%. (4) Conclusions: Trigeminal schwannomas are rare benign lesions with intra- and extracranial extension. Considering the low operative morbidity and satisfying functional outcome, gross total resection of trigeminal schwannomas is achievable by classic, but also individually tailored approaches. More invasive or combined techniques were not needed with meticulous surgical planning.

Fungal brain infection-no longer a death sentence.

The aim of this case series was to provide a modern cohort of patients with cerebral aspergillosis and show the effectiveness of modern treatment concepts. In a 10-year period from January 2009 to January 2019, we identified 10 patients (6 male, 4 female) who received surgery or frameless stereotactic drainage of a cerebral aspergilloma at our center. Patients' and disease characteristics were recorded. The median age was 65 (range 45 to 83). We conducted 133 cranial surgeries in 100 patients due to cerebral brain abscess (BA) during that time, which leads to a percentage of 10% of aspergilloma within BAs in our patient sample. We performed 3.1 surgeries per patient followed by antifungal treatment for 6 months (= median) according to the microbiological findings. Regarding comorbidities, the mean Charlson comorbidity index (CCI) at the time of admission was 5, representing an estimated 10-year survival of 21%. Six (60%) of 10 patients showed conditions of immunosuppression, one suffered endocarditis after replacement of aortic valves. Four patients showed associated frontobasal bone destruction, mycotic aneurysms, or thromboses. The mean duration of hospital stay was 37 days. Mortality was much lower than in literature. Sixty percent of the patients died during the follow-up period. The outcome of the two immunocompetent patients was more favorable. Cerebral aspergillosis is a rare, but still life-threatening, condition, which predominantly occurs in immunosuppressive conditions. Due to radical surgical and antifungal therapy for several months, mortality can be reduced dramatically.

Midline Meningiomas of the Anterior Skull Base: Surgical Outcomes and a Decision-Making Algorithm for Classic Skull Base Approaches.

(1) Background: Midline meningiomas such as olfactory groove (OGMs), planum sphenoidale (PSMs), or tuberculum sellae meningiomas (TSMs) are challenging, and determining the appropriate approach is important. We propose a decision algorithm for choosing suitable transcranial approaches. (2) Methods: A retrospective chart review between 06/2007 and 01/2020. Clinical outcomes, radiographic findings, and postoperative complication rates were analyzed with respect to operative approaches. (3) Results: We included 88 patients in the analysis. Of these, 18.2% (16/88) underwent an interhemispheric approach, 72.7% (64/88) underwent a pterional/frontolateral/supraorbital approach, 2.3% (2/88) underwent a unilateral subfrontal approach, and 6.8% (6/88) underwent a bifrontal approach. All OGMs underwent median approaches, along with one PSM. All of the other PSMs and TSMs were resected via lateral approaches. The preoperative tumor volume was ∅20.2 ± 27.1 cm3. Median approaches had significantly higher tumor volume but also higher rates of Simpson I resection (75.0% vs. 34.4%). An improvement of visual deficits was observed in 34.1% (30/88). The adverse event rate was 17.0%. Median follow-up was 15.5 months (range 0-112 months). (4) Conclusions: Median approaches provides satisfying results for OGMs, lateral approaches enable sufficient exposure of the visual apparatus for PSMs and TSMs. In proposing a simple decision-making algorithm, the authors found that satisfactory outcomes can be achieved for midline meningiomas.

Psychological predictors of quality of life after anterior cervical discectomy and fusion for degenerative cervical spine disease.

We aimed to identify independent psychological predictors of quality of life (QOL) and functional outcome after anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. We prospectively included patients undergoing ACDF for degenerative cervical disc herniation and stenosis. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and - Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol-5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores. Of 104 included patients who underwent ACDF between March 2013 and November 2017, 92 completed follow-up after 3 and 12 months. The mean Visual Analogue Scale (VAS) scores for neck pain (- 1.4; p < .001) and arm pain (- 1.8; p = .031) significantly decreased by 12 months. QOL scores significantly increased by 3 months (EQ: + 0.2; p < .001; SF-36 PCS: + 6.2; p < .001; SF-36 MCS: + 2.5; p = .044), a benefit which was retained at 12 months. Linear regression analyses identified statistically significant predictors in preoperative ASI-3, SF-36 MCS and STAI-S for postoperative QOL and ODI scores. There is a benefit for patients in terms of quality of life and function after undergoing surgery for degenerative cervical spine disease. With the ASI-3, SF-36 MCS and STAI-S there exist some predictors for postoperative QOL and ODI scores.

Low-Grade Infection and Implant Failure Following Spinal Instrumentation: A Prospective Comparative Study.

BACKGROUND: Spinal instrumentation can be associated with complications, including implant loosening. Hitherto, implant loosening has mainly been attributed to mechanical overload. OBJECTIVE: To examine the role of low-grade infections as the cause of implant failure in suspected aseptic implant loosening following spinal instrumentation. METHODS: A prospective single center observational study was performed. All patients who had revision surgery following spinal instrumentation between August 2015 and February 2018 were screened. Patients with revision surgery due to screw loosening on the computed tomograhy scan constituted the study group. Patients in which the screws where not loosened but removal was performed for other reasons formed the comparison group. Intraoperative swabs were taken and sonication was performed with the explanted material. Results of microbiological cultivation were analyzed. RESULTS: A total of 59 patients were included in the study group and 34 in the comparison group. In the study group in 42.4% of the cultures a bacterium was detected, while in the comparison group only in 17.6%. 84%, and 83.3% of these germs were detected by sonication in the study and comparison group, respectively. The rate of positive cultures was significantly higher in the study group compared to the comparison group (P = .001). The most frequent bacterium cultivated in both groups was Propionibacterium acnes, followed by Staphylococcus species. CONCLUSION: For patients with screw loosening a high level of suspicion for a low-grade infection should be raised. Cultures should be performed from the sonication fluid of the explanted devices in all patients with symptomatic screw loosening.

Metabolic Parameters Influence Brain Infarction and Outcome after Resection of Brain Metastases.

Perioperative infarction in brain tumor surgery occurs in about 30-80% of cases and is strongly associated with poor patient outcomes and longer hospital stays. Risk factors contributing to postoperative brain infarction should be assessed. We retrospectively included all patients who underwent surgery for brain metastases between January 2015 and December 2017. Hemodynamic parameters were analyzed and then correlated to postoperative infarct volume and overall survival. Of 249 patients who underwent biopsy or resection of brain metastases during that time, we included 234 consecutive patients in this study. In total, 172/249 patients showed ischemic changes in postoperative magnet resonance imaging (MRI) (73%). Independent risk factors for postoperative brain infarction were perioperative blood loss (rho 0.189, p = 0.00587), blood glucose concentration (rho 0.206, p = 0.00358), blood lactate concentration (rho 0.176; p = 0.0136) and cumulative time of reduced PaCO2 (rho -0.142; p = 0.0445). Predictors for reduced overall survival were blood lactate (p = 0.007) and blood glucose levels (p = 0.032). Other hemodynamic parameters influenced neither infarct volume, nor overall survival. Intraoperative elevated lactate and glucose levels are independently associated with postoperative brain infarction in surgery of brain metastases. Furthermore, they might predict reduced overall survival after surgery. Blood loss during surgery also leads to more cerebral ischemic changes. Close perioperative monitoring of metabolism might reduce those complications.