Deep learning aided preoperative diagnosis of primary central nervous system lymphoma.

The preoperative distinction between glioblastoma (GBM) and primary central nervous system lymphoma (PCNSL) can be difficult, even for experts, but is highly relevant. We aimed to develop an easy-to-use algorithm, based on a convolutional neural network (CNN) to preoperatively discern PCNSL from GBM and systematically compare its performance to experienced neurosurgeons and radiologists. To this end, a CNN-based on DenseNet169 was trained with the magnetic resonance (MR)-imaging data of 68 PCNSL and 69 GBM patients and its performance compared to six trained experts on an external test set of 10 PCNSL and 10 GBM. Our neural network predicted PCNSL with an accuracy of 80% and a negative predictive value (NPV) of 0.8, exceeding the accuracy achieved by clinicians (73%, NPV 0.77). Combining expert rating with automated diagnosis in those cases where experts dissented yielded an accuracy of 95%. Our approach has the potential to significantly augment the preoperative radiological diagnosis of PCNSL.

High Rate of Pulmonary Cement Embolism after Cement-Augmented Pedicle Screw Fixation: A 12-Year Single-Center Study.

BACKGROUND: The global trend toward increased life expectancy because of remarkable improvements in health care quality has drawn increased attention to osteoporotic fractures and degenerative spine diseases. Cement-augmented pedicle screw fixation has been established as the mainstay treatment for patients with poor bone quality. This study aimed to determine the number of patients with cement leakage and pulmonary cement embolism (PCE) as detected on thoracic computed tomography (CT), and to assess the potential risk factors for PCE. METHODS: Patients undergoing cement-augmented pedicle screw placement in our institution between May 2008 and December 2020 were included. Data regarding baseline characteristics, complications, and cement leakage rates were collected. Indications for the performance of a postoperative thoracic CT due to the suspicion of PCE were intra- or postoperative complications, or postoperative oxygen supplementation. Moreover, PCE was accidently diagnosed because the thoracic CT was performed for medical reasons other than the suspicion of PCE (tumor staging, severe pneumonia, or exacerbated chronic pulmonary obstructive disease). RESULTS: A total of 104 patients with a mean age of 72.8 years (standard deviation of 6.7) were included. Of 802 screws, 573 were cement augmented. Of the 104 patients, 44 (42.3%) underwent thoracic CT scans to diagnose PCE; additionally, 67 (64.4%) demonstrated cement leakage, of whom 27 developed PCE and 4 were symptomatic. Cement-augmented thoracic screws were a risk factor for PCE (odds ratio: 1.5; 95% confidence interval: 1.2-2.1; p = 0.004). CONCLUSIONS: This study showed a high prevalence of cement leakage after cement-augmented pedicle screw insertion, with a relatively frequent incidence of PCE, as tracked by thoracic CT scans. Cement-augmented thoracic screw placement was a unique risk factor for PCE.

Emergency Posterior Decompression for Metastatic Spine Tumors in Octogenarians: Clinical Course and Prognostic Factors for Functional Outcomes.

BACKGROUND: This study aimed to describe the clinical outcome of metastatic epidural spinal cord compression in octogenarians with an acute onset of neurological illness who undergo laminectomy, further assess morbidity and mortality rates, and determine potential risk factors for a nonambulatory outcome. METHODS: This retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. RESULTS: Thirty-four patients aged 80 years and older who posterior decompression via laminectomy were enrolled in the present study. The mean Charlson Comorbidity Index was >6 (9.2 ± 2.1). The thoracic spine was the most common site of metastasis. A potentially unstable spine, determined using the Spinal Instability Neoplastic Score, was identified in 79.4% of the cases. Preoperatively, the neurological condition and functional status exhibited a notable decline (mean Motor Score of the American Spinal Injury Association grading system, 78.2 ± 16.4; mean Karnofsky Performance Index, 47.8 ± 19.5). The Motor Score of the American Spinal Injury Association grading system and Karnofsky Performance Index scores improved significantly after surgery. Motor weakness and comorbidities were unique risk factors for the loss of ambulation. CONCLUSIONS: Emergent decompressive laminectomy in patients with acute onset of neurological decline and potentially unstable spines improved functional outcome at discharge. Age should not be a determinant of whether to perform surgery; surgery should be performed in older patients when indicated.

ACDF versus corpectomy in octogenarians with cervical epidural abscess: early complications and outcomes with 2 years of follow-up.

PURPOSE: Cervical spinal epidural abscess (CSEA) is a rare condition, manifesting as rapid neurological deterioration and leading to early neurological deficits. Its management remains challenging, especially in patients older than 80 years. Therefore, we aimed to compare the clinical course and determine morbidity and mortality rates after anterior cervical discectomy and fusion (ACDF) versus corpectomy in octogenarians with ventrally located CSEA at two levels. METHODS: In this single-center retrospective review, we obtained the following from electronic medical records between September 2005 and December 2021: patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality rate. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). RESULTS: Over 16 years, 15 patients underwent ACDF, and 16 patients underwent corpectomy with plate fixation. Between the two groups, patients who underwent corpectomy had a significantly poorer baseline reserve (9.0 ± 2.6 vs. 10.8 ± 2.7; p = 0.004) and had a longer hospitalization period (16.4 ± 13.1 vs. 10.0 ± 5.3 days; p = 0.004) since corpectomy lasted significantly longer (229.6 ± 74.9 min vs. 123.9 ± 47.5 min; p < 0.001). Higher in-hospital and 90-day mortality and readmission rates were observed in the corpectomy group, but the difference was not statistically significant. Both surgeries significantly improved blood infection parameters and neurological status at discharge. Revision surgery due to pseudoarthrosis was required in two patients after corpectomy. CONCLUSIONS: We showed that both ACDF and corpectomy for ventrally located CSEA can be considered as safe treatment strategies for patients aged 80 years and above. However, the surgical approach should be carefully weighed and discussed with the patients and their relatives.

Spinal Meningioma Surgery in Octogenarians: Functional Outcomes and Complications over a 2-Year Follow-Up Period.

Background and Objectives: Population aging in industrial nations has led to an increased prevalence of benign spinal tumors, such as spinal meningiomas (SMs), in the elderly. The leading symptom of SM is local pain, and the diagnosis is confirmed after acute neurological decline. However, little is known about the optimal treatment for this frail patient group. Therefore, this study sought to assess the clinical outcome, morbidity, and mortality of octogenarians with SMs and progressive neurological decline undergoing surgery and to determine potential risk factors for complications. Materials and Methods: Electronic medical records dated between September 2005 and December 2020 from a single institution were retrieved. Data on patient demographics, neurological conditions, functional status, degree of disability, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Results: Thirty patients aged ≥80 years who were diagnosed with SMs underwent posterior decompression via laminectomy and microsurgical tumor resection. The patients presented with a poor baseline history (mean CCI 8.9 ± 1.6 points). Almost all SMs were located in the thoracic spine (n = 25; 83.3%). Progressive preoperative neurological decline was observed in 21/30 (n = 21; 70%) patients with McCormick Scores (mMCS) ≥3, and their mean motor score (MS) was 85.9 ± 12.3. in the in-hospital and 90-day mortality rates were 6.7% and 10.0%, respectively. The MS (93.6 ± 8.3) and mMCS (1.8 ± 0.9) improved significantly postoperatively (p < 0.05). The unique risk factor for complications was the severity of comorbidities. Conclusions: Decompressive laminectomy and tumor removal in octogenarians with progressive neurological decline improved patient functional outcomes at discharge. Surgery seems to be the "state of the art" treatment for symptomatic SMs in elderly patients, even those with poor preoperative clinical and neurologic conditions, whenever there is an acceptable risk from an anesthesiological point of view.

Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65-79 Years and ≥80 Years with 3-Year Follow-Up.

BACKGROUND: Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. METHODS: Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. RESULTS: We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n = 3, 9.4% vs. n = 0, 0.0%; P = 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. CONCLUSIONS: Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.

Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up.

Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression ("decompression group"), and 17 underwent surgical decompression with instrumentation ("instrumentation group"). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.

Early Complications and Cement Leakage in Elderly Patients Who Have Undergone Intraoperative Computed Tomography (CT)-Guided Cement Augmented Pedicle Screw Placement: Eight-Year Single-Center Experience.

OBJECTIVE: To assess early complications, mortality rate, and cement leakage in elderly patients who had undergone navigation-based pedicle screw placement of the thoracic and lumbar spine. METHODS: Eighty-six patients older than 65 years of age who had received cement-augmented pedicle screws for various conditions were retrospectively included between May 2008 and December 2016. Complications, mortality, and cement leakage were determined. All patients had a radiograph as a control. In patients with cement leakage seen on radiographs, a computed tomography scan of the surgical area was also obtained. RESULTS: Average age was 73.4 years (range 65-86 years). A total of 319 vertebral bodies with 637 screws were inserted, of which 458 screws were cement-augmented; 348 (76%) of the augmented screws were placed in the lumbar spine and 110 (24%) in the thoracic spine. Cement leakage occurred in 55 of 86 patients, of whom 52 (60%) were asymptomatic. In all cases with cement leakage (asymptomatic or symptomatic), cement could be found in the perivertebral veins: in the inferior vena cava in 25%, in the epidural space in 7%, in the azygos vein in 5%, and in pulmonary arteries in 7%. CONCLUSIONS: Our study confirms that the use of cement correlates with a high risk of cement leakage in elderly patients. Using computed tomography navigation for screw placement did not reduce the risk of venous cement leakage, but leakage into the epidural space or through a cortical defect seems to be low.