Endoscopic treatment of thoracolumbar spondylodiscitis: a systematic review and meta-analysis.

INTRODUCTION: Endoscopic surgery is a minimally invasive procedure that has been shown to relieve intradiscal pressure, irrigation of inflammatory factors, and visual debridement, which are crucial for the successful treatment of spondylodiscitis. This study proposes a systematic review and meta-analysis to evaluate the effectiveness and safety of endoscopic treatment of thoracolumbar spondylodiscitis. METHODS: Multiple databases were searched for studies involving thoracolumbar spondylodiscitis treated by endoscopic disc drainage with or without additional posterior fixation over the last twenty years. Studies that met the inclusion criteria, which included outcomes related to the percentage of cured infections, patient satisfaction, regression of inflammatory markers, and/or the percentage of adverse event rates, were included in the analysis. For each study, the percentage of patients who showed improvement or experienced an adverse event was abstracted and pooled in a meta-analysis. RESULTS: Based on the search strategy and inclusion criteria, our systematic review and meta-analysis included 20 studies with 546 participants. The success rate was 89.4% (95% CI 83.1%-94.5%). The rate of major adverse events was 0.3%, while that of postoperative transient paresthesia 2.6% (95% CI 0.8%-5.1%). The recurrence rate was 1.7% (95% CI 0.3%-4.0%), and revision surgery was 8.5% (95% CI 3.8%-14.6%). The causative pathogen diagnosis rate was 73.9% (95% CI 67.7%-79.8%), while progression of deformity was 3.7% (95% CI 0.2%-9.8%), and spontaneous fusion was 40.1% (95% CI 11.0%-73.3%). CONCLUSIONS: Endoscopic discectomy for thoracolumbar spondylodiscitis has been shown to be a safe technique with satisfactory clinical outcomes and a high causative pathogen identification rate.

Combined unilateral biportal endoscopy and video-assisted thoracoscopic surgery for complete excision of a T3-T4 right ganglioneuroma.

Ganglioneuroma (GN) is a rare solid neoplasm developing from neural crest cells of sympathetic ganglia or adrenal medulla. It usually presents as an asymptomatic mass in the retroperitoneal space and mediastinum. Resection through open surgery or minimal access is recommended. The video illustrates the case of a 23-year-old female with an incidental finding of thoracic GN. The authors performed a combined, staged approach to ensure complete resection, which involved unilateral T3-4 biportal endoscopy (UBE) for rhizotomy and nerve root decompression, followed by video-assisted thoracoscopic surgery (VATS) for complete excision. The procedure was uneventful, with full recovery and no postoperative complications. The video can be found here: https://stream.cadmore.media/r10.3171/2024.2.FOCVID23210.

Navigation-guided endoscopic lumbar decompression on foramen and lateral recess in advanced scoliosis.

An 84-year-old woman presented with left leg radiating pain for 18 months and a numeric rating scale score of 8. From examination, motoric on left knee extension was grade 4, with dysesthesia and numbness along the left anterolateral thigh. Imaging showed left L3-4 foraminal and lateral recess stenosis with severe-degree scoliosis. The patient underwent navigation-guided endoscopic transforaminal foraminotomy and lateral recess decompression on the left L3-4 level with a good outcome. Three-years' follow-up showed a well-maintained clinical outcome and coronal sagittal balance. This video explores navigation-guided endoscopic lumbar decompression for neural compression in advanced scoliosis. Further research is encouraged to establish long-term efficacy. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23195.

Systematic Review and Meta-Analysis on Optimal Timing of Surgery for Acute Symptomatic Metastatic Spinal Cord Compression.

Introduction: Symptomatic acute metastatic spinal epidural cord compression (MSCC) is an emergency that requires multimodal attention. However, there is no clear consensus on the appropriate timing for surgery. Therefore, to address this issue, we conducted a systematic review and meta-analysis of the literature to evaluate the outcomes of different surgery timings. Methods: We searched multiple databases for studies involving adult patients suffering from symptomatic MSCC who underwent decompression with or without fixation. We analyzed the data by stratifying them based on timing as emergent (≤24 h vs. >24 h) and urgent (≤48 h vs. >48 h). The analysis also considered adverse postoperative medical and surgical events. The rates of improved outcomes and adverse events were pooled through a random-effects meta-analysis. Results: We analyzed seven studies involving 538 patients and discovered that 83.0% (95% CI 59.0-98.2%) of those who underwent urgent decompression showed an improvement of ≥1 point in strength scores. Adverse events were reported in 21% (95% CI 1.8-51.4%) of cases. Patients who underwent emergent surgery had a 41.3% (95% CI 20.4-63.3%) improvement rate but a complication rate of 25.5% (95% CI 15.9-36.3%). Patients who underwent surgery after 48 h showed 36.8% (95% CI 12.2-65.4%) and 28.6% (95% CI 19.5-38.8%) complication rates, respectively. Conclusion: Our study highlights that a 48 h window may be the safest and most beneficial for patients presenting with acute MSCC and a life expectancy of over three months.

Monocentric experience of transforaminal endoscopic lumbar discectomy and foraminotomy outcomes: pushing the indications and avoiding failure. Report of 200 cases.

BACKGROUND: This paper reports the results of the treatment of our first 200 cases of lumbar disc herniation and foraminal stenosis using full-endoscopic transforaminal lumbar discectomy (FETLD). We analyzed outcomes and radiological parameters to overcome failure and inappropriate indications and also highlighted the red flags for surgeons coming to this field as well as the pathways to success. METHODS: Data on endoscopic procedures were retrospectively analyzed between October 2018 and March 2023. We abstracted sex, age, leg pain by NPRS, postoperative satisfaction according to the MacNaab score, postoperative surgical complications/adverse events (≤30 days), and history of any previous surgery. Furthermore, we measured different radiological parameters to determine the grade of stenosis or discopathy. RESULTS: Once the learning curve was completed, patients' satisfaction increased to 94%, with only a small percentage (6%) of patients unsatisfied 30 days after the operation. Perioperatively, 33.5% of the patients experienced mild to moderate transitory paresthesia. Univariate analysis showed a tendency toward a higher risk of failure in those patients with degenerative listhesis (odds ratio [OR] 4.8, 95% CI 0.97-23.9, P=0.055) as well as those with severely degenerated discs (OR 8.7, 95% CI 0.96-79.4, P=0.054). Conversely, the chances of failure seemed to be lower in patients with severe foraminal stenosis. CONCLUSIONS: FETLD proved its efficacy in treating several degenerative spine conditions or was useful for avoiding previous scarring in patients already operated on to the same extent. Therefore, FETLD can be safely used in patients with comorbidities, the elderly, and when the invasiveness of an open technique is not suitable.

Dural Arteriovenous Fistulas With Cognitive Impairment: Angiographic Characteristics and Treatment Outcomes.

BACKGROUND AND OBJECTIVES: Anecdotal cases of rapidly progressing dementia in patients with dural arteriovenous fistulas (dAVFs) have been reported in small series. However, large series have not characterized these dAVFs. We conducted an analysis of the largest cohort of dAVFs presenting with cognitive impairment (dAVFs-CI), aiming to provide a detailed characterization of this subset of dAVFs. METHODS: Patients with dAVFs-CI were analyzed from the CONDOR Consortium, a multicenter repository comprising 1077 dAVFs. A propensity score matching analysis was conducted to compare dAVFs-CI with Borden type II and type III dAVFs without cognitive impairment (controls). Logistic regression was used to identify angiographic characteristics specific to dAVFs-CI. Furthermore, post-treatment outcomes were analyzed. RESULTS: A total of 60 patients with dAVFs-CI and 60 control dAVFs were included. Outflow obstruction leading to venous hypertension was observed in all dAVFs-CI. Sinus stenosis was significantly associated with dAVFs-CI (OR 2.85, 95% CI: 1.16-7.55, P = .027). dAVFs-CI were more likely to have a higher number of arterial feeders (OR 1.56, 95% CI 1.22-2.05, P < .001) and draining veins (OR 2.05, 95% CI 1.05-4.46, P = .004). Venous ectasia increased the risk of dAVFs-CI (OR 2.38, 95% CI 1.13-5.11, P = .024). A trend toward achieving asymptomatic status at follow-up was observed in patients with successful closure of dAVFs (OR 2.86, 95% CI 0.85-9.56, P = .09). CONCLUSION: Venous hypertension is a key angiographic feature of dAVFs-CI. Moreover, these fistulas present at a mean age of 58 years-old, and exhibit a complex angioarchitecture characterized by an increased number of arteriovenous connections and stenosed sinuses. The presence of venous ectasia further exacerbates the impaired drainage and contributes to the development of dAVFs-CI. Notably, in certain cases, closure of the dAVF has the potential to reverse symptoms.

Current status of research on emergency surgery score in trauma patients: a bibliometric analysis.

Background: The use of a relevant emergency score can provide an accurate assessment of the patient's condition and prognosis. However, the status of related studies remains unclear. The current study analyzed the research status of emergency surgery score (ESS) of trauma patients by using bibliometric methods. Methods: The Science Citation Index Expanded (SCI-E) database in the Web of Science Core Collection (WOSCC) was searched using keywords "trauma" and "emergency surgery score". All records from the search results and cited references were exported to Excel, duplicate literature records were removed, information for the same author and organization in different signature forms were merged. The resulting literatures were analyzed by year of publication, citation, discipline, countries and research institutions, journals, authors, and use of keywords. The cooperation among countries, institutions, and authors was also examined. Results: A total of 2,175 document were retrieved. The number of published literature and the number of citations per year increased annually. The number of published documents (n=1,029) and research cooperation (centrality score, 0.44) in the United States were significantly ahead of those in other countries. The ten research institutions with the largest number of published documents were all from the United States, with much cooperation between research institutions and authors. There were many publications from China (n=108), but with few cooperations (centrality score, 0.22). The journals with the largest number of published articles were professional in the fields of trauma, emergency, and critical care. Keyword analysis showed that infection and shock were important issues besides surgery in the research related to ESS of trauma patients. Conclusions: Research related to ESS of trauma patients has been mainly conducted in the United States, and Chinese researchers should increase their level of cooperation.

The Correlation Between Paraspinal Muscular Morphology, Spinopelvic Parameters, and Back Pain: A Comparative Cohort Study.

BACKGROUND: The relationship between paraspinal muscle degeneration and low back pain (LBP), disability, and structural changes has been investigated in the literature, but it is still a matter of debate. We differentiated paraspinal muscle magnetic resonance imaging by quality and quantity, focusing on fatty infiltration (FI) and paraspinal muscles cross-sectional area (CSA) from T12 to S1 in patients with and without chronic LBP. We aimed to determine whether paraspinal muscle quantity (CSA) and quality (FI) are positively associated with LBP or degenerative/spinopelvic changes in the spine. METHODS: Between 2018 and 2021, we prospectively enrolled 205 patients aged between 18 to 65 years, of whom 153 patients had chronic back pain (back pain group) and 52 patients did not have chronic back pain (no back pain group), and collected clinicodemographic, structural, and spinopelvic data. We correlated these data with paraspinal muscle FI and CSA from T12 to S1. Multivariate models were run to highlight associations between pain, disability, or degenerative and spinopelvic parameters. RESULTS: Age was not associated with increased FI but consistently with decreased CSA values. After adjusting for age, sex, and body mass index, FI was associated with an increased risk of back pain (OR, 8.80; 95% CI, 1.9-39.79; P = 0.006) and high disability scores (OR, 3.41; 95% CI, 1.12-10.30; P = 0.030). Decreased CSA was associated with reduced disc height (P < 0.001), while FI and CSA did not associate with abnormal spinopelvic parameters. CONCLUSIONS: FI on paraspinal muscle highly correlates with back pain and disability but was not found in structural and degenerative changes in the lower back. CLINICAL RELEVANCE: Findings from this study are clinically relevant for patient counseling and rehabilitation strategies. LEVEL OF EVIDENCE: 2b.

The extent of resection of T2-flair hyperintense area for eloquent glioblastomas: outcomes analysis between awake and general anesthesia patients.

BACKGROUND: Maximum safe resection for eloquent areas glioblastomas (GBMs) is the greatest tumor resection achievable without causing neurological deficits. This study aims to assess, through quantitative volumetric analysis, the outcomes of patients with eloquent areas GBMs and correlate the extent of resection (EOR), based on MRI T1-contrast enhanced (CE) and T2- fluid-attenuated inversion recovery (FLAIR) sequences, with patient outcomes and overall survival. METHODS: We prospectively collected and analyzed patients with a diagnosis of primary GBM located in an eloquent area operated between January 2012 and April 2018. We examined 295 consecutive patients' records with GBM and identified 82 eloquent GBMs who met inclusion criteria. We stratified our patients by type of treatment-awake surgery (AS) and general anesthesia (GA) craniotomies. The kind of treatment was correlated with EOR, focusing on exeresis over the limit of the contrast-enhanced signal intensity, including both T1-CE and T2-FLAIR MRI signal alterations. RESULTS: The overall mean EOR value was higher in AS than in GA on T1-CE (P value: 0.010) and T2-Flair MRI images (P value: 0.007). Also, patients who had at least 30% of T2-FLAIR signal resection (EOR≥30%) had a significantly lower risk of death and recurrence (P value: 0.020), independent of residual T1-CE tumor volume. CONCLUSIONS: Extensive T2-Flair resection and AS improve overall survival and reduce risk of recurrence while simultaneously minimizing surgical and medical complications among patients with GBMs in eloquent areas.

Bibliographic Study and Meta-Analysis of Clinical Outcomes of Full-Endoscopic Spine Surgery for Painful Lumbar Spine Conditions.

BACKGROUND: Full-endoscopic spine surgery (FESS) indications already cover degenerative, infectious, and neoplastic diseases. This study aimed to use a bibliometric search and meta-analysis of the highest-quality studies in the last 20 years to determine the quantity and quality of FESS research, geographic distribution, and the outcomes for lumbar conditions. METHODS: Articles on FESS published from 2000 to 2022 were screened and assessed through Web of Science, PubMed, and Scopus. Also, databases were searched for longitudinal studies to pool in a meta-analysis of patients undergoing FESS for lumbar conditions. After stratifying the risk of bias and having collected the studies of the highest quality, we included the proportion of patients with a satisfactory outcome and intraoperative and postoperative adverse events after the analysis of lumbar spine conditions. RESULTS: A total of 728 articles were identified by the bibliographic search. Between 2000 and 2021, the published articles increased 21-fold. Most were from China (70.15%), followed by South Korea (19.5%). Most were retrospective (68.3%) and regarding treatment of lumbar disease (86.4%). Fifty studies, including 34,828 patients, were pooled in the meta-analysis. More than 85% of patients experienced satisfactory improvement in each of different lumbar conditions. Major adverse events were <2%; recurrence and postoperative dysesthesia rates were within those reported for open or mini-invasive procedures. CONCLUSIONS: This study may fill research gaps on FESS and lead to adequately designed studies. Our meta-analysis showed that FESS for lumbar diseases is a procedure with satisfactory outcomes and low rates of adverse events.

Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas.

BACKGROUND: Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs. METHODS: The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed. RESULTS: 60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs. CONCLUSION: Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.

Intracranial hemorrhage after spinal surgery: a literature review.

Background and Objective: Intracranial hemorrhage following spinal surgery is an infrequent but severe complication. Due to its rarity, the etiology, clinical characteristics, and treatment have not yet been fully elucidated. This literature review analyzed the incidence, clinical manifestations, hemorrhage location, current therapeutic strategies, location of operation, and interval time between surgery and bleeding. The objectives of the article were to provide insights for clinicians to promptly identify and prevent potential cases of intracranial hemorrhage. Methods: The authors queried PubMed and Web of Science databases using predefined keywords and included published literature reporting on intracranial hemorrhage after spinal surgery. Relevant case reports, case series, and reviews describing the mechanism of intracranial hemorrhage after spinal surgery and meeting diagnostic criteria for intracranial hemorrhage related to spinal surgery were included. Clinico-demographc data, presentations symptoms, location, index surgery type, and neurological outcomes after brain hemorrhage. Oxford Centre Level of Evidence guidelines was used to evaluate the quality of included studies. Descriptive statistics were used to synthesize the results. Key Content and Findings: A total of 80 publications of level of evidence IV involving 108 patients with median age at diagnosis was 58.5 years (inter-quartile range: 6-85) were analyzed. The incidence of intracranial hemorrhage was 0.08-0.37% among patients who underwent spinal surgery, and this complication occurred predominantly within 48 hours postoperatively. The initial presentation included headache, reduced level of consciousness, dysarthria, nausea, vomiting, hearing loss, blurred vision, neck rigidity, and delayed recovery from anesthesia. More than half (58.3%) of patients improved, while 23.1% still experienced neurological dysfunctions, and 7.4% died. Conclusions: The present study is limited by the levels of evidence of the included studies. There is heterogeneity among cases with respect to patient demographics and medical history. Angiography is critical in assessing the presence and extent of underlying vascular diseases. Intracranial hemorrages may be caused by intraoperative or postoperative cerebrospinal fluid leakage that will lead to intracranial pressure change and induced by intracranial venous or arterial bleeding. The treatment strategies include conservative medical management and surgical treatment. Individualized treatment should be emphasized.

Treatment of thoracolumbar burst fractures: SpineJack vs. posterior arthrodesis-comparison of clinical and radiological outcomes.

Background: Thoracolumbar fractures sometimes require anterior support and post-traumatic deformity correction. SpineJack proved favorable results in cadaveric and clinical studies, with satisfactory pain relief, vertebral height restoration, and low rates of above adjacent fractures, in neurologically intact fractures. We compared patients' clinical and radiological outcomes of thoracolumbar fractures treated either with posterior arthrodesis or SpineJack. Methods: We prospectively collected A2 split and A3, and A4 burst fractures between 2017 and 2021. Patients were stratified in posterior arthrodesis (PA group) and SpineJack (SJ group) and included if age ≥18 years, T11-L3 level, emergent or elective surgery, single or multiple, and neurologically intact. Age, sex, type and level, pain, operative and discharge time, vertebral body heights (VBH), posterior wall retropulsion (PWR), vertebral kyphosis (VK) and local kyphosis (LK) angles, vertebral body (VB) volume, and complications were collected. We then compared clinical-radiographic outcomes between the two groups. Results: We found no significant differences in median postoperative pain while operative time and discharge time were shorter for SJ patients than PA ones (P<0.001). Mean anterior VBH increase was 20.7%, mid-VBH was 25.5%, and posterior VBH was 8.8%, while increase in VB volume was 26.2%. SJ patients had non-inferior VK e LK angles correction to PA ones. Mean PWR value between pre and post SJ implantation was 0.15±0.65 mm, and no adjacent above-level fractures occurred. Conclusions: We showed satisfactory outcomes in a selected range of neurologically intact thoracolumbar split or burst fractures. SJ leads to shorter operative and discharge time and good VB angles and diameters restoration.

Risk of Early Versus Later Rebleeding From Dural Arteriovenous Fistulas With Cortical Venous Drainage.

BACKGROUND: Cranial dural arteriovenous fistulas with cortical venous drainage are rare lesions that can present with hemorrhage. A high rate of rebleeding in the early period following hemorrhage has been reported, but published long-term rates are much lower. No study has examined how risk of rebleeding changes over time. Our objective was to quantify the relative incidence of rebleeding in the early and later periods following hemorrhage. METHODS: Patients with dural arteriovenous fistula and cortical venous drainage presenting with hemorrhage were identified from the multinational CONDOR (Consortium for Dural Fistula Outcomes Research) database. Natural history follow-up was defined as time from hemorrhage to first treatment, rebleed, or last follow-up. Rebleeding in the first 2 weeks and first year were compared using incidence rate ratio and difference. RESULTS: Of 1077 patients, 250 met the inclusion criteria and had 95 cumulative person-years natural history follow-up. The overall annualized rebleed rate was 7.3% (95% CI, 3.2-14.5). The incidence rate of rebleeding in the first 2 weeks was 0.0011 per person-day; an early rebleed risk of 1.6% in the first 14 days (95% CI, 0.3-5.1). For the remainder of the first year, the incidence rate was 0.00015 per person-day; a rebleed rate of 5.3% (CI, 1.7-12.4) over 1 year. The incidence rate ratio was 7.3 (95% CI, 1.4-37.7; P, 0.026). CONCLUSIONS: The risk of rebleeding of a dural arteriovenous fistula with cortical venous drainage presenting with hemorrhage is increased in the first 2 weeks justifying early treatment. However, the magnitude of this increase may be considerably lower than previously thought. Treatment within 5 days was associated with a low rate of rebleeding and appears an appropriate timeframe.

A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment.

BACKGROUND: Different procedures have been used for the treatment of lumbar juxtafacet cysts (JFCs). Recently, full-endoscopic cyst excision has been suggested as a reasonable alternative. We performed a meta-analysis to assess the overall rates of favorable outcomes and adverse events for each available treatment and determine the outcome and complication rates concerning spine stability. METHODS: Multiple databases were searched for English-language studies involving adult patients with lumbar JFCs who had been followed for more than 6 months. Outcomes included the proportion of patients with a satisfactory outcome. Adverse events included recurrence and revision rates as well as intraoperative complications. We further stratified the analysis based on the spine's condition (degenerative listhesis vs without degenerative listhesis). RESULTS: A total of 43 studies, including 2226 patients, were identified. Over 80% of patients experienced satisfactory improvement after surgical excision but only 66.2% after percutaneous cyst rupture and aspiration. Overall, recurrence and revision rates were almost double in patients with preoperative degenerative listhesis at the cyst level, especially in the minimally invasive group (2.1% vs 31.3% and 6.8% vs 13.1%, respectively). The rate of full-endoscopic satisfactory outcomes was approximately 90%, with low rates of adverse events (<2%). CONCLUSION: We analyzed the outcome and adverse event rates for each kind of available treatment for JFC. Full endoscopy has outcomes and rates of adverse events that overlap with open and minimally invasive approaches. LEVEL OF EVIDENCE: 2A.

Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study.

OBJECTIVE: The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs. METHODS: The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0-2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics. RESULTS: The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation. CONCLUSIONS: Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.

Dural arteriovenous fistulas without cortical venous drainage: presentation, treatment, and outcomes.

OBJECTIVE: Current evidence suggests that intracranial dural arteriovenous fistulas (dAVFs) without cortical venous drainage (CVD) have a benign clinical course. However, no large study has evaluated the safety and efficacy of current treatments and their impact over the natural history of dAVFs without CVD. METHODS: The authors conducted an analysis of the retrospectively collected multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Patient demographics and presenting symptoms, angiographic features of the dAVFs, and treatment outcomes of patients with Borden type I dAVFs were reviewed. Clinical and radiological follow-up information was assessed to determine rates of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND), worsening of venous hyperdynamic symptoms (VHSs), angiographic recurrence, and progression or spontaneous regression of dAVFs over time. RESULTS: A total of 342 patients/Borden type I dAVFs were identified. The mean patient age was 58.1 ± 15.6 years, and 62% were women. The mean follow-up time was 37.7 ± 54.3 months. Of 230 (67.3%) treated dAVFs, 178 (77%) underwent mainly endovascular embolization, 11 (4.7%) radiosurgery alone, and 4 (1.7%) open surgery as the primary modality. After the first embolization, most dAVFs (47.2%) achieved only partial reduction in early venous filling. Multiple complementary interventions increased complete obliteration rates from 37.9% after first embolization to 46.7% after two or more embolizations, and 55.2% after combined radiosurgery and open surgery. Immediate postprocedural complications occurred in 35 dAVFs (15.2%) and 6 (2.6%) with permanent sequelae. Of 127 completely obliterated dAVFs by any therapeutic modality, 2 (1.6%) showed angiographic recurrence/recanalization at a mean of 34.2 months after treatment. Progression to Borden-Shucart type II or III was documented in 2.2% of patients and subsequent development of a new dAVF in 1.6%. Partial spontaneous regression was found in 22 (21.4%) of 103 nontreated dAVFs. Multivariate Cox regression analysis demonstrated that older age, NHND, or severe venous-hyperdynamic symptoms at presentation and infratentorial location were associated with worse prognosis. Kaplan-Meier curves showed no significant difference for stable/improved symptoms survival probability in treated versus nontreated dAVFs. However, estimated survival times showed better trends for treated dAVFs compared with nontreated dAVFs (288.1 months vs 151.1 months, log-rank p = 0.28). This difference was statistically significant for treated dAVFs with 100% occlusion (394 months, log-rank p < 0.001). CONCLUSIONS: Current therapeutic modalities for management of dAVFs without CVD may provide better symptom control when complete angiographic occlusion is achieved.

Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR): rationale, design, and initial characterization of patient cohort.

OBJECTIVE: Cranial dural arteriovenous fistulas (dAVFs) are rare lesions, hampering efforts to understand them and improve their care. To address this challenge, investigators with an established record of dAVF investigation formed an international, multicenter consortium aimed at better elucidating dAVF pathophysiology, imaging characteristics, natural history, and patient outcomes. This report describes the design of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) and includes characterization of the 1077-patient cohort. METHODS: Potential collaborators with established interest in the field were identified via systematic review of the literature. To ensure uniformity of data collection, a quality control process was instituted. Data were retrospectively obtained. RESULTS: CONDOR comprises 14 centers in the United States, the United Kingdom, the Netherlands, and Japan that have pooled their data from 1077 dAVF patients seen between 1990 and 2017. The cohort includes 359 patients (33%) with Borden type I dAVFs, 175 (16%) with Borden type II fistulas, and 529 (49%) with Borden type III fistulas. Overall, 852 patients (79%) presented with fistula-related symptoms: 427 (40%) presented with nonaggressive symptoms such as tinnitus or orbital phenomena, 258 (24%) presented with intracranial hemorrhage, and 167 (16%) presented with nonhemorrhagic neurological deficits. A smaller proportion (224 patients, 21%), whose dAVFs were discovered incidentally, were asymptomatic. Many patients (85%, 911/1077) underwent treatment via endovascular embolization (55%, 587/1077), surgery (10%, 103/1077), radiosurgery (3%, 36/1077), or multimodal therapy (17%, 184/1077). The overall angiographic cure rate was 83% (758/911 treated), and treatment-related permanent neurological morbidity was 2% (27/1467 total procedures). The median time from diagnosis to follow-up was 380 days (IQR 120-1038.5 days). CONCLUSIONS: With more than 1000 patients, the CONDOR registry represents the largest registry of cranial dAVF patient data in the world. These unique, well-annotated data will enable multiple future analyses to be performed to better understand dAVFs and their management.

Recurrence after cure in cranial dural arteriovenous fistulas: a collaborative effort by the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR).

OBJECTIVE: Cranial dural arteriovenous fistulas (dAVFs) are often treated with endovascular therapy, but occasionally a multimodality approach including surgery and/or radiosurgery is utilized. Recurrence after an initial angiographic cure has been reported, with estimated rates ranging from 2% to 14.3%, but few risk factors have been identified. The objective of this study was to identify risk factors associated with recurrence of dAVF after putative cure. METHODS: The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) data were retrospectively reviewed. All patients with angiographic cure after treatment and subsequent angiographic follow-up were included. The primary outcome was recurrence, with risk factor analysis. Secondary outcomes included clinical outcomes, morbidity, and mortality associated with recurrence. Risk factor analysis was performed comparing the group of patients who experienced recurrence with those with durable cure (regardless of multiple recurrences). Time-to-event analysis was performed using all collective recurrence events (multiple per patients in some cases). RESULTS: Of the 1077 patients included in the primary CONDOR data set, 457 met inclusion criteria. A total of 32 patients (7%) experienced 34 events of recurrence at a mean of 368.7 days (median 192 days). The recurrence rate was 4.5% overall. Kaplan-Meier analysis predicted long-term recurrence rates approaching 11% at 3 years. Grade III dAVFs treated with endovascular therapy were statistically significantly more likely to experience recurrence than those treated surgically (13.3% vs 0%, p = 0.0001). Tentorial location, cortical venous drainage, and deep cerebral venous drainage were all risk factors for recurrence. Endovascular intervention and radiosurgery were associated with recurrence. Six recurrences were symptomatic, including 2 with hemorrhage, 3 with nonhemorrhagic neurological deficit, and 1 with progressive flow-related symptoms (decreased vision). CONCLUSIONS: Recurrence of dAVFs after putative cure can occur after endovascular treatment. Risk factors include tentorial location, cortical venous drainage, and deep cerebral drainage. Multimodality therapy can be used to achieve cure after recurrence. A delayed long-term angiographic evaluation (at least 1 year from cure) may be warranted, especially in cases with risk factors for recurrence.

Novel Polyethylene Terephthalate Screw Sleeve Implant: Salvage Treatment in a Case of Spine Instability after Vertebroplasty Failure.

INTRODUCTION: The management of osteoporotic fractures is sometimes rather challenging for spinal surgeons, and considering the longer life expectancy induced by improved living conditions, their prevalence is expected to increase. At present, the approaches to osteoporotic fractures differ depending on their severity, location, and the patient's age. State-of-the-art treatments range from vertebroplasty/kyphoplasty to hardware-based spinal stabilization in which screw augmentation with cement is the gold standard. CASE PRESENTATION: We describe the case of a 74-year-old man with an L5 osteoporotic fracture. The patient underwent a vertebroplasty (VP) procedure, which was complicated by a symptomatic cement leakage in the right L4-L5 neuroforamen. We urgently decompressed the affected pedicle via hemilaminectomy. At that point, the column required stability. The extravasation of cement had ruled out the use of cement-augmented pedicle screws but leaving the pedicular screws alone was not considered sufficient to achieve stability. We decided to cover the screws with a polyethylene terephthalate sleeve (OGmend®) to avoid additional cement leakage and to reinforce the screw strength required by the poor bone quality. CONCLUSION: In the evolving technologies used for spinal surgery, screws sleeve implants such as OGmend® are a useful addition to the surgeon's armamentarium when an increased pull-out strength is required and other options are not available.