Clinical safety and feasibility of a novel implantable neuroimmune modulation device for the treatment of rheumatoid arthritis: initial results from the randomized, double-blind, sham-controlled RESET-RA study.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes persistent synovitis, bone damage, and progressive joint destruction. Neuroimmune modulation through electrical stimulation of the vagus nerve activates the inflammatory reflex and has been shown to inhibit the production and release of inflammatory cytokines and decrease clinical signs and symptoms in RA. The RESET-RA study was designed to determine the safety and efficacy of an active implantable device for treating RA. METHODS: The RESET-RA study is a randomized, double-blind, sham-controlled, multi-center, two-stage pivotal trial that enrolled patients with moderate-to-severe RA who were incomplete responders or intolerant to at least one biologic or targeted synthetic disease-modifying anti-rheumatic drug. A neuroimmune modulation device (SetPoint Medical, Valencia, CA) was implanted on the left cervical vagus nerve within the carotid sheath in all patients. Following post-surgical clearance, patients were randomly assigned (1:1) to active stimulation or non-active (control) stimulation for 1 min once per day. A predefined blinded interim analysis was performed in patients enrolled in the study's initial stage (Stage 1) that included demographics, enrollment rates, device implantation rates, and safety of the surgical procedure, device, and stimulation over 12 weeks of treatment. RESULTS: Sixty patients were implanted during Stage 1 of the study. All device implant procedures were completed without intraoperative complications, infections, or surgical revisions. No unanticipated adverse events were reported during the perioperative period and at the end of 12 weeks of follow-up. No study discontinuations were due to adverse events, and no serious adverse events were related to the device or stimulation. Two serious adverse events were related to the implantation procedure: vocal cord paresis and prolonged hoarseness. These were reported in two patients and are known complications of surgical implantation procedures with vagus nerve stimulation devices. The adverse event of vocal cord paresis resolved after vocal cord augmentation injections with filler and speech therapy. The prolonged hoarseness had improved with speech therapy, but mild hoarseness persists. CONCLUSIONS: The surgical procedures for implantation of the novel neuroimmune modulation device for the treatment of RA were safe, and the device and its use were well tolerated. TRIAL REGISTRATION: NCT04539964; August 31, 2020.

A New Method to Evaluate Pressure Distribution Using a 3D-Printed C2-C3 Cervical Spine Model with an Embedded Sensor Array.

Cervical degenerative disc diseases such as myelopathy and radiculopathy often require conventional treatments like artificial cervical disc replacement or anterior cervical discectomy and fusion (ACDF). When designing a medical device, like the stand-alone cage, there are many design inputs to consider. However, the precise biomechanics of the force between the vertebrae and implanted devices under certain conditions require further investigation. In this study, a new method was developed to evaluate the pressure between the vertebrae and implanted devices by embedding a sensor array into a 3D-printed C2-C3 cervical spine. The 3D-printed cervical spine model was subjected to a range of axial loads while under flexion, extension, bending and compression conditions. Cables were used for the application of a preload and a robotic arm was used to recreate the natural spine motions (flexion, extension, and bending). To verify and predict the total pressure between the vertebrae and the implanted devices, a 3D finite element (FE) numerical mathematical model was developed. A preload was represented by applying 22 N of force on each of the anterior tubercles for the C2 vertebra. The results of this study suggest that the sensor is useful in identifying static pressure. The pressure with the robot arm was verified from the FE results under all conditions. This study indicates that the sensor array has promising potential to reduce the trial and error with implants for various surgical procedures, including multi-level artificial cervical disk replacement and ACDF, which may help clinicians to reduce pain, suffering, and costly follow-up procedures.

Effect of graded posterior element and ligament removal on annulus stress and segmental stability in lumbar spine stenosis: a finite element analysis study.

The study aimed to investigate the impact of posterior element and ligament removal on the maximum von Mises stress, and maximum shear stress of the eight-layer annulus for treating stenosis at the L3-L4 and L4-L5 levels in the lumbar spine. Previous studies have indicated that laminectomy alone can result in segmental instability unless fusion is performed. However, no direct correlations have been established regarding the impact of posterior and ligament removal. To address this gap, four models were developed: Model 1 represented the intact L2-L5 model, while model 2 involved a unilateral laminotomy involving the removal of a section of the L4 inferior lamina and 50% of the ligament flavum between L4 and L5. Model 3 consisted of a complete laminectomy, which included the removal of the spinous process and lamina of L4, as well as the relevant connecting ligaments between L3-L4 and L4-L5 (ligament flavum, interspinous ligament, supraspinous ligament). In the fourth model, a complete laminectomy with 50% facetectomy was conducted. This involved the same removals as in model 3, along with a 50% removal of the inferior/superior facets of L4 and a 50% removal of the facet capsular ligaments between L3-L4 and L4-L5. The results indicated a significant change in the range of motion (ROM) at the L3-L4 and L4-L5 levels during flexion and torque situations, but no significant change during extension and bending simulation. The ROM increased by 10% from model 1 and 2 to model 3, and by 20% to model 4 during flexion simulation. The maximum shear stress and maximum von-Mises stress of the annulus and nucleus at the L3-L4 levels exhibited the greatest increase during flexion. In all eight layers of the annulus, there was an observed increase in both the maximum shear stress and maximum von-Mises stress from model 1&2 to model 3 and model 4, with the highest rate of increase noted in layers 7&8. These findings suggest that graded posterior element and ligament removal have a notable impact on stress distribution and range of motion in the lumbar spine, particularly during flexion.

A Review of Finite Element Modeling for Anterior Cervical Discectomy and Fusion.

The cervical spine poses many complex challenges that require complex solutions. Anterior cervical discectomy and fusion (ACDF) has been one such technique often employed to address such issues. In order to address the problems with ACDF and assess the modifications that have been made to the technique over time, finite element analyses (FEA) have proven to be an effective tool. The variations of cervical spine FEA models that have been produced over the past couple of decades, particularly more recent representations of more complex geometries, have not yet been identified and characterized in any literature. Our objective was to present material property models and cervical spine models for various simulation purposes. The outlining and refinement of the FEA process will yield more reliable outcomes and provide a stable basis for the modeling protocols of the cervical spine.

In Vitro and In Vivo Drug-Response Profiling Using Patient-Derived High-Grade Glioma.

BACKGROUND: Genomic profiling cannot solely predict the complexity of how tumor cells behave in their in vivo microenvironment and their susceptibility to therapies. The aim of the study was to establish a functional drug prediction model utilizing patient-derived GBM tumor samples for in vitro testing of drug efficacy followed by in vivo validation to overcome the disadvantages of a strict pharmacogenomics approach. METHODS: High-throughput in vitro pharmacologic testing of patient-derived GBM tumors cultured as 3D organoids offered a cost-effective, clinically and phenotypically relevant model, inclusive of tumor plasticity and stroma. RNAseq analysis supplemented this 128-compound screening to predict more efficacious and patient-specific drug combinations with additional tumor stemness evaluated using flow cytometry. In vivo PDX mouse models rapidly validated (50 days) and determined mutational influence alongside of drug efficacy. We present a representative GBM case of three tumors resected at initial presentation, at first recurrence without any treatment, and at a second recurrence following radiation and chemotherapy, all from the same patient. RESULTS: Molecular and in vitro screening helped identify effective drug targets against several pathways as well as synergistic drug combinations of cobimetinib and vemurafenib for this patient, supported in part by in vivo tumor growth assessment. Each tumor iteration showed significantly varying stemness and drug resistance. CONCLUSIONS: Our integrative model utilizing molecular, in vitro, and in vivo approaches provides direct evidence of a patient's tumor response drifting with treatment and time, as demonstrated by dynamic changes in their tumor profile, which may affect how one would address that drift pharmacologically.

Upregulation of the Oct3/4 Network in Basal Breast Cancer Is Associated with Its Metastatic Potential and Shows Tissue Dependent Variability.

Adaptive plasticity of Breast Cancer stem cells (BCSCs) is strongly correlated with cancer progression and resistance, leading to a poor prognosis. In this study, we report the expression profile of several pioneer transcription factors of the Oct3/4 network associated with tumor initiation and metastasis. In the triple negative breast cancer cell line (MDA-MB-231) stably transfected with human Oct3/4-GFP, differentially expressed genes (DEGs) were identified using qPCR and microarray, and the resistance to paclitaxel was assessed using an MTS assay. The tumor-seeding potential in immunocompromised (NOD-SCID) mice and DEGs in the tumors were also assessed along with the intra-tumor (CD44+/CD24-) expression using flow cytometry. Unlike 2-D cultures, the Oct3/4-GFP expression was homogenous and stable in 3-D mammospheres developed from BCSCs. A total of 25 DEGs including Gata6, FoxA2, Sall4, Zic2, H2afJ, Stc1 and Bmi1 were identified in Oct3/4 activated cells coupled with a significantly increased resistance to paclitaxel. In mice, the higher Oct3/4 expression in tumors correlated with enhanced tumorigenic potential and aggressive growth, with metastatic lesions showing a >5-fold upregulation of DEGs compared to orthotopic tumors and variability in different tissues with the highest modulation in the brain. Serially re-implanting tumors in mice as a model of recurrence and metastasis highlighted the sustained upregulation of Sall4, c-Myc, Mmp1, Mmp9 and Dkk1 genes in metastatic lesions with a 2-fold higher expression of stem cell markers (CD44+/CD24-). Thus, Oct3/4 transcriptome may drive the differentiation and maintenance of BCSCs, promoting their tumorigenic potential, metastasis and resistance to drugs such as paclitaxel with tissue-specific heterogeneity.

Factors influencing cage subsidence in anterior cervical corpectomy and discectomy: a systematic review.

PURPOSE: Various factors have been examined in relation to cage subsidence risk, including cage material, cage geometry, bone mineral density, device type, surgical level, bone graft, and patient age. The present study aims to compare and synthesize the literature of both clinical and biomechanical studies to evaluate and present the factors associated with cage subsidence. METHODS: A comprehensive search of the literature from January 2003 to December 2021 was conducted using the PubMed and ScienceDirect databases by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following the screening for inclusion and exclusion criteria, a total of 49 clinical studies were included. Correlations between clinical and biomechanical studies are also discussed. RESULTS: Patients treated with the cage and plate combination had a lower subsidence rate than patients with the stand-alone cage. Overall, Polyetheretherketone material was shown to have a lower subsidence rate than titanium and other materials. The subsidence rate was also higher when the surgery was performed at levels C5-C7 than at levels C2-C5. No significant correlation was found between age and cage subsidence clinically. CONCLUSIONS: Cage subsidence increases the stress on the anterior fixation system and may cause biomechanical instability. Severe cage subsidence decreases the Cobb angle and intervertebral height, which may cause destabilization of the implant system, such as screw/plate loosening or breakage of the screw/plate. Various factors have been shown to influence the risk of cage subsidence. Examining clinical research alongside biomechanical studies offers a more comprehensive understanding of the subject.

Inter-Specimen Analysis of Diverse Finite Element Models of the Lumbar Spine.

Over the past few decades, there has been a growing popularity in utilizing finite element analysis to study the spine. However, most current studies tend to use one specimen for their models. This research aimed to validate multiple finite element models by comparing them with data from in vivo experiments and other existing finite element studies. Additionally, this study sought to analyze the data based on the gender and age of the specimens. For this study, eight lumbar spine (L2-L5) finite element models were developed. These models were then subjected to finite element analysis to simulate the six fundamental motions. CT scans were obtained from a total of eight individuals, four males and four females, ranging in age from forty-four (44) to seventy-three (73) years old. The CT scans were preprocessed and used to construct finite element models that accurately emulated the motions of flexion, extension, lateral bending, and axial rotation. Preloads and moments were applied to the models to replicate physiological loading conditions. This study focused on analyzing various parameters such as vertebral rotation, facet forces, and intradiscal pressure in all loading directions. The obtained data were then compared with the results of other finite element analyses and in vivo experimental measurements found in the existing literature to ensure their validity. This study successfully validated the intervertebral rotation, intradiscal pressure, and facet force results by comparing them with previous research findings. Notably, this study concluded that gender did not have a significant impact on the results. However, the results did highlight the importance of age as a critical variable when modeling the lumbar spine.

Biomechanical Study of Cervical Endplate Removal on Subsidence and Migration in Multilevel Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This study compares four cervical endplate removal procedures, validated by finite element models. PURPOSE: To characterize the effect of biomechanical strength and increased contact area on the maximum von Mises stress, migration, and subsidence between the cancellous bone, endplate, and implanted cage. OVERVIEW OF LITERATURE: Anterior cervical discectomy and fusion (ACDF) has been widely used for treating patients with degenerative spondylosis. However, no direct correlations have been drawn that incorporate the impact of the contact area between the cage and the vertebra/endplate. METHODS: Model 1 (M1) was an intact C2C6 model with a 0.5 mm endplate. In model 2 (M2), a cage was implanted after removal of the C4-C5 and C5-C6 discs with preservation of the osseous endplate. In model 3 (M3), 1 mm of the osseous endplate was removed at the upper endplate. Model 4 (M4) resembles M3, except that 3 mm of the osseous endplate was removed. RESULTS: The range of motion (ROM) at C2C6 in the M2-M4 models was reduced by at least 9º compared to the M1 model. The von Mises stress results in the C2C3 and C3C4 interbody discs were significantly smaller in the M1 model and slightly increased in the M2-M3 and M3-M4 models. Migration and subsidence decreased from the M2-M3 model, whereas further endplate removal increased the migration and subsidence as shown in the transition from M3 to M4. CONCLUSIONS: The M3 model had the least subsidence and migration. The ROM was higher in the M3 model than the M2 and M4 models. Endplate preparation created small stress differences in the healthy intervertebral discs above the ACDF site. A 1 mm embedding depth created the best balance of mechanical strength and contact area, resulting in the most favorable stability of the construct.

Finite Element Analysis of the Effect of Dynamic Plating on Two-Level Anterior Cervical Discectomy Fusion Biomechanics.

BACKGROUND: The limitations of anterior cervical discectomy and fusion (ACDF) are related to mechanical failure of the construct after recurring subsidence and migration. In the present study, we evaluated the effect of the maximum rotation of variable angle screws on the range of motion (ROM), cage migration, and subsidence. METHODS: Five finite element models were developed from a C2-C7 cervical spine model. The first model was an intact C2-C7 spine model, and the second model was an altered C2-C7 model with C4-C6 cage insertion and a 2-level static plate. The other three models were altered C2-C7 models with the same C4-C6 cage insertion and a 2-level dynamic plate. RESULTS: The ROM of C4-C6 in the static plate model was reduced by ∼14° from the intact model but only reduced by ∼9° in the dynamic plate models. The maximum migration and subsidence at the cage-endplate interface in the dynamic plate models were lower than those in the static plate model for all moments. The von Mises stress of the C3-C4 and C6-C7 discs in the dynamic plate models was lower than that in the static plate model. CONCLUSIONS: Our results indicate that dynamic plating has promising potential (greater ROM and lower von Mises stress of discs) for stabilization in multilevel anterior cervical discectomy and fusion than static plating, although both dynamic and static plates showed lower ROM than the intact model. A lower screw rotational angle resulted in superior biomechanical performance (lower incidence of migration and subsidence) compared with a higher rotational angle in multilevel applications, regardless of loading.

Gliomagenesis is orchestrated by the Oct3/4 regulatory network.

Glioblastoma multiforme (GBM) is a lethal brain tumor characterized by developmental hierarchical phenotypic heterogeneity, therapy resistance and recurrent growth. Neural stem cells (NSCs) from human central nervous system (CNS), and glioblastoma stem cells from patient-derived GBM (pdGSC) samples and cultured in both 2D well-plate and 3D monoclonal neurosphere culture system (pdMNCS). The pdMNCS model shows promise to establish a relevant 3D-tumor environment that maintains GBM cells in the stem cell phase within suspended neurospheres. Utilizing the pdMNCS, we examined GBM cell-lines for a wide spectrum of developmental cancer stem cell markers, including the early blastocyst inner-cell mass (ICM)-specific Nanog, Oct3/4,B, and CD133. We observed that MNCS epigenotype is recapitulated using gliomasphere-derived cells. CD133, the marker of GSC is robustly expressed in 3D-gliomaspheres and localized within the plasma membrane compartment. Conversely, gliomasphere cultures grown in conventional 2D culture quickly lost CD133 expression, indicating its variable expression is dependent on cell-culture conditions. Critically, this experiment demonstrates incomplete differentiation of cytoskeleton microtubules and intermediate filaments (IFs) of patient derived cells, similar to commercially available GBM cell lines. Subsequently, in order to determine whether Oct3/4 it was necessary for CD133 expression and cancer stemness, we transfected 2D and 3D culture with siRNA against Oct3/4 and found a significant reduction in gliomasphere formation. These results suggest that expression of Oct3/4,Aand CD133 suppress differentiation of GSCs.

Advances in CSF shunt devices and their assessment for the treatment of hydrocephalus.

INTRODUCTION: Hydrocephalus is a neurological disorder caused by excessive accumulation of the cerebrospinal fluid (CSF) in the ventricles of the brain. It can be treated by diverting the extra fluid to different parts of the body using a device called a shunt. This paper reviews different shunt devices that are used for this purpose. AREAS COVERED: Shunts have high failure rates either due to infection or mechanical failure, therefore there is still ongoing work to address these two main handicaps. They require additional devices for performance assessment. Here, the paper also reviews different approaches for assessing shunt limitations. Moreover, future prospects are also discussed. EXPERT OPINION: This study shows that shunt devices still remain an important treatment option for hydrocephalus. However, further efforts are required to design more advanced shunts, to eliminate high failure rates in clinical use. Sophisticated sensor systems that can accurately detect and regulate changes in CSF drainage to optimize drainage for individual needs. Moreover, shunt infection problem is still present despite recent improvements such as antibiotic impregnated catheters.

Cage-screw and anterior plating combination reduces the risk of micromotion and subsidence in multilevel anterior cervical discectomy and fusion-a finite element study.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is widely used to treat patients with spinal disorders, where the cage is a critical component to achieve satisfactory fusion results. However, it is still not clear whether a cage with screws or without screws will be the best choice for long-term fusion as the micromotion (sliding distance) and subsidence (penetration) of the cage still take place repeatedly. PURPOSE: This study aims to examine the effect of cage-screws on the biomechanical characteristics of the human spine, implanted cage, and associate hardware by comparing the micromotion and subsidence. STUDY DESIGN: A finite element (FE) analysis study. METHODS: A FE model of a C3-C5 cervical spine with ACDF was developed. The spinal segment was modeled with the removal of the anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), and discectomy was then implanted with a cage-screw system. Three models were analyzed: the first was the original spine (S1 model), the second, S2, was implanted with cages and anterior plating, and the third, S3, was implanted with a cage-screw system in addition to the anterior plate. All investigations were under 1 N•m in flexion, extension, lateral bending, and axial rotation situations. RESULTS: Finite element analysis (FEA) demonstrated that range of motion (ROM) at C3-C4 in the S2 model was significantly reduced more than that in the S3 model, while the ROM at both C4-C5 in the S3 model was reduced more than that in the S2 model in all simulations. The ROM at C3-C5 in the S1 model was reduced by over 5° in the S2 and S3 models in all loading conditions. The micromotion and subsidence at all contacts of C3-C5 in the S3 model were lower than that in the S2 model in all flexion, extension, bending, and axial simulations. The subsidence and micromotion could be seen in the barrier area of the S2 model, while they occurred near the edge of the screw in the S3 model. CONCLUSIONS: These results showed that the cage-screw and anterior plating combination has promising potential to reduce the risk of micromotion and subsidence of implanted cages in two or more level ACDFs. CLINICAL SIGNIFICANCE: The use of double segmental fixation with cage-screw anterior plating combination constructs may increase the stiffness of the construct and reduce the incidence of clinical and radiographic pseudarthrosis following multilevel ACDF, which in turn, could decrease the need for revision surgeries or supplemental posterior fixation.

Robotic Replica of a Human Spine Uses Soft Magnetic Sensor Array to Forecast Intervertebral Loads and Posture after Surgery.

Cervical disc implants are conventional surgical treatments for patients with degenerative disc disease, such as cervical myelopathy and radiculopathy. However, the surgeon still must determine the candidacy of cervical disc implants mainly from the findings of diagnostic imaging studies, which can sometimes lead to complications and implant failure. To help address these problems, a new approach was developed to enable surgeons to preview the post-operative effects of an artificial disc implant in a patient-specific fashion prior to surgery. To that end, a robotic replica of a person's spine was 3D printed, modified to include an artificial disc implant, and outfitted with a soft magnetic sensor array. The aims of this study are threefold: first, to evaluate the potential of a soft magnetic sensor array to detect the location and amplitude of applied loads; second, to use the soft magnetic sensor array in a 3D printed human spine replica to distinguish between five different robotically actuated postures; and third, to compare the efficacy of four different machine learning algorithms to classify the loads, amplitudes, and postures obtained from the first and second aims. Benchtop experiments showed that the soft magnetic sensor array was capable of precisely detecting the location and amplitude of forces, which were successfully classified by four different machine learning algorithms that were compared for their capabilities: Support Vector Machine (SVM), K-Nearest Neighbor (KNN), Random Forest (RF), and Artificial Neural Network (ANN). In particular, the RF and ANN algorithms were able to classify locations of loads applied 3.25 mm apart with 98.39% ± 1.50% and 98.05% ± 1.56% accuracies, respectively. Furthermore, the ANN had an accuracy of 94.46% ± 2.84% to classify the location that a 10 g load was applied. The artificial disc-implanted spine replica was subjected to flexion and extension by a robotic arm. Five different postures of the spine were successfully classified with 100% ± 0.0% accuracy with the ANN using the soft magnetic sensor array. All results indicated that the magnetic sensor array has promising potential to generate data prior to invasive surgeries that could be utilized to preoperatively assess the suitability of a particular intervention for specific patients and to potentially assist the postoperative care of people with cervical disc implants.

First-in-Human Experience With Integration of a Hydrocephalus Shunt Device Within a Customized Cranial Implant.

BACKGROUND: Implantable shunt devices are critical and life saving for hydrocephalus patients. However, these devices are fraught with high complication rates including scalp dehiscence, exposure, and extrusion. In fact, high shunt valve profiles are correlated with increased complications compared to those with lower profiles. As such, we sought a new method for integrating shunt valves for those challenging patients presenting with scalp-related complications. OBJECTIVE: To safely implant and integrate a hydrocephalus shunt valve device within a customized cranial implant, in an effort to limit its high-profile nature as a main contributor to shunt failure and scalp breakdown, and at the same time, improve patient satisfaction by preventing contour deformity. METHODS: A 64-yr-old male presented with an extruding hydrocephalus shunt valve and chronic, open scalp wound. The shunt valve was removed and temporary shunt externalization was performed. He received 2 wk of culture-directed antibiotics. Next, a contralateral craniectomy was performed allowing a new shunt valve system to be implanted within a low-profile, customized cranial implant. All efforts were made, at the patient's request, to decrease the high-profile nature of the shunt valve contributing to his most recent complication. RESULTS: First-in-human implantation was performed without complication. Postoperative shunt identification and programming was uncomplicated. The high-profile nature of the shunt valve was decreased by 87%. At 10 mo, the patient has experienced no complications and is extremely satisfied with his appearance. CONCLUSION: This first-in-human experience suggests that a high-profile hydrocephalus shunt device may be safely integrated within a customized cranial implant.

Clinical outcomes from maximum-safe resection of primary and metastatic brain tumors using awake craniotomy.

OBJECTIVE: To retrospectively analyze outcomes in patients undergoing awake craniotomies for tumor resection at our institution in terms of extent of resection, functional preservation and length of hospital stay. PATIENTS AND METHODS: All cases of adults undergoing awake-craniotomy from September 2012-February 2015 were retrospectively reviewed based on an IRB approved protocol. Information regarding patient age, sex, cancer type, procedure type, location, hospital stay, extent of resection, and postoperative complications was extracted. RESULTS: 76 patient charts were analyzed. Resected cancer types included metastasis to the brain (41%), glioblastoma (34%), WHO grade III anaplastic astrocytoma (18%), WHO grade II glioma (4%), WHO grade I glioma (1%), and meningioma (1%). Over a half of procedures were performed in the frontal lobes, followed by temporal, and occipital locations. The most common indication was for motor cortex and primary somatosensory area lesions followed by speech. Extent of resection was gross total for 59% patients, near-gross total for 34%, and subtotal for 7%. Average hospital stay for the cohort was 1.7days with 75% of patients staying at the hospital for only 24h or less post surgery. In the postoperative period, 67% of patients experienced improvement in neurological status, 21% of patients experienced no change, 7% experienced transient neurological deficits, which resolved within two months post op, 1% experienced transient speech deficit, and 3% experienced permanent weakness. CONCLUSIONS: In a consecutive series of 76 patients undergoing maximum-safe resection for primary and metastatic brain tumors, awake-craniotomy was associated with a short hospital stay and low postoperative complications rate.

Cerebrospinal Fluid and Hydrocephalus: Physiology, Diagnosis, and Treatment.

BACKGROUND: Cerebrospinal fluid (CSF) is found around and inside the brain and vertebral column. CSF plays a crucial role in the protection and homeostasis of neural tissue. METHODS: Key points on the physiology of CSF as well as the diagnostic and treatment options for hydrocephalus are discussed. RESULTS: Understanding the fundamentals of the production, absorption, dynamics, and pathophysiology of CSF is crucial for addressing hydrocephalus. Shunts and endoscopic third ventriculostomy have changed the therapeutic landscape of hydrocephalus. CONCLUSIONS: The treatment of hydrocephalus in adults and children represents a large part of everyday practice for the neurologist, both in benign cases and cancer-related diagnoses.

Surgical Treatment for Leptomeningeal Disease.

BACKGROUND: Advancements in cancer treatment have led to more cases of leptomeningeal disease, which requires a multimodal approach. METHODS: Treatment modalities are reviewed from a neurosurgical standpoint, focusing on intrathecal chemotherapy and shunting devices. Potential complications and how to avoid them are discussed. RESULTS: The Ommaya reservoir and the chemoport are used for administering intrathecal chemotherapy. Use of ventriculo-lumbar perfusion can efficiently deliver chemotherapeutic agents and improve intracerebral pressure. Shunting systems, in conjunction with all of their variations, address the challenge of hydrocephalus in leptomeningeal carcinomatosis. Misplaced catheters, malfunction of the system, and shunt-related infections are known complications of treatment. CONCLUSIONS: From an oncological perspective, the surgical treatment for leptomeningeal disease is limited; however, neurosurgery can be used to aid in the administration of chemotherapy and address the issue of hydrocephalus. Minimizing surgical complications is important in this sensitive patient population.

Resection of the First Rib With Preservation of the T1 Nerve Root in Pancoast Tumors of the Lung.

BACKGROUND: Surgical outcomes for Pancoast (superior sulcus) tumors of the lung have significantly changed during the last few decades and have improved with use of curative-intent surgery by utilizing en bloc complete resections. METHODS: A retrospective analysis was conducted of 11 selected patients treated at Moffitt Cancer Center from 2007 to 2016. Data from patient records were collected and analyzed. RESULTS: All 11 patients with a Pancoast tumor involving the first rib had their T1 root preserved at surgery. In 10 patients (90.9%), the tumor was removed en bloc. Clear margins of resection were documented in 4 cases (36.0%). No patient developed postoperative hand weakness, but 3 patients (27.3%) had minor postoperative complications, including air leak, chylothorax, and pericardial effusion. One iatrogenic injury to the subclavian artery was reported during surgery; the injury was subsequently repaired. No operative mortality was reported. CONCLUSIONS: Radical resection of Pancoast tumors is considered to be safe, and preserving the T1 nerve root provides more favorable, functional outcomes.