Surgical Outcome of Patients With Supratentorial Meningiomas Aged 80 Years or Older-Retrospective International Multicenter Study.

BACKGROUND AND OBJECTIVES: Demographic changes will lead to an increase in old patients, a population with significant risk of postoperative morbidity and mortality, requiring neurosurgery for meningiomas. This multicenter study aims to report neurofunctional status after resection of patients with supratentorial meningioma aged 80 years or older, to identify factors associated with outcome, and to validate a previously proposed decision support tool. METHODS: Neurofunctional status was assessed by the Karnofsky Performance Scale (KPS). Patients were categorized in poor (KPS ≤40), intermediate (KPS 50-70), and good (KPS ≥80) preoperative subgroups. Volumetric analyses of tumor and peritumoral brain edema (PTBE) were performed; volumes were scored as small (<10 cm 3 ), medium (10-50 cm 3 ), and large (>50 cm 3 ). RESULTS: The study population consisted of 262 patients, and the median age at surgery was 83.0 years. The median preoperative KPS was 70; 117 (44.7%) patients were allotted to the good, 113 (43.1%) to the intermediate, and 32 (12.2%) to the poor subgroup. The median tumor and PTBE volumes were 30.2 cm 3 and 27.3 cm 3 ; large PTBE volume correlated with poor preoperative KPS status ( P = .008). The 90-day and 1-year mortality rates were 9.0% and 13.2%, respectively. Within the first postoperative year, 101 (38.5%) patients improved, 87 (33.2%) were unchanged, and 74 (28.2%) were functionally worse (including deaths). Each year increase of age associated with 44% (23%-70%) increased risk of 90-day and 1-year mortality. In total, 111 (42.4%) patients suffered from surgery-associated complications. Maximum tumor diameter ≥5 cm (odds ratio 1.87 [1.12-3.13]) and large tumor volume (odds ratio 2.35 [1.01-5.50]) associated with increased risk of complications. Among patients with poor preoperative status and large PTBE, most (58.3%) benefited from surgery. CONCLUSION: Patients with poor preoperative neurofunctional status and large PTBE most often showed postoperative improvements. The decision support tool may be of help in identifying cases that most likely benefit from surgery.

[Lumbar spinal stenosis]. / Lumbale Spinalkanalstenose.

Lumbar spinal stenosis (LSS) represents a frequent degenerative condition, however, striking a clear correlation between typical symptoms and imaging features remains a challenge. Reasons are a high prevalence of radiological LSS in the older population, a considerable percentage of asymptomatic LSS and the existence of differential diagnoses with similar symptomatology. This discrepancy also affects the outcomes - especially of surgically treated patients with LSS. When considering surgical decompression of LSS, the decision with regards to additive instrumentation and/or fusion remains a controversial point of discussion, in particular at the presence of degenerative spondylolisthesis. Recent, well-designed studies, however, clearly point towards a non-inferiority of decompression alone as opposed to the more invasive strategies.

Intraoperative ultrasonography in laminectomy for degenerative cervical spondylotic myelopathy: a clinical and radiological evaluation.

BACKGROUND: The incidence of cervical myelopathy due to spinal stenosis is constantly growing in an aging population. Especially in multisegmental disease, dorsal laminectomy is the intervention of choice. Intraoperative imaging with ultrasound might provide additional information about extent and sufficiency of spinal cord decompression. METHODS: In this prospective study, the width of the subarachnoid space was systematically measured by intraoperative ultrasound at predefined sites at the cranial and caudal edge of decompression in axial and sagittal reconstruction. These data were compared with corresponding sites on postoperative T2-weighted MRI imaging. In addition, the functional outcome was assessed by modified Japanese Orthopaedic Association (mJOA) score. A historical patient cohort treated without ultrasound-guided laminectomy served as control group. RESULTS: Altogether, 29 patients were included. According to mJOA score at last follow-up, 7/29 patients reported stable symptoms and 21/29 patients showed a substantial benefit with no or minor residual neurological deficits. One patient suffered from a new C5 palsy. Intraoperative ultrasound-guided posterior decompression provided excellent overview in all cases. Measurement of the width of the subarachnoid space acquired by intraoperative ultrasound and postoperative MRI images showed a very high correlation, especially at the cranial level (p < 0.001, r = 0.880). Bland-Altman analysis showed that most patients were within the 1.96 × SD limits of agreement throughout all measurements. No ultrasound procedure-related complications were observed. Compared to a historical cohort of 27 patients, no significant differences were found regarding functional outcome (p = 0.711). CONCLUSION: Intraoperative sonography visualises the surgically achieved restoration of the subarachnoid space in good correlation with postoperative MRI and might serve as a fast, precise and reliable tool for intraoperative imaging in cervical laminectomy. However, we could not demonstrate a clinical benefit with regard to functional outcome.

Vertebral Body Replacement With an Anchored Expandable Titanium Cage in the Cervical Spine: A Clinical and Radiological Evaluation.

BACKGROUND: Expandable cervical cages have been used successfully to reconstruct the anterior spinal column. OBJECTIVE: To perform clinical and radiological evaluation of vertebral body replacement with an anchored expandable titanium cage in the cervical spine after single-level and 2-level corpectomies. METHODS: Between 2011 and 2017, 40 patients underwent a single-level (N = 32) or 2-level (N = 8) anterior corpectomy and fusion using an anchored expandable vertebral body replacement cage. Clinical and radiological data at admission, postoperatively, and at 3- and 12-mo follow-up were retrospectively analyzed. Clinical assessment was performed via standardized neurological evaluation, Odom score, and McCormick classification. Radiological assessment was performed via evaluation of sagittal profile, postoperative position, fusion, and subsidence rates. RESULTS: Mean last follow-up was 14.8 ± 7 mo. Overall clinical and myelopathy-related improvements were shown directly after operation and at last follow-up. A stable centralized positioning of cages was achieved in 37 patients (93%). A mild ventral (>1.5 mm) malplacement was noted in 3 patients (7%) without clinical consequences. Sagittal alignment and preoperative cervical kyphosis improved significantly (7.8° gain of lordosis) and remained stable. Mean preoperative height of operated segments increased by 10 mm postoperatively and remained stable. Fusion rate in non-neoplastic patients and subsidence rate at last follow-up comprised 87.5% and 17.8%. With exception of 1 patient suffering from severe osteoporosis and cage subsidence, no patient needed additional secondary stabilization. CONCLUSION: Anterior corpectomy and fusion by an expandable anchored titanium cage with anchor screws without additional instrumentation resulted in overall clinical improvement and radiological anterior column support, achieving significant and reliable restoration of the physiological sagittal cervical profile.

A high-definition 3D exoscope as an alternative to the operating microscope in spinal microsurgery.

OBJECTIVE: Since the 1970s, the operating microscope (OM) has been a standard for visualization and illumination of the surgical field in spinal microsurgery. However, due to its limitations (e.g., size, costliness, and the limited movability of the binocular lenses, in addition to discomfort experienced by surgeons due to the posture required), there are efforts to replace the OM with exoscopic video telescopes. The authors evaluated the feasibility of a new 3D exoscope as an alternative to the OM in spine surgeries. METHODS: Patients with degenerative pathologies scheduled for single-level lumbar or cervical spinal surgery with use of a high-definition 3D exoscope were enrolled in a prospective cohort study between January 2019 and September 2019. Age-, sex-, body mass index-, and procedure-matched patients surgically treated with the assistance of the OM served as the control group. Operative baseline and postoperative outcome parameters were assessed. Periprocedural handling, visualization, and illumination by the exoscope, as well as surgeons' comfort level in terms of posture, were scored using a questionnaire. RESULTS: A 3D exoscope was used in 40 patients undergoing lumbar posterior decompression (LPD) and 20 patients undergoing anterior cervical discectomy and fusion (ACDF); an equal number of controls in whom an OM was used were studied. Compared with controls, there were no significant differences for mean operative time (ACDF: 132 vs 116 minutes; LPD: 112 vs 113 minutes) and blood loss (ACDF: 97 vs 93 ml; LPD: 109 vs 55 ml) as well as postoperative improvement of symptoms (ACDF/Neck Disability Index: p = 0.43; LPD/Oswestry Disability Index: p = 0.76). No intraoperative complications occurred in either group. According to the attending surgeon, the intraoperative handling of instruments was rated to be comparable to that of the OM, while the comfort level of the surgeon's posture intraoperatively (especially during "undercutting" procedures) was rated as superior. In cases of ACDF procedures and long approaches, depth perception, image quality, and illumination were rated as inferior when compared with the OM. By contrast, for operating room nursing staff participating in 3D exoscope procedures, the visualization of intraoperative process flow and surgical situs was rated to be superior to the OM, especially for ACDF procedures. CONCLUSIONS: A 3D exoscope seems to be a safe alternative for common spinal procedures with the unique advantage of excellent comfort for the surgical team, but the drawback is the still slightly inferior visualization/illumination quality compared with the OM.

Cystic Craniopharyngiomas: Microsurgical or Stereotactic Treatment?

BACKGROUND: Prognosis and treatment of cystic craniopharyngiomas are poorly defined. OBJECTIVE: To analyze progression-free survival (PFS) and safety profile of cystic craniopharyngiomas undergoing resection or minimally invasive drainage procedures. We compared further outcome measurements for cystic and solid tumors undergoing resection to elucidate the impact of the initial tumor composition on both PFS and the toxicity profile. METHODS: All patients with craniopharyngiomas consecutively treated between 1999 and 2014 were included. A treatment decision in favor of microsurgery or stereotactic treatment was made interdisciplinarily. For stereotactic drainage, a catheter was implanted, allowing both permanent upstream (into ventricular spaces) and downstream (into prepontine cistern) drainage. Study endpoints were tumor progression, functional outcome, and treatment toxicity. Functional endocrinological and visual outcome analyses referred to data obtained preoperatively and 6 weeks after treatment. The Kaplan-Meier method was used for survival analysis. Prognostic factors were obtained from proportional hazard models. RESULTS: Seventy-nine patients were included. The distribution of clinical and tumor-related data was well balanced among patients with solid (n = 35) and cystic (n = 44) tumors and those undergoing microsurgical or stereotactic treatment. Cystic tumors had shorter PFS (5-year PFS: 53.6% vs 66.8%, P = .10) and needed significantly more therapeutic interventions, which was independent of the initial treatment mode. The endocrinological deterioration rate was high for both solid and cystic tumors after microsurgery (59.4% and 85.7%, respectively), whereas it was significantly lower for cystic tumors undergoing stereotactic treatment (23.1%, P < .001). CONCLUSION: Stereotactic bidirectional drainage of cystic craniopharyngiomas is effective and provides a better endocrinological outcome than conventional microsurgery.

Stereotactic intracavitary brachytherapy with P-32 for cystic craniopharyngiomas in children.

PURPOSE: Although microsurgery remains the first-line treatment, gross total resection of cystic craniopharyngeomas (CP) is associated with significant morbidity and mortality and the addition of external irradiation to subtotal resection proves to achieve similar tumor control. However, concern regarding long-term morbidity associated with external irradiation in children still remains. With this retrospective analysis, the authors emphasize intracavitary brachytherapy using phosphorus-32 (P-32) as a treatment option for children with cystic CP. PATIENTS AND METHODS: Between 1992 and 2009, 17 children (median age 15.4 years; range 7-18 years) with cystic CP underwent intracavitary brachytherapy using P-32. Eleven patients were treated for recurrent tumor cysts; 6 patients were treated primarily. MR imaging revealed solitary cysts in 7 patients; 10 patients had mixed solid-cystic lesions (median tumor volume 11.1 ml; range 0.5-78.9 ml). The median follow-up time was 61.9 months (range 16.9-196.6 months). RESULTS: Local cyst control could be achieved in 14 patients (82 %). Three patients showed progression of the treated cystic formation (in-field progression) after a median time of 8.3 months (range 5.3-10.3 months), which led to subsequent interventions. The development of new, defined cysts and progression of solid tumor parts (out-of-field progression) occurred in 5 patients and led to additional interventions in 4 cases. There was neither surgery-related permanent morbidity nor mortality in this study. The overall progression-free survival was 75, 63, and 52 % after 1, 3, and 5 years, respectively. CONCLUSION: Intracavitary brachytherapy using P-32 represents a safe and effective treatment option for children harboring cystic CP, even as primary treatment. However, P-32 does not clearly affect growth of solid tumor parts or the development of new cystic formations.

Intracavitary brachytherapy using stereotactically applied phosphorus-32 colloid for treatment of cystic craniopharyngiomas in 53 patients.

This paper summarizes outcomes of a single-center study of intracavitary brachytherapy (IBT) with stereotactically applied phosphorus-32 ((32)P) colloid for treatment of cystic craniopharyngiomas. We assessed its efficacy and safety, on the basis of clinical and radiological outcomes in one of the largest reported patient series. Between 1992 and 2011, 53 patients were treated with IBT, 14 without previous treatment and 39 who had previously been treated for recurrent cysts. Intervention was performed by applying 200 Gy to the internal cyst wall (median volume 6.1 ml). Median clinical and radiological follow-up were 60.2 and 53.0 months, respectively. Actuarial tumor cyst control was 86.0 ± 5.3 % at 12, 24, and 60 months. Actuarial out-of-field control (development of new cysts or progression of solid tumor parts) was 90.9 ± 4.3, 84.0 ± 5.6, and 54.5 ± 8.8 % after 12, 24, and 60 months, respectively. Corresponding actuarial overall progression-free survival was 79.4 ± 6.1, 72.4 ± 6.8, and 45.6 ± 8.7 % at 12, 24, and 60 months, respectively. Visual function improved for 12 patients (23.5 %), remained unchanged for 34 patients (66.7 %), and worsened for five patients (9.8 %), correlating with tumor progression in each case. Endocrinological deterioration occurred for ten patients (19.6 %); for nine patients this was a result of tumor progression or after tumor resection and for one it was attributed to irradiation. Within six months of IBT seven patients (13.7 %) experienced transient neurological deficits and two patients (3.9 %) deteriorated permanently (hemiparesis and third nerve palsy). Stereotactically applied (32)P is highly efficacious for control of cystic components of craniopharyngiomas and is associated with a low risk of permanent morbidity. The procedure does not, however affect the development of new cysts or the progression of solid tumor parts.