Gross total resection of spinal chondrosarcoma is associated with improved locoregional relapse-free survival and overall survival.

BACKGROUND: Spinal chondrosarcomas are rare malignant osseous tumors. The low incidence of spinal chondrosarcomas and the complexity of spine anatomy have led to heterogeneous treatment strategies with varying curative and survival rates. The goal of this study is to investigate prognostic factors for locoregional recurrence-free survival (LRFS) and overall survival (OS) comparing en bloc vs. piecemeal resection for the management of spinal chondrosarcoma. METHODS: We retrospectively identified patients who underwent curative-intent resection of primary and metastatic spinal chondrosarcoma over a 25-year period. Univariate and multivariate survival analyses were conducted with LRFS as primary endpoint and OS as secondary endpoint. LRFS and OS were modeled using the Kaplan-Meier method and assessed using Cox regression analysis. RESULTS: For 72 patients who underwent first resection, the median follow-up time was 5.1 years (95% CI 2.2-7.0). Thirty-three patients (45.8%) had en bloc resection, and 39 (54.2%) had piecemeal resection. Of the 68 patients for whom extent of resection was known, 44 patients had gross total resection (GTR) and 24 patients had subtotal resection. In survival analyses, both LRFS and OS showed statistically significant difference based on the extent of resection (p = 0.001; p = 0.04, respectively). However, only LRFS showed statistically significant difference when assessing the type of resection (p = 0.02). In addition, higher tumor grade and more invasive disease were associated with worse LRFS and OS rates. CONCLUSION: Although in our study en bloc and GTR were associated with improved survival, heterogenous and complex spinal presentations may limit total resection. Therefore, the surgical management should be tailored individually to ensure the best local control and maximum preservation of function.

Deep Learning for Adjacent Segment Disease at Preoperative MRI for Cervical Radiculopathy.

Background Patients who undergo surgery for cervical radiculopathy are at risk for developing adjacent segment disease (ASD). Identifying patients who will develop ASD remains challenging for clinicians. Purpose To develop and validate a deep learning algorithm capable of predicting ASD by using only preoperative cervical MRI in patients undergoing single-level anterior cervical diskectomy and fusion (ACDF). Materials and Methods In this Health Insurance Portability and Accountability Act-compliant study, retrospective chart review was performed for 1244 patients undergoing single-level ACDF in two tertiary care centers. After application of inclusion and exclusion criteria, 344 patients were included, of whom 60% (n = 208) were used for training and 40% for validation (n = 43) and testing (n = 93). A deep learning-based prediction model with 48 convolutional layers was designed and trained by using preoperative T2-sagittal cervical MRI. To validate model performance, a neuroradiologist and neurosurgeon independently provided ASD predictions for the test set. Validation metrics included accuracy, areas under the curve, and F1 scores. The difference in proportion of wrongful predictions between the model and clinician was statistically tested by using the McNemar test. Results A total of 344 patients (median age, 48 years; interquartile range, 41-58 years; 182 women) were evaluated. The model predicted ASD on the 93 test images with an accuracy of 88 of 93 (95%; 95% CI: 90, 99), sensitivity of 12 of 15 (80%; 95% CI: 60, 100), and specificity of 76 of 78 (97%; 95% CI: 94, 100). The neuroradiologist and neurosurgeon provided predictions with lower accuracy (54 of 93; 58%; 95% CI: 48, 68), sensitivity (nine of 15; 60%; 95% CI: 35, 85), and specificity (45 of 78; 58%; 95% CI: 56, 77) compared with the algorithm. The McNemar test on the contingency table demonstrated that the proportion of wrongful predictions was significantly lower by the model (test statistic, 2.000; P < .001). Conclusion A deep learning algorithm that used only preoperative cervical T2-weighted MRI outperformed clinical experts at predicting adjacent segment disease in patients undergoing surgery for cervical radiculopathy. © RSNA, 2021 An earlier incorrect version appeared online. This article was corrected on September 22, 2021.

Minimally invasive versus open surgery for the correction of adult degenerative scoliosis: a systematic review.

While open surgery has been the primary surgical approach for adult degenerative scoliosis, minimally invasive surgery (MIS) represents an alternative option and appears to be associated with reduced morbidity. Given the lack of consensus, we aimed to conduct a systematic review on available literature comparing MIS versus open surgery for adult degenerative scoliosis. PubMed, Embase, and Cochrane databases were searched through December 16, 2019, for studies that compared both MIS and open surgery in patients with degenerative scoliosis. Four cohort studies reporting on 350 patients met the inclusion criteria. In two studies, patients undergoing open surgery were younger and had more severe disease at baseline as compared with MIS. Patients who underwent MIS had less blood loss, shorter length of stay, and a reduced rate of complications and infections. Both MIS and open surgery resulted in a significant change in pain and disability scores and both approaches provided significant correction of deformity in all studies, although open surgery was associated with a greater change in pelvic incidence-lumbar lordosis mismatch (PI-LL) and sagittal vertical axis (SVA) in two and three studies, respectively. In patients with adult degenerative scoliosis undergoing surgery, both MIS and open approaches appeared to offer comparable improvements in pain and function. However, MIS was associated with better safety outcomes, while open surgery provided greater correction of spinal deformity. Further studies are needed to identify specific subset of patients who may benefit from one approach versus the other.

Adult spinal deformity surgery: a systematic review of venous thromboprophylaxis and incidence of venous thromboembolic events.

Venous thromboprophylaxis consisting of chemical and/or mechanical prophylaxis is administered to patients undergoing adult spinal deformity (ASD) surgery to prevent venous thromboembolic events. However, the true incidence of venous thromboembolism (VTE) after these surgeries is unknown resulting in weak recommendations and lack of consensus regarding type and timing of prophylaxis in these patients. A systematic literature review was conducted to examine VTE incidence in addition to optimal type and timing of VTE prophylaxis. A detailed search was carried out on Embase, PubMed, and Cochrane Library databases through October 18, 2017, for studies that evaluated venous thromboembolic outcomes, type, and timing of prophylaxis administration among ASD surgery patients who were on VTE prophylaxis. The randomized study was assessed for risk of bias using the Cochrane tool and the observational studies using the Newcastle-Ottawa scale (NOS). The search yielded 1180 studies, and three articles published between 1996 and 2008 met the inclusion criteria. There were 583 surgeries performed on 537 patients with a mean age ranging from 45 to 52 years. Females dominated the study with percentages ranging from 60 to 94% in the different study populations. VTE prophylaxis was initiated before surgery in 87.7% patients and intraoperatively in 12.3% patients. VTE incidence ranged between 0 and 9.1% among the studies. VTE can occur after ASD surgery regardless of the type of prophylaxis, and incidence may be higher when mechanical prophylaxis alone is initiated intraoperatively. Further studies to examine VTE prophylaxis in patients undergoing ASD surgery should be considered.

Computed Tomography Angiography Versus Digital Subtraction Angiography for Postclipping Aneurysm Obliteration Detection.

Background and Purpose- Digital subtraction angiography has been used as the gold standard to confirm successful aneurysmal obliteration after aneurysm clipping procedures using titanium or cobalt alloy clips. Computed tomographic angiography is a newer, less invasive imaging technique also used to confirm successful aneurysmal obliteration; however, its use compared with digital subtraction angiography remains controversial. Methods- A comprehensive literature search was conducted on Pubmed, EMBASE, and Cochrane databases through November 6, 2017, for studies that evaluated postclipping aneurysm obliteration with both computed tomographic angiography and digital subtraction angiography. Pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were calculated using the bivariate random-effects model. Results- Out of 6916 studies, 13 studies met inclusion criteria for this meta-analysis. A total of 510 patients with 613 aneurysms were included. Compared with digital subtraction angiography, which detected 87 residual aneurysms, computed tomographic angiography detected 58 resulting in a pooled sensitivity of 69% (95% CI, 54%-81%) and a pooled specificity of 99% (95% CI, 97%-99%). This corresponded to LR+ of 55.5 (95% CI, 23.6-130.9) and LR- of 0.31 (95% CI, 0.20-0.48). Univariate meta-regression revealed that the pooled sensitivity was worse in prospective designs ( P interaction <0.05), and the pooled specificity was better in higher-quality studies and for postoperative aneurysm diameters of <2 mm ( P interaction <0.001 for both). Conclusions- This meta-analysis revealed that computed tomographic angiography had a favorable LR+ but not a favorable LR-. Thus, this imaging modality may be applicable to rule in, but not rule out, residual aneurysms after clipping.

PKCδ inhibition as a novel medical countermeasure for radiation-induced vascular damage.

In the event of a radiologic catastrophe, endothelial cell and neutrophil dysfunction play important roles in tissue injury. Clinically available therapeutics for radiation-induced vascular injury are largely supportive. PKCδ was identified as a critical regulator of the inflammatory response, and its inhibition was shown to protect critical organs during sepsis. We used a novel biomimetic microfluidic assay (bMFA) to interrogate the role of PKCδ in radiation-induced neutrophil-endothelial cell interaction and endothelial cell function. HUVECs formed a complete lumen in bMFA and were treated with 0.5, 2, or 5 Gy ionizing radiation (IR). At 24 h post-IR, the cells were treated with a PKCδ inhibitor for an additional 24 h. Under physiologic shear flow, the role of PKCδ on endothelium function and neutrophil adherence/migration was determined. PKCδ inhibition dramatically attenuated IR-induced endothelium permeability increase and significantly decreased neutrophil migration across IR-treated endothelial cells. Moreover, neutrophil adhesion to irradiated endothelial cells was significantly decreased after PKCδ inhibition in a flow-dependent manner. PKCδ inhibition downregulated IR-induced P-selectin, intercellular adhesion molecule 1, and VCAM-1 but not E-selectin overexpression. PKCδ is an important regulator of neutrophil-endothelial cell interaction post-IR, and its inhibition can serve as a potential radiation medical countermeasure.-Soroush, F., Tang, Y., Zaidi, H. M., Sheffield, J. B., Kilpatrick, L. E., Kiani, M. F. PKCδ inhibition as a novel medical countermeasure for radiation-induced vascular damage.

Randomized controlled trials comparing surgery to non-operative management in neurosurgery: a systematic review.

BACKGROUND: A randomized controlled trial (RCT) remains the pinnacle of clinical research design. However, RCTs in neurosurgery, especially those comparing surgery to non-operative treatment, are rare and their relevance and applicability have been questioned. This study set out to assess trial design and quality and identify their influence on outcomes in recent neurosurgical trials that compare surgery to non-operative treatment. METHODS: From 2000 to 2017, PubMed and Embase databases and four trial registries were searched. RCTs were evaluated for study design, funding, adjustments to reported outcome measures, accrual of patients, and academic impact. RESULTS: Eighty-two neurosurgical RCTs were identified, 40 in spine disorders, 19 neurovascular and neurotrauma, 11 functional neurosurgery, ten peripheral nerve, and two pituitary surgery. Eighty-four RCTs were registered, of which some are ongoing. Trial registration rate differed per subspecialty. Funding was mostly from non-industry institutions (58.5%), but 25.6% of RCTs did not report funding sources. 36.4% of RCTs did not report a difference between surgical and non-operative treatment, 3.7% favored non-operative management. Primary and secondary outcome measures were changed in 13.2% and 34.2% of RCTs respectively and varied by subspecialty. 41.9% of RCTs subtracted ≥ 10% of the anticipated accrual and 12.9% of RCTs added ≥ 10%. 7.3% of registered RCTs were terminated, mostly due to too slow recruitment. Subspecialty, registration, funding, masking, population size, and changing outcome measures were not significantly associated with a reported benefit of surgery. High Jadad scores (≥ 4) were negatively associated with a demonstration of surgical benefit (P < 0.05). CONCLUSIONS: Neurosurgical RCTs comparing surgical to non-operative treatment often find a benefit for surgical treatment. Changes to outcome measurements and anticipated accrual are common and funding sources are not always reported.

A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery.

INTRODUCTION: Patients undergoing transsphenoidal pituitary surgery (TSS) are at risk for several serious complications, including the syndrome of inappropriate antidiuretic hormone and subsequent hyponatremia. OBJECTIVE: In this study, we examined the effect of 1 week of post-discharge fluid restriction to 1.0 L daily on rates of post-operative readmission for hyponatremia. METHODS: We retrospectively analyzed all patients undergoing TSS from 2008 to 2014 and prospectively recorded patient data from 2015 to 2017. Patients were divided into a control cohort (2008-2014), who were discharged with instructions to drink to thirst; and an intervention cohort (2015-2017) who were instructed to drink less than 1.0 L daily for 1 week post-operatively. RESULTS: This study included 788 patients; 585 (74.2%) in the control cohort and 203 (25.8%) in the intervention cohort. Overall, 436 (55.3%) were women, the median age was 47 (range 15-89), and average BMI was 29.4 kg/m2 (range 17.7-101.7). Patients were relatively well matched. Of patients in the intervention group, none was readmitted for hyponatremia (0/203), compared to 3.41% (20/585) in the control group (p = 0.003). Patients in the intervention group also had significantly higher post-operative week one sodium levels (140.1 vs 137.5 mEq/L; p = 0.002). No fluid balance complications occurred in patients who followed this protocol. CONCLUSION: Hyponatremia can be a life-threatening complication of TSS, and prevention of readmission for hyponatremia can help improve patient safety and decrease costs. Mandatory post-discharge fluid restriction is a simple and inexpensive intervention associated with decreased rates of readmission for hyponatremia and normal post-operative sodium levels.

Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis.

BACKGROUND: Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. METHODS: A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. RESULTS: Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 = 84.0%) in a fixed-effect model (P-interaction < 0.01). For functioning pituitary adenomas (FPAs) (n = 1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 = 63.9%) and mTSS (GTR=75.5%; I2 = 79.0%); (P-interaction = 0.92). For nonfunctioning pituitary adenomas (NFPAs) (n = 2655 patients), eTSS (GTR=71.0%; I2 = 86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 = 87.5%) in a fixed-effect model (P-interaction < 0.01). None of the associations were significant in a random-effect model (all P-interaction > 0.05). No significant publication bias was identified for any of the outcomes. CONCLUSION: Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.

The extended, transnasal, transsphenoidal approach for anterior skull base meningioma: considerations in patient selection.

PURPOSE: In this study, we set out to define our institutional criteria for patient eligibility for transsphenoidal resection of parasellar meningiomas, and to report our experience with extended transnasal approaches for these lesions. We aimed to discuss the important considerations of patient selection and risk stratification to optimize outcomes for patients with these difficult lesions, and also include considerations that should be reviewed during surgical approach selection. METHODS: Medical records from Brigham and Women's Hospital were retrospectively reviewed for all patients who underwent transsphenoidal surgery for pituitary disease with the senior author from April 2008 to March 2017 (938 procedures). Patients undergoing surgery for anterior skull base meningioma were identified and patient data were collected. RESULTS: Seven patients (four women, three men) underwent transsphenoidal resection (five endoscopic, one microscopic, and one hybrid endoscopic/microscopic) of pathologically-confirmed anterior skull base meningiomas during the study period. Five patients presented with visual field deficits, three presented with headache, two presented with hypopituitarism, and one woman presented with infertility. The median maximum tumor diameter was 1.7 cm (range 1.4-4.2 cm). Six patients underwent subtotal resection, and one underwent gross total resection. The median MIB-1 index was 2.3 (range 1.0-7.6). Complications included two readmissions (one on POD11 for small bowel obstruction, one on POD48 for epistaxis), and the development of new onset thyroid deficiency and transient diabetes insipidus in one patient. Two patients had reoperations by craniotomy for tumor recurrence after 5 and 6 years, respectively. CONCLUSIONS: Although more commonly treated transcranially, anterior skull base meningiomas are sometimes amenable to resection transphenoidally. Patient selection is critical, and multiple factors, including tumor size, consistency, and location, patient and surgeon preference, and presenting symptoms each affect the optimum surgical approach. We have developed criteria for patient selection so that transsphenoidal surgery can be used to resect or debulk anterior skull base meningiomas safely and with favorable outcomes.

The utility of high-resolution intraoperative MRI in endoscopic transsphenoidal surgery for pituitary macroadenomas: early experience in the Advanced Multimodality Image Guided Operating suite.

OBJECTIVE: Endoscopic skull base surgery has become increasingly popular among the skull base surgery community, with improved illumination and angled visualization potentially improving tumor resection rates. Intraoperative MRI (iMRI) is used to detect residual disease during the course of the resection. This study is an investigation of the utility of 3-T iMRI in combination with transnasal endoscopy with regard to gross-total resection (GTR) of pituitary macroadenomas. METHODS: The authors retrospectively reviewed all endoscopic transsphenoidal operations performed in the Advanced Multimodality Image Guided Operating (AMIGO) suite from November 2011 to December 2014. Inclusion criteria were patients harboring presumed pituitary macroadenomas with optic nerve or chiasmal compression and visual loss, operated on by a single surgeon. RESULTS: Of the 27 patients who underwent transsphenoidal resection in the AMIGO suite, 20 patients met the inclusion criteria. The endoscope alone, without the use of iMRI, would have correctly predicted extent of resection in 13 (65%) of 20 cases. Gross-total resection was achieved in 12 patients (60%) prior to MRI. Intraoperative MRI helped convert 1 STR and 4 NTRs to GTRs, increasing the number of GTRs from 12 (60%) to 16 (80%). CONCLUSIONS: Despite advances in visualization provided by the endoscope, the incidence of residual disease can potentially place the patient at risk for additional surgery. The authors found that iMRI can be useful in detecting unexpected residual tumor. The cost-effectiveness of this tool is yet to be determined.

Frontal dermoid cyst coexisting with suprasellar craniopharyngioma: a spectrum of ectodermally derived epithelial-lined cystic lesions?

There is a wide group of lesions that may exist in the sellar and suprasellar regions. Embryologically, there is varying evidence that many of these entities may in fact represent a continuum of pathology deriving from a common ectodermal origin. The authors report a case of a concomitant suprasellar craniopharyngioma invading the third ventricle with a concurrent frontal lobe cystic dermoid tumor. A 21-year-old man presented to the authors' service with a 3-day history of worsening headache, nausea, vomiting, and blurry vision. Magnetic resonance imaging depicted a right frontal lobe lesion associated with a separate suprasellar cystic lesion invading the third ventricle. The patient underwent a right pterional craniotomy for resection of both lesions. Gross-total resection of the right frontal lesion was achieved, and subtotal resection of the suprasellar lesion was accomplished with some residual tumor adherent to the walls of the third ventricle. Histopathological examination of the resected right frontal lesion documented a diagnosis of dermoid cyst and, for the suprasellar lesion, a diagnosis of adamantinomatous craniopharyngioma. The occurrence of craniopharyngioma with dermoid cyst has not been reported in the literature before. Such an association might indeed suggest the previously reported hypothesis that these lesions represent a spectrum of ectodermally derived epithelial-lined cystic lesions.

National treatment trends, complications, and predictors of in-hospital charges for the surgical management of craniopharyngiomas in adults from 2007 to 2011.

OBJECT: Treatment of craniopharyngiomas is one of the most demanding and controversial neurosurgical procedures performed. The authors sought to determine the factors associated with hospital charges and fees for craniopharyngioma treatment to identify possible opportunities for improving the health care economics of inpatient care. METHODS: The authors analyzed the hospital discharge database of the Nationwide Inpatient Sample (NIS) covering the period from 2007 through 2011 to examine national treatment trends for adults (that is, those older than 18 years) who had undergone surgery for craniopharyngioma. To predict the drivers of in-hospital charges, a multistep regression model was developed that accounted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications. RESULTS: The analysis included 606 patients who underwent resection of craniopharyngioma; 353 resections involved a transsphenoidal approach (58%) and 253 a transfrontal approach (42%). The mean age (± SD) of patients was 47.7 ± 16.3 years. The average hospital length of stay (LOS) was 7.6 ± 9 days. The mean hospital charge (± SD) was $92,300 ± $83,356. In total, 48% of the patients experienced postoperative diabetes insipidus or an electrolyte abnormality. A multivariate regression model demonstrated that LOS, hospital volume for the selected procedure, the surgical approach, postoperative complications, comorbidities, and year of surgery were all significant predictors of in-hospital charges. The statistical model accounted for 54% of the variance in in-hospital charge. CONCLUSIONS: This analysis of inpatient hospital charges in patients undergoing craniopharyngioma surgery identified key drivers of charges in the perioperative period. Prospective studies designed to evaluate the long-term resource utilization in this complex patient population would be a useful future direction.

Contemporary management of spinal AVFs and AVMs: lessons learned from 110 cases.

OBJECT: Spinal arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs) are rare, complex spinal vascular lesions that are challenging to manage. Recently, understanding of these lesions has increased thanks to neuroimaging technology. Published reports of surgical results and clinical outcome are limited to small series. The authors present a large contemporary series of patients with spinal AVFs and AVMs who were treated at Barrow Neurological Institute in Phoenix, Arizona. METHODS: Retrospective detailed review of a prospective vascular database was performed for all patients with spinal AVFs and AVMs treated between 2000 and 2013. Patient demographic data, AVF and AVM characteristics, surgical results, clinical outcomes, complications, and long-term follow-up were reviewed. RESULTS: Between 2000 and 2013, 110 patients (57 male and 53 female) underwent obliteration of spinal AVFs and AVMs. The mean age at presentation was 42.3 years (range 18 months-81 years). There were 44 patients with AVFs and 66 with AVMs. The AVM group included 27 intramedullary, 21 conus medullaris, 12 metameric, and 6 extradural. The most common location was thoracic spine (61%), followed by cervical (22.7%), lumbar (14.5%), and sacral (1.8%). The most common presenting signs and symptoms included paresis/paralysis (75.5%), paresthesias (60%), pain (51.8%), bowel/bladder dysfunction (41.8%), and myelopathy (36.4%). Evidence of rupture was seen in 26.4% of patients. Perioperative embolization was performed in 42% of patients. Resection was performed in 95 patients (86.4%). Embolization alone was the only treatment in 14 patients (12.7%). One patient was treated with radiosurgery alone. Angiographically verified AVF and AVM obliteration was achieved in 92 patients (83.6%). At a mean follow-up duration of 30.5 months (range 1-205 months), 43 patients (97.7%) with AVFs and 57 (86.4%) with AVMs remained functionally independent (McCormick Scale scores ≤ 2). Perioperative complications were seen in 8 patients (7%). No deaths occurred. Temporary neurological deficits were observed in 27 patients (24.5%). These temporary deficits recovered 6-8 weeks after treatment. Recurrence was identified in 6 patients (13.6%) with AVFs and 10 (15.2%) with AVMs. CONCLUSIONS: Spinal AVFs and AVMs are complex lesions that should be considered for surgical obliteration. Over the last several decades the authors have changed surgical strategies and management to achieve better clinical outcomes. Transient neurological deficit postoperatively is a risk associated with intervention; however, clinical outcomes appear to exceed the natural history based on patients' ability to recover during the follow-up period. Due to the recurrence rate associated with these lesions, long-term follow-up is required.

Defining the Post-Operative Progression of Degenerative Scoliosis: An Analysis of Cases without Instrument Failure.

OBJECTIVE: The expected post-operative changes in radiographic alignment over time remain poorly defined in patients surgically treated for degenerative scoliosis without instrument failure. Here we aim to describe the optimal natural progression of radiographic degenerative scoliosis at multiple timepoints in patients treated with a transforaminal lumbar interbody fusion (TLIF). METHODS: We identified an initial retrospective cohort of 114 patients treated with a TLIF for degenerative scoliosis between 2018 and 2022, with 39 patients ultimately meeting the imaging inclusion criteria. Patients who completed a primary or revision procedure with no evidence of instrument failure, proximal junctional kyphosis, or proximal junctional failure at last follow-up were included. Radiographic measurements of spinopelvic alignment were manually extracted from X-Ray scoliosis films. RESULTS: Thirty-nine patients (mean age 62.6 ± 8.7, mean follow-up 2.9 years), of which 23 underwent a primary TLIF (Primary) and 16 a revision procedure (Revision), were analyzed. Patients in the Primary group experienced a durable improvement in Thoracolumbar Cobb angle (-25° ± 15°), Thoracic Kyphosis (10° ± 13°), and Pelvic Incidence/lumbar lordosis mismatch (PI/LL) (-19° ± 19°) through the first year of follow-up. In the Revision group, at one year follow-up, all measures of spinopelvic alignment except PI/LL mismatch had reverted to pre-operative levels. Thoracolumbar Cobb angle decreased to a significantly greater degree in the Primary group compared to the Revision group. CONCLUSION: Primary TLIF operations without instrument failure consistently improve radiographic outcomes in three key measures through the first year. For revision procedures, there appears to be modest radiographic benefit at follow-up.

Utility of Expandable Interbody Cages in Open Transforaminal Interbody Fusions: A Comparison With Static Cages.

Background Expandable interbody cages, while popular in minimally invasive fusions due to their slim profile and increased ease of insertion, have not been widely explored in open surgery. The benefits of expandable cages may also extend to open fusions through their potential to achieve a greater restoration of lumbar lordosis while minimizing intraoperative complications. To highlight these benefits, we present a case series of adult spinal deformity (ASD) patients treated with an open transforaminal lumbar interbody fusion (TLIF) using expandable cages and compare outcomes to those of patients treated with static cages from the literature. Methods A retrospective cohort study of patients who underwent a deformity correction procedure and TLIF with expandable interbody cages at Brigham and Women's Hospital between 2018 and 2022 was conducted. Patient demographics, complications, and pre- and postoperative radiographic parameters of spinopelvic alignment were collected. A literature search was completed to identify studies employing static cages. T-tests were performed to compare postoperative changes in radiographic parameters by cage type. Results Forty-five patients (mean age of 62.6 years) with an average of 2.1 cages placed met the inclusion criteria. Patients experienced five intraoperative complications and 23 neurologic deficits (from minor to major), while nine patients required a revision operation. Lumbar lordosis increased by 9.8° ± 14.5° (p < 0.0001), the sagittal vertical axis (SVA) decreased by 25.5 mm ± 56.7 mm (p = 0.0048), and pelvic incidence-lumbar lordosis mismatch decreased by 13.3° ± 17.5° (p < 0.0001) with the use of expandable cages. Expandable cages yielded similar changes in lumbar lordosis to 15° and 8° cages but improved the lumbar lordosis generated from rectangular and 4° cages. When compared to static cages, expandable cages mildly reduced intraoperative complications. Conclusions Expandable interbody cages are an effective means of restoring spinopelvic alignment in ASD that have the potential to improve patient outcomes in open fusions compared to standard static cages. Especially when compared to rectangular and 4° static cages, expandable cages provide a clear benefit in the correction of lumbar lordosis. The impact of open spinal fusions with expandable cages on outcomes should continue to be explored in other cohorts.

Spinal Metastases from Colorectal Cancer at Mass General Brigham: A Twenty-Year Case Series With Literature Review.

OBJECTIVE: We present an institutional case series of patients treated for colorectal carcinoma (CRC) spinal metastases to investigate the outcomes between no treatment, radiation, surgery, and surgery/radiation. METHODS: A retrospective cohort of patients with CRC spinal metastases presenting to affiliated institutions between 2001 and 2021 wereidentified. Information related to patient demographics, treatment modality, treatment outcomes, symptom improvement, and survival was collected by chart review. Overall survival (OS) was compared between treatments by log-rank significance testing. A literature review was conducted to identify other cases series of CRC patients with spinal metastases. RESULTS: Eighty-nine patients (mean age 58.5) with CRC spinal metastases across a mean of 3.3 levels met inclusion criteria: 14 (15.7%) received no treatment, 11 (12.4%) received surgery alone, 37 (41.6%) received radiation alone, and 27 (30.3%) received both radiation and surgery. Patients treated with combination therapy had the longest median OS of 24.7 months (range 0.6-85.9), which did not significantly differ from the median OS of 8.9 months (range 0.2-42.6) observed in patients who received no treatment (P = 0.075). Combination therapy provided objectively longer survival time in comparison to other treatment modalities but failed to reach statistical significance. The majority of patients that received treatment (n = 51/75, 68.0%) experienced some degree of symptomatic or functional improvement. CONCLUSIONS: Therapeutic intervention has the potential to improve the quality of life in patients with CRC spinal metastases. We demonstrate that surgery and radiation are useful options for these patients, despite their lack of objective improvement in OS.

A comparison of the safety and efficacy of minimally invasive surgery versus open surgery in treating cauda equina syndrome: A systematic review and meta-analysis.

PURPOSE: To compare the safety and efficacy of minimally invasive surgery (MIS) and open surgery (OS) in treating cauda equina syndrome (CES). METHODS: A systematic literature search was conducted, searching relevant databases for studies investigating MIS and/or OS in treating CES. Pooled outcomes and their 95% confidence intervals (CIs) were meta-analyzed via random-effects models. RESULTS: Ten studies were included in the meta-analysis. Pooled mean operation times were shorter for MIS (75.4 min; 95 %CI: 40.8, 110.0) than OS (155.1 min; 121.3, 188.9). Similarly, mean hospital stay was shorter for MIS (4.08 days; 2.77, 5.39 vs. 8.85 days; 6.56, 11.13). Mean blood loss was smaller for MIS (71.7 mL; 0, 154.5 vs. 366.5; 119.1, 614.0). Mean post-op lumbar/back visual analogue scale (VAS) score was lower for MIS (3.65; 2.75, 4.56 vs. 5.80; 4.55, 7.05). Mean post-op leg VAS score was 1.27 (0.41, 21.4) for MIS and 1.29 (0.47, 2.12) for OS. Mean complete bladder recovery rate was 81.0% (55.0%, 94.0%) for MIS and 75.0% (44.0%, 92.0%) for OS. Mean complete motor recovery rate was larger for MIS (70.0%; 48.0, 85.0 vs. 42.0%; 34.0, 51.0). Mean percentages of "excellent" patient outcomes were equal for MIS (64.0%; 48.0%, 77.0%) and OS (64.0%; 22.0%, 92.0%). CONCLUSION: MIS for CES was associated with reduced operative time, length of stay, and blood loss, compared to OS. MIS was also associated with better post-operative lumbar/back and leg VAS scores and complete motor and bladder recovery rates. MIS and OS produced an equal average percentage of "excellent" patient outcomes.