Multimodal management of surgery- and radiation-refractory meningiomas: an analysis of the French national tumor board meeting on meningiomas cohort.

PURPOSE: Meningiomas represent the most frequent tumor of the central nervous system in adults. While most meningiomas are efficiently treated by surgery and radiotherapy/radiosurgery, there is a small portion of radiation- and surgery-refractory tumors for which there is no clear recommendation for optimal management. The French National Tumor Board Meeting on Meningiomas (NTBM) offers a glimpse on the current management of such patients. METHODS: We retrospectively reviewed the charts of patients presented to the multidisciplinary Meeting between 2016 and 2019. We selected patients with a progressive disease after at least two treatments, including surgery and radiotherapy. RESULTS: In this multicentric cohort of 86 cases, patients harbored 17 (19.8%) WHO Grade I, 48 (55.8%) WHO Grade II and 21 (24.4%) WHO Grade III tumors. The median number of treatments received before inclusion was 3 (range: 2 - 11). Following the Board Meeting, 32 patients (37.2%) received chemotherapy, 11 (12.8%) surgery, 17 (19.8%) radiotherapy, 14 (16.3%) watchful observation and 12 (13.9%) palliative care. After a mean follow-up of 13 months post-inclusion, 32 patients (37.2%) had died from their disease. The mean progression free survival was 27 months after radiotherapy, 10 months after surgery, 8.5 months after chemotherapy (Bevacizumab: 9 months - Octreotide/Everolimus: 8 months). CONCLUSIONS: Surgery- and radiation-refractory meningiomas represent a heterogeneous group of tumors with a majority of WHO Grade II cases. If re-irradiation and redo-surgery are not possible, bevacizumab and octreotide-everolimus appear as a valuable option in heavily pre-treated patients considering the current EANO guidelines.

Surgical Site Infections after glioblastoma surgery: results of a multicentric retrospective study.

BACKGROUND: The effects of surgical site infections (SSI) after glioblastoma surgery on patient outcomes are understudied. The aim of this retrospective multicenter study was to evaluate the impact of SSI on the survival of glioblastoma patients. METHODS: Data from SSI cases after glioblastoma surgeries between 2009 and 2016 were collected from 14 French neurosurgical centers. Collected data included patient demographics, previous medical history, risk factors, details of the surgical procedure, radiotherapy/chemotherapy, infection characteristics, and infection management. Similar data were collected from gender- and age-paired control individuals. RESULTS: We used the medical records of 77 SSI patients and 58 control individuals. 13 were excluded. Our analyses included data from 64 SSI cases and 58 non-infected glioblastoma patients. Infections occurred after surgery for primary tumors in 38 cases (group I) and after surgery for a recurrent tumor in 26 cases (group II). Median survival was 381, 633, and 547 days in patients of group I, group II, and the control group, respectively. Patients in group I had significantly shorter survival compared to the other two groups (p < 0.05). The one-year survival rate of patients who developed infections after surgery for primary tumors was 50%. Additionally, we found that SSIs led to postoperative treatment discontinuation in 30% of the patients. DISCUSSION: Our findings highlighted the severity of SSIs after glioblastoma surgery, as they significantly affect patient survival. The establishment of preventive measures, as well as guidelines for the management of SSIs, is of high clinical importance.

A Phase 2 Randomized Trial of Asleep versus Awake Subthalamic Nucleus Deep Brain Stimulation for Parkinson's Disease.

OBJECTIVE: Asleep deep brain stimulation (DBS) for Parkinson's disease (PD) is being performed more frequently; however, motor outcomes and safety of asleep DBS have never been assessed in a prospective randomized trial. METHODS: We conducted a prospective, randomized, noncomparative trial to assess the motor outcomes of asleep DBS. Leads were implanted in the subthalamic nucleus (STN) according to probabilistic stereotactic coordinates with a surgical robot under O-arm© imaging guidance under either general anesthesia without microelectrode recordings (MER) (20 patients, asleep group) or local anesthesia with MER and clinical testing (9 patients, awake group). RESULTS: The mean motor improvement rates on the Unified Parkinson's Disease Rating Scale Part III (UPDRS-3) between OFF and ON stimulation without medication were 52.3% (95% CI: 45.4-59.2%) in the asleep group and 47.0% (95% CI: 23.8-70.2%) in the awake group, 6 months after surgery. Except for a subcutaneous hematoma, we did not observe any complications related to the surgery. Three patients (33%) in the awake group and 8 in the asleep group (40%) had at least one side effect potentially linked with neurostimulation. CONCLUSIONS: Owing to its randomized design, our study supports the hypothesis that motor outcomes after asleep STN-DBS in PD may be noninferior to the standard awake procedure.

Occipital Nerve Stimulation for Refractory Chronic Cluster Headache: A Cost-Effectiveness Study.

INTRODUCTION: Occipital nerve stimulation (ONS) is proposed to treat refractory chronic cluster headache (rCCH), but its cost-effectiveness has not been evaluated, limiting its diffusion and reimbursement. MATERIALS AND METHODS: We performed a before-and-after economic study, from data collected prospectively in a nation-wide registry. We compared the cost-effectiveness of ONS associated with conventional treatment (intervention and postintervention period) to conventional treatment alone (preintervention period) in the same patients. The analysis was conducted on 76 rCCH patients from the French healthcare perspective at three months, then one year by extrapolation. Because of the impact of the disease on patient activity, indirect cost, such as sick leave and disability leave, was assessed second. RESULTS: The average total cost for three months was €7602 higher for the ONS strategy compared to conventional strategy with a gain of 0.07 quality-adjusted life-years (QALY), the incremental cost-effectiveness ratio (ICER) was then €109,676/QALY gained. The average extrapolated total cost for one year was €1344 lower for the ONS strategy (p = 0.5444) with a gain of 0.28 QALY (p < 0.0001), the ICER was then €-4846/QALY gained. The scatter plot of the probabilistic bootstrapping had 80% of the replications in the bottom right-hand quadrant, indicating that the ONS strategy is dominant. The average indirect cost for three months was €377 lower for the ONS strategy (p = 0.1261). DISCUSSION: This ONS cost-effectiveness study highlighted the limitations of a short-time horizon in an economic study that may lead the healthcare authorities to reject an innovative strategy, which is actually cost-effective. One-year extrapolation was the proposed solution to obtain results on which healthcare authorities can base their decisions. CONCLUSION: Considering the burden of rCCH and the efficacy and safety of ONS, the demonstration that ONS is dominant should help its diffusion, validation, and reimbursement by health authorities in this severely disabled population.

How Should we Use Multicolumn Spinal Cord Stimulation to Optimize Back Pain Spatial Neural Targeting? A Prospective, Multicenter, Randomized, Double-Blind, Controlled Trial (ESTIMET Study).

BACKGROUND: Recent studies have highlighted multicolumn spinal cord stimulation (SCS) efficacy, hypothesizing that optimized spatial neural targeting provided by new-generation SCS lead design or its multicolumn programming abilities could represent an opportunity to better address chronic back pain (BP). OBJECTIVE: To compare multicolumn vs. monocolumn programming on clinical outcomes of refractory postoperative chronic BP patients implanted with SCS using multicolumn surgical lead. MATERIALS AND METHODS: Twelve centers included 115 patients in a multicenter, randomized, double-blind, controlled trial. After randomization, leads were programmed using only one or several columns. The primary outcome was change in BP visual analogic scale (VAS) at six months. All patients were then programmed using the full potential of the lead up until 12-months follow-up. RESULTS: At six months, there was no significant difference in clinical outcomes whether the SCS was programmed using a mono or a multicolumn program. At 12 months, in all patients having been receiving multicolumn SCS for at least six months (n = 97), VAS decreases were significant for global pain (45.1%), leg pain (55.8%), and BP (41.5%) compared with baseline (p < 0.0001). CONCLUSION: The ESTIMET study confirms the significant benefit experienced on chronic BP by patients implanted with multicolumn SCS, independently from multicolumn lead programming. These good clinical outcomes might result from the specific architecture of the multicolumn lead, giving the opportunity to select initially the best column on a multicolumn grid and to optimize neural targeting with low-energy requirements. However, involving more columns than one does not appear necessary, once initial spatial targeting of the "sweet spot" has been achieved. Our findings suggest that this spatial concept could also be transposed to cylindrical leads, which have drastically improved their capability to shape the electrical field, and might be combined with temporal resolution using SCS new modalities.

Relevance of emergency head CT scan for fall in the elderly person.

OBJECTIVES: Fall of the elderly person is a public health problem. The objectives of our study were to evaluate the relevance of systematically performing in emergency a computed tomography (CT) scan for fall in the elderly person, to identify specific criteria predicting the appearance of lesions. MATERIAL AND METHODS: We performed a retrospective analysis of 500 consecutive patients aged 65 and over, who underwent an emergency head CT scan for fall from their height. Outcome at the end of the acute care, clinico-biological data and delays between trauma an d CT were collected, and crossed with a detection of head lesion on the CT scan. RESULTS: Of 500 patients, 38 (7.6%) had traumatic lesions depicted on the CT scan and 267 (53.4%) were hospitalized after the CT scan. Three (0.6%) had been operated for urgent head surgery. Nine of the 38 (23.6%) patients with traumatic lesion returned home. Presence of a lesion depicted on the CT scan was not correlated with the orientation of the patient (P < 0.0001). Post-traumatic injury was significantly associated with male sex (RR = 2.19, P = 0.0217), consciousness impairment (RR = 1.56, P < 0.0001), focal neurological deficit (RR = 6.36, P = 0.0362) and past history of post-traumatic brain injury (RR = 7.17, P = 0.0027). Anticoagulant therapy was not associated with increased risk of traumatic lesions (P = 0.3315). ROC analysis determined that a 5-hours time-interval between head trauma and CT allowed optimal detection of lesions. CONCLUSION: The systematic indication of an emergency head CT scan for fall in elderly patients presents a low diagnostic and therapeutic yield and is not relevant. Male sex, consciousness impairment, focal neurological deficit, past history of post-traumatic brain injury and time-interval between head trauma and CT are statistically related to the presence of lesions and should therefore be taken into account.

Pre-surgical embolization of intracranial meningioma with Onyx: A safety and efficacy study.

BACKGROUND AND PURPOSE: Pre-surgical embolization of large intracranial meningioma has been demonstrated to decrease blood loss and to improve the resectability of the tumor. Few reports have evaluated the risk and benefits of using Onyx in this indication. The objective of our study was to assess the efficiency and safety of pre-surgical embolization in a consecutive series of intracranial meningioma using Onyx. MATERIALS AND METHODS: We conducted a retrospective study of consecutive patients treated from 2010 to 2018 with pre-surgical embolization with Onyx for intracranial histologically-proven meningioma. Safety was evaluated by a report of the complications related to the procedure while efficacy was assessed on angiographic and histopathologic criteria. RESULTS: Forty-four meningioma in 44 patients treated with pre-surgical embolization were included in this study. Proximal artery occlusion was obtained in 97.6% (41/42) of the cases and good intra-tumoral penetration was achieved in 75.6% (31/41). Embolic agent inside blood vessels was identified in 63.5% (28/44) of cases. Embolization-induced necrosis was present in 79.6% (35/44) of cases. Six complications have been encountered (13.6%); 3 were stated as minor complications (6.8%) and 3 as major occurring in case of trans-ophthalmic route (6.8%). CONCLUSIONS: The present work is to date the largest study to evaluate intracranial meningioma embolization using Onyx. Onyx's allowed good intra-tumoral penetration and proximal artery occlusion in most cases but carries a higher risk of complication in case of ophthalmic supply.

Prognostic factors for survival in adult patients with recurrent glioblastoma: a decision-tree-based model.

We assessed prognostic factors in relation to OS from progression in recurrent glioblastomas. Retrospective multicentric study enrolling 407 (training set) and 370 (external validation set) adult patients with a recurrent supratentorial glioblastoma treated by surgical resection and standard combined chemoradiotherapy as first-line treatment. Four complementary multivariate prognostic models were evaluated: Cox proportional hazards regression modeling, single-tree recursive partitioning, random survival forest, conditional random forest. Median overall survival from progression was 7.6 months (mean, 10.1; range, 0-86) and 8.0 months (mean, 8.5; range, 0-56) in the training and validation sets, respectively (p = 0.900). Using the Cox model in the training set, independent predictors of poorer overall survival from progression included increasing age at histopathological diagnosis (aHR, 1.47; 95% CI [1.03-2.08]; p = 0.032), RTOG-RPA V-VI classes (aHR, 1.38; 95% CI [1.11-1.73]; p = 0.004), decreasing KPS at progression (aHR, 3.46; 95% CI [2.10-5.72]; p < 0.001), while independent predictors of longer overall survival from progression included surgical resection (aHR, 0.57; 95% CI [0.44-0.73]; p < 0.001) and chemotherapy (aHR, 0.41; 95% CI [0.31-0.55]; p < 0.001). Single-tree recursive partitioning identified KPS at progression, surgical resection at progression, chemotherapy at progression, and RTOG-RPA class at histopathological diagnosis, as main survival predictors in the training set, yielding four risk categories highly predictive of overall survival from progression both in training (p < 0.0001) and validation (p < 0.0001) sets. Both random forest approaches identified KPS at progression as the most important survival predictor. Age, KPS at progression, RTOG-RPA classes, surgical resection at progression and chemotherapy at progression are prognostic for survival in recurrent glioblastomas and should inform the treatment decisions.

Comparison of 8 and 5 mm robotic instruments in small cavities : 5 or 8 mm robotic instruments for small cavities?

INTRODUCTION: Robotic surgery has seen increasing use in the field of pediatric surgery. Our clinical experience suggested instrument size can impact on the surgical ability. This study aimed to compare the performance of robot-assisted laparoscopic skills in confined spaces using either 5 or 8 mm instruments. METHODS: A preclinical randomized crossover study design was implemented. 24 assessors performed three different reproducible drill procedures (M1: peg transfer, M2: circle cutting, M3: intracorporeal suturing). To assess surgical proficiency in confined working spaces, these exercises were performed with 5 and 8 mm instruments of the da Vinci® Surgical Systems Si in a cubic box with 60 mm-sized edges. Each performance was recorded and evaluated by two reviewers using both objective structured assessment of technical skills (OSATS) and global evaluative assessment of robotic skills (GEARS) scores. Parietal iatrogenic impacts and instrument collisions were specifically analyzed using a dedicated scoring system. RESULTS: Regardless of their experience, trainees performed significantly better when using 8 mm instruments in terms of OSATS scores (20.5 vs. 18.4; p < 0.01) and GEARS scores (23.4 vs. 21.9; p < 0.01) for most items, except for "depth perception" and "autonomy." The 8 mm performances involved significantly less parietal box damage (4.1 vs. 3.4; p < 0.01), and tool collisions (4.1 vs. 3.2; p < 0.01). CONCLUSIONS: In light of the better performances with 8 mm tools for specific tasks and parietal sparing constraints in restricted spaces, this study indicates that 5 mm instruments can be deemed to be less effective for reconstructive procedures in small children.

[Calcifying pseudoneoplasm of the neuraxis]. / Pseudo-tumeur calcifiante du névraxe.

Calcifying pseudoneoplasms of the neuraxis (CAPNON) are rare lesions of the central nervous system. To date, about 60 cases have been reported in literature. We present a case that had the peculiarity to occur in a pregnant woman. At 32 weeks of gestation, a 26-year-old woman was hospitalized to explore nocturnal epigastralgia. During the hospitalisation, the patient presented generalised seizures. As an eclampsia had been suspected, a caesarean delivery was performed. Post-operatively, the patient harboured memory disorders and neuro-imaging explorations were done. They showed an intracerebral calcified mass located in the left frontal lobe and surrounded by an oedema. A complete surgical resection was performed. Histological examination of the surgical specimen showed a calcified tissue containing a fibrillary or granular material. A dense and hyalinised eosinophilic material focally surrounded the calcifications and contained regular fusiform cells of fibroblastic type. Foci of lipomatous and osseous metaplasia were present. Immunohistochemical staining for EMA and STAT6 was negative. There was no associated meningioangiomatosis nor tumour proliferation. Forty-five months after surgery, the patient did not present any seizures and had no sequelae. CAPNON are rare lesions occurring at any age. Their location in the central nervous system is ubiquitous and they can be intra or extra axial. The treatment is surgical and the prognosis excellent. CAPNON must be recognized and distinguished from the other calcified lesions, tumoural or non-tumoural, to avoid an inadequate and potentially harmful treatment.

Occipital nerve stimulation improves the quality of life in medically-intractable chronic cluster headache: Results of an observational prospective study.

Background Occipital nerve stimulation (ONS) has been proposed to treat chronic medically-intractable cluster headache (iCCH) in small series of cases without evaluation of its functional and emotional impacts. Methods We report the multidimensional outcome of a large observational study of iCCH patients, treated by ONS within a nationwide multidisciplinary network ( https://clinicaltrials.gov NCT01842763), with a one-year follow-up. Prospective evaluation was performed before surgery, then three and 12 months after. Results One year after ONS, the attack frequency per week was decreased >30% in 64% and >50% in 59% of the 44 patients. Mean (Standard Deviation) weekly attack frequency decreased from 21.5 (16.3) to 10.7 (13.8) ( p = 0.0002). About 70% of the patients responded to ONS, 47.8% being excellent responders. Prophylactic treatments could be decreased in 40% of patients. Functional (HIT-6 and MIDAS scales) and emotional (HAD scale) impacts were significantly improved, as well as the health-related quality of life (EQ-5D). The mean (SD) EQ-5D visual analogic scale score increased from 35.2 (23.6) to 51.9 (25.7) ( p = 0.0037). Surgical minor complications were observed in 33% of the patients. Conclusion ONS significantly reduced the attack frequency per week, as well as the functional and emotional headache impacts in iCCH patients, and dramatically improved the health-related quality of life of responders.

Recurrent glioblastomas in the elderly after maximal first-line treatment: does preserved overall condition warrant a maximal second-line treatment?

A growing literature supports maximal safe resection followed by standard combined chemoradiotherapy (i.e. maximal first-line therapy) for selected elderly glioblastoma patients. To assess the prognostic factors from recurrence in elderly glioblastoma patients treated by maximal safe resection followed by standard combined chemoradiotherapy as first-line therapy. Multicentric retrospective analysis comparing the prognosis and optimal oncological management of recurrent glioblastomas between 660 adult patients aged of < 70 years (standard group) and 117 patients aged of ≥70 years (elderly group) harboring a supratentorial glioblastoma treated by maximal first-line therapy. From recurrence, both groups did not significantly differ regarding Karnofsky performance status (KPS) (p = 0.482). Oncological treatments from recurrence significantly differed: patients of the elderly group received less frequently oncological treatment from recurrence (p < 0.001), including surgical resection (p < 0.001), Bevacizumab therapy (p < 0.001), and second line chemotherapy other than Temozolomide (p < 0.001). In multivariate analysis, Age ≥70 years was not an independent predictor of overall survival from recurrence (p = 0.602), RTOG-RPA classes 5-6 (p = 0.050) and KPS at recurrence <70 (p < 0.001), available in all cases, were independent significant predictors of shorter overall survival from recurrence. Initial removal of ≥ 90% of enhancing tumor (p = 0.004), initial completion of the standard combined chemoradiotherapy (p = 0.007), oncological treatment from recurrence (p < 0.001), and particularly surgical resection (p < 0.001), Temozolomide (p = 0.046), and Bevacizumab therapy (p = 0.041) were all significant independent predictors of longer overall survival from recurrence. Elderly patients had substandard care from recurrence whereas age did not impact overall survival from recurrence contrary to KPS at recurrence <70. Treatment options from recurrence should include repeat surgery, second line chemotherapy and anti-angiogenic agents.

Delayed-onset post-craniotomy headache responsive to botulinum toxin A: a case series.

We report here the case of four patients presenting with delayed-onset temporal pain after pterional craniotomy. They reported similar symptoms: attacks of pain over the temporal region, ipsilateral to the operative site, irradiating around the eye and lasting from 10 min to 1 h. All patients had hypertrophy of at least one part of the temporalis muscle. All responded dramatically to botulinum toxin A injection (25 to 50 Botox® units) into the temporalis muscle. We suggest that the headaches were caused by aberrant nerve regeneration following surgical injury to the frontal branch of the facial nerve.

OnabotulinumtoxinA injections in chronic migraine, targeted to sites of pericranial myofascial pain: an observational, open label, real-life cohort study.

BACKGROUND: OnabotulinumtoxinA has proven its efficacy in reducing the number of headache days in chronic migraine (CM) patients. The usual paradigm includes 31 pericranial injection sites with low dose (5 U) per site. The aim of this study is to present the results obtained using a simpler injection protocol of onabotulinumtoxinA, with injection sites targeted to pericranial myofascial sites of pain. METHODS: Observational, open label, real-life, cohort study. We enrolled 63 consecutive patients fulfilling the diagnostic criteria of CM, and refractory to conventional treatments. The patients were injected using a "follow-the-pain" pattern into the corrugator and/or temporalis and/or trapezius muscles. The doses per muscle were fixed. According to the number of muscles injected, the total dose could vary from 70 to 150 U per session. Patients were considered responders if they had a ≥ 50% decrease in number of headache days in at least two consecutive injection cycles. RESULTS: Forty one patients (65.1% in intention to treat analysis) responded to treatment. In 70.7% of responders, the effect size was even higher, with a reduction ≥70% in the number of headache days. The associated cervical pain and muscle tenderness, present in 33 patients, was reduced by ≥50% in 31 patients (94%). Triptan consumption dramatically decreased (81%) in responders. The trapezius was the most frequently injected muscle. We observed no serious adverse event. The mean patient satisfaction rate was 8.5/10. CONCLUSIONS: This study provides additional robust evidence supporting the efficacy of onabotulinumtoxinA injections in CM. Furthermore, the paradigm we used, with reduced number of injection sites targeted to pericranial myofascial sites of pain, may provide evidence in favor of the implication of myofascial trigger points in migraine chronicization. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Record I17022 ClinicalTrials.gov Identifier: NCT03175263 . Date of registration: June 7, 2017. Retrospectively registered.

A systematic review of studies on anatomical position of electrode contacts used for chronic subthalamic stimulation in Parkinson's disease.

BACKGROUND: The dorso-lateral part of the subthalamic nucleus (STN) is considered as the usual target of deep brain stimulation for Parkinson's disease. Nevertheless, the exact anatomical location of the electrode contacts used for chronic stimulation is still a matter of debate. The aim of this study was to perform a systematic review of the existing literature on this issue. METHOD: We searched for studies on the anatomical location of active contacts published until December 2012. RESULTS: We identified 13 studies, published between 2002 and 2010, including 260 patients and 466 electrodes. One hundred and sixty-four active contacts (35 %) were identified within the STN, 117 (25 %) at the interface between STN and the surrounding structures, 184 (40 %) above the STN and one within the substantia nigra. We observed great discrepancies between the different series. The contra-lateral improvement was between 37 and 78.5 % for contacts located within the STN, between 48.6 and 73 % outside the STN, between 65.3 and 66 % at the interface. The authors report no clear correlation between anatomical location and stimulation parameters. CONCLUSIONS: Post-operative analysis of the anatomical location of active contacts is difficult, and all the methods used are debatable. The relationship between the anatomical location of active contacts and the clinical effectiveness of stimulation is unclear. It would be necessary to take into account the volume of the electrode contacts and the diffusion of the stimulation. We can nevertheless assume that the interface between dorso-lateral STN, zona incerta and Forel's fields could be directly involved in the effects of stimulation.

Treatment of A3.2 and A2 traumatic thoracolumbar spine compression fractures using vertebral body stenting: a 63-patient series.

BACKGROUND: Percutaneous treatments for spinal injury are underused by neuroradiologists and spine surgeons, mainly owing to a lack of data on indications. OBJECTIVE: To assess the safety and efficacy of vertebral body stenting (VBS) for post-traumatic A3.2 and A2 fractures (Magerl classification) and determine the factors that influence the improvements. METHODS: We retrospectively reviewed patients who underwent VBS to treat a single traumatic thoracolumbar fracture from 2010 to 2019. Kyphosis, loss of vertebral body height (VBH), and clinical and functional outcomes (including the Visual Analog Scale pain score and Oswestry Disability Index) were assessed. We examined the overall effects of VBH in all patients by constructing a linear statistical model and evaluated whether the efficacy was dependent on the characteristics of the patients or fractures. RESULTS: We included 63 patients comprising 44 A3.2 and 19 A2 fractures. No patient had worsening neurological symptoms or wound infection. The average rates of change were 67.1% (95% CI 59.1% to 75%) for kyphosis and 88.5% (95% CI 85.6% to 91.3%) for VBH (both p<0.0001). After 1 year, the VBS treatment was more effective for kyphosis in younger patients and at the L1 level, and for VBH in younger patients and cases of Magerl A3.2 fracture. CONCLUSIONS: This large reported series on VBS validates this surgical treatment. All patients had improved kyphosis and restored VBH. We recommend using VBS rather than open surgery for A3.2 and A2 fractures at the thoracolumbar junction and in young patients.

Combining Awake Anesthesia with Minimal Invasive Surgery Optimizes Intraoperative Surgical Spinal Cord Stimulation Lead Placement.

Spinal cord stimulation (SCS) is an effective and validated treatment to address chronic refractory neuropathic pain in persistent spinal pain syndrome-type 2 (PSPS-T2) patients. Surgical SCS lead placement is traditionally performed under general anesthesia due to its invasiveness. In parallel, recent works have suggested that awake anesthesia (AA), consisting of target controlled intra-venous anesthesia (TCIVA), could be an interesting tool to optimize lead anatomical placement using patient intra-operative feedback. We hypothesized that combining AA with minimal invasive surgery (MIS) could improve SCS outcomes. The goal of this study was to evaluate SCS lead performance (defined by the area of pain adequately covered by paraesthesia generated via SCS), using an intraoperative objective quantitative mapping tool, and secondarily, to assess pain relief, functional improvement and change in quality of life with a composite score. We analyzed data from a prospective multicenter study (ESTIMET) to compare the outcomes of 115 patients implanted with MIS under AA (MISAA group) or general anesthesia (MISGA group), or by laminectomy under general anesthesia (LGA group). All in all, awake surgery appears to show significantly better performance than general anesthesia in terms of patient pain coverage (65% vs. 34-62%), pain surface (50-76% vs. 50-61%) and pain intensity (65% vs. 35-40%), as well as improved secondary outcomes (quality of life, functional disability and depression). One step further, our results suggest that MISAA combined with intra-operative hypnosis could potentialize patient intraoperative cooperation and could be proposed as a personalized package offered to PSPS-T2 patients eligible for SCS implantation in highly dedicated neuromodulation centers.

The mamillothalamic tract is a good landmark for the anterior border of the subthalamic nucleus on axial MR images.

BACKGROUND: Identification of the subthalamic nucleus (STN) on MR images is difficult, and the use of external landmarks could be of interest for STN targeting in deep brain stimulation (DBS). OBJECTIVES: Our aim was to explore the relationship between the anteroposterior coordinates of (1) the center of the mamillothalamic tract and (2) the anterior border of the STN on axial MR images. PATIENTS AND METHODS: The brains of 16 healthy volunteers were imaged on a 3T MR system. Four millimeters under the anterior-posterior commissure plane, we noted the y coordinates of (1) the center of the mamillothalamic tract and (2) the anterior border of the STN. RESULTS: The coordinates were y(STN) = 14.7 ± 1.23 mm and y(Tmth) = 14.3 ± 1.13 mm from the posterior commissure for the STN and the mamillothalamic tract, respectively. The mean difference was 0.4 mm (range 0-1 mm). Pearson's coefficient was 0.97 (p < 0.01). CONCLUSION: We observed a strong correlation between the anteroposterior coordinates of the mamillothalamic tract and the anterior border of the STN (which is located between 0 and 1 mm in front of the mamillothalamic tract). The mamillothalamic tract could be a good anterior landmark for STN targeting. It could also be tested for target determination in DBS for severe obsessive-compulsive disorder.

Treating traumatic thoracolumbar spine fractures using minimally invasive percutaneous stabilization plus balloon kyphoplasty: a 102-patient series.

BACKGROUND: There is no consensus on the treatment for spinal injuries resulting in thoracolumbar fractures without neurological impairment. Many trauma centers are opting for open surgery rather than a neurointerventional approach combining posterior percutaneous short fixation (PPSF) plus balloon kyphoplasty (BK). OBJECTIVE: To assess the safety and efficacy of PPSF+BK and to estimate the expected improvement by clarifying the factors that influence improvement. METHODS: We retrospectively reviewed patients who underwent PPSF+BK for the treatment of single traumatic thoracolumbar fractures from 2007 to 2019. Kyphosis, loss of vertebral body height (VBH), clinical and functional outcomes including visual analog scale and Oswestry disability index were assessed. We examined the overall effects in all patients by constructing a linear statistical model, and then examined whether efficacy was dependent on the characteristics of the patients or the fractures. RESULTS: A total of 102 patients were included. No patient experienced neurological worsening or wound infections. The average rates of change were 74.4% (95% CI 72.6% to 76.1%) for kyphosis and 85.5% (95% CI 84.4% to 86.6%) for VBH (both p<0.0001). The kyphosis treatment was more effective on Magerl A3 and B2 fractures than on those classified as A2.3, as well as for fractures with slight posterior wall protrusion on the spinal canal. A higher postoperative visual analog scale score was predictive of poorer outcome at 1 year. CONCLUSIONS: This is the largest series reported to date and confirms and validates this surgical treatment. All patients exhibited improved kyphosis and restoration of VBH. We advise opting for this technique rather than open surgery.

Isolated cerebral Rosai-Dorfman disease presenting as a sole mass protruding into the fourth ventricle: A case report.

Rosai-Dorfman disease is a non-Langherans cell histiocytosis typically revealed by a lymphadenopathy. Central nervous system involvement is rare, exceptionally isolated, and usually consists of dural masses mimicking meningioma. Very few reports have described non-dural-based lesions, especially with an intra-ventricular development. We report hereby the case of a Rosai-Dorfman disease in a 30-year-old man presenting as an isolated mass arising from the right cerebellar peduncle and protruding into the fourth ventricle. We provide the results of the MRI examination with a special focus on advanced MRI features. As the diagnosis relies on pathological examination, we also detail the results of the analysis that followed the surgical resection of the mass including the immunohistochemical profile. This report highlights the necessity to consider Rosai-Dorfman disease as a potential diagnosis in case of an infra-tentorial mass and/or intra-ventricular mass.