Acute back pain - Role of injection techniques and surgery: WFNS spine committee recommendations.

Objective: Lower back pain is a significant cause of morbidity, and despite a range of interventions available, there is a lack of consensus on the most efficacious treatments. The aim of this systematic review is to formulate a list of recommendations for the role of spinal injections and surgery in the treatment of acute back pain. Methods: A systematic literature search from 2012 to 2022 was conducted on Pubmed, Medline, and Cochrane Central Register of Controlled Trials for papers focusing on the role of injections and surgery for the management of acute lower back pain. Inclusion criteria included randomised controlled trials, as well as prospective and retrospective studies reporting primary outcomes (pain improvement (VAS score) and back-specific functional status) and secondary outcomes (post-procedure complications). These data were reviewed, presented, and voted on by an expert panel consisting of 14 attending spine surgeons from 14 countries at the consensus meeting of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. A two-round consensus-based Delphi method was used to generate consensus, and topics with >66% agreement were categorized as having reached consensus. Results: 100 studies met inclusion criteria. Of these, 20 were selected by the committee for full text review and presented at the consensus meeting. The committee voted on 8 statements and achieved consensus on the following 7 statements: (1) Epidural steroid injections (ESIs) show significant benefit to discogenic back pain; (2) A lateral approach is superior to a midline approach for ESIs; (3) Short-term (<1 week) effect of ESIs is similar between steroids; (4) ESIs have a variety of potential complications; (5) CT or fluoroscopy guidance can be used for lumbar medial branch blocks; (6) Lumbar medial branch radiofrequency ablations can be performed on patients with recurrent pain after a successful ESI, and (7) Acute lower back pain is usually self-limiting, resolves in <6 weeks, and does not require surgical intervention. Conclusion: Given significant treatment heterogeneity, we provide the latest, evidence-based recommendations for management of acute lower back pain. ESIs are effective at short-term pain relief, and surgical intervention should be reserved for patients failing conservative measures.

Low-Cost 3D Models for Cervical Spine Tumor Removal Training for Neurosurgery Residents.

BACKGROUND AND OBJECTIVES: Spinal surgery, particularly for cervical pathologies such as myelopathy and radiculopathy, requires a blend of theoretical knowledge and practical skill. The complexity of these conditions, often necessitating surgical intervention, underscores the need for intricate understanding and precision in execution. Advancements in neurosurgical training, especially with the use of low-cost 3D models for simulating cervical spine tumor removal, are revolutionizing this field. These models provide the realistic and hands-on experience crucial for mastering complex neurosurgical techniques, filling gaps left by traditional educational methods. MATERIALS AND METHODS: This study aimed to assess the effectiveness of 3D-printed cervical vertebrae models in enhancing surgical skills, focusing on tumor removal, and involving 20 young neurosurgery residents. These models, featuring silicone materials to simulate the spinal cord and tumor tissues, provided a realistic training experience. The training protocol included a laminectomy, dural incision, and tumor resection, using a range of microsurgical tools, focusing on steps usually performed by senior surgeons. RESULTS: The training program received high satisfaction rates, with 85% of participants extremely satisfied and 15% satisfied. The 3D models were deemed very realistic by 85% of participants, effectively replicating real-life scenarios. A total of 80% found that the simulated pathologies were varied and accurate, and 90% appreciated the models' accurate tactile feedback. The training was extremely useful for 85% of the participants in developing surgical skills, with significant post-training confidence boosts and a strong willingness to recommend the program to peers. CONCLUSIONS: Continuing laboratory training for residents is crucial. Our model offers essential, accessible training for all hospitals, regardless of their resources, promising improved surgical quality and patient outcomes across various pathologies.

Is surgery beneficial for patients with concurrent multiple sclerosis and degenerative cervical myelopathy? A review of literature.

Introduction: Due to an overlap in symptoms, there is significant delay in surgical treatment of patients that have concomitant multiple sclerosis (MS) and degenerative cervical Myelopathy (DCM). The purpose of this review is to evaluate if surgical intervention is beneficial to patients that have concurrent presentations. Research question: Is surgery beneficial in concurrent MS and DCM? Materials and methods: A literature search with no date restrictions was conducted on Pubmed and Medline databases. Keywords searched: Degenerative Cervical Myelopathy, Multiple sclerosis, Treatment, Surgery, Quality of Life. Randomised controlled trials, prospective, retrospective, and case series reporting timing of surgery, post-operative outcomes such as improvement in myelopathic symptoms, quality of life, and any serious complications were included. Results: The literature search yielded a total of 8 studies across all databases. Seven articles were selected for full text review, and all of them were sectioned for inclusion in this review. Seven studies evaluated 160 participants with concurrent multiple sclerosis and degenerative cervical myelopathy. Earlier studies had discouraged performing surgery in this subset of patients, the majority of studies found it worthwhile to perform early surgery for patients with concomitant multiple sclerosis and degenerative cord compression, if the patients had radiculopathy. Quality of life for MS patients did not improve as much as it did for patients that did not have MS. Discussion and conclusion: Patients with radiculopathy, neck pain and cord compression are most likely to benefit from early surgery. There is no need for delaying to offer surgery unless other medical/anaesthetic contraindications exist.

Sexual discrimination in neurosurgery: a questionnaire-based nationwide study amongst women neurosurgeons in Bulgaria.

BACKGROUND: The aim of this qualitative, descriptive, cross-sectional study was to identify potential factors influencing the progression of female neurosurgeons in Bulgaria. METHODS: The study was conducted nationally, by sending out an online (SurveyMonkey®) questionnaire with 30 questions over a 3-month period to 15 registered female neurosurgeons in practice including residents/trainees and specialists from state universities, private universities and regional hospitals in Bulgaria. The questionnaire covered basic demographics, level of academic achievement and aspects of personal and professional experience, along with questions on the perceived barriers that female neurosurgeons nationally encountered during their clinical and academic career. These results were compared with similar studies conducted in other countries following a literature search on PubMed. RESULTS: Eleven out of fifteen respondents returned the completed survey, covering 10 institutions which included 8 university clinics and two regional clinics, achieving a response rate of 73.3%. No questionnaires were excluded. The factors negatively influencing the clinical and academic professional development and progression in the field included lack of mentors and other female role models, perceived bias regarding remuneration and leave, as well as a lack of support with regards to work-life balance and difficulty progressing in the academic fields. CONCLUSIONS: Although there is an ever increasing and growing awareness of the factors negatively impacting women progression in neurosurgery worldwide, there are still significant gaps and biases that hinder career progression amongst female neurosurgical communities and highlight a need for potential practices to be established in the workplace to counteract this.

A Year of Pandemic-Comparison of Depression Among Neurosurgeons After the Advent of the COVID-19 Vaccine.

OBJECTIVE: To determine factors associated with anxiety and depression among neurosurgeons after vaccination during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: An online survey was completed by neurosurgeons worldwide over 4 weeks. Depression in neurosurgeons was assessed by the 20-item self-reporting questionnaire. RESULTS: A total of 534 responses were received and analyzed. Almost half of the respondents were from Asia (50.9%), followed by Europe (38.8%). The majority of the respondents were <40 years old (88%), and almost two thirds were trainees (62.2%). Half of the respondents worked in departments with <40 beds (50.7%), and the majority were practicing in the private sector (72.5%). Most of the respondents (85.8%) had COVID-19-positive colleagues in their department, and 64% had exposure to a COVID-19-positive colleague, family member, and/or patient. More than half of the respondents were exposed to infected patients and/or colleagues, and almost half (43.1%) underwent COVID-19 testing when exposed. Nearly half of the respondents underwent COVID-19 testing more than twice (52.4%). Of respondents, 83% had received at least the first dose of the vaccine. The odds of depression among vaccinated respondents were found to be significantly less than among unvaccinated respondents in the univariable model. CONCLUSIONS: Among health care workers, neurosurgeons are one of the groups indirectly affected by the pandemic. Adaptation to the new normal and advent of vaccines is speculated to control psychological distress among all groups of health care workers, including neurosurgeons. We found that odds of depression among vaccinated people were lower than among people who were not vaccinated.

Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: A systematic review of 15 studies.

BACKGROUND: Intraoperative imaging in minimally invasive spinal surgeries is associated with significant radiation exposure to surgeons, which overtime can lead to serious health hazards including malignancy. In this study, the authors conducted a systematic review to evaluate the efficacy of navigation assisted fluoroscopy methods on radiation exposure to the surgeon in minimally invasive spine surgeries, percutaneous endoscopic lumbar discectomy/percutaneous endoscopic transforaminal discectomy versus minimally invasive spine transforaminal lumbar interbody fusion (PELD/PETD versus MIS-TLIF). METHODS: A systematic literature search was conducted using PUBMED/MEDLINE on 20th July, 2020. Inclusion criteria were applied according to study design, surgical technique, spinal region, and language. Data extracted included lumbar segment, average operation time (min), fluoroscopic time (s), and radiation dose (µSV), efficacy of modified navigation versus conventional techniques; on reducing operation, fluoroscopy times and effective radiation dose. RESULTS: Fifteen studies (ten prospectives, and five retrospectives) were included for quantitative analysis. PELD recorded a shorter operation time (by 126.3min, p<0.001) and fluoroscopic time (by 22.9s, p=0.3) than MIS-TLIF. The highest radiation dose/case (µSV) for both techniques were recorded at the surgeon's: finger, chest, neck and eye. The effective dose for MIS-TLIF was 30µSV higher than PELD. Modified navigation techniques recorded a shorter operation time (by 15.9min, p=0.3); fluoroscopy time (by 289.8s, p=0.3); effective radiation dose (by 169.5µSV, p=0.3) than conventional fluoroscopy methods. DISCUSSION: This systematic literature review showed that although navigation assisted fluoroscopy techniques are superior to conventional methods in minimising radiation exposure, lack of statistical significance warrants future randomised controlled trials, to solidify their efficacy in reducing radiation related hazards.

Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations.

Thoracolumbar spine is the most injured spinal region in blunt trauma. Literature on the indications for nonoperative treatment of thoracolumbar fractures is conflicting. The purpose of this systematic review is to clarify the indications for nonsurgical treatment of thoracolumbar fractures. We conducted a systematic literature search between 2010 to 2020 on PubMed/MEDLINE, and Cochrane Central. Up-to-date literature on the indications for nonoperative treatment of thoracolumbar fractures was reviewed to reach an agreement in a consensus meeting of WFNS (World Federation of Neurosurgical Societies) Spine Committee. The statements were voted and reached a positive or negative consensus using the Delphi method. For all of the questions discussed, the literature search yielded 1,264 studies, from which 54 articles were selected for full-text review. Nine studies (4 trials, and 5 retrospective) evaluating 759 participants with thoracolumbar fractures who underwent nonoperative/surgery were included. Although, compression type and stable burst fractures can be managed conservatively, if there is major vertebral body damage, kyphotic angulation, neurological deficit, spinal canal compromise, surgery may be indicated. AO type B, C fractures are preferably treated surgically. Future research is necessary to tackle the relative paucity of evidence pertaining to patients with thoracolumbar fractures.

Classification and Radiological Diagnosis of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations.

The aim of this review to determine recommendations for classification and radiological diagnosis of thoracolumbar spine fractures. Recommendation was made through a literature review of the last 10 years. The statements created by the authors were discussed and voted on during 2 consensus meetings organized by the WFNS (World Federation Neurosurgical Societies) Spine Committee. The literature review was yielded 256 abstracts, of which 32 were chosen for full-text analysis. Thirteen papers evaluated the reliability of a classification system by our expert members and were also chosen in this guideline analysis. This literature review-based recommendation provides the classification and radiologic diagnosis in thoracolumbar spine fractures that can elucidate the management decision-making in clinical practice.

Delayed surgical resections of brain metastases after gamma knife radiosurgery.

Although brain metastases are one of the most frequently diagnosed sequelae of systemic malignancy, their optimal management still is not well defined. In that respect, the different diagnostic and therapeutic approaches of BMs patients is an issue for serious discussions. The treatment options include surgical excision, WBRT, radiosurgery, chemotherapy, immunotherapy, etc. Nowadays, the aforementioned treatment modalities are usually combined in different treatment schemes. More than one option is used for the same patient and combining these treatment modalities gives better results than when separately use them. The value of surgical excision of progressing brain metastases treated with gamma knife surgery (GKS) is not well investigated.With the present study, we aim to investigate the value of surgical excision of symptomatic brain lesions that have been previously treated with GKS.

Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review.

OBJECTIVE: Recurrent lumbar disc herniation (rLDH) is a common issue after primary discectomy and can cause severe pain, morbidity, and reoperation. The purpose of this systematic review was to evaluate the surgical management of recurrent lumbar disc herniation. METHODS: A systematic literature search was conducted using Pubmed and Embase databases on 18thAugust, 2019. The inclusion and exclusion criteria were applied according to study design, surgical approach, language, number of patients; and spinal level. Data extracted included patient demographics, and clinical outcomes (patients with excellent/good outcomes; VAS back and leg score improvement, complication and recurrence rates). RESULTS: Sixteen studies, (comprising of seven prospective and nine retrospective) met the inclusion criteria. Ten studies evaluated discectomy only; four analysed fusion, and two analysed both discectomy only and fusion approaches. Fusion approaches recorded a superior success rate (8.3 % higher, p>0.05); postoperative VAS back score improvement (5 % higher, p>0.05) than discectomy alone.  However, discectomy alone approaches recorded a more favourable postoperative VAS leg score improvement (4.2 % higher p>0.05), and complication rate (3.2% lower, p>0.05) than fusion techniques. CONCLUSION: There is significant heterogeneity in clinical outcomes reported for studies after surgical intervention in rLDH patients. Neither discectomy nor fusion's superiority was statistically significant. Despite fusion yielding longer operative times, and length of stay (adding to the expense), it is superior in minimising mechanical instability and recurrence. Finally, we conclude that both approaches are equally efficacious in rLDH cases, and choice should be based on a case by case basis.

Rehabilitation of Spinal Cord Injury: WFNS Spine Committee Recommendations.

Spinal cord injury (SCI) is accompanied by a significant number of complications associated with damage to the spinal cord, gross functional impairments leading to limited self-care and movement, leading to a high level of disability, social and psychological maladaptation of the patients. Besides, pain and spasticity negatively affect rehabilitation programs. This search was conducted in PubMed/MEDLINE database. All studies published in English language (n = 16,297) were considered for inclusion. Of all studies evaluating rehabilitation in SCI patients (n = 80) were included. Based on the literature review the faculty of the WFNS Spine Committee created statements covering different aspects of the contemporary rehabilitation process of the SCI patients. The prepared statements were subjected to discussions, followed by anonymous voting process by the members of the WFNS Spine Committee. As result of the diccussions and the voting process the statements were modified and published as recommendations of the WFNS Spine Committee. The care for the SCI has gone a long way from the times after the World War II when these patients were considered hopeless in terms of any functional recovery, to the contemporary comprehensive rehabilitation programs. The rehabilitation is important part of the modern comprehencive treatment of SCI patients nowadays. The current manuscript reflects different aspects of the contemporary rehabilitaton process and decision makings, which were discussed by the faculty of the WFNS Spine Committee resulting in issuing of the following recommendations.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations.

Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.

COVID 19-Depression and Neurosurgeons.

OBJECTIVE: The goal of this survey was to determine factors associated with anxiety/depression among neurosurgeons during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: An online survey was performed of neurosurgeons worldwide, conducted over 3 weeks. Depression in neurosurgeons was assessed by Self-Reporting Questionnaire-20. RESULTS: A total of 375 responses were received from 52 countries. Among all neurosurgeons, 34% felt tense, 32.5% were unhappy, 25% experienced insomnia, almost 20% had headaches, and 5% had suicidal ideation during the pandemic. Of participants, 14% had a score on Self-Reporting Questionnaire-20 consistent with depression. The likelihood of depression was significantly higher among those who did not receive guidance about self-protection from their institutions (odds ratio [OR], 2.47), those who did not feel safe with provided personal protective equipments (OR, 3.13), and those whose families considered their workplace unsafe (OR, 2.29). Depression was less likely in neurosurgeons who had minor concerns, compared with those with significant health concerns for their families (OR, 0.36). In multivariate analysis after controlling for effects of other covariates, odds of depression were significantly higher among neurosurgeons who did not feel safe with the provided personal protective equipment (OR, 2.43) and who were exposed to a COVID-19-positive colleague (OR, 2.54). Participants who had moderate concerns for their families had lesser odds of anxiety/depression than did those with significant concerns (OR, 0.28). CONCLUSIONS: Based on the modifiable risk factors of depression in this study, it is recommended that the safety of neurosurgeons be ensured by providing appropriate safety measures for them to regain their confidence and hence reduce the incidence of depression.

Minimally Invasive Spinal Surgery: How to Keep out of Trouble.

Innovative techniques have revolutionized minimally invasive surgeries, which has significant benefits for the patients. Despite the benefits, these advancements require a longer learning curve for an inexperienced surgeon. The authors have collected some pearls from their experience and from other surgeons. Tips and tricks about common MISS procedures such as minimally invasive endoscopic transforaminal lumbar disc and interlaminar discectomy, MIS, TLIF, LLIF, ALIF, spinal tumor excision, posterior cervical fixation and foraminotomy are described. How to stay out of trouble is explained with these surgeries. These techniques will help young surgeons to become proficient and achieve better outcome.

Alcaptonuria with lumbar disc prolapse: case study and review of the literature.

BACKGROUND CONTEXT: Patients with alcaptonuria frequently complain of pain in the large joints and the spinal column, this condition is being assumed to be normal. It is very rare for patients with ochronosis to undergo lumbar surgery since the disk protrusion is not characteristic for them and overlaps with the general complaints due to the spondiloarthritic and stenotic changes. PURPOSE: To prove the possibility of a lumbar disc herniation in a patient with alcaptonuria as a real entity that causes lumbar and radiculalgic complaints. STUDY DESIGN: A case of a 33-year old patient with alcaptonuria and lumbar disc herniation is presented. METHODS: The case is presented together with its clinical course, the diagnostic techniques, the surgical findings, histological results and the treatment outcome. RESULTS: After the surgical treatment the patient's complaints were alleviated and almost no complaints were registered, during the next follow-up. CONCLUSIONS: The most common symptoms seen in alcaptonuria are complaints of pain in large joints and back pain. They are usually associated with the main disease. The case we present demonstrates that even there is a small likelihood for a prolapsed lumbar disk, it should be sought in such patients as the surgical treatment is able to yields a positive results.

Double trouble: a tale of two radio-treatments.

In recent years, an increasing number of patients are treated with radiation. In the early era of radiotherapy, which began soon after X-rays were discovered by Roentgen in 1895, tumours were irradiated with high doses of X-rays in a single fraction. The major initial setback was the damage caused to normal tissues; however, in recent times the use of stereotactic radiosurgery, which delivers high doses of radiation precisely to abnormal tissue targets while sparing the surrounding normal brain tissue, and particularly for surgically inaccessible tumours, has taken centre stage. Prophylactic whole brain radiation (in conjunction with aggressive chemotherapy) for childhood acute lymphoblastic leukaemia has been shown to improve patient survival, however, this is associated with complications in survivors. We report an interesting case of one of the longest survivors who has had double complications from radiotherapy-based interventions.

Lumbar intraforaminal synovial cyst in young adulthood: case report and review of the literature.

Study Design Case report. Objective Lumbar juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Most patients with lumbar cysts are in their sixth decade of life and have significant facet joint and disk degeneration. Lumbar synovial cysts (LSCs) are extremely rare in adolescence and young adulthood, and to our knowledge, only two pediatric cases of LSC have been reported in the literature. We aim to prove the existence of LSC in adolescent patients as a real entity that causes low back and radicular complaints and to discuss the possibility of traumatic injury as a pathogenic cause of LSC formation in adolescence. A case of an 18-year old patient with LSC is presented. We report the clinical presentation, management, outcome, and review of the literature, focusing on issues that remain debatable. Methods The case is presented together with its clinical course, the diagnostic techniques, the surgical findings, histologic results, and the treatment outcome. Results After surgical treatment, the patient's complaints were alleviated and almost no complaints were registered during the next 6 months' follow-up. Conclusions LSCs are extremely rare in adolescence, but they could be considered in the differential diagnosis in adolescent patients with low back pain and radiculopathy. Surgical removal of LSC could be considered as a treatment option to provide immediate and safe symptomatic relief.