Postoperative Neurological Status Research Articles

Local anesthesia versus general anesthesia for evacuation of chronic subdural hematoma in elderly patients above 70 years old.

Background: The aim of this study was to assess the safety and efficacy of chronic subdural hematoma (CSDH) evacuation by two burr-hole craniostomies under local versus general anesthesia (GA) in elderly patients over 70 years.Methods: This retrospective study included 45 patients with CSDH aged over 70 years old treated from March 2018 to April 2020. The cases were subdivided into Group A (n = 22) that underwent evacuation under local anesthesia and Group B (n = 23) that was treated under GA. Patients’ demographics and history of comorbidities were recorded. Variables including pre- and post-operative neurological status and Markwalder’s score, complication rate, operative time, and length of hospital stay were evaluated.Results: The mean and standard deviation of patients’ age of groups (A) and (B) were 74.3 ± 2.5 and 73.2 ± 1.7 years, respectively. Postoperative Glasgow Coma Scale of group (A) was statistically higher than Group B at postoperative day 1 (P = 0.01). Operative time was statistically shorter in Group A than B (P < 0.0001). The length of hospital stay was found to be longer in group (B) than (A) (P = 0.0001). The complication rate was found to be higher in group (B) than (A) (P = 0.044).Conclusion: Evacuation of CSDH under local anesthesia in elderly patients over 70 years is effective, safe, and economic with less complication rate than the traditional technique with GA.

Atlantoaxial posterior screw fixation using intra-operative spinal navigation with three-dimensional isocentric C-arm fluoroscopy.

Intra-operative image acquisition coupled with navigation aims to increase screw placement accuracy, and it is particularly helpful in complex spinal procedures. The aim of this study is to analyze the accuracy and reliability of posterior atlanto-axial fixation using spinal navigation combined with intra-operative 3D isocentric C-arm. We retrospectively reviewed all patients presenting with C1-C2 instability and treated by posterior atlanto-axial fixation in our center between December 2016 and September 2018. Screw positioning was guided by intra-operative navigation, registered with surface matching procedure on a previously obtained CT scan and controlled by intra-operative 3D isocentric C-arm. Age, sex, pre- and post-operative neurological status, duration of surgery, presence/absence of vertebral artery injury, and screw placement were retrospectively collected from patients' records. All patients underwent clinical and radiological follow-up at threemonths after surgery. Radiological assessment of screw positioning was performed by an independent radiologist using the Gertzbein and Robbins grading. N = 11 (7F, 4M) consecutive patients were included, with a mean age of 72years (range from 51 to 85). N = 44 navigated screws were inserted and controlled with intra-operative 3D fluoroscopy at the end of the procedure. An acceptable screw positioning (Gertzbein-Robbins grade A and B) was obtained in all cases (100%). No vertebral artery injury was observed. Mean operating time was 123minutes. At threemonths, no screw loosening or displacement was observed. In our experience, spinal navigation coupled with intra-operative 3D fluoroscopy proved to be reliable and safe for C1-C2 screw placement.

Microendoscopic Dorsal Laminectomy for Multi-Level Cervical Intervertebral Disc Protrusions in Dogs.

The objective of this study was to evaluate the feasibility and clinical outcomes of microendoscopic dorsal laminectomy for multi-level cervical intervertebral disc protrusions in dogs. Eight client-owned dogs diagnosed with multi-level cervical intervertebral disc protrusions using computed tomography (CT) and magnetic resonance imaging (MRI) were included in this retrospective case series. Microendoscopic dorsal laminectomies (MEL) were performed with an integrated endoscopic system to the cranial and caudal vertebrae of the affected intervertebral joints. Pre- and post-operative neurological status, operation time, intra-operative complications, and postoperative complications were reviewed. Post-operative CT images were obtained to measure the dimensions of laminectomy and compared to those of planned laminectomy. Full endoscopic procedures were feasible in 7 dogs (87.5%) and the laminectomy dimensions were in agreement with pre-operative planning. In all dogs, major intra- and postoperative complications did not occur. Conversion to open surgery was required in one case. Short-term postoperative clinical deterioration was found in two dogs. Long-term clinical outcomes were good and comparable to those reported in previous studies of open dorsal laminectomies. MEL is a promising minimally invasive approach to multi-level cervical dorsal laminectomy for intervertebral disc protrusions. This technique may improve postoperative discomfort compared to the open approach. Further studies are needed to directly compare outcomes between these two approaches.

Evaluation of Single Stage Posterolateral Decompression and Posterior Fixation in Dorsolumbar Spinal Tuberculosis: A Prospective Study

Introduction: The study has been designed with all perseverance’s, to observe and evaluate the results of single stage transpedicular decompression and posterior fixation in Dorso Lumbar Spinal Tuberculosis. Material and Methods: The present study “Evaluation of Single Stage Posterolateral Decompression and Posterior Fixation in Dorsolumbar Spinal Tuberculosis: A Prospective Study” was conducted on clinicopathologically diagnosed cases of spinal tuberculosis of dorsal and lumbar region during a period of two years from “October 2018 to October 2020” in the Department of Orthopaedics, S.C.B. Medical College and Hospital, Cuttack, Odisha. Method of Collection of Data: This is a clinical and prospective study conducted on patients admitted to S.C.B. Medical College, Cuttack after obtaining ethical clearance from the institutional ethical committee. A total of 25 cases of tuberculosis of spine in thoracic and lumbar region were selected for this procedure after obtaining proper informed and written consent.Patients were admitted based on clinical presentation such as prolonged back pain usually with tender gibbus, with/ without neurologic deficit. Objective of the Study: The objective of the study is to evaluate the efficacy of single stage posterolateral decompression and posterior fixation in spinal tuberculosis. The patients are to be evaluated postoperatively regarding following parameters: – • Postoperative neurological status and its improvement • Degree of pain relief • Radiological fusion of vertebra • Correction of angle of kyphosis Discussion: This piece of work conducted in Department of Orthopaedics, SCB Medical College, Cuttack, is meant for an analytical study of transpedicular decompression and debridement of spinal cord and fixation of the unstable spine by means of screws &amp; rod system in a single stage posterior approach surgery. In our study we followed Tuli’s Middle Path Regimen in the management. Hence, all clinicoradiological diagnosed TB spine cases were administered ATT drugs under govt. sponsored DOTS Therapy Schedule. The pts who didn’t show signs of improvement, or deteriorating neural deficit, or progressive and gross kyphosis, or patients with severe pain were taken up for surgery and then followed up regularly at 3 months interval for a minimum average follow up period of 1 year. In our study, out of 25, 11 patients recovered completely from neurological deficit and was found to have Frenkel grade E. Another 12 patients had recovered to Frenkel grade D. Hence almost 92 percent of patients had satisfactory neurological recovery. In our study fusion was seen in 64 percent of cases which was significant and comparable with the studies of Gueven et al, Lee et al, and Chacko et al. Pain reduced in all cases. Conclusion: There was neurological recovery in all cases except one, indicating debridement by transpedicular approach is still effective though not radical. Pain was significantly reduced in all cases. Another vital observation was a correction in kyphotic deformity which was significant and also quite stable. There was fusion in more than half of the cases Keywords: Single Stage Posterolateral Decompression, Posterior Fixation in Dorsolumbar Spinal Tuberculosis, Potts Paraplegia

Surgical treatment of glossopharyngeal nerve schwannomas: Results of two-center study (14 patients included) and literature review

Objective: This study is aimed to analyze the outcomes of surgical treatment of glossopharyngeal schwannomas based on pre- and postoperative neurological status assessment. Materials and methods: This paper is a retrospective analysis of examination and surgical treatment of 14 patients who were operated on in two large clinics from 2018 to 2021 inclusive. When analyzing the collected data, gender, age, disease symptoms, tumor size and location, surgical approach, tumor to cranial nerves (CN) ratio, jugular foramen (JF) condition, and tumor removal volume were taken into account. All tumors were divided into groups depending on tumor location relative to the JF. Particular attention was paid to assessing cranial nerves functions. Facial nerve function was assessed as per House-Brackmann Scale (HBS), hearing function as per Gardner-Robertson Scale (GRS). Results: 3 (21.4%) patients had total tumor removal: 2 patients had type A tumors and one had type B tumor. Subtotal resection took place in 7 (50%) cases. In 4 cases, a tumor was partially removed: 3 patients had type D tumors and one had type B tumor. 3 (21.4%) patients had preoperative FN deficit (HBS Grade II) and mild dysfunction. 5 (35.7%) patients had postoperative facial nerve deficit: HBS ІІ, 2; ІІІ, 1; V, 2. Preoperative sensorineural type hearing impairment on the affected side was diagnosed in 13 (92.6%) patients. Before surgery, 6 patients had non-serviceable hearing, which remained at the same level after surgery. None of the patients with grade I or II hearing before surgery had any hearing impairment postoperatively. In 2 (14.3%) cases, hearing improved from grade V to grade III after surgery. 6 (42.9%) patients developed new neurological deficit in the caudal group CN. Postoperative deficit of the caudal group CN occurred in type D tumors in 3 patients, type A tumors 2 patients, and type B tumors one patient. Conclusions: Applying a retrosigmoid approach only makes it possible to achieve total tumor removal in case of type A tumors. To remove other tumor types, it is necessary to select approaches that enable access to the jugular foramen and infratemporal fossa. Intraoperative neurophysiological monitoring is an extremely important tool in glossopharyngeal schwannoma surgery. The most common postoperative complication is a developed or increased deficit of the caudal CN group, which can lead to persistent impairments in the patients’ quality of life. Preservation of the CN VII and VIII function in most cases is a feasible task and shall be ensured as a standard for this pathology.

Efficacy, Outcome, and Safety of Elderly Patients with Glioblastoma in the 5-ALA Era: Single Center Experience of More Than 10 Years.

Simple SummaryIn the next decades, the incidence of patients with glioblastoma (GBM) will markedly increase due to the growth of the elderly population. Despite the increasing incidence of GBM, elderly patients are frequently excluded from clinical studies and thus, only few data are available specifically focusing on the elderly population. In the current study, we aimed to investigate the efficacy, outcome, and safety of surgically-treated GBM including resections and biopsies in the 5-ALA era in a large elderly cohort of altogether 272 patients. Our data of this large elderly cohort demonstrate for the first time the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients.Background: In the next decades, the incidence of patients with glioblastoma (GBM) will increase due to the growth of the elderly population. Fluorescence-guided resection using 5-aminolevulinic acid (5-ALA) is widely applied to achieve maximal safe resection of GBM and is identified as a novel intraoperative marker for diagnostic tissue during biopsies. However, detailed analyses of the use of 5-ALA in resections as well as biopsies in a large elderly cohort are still missing. The aim of this study was thus to investigate the efficacy, outcome, and safety of surgically- treated GBM in the 5-ALA era in a large elderly cohort. Methods: All GBM patients aged 65 years or older who underwent neurosurgical intervention between 2007 and 2019 were included. Data on 5-ALA application, intraoperative fluorescence status, and 5-ALA-related side effects were derived from our databank. In the case of resection, the tumor resectability and the extent of resection were determined. Potential prognostic parameters relevant for overall survival were analyzed. Results: 272 GBM patients with a median age of 71 years were included. Intraoperative 5-ALA fluorescence was applied in most neurosurgical procedures (n = 255/272, 88%) and visible fluorescence was detected in most cases (n = 252/255, 99%). In biopsies, 5-ALA was capable of visualizing tumor tissue by visible fluorescence in all but one case (n = 91/92, 99%). 5-ALA administration did not result in any severe side effects. Regarding patient outcome, smaller preoperative tumor volume (<22.75 cm3), gross total resection, single lesions, improved postoperative neurological status, and concomitant radio-chemotherapy showed a significantly longer overall survival. Conclusions: Our data of this large elderly cohort demonstrate the clinical utility and safety of 5-ALA fluorescence in GBM for improved tumor visualization in both resections as well as biopsies. Therefore, we recommend the use of 5-ALA not only in resections, but also in open/stereotactic biopsies to optimize the neurosurgical management of elderly GBM patients.

Upper Thoracic Spine Fractures Outcomes and Complications in King Abdul-Aziz Medical City, Riyadh

Introduction: Upper thoracic spine fractures (T1-T6) are not uncommon. They are often high-energy injuries complicated by multiple life-threatening comorbidities. There is a controversial discussion in the literature regarding the treatment choices. Thoracic pedicle screw fixation has replaced all other fixation techniques for its success rate and safety. Despite the number of studies discussing upper thoracic spine fractures, data on literature reporting postoperative complications are deficient. The aim of the study was to assess, in a series of patients, the impact of traumatic upper thoracic fractures on sagittal alignment, the incidence of possible complications, and the effect of associated injuries.&#x0D; Methodology: This retrospective chart review study included all adult cases diagnosed as traumatic upper thoracic spine fractures in KAMC in Riyadh. Data were obtained from the computerized database. The information reviewed included fracture characteristics, associated injuries, pre- and postoperative neurological status and sagittal alignment, follow-up duration, and the presence of complications.&#x0D; Result: A total of 19 patients were included in the study. Of them, 17 (89.5%) were injured secondary to a motor vehicle accident. There were three patients with a fixation level crossing the CT junction, more blood loss and procedure time was noticed with these cases. There was a notable improvement in upper thoracic kyphosis by 9º when measuring pre- and postop fracture Cobb's angle. The mean preop angle was 28.98 and the mean postop was 20.76. Of all the 19 cases involved in the study, 3 patients had developed surgical site infection as a complication. No other complication was reviewed.&#x0D; Conclusion: It is well-known in the literature that the correction of kyphosis and the absence of residual deformity postoperatively are indicators of the success and safety of the procedure used. Our findings correspond to the literature discussion that the current practice in managing traumatic upper thoracic spine fracture in KAMC in Riyadh is relatively safe and effective. Yet, further studies are needed to elaborate more on the relationship between the presence of other injuries and patients’ factors and postoperative outcomes.

Efficacy of the Suboccipital Paracondylar-Lateral Cervical Approach: The Series of 64 Jugular Foramen Tumors Along With Follow-Up Data.

ObjectiveComplete resection of jugular foramen tumors with minimal cranial nerve complications remains challenging even for skilled neurosurgeons. Here, we introduce a modified paracondylar approach, named the suboccipital paracondylar-lateral cervical (SPCLC) approach for this purpose. We also share the follow-up data of our series and discuss the advantages and limitations of this modified paracondylar approach.MethodsWe included 64 patients with jugular foramen tumors who underwent surgery by the same senior neurosurgeon between November 2011 and August 2020. All patients were treated with the SPCLC approach, which aimed for gross total tumor removal in a single-stage operation. The clinical characteristics, including preoperative and postoperative neurological status, the extent of surgical resection, and follow-up data were retrospectively acquired and evaluated.ResultsThere were 48 schwannomas, nine meningiomas, three paragangliomas, one hemangiopericytoma, one chordoma, one endolymphatic sac tumor, and one Langerhans’ cell histiocytosis. The median age of our patients was 43 years (range: 21–77 years). Dysphagia, hoarseness, and tongue deviation were observed in 36, 26, and 28 patients, respectively. Thirty-two patients had hearing function impairments, including hearing loss or tinnitus. Gross total resection was achieved in 59 patients (59/64, 92.2%). Gamma Knife treatment was used to manage residual tumors in five patients. Postoperatively, new-onset or aggravative dysphagia and hoarseness occurred in 26 and 18 cases, respectively. Nine patients developed new-onset facial palsy, and one patient developed new-onset hearing loss. There were no cases of intracranial hematoma, re-operation, tracheostomy, or death. At the latest follow-up, hearing loss and tinnitus had improved in 20 cases (20/32, 62.5%), dysphagia alleviated in 20 cases (20/36, 55.6%), and hoarseness improved in 14 cases (14/26, 53.8%). Over a mean follow-up period of 27.8 ± 19.5 months (range: 3–68 months), tumor recurrence was observed in one patient.ConclusionThe SPCLC approach, modified from the paracondylar approach, and was less invasive, safe, and efficient for certain jugular foramen tumors. Taking advantage of the anatomic understanding, clear operational vision, and appropriate surgical skills, it is possible to achieve gross total tumor removal and the preservation of neurological function.

Minimal Invasive Fluoroscopic Percutaneous Lateral Stabilization of Thoracolumbar Spinal Fractures and Luxations Using Unilateral Uniplanar External Skeletal Fixators in Dogs and Cats.

The aim of this study was to describe minimally invasive spinal stabilization using a unilateral uniplanar external skeletal fixator (ESF, type 1a) with polymethylmethacrylate, and to review short- and long-term outcomes and complications in a clinical case series. Medical records from animals affected by spinal fracture luxation were reviewed. The data included breed, age, gender, body weight, aetiology, preoperative and postoperative neurological state, radiographic findings, surgical treatment, pin size, number of pins and stabilized vertebrae, intra- and postoperative complications and neurological state at re-examinations. Thirty-two animals were identified; three were treated conservatively, 19 surgically and 10 were euthanatized. In eight dogs and six cats, the injured spinal column was treated with a laterally applied percutaneous type 1a ESF under fluoroscopic guidance. Positive profile end-threaded pins inserted were from 1.6/1.9 to 3.5/4.3 mm in dogs and 1.6/1.9 to 2/2.3 mm in cats and were placed into two to five vertebral bodies. At the re-examinations, the neurological status had improved in 12 animals, deteriorated in one, and was unchanged in another one. In eight cases, no complications were detected. The most common complications included erythema, exudation and pin loosening. The present work shows that type 1a ESF can be successfully and minimally invasively applied to fractures and luxations of the spine in dogs and cats with minimal major complications.

Stabilization does not guarantee neurological recovery but prevents deterioration in the management of AO type-B Sub axial cervical spine injuries: 15 years clinic-radiological outcome from a retrospective cohort analysis

Study Design: Retrospective cohort analysis. Purpose: To evaluate the long-term clinical and radiological outcome of AO type-B Sub axial cervical spine fractures managed with combined anterior and posterior spinal fusion. Overview of Literature: AO Type-B sub axial Cervical fractures involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries demand early surgical management with effective reduction and fusion of the involved vertebra. Though different methods of reduction and surgical approaches have been published in the literature, we preferred global stabilization and fusion and evaluated their long-term outcome. Methods: We retrospectively evaluated 22 patients with post-traumatic unstable sub axial cervical spine injuries which got treated from 2006-2008 with their preoperative clinical details, radiographs, computed tomography, and magnetic resonance imaging of the cervical spine. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to the status of fusion, pre-and post-operative neurological status based on Frenkel staging, along with their complications. Results: The mean age of the included patients was 32.9±12.14 years, with M:F ratio of 21:1. The average length of hospitalization was 20±12.63 days. All patients achieved fusion at a mean period of 4±1.45 months. Among the included 22 patients, only 68.18% (n=15) patients improved from their pre-operative stage whereas the remaining 7 patients did not show any significant improvement in their clinical-grade since injury despite achieving solid fusion at the operated levels at a mean follow-up period of 15.42±1.43 years. No major complications were noted in the included patients. None of the patients showed deterioration in their clinical-grade although 2 patients died in the follow-up period. Conclusions: In AO type-B sub axial cervical injuries, global stabilization and fusion in a single sitting is a viable option in surgical management without major complications. Although the procedure achieves fusion at the intended level, it does not guarantee neurological recovery.

Evaluation of classification of petroclival meningiomas and proposed selection of microsurgical approach: a single center experience of 179 cases

Objective: To evaluate the classification of petroclival meningiomas(PCM), proposed selection of microsurgical approach and therapeutic outcomes. Methods: Retrospectively analyzed clinical data of 179 cases of PCM from Department of Neurosurgery, Xiangya Hospital, Central South University between January 2011 and November 2020. There were 28 males and 151 females with an age of(49.9±10.2) years(range: 22 to 75 years) and the tumor size of(44.8±10.3)mm(range: 15 to 80 mm). The mean duration of symptom(M(QR)) was 18.0(40.6)months(range:1 week to 320 months) and the mean preoperative Karnofsky performance scale(KPS) was 78.6±13.3(range: 40 to 100). The PCM were classified into 5 types according to the difference in the origin of dural attachment, involvement of adjacent structures and growth patterns through preoperative MRI. The surgical approaches were selected based on the proposed classification, and the clinical characteristics, surgical record, and follow-up data of each type were reviewed. Results: The PCM were divided into clivus type(CV, 4 cases), petroclival type(PC, 60 cases), petroclivosphenoidal type(PC-S, 62 cases), sphenopetroclival type with 2 subtypes(S-PC, 50 cases) and central skull base type(CSB, 3 cases). All of 176 cases were obtained microsurgical treatment except CSB type. The gross total resection reached in 124 cases(70.5%) with 112 cases of retrosigmoid approach(RSA), 27 cases of subtemporal transtentorial transpetrosal approach, 13 cases of pretemporal trancavernous anterior transpetrosal approach(PTCA), 12 cases of extended pterional transtentorial approach(EPTA) and presigmoid combined supra-infratentorial approach, respectively. The RSA could be adopted in both of CV type and PC type and most of PC-S type(71.0%). S-PC subtype Ⅰ and subtype Ⅱ were mainly underwent EPTA(40.8%) and PTCA(52.2%), respectively. Seventy-two cases(40.9%) gained new neurological dysfunctions mainly with the cranial nerve paralysis. The postoperative morbidity and complications were recovered or improved with conservative and positive symptomatic and supportive treatment. There was no intraoperative and postoperative death case. One hundred and sixty four cases(93.2%) of operative patients were followed with the duration of 24(48)months(range:3 to 108 months). Tumor recurrence and progress were identified in 14 cases(10.4%) and 14 cases(28.6%), respectively. Compared with postoperative neurological status, 89 patients(54.3%) had improved and 38 patients(23.2%) were still suffering various degrees of neurological dysfunctions during the follow-up. The recent KPS was 84.2±11.4(range: 50 to 100) without statistical difference from preoperative KPS(t=-1.356,P=0.125). As for each type, there were statistically significant differences in brain stem edema(χ2=3.482,P=0.038), gross total resection(χ2=9.127,P=0.001), surgical duration(F=8.954, P=0.013), postoperative length of stay(F=3.652, P=0.025), postoperative complications(χ2=1.550,P=0.024), postoperative KPS(F=2.856, P=0.042) and tumor recurrence/progress(χ2=4.824,P=0.013). Conclusion: The precise and comprehensive classification of PCM and specific individual treatment strategy are benefit to evaluate the diverse clinical prognosis, choose optimal surgical approaches, elevate gross total resection, diminish neurological dysfunctions and restraint tumor recurrence, so as to improve the quality of life for patients.

240. Utility of intraoperative neuromonitoring alerts relating to adverse outcomes in spine surgery: a study of 289 patients

<h3>BACKGROUND CONTEXT</h3> Although rare, one of the most problematic complications during spine surgery is neurologic injury with subsequent deficit. The use of multimodal intraoperative neuromonitoring (MIOM) during spine surgery provides the surgical team with real-time assessment of the neurological physiology and function. MIOM is thought to be sensitive and specific for identifying perioperative neurological injury in spinal surgery especially deformity surgery. However, results from recent studies have cast doubt on the effectiveness of certain MIOM techniques in detecting neurological injury in spine surgery patients. <h3>PURPOSE</h3> The purpose of this study was to improve spine surgery patient safety and outcomes by minimizing the incidence of postoperative new neurological deficits correlated to intraoperative neuromonitoring alerts from two neuromonitoring signals: motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs). <h3>STUDY DESIGN/SETTING</h3> A multicenter, multisurgeon prospective quality improvement initiative that was performed in conjunction with neuro alert (NA) monitoring services. All data was retrospectively analyzed. <h3>PATIENT SAMPLE</h3> A total of 289 patients who (1) received nondeformity lumbar (45%), cervical (45%) or thoracic (10%) surgery between July 2018 and July 2019 and (2) underwent SSEP and MEP monitoring throughout the entire surgery. <h3>OUTCOME MEASURES</h3> This study investigated the incidence of immediate postoperative (≤ 48 hours) new neurological deficits. sensitivty, specificity, postive predictive value (PPV), and negative predictive value (NPV) was calculated for the SSEP and MEP signals. <h3>METHODS</h3> This study was a multicenter, multisurgeon prospective quality improvement initiative that was performed in conjunction with neuro alert (NA) monitoring services. All neuromonitoring was carried out in accordance with the guidelines set forth by the American Academy of Neurology and the American Board for Neurophysiological Monitoring Programs. Two commonly used MIOM signals were tracked: somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs). Intraoperative data were recorded using a paper data collection tool. SSEP and MEP signal changes were classified as alerts based on the following best practices guidelines outlined in the literature: 50% or greater decrease in signal amplitude and/or a 10% or greater increase in signal latency with no signal recovery. Immediate postoperative (≤ 48 hours) new neurological deficit status was assessed for all patients. Neurological deficit information was recorded via paper during a postoperative physical exam that all physicians conducted on the patient within 48 hours after surgery. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the SSEP and MEP signals were calculated. <h3>RESULTS</h3> SSEP and MEP neuromonitoring data was analyzed for 289 patients who (1) received non-deformity lumbar (45%), cervical (45%) or thoracic (10%) surgery between July 2018 and July 2019 and (2) underwent SSEP and MEP monitoring throughout the entire surgery. A total of 22 MEP and 16 SSEP alerts were triggered. Ninety percent (20) of MEP alerts occurred during anterior cervical discectomy and fusion (ACDF) procedures; one MEP alert was triggered during a posterior cervical fusion and one MEP alert was triggered during a lumbar laminectomy. 56% (9) of SSEP alerts occurred during transforaminal lumbar interbody fusion procedures while 25% (4) occurred during ACDFs and 19% (3) occurred during lumbar laminectomy surgeries. MEP and SSEP alerts were most frequently triggered during the decompression surgical step (45% and 25%, respectively). There were 6 instances (n = 6) of new neurological deficits that occurred within 48 hours postsurgery. These deficits were as follows: foot drop (n = 1), leg weakness (n = 1), arm weakness (n = 2), bilateral paraparesis (n = 1) and unilateral paraparesis (n = 1). The patient who developed unilateral paraparesis was myelopathic. All other patients with new neurological deficits did not have a history of myelopathy. The MEP alert should have been triggered for all 6 patients, however the signal was only alerted in the patient who developed bilateral paraparesis and in one patient who developed arm weakness. In 4/6 patients, MEP alerts were not triggered but a new neurological deficit occurred, resulting in a false negative rate of 67% and a sensitivity of 33%. In addition, MEPs had a specificity of 92.4%, PPV of 11% and NPV of 98.5%. The SSEP signal showed 100% sensitivity and displayed a specificity, PPV and NPV of 95.2%, 12.5% and 100%, respectively. <h3>CONCLUSIONS</h3> The MEP signal had a low sensitivity of 33%, which differed greatly from that of the SSEP signal (100%). The specificity, PPV and NPV were comparable between the SSEPs and MEPs. The PPV was low for both signals. Results indicate that the accuracy of SSEP and MEP alerts in detecting new neurological deficits in spine surgery patients immediately postsurgery is questionable. The effectiveness of these two intraoperative neuromonitoring techniques in identifying neurological injury seems uncertain and needs to be explored further. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs

Intradural Spinal Cord Tumors Surgical Experience with Modified Sheehan Technique

Background: Primary spinal cord tumors are rare neoplasms that lead to significant morbidities. They representing about 2–4% of all tumors that affect the central nervous system. According to their relation to the dura, and spinal cord they are classified into extradural, intradural extramedullary and intradural intramedullary tumors. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of intradural tumors both intra and extramedullary. Surgical excision is the best treatment modality in the majority of patients. Patients and Methods: This is a retrospective study of thirty patients, fifteen males, and fifteen females suffering spinal cord tumors. Median age at diagnosis 41years. Follow up period range from 6months to 43 months with average 24 months. Neurological assessment of the patients carried out by ASIA (American spinal injury association) scoring. Radiological evaluation occurs through MRI (magnetic resonance imaging) with contrast. Of the studied group seven cases were intradural intramedullary and twenty-three cases were intradural extramedullary. The utilized surgical approach was modified Sheehan technique and all the cases were operated by a single surgeon to avoid the inter surgeon variability. Histopathological assessment was done for the excised specimen for all patients. Results: Thoracic region most affected 53.3%, followed by cervical 23.4%, then lumbar (20%) regions. 76.7% intradural extramedullary, and 23.3% intradural intramedullary. Schwannoma 43.3% and Meningioma (20%) were the most pathology. ASIA group C decreased from 40% to 6.7%, and ASIA group D decreased from 60% to 26.7%, and we got a new ASIA group E 66.7% didn’t exist before surgery. Conclusion: The utilized surgical technique is very effective and safe as we get wide corridor for tumor excision, so increasing the effectiveness of operative microscopy and other operative tools, and improve the surgical outcome as noticed in postoperative neurological status.

Surgical treatment of solitary intradural extramedullary spinal cord metastases from solid cancers of non-neurogenic origin. A multicenter study.

Intradural extramedullary spinal metastases (IESM) represent an extremely rare manifestation of systemic cancer. We evaluated the surgical indications, complications and outcome in a series of 43 patients with solitary intradural extramedullary metastases originating from solid cancer of non-neurogenic origin. Patients' age, histopathological diagnoses of primary cancer, tumor size, spinal location, and extramedullary tumor dissemination were collected. Preoperative functional status, pre- and post-operative neurological status, extent of the tumor resection were also analyzed. The majority of IEMS occurred in the thoracic area, with the most common presenting symptoms ranging from motor (76.7%) to sensory (72%) deficits. Gross total resection was achieved in 55.8% of cases, while In 44.2% of patients a subtotal resection was performed due to strong adherence between the tumor and neural tissue. After surgery, 72.1% of patients exhibited improvement of symptoms in terms of pain relief and partial recovery of motor and/or sensory deficits, while neurologic functional status was severely affected postoperatively in 3 patients. Although there was no statistical significance between the different parameters and overall survival, KPS and the presence of other metastases were the strongest prognostic factors for overall survival and postoperative neurologic outcome.

The enigma of acute worsening after a latent interval in post-operative patients of craniovertebral junction instability

ObjectiveFor reasons that are poorly understood and still undocumented, few patients of craniovertebral junction (CVJ) anomalies with instability/atlantoaxial dislocation (AAD) in our practice have been seen to suffer unprecedented acute neurological deterioration with respiratory compromise about 48–72 h post-surgery. This has been specifically observed after an uneventful, stable clinical condition in the immediate postoperative period. This study attempts to elucidate the factors and outcomes related to such latent worsening. Patients and methodsThe 4-year surgical data of 268-patients with CVJ instability (AAD/basilar-invagination) who underwent C1-C2 fixation were retrospectively studied. The relevant factors of 17 patients who showed such deterioration were compared with that of the remaining in a multivariate model. ResultsSeventeen patients had acute neurological worsening with respiratory arrest after a latent period. Ten improved at follow-up. Contrary to the general expectation, poor preoperative neurological score or severe dislocation that needed considerable manipulation did not influence such worsening. Dural injury in patients with associated Chiari malformation and vertebral arterial (VA) injury emerged as independent factors (p < 0.01) associated with this pattern of delayed neurological decline. ConclusionsWe report our management and outcomes of a unique subset of AAD with neurological worsening in the postoperative period after 48–72 h. Such a subgroup was not previously identified in literature. Dural lacerations in AAD with Chiari, and VA injury seem to predispose to such complications and should be prevented at best. Close observation, and caution regarding early extubation (<72 h) is recommended in this subset despite an apparently uneventful immediate postoperative neurological status.

Clinical features and prognostic factors in spinal meningioma surgery from a multicenter study

Meningiomas are benign tumors that are treated surgically. Local recurrence is likely if the dura is preserved, and en bloc tumor and dura resection (Simpson grade I) is recommended. In some cases the dura is cauterized and preserved after tumor resection (Simpson grade II). The purpose of this study was performed to analyze clinical features and prognostic factors associated with spinal meningioma, and to identify the most effective surgical treatment. The subjects were 116 patients (22 males, 94 females) with spinal meningioma who underwent surgery at seven NSG centers between 1998 and 2018. Clinical data were collected from the NSG database. Pre- and postoperative neurological status was defined using the modified McCormick scale. The patients had a mean age of 61.2 ± 14.8 years (range 19–91 years) and mean symptom duration of 11.3 ± 14.7 months (range 1–93 months). Complete resection was achieved in 108 cases (94%), including 29 Simpson grade I and 79 Simpson grade II resections. The mean follow-up period was 84.8 ± 52.7 months. At the last follow-up, neurological function had improved in 73 patients (63%), was stable in 34 (29%), and had worsened in 9 (8%). Eight patients had recurrence, and recurrence rates did not differ significantly between Simpson grades I and II in initial surgery. Kaplan–Meier analysis of recurrence-free survival showed that Simpson grade III or IV, male, and dural tail sign were significant factors associated with recurrence (P < 0.05). In conclusion, Simpson I resection is anatomically favorable for spinal meningiomas. Younger male patients with a dural tail and a high-grade tumor require close follow-up. The tumor location and feasibility of surgery can affect the surgical morbidity in Simpson I or II resection. All patients should be carefully monitored for long-term outcomes, and we recommend lifelong surveillance after surgery.

Predictors of stimulation-induced seizures during perirolandic glioma resection using intraoperative mapping techniques.

Background: Intraoperative mapping techniques maximize safety and efficacy during perirolandic glioma resection but may induce seizures and limit the procedure. We aim to report the incidence and predictors of stimulation-induced seizures during mapping either patient is awake or under general anesthesia (GA).Methods: Retrospective analysis of 64 patients (40 awake and 24 GA) with perirolandic glioma underwent resection using intraoperative mapping techniques between 2014 and 2019. Preoperative data, operative details, postoperative neurological status, and extent of resection (EOR) were analyzed. Predictors of intraoperative seizures were assessed.Results: The mean cortical and subcortical stimulation intensities needed to evoke motor responses were significantly lower in awake cases than in GA patients (4.9 ± 0.42 vs. 8.9 ± 1.2 mA) and (8.3 ± 0.62 vs. 12.1 ± 1.1 mA), respectively (P = 0.01). Incidence of intraoperative seizures was lower but statistically non-significant in awake cases (10% vs. 12.5%) (P = 0.76). Preoperative multiple antiepileptic drugs (AEDs) (P = 0.03) and low-grade glioma (P = 0.04) were statistically significant predictors for intraoperative seizures. Mean EOR in awake cases was 92.03% and 90.05% in GA cases (P = 0.23). Postoperative deficits were permanent after 3 months only in 5% of awake patients versus 8.3% of GA group (P = 0.59).Conclusion: Awake craniotomy with intraoperative mapping can be done safely for perirolandic gliomas with lower but statistically nonsignificant incidence of intraoperative seizures and this could be attributed to statistically significant lower stimulation intensities required for mapping. Preoperative multiple AEDs and low-grade glioma are significant predictors for intraoperative seizures.

Fluorescein-guided resection of cerebral metastases is associated with greater tumor resection.

Sodium fluorescein (fluorescein) crosses a disrupted blood-brain barrier similarly to gadolinium contrast in contrast-enhancing cerebral tumors. When exposed to light with 560 nm wavelength during surgery, fluorescein emits a yellow-green fluorescent light that can be visualized through an operating microscope equipped with an appropriate emission filter. The distribution of the fluorescence correlates with the contrast on a gadolinium contrast-enhanced MRI. The objective of this single-center retrospective study was to investigate if the use of fluorescein would increase the extent of resection and to examine if fluorescein guided resection influences postoperative neurological status. During the study period from August 2014 to August 2018, 117 patients were operated for cerebral metastases. Of these, 56 operations were guided by fluorescein and 61 by traditional white light. All patients had an early postoperative MRI within 72 h after surgery. The use of fluorescein increased the extent of resection in patients with cerebral metastases. The use of fluorescein was not associated with increased postoperative sequelae or neurological damage regardless of underlying primary cancer. Fluorescein is a helpful supplement in the neurosurgical treatment of cerebral metastases.

Retrospective Analysis on Intraoperative Neuromonitoring (IOM) of Potential Nerve Injury in Scoliosis Correction Surgery

Iatrogenic spinal injury resulting in paraplegia or paraparesis after surgical correction of scoliosis deformity is a rare complication but is very detrimental to the patient. Intraoperative Neuromonitoring (IOM) has become the gold standard to monitor surgical procedures which has potential risks to damage the spinal cord. This study aimed to retrospectively analyze the role of IOM in predicting the severity and extent of neurological injury during and after spinal correction surgery in adult idiopathic scoliosis cases related to surgical variables. This was a retrospective cohort study conducted at Dr. Cipto Mangunkusumo National Central Hospital, Fatmawati Central Hospital, and dr. Drajat Prawiranegara General Hospital during the period of 20 March 2018 to 20 August 2019. The primary outcomes were intraoperative monitoring status and post-operative neurological deficits status. Confounder data on scoliosis correction degree, intraoperative hemorrhage, and type of anesthesia used during surgery were retrieved. Chi-Square statistic was used in the analysis. Out of the ninety three patients eligible for this study, twenty two patients was detected as positive in IOM assessment. Four of the patients were found to be positive for post-operative neuromuscular defect. Thereby it can be concluded that IOM procedure can effectively prevent neurological deficits post-surgery with 81.8% specificity and 95.7% sensitivity among thosepositively detected by IOM. Some of the factors that could potentially influence false positive IOM results such as anesthetic used; dosage and administration procedures; magnitude of the scoliosis correction angle; and amount of bleeding during surgery have to be carefully analyzed.

Perspectives on (A)symmetry of Arcuate Fasciculus. A Short Review About Anatomy, Tractography and TMS for Arcuate Fasciculus Reconstruction in Planning Surgery for Gliomas in Language Areas.

Gliomas are brain tumors that are treated with surgical resection. Prognosis is influenced by the extent of resection and postoperative neurological status. As consequence, given the extreme interindividual and interhemispheric variability of subcortical white matter (WM) surgical planning requires to be patient's tailored. According to the “connectionist model,” there is a huge variability among both cortical areas and subcortical WM in all human beings, and it is known that brain is able to reorganize itself and to adapt to WM lesions. Brain magnetic resonance imaging diffusion tensor imaging (DTI) tractography allows visualization of WM bundles. Nowadays DTI tractography is widely available in the clinical setting for presurgical planning. Arcuate fasciculus (AF) is a long WM bundle that connects the Broca's and Wernicke's regions with a complex anatomical architecture and important role in language functions. Thus, its preservation is important for the postoperative outcome, and DTI tractography is usually performed for planning surgery within the language-dominant hemisphere. High variability among individuals and an asymmetrical pattern has been reported for this WM bundle. However, the functional relevance of AF in the contralateral non-dominant hemisphere in case of tumoral or surgical lesion of the language-dominant AF is unclear. This review focuses on AF anatomy with special attention to its asymmetry in both normal and pathological conditions and how it may be explored with preoperative tools for planning surgery on gliomas in language areas. Based on the findings available in literature, we finally speculate about the potential role of preoperative evaluation of the WM contralateral to the surgical site.