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Background Increased life expectancy has led to indications for spine surgery in patients older than 90 years, but data on associated risks and outcome are lacking. Methods Indication, type of surgery, complications, functional outcome, and mortality were retrospectively collected from all patients aged 90 years or older operated between 2006 and 2016 at the University Hospital Basel, Switzerland. Results Sixty-nine patients were included, of which 55% had degenerative, 36% traumatic, and 9% other pathologies. Most surgeries (84%) were performed electively and 16% as emergencies. More than a third (36%) of elective and 58% of emergency surgeries required stabilization. The complication rate was 54% in the elective surgery group (ELSG) and 125% in the emergency surgery group (EMSG). Stabilization (P = 0.006) and emergency surgeries (P = 0.032) were significant risk factors for experiencing complications. Six weeks after surgery, 80% of the patients reported symptomatic improvement. More than half (58%) of the patients in the ELSG reached their specific median life expectancy, compared with 38% in the EMSG. Seventeen percent of patients in the EMSG versus 0% in the ELSG died in the first 3 months after surgery. In the nonstabilized group, 67% of the patients reached their median life expectancy, compared with 38% of the stabilized group. Conclusions Elective spinal surgery in patients older than 90 years of age does not reduce life expectancy and has a good functional outcome for well-selected patients, whereas emergency surgery and stabilization surgery in this age group are associated with a high rate of complications and higher mortality.

Objective Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approach-related complications of these so-called “keyhole craniotomies”. Methods We review pertinent articles retrieved by search in the PubMed/Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results. Results A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant. Conclusions Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice.

Background Conventional craniotomy approaches involve substantial soft tissue manipulation that can cause complications. The transciliary supraorbital keyhole approach was developed to avoid these complications. The aim of this review is to evaluate the safety and the effectiveness of the transciliary supraorbital keyhole approach. Methods We searched the PubMed/Medline database for full-text publications from 1996 onward containing data on 100 or more cases of aneurysm clipping or tumor resection by the transciliary supraorbital keyhole approach. The primary outcome was the incidence of approach-related complications. The secondary outcomes were the aneurysm occlusion rate and the extent of tumor resection. Results Eight publications met the eligibility criteria. All publications were of the retrospective case–series or case–cohort type without any independent assessment of outcomes. The risk of bias at the individual study level may thus have influenced any conclusions drawn from the overall study population, which included 2783 patients with 3085 lesions (2508 aneurysms and 577 tumors). Approach-related complications included 3.3% cerebrospinal fluid collection or leak, 4.3% permanent and 1.6% temporary supraorbital hypesthesia, 2.9% permanent and 1% temporary facial nerve palsy, and 1% wound healing disturbance or wound infection. Complete aneurysm clipping was achieved in 97% of cases. Complete tumor resection in 90% of cases. The overall surgical revision rate was 2.5%. The esthetic outcome was typically reported as highly acceptable. Conclusions This approach may represent a safe, effective, and less invasive alternative to conventional craniotomies in experienced hands and for a well-selected subset of patients. However, higher-level evidence is needed to confirm this hypothesis.