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Despite formal cardiac clearance, a subset of 3-column osteotomy (3CO) patients still experience cardiac complications (CCs).To define the incidence and risk factors for CC in 3CO patients who had formal cardiac clearance and assess the utility of the Revised Cardiac Risk Index (RCRI) and preoperative metabolic equivalent (MET) functional ability in predicting perioperative CC.Patients with adult spinal deformity (ASD) who underwent 3CO deformity correction from 2006 to 2019 were retrospectively reviewed. Multivariate and recursive partitioning analyses were performed to assess risk factors.A total of 390 patients with ASD were included. The mean age was 64.6 years, and 60.3% were female. The CC rate was 9.7%. Patients with CCs were older ( Plt; .001), had an increased history of heart disease ( P = .001), and higher blood loss ( P = .045). RCRI score ( P = .646) or MET functional ability ( P = .493) were not associated with CC. On multivariate analysis, age ( Plt; .001), blood loss ( P = .008), and prior spinal fusion ( P = .025) were independent risk factors for CC. Patients age older than 81 years had a significantly higher CC rate than those younger than 81 years. In patients age 81 years and younger, if blood loss wasgt;3900 mL, CC rate was significantly higher. Among patients age 81 years and younger and withgt;3900 mL blood loss, CC rate is significantly higher in patients with ejection fraction (EF) ≤54.5%.RCRI and MET functional ability are limited risk assessment tools in ASD 3CO patients with formal cardiac clearance. Patients older than 81 years are at high risk for CC. In younger patients, cardiac EF and blood loss are significant components to risk stratify for CC.

Background Terminology to describe extent of resection in glioblastoma is inconsistent across clinical trials. A surgical classification system was previously proposed based upon residual contrast-enhancing (CE) tumor. We aimed to (1) explore the prognostic utility of the classification system and (2) define how much removed non-CE tumor translates into a survival benefit. Methods The international RANO resect group retrospectively searched previously compiled databases from 7 neuro-oncological centers in the USA and Europe for patients with newly diagnosed glioblastoma per WHO 2021 classification. Clinical and volumetric information from pre- and postoperative MRI were collected. Results We collected 1,008 patients with newly diagnosed IDHwt glioblastoma. 744 IDHwt glioblastomas were treated with radiochemotherapy per EORTC-26981/22981 (TMZ/RT→TMZ) following surgery. Among these homogenously treated patients, lower absolute residual tumor volumes (in cm3) were favorably associated with outcome: patients with “maximal CE resection” (class 2) had superior outcome compared to patients with “submaximal CE resection” (class 3) or “biopsy” (class 4). Extensive resection of non-CE tumor (≤5 cm3 residual non-CE tumor) was associated with better survival among patients with complete CE resection, thus defining class 1 (“supramaximal CE resection”). The prognostic value of the resection classes was retained on multivariate analysis when adjusting for molecular and clinical markers. Conclusions The proposed “RANO categories for extent of resection in glioblastoma” are highly prognostic and may serve for stratification within clinical trials. Removal of non-CE tumor beyond the CE tumor borders may translate into additional survival benefit, providing a rationale to explicitly denominate such “supramaximal CE resection.”

Cancer-associated fibroblasts (CAFs) were presumed absent in glioblastoma given the lack of brain fibroblasts. Serial trypsinization of glioblastoma specimens yielded cells with CAF morphology and single-cell transcriptomic profiles based on their lack of copy number variations (CNVs) and elevated individual cell CAF probability scores derived from the expression of 9 CAF markers and absence of 5 markers from non-CAF stromal cells sharing features with CAFs. Cells without CNVs and with high CAF probability scores were identified in single-cell RNA-Seq of 12 patient glioblastomas. Pseudotime reconstruction revealed that immature CAFs evolved into subtypes, with mature CAFs expressing actin alpha 2, smooth muscle (ACTA2). Spatial transcriptomics from 16 patient glioblastomas confirmed CAF proximity to mesenchymal glioblastoma stem cells (GSCs), endothelial cells, and M2 macrophages. CAFs were chemotactically attracted to GSCs, and CAFs enriched GSCs. We created a resource of inferred crosstalk by mapping expression of receptors to their cognate ligands, identifying PDGF and TGF-β as mediators of GSC effects on CAFs and osteopontin and HGF as mediators of CAF-induced GSC enrichment. CAFs induced M2 macrophage polarization by producing the extra domain A (EDA) fibronectin variant that binds macrophage TLR4. Supplementing GSC-derived xenografts with CAFs enhanced in vivo tumor growth. These findings are among the first to identify glioblastoma CAFs and their GSC interactions, making them an intriguing target.

Introduction: The benefits of performing open and endovascular procedures in a hybrid neuroangiography surgical suite include confirmation of treatment results and reduction in number of procedures, leading to improved efficiency of care. Combined procedural suites are infrequently used in pediatric facilities due to technical and logistical limitations. We report the safety, utility, and lessons learned from a single-institution experience using a hybrid suite equipped with biplane rotational digital subtraction angiography and pan-surgical capabilities. Methods: We conducted a retrospective review of consecutive cases performed at our institution that utilized the hybrid neuroangiography surgical suite from February 2020 to August 2021. Demographics, surgical metrics, and imaging results were collected from the electronic medical record. Outcomes, interventions, and nuances for optimizing preoperative/intraoperative setup and postoperative care were presented. Results: Eighteen procedures were performed in 17 patients (mean age 13.4 years, range 6–19). Cases included 14 arteriovenous malformations (AVM; 85.7% ruptured), one dural arteriovenous fistula, one mycotic aneurysm, and one hemangioblastoma. The average operative time was 416 min (range 321–745). There were no intraoperative or postoperative complications. All patients were alive at follow-up (range 0.1–14.7 months). Five patients had anticipated postoperative deficits arising from their hemorrhage, and 12 returned to baseline neurological status. Four illustrative cases demonstrating specific, unique applications of the hybrid angiography suite are presented. Conclusion: The hybrid neuroangiography surgical suite is a safe option for pediatric cerebrovascular pathologies requiring combined surgical and endovascular intervention. Hybrid cases can be completed within the same anesthesia session and reduce the need for return to the operating room for resection or surveillance angiography. High-quality intraoperative angiography enables diagnostic confirmation under a single procedure, mitigating risk of morbidity and accelerating recovery. Effective multidisciplinary planning enables preoperative angiograms to be completed to inform the operative plan immediately prior to definitive resection.

BackgroundWhile genetic alterations in brain metastases (BMs) have been previously explored, there are limited data examining their association with recurrence after surgical resection. This study aimed to identify genetic alterations within BMs associated with CNS recurrence after surgery across multiple cancer types.MethodsA retrospective, single-center study was conducted with patients who underwent resection of a BM with available clinical and gene sequencing data available. Local and remote CNS recurrence were the primary study outcomes. Next-generation sequencing of the coding regions in over 500 oncogenes was performed in brain metastasis specimens. Cox proportional hazards analyses were performed to identify clinical features and genomic alterations associated with CNS recurrence.ResultsA total of 90 patients undergoing resection of 91 BMs composed the cohort. Genes most frequently mutated in the cohort included TP53 (64%), CDKN2A (37%), TERT (29%), CDKN2B (23%), NF1 (14%), KRAS (14%), and PTEN (13%), all of which occurred across multiple cancer types. CDKN2A/B co-deletion was seen in 21 (23.1%) brain metastases across multiple cancer types. In multivariate Cox proportional hazard analyses including patient, tumor, and treatment factors, CDKN2A/B co-deletion in the brain metastasis was associated with increased risk of local (HR 4.07, 95% CI 1.32-12.54, P = 0.014) and remote (HR 2.28, 95% CI 1.11-4.69, P = 0.025) CNS progression. Median survival and length of follow-up were not different based on CDKN2A/B mutation status.ConclusionsCDKN2A/B co-deletion detected in BMs is associated with increased CNS recurrence after surgical resection. Additional work is needed to determine whether more aggressive treatment in patients with this mutation may improve outcomes.

Background There is a concern that glioma patients undergoing repeat craniotomies are more prone to complications. The study’s goal was to assess if the complication profiles for initial and repeat craniotomies were similar, to determine predictors of complications, and to compare results with those in the literature. Methods A retrospective study was conducted of glioma patients (WHO grade II–IV) who underwent either an initial or repeat craniotomy performed by the senior author from 2012 until 2019. Complications were recorded by discharge, 30 days, and 90 days postoperatively. New neurologic deficits were recorded by 90 days postoperatively. Multivariate regression was performed to identify factors associated with complications. A meta-analysis was performed to identify rates of complications based on number of prior craniotomies. Results Within the cohort of 714 patients, 400 (56%) had no prior craniotomies, 218 (30.5%) had undergone 1 prior craniotomy, and 96 (13.5%) had undergone ≥ 2 prior craniotomies. There were 27 surgical and 10 medical complications in 30 patients (4.2%) and 19 reoperations for complications in 19 patients (2.7%) with no deaths by 90 days. Complications, reoperation rates, and new neurologic deficits did not differ based on number of prior craniotomies. On multivariate analysis, older age (OR1.5, 95%CI 1.0–2.2) and significant leukocytosis due to steroid use (OR12.6, 95%CI 2.5–62.9) were predictors of complications. Complication rates in the cohort were lower than rates reported in the literature. Conclusion Contrary to prior reports in the literature, repeat craniotomies can be as safe as initial operations if surgeons implement best practices.

OBJECTIVE Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-recognized complications of long-segment spinal fusion. Previous studies have suggested that ligament augmentation can decrease rates of PJF by reducing junctional stress and strengthening upper instrumented vertebrae (UIVs) and adjacent segments. However, there is a paucity of long-term data on the efficacy of ligament augmentation in preventing PJF. In this study, the authors sought to determine the effect of ligament augmentation on rates of PJF in a cohort of adult spinal deformity patients with at least 1 year of follow-up. METHODS They conducted a retrospective analysis of ligament augmentation in a consecutive series of surgical patients with adult spinal deformity. Data on patient demographics, surgical characteristics, and surgery for PJF were collected. The minimum follow-up was 12 months. Univariate and multivariate analyses were performed to identify factors associated with reoperation for PJF. RESULTS The authors identified a total of 242 patients (166 women [68.6%]) with ligament augmentation whose mean age was 66 years. The mean number of fused levels was 10, with a UIV distribution as follows: 90 upper thoracic UIVs (37.2%) and 152 lower thoracic UIVs (62.8%). Compared to a historical cohort of 77 patients treated before implementation of ligament augmentation, reoperation for PJF was significantly lower with ligament augmentation (15.6% vs 3.3%, p < 0.001). In a multivariate model, only ligament augmentation (OR 0.184, 95% CI 0.071–0.478, p = 0.001) and number of fused levels (OR 0.762, 95% CI 0.620–0.937, p = 0.010) were associated with reductions in reoperation for PJF. CONCLUSIONS Ligament augmentation was associated with significant reductions in the rate of reoperation for PJF at 12 months in a cohort of adult spinal deformity patients. The most dramatic reduction was seen among patients with lower thoracic UIV. These data suggest that in appropriately selected patients, ligament augmentation may be a valuable adjunct for PJF reduction; however, long-term follow-up is needed.

OBJECTIVE Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF. METHODS A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported. RESULTS A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2–4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01–1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01–1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05–3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility. CONCLUSIONS After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

BACKGROUND Geriatric patients have the highest rates of Traumatic Brain Injury (TBI)-related hospitalization and death. This contributes to an assumption of futility in aggressive management in this population. OBJECTIVE To evaluate the effect of surgical intervention on the morbidity and mortality of geriatric patients with TBI. METHODS A retrospective analysis of patients ≥80 yr old with TBI from 2003 to 2016 was performed using the National Trauma Data Bank. Univariate and multivariate analyses were performed to compare outcomes between surgery and nonsurgery groups. RESULTS A total of 127 129 patient incidents were included: 121 185 (95.3%) without surgery and 5944 (4.7%) with surgery. The surgical group was slightly younger (84.0 vs 84.3, P

OBJECTIVE The purpose of this study was to compare rod fracture (RF) rates among three types of rod constructs (RCs) following lumbar pedicle subtraction osteotomy (PSO) for adult spinal deformity (ASD). METHODS A retrospective review of consecutive patients with adult spinal deformity who were treated with lumbar PSO between 2007 and 2017 was performed. The minimum follow-up was 2 years. Three RCs were compared: standard (2 main rods), satellite (2 main rods with satellite rod), and nested (2 main rods and 2 short rods spanning osteotomy). Outcomes examined included RF rate, time to RF, pseudarthrosis, and reoperation. Multivariate analysis was used. RESULTS A total of 141 patients were included 55 with standard, 23 with satellite, and 63 with nested RCs. The mean age was 65.2 years and 34.8% of patients were male. Radiographic preoperative and postoperative results were as follows: sagittal vertical axis (11.0 vs 3.9 cm), lumbar lordosis (28.5° vs 57.1°), pelvic tilt (30.6° vs 21.0°), pelvic incidence (61.5° vs 60.0°), distance between central sacral vertical line and C7 plumb line (2.2 vs 1.5 cm), and scoliosis (18.9° vs 11.3°). The average time to RF was 12.4 months. Overall RF, bilateral RF, pseudarthrosis, and reoperation rates were 22.7%, 5.0%, 20.6%, and 17.7%, respectively. Standard RCs had a significantly higher RF (36.4% vs 13.0% vs 14.3%, p = 0.008), bilateral RF (35.0% vs 0.0% vs 0.0%, p = 0.021), pseudarthrosis (34.5% vs 8.7% vs 12.7%, p = 0.004), and reoperation (30.9% vs 4.3% vs 11.1%, p = 0.004) rates. Satellite RCs (OR 0.21, p = 0.015), nested RCs (OR 0.24, p = 0.003), and bone morphogenetic protein–2 (OR 0.28, p = 0.005) were independently associated with lower odds of RF. CONCLUSIONS Use of multiple rods in the satellite RC and nested RC groups was associated with lower rates of RF, pseudarthrosis, and reoperations following lumbar PSO. Bone morphogenetic protein–2 was associated with a reduction in RF rate as well.

Maximal safe surgical resection plays a key role in the care of patients with gliomas. A range of technologies have been developed to aid surgeons in distinguishing tumor from normal tissue, with the goal of increasing tumor resection and limiting postoperative neurological deficits. Technologies that are currently being investigated to aid in improving tumor control include intraoperative imaging modalities, fluorescent tumor makers, intraoperative cell and molecular profiling of tumors, improved microscopic imaging, intraoperative mapping, augmented and virtual reality, intraoperative drug and radiation delivery, and ablative technologies. In this review, we summarize the aforementioned advancements in neurosurgical oncology and implications for improving patient outcomes.

ObjectiveThe use of telemedicine has dramatically increased due to the coronavirus disease 2019 pandemic. Many neurosurgeons are now using telemedicine technologies for preoperative evaluations and routine outpatient visits. Our goal was to standardize the telemedicine motor neurologic examination, summarize the evidence surrounding clinical use of telehealth technologies, and discuss financial and legal considerations.MethodsWe identified a 12-member panel composed of spine surgeons, fellows, and senior residents at a single institution. We created an initial telehealth strength examination protocol based on published data and developed 10 agree/disagree statements summarizing the protocol. A blinded Delphi method was utilized to build consensus for each statement, defined as > 80% agreement and no significant disagreement using a 2-way binomial test (significance threshold of p < 0.05). Any statement that did not meet consensus was edited and iteratively resubmitted to the panel until consensus was achieved. In the final round, the panel was unblinded and the protocol was finalized.ResultsAfter the first round, 4/10 statements failed to meet consensus ( < 80% agreement, and p = 0.031, p = 0.031, p = 0.003, and p = 0.031 statistical disagreement, respectively). The disagreement pertained to grading of strength of the upper (3/10 statements) and lower extremities (1/10 statement). The amended statements clarified strength grading, achieved consensus ( > 80% agreement, p > 0.05 disagreement), and were used to create the final telehealth strength examination protocol.ConclusionThe resulting protocol was used in our clinic to standardize the telehealth strength examination. This protocol, as well as our summary of telehealth clinical practice, should aid neurosurgical clinics in integrating telemedicine modalities into their practice.

Hospital length of stay (HLOS) after traumatic brain injury (TBI) is an important metric of injury severity, resource utilization, and access to post-acute care services. Risk factors for protracted HLOS after TBI require further characterization.Data regarding adult inpatients admitted to a single U.S. level 1 trauma center with a diagnosis of acute TBI between August 1, 2019, and April 1, 2022, were extracted from the electronic health record. Patients with extreme HLOS (XHLOS,99th percentile of institutional TBI HLOS) were compared with those without XHLOS. Socioeconomic status (SES), clinical/injury factors, and discharge disposition were analyzed.In 1638 patients, the median HLOS was 3 days (interquartile range [IQR]: 2-8 days). XHLOS threshold was70 days (N = 18; range: 72-146 days). XHLOS was associated with younger age (XHLOS/non-XHLOS: 50.4/59.6 years; P = 0.042) and greater proportions with severe TBI (55.6%/11.4%; P0.001), low SES (72.2%/31.4%; P0.001), and Medicaid insurance (77.8%/30.1%; P0.001). XHLOS patients were more likely to die in hospital (22.2%/8.1%) and discharge to post-acute facility (77.8%/16.3%; P0.001). No XHLOS patients were discharged to home. In XHLOS patients alive at discharge, medical stability was documented at median 39 days (IQR: 28-58 days) and were hospitalized for another 56 days (IQR: 26.5-78.5 days).XHLOS patients were more likely to have severe injuries, low SES, and Medicaid. XHLOS is associated with in-hospital mortality and need for post-acute placement. XHLOS patients often demonstrated medical stability long before placement, underscoring complex relationships between SES, health insurance, and outcome. These findings have important implications for quality improvement and resource utilization at acute care hospitals and await validation from larger trials.

Background Rigid and ankylosed thoracolumbar spinal deformities require three-column osteotomy (3CO) to achieve adequate correction. For severe and multiregional deformities, multilevel 3CO is required but its use and outcomes are rarely reported. Objective To describe the use of multilevel pedicle subtraction osteotomy (PSO) in adult spinal deformity (ASD) patients with severe, rigid, and ankylosed multiregional deformity. Methods Retrospective review of 5 ASD patients who underwent multilevel PSO for the correction of severe fixed deformity and review the literature regarding the use of multilevel PSO. Results Five patients presented with spinal imbalance secondary to regional and multiregional spinal deformities involving the thoracolumbar spine. All patients underwent a single-stage two-level noncontiguous PSO, and 2 of the patients underwent a staged third PSO to treat deformity involving a separate spinal region. Significant radiographic correction was achieved with normalization of spinal alignment and parameters. Two-level PSO was able to provide greater than 80 degrees of sagittal plane correction in both the lumbar and thoracic spine. Two patients experienced new postoperative weakness which recovered to preoperative baseline at 3 to 6 mo follow-up. At most recent follow-up, 4 of the 5 patients gained significant pain relief and had improved functionality. Conclusion Noncontiguous multilevel PSO is a formidable surgical technique. Additional risk (compared to single-level 3CO) comes in the form of greater blood loss and higher risk for postoperative weakness. Nonetheless, multilevel PSO is feasible and effective for correcting severe multiplanar and multiregional ASD, and patients gain significant benefits in increased functionality and pain relief.

The standard of care for isocitrate dehydrogenase (IDH)-wildtype glioblastoma (GBM) is maximal resection followed by chemotherapy and radiation. Studies investigating the resection of GBM have primarily focused on the contrast enhancing portion of the tumor on magnetic resonance imaging. Histopathological studies, however, have demonstrated tumor infiltration within peri-tumoral fluid-attenuated inversion recovery (FLAIR) abnormalities, which is often not resected. The histopathology of FLAIR and local recurrence patterns of GBM have prompted interest in the resection of peri-tumoral FLAIR, or FLAIRectomy. To this point, recent studies have suggested a significant survival benefit associated with safe peri-tumoral FLAIR resection. In this review, we discuss the evidence surrounding the composition of peri-tumoral FLAIR, outcomes associated with FLAIRectomy, future directions of the field, and potential implications for patients.

Immunotherapies seek to unleash the immune system against cancer cells. While a variety of immunotherapies exist, one of the most commonly used is immune checkpoint blockade, which refers to the use of antibodies to interfere with immunosuppressive signaling through immune checkpoint molecules. Therapies against various checkpoints have had success in the clinic across cancer types. However, the efficacy of checkpoint inhibitors has varied across different cancer types and non-responsive patient populations have emerged. Non-responders to these therapies have highlighted the importance of understanding underlying mechanisms of resistance in order to predict which patients will respond and to tailor individual treatment paradigms. In this review we discuss the literature surrounding tumor mediated mechanisms of immune checkpoint resistance. We also describe efforts to overcome resistance and combine checkpoint inhibitors with additional immunotherapies. Finally, we provide insight into the future of immune checkpoint blockade, including the need for improved preclinical modeling and predictive biomarkers to facilitate personalized cancer treatments for patients.

Background The treatment of pseudarthrosis after transforaminal lumbar interbody fusion (TLIF) can be challenging, particularly when anterior column reconstruction is required. There are limited data on TLIF cage removal through an anterior approach. Objective To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a treatment for pseudarthrosis after TLIF. Methods ALIFs performed at a single academic medical center were reviewed to identify cases performed for the treatment of pseudarthrosis after TLIF. Patient demographics, surgical characteristics, perioperative complications, and 1-yr radiographic data were collected. Results A total of 84 patients were identified with mean age of 59 yr and 37 women (44.0%). A total of 16 patients (19.0%) underwent removal of 2 interbody cages for a total of 99 implants removed with distribution as follows: 1 L2/3 (0.9%), 6 L3/4 (5.7%), 37 L4/5 (41.5%), and 55 L5/S1 (51.9%). There were 2 intraoperative venous injuries (2.4%) and postoperative complications were as follows: 7 ileus (8.3%), 5 wound-related (6.0%), 1 rectus hematoma (1.1%), and 12 medical complications (14.3%), including 6 pulmonary (7.1%), 3 cardiac (3.6%), and 6 urinary tract infections (7.1%). Among 58 patients with at least 1-yr follow-up, 56 (96.6%) had solid fusion. There were 5 cases of subsidence (6.0%), none of which required surgical revision. Two patients (2.4%) required additional surgery at the level of ALIF for pseudarthrosis. Conclusion ALIF is a safe and effective technique for the treatment of TLIF cage pseudarthrosis with a favorable risk profile.

OBJECTIVE Decision-making in how to manage pituitary adenomas (PAs) in the elderly (age ≥ 65 years) can be challenging given the benign nature of these tumors and concerns about surgical morbidity in these patients. In this study involving a large multicenter national registry, the authors examined treatment trends and surgical outcomes in elderly compared to nonelderly patients. METHODS The National Cancer Data Base (NCDB) was queried for adults aged ≥ 18 years with PA diagnosed by MRI (in observed cases) or pathology (in surgical cases) from 2004 to 2016. Univariate and multivariate logistic regressions were used to evaluate the prognostic impact of age and other covariates on 30- and 90-day postsurgical mortality (30M/90M), prolonged (≥ 5 days) length of inpatient hospital stay (LOS), and extent of resection. RESULTS A total of 96,399 cases met the study inclusion criteria, 27% of which were microadenomas and 73% of which were macroadenomas. Among these cases were 25,464 elderly patients with PA. Fifty-three percent of these elderly patients were treated with surgery, 1.9% underwent upfront radiotherapy, and 44.9% were observed without treatment. Factors associated with surgical treatment compared to observation included younger age, higher income, private insurance, higher Charlson-Deyo comorbidity (CD) score, larger tumor size, and receiving treatment at an academic hospital (each p ≤ 0.01). Elderly patients undergoing surgery had increased rates of 30M (1.4% vs 0.6%), 90M (2.8% vs 0.9%), prolonged LOS (26.1% vs 23.0%), and subtotal resection (27.2% vs 24.5%; each p ≤ 0.01) compared to those in nonelderly PA patients. On multivariate analysis, age, tumor size, and CD score were independently associated with worse postsurgical mortality. High-volume facilities (HVFs) had significantly better outcomes than low-volume facilities: 30M (0.9% vs 1.8%, p < 0.001), 90M (2.0% vs 3.5%, p < 0.001), and prolonged LOS (21.8% vs 30.3%, p < 0.001). A systematic literature review composed of 22 studies demonstrated an elderly PA patient mortality rate of 0.7%, which is dramatically lower than real-world NCDB outcomes and speaks to substantial selection bias in the previously published literature. CONCLUSIONS The study findings confirm that elderly patients with PA are at higher risk for postoperative mortality than younger patients. Surgical risk in this age group may have been previously underreported in the literature. Resection at HVFs better reflects these historical rates, which has important implications in elderly patients for whom surgery is being considered.

In IDH-wildtype glioblastomas which meet the histopathological or molecular diagnosis criteria, it remains unclear whether the presence of TERT promotor mutations provides additional prognostic information. Based on a multicenter cohort of 466 IDH-wildtype glioblastomas (including 396 with and 70 patients without TERT promotor mutations), we found that TERT promotor mutations were neither associated with progression-free survival nor overall survival. This held true in various treatment-based or molecular subgroups. This argues against standardized analysis for TERT promotor mutation status for the purpose of prognostic or therapeutic relevance in newly diagnosed IDH-wildtype glioblastoma that otherwise meets the histopathological and molecular diagnosis criteria.

Adult spinal deformity (ASD) is a complex disease that significantly affects the lives of many patients. Surgical correction has proven to be effective in achieving improvement of spinopelvic parameters as well as improving quality of life (QoL) for these patients. However, given the relatively high complication risk associated with ASD correction, it is of paramount importance to develop robust prognostic tools for predicting risk profile and outcomes. Historically, statistical models such as linear and logistic regression models were used to identify preoperative factors associated with postoperative outcomes. While these tools were useful for looking at simple associations, they represent generalizations across large populations, with little applicability to individual patients. More recently, predictive analytics utilizing artificial intelligence (AI) through machine learning for comprehensive processing of large amounts of data have become available for surgeons to implement. The use of these computational techniques has given surgeons the ability to leverage far more accurate and individualized predictive tools to better inform individual patients regarding predicted outcomes after ASD correction surgery. Applications range from predicting QoL measures to predicting the risk of major complications, hospital readmission, and reoperation rates. In addition, AI has been used to create a novel classification system for ASD patients, which will help surgeons identify distinct patient subpopulations with unique risk-benefit profiles. Overall, these tools will help surgeons tailor their clinical practice to address patients' individual needs and create an opportunity for personalized medicine within spine surgery.

Background:Levetiracetam (LEV) is an anti-epileptic drug (AED) that sensitizes glioblastoma (GBM) to temozolomide (TMZ) chemotherapy by inhibiting O6-methylguanine-DNA methyltransferase (MGMT) expression. Adding LEV to the standard of care (SOC) for GBM may improve TMZ efficacy. This study aimed to pool the existing evidence in the literature to quantify LEV’s effect on GBM survival and characterize its safety profile to determine whether incorporating LEV into the SOC is warranted.Method:A search of CINAHL, Embase, PubMed, and Web of Science from inception to May 2021 was performed to identify relevant articles. Hazard ratios (HR), median overall survival, and adverse events were pooled using random-effect models. Meta-regression, funnel plots, and the Newcastle-Ottawa Scale were utilized to identify sources of heterogeneity, bias, and statistical influence.Results:From 20 included studies, 5804 GBM patients underwent meta-analysis, of which 1923 (33%) were treated with LEV. Administration of LEV did not significantly improve survival in the entire patient population (HR=0.89, p=0.094). Significant heterogeneity was observed during pooling of HRs (I2=75%, pp=0.02) and increased with greater proportions of female patients (RC=-0.05, p=0.002). Concurrent LEV with the SOC for GBM did not increase odds of adverse events relative to other AEDs.Conclusions:Levetiracetam treatment may not be effective for all GBM patients. Instead, LEV may be better suited for treating specific molecular profiles of GBM. Further studies are necessary to identify optimal GBM candidates for LEV.

OBJECTIVE Spinal meningiomas pose unique challenges based on the location of their dural attachment. However, there is a paucity of literature investigating the role of dural attachment location on outcomes after posterior-based approach for spinal meningioma resection. The aim of this study was to investigate any differences in outcomes between dural attachment location subgroups in spinal meningioma patients who underwent posterior-based resection. METHODS This was a single-institution review of patients who underwent resection of a spinal meningioma from 1997 to 2017. Surgical, oncological, and neurological outcomes were compared between patients with varying dural attachments. Multivariate analysis was utilized. RESULTS A total of 141 patients were identified. The mean age was 62 years, and 110 women were included. The sites of dural attachments were as follows: 16 (11.3%) dorsal, 31 (22.0%) dorsolateral, 17 (12.1%) lateral, 40 (28.4%) ventral, and 37 (26.2%) ventrolateral. Most meningiomas were WHO grade I (92.2%) and in the thoracic spine (61.0%). All patients underwent a posterior approach for tumor resection. There were no differences between subgroups in terms of largest diameter of tumor resected (p = 0.201), gross-total resection (GTR) or subtotal resection (p = 0.362), Simpson grade of resection, perioperative complications (p = 0.116), long-term neurological deficit (p = 0.100), or postoperative radiation therapy (p = 0.971). Cervical spine location was associated with reduced incidence of GTR (OR 0.271, 95% CI 0.108–0.684, p = 0.006) on multivariate analysis. The overall incidence of recurrence/progression was 4.6%, with no difference (p = 0.800) between subgroups. Similarly, the average length of follow-up was 28.1 months, with no difference between subgroups (p = 0.413). CONCLUSIONS Posterior-based approaches for resection of spinal meningiomas are safe and effective, regardless of dural attachment location, with similar surgical, oncological, and neurological outcomes. Comparison of long-term recurrence rates between dural attachment subgroups is required.

Introduction Posterior cervical foraminotomy and anterior cervical discectomy and fusion (ACDF) are the mainstay treatments for cervical radiculopathy. A recent alternative or adjunct involves the placement of interfacet spacers, which promote indirect decompression by increasing foraminal height. Cervical interfacet spacers have been shown to be safe options for indirect decompression and improve short-term clinical outcomes in patients with cervical spine pathologies. However, no previous data regarding malpositioned spacers and their management have been reported. Given this paucity of data, we aim to present examples of malpositioned interfacet spacers and their management. Methods This was a retrospective single-center review. Results Twenty-five patients were identified in which interfacet spacers were used at a single level in 19 cases, two levels in five cases, and three levels in one case. The cohort had a mean follow-up of 14.4 months. Among 60 total spacers placed, two required repositioning (3.3%). The first underwent bilateral placement at C4/5 and developed a unilateral deltoid palsy postoperatively. She was taken back to the operating room the same day for implant removal. A second patient underwent removal after a malpositioned implant at C4/5 was identified on an intraoperative CT scan. A third patient had spacers placed at a referring hospital and presented with progressive neck pain and radiculopathy. She underwent successful removal with a resolution of her symptoms. Conclusions Interfacet spacers represent a novel technique for the treatment of cervical radiculopathy, however, there are limited data on their utilization. We present the first reports of malpositioned spacers and their management. Patients with small facet joints and lateral masses may be at increased risk for malposition, and intraoperative fluoroscopy may not adequately confirm implant placement. Surgeons should use caution when implementing new technology with a low threshold for intraoperative CT to confirm the appropriate placement of these devices.

BACKGROUND Lower-grade insular gliomas often appear as expansile and infiltrative masses on magnetic resonance imaging (MRI). However, there are nonneoplastic lesions of the insula, such as demyelinating disease and vasculopathies, that can mimic insular gliomas. OBSERVATIONS The authors report two patients who presented with headaches and were found to have mass lesions concerning for lower-grade insular glioma based on MRI obtained at initial presentation. However, on the immediate preoperative MRI obtained a few weeks later, both patients had spontaneous and complete resolution of the insular lesions. LESSONS Tumor mimics should always be in the differential diagnosis of brain masses, including those involving the insula. The immediate preoperative MRI (within 24–48 hours of surgery) must be compared carefully with the initial presentation MRI to assess interval change that suggests tumor mimics to avoid unnecessary surgical intervention.

Levetiracetam (LEV) is an anti-epileptic drug (AED) that sensitizes glioblastoma (GBM) to temozolomide (TMZ) chemotherapy by inhibiting OA search of CINAHL, Embase, PubMed, and Web of Science from inception to May 2021 was performed to identify relevant articles. Hazard ratios (HR), median overall survival, and adverse events were pooled using random-effect models. Meta-regression, funnel plots, and the Newcastle-Ottawa Scale were utilized to identify sources of heterogeneity, bias, and statistical influence.From 20 included studies, 5804 GBM patients underwent meta-analysis, of which 1923 (33%) were treated with LEV. Administration of LEV did not significantly improve survival in the entire patient population (HR 0.89, p = 0.094). Significant heterogeneity was observed during pooling of HRs (ILevetiracetam treatment may not be effective for all GBM patients. Instead, LEV may be better suited for treating specific molecular profiles of GBM. Further studies are necessary to identify optimal GBM candidates for LEV.

Intravestibular schwannomas are rare tumors within the intralabyrinthine region and involve different management considerations compared to more common vestibular schwannomas. In this report, the authors review a case of a 52-year-old woman who presented with hearing loss and vestibular symptoms and was found to have a left intravestibular schwannoma. Given her debilitating vestibular symptoms, she underwent microsurgical resection. In this video, the authors review the relevant anatomy, surgical technique, and management considerations in these patients. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2187

Glioblastoma (GBM) is an incurable brain tumor with a median survival of approximately 15 months despite an aggressive standard of care that includes surgery, chemotherapy, and ionizing radiation. Mouse models have advanced our understanding of GBM biology and the development of novel therapeutic strategies for GBM patients. However, model selection is crucial when testing developmental therapeutics, and each mouse model of GBM has unique advantages and disadvantages that can influence the validity and translatability of experimental results. To shed light on this process, we discuss the strengths and limitations of 3 types of mouse GBM models in this review: syngeneic models, genetically engineered mouse models, and xenograft models, including traditional xenograft cell lines and patient-derived xenograft models.

Author(s): Haddad, Alexander F; Scheer, Justin K; Fury, Marissa T; Smith, Justin S; Deviren, Vedat; Ames, Christopher P | Abstract: ObjectiveExtension of the posterior upper-most instrumented vertebra (UIV) into the upper thoracic (UT) spine allows for greater deformity correction and reduced incidence of proximal junction kyphosis (PJK) in adult spinal deformity (ASD) patients. However, it may be associated with chronic postoperative scapular pain (POSP). The goal of this study was to assess the relationship between UT UIV and persistent POSP, describe the pain, and assess its impact on patient disability.MethodsASD patients who underwent multilevel posterior fusion were retrospectively identified then administered a survey regarding scapular pain and the Oswestry Disability Index (ODI), by telephone. Univariate and multivariate analysis were utilized.ResultsA total of 74 ASD patients were included in the study: 37 patients with chronic POSP and 37 without scapular pain. The mean age was 70.5 years, and 63.9% were women. There were no significant differences in clinical characteristics, including mechanical complications (PJK, pseudarthrosis, and rod fracture) or reoperation between groups. Patients with persistent POSP were more likely to have a UT than a lower thoracic UIV (p = 0.018). UT UIV was independently associated with chronic POSP on multivariate analysis (p = 0.022). ODI score was significantly higher in patients with scapular pain (p = 0.001). Chronic POSP (p = 0.001) and prior spine surgery (p = 0.037) were independently associated with ODI on multivariate analysis.ConclusionA UT UIV is independently associated with increased odds of chronic POSP, and this pain is associated with significant increases in patient disability. It is a significant clinical problem despite solid radiographic fusion and the absence of PJK.

BACKGROUND Terminology to describe extent of resection in glioblastoma is inconsistent across clinical trials. A surgical classification system was previously proposed based upon residual contrast-enhancing (CE) tumor. We aimed to (I) explore the prognostic utility of the classification system and (II) define how much removed non-CE tumor translates into a survival benefit. METHODS The international RANO resect group retrospectively searched the databases from seven neuro-oncological centers in the USA and Europe for patients with newly diagnosed glioblastoma per WHO 2021 classification. Clinical and volumetric information from pre- and post-operative MRI were collected. RESULTS We collected 1021 patients with newly diagnosed glioblastoma, including 1008 IDHwt patients. 744 IDHwt glioblastomas were treated with radiochemotherapy per EORTC 26981/22981 (TMZ/RT→TMZ) following surgery. Among such homogenously treated patients, lower absolute residual tumor volumes (in cm3) were favorably associated with outcome: patients with ‘maximal CE resection’ (class 2) had superior outcome compared to patients with ‘submaximal CE resection’ (class 3) or ‘biopsy’ (class 4) (median OS: 19 versus 15 versus 10 months; p=0.001). Extensive resection of non-CE tumor (≤ 5 cm3 residual non-CE tumor) provided an additional survival benefit in patients with complete CE resection, thus defining class 1 (‘supramaximal CE resection’) (median OS: 24 versus 19 months; p=0.008). The prognostic value of the resection classes was retained on multivariate analysis when adjusting for molecular and clinical markers including MGMT promotor status. Relative tumor reduction (in percentage) was not prognostic for outcome on multivariate analysis, and inter-rater agreement for CE and non-CE tumor on post-operative MRI was sufficient. CONCLUSION The proposed “RANO categories for extent of resection in glioblastoma” are highly prognostic and may serve for stratification of clinical trials. Removal of non-CE tumor beyond the CE tumor borders translates into additional survival benefit, providing a rationale to explicitly denominate such a ‘supramaximal CE resection’.

Glioblastoma (GBM) has demonstrated a limited therapeutic response to single-agent immunotherapies, highlighting the need for a better understanding of GBM tumor immune phenotypes to inform targeted immunologic treatments. To elucidate GBM immunologic phenotypes we performed unsupervised machine learning on microarray transcriptomic data from 815 newly diagnosed GBM patients. We utilized immune genes only and performed k-means clustering for k=2-10 with within-cluster sum of squares and silhouette methods used to identify the optimal number of clusters. Identified subtypes were further characterized using xCell to estimate the tumor infiltration of 64 immune and stromal cell types. Two primary immunologic subtypes were identified: subtype 1 (423 patients) and subtype 2 (392 patients). There was no difference in patient age (mean age 58 years) or gender between subtypes. Subtype 1 was primarily classical subtype GBMs (50.5%, p< 0.001), while subtype 2 was composed of primarily mesenchymal subtype GBMs (74.2%). Relative to subtype 1, subtype 2 was characterized by high expression of immune checkpoint and co-stimulatory proteins, including CD86, OX40L, IDO1, and LAG3. Subtype 2 also had increased activation of immune genes associated with cytolytic activity and antigen processing. In addition, subtype 2 had increased infiltration of M2 macrophages, monocytes, dendritic cells, and neutrophils while subtype 1 had higher infiltration of CD8 naïve T cells. Multivariate logistic regression confirmed that subtype 2 was characterized by monocytes, M1 and M2 macrophages, neutrophils, and dendritic cells while subtype 1 was characterized by CD8 naïve T cells, regulatory T cells, and naive B cells. Subtype 2 had reduced progression-free survival, but there was no difference in overall survival between the two subtypes. In summary, unsupervised machine learning of GBM immune transcriptomic data identified two immune phenotypes, one of which was more immunologically active than the other, potentially informing future personalized immunotherapy treatments.

Cancer-associated fibroblasts (CAFs) constitute a key component of the tumor microenvironment. Pro-tumoral cancer-associated fibroblasts were presumed absent in glioblastoma given the lack of brain fibroblasts. Using single-cell RNA sequencing we identified CAFs in patient GBMs. CAFs were identified using a negative selection strategy to filter endothelial, epithelial, immune cells and pericytes and for the positive expression of previously defined CAF markers. Copy number variation (CNV) analysis was performed to distinguish CAFs from malignant cells. Single-cell spatial transcriptomics from 16 GBM patients confirmed the proximity of CAFs to mesenchymal GBM stem cells (GSCs), endothelial cells, and M2-macrophages. Serial trypsinization of glioblastoma specimens yielded cells with CAF morphology and transcriptomic profile. CAFs were chemotactically attracted to GSCs and CAFs induced GSC proliferation. To identify CAF and GSC interaction mediators, we created a resource of inferred crosstalk by mapping expression of receptors to their cognate ligands, identifying PDGF and TGFB as mediators of GSC effects on CAFs, and osteopontin and HGF as mediators of CAF-induced GSC enrichment. Furthermore, CAFs were found to induce M2-macrophage polarization by producing the EDA fibronectin variant which binds macrophage toll-like receptor 4 (TLR4) in a targetable manner. Glioblastoma CAFs were enriched in the subventricular zone which houses the neural stem cells that houses GSCs. Including CAFs in GSC-derived xenografts induced in vivo tumor growth and reduced survival in two different xenograft models. These findings are among the first to identify glioblastoma CAFs and their GSC interactions, making them an intriguing target for Glioblastomas.

OBJECTIVE This study attempts to use neurosurgical workforce distribution to uncover the social determinants of health that are associated with disparate access to neurosurgical care. METHODS Data were compiled from public sources and aggregated at the county level. Socioeconomic data were provided by the Brookings Institute. Racial and ethnicity data were gathered from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research. Physician density was retrieved from the Health Resources and Services Administration Area Health Resources Files. Catchment areas were constructed based on the 628 counties with neurosurgical coverage, with counties lacking neurosurgical coverage being integrated with the nearest covered county based on distances from the National Bureau of Economic Research’s County Distance Database. Catchment areas form a mutually exclusive and collectively exhaustive breakdown of the entire US population and licensed neurosurgeons. Socioeconomic factors, race, and ethnicity were chosen as independent variables for analysis. Characteristics for each catchment area were calculated as the population-weighted average across all contained counties. Linear regression analysis modeled two outcomes of interest: neurosurgeon density per capita and average distance to neurosurgical care. Coefficient estimates (CEs) and 95% confidence intervals were calculated and scaled by 1 SD to allow for comparison between variables. RESULTS Catchment areas with higher poverty (CE = 0.64, 95% CI 0.34–0.93) and higher prime age employment (CE = 0.58, 95% CI 0.40–0.76) were significantly associated with greater neurosurgeon density. Among categories of race and ethnicity, catchment areas with higher proportions of Black residents (CE = 0.21, 95% CI 0.06–0.35) were associated with greater neurosurgeon density. Meanwhile, catchment areas with higher proportions of Hispanic residents displayed lower neurosurgeon density (CE = −0.17, 95% CI −0.30 to −0.03). Residents of catchment areas with higher housing vacancy rates (CE = 2.37, 95% CI 1.31–3.43), higher proportions of Native American residents (CE = 4.97, 95% CI 3.99–5.95), and higher proportions of Hispanic residents (CE = 2.31, 95% CI 1.26–3.37) must travel farther, on average, to receive neurosurgical care, whereas people living in areas with a lower income (CE = −2.28, 95% CI −4.48 to −0.09) or higher proportion of Black residents (CE = −3.81, 95% CI −4.93 to −2.68) travel a shorter distance. CONCLUSIONS Multiple factors demonstrate a significant correlation with neurosurgical workforce distribution in the US, most notably with Hispanic and Native American populations being associated with greater distances to care. Additionally, higher proportions of Hispanic residents correlated with fewer neurosurgeons per capita. These findings highlight the interwoven associations among socioeconomics, race, ethnicity, and access to neurosurgical care nationwide.

The natural history of spinal cord injury is in a state of flux. Our knowledge about the prevalence, epidemiology, and natural history spinal cord injury is in evolution. In this article, we summarize these considerations to provide a state-of-the-art synopsis of the neurologic outcomes of this condition.

OBJECTIVE Diabetes insipidus (DI) following transsphenoidal surgery can adversely impact quality of life and be difficult to manage. This study sought to characterize pre- and perioperative risk factors that may predispose patients to DI after pituitary surgery. METHODS A retrospective review of patients treated at a single institution from 2007 to 2019 was conducted. DI was defined as postoperative sodium > 145 mEq/L and urine output > 300 ml/hr and/or postoperative desmopressin (ddAVP) use. DI was further characterized as transient or permanent. Uni- and multivariate analyses were performed to determine variables associated with postoperative DI. RESULTS The authors identified 2529 patients who underwent transsphenoidal surgery at their institution. Overall, DI was observed in 270 (10.7%) of the 2529 patients, with 114 (4.5%) having permanent DI and 156 (6.2%) with transient symptoms. By pathology type, DI occurred in 31 (46.3%) of 67 craniopharyngiomas, 10 (14.3%) of 70 apoplexies, 46 (14.3%) of 322 Rathke’s cleft cysts, 77 (7.7%) of 1004 nonfunctioning pituitary adenomas (NFPAs), and 62 (7.6%) of 811 functioning pituitary adenomas (FPAs). Final lesion pathology significantly affected DI rates (p < 0.001). Multivariate analysis across pathologies showed that younger age (odds ratio [OR] 0.97, p < 0.001), intraoperative CSF encounter (OR 2.74, p < 0.001), craniopharyngioma diagnosis (OR 8.22, p = 0.007), and postoperative hyponatremia (OR 1.50, p = 0.049) increased the risk of DI. Because surgery for each pathology created specific risk factors for DI, the analysis was then limited to the 1815 pituitary adenomas (PAs) in the series, comprising 1004 NFPAs and 811 FPAs. For PAs, younger age (PA: OR 0.97, p < 0.001; NFPA: OR 0.97, p < 0.001; FPA: OR 0.97, p = 0.028) and intraoperative CSF encounter (PA: OR 2.99, p < 0.001; NFPA: OR 2.93, p < 0.001; FPA: OR 3.06, p < 0.001) increased DI rates in multivariate analysis. Among all PAs, patients with DI experienced peak sodium levels later than those without DI (postoperative day 11 vs 2). Increasing tumor diameter increased the risk of DI in FPAs (OR 1.52, p = 0.008), but not in NFPAs (p = 0.564). CONCLUSIONS In more than 2500 patients treated at a single institution, intraoperative CSF encounter, craniopharyngioma diagnosis, and young age all increased the risk of postoperative DI. Patients with postoperative hyponatremia exhibited higher rates of DI, suggesting possible bi- or triphasic patterns to DI. Greater vigilance should be maintained in patients meeting these criteria following transsphenoidal surgery to ensure early recognition and treatment of DI.

BACKGROUND CONTEXT The optimal surgical approach to resection of a spinal meningioma remains controversial, especially for tumors with ventral or ventrolateral dural attachments. There is a paucity of literature investigating the impact of dural attachment location on outcomes following a posterior approach for resection of a spinal meningioma. PURPOSE We sought to investigate differences in short and long-term outcomes between dural attachment location subgroups in spinal meningioma patients undergoing a posterior-based resection. STUDY DESIGN/SETTING This is a single-institution, retrospective cohort study. PATIENT SAMPLE All patients who underwent resection of a spinal meningioma from 1997 to 2017 at the University of California, San Francisco Department of Neurological Surgery. OUTCOME MEASURES Outcome measures were determined using patient medical records and included: largest diameter of tumor resected, radiographic extent of resection, incidence of pedicle resection, incidence of fusion, operative time, perioperative complications, long-term neurological deficit, postoperative radiation therapy, and incidence of recurrence. METHODS A retrospective review of a single institution experience from 1997 to 2017 of all patients who underwent resection of a spinal meningioma was performed. Clinical and surgical characteristics as well as outcomes were collected from patient medical records. Outcomes were compared between patients with varying dural attachments. Multivariate analysis was utilized. RESULTS A total of 121 patients were identified. Mean age was 61 years with 95 women. Sites of dural attachments were as follows: 12 (9.3%) dorsal, 28 (21.7%) dorsolateral, 10 (7.8%) lateral, 38 (29.5%) ventral, and 33 (25.6%) ventrolateral. Most meningiomas were WHO Grade I (91.7%) and in the thoracic spine (62.8%) with no differences in medial-lateral, craniocaudal, or superior-inferior tumor radiographic measurements between subgroups. All patients underwent a posterior approach for tumor resection. There were no differences in largest diameter of tumor resected (p=0.224), gross-total (GTR) or subtotal resections (STR,p=0.068), operative time (p=0.082), perioperative complications (p=0.232), long-term neurological deficit (p=0.437), or postoperative radiation therapy (p=0.969) between subgroups. Thoracic spine location was associated with GTR (OR:5.30,CI:1.85-15.10,p=0.002) on multivariate analysis. The overall incidence of recurrence/progression was 5.5% with no difference (p=0.313) between subgroups. Similarly, the average length of follow-up was 33.0 months with no difference between subgroups (p=0.255). CONCLUSIONS Posterior-based approaches for resection of spinal meningiomas are safe and effective, regardless of dural attachment location, with similar surgical and neurologic outcomes between dural attachment subgroups. Comparison of long-term recurrence rates between dural attachment subgroups is required. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Preoperative mapping of cortical structures prior to neurosurgical intervention can provide a roadmap of the brain with which neurosurgeons can navigate critical cortical structures. In patients undergoing surgery for brain tumors, preoperative mapping allows for improved operative planning, patient risk stratification, and personalized preoperative patient counseling. Navigated transcranial magnetic stimulation (nTMS) is one modality that allows for highly accurate, image-guided, non-invasive stimulation of the brain, thus allowing for differentiation between eloquent and non-eloquent cortical regions. Motor mapping is the best validated application of nTMS, yielding reliable maps with an accuracy similar to intraoperative cortical mapping. Language mapping is also commonly performed, although nTMS language maps are not as highly concordant with direct intraoperative cortical stimulation maps as nTMS motor maps. Additionally, nTMS has been used to localize cortical regions involved in other functions such as facial recognition, calculation, higher-order motor processing, and visuospatial orientation. In this review, we evaluate the growing literature on the applications of nTMS in the preoperative setting. First, we analyze the evidence in support of the most common clinical applications. Then we identify usages that show promise but require further validation. We also discuss developing nTMS techniques that are still in the experimental stage, such as the use of nTMS to enhance postoperative recovery. Finally, we highlight practical considerations when utilizing nTMS and, importantly, its safety profile in neurosurgical patients. In so doing, we aim to provide a comprehensive review of the role of nTMS in the neurosurgical management of a patient with a brain tumor.

OBJECTIVE Within the Spine Instability Neoplastic Score (SINS) classification, tumor-related potential spinal instability (SINS 7–12) may not have a clear treatment approach. The authors aimed to examine the proportion of patients in this indeterminate zone who later required surgical stabilization after initial nonoperative management. By studying this patient population, they sought to determine if a clear SINS cutoff existed whereby the spine is potentially unstable due to a lesion and would be more likely to require stabilization. METHODS Records from patients treated at the University of California, San Francisco, for metastatic spine disease from 2005 to 2019 were retrospectively reviewed. Seventy-five patients with tumor-related potential spinal instability (SINS 7–12) who were initially treated nonoperatively were included. All patients had at least a 1-year follow-up with complete medical records. A univariate chi-square test and Student t-test were used to compare categorical and continuous outcomes, respectively, between patients who ultimately underwent surgery and those who did not. A backward likelihood multivariate binary logistic regression model was used to investigate the relationship between clinical characteristics and surgical intervention. Recursive partitioning analysis (RPA) and single-variable logistic regression were performed as a function of SINS. RESULTS Seventy-five patients with a total of 292 spinal metastatic sites were included in this study; 26 (34.7%) patients underwent surgical intervention, and 49 (65.3%) did not. There was no difference in age, sex, comorbidities, or lesion location between the groups. However, there were more patients with a SINS of 12 in the surgery group (55.2%) than in the no surgery group (44.8%) (p = 0.003). On multivariate analysis, SINS > 11 (OR 8.09, CI 1.96–33.4, p = 0.004) and Karnofsky Performance Scale (KPS) score < 60 (OR 0.94, CI 0.89–0.98, p = 0.008) were associated with an increased risk of surgery. KPS score was not correlated with SINS (p = 0.4). RPA by each spinal lesion identified an optimal cutoff value of SINS > 10, which were associated with an increased risk of surgical intervention. Patients with a surgical intervention had a higher incidence of complications on multivariable analysis (OR 2.96, CI 1.01–8.71, p = 0.048). CONCLUSIONS Patients with a mean SINS of 11 or greater may be at increased risk of mechanical instability requiring surgery after initial nonoperative management. RPA showed that patients with a KPS score of 60 or lower and a SINS of greater than 10 had increased surgery rates.