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The Scottish Talipes Register is a record of all newly diagnosed cases of idiopathic congenital talipes equinovarus (CTEV) in Scotland over a four.year period. Two hundred and sixteen children were entered into the register, which recorded initial management and all subsequent interventions, both non-operative and operative. The data, therefore, represent a record of the different management regimens used within Scotland highlighting the variations in duration of conservative management and variations in surgical intervention following different methods of conservative management. [ABSTRACT FROM AUTHOR]

Objective: There is a paucity of high-quality return-to-play (RTP) data following treatment of cervical spine injuries in contact sports. In this study, the authors gathered insights from National Football League (NFL) team spine surgeon consultants to highlight current practices in treating cervical spine injuries and report decision-making regarding RTP in professional American football players., Methods: A cross-sectional, online survey was distributed to all NFL consulting physicians specializing in the management of spine injuries. The survey covered the following five clinical vignettes of cervical spine injuries: 1) radiculopathy, 2) myelopathy, 3) unilateral facet fracture, 4) unilateral facet dislocation, and 5) neck pain with MRI showing a ligamentous STIR signal. Participants were asked about management options and criteria to clear players for RTP using a combination of multiple-choice and open-ended answers., Results: A total of 26 physicians from 21 of 32 (66%) teams responded. Anterior surgery was most commonly recommended for cervical disc herniation causing radiculopathy or myelopathy (73% and 88%, respectively). A rigid cervical orthosis was preferred by 68% of experts for initial management of nondisplaced unilateral facet fracture, but single-level anterior fusion was preferred by 56% for a unilateral facet dislocation. Common criteria to clear players for RTP with cervical disc herniation causing radiculopathy included a normal examination (85%), radiographic fusion postoperatively (58%), and pain-free range of motion (50%). Contraindications for RTP included persistent stenosis (35%), instability (31%), multilevel fusion (27%), and persistent cord signal change (23%). Additional criteria for RTP in players with facet fractures or dislocations included radiographic evidence of fracture healing (32% and 24%, respectively) and normal flexion/extension radiographs (24% and 32%, respectively). Finally, for players with isolated ligamentous STIR signal changes, resolution of MRI findings was required by 36% of responding physicians prior to RTP., Conclusions: Decision-making regarding RTP after cervical spine injuries in professional football players is complex and influenced by improvement of symptoms, pain-free range of motion, and radiographic evidence of fusion or fracture healing. Respondents preferred anterior cervical discectomy and fusion for disc herniations causing cervical radiculopathy and myelopathy, rigid orthosis for unilateral facet fractures, and surgery for unilateral facet dislocations. The results of this study provide insight into how surgeons serving as consultants to professional football teams may counsel players who sustain cervical spine injuries.

Objective: Because gliomas have poorly defined tumor margins, the ability to achieve maximal resection is limited. To better discern these margins, fluorescence-guided surgery has been used to aid maximal safe resection. The authors describe their experience with the simultaneous use of intraoperative fluorescein sodium (FNa) confocal laser endomicroscopy (CLE) and operating microscope 5-aminolevulinic acid (5-ALA) fluorescence imaging for glioma resection to improve CLE use for better margin discrimination., Methods: FNa CLE and 5-ALA wide-field imaging were used in 33 patients with gliomas. CLE imaging was enhanced with the use of a telesurgical pathology software platform that enables real-time conversation between the operating neurosurgeons and the pathologists located remotely. CLE was used for imaging tumor regions that were subjectively regarded as tumor margins under normal visualization with the operative microscope. After FNa CLE imaging, 5-ALA wide-field imaging was performed in the same regions. Tissue was biopsied at imaging locations, and interpretations of FNa CLE and 5-ALA wide-field imaging were compared to those of permanent histological sections., Results: Eighty-eight deep- and superficial-margin regions of interest (ROIs) were imaged with FNa CLE and 5-ALA imaging. Most of the ROIs interpreted by the neuropathologist as infiltrative glioma based on FNa CLE imaging lacked 5-ALA-induced fluorescence. Permanent histological sections from the corresponding regions were concordant with the interpretation of FNa CLE images in 57 of 88 (65%) ROIs and with the interpretation of 5-ALA imaging in 43 of 88 (49%) ROIs. The sensitivity and specificity of FNa CLE for the interpretation of tumor margins were 73% and 41%, respectively, and those of 5-ALA were 38% and 82%, respectively. Positive and negative predictive values for CLE were 79% and 33%, respectively, and those for 5-ALA were 86% and 31%, respectively., Conclusions: Conventional intraoperative evaluation of tumor margins, based on MRI and wide-field fluorescence imaging, can underestimate the invasiveness of gliomas. FNa CLE showed higher accuracy in detecting regions with infiltrating tumors than intraoperative 5-ALA imaging. Future considerations should include more rigorous comparisons of FNa CLE imaging and 5-ALA-guided resections on a larger cohort of patients.

Objectives: Confocal laser endomicroscopy (CLE) is an intraoperative real-time cellular resolution imaging technology that images brain tumor histoarchitecture. Previously, we demonstrated that CLE images may be interpreted by neuropathologists to determine the presence of tumor infiltration at glioma margins. In this study, we assessed neurosurgeons' ability to interpret CLE images from glioma margins and compared their assessments to those of neuropathologists., Methods: In vivo CLE images acquired at the glioma margins that were previously reviewed by CLE-experienced neuropathologists were interpreted by four CLE-experienced neurosurgeons. A numerical scoring system from 0 to 5 and a dichotomous scoring system based on pathological features were used. Scores from assessments of hematoxylin and eosin (H&E)-stained sections and CLE images by neuropathologists from a previous study were used for comparison. Neurosurgeons' scores were compared to the H&E findings. The inter-rater agreement and diagnostic performance based on neurosurgeons' scores were calculated. The concordance between dichotomous and numerical scores was determined., Results: In all, 4275 images from 56 glioma margin regions of interest (ROIs) were included in the analysis. With the numerical scoring system, the inter-rater agreement for neurosurgeons interpreting CLE images was moderate for all ROIs (mean agreement, 61%), which was significantly better than the inter-rater agreement for the neuropathologists (mean agreement, 48%) ( p < 0.01). The inter-rater agreement for neurosurgeons using the dichotomous scoring system was 83%. The concordance between the numerical and dichotomous scoring systems was 93%. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 78%, 32%, 62%, and 50%, respectively, using the numerical scoring system and 80%, 27%, 61%, and 48%, respectively, using the dichotomous scoring system. No statistically significant differences in diagnostic performance were found between the neurosurgeons and neuropathologists., Conclusion: Neurosurgeons' performance in interpreting CLE images was comparable to that of neuropathologists. These results suggest that CLE could be used as an intraoperative guidance tool with neurosurgeons interpreting the images with or without assistance of the neuropathologists. The dichotomous scoring system is robust yet simple and may streamline rapid, simultaneous interpretation of CLE images during imaging., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Xu, On, Abramov, Restelli, Belykh, Mathis, Schlegel, Hewer, Pollo, Maragkou, Quint, Porter, Smith and Preul.)

Objective: Although audio-video recordings of clinic visits improve patient satisfaction and recall, the associated presumed risk of increased malpractice claims limits their use. In this study, we identified whether video recording clinic visits was associated with increases in professional liability claims., Methods: From 2015 to 2017, the institution's loss run was analyzed, and the rates of medical malpractice claims per physician-year were compared between physicians who used video recordings of clinic visits (V-RoCs) and those who did not. The term "users" was applied to all physicians whose mean percentage of patient visits with video recording was greater than the mean percentage for the practice overall., Results: Over three years, 15,254 patients used V-RoCs. The use of video recordings for clinic visits increased at a rate of 23% per year. No association was found between video recordings and increased malpractice claims. The rate of all claims between users and nonusers did not differ significantly (P=0.66). Of seven paid claims or lawsuits from 2000 to 2017, none were against physicians who used video recordings., Conclusion: Video recording of patient-physician encounters was not associated with an increase in malpractice lawsuits. According to federal law, a patient can legally record a clinic encounter without physician consent, which has many ethical implications. Formalizing the recording process is beneficial for both parties and allows the resource to be used to its maximum potential., Competing Interests: Randall W. Porter, MD, has stock ownership in The Medical Memory, LLC (Phoenix, AZ), which manufactures the audio-video recording software used in the study., (Copyright © 2024, Naeem et al.)

Objective: Confocal laser endomicroscopy (CLE) is a US Food and Drug Administration-cleared intraoperative real-time fluorescence-based cellular resolution imaging technology that has been shown to image brain tumor histoarchitecture rapidly in vivo during neuro-oncological surgical procedures. An important goal for successful intraoperative implementation is in vivo use at the margins of infiltrating gliomas. However, CLE use at glioma margins has not been well studied., Methods: Matching in vivo CLE images and tissue biopsies acquired at glioma margin regions of interest (ROIs) were collected from 2 institutions. All images were reviewed by 4 neuropathologists experienced in CLE. A scoring system based on the pathological features was implemented to score CLE and H&E images from each ROI on a scale from 0 to 5. Based on the H&E scores, all ROIs were divided into a low tumor probability (LTP) group (scores 0-2) and a high tumor probability (HTP) group (scores 3-5). The concordance between CLE and H&E scores regarding tumor probability was determined. The intraclass correlation coefficient (ICC) and diagnostic performance were calculated., Results: Fifty-six glioma margin ROIs were included for analysis. Interrater reliability of the scoring system was excellent when used for H&E images (ICC [95% CI] 0.91 [0.86-0.94]) and moderate when used for CLE images (ICC [95% CI] 0.69 [0.40-0.83]). The ICCs (95% CIs) of the LTP group (0.68 [0.40-0.83]) and HTP group (0.68 [0.39-0.83]) did not differ significantly. The concordance between CLE and H&E scores was 61.6%. The sensitivity and specificity values of the scoring system were 79% and 37%. The positive predictive value (PPV) and negative predictive value were 65% and 53%, respectively. Concordance, sensitivity, and PPV were greater in the HTP group than in the LTP group. Specificity was higher in the newly diagnosed group than in the recurrent group., Conclusions: CLE may detect tumor infiltration at glioma margins. However, it is not currently dependable, especially in scenarios where low probability of tumor infiltration is expected. The proposed scoring system has excellent intrinsic interrater reliability, but its interrater reliability is only moderate when used with CLE images. These results suggest that this technology requires further exploration as a method for consistent actionable intraoperative guidance with high dependability across the range of tumor margin scenarios. Specific-binding and/or tumor-specific fluorophores, a CLE image atlas, and a consensus guideline for image interpretation may help with the translational utility of CLE.

Background: Single-cell RNA-seq has emerged as an innovative technology used to study complex tissues and characterize cell types, states, and lineages at a single-cell level. Classification of bulk tumors by their individual cellular constituents has also created new opportunities to generate single-cell atlases for many organs, cancers, and developmental models. Despite the tremendous promise of this technology, recent evidence studying epithelial tissues and diverse carcinomas suggests the methods used for tissue processing, cell disaggregation, and preservation can significantly bias gene expression and alter the observed cell types. To determine whether sarcomas - tumors of mesenchymal origin - are subject to the same technical artifacts, we profiled patient-derived tumor explants (PDXs) propagated from three aggressive subtypes: osteosarcoma (OS), Ewing sarcoma (ES), desmoplastic small round cell tumor (DSRCT). Given the rarity of these sarcoma subtypes, we explored whether single-nuclei RNA-seq from more widely available archival frozen specimens could accurately be identified by gene expression signatures linked to tissue phenotype or pathognomonic fusion proteins., Results: We systematically assessed dissociation methods across different sarcoma subtypes. We compared gene expression from single-cell and single-nucleus RNA-sequencing of 125,831 whole-cells and nuclei from ES, DSRCT, and OS PDXs. We detected warm dissociation artifacts in single-cell samples and gene length bias in single-nucleus samples. Classic sarcoma gene signatures were observed regardless of the dissociation method. In addition, we showed that dissociation method biases could be computationally corrected., Conclusions: We highlighted transcriptional biases, including warm dissociation and gene-length biases, introduced by the dissociation method for various sarcoma subtypes. This work is the first to characterize how the dissociation methods used for sc/snRNA-seq may affect the interpretation of the molecular features in sarcoma PDXs., (© 2023. The Author(s).)

Objective: Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion are common techniques that typically require staged procedures when performed in combination. Interest is emerging in single-position surgery to increase operative efficiency. We report a novel surgical technique, supine extended reach lateral fusion, to perform ALIF and lateral lumbar interbody fusion with the patient in a single supine position., Methods: A man in his fifties presented with degenerative levoscoliosis, spondylolisthesis, sagittal plane deformity, and progressive low back pain. He was offered L3-S1 anterolateral fusion., Results: With the patient supine, a left abdominal paramedian incision was performed to gain anterior retroperitoneal access, and standard L5-S1 and L4-5 ALIFs were performed. The anterior incision was used for direct visualization, retraction, and bimanual dissection. A left lateral incision was then made to perform an L3-4 lateral lumbar interbody fusion. He subsequently underwent a second-stage L3-S1 posterior percutaneous fixation. The patient tolerated the procedures well, without complications. His postoperative radiograph findings confirmed acceptable implant positioning. He was discharged home in stable condition and was doing well at follow-up., Conclusions: This case description is the first report of the supine extended reach technique, which allows incorporation of anterior and lateral fusion constructs at adjacent levels without changing patient positioning. Many surgeons believe the ALIF to be the most powerful technique for achieving lordosis, and this technique enables concomitant lateral access in a supine position. It can also be used as an alternative strategy when anterior access to the disc space is unobtainable. Further clinical investigation of this technique is warranted., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Infections associated with giant intradiploic cranial epidermoid cysts are rare. This case report describes the successful surgical management of a 71-year-old diabetic man with a giant intradiploic cranial epidermoid cyst associated with a secondary infection. The patient underwent successful resection of the infected lesion with washout, debridement, and obliteration of the eustachian canal and external auditory canal. At the six-month follow-up, the infection was resolved and the patient was doing well clinically. Intradiploic epidermoid cysts are rare, and the presence of a superimposed otogenic infection is exceptionally rare and infrequently reported in the neurosurgical literature., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Catapano et al.)

Background: Precise communication between neurosurgeons and pathologists is crucial for optimizing patient care, especially for intraoperative diagnoses. Confocal laser endomicroscopy (CLE) combined with a telepathology software platform (TSP) provides a novel venue for neurosurgeons and pathologists to review CLE images and converse intraoperatively in real-time., Objective: To describe the feasibility of integrating CLE and a TSP in the surgical workflow for real-time review of in vivo digital fluorescence tissue imaging in 3 patients with intracranial tumors., Methods: Although the neurosurgeon used the CLE probe to generate fluorescence images of histoarchitecture within the operative field that were displayed on monitors in the operating room, the pathologist simultaneously remotely viewed the CLE images. The neurosurgeon and pathologist discussed in real-time the histological structures of intraoperative imaging locations., Results: The neurosurgeon placed the CLE probe at various locations on and around the tumor, in the surgical resection bed, and on surrounding brain tissue with communication through the TSP. The neurosurgeon oriented the pathologist to the location of the CLE, and the pathologist and neurosurgeon discussed the CLE images in real-time. The TSP and CLE were integrated successfully and rapidly in the operating room in all 3 cases. No patient had perioperative complications., Conclusion: Two novel digital neurosurgical cellular imaging technologies were combined with intraoperative neurosurgeon-pathologist communication to guide the identification of abnormal histoarchitectural tissue features in real-time. CLE with the TSP may allow rapid decision-making during tumor resection that may hold significant advantages over the frozen section process and surgical workflow in general., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Objective: The authors evaluated the feasibility of using the first clinical-grade confocal laser endomicroscopy (CLE) system using fluorescein sodium for intraoperative in vivo imaging of brain tumors., Methods: A CLE system cleared by the FDA was used in 30 prospectively enrolled patients with 31 brain tumors (13 gliomas, 5 meningiomas, 6 other primary tumors, 3 metastases, and 4 reactive brain tissue). A neuropathologist classified CLE images as interpretable or noninterpretable. Images were compared with corresponding frozen and permanent histology sections, with image correlation to biopsy location using neuronavigation. The specificities and sensitivities of CLE images and frozen sections were calculated using permanent histological sections as the standard for comparison. A recently developed surgical telepathology software platform was used in 11 cases to provide real-time intraoperative consultation with a neuropathologist., Results: Overall, 10,713 CLE images from 335 regions of interest were acquired. The mean duration of the use of the CLE system was 7 minutes (range 3-18 minutes). Interpretable CLE images were obtained in all cases. The first interpretable image was acquired within a mean of 6 (SD 10) images and within the first 5 (SD 13) seconds of imaging; 4896 images (46%) were interpretable. Interpretable image acquisition was positively correlated with study progression, number of cases per surgeon, cumulative length of CLE time, and CLE time per case (p ≤ 0.01). The diagnostic accuracy, sensitivity, and specificity of CLE compared with frozen sections were 94%, 94%, and 100%, respectively, and the diagnostic accuracy, sensitivity, and specificity of CLE compared with permanent histological sections were 92%, 90%, and 94%, respectively. No difference was observed between lesion types for the time to first interpretable image (p = 0.35). Deeply located lesions were associated with a higher percentage of interpretable images than superficial lesions (p = 0.02). The study met the primary end points, confirming the safety and feasibility and acquisition of noninvasive digital biopsies in all cases. The study met the secondary end points for the duration of CLE use necessary to obtain interpretable images. A neuropathologist could interpret the CLE images in 29 (97%) of 30 cases., Conclusions: The clinical-grade CLE system allows in vivo, intraoperative, high-resolution cellular visualization of tissue microstructure and identification of lesional tissue patterns in real time, without the need for tissue preparation.

Desmoplastic small round cell tumor (DSRCT) is an aggressive, usually incurable sarcoma subtype that predominantly occurs in post-pubertal young males. Recent evidence suggests that the androgen receptor (AR) can promote tumor progression in DSRCTs. However, the mechanism of AR-induced oncogenic stimulation remains undetermined. Herein, we demonstrate that enzalutamide and AR-directed antisense oligonucleotides (AR-ASO) block 5α-dihydrotestosterone (DHT)-induced DSRCT cell proliferation and reduce xenograft tumor burden. Gene expression analysis and chromatin immunoprecipitation sequencing (ChIP-seq) were performed to elucidate how AR signaling regulates cellular epigenetic programs. Remarkably, ChIP-seq revealed novel DSRCT-specific AR DNA binding sites adjacent to key oncogenic regulators, including WT1 (the C-terminal partner of the pathognomonic fusion protein) and FOXF1. Additionally, AR occupied enhancer sites that regulate the Wnt pathway, neural differentiation, and embryonic organ development, implicating AR in dysfunctional cell lineage commitment. Our findings have direct clinical implications given the widespread availability of FDA-approved androgen-targeted agents used for prostate cancer., (© 2022. The Author(s).)

Objective: Communication between neurosurgeons and pathologists is mandatory for intraoperative decision-making and optimization of resection, especially for invasive masses. Handheld confocal laser endomicroscopy (CLE) technology provides in vivo intraoperative visualization of tissue histoarchitecture at cellular resolution. The authors evaluated the feasibility of using an innovative surgical telepathology software platform (TSP) to establish real-time, on-the-fly remote communication between the neurosurgeon using CLE and the pathologist., Methods: CLE and a TSP were integrated into the surgical workflow for 11 patients with brain masses (6 patients with gliomas, 3 with other primary tumors, 1 with metastasis, and 1 with reactive brain tissue). Neurosurgeons used CLE to generate video-flow images of the operative field that were displayed on monitors in the operating room. The pathologist simultaneously viewed video-flow CLE imaging using a digital tablet and communicated with the surgeon while physically located outside the operating room (1 pathologist was in another state, 4 were at home, and 6 were elsewhere in the hospital). Interpretations of the still CLE images and video-flow CLE imaging were compared with the findings on the corresponding frozen and permanent H&E histology sections., Results: Overall, 24 optical biopsies were acquired with mean ± SD 2 ± 1 optical biopsies per case. The mean duration of CLE system use was 1 ± 0.3 minutes/case and 0.25 ± 0.23 seconds/optical biopsy. The first image with identifiable histopathological features was acquired within 6 ± 0.1 seconds. Frozen sections were processed within 23 ± 2.8 minutes, which was significantly longer than CLE usage (p < 0.001). Video-flow CLE was used to correctly interpret tissue histoarchitecture in 96% of optical biopsies, which was substantially higher than the accuracy of using still CLE images (63%) (p = 0.005)., Conclusions: When CLE is employed in tandem with a TSP, neurosurgeons and pathologists can view and interpret CLE images remotely and in real time without the need to biopsy tissue. A TSP allowed neurosurgeons to receive real-time feedback on the optically interrogated tissue microstructure, thereby improving cross-functional communication and intraoperative decision-making and resulting in significant workflow advantages over the use of frozen section analysis.

Desmoplastic small round cell tumor (DSRCT) is a highly aggressive soft tissue sarcoma that is characterized by the EWSR1-WT1 fusion protein. Patients present with hundreds of tumor implants in their abdominal cavity at various sites. To determine the genetic relatedness among these sites, exome and RNA sequencing were performed on 22 DSRCT specimens from 14 patients, four of whom had specimens from various tissue sites. Multi-site tumors from individual DSRCT patients had a shared origin and were highly related. Other than the EWSR1-WT1 fusion, very few secondary cancer gene mutations were shared among the sites. Among these, ARID1A, was recurrently mutated, which corroborates findings by others in DSRCT patients. Knocking out ARID1A in JN-DSRCT cells using CRISPR/CAS9 resulted in significantly lower cell proliferation and increased drug sensitivity. The transcriptome data were integrated using network analysis and drug target database information to identify potential therapeutic opportunities in EWSR1-WT1-associated pathways, such as PI3K and mTOR pathways. Treatment of JN-DSRCT cells with the PI3K inhibitor alpelisib and mTOR inhibitor temsirolimus reduced cell proliferation. In addition, the low mutation burden was associated with an immune-cold state in DSRCT. Together, these data reveal multiple genomic and immune features of DSRCT and suggest therapeutic opportunities in patients., (© 2022. The Author(s).)

Osteosarcoma (OS) is a genetically diverse bone cancer that lacks a consistent targetable mutation. Recent studies suggest the IGF/PI3K/mTOR pathway and YAP/TAZ paralogs regulate cell fate and proliferation in response to biomechanical cues within the tumor microenvironment. How this occurs and their implication upon osteosarcoma survival, remains poorly understood. Here, we show that IGF-1R can translocate into the nucleus, where it may act as part of a transcription factor complex. To explore the relationship between YAP/TAZ and total and nuclear phosphorylated IGF-1R (pIGF-1R), we evaluated sequential tumor sections from a 37-patient tissue microarray by confocal microscopy. Next, we examined the relationship between stained markers, clinical disease characteristics, and patient outcomes. The nuclear to cytoplasmic ratios (N:C ratio) of YAP and TAZ strongly correlated with nuclear pIGF-1R (r = 0.522, p = 0.001 for each pair). Kaplan-Meier analyses indicated that nuclear pIGF-1R predicted poor overall survival, a finding confirmed in the Cox proportional hazards model. Though additional investigation in a larger prospective study will be required to validate the prognostic accuracy of these markers, our results may have broad implications for the new class of YAP, TAZ, AXL, or TEAD inhibitors that have reached early phase clinical trials this year., Competing Interests: CONFLICTS OF INTEREST Authors have no conflicts of interest to declare., (Copyright: © 2022 Molina et al.)

Background: Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) are commonly performed in separate stages with a change in patient positioning to provide arthrodesis in the lumbar spine. Interest has emerged in performing these approaches as a single-stage surgery with the patient in the lateral decubitus position. The objective of this study was to evaluate the technical feasibility of performing minimally invasive anterolateral fixation in a single supine position., Methods: Two fresh-frozen cadavers were used and placed supine. Standard minimally invasive anterior access was obtained by the approach surgeon. ALIF was performed at L5-S1 using standard techniques. A lateral incision was marked over the L4-5 disc space using fluoroscopy. Direct palpation and bimanual dissection were achieved through the same anterior incision, allowing access to the retroperitoneal space. Dilator and retractor docking was performed under fluoroscopic guidance. Direct visualization of the docking hardware through the anterior incision was used to ensure the safety of peritoneal contents and vasculature. LLIF was then performed using standard techniques at L4-5., Results: Plain radiographs confirmed acceptable positioning of both ALIF and LLIF grafts. No injury to the cadaveric peritoneum, vasculature, or lumbar plexus was observed. A slightly enlarged anterior incision also permitted retroperitoneal access and visualization of the L3-4 disc space., Conclusions: This cadaveric feasibility study demonstrates that combined minimally invasive ALIF and LLIF may be performed as a single-stage procedure with the patient in the supine position. Clinical consideration and study of this approach are warranted., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Lateral lumbar interbody fusion (LLIF) via a transpsoas approach is a workhorse minimally invasive approach for lumbar arthrodesis that is often combined with posterior pedicle screw fixation. There has been increasing interest in performing single-position surgery, allowing access to the anterolateral and posterior spine without requiring patient repositioning. The feasibility of the transpsoas approach in patients in the prone position has been reported. Herein, the authors present a consecutive case series of all patients who underwent single-position prone transpsoas LLIF performed by an individual surgeon since adopting this approach., Methods: A retrospective review was performed of a consecutive case series of adult patients (≥ 18 years old) who underwent single-position prone LLIF for any indication between October 2019 and November 2020. Pertinent operative details (levels, cage use, surgery duration, estimated blood loss, complications) and 3-month clinical outcomes were recorded. Intraoperative and 3-month postoperative radiographs were reviewed to assess for interbody subsidence., Results: Twenty-eight of 29 patients (97%) underwent successful treatment with the prone lateral approach over the study interval; the approach was aborted in 1 patient, whose data were excluded. The mean (SD) age of patients was 67.9 (9.3) years; 75% (21) were women. Thirty-nine levels were treated: 18 patients (64%) had single-level fusion, 9 (32%) had 2-level fusion, and 1 (4%) had 3-level fusion. The most commonly treated levels were L3-4 (n = 15), L2-3 (n = 12), and L4-5 (n = 11). L1-2 was fused in 1 patient. The mean operative time was 286.5 (100.6) minutes, and the mean retractor time was 29.2 (13.5) minutes per level. The mean fluoroscopy duration was 215.5 (99.6) seconds, and the mean intraoperative radiation dose was 170.1 (94.8) mGy. Intraoperative subsidence was noted in 1 patient (4% of patients, 3% of levels). Intraoperative lateral access complications occurred in 11% of patients (1 cage repositioning, 2 inadvertent ruptures of anterior longitudinal ligament). Subsidence occurred in 5 of 22 patients (23%) with radiographic follow-up, affecting 6 of 33 levels (18%). Postoperative functional testing (Oswestry Disability Index, SF-36, visual analog scale-back and leg pain) identified significant improvement., Conclusions: This single-surgeon consecutive case series demonstrates that this novel technique is well tolerated and has acceptable clinical and radiographic outcomes. Larger patient series with longer follow-up are needed to further elucidate the safety profile and long-term outcomes of single-position prone LLIF.

Objectives  To better understand the risk-benefit profile of skull base meningioma resection in older patients, we compared perioperative complications among older and younger patients. Design  Present study is based on retrospective outcomes comparison. Setting  The study was conducted at a single neurosurgery institute at a quaternary center. Participants  All older (age ≥ 65 years) and younger (<65 years) adult patients treated with World Health Organization grade 1 skull base meningiomas (2008-2017). Main Outcome Measures  Perioperative complications and patient functional status are the primary outcomes of this study. Results  The analysis included 287 patients, 102 older and 185 younger, with a mean (standard deviation [SD]) age of 72 (5) years and 51 (9) years ( p  < 0.01). Older patients were more likely to have hypertension ( p  < 0.01) and type 2 diabetes mellitus ( p  = 0.01) but other patient and tumor factors did not differ ( p ≥ 0.14). Postoperative medical complications were not significantly different in older versus younger patients (10.8 [11/102] vs. 4.3% [8/185]; p  = 0.06) nor were postoperative surgical complications (13.7 [14/102] vs. 10.8% [20/185]; p  = 0.46). Following anterior skull base meningioma resection, diabetes insipidus (DI) was more common in older versus younger patients (14 [5/37] vs. 2% [1/64]; p  = 0.01). Among older patients, a decreasing preoperative Karnofsky performance status score independently predicted perioperative complications by logistic regression analysis ( p  = 0.02). Permanent neurologic deficits were not significantly different in older versus younger patients (12.7 [13/102] vs. 10.3% [19/185]; p  = 0.52). Conclusion  The overall perioperative complication profile of older and younger patients was similar after skull base meningioma resection. Older patients were more likely to experience DI after anterior skull base meningioma resection. Decreasing functional status in older patients predicted perioperative complications., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)