Development and Internal Validation of the ARISE Prediction Models for Rebleeding After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Aneurysmal rerupture is one of the most important determents for outcome after aneurysmal subarachnoid hemorrhage and still occurs frequently because individual risk assessment is challenging given the heterogeneity in patient characteristics and aneurysm morphology. OBJECTIVE: To develop and internally validate a practical prediction model to estimate the risk of aneurysmal rerupture before aneurysm closure. METHODS: We designed a multinational cohort study of 2 prospective hospital registries and 3 retrospective observational studies to predict the risk of computed tomography confirmed rebleeding within 24 and 72 hours after ictus. We assessed predictors with Cox proportional hazard regression analysis. RESULTS: Rerupture occurred in 269 of 2075 patients. The cumulative incidence equaled 7% and 11% at 24 and 72 hours, respectively. Our base model included hypertension, World Federation of Neurosurgical Societies scale, Fisher grade, aneurysm size, and cerebrospinal fluid drainage before aneurysm closure and showed good discrimination with an optimism corrected c-statistic of 0.77. When we extend the base model with aneurysm irregularity, the optimism-corrected c-statistic increased to 0.79. CONCLUSION: Our prediction models reliably estimate the risk of aneurysm rerupture after aneurysmal subarachnoid hemorrhage using predictor variables available upon hospital admission. An online prognostic calculator is accessible at https://www.evidencio.com/models/show/2626 .

Malpractice claims in spine surgery in Germany: a 5-year analysis.

STUDY DESIGN: Retrospective analysis of anonymized malpractice claims. SUMMARY OF BACKGROUND DATA: Spine surgery is considered a high-risk specialty with regards to malpractice claims. However, limited data is available for Germany. We analyzed the rate, subject, and legal outcome of malpractice claims faced by spine surgeons in one of the largest Medical Council coverage areas in Germany, representing 60,000 physicians and a population of 10 million. METHODS: Analysis of all malpractice claims regarding spinal surgeries completed by the Review Board of the North Rhine Medical Council (NRMC) from 2012 to 2016. Claim merit, content, and actual treatment errors were reviewed. Severity of damage was graded from negligible (1) to death (6). RESULTS: A total of 8,381 malpractice cases were reviewed by the NRMC from 2012 to 2016. Four percent (340 cases: 181 females, 159 males) pertained to patients undergoing spinal surgery with 94.7% of patients undergoing inhospital treatment and 5.3% as outpatients. Malpractice claims most frequently involved neurosurgery (48.5%) and orthopedic surgery (37.6%). Trauma surgery was involved in 9.1% and other specialties in 4.8%. Actual treatment errors were found in 89 of 340 cases (26.2%).Of those, 81 resulted in treatment-associated health impairment. Negligible and/or temporary impairment was found in 49.3%. Negligible to moderate but permanent damage was observed in 39.5%. Nine patients suffered severe permanent damage or death (11.1%). The treated diagnosis was degenerative disc disease in 34 patients (41.9%), spinal canal stenosis in 13 (16%), vertebral body fractures in 10 (12.3%), spondylolisthesis in 6 (7.4%), and other diagnoses accounting for the remaining 18 (22.2%). Errors involved actual surgical treatment in 40.7%, surgical indication and preoperative workup in 28.4%, postoperative treatment in 25.9%, and patient consent in 4.9%. CONCLUSIONS: Spinal surgery claims account for 4% of all claims reviewed by the NRMC in the 5-year period from 2012 to 2016. Eighty-nine (26.2%) were deemed justified. The majority of treatment errors (59.3%) occurred during workup, indication and consent, or during postoperative care. Errors during actual surgery were responsible for 40.7% of all treatment-associated damages. Understanding the distribution and content of claims is key to improving patient satisfaction not only by honing surgical skills, but also by improving pre- and postoperative communication and care.

Is it all a matter of size? Impact of maximization of surgical resection in cerebral tumors.

The oncological impact of cytoreductive surgery for malignant glioma has been analyzed in a few prospective, randomized studies; however, the impact of different cytoreductive surgical techniques of cerebral tumors remains controversial. Despite retrospective analyses revealing an oncological impact of complete surgical resection in cerebral metastases and low-grade glioma, the oncological impact of further extension of resection to a supramarginal resection remains disputable lacking high-grade evidence: supramarginal resections have yet to be analyzed in malignant glioma. Although extension of resection towards a supramarginal resection was thought to improve outcome and prevent malignant transformation in low-grade glioma, the rate of (temporary) deficits was higher than 50% in recent retrospective studies, and the oncological impact and long-term results have to be analyzed in further (prospective and controlled) studies. Cerebral metastases show a growth pattern different from glioma with less and more locally limited brain invasion. Therefore, local control may be achieved by extension of resection after complete lesionectomy of cerebral metastases. Therefore, supramarginal resection may be a promising approach but must be evaluated in further studies.

Mini Screws for Improving Accuracy in Navigation-assisted Spine Surgery.

STUDY DESIGN: Presentation of a surgical technique with accompanying video (Supplemental Digital Content 1, http://links.lww.com/CLINSPINE/A67) of an illustrative case. OBJECTIVE: The objective of this study was to present a helpful and easy-to-implement technique for improving initial referencing accuracy, as well as rereferencing accuracy in cases of multilevel instrumentation or in cases of dislocation of the reference array. SUMMARY OF BACKGROUND DATA: Navigation-assisted spine surgery has become standard of care in most hospitals performing complex spine interventions. Although short-segment instrumentations are fairly straight-forward with current hardware and software solutions, obtaining ideal accuracies and troubleshooting reference array disruptions remain challenging. METHODS: A surgical technique is presented as a step-by-step guide using intraoperative videos and photographs as well as imaging data in an illustrative case of thoracic hemivertebra resection and dorsal instrumentation. TECHNIQUE/RESULTS: After skin incision is performed at the index level, posterior soft tissue preparation is performed. Before firmly attaching the reference array to a spinous process we then insert a minimum of four 5 mm mini screws at any bony structure within the exposure. Then an intraoperative navigation scan (3-dimensional computed tomography or x-ray) is obtained, and initial referencing is performed using the previously inserted mini screws as landmarks. This yields mean accuracies of 1 mm or lower and is easily verifiable by placing the navigation probe on a mini screw head. This action can be swiftly repeated at any time to prevent reduced accuracy because of insertion forces applied during pedicle screw placement. In addition, this allows for easy rereferencing in cases of disruption or complete removal of the navigation array, eliminating the need to perform additional computed tomography or x-ray scans during the procedure. CONCLUSIONS: The technique presented allows for rapid and highly accurate initial referencing and can be used in all cases of navigation-assisted spine surgery. It also allows for hassle-free rereferencing in cases of disruption or accidental removal of the reference array.

First Clinical Applications of a High-Definition Three-Dimensional Exoscope in Pediatric Neurosurgery.

The ideal visualization tools in microneurosurgery should provide magnification, illumination, wide fields of view, ergonomics, and unobstructed access to the surgical field. The operative microscope was the predominant innovation in modern neurosurgery. Recently, a high-definition three-dimensional (3D) exoscope was developed. We describe the first applications in pediatric neurosurgery. The VITOM 3D exoscope (Karl Storz GmbH, Tuttlingen, Germany) was used in pediatric microneurosurgical operations, along with an OPMI PENTERO operative microscope (Carl Zeiss AG, Jena, Germany). Experiences were retrospectively evaluated with five-level Likert items regarding ease of preparation, image definition, magnification, illumination, field of view, ergonomics, accessibility of the surgical field, and general user-friendliness. Three operations were performed: supratentorial open biopsy in the supine position, infratentorial brain tumor resection in the park bench position, and myelomeningocele closure in the prone position. While preparation and image definition were rated equal for microscope and exoscope, the microscope's field of view, illumination, and user-friendliness were considered superior, while the advantages of the exoscope were seen in ergonomics and the accessibility of the surgical field. No complications attributed to visualization mode occurred. In our experience, the VITOM 3D exoscope is an innovative visualization tool with advantages over the microscope in ergonomics and the accessibility of the surgical field. However, improvements were deemed necessary with regard to field of view, illumination, and user-friendliness. While the debate of a "perfect" visualization modality is influenced by personal preference, this novel visualization device has the potential to become a valuable tool in the neurosurgeon's armamentarium.

Multidimensional long-term outcome analysis after single-level lumbar microdiscectomy: a retrospective single-centre study.

OBJECTIVE: To present multidimensional long-term results after mono-segmental microdiscectomy for lumbar disc herniation (LDH) in a large adult cohort treated at a tertiary care centre. METHODS: Retrospective study design with Oswestry Disability Index (ODI) questionnaire employed at follow-up. All patients undergoing surgical treatment for single-level LDH between 2003 and 2009 were identified. Electronic patient records and imaging data were analysed. RESULTS: A total of 939 patients underwent single-level lumbar MD at our institution. Three hundred and seven complete ODI forms (32.7%) were returned at a median follow-up of 48 months. Mean ODI score was 24.04, and mean age was 58 years. Females reported slightly higher ODI scores (25.52 vs. 22.68). Age and ODI score showed statistically significant correlation. Early surgery yielded lower ODI scores with patients faring significantly worse if symptoms persisted for a year or longer (one-way ANOVA, p < 0.001). ODI scores increased sharply even among those operated later than 1 week after symptom onset. Sequestered herniations were associated with significantly lower ODI scores than contained discs on MRI (21.96 vs. 39.89). Surgical complications occurred in 17 cases (5.6%), 82 patients (26.7%) required additional surgery, 58 (18.9%) of those for recurrent disc herniations. CONCLUSION: Our findings suggest better outcomes with early surgical treatments. Time limits for conservative treatments should be set to avoid the chronification of pain and the worse overall outcomes that go along with belated surgery. Particularly in those with acute onset of pain, sequestered herniations and only mild degrees of immobilization good outcomes are common and surgical treatment appears best if indicated early.

High-Frequency Spinal Cord Stimulation in Surgery-Naïve Patients-A Prospective Single-Center Study.

INTRODUCTION: A multitude of evidence supporting the beneficial effects of spinal cord stimulation (SCS) in patients suffering from chronic pain syndromes following spinal surgery has been published in the last decade. Evidence is scarce, however, for the use of high frequency SCS (HF-SCS) in the treatment of surgery naïve patients suffering from lower back pain (LBP). METHODS: From June 2014 to April 2015, we prospectively enrolled patients suffering from LBP alone or in conjunction with leg pain in a trial of HF-SCS. None of the patients had undergone surgical procedures of the lumbar spine. Patients suffered medically intractable LBP and were deemed ineligible for spine surgery. All patients underwent trial stimulation for at least one week. Pain levels were assessed daily during initial stay, 4 weeks later and then every 3 months. Different preprogrammed modes of HF-SCS were changed if pain persisted or increased during trial or postimplant follow-up (FU). RESULTS: Eight patients (four male, four female) underwent HF-SCS trials. Mean age was 60 ± 4.8 years. Mean numeric rating scale (NRS) baseline intensity for back pain was 8.9 ± 0.23 and 8.1 ± 0.6 for leg pain. All patients achieved meaningful reductions in pain intensities and underwent IPG implantation at a mean interval of 13 days. Mean follow-up was 306 days. Mean back pain reduction from baseline at last follow-up was -4.13 ± 0.85, and -6.2 ± 1.03 for leg pain. Two patients showed skin irritations and localized pain at the IPG site. Both patients underwent surgery to replant the IPG. No infections were seen in any of the eight patients enrolled. CONCLUSIONS: In this prospective cohort of surgery naïve patients, we were able to show good efficacy of HF-SCS with mean NRS reductions of 4.13 and 6.2 for back and leg pain, respectively, after a mean follow-up of 10 months.

Early surgical occipitocervical stabilization for plasma cell neoplasms at the craniocervical junction: systematic review and proposal of a treatment algorithm.

BACKGROUND CONTEXT: Plasma cell neoplasms (PCNs) of the craniocervical junction (CCJ) are rare. Because of their destructive growth, PCNs may induce spinal instability and harbor the risk of sudden death. Therefore, PCNs at the CCJ require special consideration. Although the commonly used primary treatment of PCN is radiotherapy (RT), treatment guidelines are inexistent for CCJ occurrences. PURPOSE: This study aimed to conduct a systematic review of the literature, evaluate the benefit of early and extended surgical treatment followed by RT, and outline a treatment algorithm based on the data gathered. STUDY DESIGN/SETTING: Case series and systematic review of all reported cases in the English, Spanish and German medical literature were carried out. CASE SERIES: retrospective clinical study, tertiary care center (2004-2014). Patients with a lesion of the CCJ (C0-C2) were identified. Clinical charts, imaging data, operative reports, and follow-up data were analyzed. REVIEW: a systematic literature review was performed using PubMed. Further manuscripts were identified by the web search engine Google. RESULTS: Our series comprised four patients (one female, three males), mean age 58 years. There was one lesion of C1 and three of C2. Two patients with neck pain received vertebroplasty (C1 and C2, respectively) and RT as primary management. Both developed secondary instability of the CCJ after 12 and 5 months, respectively, and required occipitocervical stabilization (OCS). The other two patients underwent OCS and required no additional surgery and no signs of instability at follow-up. Forty-nine cases of OCS were published previously. Spinal stability was achieved significantly more frequently by OCS than by less invasive or medical interventional treatment options (p=.001; two-sided Fisher exact test). CONCLUSIONS: Plasma cell neoplasms are highly radiosensitive. However, at the CCJ, a life-threatening instability may occur early and require surgical treatment. Based on personal experience, we favor OCS in this location. A systematic review of the literature supports this approach. We present a summary of our findings in a concise treatment algorithm for PCN of the CCJ.

Attenuation of vesicular stomatitis virus infection of brain using antiviral drugs and an adeno-associated virus-interferon vector.

Vesicular stomatitis virus (VSV) shows promise as a vaccine-vector and oncolytic virus. However, reports of neurotoxicity of VSV remain a concern. We compared 12 antiviral compounds to control infection of VSV-CT9-M51 and VSV-rp30 using murine and human brain cultures, and in vivo mouse models. Inhibition of replication, cytotoxicity and infectivity was strongest with ribavirin and IFN-α and to some extent with mycophenolic acid, chloroquine, and adenine 9-ß-d-arabinofuranoside. To generate continuous IFN exposure, we made an adeno-associated virus vector expressing murine IFN; AAV-mIFN-ß protected mouse brain cells from VSV, as did a combination of IFN, ribavirin and chloroquine. Intracranial AAV-mIFN-ß protected the brain against VSV-CT9-M51. In SCID mice bearing human glioblastoma, AAV-mIFN-ß moderately enhanced survival. VSV-CT9-M51 doubled median survival when administered after AAV-mIFN-ß; some surviving mice showed complete tumor destruction. Together, these data suggest that AAV-IFN or IFN with ribavirin and chloroquine provide an optimal anti-virus combination against VSV in the brain.

Marking wire placement for improved accuracy in thoracic spinal surgery.

OBJECTIVE: To present an innovative approach that does not rely on intraoperative X-ray imaging for identifying thoracic target levels and critically appraise its value in reducing the risk of wrong-level surgery and radiation exposure. METHODS: 96 patients admitted for surgery of the thoracic spine were prospectively enrolled, undergoing a total of 99 marking wire placements. Preoperatively a flexible marking wire derived from breast cancer surgery was inserted with computed tomography (CT) guidance at the site of interest--the wire was then used as an intraoperative guidance tool. RESULTS: Wire placement was considered successful in 96 cases (97%). Most common pathologies were tumors (62.5%) and degenerative disorders (16.7%). Effective doses from CT imaging were significantly higher for wire placements in the upper third of the thoracic spine compared to the lower two thirds (p = 0.015). Radiation exposure to operating room personnel could be reduced by more than 90% in all non-instrumented cases. No adverse reactions were observed, one patient (1.04%) underwent surgical revision due to an epifascial empyema. No wires had to be removed due to lack of patient compliance or infection. CONCLUSIONS: This is a safe and practical approach to identify the level of interest in thoracic spinal surgery employing a marking wire. Its application merits consideration in any spinal case where X-ray localization could prove unsafe, particularly in cases lacking bony pathologies such as intradural tumors.

Primary spinal marginal zone lymphoma: case report and review of the literature.

BACKGROUND AND IMPORTANCE: Marginal zone lymphoma (MZL) describes a heterogeneous group of indolent B-cell lymphomas. The World Health Organization recognizes 3 types of MZLs: splenic MZL, nodal MZL, and extranodal MZL of mucosa-associated lymphoid tissue. There is no consensus on the optimal adjuvant treatment modalities for intracranial primary MZLs. To date, no case of spinal primary MZL has been reported. CLINICAL PRESENTATION: We present the first case of spinal MZL diagnosed in a 65-year-old man with progressive paraparesis. He underwent surgical removal of the main spinal tumor mass, which extended epidurally from vertebral body T3 to T7. Surgery was followed by 10 sessions of local irradiation for a total dose of 31 Gy. On long-term follow-up in 2010, the patient was in good health without any signs of residual or recurrent disease. Twenty-seven publications reporting on 61 cases of intracranial primary MZL were identified and reviewed. In the majority of cases of marginal zone B-cell lymphoma, adjuvant radiotherapy was used, with some combining radiotherapy and chemotherapy after surgical removal of the bulk of the main tumor. Long-term follow-up in most patients showed no evidence of disease and clinical well-being years after the initial diagnosis. CONCLUSION: Chemotherapy and/or radiation have been used in larger case series. Although there is no defined treatment guideline for this rare disease entity, our review of the literature suggests a favorable prognosis when combining surgical and adjuvant radiotherapy approaches.

Spinal cord tethering following myelomeningocele repair.

OBJECT: Symptom response to spinal cord untethering, and the impact of duraplasty and scoliosis on retethering, are poorly understood in tethering after myelomeningocele (MMC) repair. In this retrospective study, the authors examined the outcomes of children who developed first-time spinal cord tethering following MMC repair. The response of symptoms to untethering and the role of duraplasty and scoliosis in retethering are explored. METHODS: The authors performed a review of 54 children with first-time symptomatic spinal cord tethering following MMC repair to determine the impact of untethering on symptoms, the impact of dural repair type on retethering, and the role of scoliosis on the prevalence and time to retethering. RESULTS: The average patient age was 10.3 ± 4.9 years, and 44% were males. The most common presenting symptoms of tethered cord syndrome were urinary (87%), motor (80%), gait (78%), and sensory (61%) dysfunction. The average postoperative time to symptom improvement was 2.02 months for sensory symptoms, 3.21 months for pain, 3.50 months for urinary symptoms, and 4.48 months for motor symptoms, with sensory improvement occurring significantly earlier than motor improvement (p = 0.02). At last follow-up (an average of 47 months), motor symptoms were improved in 26%, maintained in 62%, and worsened in 11%; for sensory symptoms, these rates were 26%, 71%, and 3%, respectively; for pain, 28%, 65%, and 7%, respectively; and for urinary symptoms, 17%, 76%, and 7%, respectively. There was no difference in symptom response with type of dural repair (primary closure vs duraplasty). Symptomatic retethering occurred in 17 (31%) of 54 patients, but duration of symptoms, age at surgery, and type of dural repair were not associated with retethering. Scoliosis was not associated with an increased prevalence of retethering, but was associated with significantly earlier retethering (32.5 vs 61.1 months; p = 0.042) in patients who underwent additional untethering operations. CONCLUSIONS: Symptomatic retethering is a common event after MMC repair. In the authors' experience, sensory improvements occur sooner than motor improvements following initial untethering. Symptom response rates were not altered by type of dural closure. Scoliosis was associated with significantly earlier retethering and should be kept in mind when caring for individuals who have had previous MMC repair.

Detailed long-term outcome analysis after decompressive craniectomy for severe traumatic brain injury.

OBJECTIVE: To assess detailed long-term clinical outcome at least 1 year after decompressive craniectomy (DC) in patients with severe traumatic brain injury (TBI). METHODS: One hundred and thirty-one patients with severe TBI underwent DC between September 1997 and September 2005. Outcome was measured using the Glasgow Outcome Scale (GOS). Detailed outcome analysis was performed using Glasgow Outcome Scale Extended, Short-Form 36 (SF-36), Beck Depression Inventory, Trail Making Test B (TMT-B), Digit-Symbol Test (DST) and Barthel Index (BI). RESULTS: Sixty-three patients (48.1%) died during their initial hospital stay, 27 (20.6%) were discharged in a vegetative state, 32 (24.4%) with severe disability and nine (6.9%) with moderate disability (GOS 3 and 4, respectively). At time of follow-up 75 patients (67.7%) were either dead or in a vegetative state. Thirty patients with GOS >2 were recruited for a detailed outcome analysis: Major depression, neurologic deficits and impaired TMT-B and DST performances were common and significantly more prevalent than in normative controls. Yet, patients reported only modestly reduced SF-36 and high BI scores. CONCLUSIONS: Despite multiple health-related problems after DC, many patients proved highly functional in activities of daily living and reported qualities of life not significantly inferior to that of healthy individuals. Depression was common and requires to be addressed with patients and caregivers. Better targeted therapies could improve neuropsychological and psychiatric outcomes in this complex cohort.

Peripheral immunization blocks lethal actions of vesicular stomatitis virus within the brain.

Vesicular stomatitis virus (VSV) is the prototype virus for 75 or more negative-strand RNA viruses in the rhabdovirus family. Some of these viruses, including VSV, can cause neurological impairment or death upon brain infection. VSV has shown promise in the prevention and treatment of disease as a vaccine vector and an oncolytic virus, but infection of the brain remains a concern. Three VSV variants, the wild-type-related VSV-G/GFP and two attenuated viruses, VSV-CT1 and VSV-CT9-M51, were compared for neuroinvasiveness and neuromorbidity. In nonimmunized mice, direct VSV-G/GFP injection into the brain invariably resulted in lethal encephalitis; in contrast, partial survival was seen after direct injection of the attenuated VSV strains. In addition, both attenuated VSV strains showed significantly reduced neuroinvasiveness after intranasal inoculation of young postnatal day 16 mice. Of the three tested variants, VSV-CT9-M51 generated the lowest degree of neuropathology. Despite its attenuated state, peripheral inoculations of VSV-CT9-M51 targeted and killed human glioblastoma implanted into the mouse brain. Importantly, we show here that intranasal or intramuscular immunization prevents the lethal effects of subsequent VSV-G/GFP, VSV-CT1, and VSV-CT9-M51 injections into the brain. These results indicate that attenuated recombinant viruses show reduced neurovirulence and that peripheral immunization blocks the lethal actions of all VSVs tested.

Intratentorial osteochondrolipoma in a 9-year-old boy.

Intracranial osteolipomas and chondromas are rare benign tumors. Forty-five chondromas, mostly supratentorial, have been reported in the literature since 1981, with origins most commonly in the sellar regions. Twenty-one osteolipomas have been described to date, usually located near the tuber cinereum or the corpus callosum. The authors present a case of an osteochondrolipoma arising from the tentorium diagnosed in a pediatric patient at the age of 9 years. The case and treatment are discussed, and a review of the literature is provided.