Parenthood and neurosurgery in Europe, a white paper from the European association of neurosurgical societies' diversity in neurosurgery committee, part II - practice with children.

Introduction: In the first part of this White Paper, the European Association of Neurosurgical Societies (EANS) Diversity in Neurosurgery Committee (DC) addressed the obstacles faced by neurosurgeons when planning to have a family and practice during pregnancy, attempting to enumerate potential, easily implementable solutions for departments to be more family-friendly and retain as well as foster talent of parent-neurosurgeons, regardless of their gender identity and/or sexual orientation. Attrition avoidance amongst parent-neurosurgeons is at the heart of these papers. Research question: In this second part, we address the obstacles posed by practice with children and measures to mitigate attrition rates among parent-neurosurgeons. For the methodology employed to compose this White Paper, please refer to Supplementary Electronic Materials (SEM) 1. Materials and methods: For composing these white papers, the European Association of Neurosurgical Societies (EANS)'s Diversity Committee (DC) recruited neurosurgeon volunteers from all member countries, including parents, aspiring parents, and individuals without any desire to have a family to create a diverse and representative working group (WG). Results: In spite of the prevailing heterogeneity in policies across the continent, common difficulties can be identified for both mothers and fathers considering the utilization of parental leave. Discussion and conclusion: Reconciliation of family and a neurosurgical career is challenging, especially for single parents. However, institutional support in form of childcare facilities and/or providers, guaranteed lactation breaks and rooms, flexible schedule models including telemedicine, and clear communication of policies can improve working conditions for parent-neurosurgeons, avoid their attrition, and foster family-friendly work environments.

Changes in frailty among patients hospitalized for spine pathologies during the COVID-19 pandemic in Germany-a nationwide observational study.

PURPOSE: In spine care, frailty is associated with poor outcomes. The aim of this study was to describe changes in frailty in spine care during the coronavirus disease 2019 (COVID-19) pandemic and their relation to surgical management and outcomes. METHODS: Patients hospitalized for spine pathologies between January 1, 2019, and May 17, 2022, within a nationwide network of 76 hospitals in Germany were retrospectively included. Patient frailty, types of surgery, and in-hospital mortality rates were compared between pandemic and pre-pandemic periods. RESULTS: Of the 223,418 included patients with spine pathologies, 151,766 were admitted during the pandemic and 71,652 during corresponding pre-pandemic periods in 2019. During the pandemic, the proportion of high-frailty patients increased from a range of 5.1-6.1% to 6.5-8.8% (p < 0.01), while the proportion of low frailty patients decreased from a range of 70.5-71.4% to 65.5-70.1% (p < 0.01). In most phases of the pandemic, the Elixhauser comorbidity index (ECI) showed larger increases among high compared to low frailty patients (by 0.2-1.8 vs. 0.2-0.8 [p < 0.01]). Changes in rates of spine surgery were associated with frailty, most clearly in rates of spine fusion, showing consistent increases among low frailty patients (by 2.2-2.5%) versus decreases (by 0.3-0.8%) among high-frailty patients (p < 0.02). Changes in rates of in-hospital mortality were not associated with frailty. CONCLUSIONS: During the COVID-19 pandemic, the proportion of high-frailty patients increased among those hospitalized for spine pathologies in Germany. Low frailty was associated with a rise in rates of spine surgery and high frailty with comparably larger increases in rates of comorbidities.

Does the interfacing angle between pedicle screws and support rods affect clinical outcomes after posterior thoracolumbar fusion? A retrospective clinical study.

BACKGROUND CONTEXT: Proper alignment and tightening of the pedicle screw/rod assembly after instrumented posterior fusion of the lower spine is known to be crucial in order to achieve satisfactory clinical results. Such interfacing angle mismatches indicate stress overloading of the implant system. PURPOSE: The objective of this study is to investigate the incidence of postoperative screw/rod interfacing angle mismatch and to analyze the impact of mismatches on clinical outcome in terms of (1) revision surgery, (2) adjacent segment degeneration (ASD), and (3) pain. STUDY DESIGN: This is a monocentric retrospective observational study. PATIENT SAMPLE: Patients underwent fusion surgery with pedicle screw/rod systems for predominantly degenerative pathologies. OUTCOME MEASURES: Pedicle screw/rod interfacing angle mismatch (mismatch is the angular deviation from 90° formed by the rod axis and the pedicle screw head axis as an indicator for missing form-fit) revision rate, ASD at the immediately adjacent cranial segment and VAS pain. METHODS: Revision refers to subsequent procedures in which all or part of the original implant configuration is changed or removed. Radiographic parameters are evaluated using a/p and lateral radiographs at final follow-up. The interfacing angle mismatch between pedicle screw and rod is measured as the angle between two parallel lines on either side of each pedicle screw head and a line laterally along the associated rod. Multiple comparisons are counteracted by Bonferroni correction, adjusted significance level is at *p<.01. RESULTS: Pedicle screw and rod interfacing angle mismatch was found in 171/406 (42.1%) of patients undergoing fusion surgery, affecting 613/3016 (20.3%) screws. The overall revision incidence was 11.8% (48/406), and a new ASD occurred in 12.1% of all patients (49/406) with an average follow-up of 5 years. Mean VAS pain score at final follow-up was 2.0. Comparison of the two groups with and without mismatches revealed statistically significantly higher (1) numbers of revision procedures performed (26.9% vs 0.9%), (2) numbers of new ASD developed (27.5% vs 3.8%), and (3) higher VAS pain scores (2.8/10 vs 1.4/10) for cases with mismatch. When comparing patients who underwent intraoperative correction and/or reduction with those who did not, statistically significant more screw mismatches (63.4% vs 39.7%) and revision surgeries (29.3% vs 9.9%) were noted in patients who had these forceful maneuvers. CONCLUSIONS: Pedicle screw/rod interfacing angle mismatch is a frequent occurrence after fusion surgery. Mismatches indicate that the construct was assembled under mechanical stress. All preventable mechanical stresses, for example, unintentional uncontrolled forces on the instrumentation, should be avoided as much as possible, as they can negatively influence the clinical outcome.

Trends in frailty in brain tumor care during the COVID-19 pandemic in a nationwide hospital network in Germany.

PURPOSE: Among brain tumor patients, frailty is associated with poor outcomes. The COVID-19 pandemic has led to increased frailty in the general population. To date, evidence on changes in frailty among brain tumor patients during the pandemic is lacking. We aimed to compare frailty among brain tumor patients in Germany during the COVID-19 pandemic to the pre-pandemic era and to assess potential effects on brain tumor care. METHODS: In this retrospective observational study, we compared frailty among brain tumor patients hospitalized during the COVID-19 pandemic in years 2020 through 2022 to pre-pandemic years 2016 through 2019 based on administrative data from a nationwide network of 78 hospitals in Germany. Using the Hospital Frailty Risk Score (HFRS), frailty was categorized as low, intermediate, or high. We examined changes in frailty, patient demographics, the burden of comorbidity, rates of surgery, and mortality rates for different frailty groups during the pandemic and compared them to pre-pandemic levels. RESULTS: Of the 20,005 included hospitalizations for brain tumors, 7979 were during the pandemic (mean age 60.0 years (± 18.4); females: 49.8%), and 12,026 in the pre-pandemic period (mean age: 59.0 years [± 18.4]; females: 49.2%). Average daily admissions decreased from 8.2 (± 5.1) during pre-pandemic years to 7.3 (± 4.5) during the pandemic (p < 0.01). The overall median HFRS decreased from 3.1 (IQR: 0.9-7.3) during the pre-pandemic years to 2.6 (IQR: 0.3-6.8) during the pandemic (p < 0.01). At the same time, the Elixhauser Comorbidity Index (ECI) decreased from 17.0 (± 12.4) to 16.1 (± 12.0; p < 0.01), but to a larger degree among high compared to low frailty cases (by 1.8 vs. 0.3 points; p = 0.04). In the entire cohort, the mean length of stay was significantly shorter in the pandemic period (9.5 days [± 10.7]) compared with pre-pandemic levels (10.2 days [± 11.8]; p < 0.01) with similar differences in the three frailty groups. Rates of brain tumor resection increased from 29.9% in pre-pandemic years to 36.6% during the pandemic (p < 0.001) without differences between frailty levels. Rates of in-hospital mortality did not change during the pandemic (6.1% vs. 6.7%, p = 0.07), and there was no interaction with frailty. CONCLUSION: Even though our findings are limited in that the HFRS is validated only for patients ≥ 75 years of age, our study among patients of all ages hospitalized for brain tumors in Germany suggests a marked decrease in levels of frailty and in the burden of comorbidities during the COVID-19 pandemic.

Incidence and outcome of patients suffering from meningitis due to spondylodiscitis.

Introduction: Meningitis is a rare but severe complication in patients with spondylodiscitis. Data about the incidence and clinical management are rare. Research question: Aim of this study was to assess the incidence, clinical course and outcome of patients suffering from meningitis due to spondylodiscitis. Material and methods: We performed a retrospective analysis of our prospective clinical database that included all patients suffering from spondylodiscitis between January 2010 and December 2019 were included. We assessed clinical findings, laboratory tests, treatment and outcome comparing patients with and without meningitis. Results: Out of 469 patients suffering from spondylodiscitis, 30 patients (14 female) were diagnosed with an associated meningitis (6.4%). The mean CSF cell count was 3375.85 ± 8486.78/µl (range 32-41500/µl). The mean age at presentation was 70.87 ± 8.84 yrs (range 48-88 yrs). Mean C-reactive protein (CRP) and white blood cell (WBC) counts at time of admission were statistically higher in patients with associated meningitis (CRP: 19.81 ± 12.56 mg/dl vs. 11.63 ± 11.08 mg/dl, p = 0.001; WBC: 14.67 ± 7.76 g/l vs. 10.88 ± 05.11 g/l, p = 0.005. Mortality was also higher, as 13.3% and 7.1% of patients with and without concomitant meningitis died, respectively. Conclusion: Bacterial meningitis due to spondylodiscitis is a rare but severe condition and is associated with higher morbidity and mortality rates. In patients with spondylodiscitis presenting with an altered state of consciousness an associated meningitis should be ruled out.

Parenthood and neurosurgery in Europe a white paper from the European Association of Neurosurgical Societies' Diversity in Neurosurgery Committee Part I - Family Planning and Practice during Pregnancy.

Introduction: Family and work have immensely changed and become intertwined over the past half century for both men and women. Additionally, alongside to traditional family structures prevalent, other forms of families such as single parents, LGBTQ + parents, and bonus families are becoming more common. Previous studies have shown that surgical trainees regularly leave residency when considering becoming a parent due to the negative stigma associated with pregnancy during training, dissatisfaction with parental leave options, inadequate lactation and childcare support, and desire for greater mentorship on work-life integration. Indeed, parenthood is one of the factors contributing to attrition in surgical specialities, neurosurgery not being an exception. Research question: The Diversity in Neurosurgery Committee (DC) of the European Association of Neurosurgical Societies (EANS) recognizes the challenges individuals face in parenthood with neurosurgery and wishes to address them in this white paper. Materials and methods: In the following sections, the authors will focus on the issues pertaining to family planning and neurosurgical practice during pregnancy in itemized fashion based on an exhaustive literature search and will make recommendations to address the matters raised. Results: Potential solutions would be to further improve the work-family time ration as well as improving working conditions in the hospital. Discussion and conclusion: While many obstacles have been quoted in the literature pertaining to parenthood in medicine, and in neurosurgery specifically, initiatives can and should be undertaken to ensure not only retention of colleagues, but also to increase productivity and job satisfaction of those seeking to combine neurosurgery and a family life, regardless of their sexual identity and orientation.

Women in leadership positions in European neurosurgery - Have we broken the glass ceiling?

Introduction: The proportion of male neurosurgeons has historically been higher than of women, although at least equal numbers of women have been entering European medical schools. The Diversity Committee (DC) of the European Association of Neurosurgical Societies (EANS) was founded recently to address this phenomenon. Research question: In this cross-sectional study, we aimed to characterize the status quo of female leadership by assessing the proportion of women heading European neurosurgical departments. Material and methods: European neurosurgical departments were retrieved from the EANS repository. The gender of all department chairs was determined via departmental websites or by personal contact. The proportion of females was stratified by region and by type of hospital (university versus non-university). Results: A total of 41 (4.3%) female department chairs were identified in 961 neurosurgery departments in 41 European countries. Two thirds (68.3%) of European countries do not have a female neurosurgery chair. The highest proportion of female chairs was found in Northern Europe (11.1%), owing to four female chairs in a relatively small number of departments (n = 36). The proportions were considerably smaller in Western Europe (n = 17/312 (5.5%)), Southern Europe (n = 14/353 (4.0%)) and Central and Eastern Europe (n = 6/260 (2.3%)) (p = 0.06). The distribution of female chairs in university (n = 19 (46.3%)) versus non-university departments (n = 22 (53.7%)) was even. Discussion and Conclusion: There is a significant gender imbalance with 4% of all European neurosurgery departments headed by women. The DC intends to develop strategies to support equal chances and normalize the presence of female leaders in European neurosurgery.

Neurosurgical care for patients with high-grade gliomas during the coronavirus disease 2019 pandemic: Analysis of routine billing data of a German nationwide hospital network.

Background: Little is known about delivery of neurosurgical care, complication rate and outcome of patients with high-grade glioma (HGG) during the coronavirus disease 2019 (Covid-19) pandemic. Methods: This observational, retrospective cohort study analyzed routine administrative data of all patients admitted for neurosurgical treatment of an HGG within the Helios Hospital network in Germany. Data of the Covid-19 pandemic (March 1, 2020-May 31, 2022) were compared to the pre-pandemic period (January 1, 2016-February 29, 2020). Frequency of treatment and outcome (in-hospital mortality, length of hospital stay [LOHS], time in intensive care unit [TICU] and ventilation outside the operating room [OR]) were separately analyzed for patients with microsurgical resection (MR) or stereotactic biopsy (STBx). Results: A total of 1763 patients underwent MR of an HGG (648 patients during the Covid-19 pandemic; 1115 patients in the pre-pandemic period). 513 patients underwent STBx (182 [pandemic]; 331 patients [pre-pandemic]). No significant differences were found for treatment frequency (MR: 2.95 patients/week [Covid-19 pandemic] vs. 3.04 patients/week [pre-pandemic], IRR 0.98, 95% CI: 0.89-1.07; STBx (1.82 [Covid-19 pandemic] vs. 1.86 [pre-pandemic], IRR 0.96, 95% CI: 0.80-1.16, P > .05). Rates of in-hospital mortality, infection, postoperative hemorrhage, cerebral ischemia and ventilation outside the OR were similar in both periods. Overall LOHS was significantly shorter for patients with MR and STBx during the Covid-19 pandemic. Conclusions: The Covid-19 pandemic did not affect the frequency of neurosurgical treatment of patients with an HGG based on data of a large nationwide hospital network in Germany. LOHS was significantly shorter but quality of neurosurgical care and outcome was not altered during the Covid-19 pandemic.

Decompressive Surgery in the Treatment of Acute Ischemic Stroke during the First Four Waves of the COVID-19 Pandemic in Germany: A Nationwide Observational Cohort Study.

BACKGROUND: The COVID-19 pandemic has significantly affected acute ischemic stroke (AIS) care. In this study, we examined the effects of the pandemic on neurosurgical AIS care by means of decompressive surgery (DS). METHODS: In this retrospective observational study, we compared the characteristics, in-hospital processes, and in-hospital mortality rates among patients hospitalized for AIS during the first four waves of the pandemic (between January 1, 2020 and October 26, 2021) versus the corresponding periods in 2019 (prepandemic). We used administrative data from a nationwide hospital network in Germany. RESULTS: Of the 177 included AIS cases with DS, 60 were from 2019 and 117 from the first four pandemic waves. Compared with the prepandemic levels, there were no changes in weekly admissions for DS during the pandemic. The same was true for patient age (range: 51.7-60.4 years), the number of female patients (range: 33.3-57.1%), and the prevalence of comorbidity, as measured by the Elixhauser Comorbidity Index (range: 13.2-20.0 points). Also, no alterations were observed in transfer to the intensive care unit (range: 87.0-100%), duration of in-hospital stay (range: 14.6-22.7 days), and in-hospital mortality rates (range: 11.8-55.6%). CONCLUSION: In Germany, compared with the prepandemic levels, AIS patients undergoing DS during the first four waves of the pandemic showed no changes in demographics, rates of comorbidity, and in-hospital mortality rates. This is in contrast to previous evidence on patients with less critical types of AIS not requiring DS and underlines the uniqueness of the subgroup of AIS patients requiring DS. Our findings suggests that these patients, in contrast to AIS patients in general, were unable to forgo hospitalization during the COVID-19 pandemic. Maintaining the delivery of DS is an essential aspect of AIS care during a pandemic.

Effects of the COVID-19 Pandemic on Spinal Fusion Procedures for Spinal Infections in a Nationwide Hospital Network in Germany.

BACKGROUND: The full impact of the COVID-19 pandemic on surgical spine care is difficult to assess due to a lack in nationwide evidence from more recent phases of the pandemic. We aimed to describe changes in in-hospital processes associated with spinal fusion procedures in the treatment of spinal infections (SI) during different phases of the pandemic. METHODS: In this retrospective observational study, we examined the in-hospital prevalence and outcomes of spinal fusion procedures for SI (along with patient characteristics, rates of transfer to intensive care units, and mortality rates) during the first four waves of the pandemic compared with the corresponding prepandemic periods in 2019. We used administrative data from a nationwide network of 76 hospitals managing 7% of all in-hospital cases in Germany. RESULTS: We observed no significant change in the prevalence of SI fusion procedures during the pandemic, neither in total numbers (349 vs. 373) nor for each wave separately. On a patient level, we found no differences in age, sex, and the prevalence of paresis, and no relevant differences in associated comorbidities. The rate of mechanical ventilation did not change during any of the examined pandemic waves: it ranged between 9.5 and 18.6% during the pandemic and 3.1 and 16.0% during the corresponding prepandemic control periods. The rate of transfer to intensive care changed only during wave 4 (from 70.4 to 54.8%; p = 0.046) but not in any other pandemic phases. We observed no changes in in-hospital mortality rates (range: 2.9-9.7% vs. 6.2-11.3%) or in duration of hospital stay (range: 26.2-30.8 days vs. 20.8-29.2 days). CONCLUSIONS: The main finding of our study is that within this nationwide network of spine care centers in Germany, the delivery of surgical treatment of SI by means of spinal fusion procedures was maintained throughout the first four waves of the pandemic. Furthermore, there were no relevant changes in patient demographics, in-hospital processes, and mortality rates.

CFR-PEEK Pedicle Screw Instrumentation for Spinal Neoplasms: A Single Center Experience on Safety and Efficacy.

(1) Background: Surgery for spinal metastases has gained a decisive role in modern oncological treatment. Recently, carbon-fiber-reinforced (CFR) polyethyl-ether-ether-ketone (PEEK) pedicle screw systems were introduced, reducing artifacts on imaging and showing less perturbation effects on photon radiation. Preliminary clinical experience with CFR-PEEK implants for spinal metastases exists. The aim of this monocentric study is to report on the safety and efficacy of CFR-PEEK pedicle screw systems for spinal neoplasms in a large cohort of consecutive patients. (2) Methods: We retrospectively analyzed prospectively the collected data of consecutive patients being operated on from 1 August 2015 to 31 October 2021 using a CFR-PEEK pedicle screw system for posterior stabilization because of spinal metastases or primary bone tumors of the spine. (3) Results: We included 321 patients of a mean age of 65 ± 13 years. On average, 5 ± 2 levels were instrumented. Anterior reconstruction was performed in 121 (37.7%) patients. Intraoperative complications were documented in 30 (9.3%) patients. Revision surgery for postoperative complications was necessary in 55 (17.1%) patients. Implant-related complications, such as intraoperative screw breakage (3.4%) and screw loosening (2.2%), were rare. (4) Conclusions: CFR-PEEK is a safe and efficient alternative to titanium for oncological spinal instrumentation, with low complication and revision rates in routine use and with the advantage of its radiolucency.

Primary Bone Tumors of the Spine-Proposal for Treatment Based on a Single Centre Experience.

This study reports a large single-center series of primary bone tumors of the spine (PBTs). We aimed to review the concepts for management, as this kind of tumor represents a very rare entity, and also propose a new treatment algorithm. Retrospective analysis revealed 92 patients receiving surgery for PBTs from 2007 to 2019 at our center. They were analyzed based on surgical management and the course of the disease. A total of 145 surgical procedures were performed (50 cervical, 46 thoracic, 28 lumbar, and 21 sacral). Complete tumor resection was achieved in 65%, of which 22% showed tumor recurrence during follow-up (mean time to recurrence 334 days). The five-year mortality rate was significantly lower after complete resection (3% versus 25% after subtotal resection). Most of the patients improved in their symptoms through surgery. Regarding the tumor entity, the most common PBTs were vertebral hemangiomas (20%), osteoid osteomas (15%), and chordomas (16%). The Enneking graduation system showed a good correlation with the risk of recurrence and mortality. Complete resection in PBTs increased survival rates and remains the method of choice. Thus, quality of life-especially with a higher extent of resection-should be considered.

Spinal Lesions as Clinical Manifestations of Plasma Cell Neoplasia.

(1) Background: Plasma cell neoplasia can be separated into independent subtypes including multiple myeloma (MM) and solitary plasmacytoma of the bone (SBP). The first clinical signs patients present with are skeletal pain, most commonly involving ribs and vertebrae. (2) Methods: Retrospective analysis of 114 patients (38 female, 76 male) receiving spinal surgery from March 2006 until April 2020. Neurological impairments and surgical instability were the criteria for intervention in this cohort. Analysis was based on demographic data, Spinal Instability Neoplastic Score (SINS), location of the lesion, spinal levels of tumor involvement, surgical treatment, histopathological workup, adjuvant therapy, functional outcome, and overall survival (OS). (3) Results: The following surgical procedures were performed: posterior stabilization only in 9 patients, posterior stabilization and decompression without vertebral body replacement in 56 patients, tumor debulking and decompression only in 8 patients, anterior approach in combined approach without vertebral body replacement and without biopsy and/or without kyphoplasty in 33 patients, 3 patients received biopsies only, and 5 patients received kyphoplasty only. The histopathology diagnoses were MM in 94 cases and SBP in 20 cases. Median OS was 72 months (53.4-90.6 months). Preoperative KPSS was 80% (range 40-100%), the postoperative KPSS was 80% (range 50-100%). (4) Conclusions: Surgery for patients with plasma cell neoplasia is beneficial in case of neurological impairment and spinal instability. Moreover, we were able to show that patients with MM and a low number of spinal levels to be supplied have a better prognosis as well as a younger age at the time of the surgical intervention.

Neuroprotective Effects of the Inert Gas Argon on Experimental Traumatic Brain Injury In Vivo with the Controlled Cortical Impact Model in Mice.

Argon has shown neuroprotective effects after traumatic brain injury (TBI) and cerebral ischemia in vitro and in focal cerebral ischemia in vivo. The purpose of this study is to show whether argon beneficially impacts brain contusion volume (BCV) as the primary outcome parameter, as well as secondary outcome parameters, such as brain edema, intracranial pressure (ICP), neurological outcome, and cerebral blood flow (CBF) in an in-vivo model. Subjects were randomly assigned to either argon treatment or room air. After applying controlled cortical impact (CCI) onto the dura with 8 m/s (displacement 1 mm, impact duration 150 ms), treatment was administered by a recovery chamber with 25%, 50%, or 75% argon and the rest being oxygen for 4 h after trauma. Two control groups received room air for 15 min and 24 h, respectively. Neurological testing and ICP measurements were performed 24 h after trauma, and brains were removed to measure secondary brain damage. The primary outcome parameter, BCV, and the secondary outcome parameter, brain edema, were not significantly reduced by argon treatment at any concentration. There was a highly significant decrease in ICP at 50% argon (p = 0.001), and significant neurological improvement (beamwalk missteps) at 25% and 50% argon (p = 0.01; p = 0.049 respectively) compared to control.

Age-adjusted Charlson comorbidity index in recurrent glioblastoma: a new prognostic factor?

BACKGROUND: For recurrent glioblastoma (GB) patients, several therapy options have been established over the last years such as more aggressive surgery, re-irradiation or chemotherapy. Age and the Karnofsky Performance Status Scale (KPSS) are used to make decisions for these patients as these are established as prognostic factors in the initial diagnosis of GB. This study's aim was to evaluate preoperative patient comorbidities by using the age-adjusted Charlson Comorbidity Index (ACCI) as a prognostic factor for recurrent GB patients. METHODS: In this retrospective analysis we could include 123 patients with surgery for primary recurrence of GB from January 2007 until December 2016 (43 females, 80 males, mean age 57 years (range 21-80 years)). Preoperative age, sex, ACCI, KPSS and adjuvant treatment regimes were recorded for each patient. Extent of resection (EOR) was recorded as a complete/incomplete resection of the contrast-enhancing tumor part. RESULTS: Median overall survival (OS) was 9.0 months (95% CI 7.1-10.9 months) after first re-resection. Preoperative KPSS > 80% (P < 0.001) and EOR (P = 0.013) were associated with significantly improved survival in univariate analysis. Including these factors in multivariate analysis, preoperative KPSS < 80 (HR 2.002 [95% CI: 1.246-3.216], P = 0.004) and EOR are the only significant prognostic factor (HR 1.611 [95% CI: 1.036-2.505], P = 0.034). ACCI was not shown as a prognostic factor in univariate and multivariate analyses. CONCLUSION: For patients with surgery for recurrent glioblastoma, the ACCI does not add further information about patient's prognosis besides the well-established KPSS and extent of resection.

Destructive per continuitatem spondylodiscitis after endovascular abdominal or thoracic aneurysm repair (EVAR/TEVAR): rare and untreatable?

INTRODUCTION: Very few publications have previously described spondylodiscitis as a potential complication of endovascular aortic procedures (EVAR/TEVAR). We present to our knowledge the first case series of spondylodiscitis following EVAR/TEVAR based on our data base. Particular focus was laid on the complexity of disease treatment and grave outcome perspectives from a spine surgeon's point of view in this seriously affected patient group. MATERIALS AND METHODS: A retrospective analysis and chart review was performed for 11 out of 284 consecutive spondylodiscitis patients who underwent EVAR/TEVAR procedure and developed destructive per continuitatem spondylodiscitis. RESULTS: All 11 patients had single or more level destructive spondylodiscitis adjacent to the thoracic/lumbar stent graft. In mean, four surgeries were performed per patient to treat this rare complication. Six out of eleven patients (55%) died within 6 months of first identification of per continuitatem spondylodiscitis. In four patients due to persisting infection of the graft and recurrence of the abscess formation, a persisting fistula from anterior approach to the skin was applied. CONCLUSIONS: Destructive per continuitatem spondylodiscitis is a rare and severe complication post-EVAR/TEVAR. Clinical and imaging features of anterior paravertebral disease and anterior vertebral body involvement suggest direct continuous spread of the graft infection to the adjacent vertebral column. The mortality rate of these severe infections is extremely high and treatment with a permanent fistula may be one salvage procedure.

Dorsal instrumentation with and without vertebral body replacement in patients with thoracolumbar osteoporotic fractures shows comparable outcome measures.

PURPOSE: In the surgical treatment of osteoporotic spine fractures, there is no clear recommendation, which treatment is best for the individual patient with vertebra plana and/or neurological deficit requiring instrumentation. The aim of this study was to evaluate clinical and radiological outcomes after dorsal or 360° instrumentation of osteoporotic fractures of the thoracolumbar spine in a cohort of patients representing clinical reality. METHODS: A total of 116 consecutive patients were operated on between 2008 and 2020. Inclusion criteria were osteoporotic fracture, thoracolumbar location, and dorsal instrumentation. In 79 cases, vertebral body replacement (VBR) was performed additionally. Patient outcomes including complications, EQ-5D at follow-up, and sagittal correction were analyzed. RESULTS: Medical and surgical complications occurred in 59.5% of patients with 360° instrumentation compared to 64.9% of patients with dorsal instrumentation only (p = 0.684). Dorsal instrumentation plus VBR resulted in a sagittal correction of 9.3 ± 7.4° (0.1-31.6°) compared to 6.0 ± 5.6° (0.2-22.8°) after dorsal instrumentation only, respectively (p = 0.0065). EQ-5D was completed by 79 patients after 4.00 ± 2.88 years (0.1-11.8 years) and was 0.56 ± 0.32 (- 0.21-1.00) for VBR compared to 0.56 ± 0.34 (- 0.08-1.00) without VBR after dorsal instrumentation (p = 0.994). CONCLUSION: 360° instrumentation represents a legitimate surgical technique with no additional morbidity even for the elderly and multimorbid osteoporotic population. Particularly, if sufficient long-term construct stability is in doubt or ventral stenosis is present, there is no need to abstain from additional ventral reinforcement and decompression.

Prognostic value of tumour volume in patients with a poor Karnofsky performance status scale - a bicentric retrospective study.

BACKROUND: Median overall survival (OS) after diagnosis of glioblastoma (GBM) remains 15 months amongst patients receiving aggressive surgical resection, chemotherapy and irradiation. Treatment of patients with a poor preoperative Karnofsky Performance Status Scale (KPSS) is still controversial. Therefore, we retrospectively assessed the outcome after surgical treatment in patients with a KPSS of ≤60%. METHODS: We retrospectively included patients with a de-novo glioblastoma WHO °IV and preoperative KPSS ≤60%, who underwent surgery at two neurosurgical centres between September 2006 and March 2016. We recorded pre- and postoperative tumour volume, pre- and postoperative KPSS, OS, age and MGMT promoter status. RESULTS: One hundred twenty-three patients (58 females/65 males, mean age 67.4 ± 13.4 years) met the inclusion criteria. Seventy-five of the 123 patients (61%) underwent surgical resection. 48/123 patients (39%) received a biopsy. The median preoperative and postoperative tumour volume of all patients was 33.0 ± 31.3 cm3 (IR 15.0-56.5cm3) and 3.1 ± 23.8 cm3 (IR 0.2-15.0 cm3), respectively. The median KPSS was 60% (range 20-60%) preoperatively and 50% (range 0-80%) postoperatively. Patients who received a biopsy showed a median OS for patients who received a biopsy only was 3.0 months (95% CI 2.0-4.0 months), compared to patients who had a resection and had a median OS of 8 months (95% CI 3.1-12.9 months). Age (p < 0.001, HR: 1.045 [95% CI 1.022-1.068]), postoperative tumour volume (p = 0.02, HR: 1.016 [95% CI 1.002-1.029]) and MGMT promotor status (p = 0.016, HR: 0.473 [95% CI 0.257-0.871]) were statistically significant in multivariate analysis. In subgroup analyses only age was shown as a significant prognostic factor in multivariate analyses for patients receiving surgery (p < 0.001, HR: 1.046 [95% CI 1.022-1.072]). In the biopsy group no significant prognostic factors were shown in multivariate analysis. CONCLUSION: GBM patients with a preoperative KPSS of ≤60% might profit from surgical reduction of tumour burden.

Spinal Manifestation of Malignant Primary (PLB) and Secondary Bone Lymphoma (SLB).

Manifestation of malignant lymphoma in the spine is rare; there have only been a few cases reported in the literature. Due to its rarity, there is no gold standard for the management of patients suffering from spinal lymphoma manifestations. Methods: We retrospectively reviewed the data for 37 patients (14 female, 23 male) with malignant lymphoma in the spine receiving intervention in our center from March 2006 until June 2020. Neurological impairment, pain, diagnostics, and/or surgical instability were the criteria for surgery in this patient cohort. Otherwise, only CT-guided biopsies were conducted. Analysis of the patient cohort was based on the Karnofsky performance status scale (KPSS), location of the lesion, spinal levels involved, spinal instability neoplastic score (SINS), surgical treatment, histopathological workup, adjuvant therapy, and overall survival. The following surgical procedures were performed: posterior stabilization and decompression in nine patients; decompression and/or tumor debulking in 18 patients; a two-staged procedure with dorsal stabilization and vertebral body replacement in four patients; decompression and biopsy in one patient; a two-stage procedure with kyphoplasty and posterior stabilization for one patient; posterior stabilization without decompression for one patient; a vertebroplasty and cement-augmented posterior stabilization for one patient; and a CT-guided biopsy alone for two patients. Twenty-one patients (56.78%) had ≥1 lesion in the thoracic spine, 10 patients (27.03%) had lesions in the lumbar spine, two patients had lesions in the cervicothoracic junction, two patients had lesions in the thoracolumbar junction, one patient had a lesion in the lumbosacral junction, and one patient had a lesion in the sacrum. The diagnoses of the histopathological workup were diffuse large B-cell lymphoma in 23 (62.16%) cases, indolent lymphoma in 11 (29.74%) cases, anaplastic T-cell lymphoma in one case (2.70%), T-cell lymphoma in one case (2.70%), and Burkitt lymphoma in one (2.70%) case. The median overall survival was 7.2 months (range 0.1-266.7 months). Pre- and postoperative KPSS scores were 70% (IQR 60-80%). Manifestation of malignant lymphomas in the spine is rare. Similar to the approach taken for spine metastases, a surgical intervention in cases of neurological impairment or manifest or potential instability is indicated, followed by chemoimmunotherapy and radiotherapy.

Occult Disco-Ligamentous Lesions of the Subaxial c-Spine-A Comparison of Preoperative Imaging Findings and Intraoperative Site Inspection.

Despite the general acceptance of magnetic resonance imaging (MRI) as the gold standard for diagnostics of traumatic disco-ligamentous injuries in the subaxial cervical spine, clinical experience shows cases where no lesion is detected in MRI exams but obtained during surgery. The aim of this study was to compare intraoperative site inspection to preoperative imaging findings and to identify radiological features of patients having a risk for under- or over-estimating disco-ligamentous lesions. We performed a retrospective analysis of our clinical database, considering all patients who underwent surgical treatment of the cervical spine via an anterior approach after trauma between June 2008 and April 2018. Only patients with availability of immediate preoperative computed tomography (CT), 3-Tesla MRI scans, and information about intraoperative findings were considered. Results of preoperative imaging were set in context to intraoperative findings, and receiver operator characteristics (ROC) were calculated. Out of 144 patients receiving anterior cervical surgery after trauma, 83 patients (mean age: 59.4 ± 20.5 years, age range: 12-94 years, 63.9% males) were included in this study. Included patients underwent surgical treatment via anterior cervical discectomy and fusion (ACDF; 79 patients) or anterior cervical corpectomy and fusion (4 patients) with ventral plating. Comparing preoperative imaging findings to intraoperative site inspection, a discrepancy between imaging and surgical findings was revealed in 14 patients, leading to an overall specificity/sensitivity of preoperative imaging to identify disco-ligamentous lesions of the cervical spine of 100%/77.4%. Yet, adding the existence of prevertebral hematoma and/or vertebral fractures according to preoperative imaging improved the sensitivity to 95.2%. Lack of sensitivity was most likely related to severe cervical spondylosis, rendering correct radiological reporting difficult. Thus, the risk of missing a traumatic disco-ligamentous injury of the cervical spine in imaging seems to be a particular threat in patients with preexisting degenerative cervical spondylosis. In conclusion, incorporating the existence of prevertebral hematoma and/or vertebral fractures can significantly improve diagnostic yield.