Evaluation of long-term clinical outcomes and the incidence of adjacent proximal segment degenerative disease with algorithmic transforaminal interbody fusion: A multicenter prospective study

Study Design: This was a prospective multicenter study. Background: Adjacent segment degenerative disease (ASDd) is a common complication of open transforaminal lumbar interbody fusion (O-TLIF), the leading cause of which is initial adjacent segment degeneration (ASD). To date, various surgical techniques for the prevention of ASDd have been developed, such as, simultaneous use of interspinous stabilization (IS) and preventive rigid stabilization of the adjacent segment. The use of these technologies is often based on the subjective opinion of the operating surgeon, or on the assessment of one of the predictors of ASDd. Only sporadic studies are devoted to a comprehensive study of risk factors of ASDd development and personalized performance of O-TLIF. Purpose: The purpose of this study was to evaluate long-term clinical outcomes and the incidence of degenerative disease of the adjacent proximal segment using clinical-instrumental algorithm for preoperative planning to O-TLIF. Materials and Methods: The prospective, nonrandomized, multicenter cohort study included 351 patients who underwent primary O-TLIF, and the adjacent proximal segment had initial ASD. Two cohorts were identified. The prospective cohort included 186 patients who were operated by using the algorithm of personalized O-TLIF performance. The control retrospective cohort consisted of patients (n = 165), from our own database who had been operated on previously without the algorithmized approach. Treatment outcomes were analyzed by Visual Analog Scale (VAS) assessment of pain syndrome, Oswestry Disability Index (ODI) scores, physical component score (PCS) and mental component score (MCS) scores of the Short Form 36 questionnaire, frequency of ASDd was compared between studied cohorts. Results: Thirty-six months after follow-up, the prospective cohort had better SF36 MCS/PCS outcomes, less disability according to ODI, and lower pain level according to VAS (P < 0.05). The incidence of ASDd in the prospective cohort was 4.9%, which was significantly lower than in the retrospective cohort (9%). Conclusions: The prospective use of a clinical-instrumental algorithm for preoperative planning of rigid stabilization, depending on the biometric parameters of the proximal adjacent segment, significantly reduced the incidence of ASDd and improved long-term clinical outcomes compared with the retrospective group

Comparison of MRI Visualization Following Minimally Invasive and Open TLIF: A Retrospective Single-Center Study

Analysis of magnetic resonance image (MRI) quality after open (Op)-transforaminal interbody fusion (TLIF) and minimally invasive (MI)-TLIF with the implantation of structurally different systems has not previously been performed. The objective of this study was to conduct a comparative analysis of the postoperative MRI following MI and Op one-segment TLIF. Material and Methods: The nonrandomized retrospective single-center study included 80 patients (46 men and 24 women) aged 48 + 14.2 years. In group I (n = 20) Op-TLIF with open transpedicular screw fixation (TSF) was performed, in II group (n = 60), the MI-TLIF technique was used: IIa (n = 20)—rigid interspinous stabilizer; IIb (n = 20)—unilateral TSF and contralateral facet fixation; IIc (n = 20)—bilateral TSF. Results: Comparison of the quality of postoperative imaging in IIa and IIb subgroups showed fewer MRI artifacts and a significantly greater MR deterioration after Op and MI TSF. Comparison of the multifidus muscle area showed less atrophy after MI-TLIF and significantly greater atrophy after Op-TLIF. Conclusion: MI-TLIF and Op-TLIF with TSF have comparable postoperative MR artifacts at the operative level, with a greater degree of muscle atrophy using the Op-TLIF. Rigid interspinous implant and unilateral TSF with contralateral facet fixation have less artifacts and changes in the multifidus muscle area

Facet Joint Fixation and Anterior, Direct Lateral, and Transforaminal Lumbar Interbody Fusions for Treatment of Degenerative Lumbar Disc Diseases: Retrospective Cohort Study of a New Minimally Invasive Technique

BACKGROUND: Anterior, direct lateral, and transforaminal lumbar interbody fusions (ALIF, DLIF, and TLIF) are usually combined with posterior fixation to treat degenerative spinal diseases. Outcomes of ALIF, TLIF, or DLIF combined with a new wedge-shaped interfacet cage plate have not been reported. We assessed early clinical outcomes of patients treated with interbody fusion and facet fixation using a titanium wedge-shaped cage plate. METHODS: This retrospective observational cohort study included patients (n = 80) who underwent 1-level interbody fusion and facet joint fixation via ALIF (n = 24) or DLIF (n = 26) with bilateral facet fixation or TLIF with ipsilateral pedicle screws and contralateral facet fixation (n = 30). Duration of surgery, estimated blood loss, pain (visual analog scale), Oswestry Disability Index (ODI) scores, and Macnab score were assessed up to 12 months after surgery. RESULTS: All patients had a significant decrease in pain scores (P \u3c 0.01) and an increase in ODI scores (P \u3c 0.01), without significant differences between treatment groups. Most surgical outcomes were excellent or good (n = 75, 93.8%) with 5 patients (6.2%) having satisfactory outcomes. Within 2 months, all patients returned to their previous work (66, 82.5%) or lighter work (14, 17.5%). Two patients had fusion failure requiring reoperation. CONCLUSIONS: Facet fixation with the wedge-shaped cage plate was associated with minimal soft tissue damage and a low level of postoperative pain. ALIF, DLIF, and TLIF combined with this technique showed good early postoperative clinical and radiologic outcomes. Further studies are needed to assess long-term results and compare them with other fusion methods

Molecular and Genetic Mechanisms of Spinal Stenosis Formation: Systematic Review

Spinal stenosis (SS) is a multifactorial polyetiological condition characterized by the narrowing of the spinal canal. This condition is a common source of pain among people over 50 years old. We perform a systematic review of molecular and genetic mechanisms that cause SS. The five main mechanisms of SS were found to be ossification of the posterior longitudinal ligament (OPLL), hypertrophy and ossification of the ligamentum flavum (HLF/OLF), facet joint (FJ) osteoarthritis, herniation of the intervertebral disc (IVD), and achondroplasia. FJ osteoarthritis, OPLL, and HLF/OLFLF/OLF have all been associated with an over-abundance of transforming growth factor beta and genes related to this phenomenon. OPLL has also been associated with increased bone morphogenetic protein 2. FJ osteoarthritis is additionally associated with Wnt/&beta;-catenin signaling and genes. IVD herniation is associated with collagen type I alpha 1 and 2 gene mutations and subsequent protein dysregulation. Finally, achondroplasia is associated with fibroblast growth factor receptor 3 gene mutations and fibroblast growth factor signaling. Although most publications lack data on a direct relationship between the mutation and SS formation, it is clear that genetics has a direct impact on the formation of any pathology, including SS. Further studies are necessary to understand the genetic and molecular changes associated with SS

MinION rapid sequencing: Review of potential applications in neurosurgery

BACKGROUND: Gene sequencing has played an integral role in the advancement and understanding of disease pathology and treatment. Although historically expensive and time consuming, new sequencing technologies improve our capability to obtain the genetic information in an accurate and timely manner. Within neurosurgery, gene sequencing is routinely used in the diagnosis and treatment of neurosurgical diseases, primarily for brain tumors. This paper reviews nanopore sequencing, an innovation utilized by MinION and outlines its potential use for neurosurgery. METHODS: A literature search was conducted for publications containing the keywords of Oxford MinION, nanopore sequencing, brain tumor, glioma, whole genome sequencing (WGS), epigenomics, molecular neuropathology, and next-generation sequencing (NGS). In total, 64 articles were selected and used for this review. RESULTS: The Oxford MinION nanopore sequencing technology has had successful applications within clinical microbiology, human genome sequencing, and cancer genotyping across multiple specialties. Technical details, methodology, and current use of MinION sequencing are discussed through the prism of potential applications to solve neurosurgery-related scientific and diagnostic questions. The MinION device has proven to provide rapid and accurate reads with longer read lengths when compared with NGS. For applications within neurosurgery, the MinION device is capable of providing critical diagnostic information for central nervous system (CNS) tumors within a single day. CONCLUSIONS: MinION provides rapid and accurate gene sequencing with better affordability and convenience compared with current NGS methods. Widespread success of the MinION nanopore sequencing technology in providing accurate, rapid, and convenient gene sequencing suggests a promising future within research laboratories and to improve care for neurosurgical patients

Laser application in neurosurgery

BACKGROUND: Technological innovations based on light amplification created by stimulated emission of radiation (LASER) have been used extensively in the field of neurosurgery. METHODS: We reviewed the medical literature to identify current laser-based technological applications for surgical, diagnostic, and therapeutic uses in neurosurgery. RESULTS: Surgical applications of laser technology reported in the literature include percutaneous laser ablation of brain tissue, the use of surgical lasers in open and endoscopic cranial surgeries, laser-assisted microanastomosis, and photodynamic therapy for brain tumors. Laser systems are also used for intervertebral disk degeneration treatment, therapeutic applications of laser energy for transcranial laser therapy and nerve regeneration, and novel diagnostic laser-based technologies (e.g., laser scanning endomicroscopy and Raman spectroscopy) that are used for interrogation of pathological tissue. CONCLUSION: Despite controversy over the use of lasers for treatment, the surgical application of lasers for minimally invasive procedures shows promising results and merits further investigation. Laser-based microscopy imaging devices have been developed and miniaturized to be used intraoperatively for rapid pathological diagnosis. The multitude of ways that lasers are used in neurosurgery and in related neuroclinical situations is a testament to the technological advancements and practicality of laser science

Prevalence of lumbosacral transitional vertebra among 4816 consecutive patients with low back pain: A computed tomography, magnetic resonance imaging, and plain radiographic study with novel classification schema

Study Design: A retrospective single-center study. Background: The prevalence of the lumbosacral anomalies remains controversial. The existing classification to characterize these anomalies is more complex than necessary for clinical use. Purpose: To assessment of the prevalence of lumbosacral transitional vertebra (LSTV) in patients with low back pain and the development of clinically relevant classification to describe these anomalies. Materials and Methods: During the period from 2007 to 2017, all cases of LSTV were preoperatively verified, and classified according to Castellvi, as well as O'Driscoll. We then developed modifications of those classifications that are simpler, easier to remember, and clinically relevant. At the surgical level, this was assessed intervertebral disc and facet joint degeneration. Results: The prevalence of the LSTV was 8.1% (389/4816). The most common L5 transverse process anomaly type was fused, unilaterally or bilaterally (48%), to the sacrum and were O'Driscoll's III (40.1%) and IV (35.8%). The most common type of S1-2 disc was a lumbarized disc (75.9%), where the disc's anterior-posterior diameter was equal to the L5-S1 disc diameter. In most cases, neurological compression symptoms (85.5%) were verified to be due to spinal stenosis (41.5%) or herniated disc (39.5%). In the majority of patients without neural compression, the clinical symptoms were due to mechanical back pain (58.8%). Conclusions: LSTV is a fairly common pathology of the lumbosacral junction, occurring in 8.1% of the patients in our series (389 out of 4,816 cases). The most common types were Castellvi's type IIA (30.9%) and IIIA (34.9%) and were O'Driscoll's III (40.1%) and IV (35.8%)

Microvascular Anastomosis Training in Neurosurgery: A Review

Cerebrovascular diseases are among the most widespread diseases in the world, which largely determine the structure of morbidity and mortality rates. Microvascular anastomosis techniques are important for revascularization surgeries on brachiocephalic and carotid arteries and complex cerebral aneurysms and even during resection of brain tumors that obstruct major cerebral arteries. Training in microvascular surgery became even more difficult with less case exposure and growth of the use of endovascular techniques. In this text we will briefly discuss the history of microvascular surgery, review current literature on simulation models with the emphasis on their merits and shortcomings, and describe the views and opinions on the future of the microvascular training in neurosurgery. In “dry” microsurgical training, various models created from artificial materials that simulate biological tissues are used. The next stage in training more experienced surgeons is to work with nonliving tissue models. Microvascular training using live models is considered to be the most relevant due to presence of the blood flow. Training on laboratory animals has high indicators of face and constructive validity. One of the future directions in the development of microsurgical techniques is the use of robotic systems. Robotic systems may play a role in teaching future generations of microsurgeons. Modern technologies allow access to highly accurate learning environments that are extremely similar to real environment. Additionally, assessment of microsurgical skills should become a fundamental part of the current evaluation of competence within a microneurosurgical training program. Such an assessment tool could be utilized to ensure a constant level of surgical competence within the recertification process. It is important that this evaluation be based on validated models

Diagnostic Accuracy of a Confocal Laser Endomicroscope for In Vivo Differentiation Between Normal Injured And Tumor Tissue During Fluorescein-Guided Glioma Resection: Laboratory Investigation

OBJECTIVE: Glioma resection with fluorescein sodium (FNa) guidance has a potential drawback of nonspecific leakage of FNa from nontumor areas with a compromised blood-brain barrier. We investigated the diagnostic accuracy of in vivo confocal laser endomicroscopy (CLE) after FNa administration to differentiate normal brain, injured normal brain, and tumor tissue in an animal glioma model. METHODS: GL261-Luc2 gliomas in C57BL/6 mice were used as a brain tumor model. CLE images of normal, injured normal, and tumor brain tissues were collected after intravenous FNa administration. Correlative sections stained with hematoxylin and eosin were taken at the same sites. A set of 40 CLE images was given to 1 neuropathologist and 3 neurosurgeons to assess diagnostic accuracy and rate image quality (1-10 scale). Additionally, we developed a deep convolution neural network (DCNN) model for automatic image classification. RESULTS: The mean observer accuracy for correct diagnosis of glioma compared with either injured or uninjured brain using CLE images was 85%, and the DCNN model accuracy was 80%. For differentiation of tumor from nontumor tissue, the experts\u27 mean accuracy, specificity, and sensitivity were 90%, 86%, and 96%, respectively, with high interobserver agreement overall (Cohen κ = 0.74). The percentage of correctly identified images was significantly higher for images with a quality rating \u3e5 (104/116, 90%) than for images with a quality rating ≤5 (32/44, 73%) (P = 0.007). CONCLUSIONS: With sufficient FNa present in tissues, CLE was an effective tool for intraoperative differentiation among normal, injured normal, and tumor brain tissue. Clinical studies are warranted to confirm these findings

Utilization of intraoperative confocal laser endomicroscopy in brain tumor surgery

Precise identification of tumor margins is of the utmost importance in neuro-oncology. Confocal microscopy is capable of rapid imaging of fresh tissues at cellular resolution and has been miniaturized into handheld probe-based systems suitable for use in the operating room. We aimed to perform a literature review to provide an update on the current status of confocal laser endomicroscopy (CLE) technology for brain tumor surgery. Aside from benchtop confocal microscopes used in ex vivo fashion, there are four CLE systems that have been investigated for potential application in the workflow of brain tumor surgery. Preclinical studies on animal tumor models and clinical studies on human brain tumors have assessed in vivo and ex vivo imaging approaches, suggesting that confocal microscopy holds promise for rapid identification of the characteristic (diagnostic) histological features of tumor and normal brain tissues. However, there are few studies assessing diagnostic accuracy sufficient to provide a definitive determination of the clinical and economical value of CLE in brain tumor surgery. Intraoperative real-time, high-resolution tissue imaging has significant clinical potential in the field of neuro-oncology. CLE is an emerging imaging technology that shows promise for improving brain tumor surgery workflow in in vivo and ex vivo studies. Future clinical studies are necessary to demonstrate clinical and economic benefit of CLE