Abstract
BACKGROUND
Novel methods in predicting survival in patients with spinal metastases may help guide clinical decision-making and stratify treatments regarding surgery vs palliative care.
...OBJECTIVE
To evaluate whether the frailty/sarcopenia paradigm is predictive of survival and morbidity in patients undergoing surgery for spinal metastasis.
METHODS
A total of 271 patients from 4 tertiary care centers who had undergone surgery for spinal metastasis were identified. Frailty/sarcopenia was defined by psoas muscle size. Survival hazard ratios were calculated using multivariate analysis, with variables from demographic, functional, oncological, and surgical factors. Secondary outcomes included improvement of neurological function and postoperative morbidity.
RESULTS
Patients in the smallest psoas tertile had shorter overall survival compared to the middle and largest tertile. Psoas size (PS) predicted overall mortality more strongly than Tokuhashi score, Tomita score, and Karnofsky Performance Status (KPS). PS predicted 90-d mortality more strongly than Tokuhashi score, Tomita score, and KPS. Patients with a larger PS were more likely to have an improvement in deficit compared to the middle tertile. PS was not predictive of 30-d morbidity.
CONCLUSION
In patients undergoing surgery for spine metastases, PS as a surrogate for frailty/sarcopenia predicts 90-d and overall mortality, independent of demographic, functional, oncological, and surgical characteristics. The frailty/sarcopenia paradigm is a stronger predictor of survival at these time points than other standards. PS can be used in clinical decision-making to select which patients with metastatic spine tumors are appropriate surgical candidates.
Graphical Abstract
Graphical Abstract
Epilepsy is a neurological disorder that affects more than 70 million people globally. A considerable proportion of epilepsy is resistant to anti-epileptic drugs (AED). For patients with ...drug-resistant epilepsy (DRE), who are not eligible for resective or ablative surgery, neuromodulation has been a palliative option. Since the approval of vagus nerve stimulation (VNS) in 1997, expansion to include other modalities, such as deep brain stimulation (DBS) and responsive neurostimulation (RNS), has led to improved seizure control in this population. In this article, we discuss the current updates and emerging trends on neuromodulation for epilepsy.
Laser interstitial thermal therapy (LITT) is a minimally invasive surgical option for the treatment of brain tumors introduced in 1983. The innovative technique was welcomed for its ability to access ...deep-seated supratentorial and posterior cranial fossa lesions. Surgical approaches to pineal region tumors are challenging and require a high degree of precision since the critical vasculature, such as the vein of Galen and precentral vein, in the area pose significant anatomical challenges to operating surgeons. To minimize the risk of damaging this key venous anatomy, an infratentorial approach may be more advantageous. We present a case where LITT was utilized through an infratentorial approach to a pineal region tumor. A 62-year-old male with no significant past medical history presented to his primary care physician complaining of ataxia and headaches for the past four weeks. An MRI was concerning for multicentric glioma within the cerebellar hemispheres, brainstem extending to the middle cerebellar peduncle, upper cervical spinal cord, and pineal region. An enhancing lesion of the midbrain tectum was concerning for a high-grade tumor. We decided to proceed with stereotactic biopsy and magnetic resonance-guided LITT via an infratentorial approach. Supratentorial trajectory planning did not allow for a safe corridor due to the venous anatomy; thus, it was decided to proceed with an infratentorial approach. The patient was positioned prone, had his bone fiducial CT fused with MRI, and the tumor was targeted using robotic guidance (ROSA, Zimmer Biomet, Warsaw, Indiana). Postoperatively, he suffered from transient diplopia due to cranial nerve VI palsy. Additionally, the postoperative MRI revealed a decrease in the size of the enhancing lesion and the hyperintense T2 signal within the brainstem. Open surgical approaches to tumors within the pineal region often pose an anatomic and neurovascular challenge. We describe the safe utilization of a novel, previously unreported infratentorial approach utilizing LITT with promising treatment, morbidity, and efficacy outcomes. A larger series will be necessary to ensure the safety and efficacy of this approach.
Although relatively rare, subarachnoid hemorrhage (SAH) may be caused by a ruptured internal carotid artery (ICA) dissection. Given the tortuous nature of the ICA, flexible flow diverting devices may ...be more promising in the management of ICA dissections than stent-graft devices. Here we demonstrate the successful application of a Pipeline Flex Flow Diverter.
A 42 year old female with a past medical history of migraines and anxiety presented to ED after several days of left-sided headaches, facial, and upper extremity numbness and tingling. Head CT demonstrated small SAH along the high left convexity tracking along the sulcus. CTA of head and neck demonstrated left ICA dissection from the distal cervical segment to the intracranial communicating segment with partial healing at the cavernous and petrous segments. She was initially started on aspirin for treatment of her dissection. Given that her SAH occurred 7 days prior to admission, it was not aggressively managed. She underwent Pipeline Flex Flow Diverter and Wingspan stenting of her left suprasellar and distal cervical ICA. She was then placed on Plavix and continued on aspirin for 6 months. At 7 month follow-up, she was asymptomatic and diagnostic cerebral angiogram demonstrated resolution of dissecting left suprasellar and cervical aneurysms with Pipeline stent construct.
The Pipeline Flex Flow Diverter is flexible enough to comfortably navigate the tortuous track of the ICA. Although its use in the management of ICA dissection has not been extensively reported, it may prove to be a valuable treatment modality.
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