Although multiple concurrent spinal arteriovenous fistulas (DAVFs) are a well-known anatomical and clinical entity, the management of these lesions and timing of surgical intervention is still a matter of debate.A 74-year-old man with a 2-year history of progressive weakness of both lower limbs and lower back pain was diagnosed angiographically with a thoracic DAVF. During the surgical procedure, double independent spinal DAVFs were identified. With the aid of neurophysiologic monitoring, we proceeded to the closure of both fistulas in a one-step surgery.Neurophysiologic monitoring represents a valid, widely available, minimally invasive tool for the detection of immediate motor fiber damage due to disruption of the incorrect vessels during DAVF surgery and facilitates a safe treatment in a one-step procedure.
Abstract Background We evaluate the feasibility of a single-stage posterior corpectomy and circumferential arthrodesis with the aid of spinal navigation for the treatment of traumatic thoracolumbar burst fractures. Methods This was a single-center, retrospective study. Demographics, clinical, and radiologic data of 19 patients who underwent surgery at our institution for thoracolumbar burst fractures between 2016 and 2019 were collected. All patients enrolled in the present study underwent surgery by means of posterior fixation and transpedicular corpectomy with the aid of an intraoperative image-guided neuronavigation system. Results Postoperative correction of the vertebral height ratio was achieved in all cases, with an average increase of 23.6% (p = 0.0005). No statistical differences (p = 0.9) were found comparing 1- and 3-month postoperative CT scans, in relation to vertebral height ratio. A statistically significant difference was found between the pre- and postoperative kyphotic angles for the thoracolumbar and lumbar segments (p = 0.0018 and 0.005, respectively), but no difference was found between kyphotic angles at the 3-month follow-up. A unilateral approach was performed on 15 patients (79%), while 4 cases (21%) required a bilateral laminectomy. We did not observe any significant intraoperative complication. Conclusion Single-stage posterior corpectomy and fixation is a safe and effective approach for thoracic and lumbar burst fractures. It provides excellent 360-degree reconstruction in a single surgical stage with satisfactory results in terms of kyphosis reduction, biomechanical stability, and reduced invasiveness. Spinal navigation represents a fundamental tool to overcome some anatomical limits of the presented technique.
Abstract Background Surgical resection represents the mainstay of treatment in skull base meningiomas (SBMs). Considering the high recurrence rate reported, an adjuvant radiation therapy (RT) treatment should be considered. The aim of this study was to evaluate the progression-free survival (PFS), overall survival (OS), and prognostic factors conditioning outcome. Methods Patients receiving surgical resection for grade I SBMs were included. The extent of resection (EOR) was dichotomized as gross total resection (GTR) and subtotal resection (STR). RT was administered only in patients receiving STR. Clinical outcome was evaluated by brain magnetic resonance imaging (MRI) performed every 6 months for the first year and yearly thereafter. Results From January 2000 to December 2015, 123 patients were treated. The majority were females (70.7%), with a Karnofsky Performance Score (KPS) ≥80 (95%), and symptoms at diagnosis (91%). GTR was performed in 30% of cases and STR in 70%. RT was performed in 18 (20.9%) patients at diagnosis and in 29 (33.7%) patients at progression. Improvement or stability of neurologic status was obtained in 78.9% of patients. The median follow-up time was 91 months (range: 40–230 months). Local recurrence occurred in 34 (27.6%) patients at a median time of 45 months (range: 6–214 months). The median, 2-, 5-, and 10-year PFS were 193 months, 89.3, 81.8, and 72.5%, respectively. On univariate and multivariate analyses, factors impacting on PFS were EOR, tumor location, neurologic postoperative status, and adjuvant RT in STR. Conclusions A safe surgical resection followed by RT adjuvant treatment could represent the better choice to obtain local control maintaining neurologic integrity. Our data underlined the value of adjuvant RT in incompletely resected meningiomas.
Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long- term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. Funding National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.