Association of Medical Comorbidities With Objective Functional Impairment in Lumbar Degenerative Disc Disease

STUDY DESIGN Analysis of a prospective 2-center database. OBJECTIVES Medical comorbidities co-determine clinical outcome. Objective functional impairment (OFI) provides a supplementary dimension of patient assessment. We set out to study whether comorbidities are associated with the presence and degree of OFI in this patient population. METHODS Patients with degenerative diseases of the spine preoperatively performed the timed-up-and-go (TUG) test and a battery of questionnaires. Comorbidities were quantified using the Charlson Comorbidity Index (CCI) and the American Society of Anesthesiology (ASA) grading. Crude and adjusted linear regression models were fitted. RESULTS Of 375 included patients, 97 (25.9%) presented at least some degree of medical comorbidity according to the CCI, and 312 (83.2%) according to ASA grading. In the univariate analysis, the CCI was inconsistently associated with OFI. Only patients with low-grade CCI comorbidity displayed significantly higher TUG test times (p = 0.004). In the multivariable analysis, this effect persisted for patients with CCI = 1 (p = 0.030). Regarding ASA grade, patients with ASA = 3 exhibited significantly increased TUG test times (p = 0.003) and t-scores (p = 0.015). This effect disappeared after multivariable adjustment (p = 0.786 and p = 0.969). In addition, subjective functional impairment according to ODI, and EQ5D index was moderately associated with comorbidities according to ASA (all p < 0.05). CONCLUSION The degree of medical comorbidities appears only weakly and inconsistently associated with OFI in patients scheduled for degenerative lumbar spine surgery, especially after controlling for potential confounders. TUG testing may be valid even in patients with relatively severe comorbidities who are able to complete the test

How I do it: minimally invasive resection of a sub-ependymoma of the fourth ventricle

Abstract Background A 54-year-old female was referred to our clinic with a lesion of the lower fourth ventricle extending to the median aperture. Here, we report the use a minimally invasive sub-occipital approach (MISA) as a safe and effective surgical management. Method We performed a MISA using a short midline incision and a 1-cm sub-occipital craniectomy. Dissection of the lesion was performed, and “en bloc” resection could be achieved. The lesion was confirmed to be a grade I sub-ependymoma. Conclusion MISA can be safely used when confronted to a lesion of the lower fourth ventricle. </jats:sec

How I do it: the trans-laminar, facet-joint sparing minimal invasive approach for ventral dural repair in spontaneous intracranial hypotension—a 2-dimensional operative video

Abstract Background We describe the minimally invasive, facet-sparing postero-lateral approach to the thoracic spine for a ventral dural repair in a patient with intracranial hypotension secondary to a spontaneous dural breach. Methods We performed a minimally invasive approach using a short paramedian posterior skin incision followed by a 10 × 10 mm targeted trans-laminar approach, to achieve a microsurgical repair of a symptomatic ventral dural defect causing severe disability. Conclusion The facet-sparing postero-lateral approach is safe and effective in the surgical management of thoracic dural tears, even in the most anterior ones, and avoids the traditional costotransversectomy. </jats:sec

Assessment of the minimum clinically important difference in the timed up and go test after surgery for lumbar degenerative disc disease

BACKGROUND The Timed Up and Go Test (TUG Test) has previously been described as a reliable tool to evaluate objective functional impairment in patients with degenerative disc disease. OBJECTIVE The aim of this study was to assess the minimum clinically important difference (MCID) of the TUG Test. METHODS The TUG Test (measured in seconds) was correlated with validated patient-reported outcome measures (PROs) of pain intensity (Visual Analog Scale for back and leg pain), functional impairment (Oswestry Disability Index, Roland Morris Disability Index), and health-related quality of life measures (Short Form-12 and EuroQol 5D). Three established methods were used to establish anchor-based MCID values using responders of the following PROs (Visual Analog Scale back and leg pain, Oswestry Disability Index, Roland Morris Disability Index, EuroQol 5D index, and Short Form-12 Physical Component Summary) as anchors: (1) average change, (2) minimum detectable change, and (3) change difference approach. RESULTS One hundred patients with a mean ± SD age of 56.2 ± 16.1 years, 57 (57%) male, 45 patients undergoing microdiscectomy, 35 undergoing lumbar decompression, and 20 undergoing fusion surgery were studied. The 3 MCID computation methods revealed a range of MCID values according to the PRO used from 0.9 s (Oswestry Disability Index based on the change difference approach) to 6.0 s (EuroQol 5D index based on the minimum detectable change approach), with a mean MCID of 3.4 s for all measured PROs. CONCLUSION The MCID for the TUG Test time is highly variable depending on the computation technique used. The average TUG Test MCID was 3.4 s using all 3 methods and all anchors. ABBREVIATIONS D3, day 3DDD, degenerative disc diseaseEQ5D, EuroQol 5DFU, follow-upHRQoL, health-related quality of lifeMCID, minimum clinically important differenceODI, Oswestry Disability IndexOFI, objective functional impairmentPCS, Physical Component SummaryPRO, patient-reported outcome measureRMDI, Roland-Morris Disability IndexSF-12, Short Form 12TUG Test, Time Up and Go TestVAS, Visual Analog Scale

Benefits of re-do surgery for recurrent intracranial meningiomas

AbstractMeningiomas are the most common intracranial extra-axial tumor. While the literature is abundant on the therapeutic management of meningioma recurrence after the initial surgery, the natural history of repeated recurrences is poorly described, as well as and their respective management. A partly retrospective, partly prospective review was conducted in a Norwegian cohort of 1469 consecutive cases of meningioma surgically treated, totaling 11 414 patient-years of follow-up. 114 recurrences (7.7%) were treated surgically with a risk a surgical retreatment of 1% per patient-year of follow-up. 36 patients were operated on 3 times or more. The time-to-retreatment (TTR) decreased significantly and steadily between surgeries, from 4.3 ± 4 years after the first surgery to 2.4 ± 2.9 years after the third surgery. The primary driver for recurrence was the WHO grade (OR 7.13 [4.40;11.55], p &lt; 0.001 for the first recurrence and OR 4.13 [1.49;12.15], p 0.008 for the second), the second predictive factor being a skull base location (OR 2.76 [1.95;3.99] p &lt; 0.001 and OR 0.24 [0.09;0.65], p0.006 respectively). The rates of postoperative hematomas and infections were not influenced by the number of surgeries, whereas the rate of postoperative neurological worsening increased from 3.9% to 16.6% and 13.9%, respectively, after the first, second, and third surgeries. We observed that the TTR decreased significantly between surgeries in patients requiring repeated resections, indicating that surgical treatment of recurrences does not reset the clock but is indeed a “race against time”. This should be considered when assessing the benefit-to-risk ratio of patients undergoing repeated surgeries for a recurrent meningioma.</jats:p

Histological transformation in recurrent WHO grade I meningiomas

AbstractAtypical or malignant transformation (AT/MT) has been described in WHO grade I meningiomas. Our aim was to identify predictive factors of AT/MT at recurrence. A total of N = 15 WHO grade increases were observed in N = 13 patients (0.96% of the study population, risk of transformation of 0.12% per patient-year follow-up). Patients with and without progression at recurrence were similar regarding age, gender distribution, skull-base location, bone infiltration, and Simpson grades. Recurrence-free survival was lower in patients with transformation (5 ± 4.06 years versus 7.3 ± 5.4 years; p = 0.03). Among patient age, gender, skull base location, extent of resection or post-operative RT, no predictor of AT/MT was identified, despite a follow-up of 10,524 patient-years. The annual risk of transformation of WHO grade I meningiomas was 0.12% per patient-year follow-up. Despite the important number of patients included and their extended follow-up, we did not identify any risk factor for transformation. A total of 1,352 patients with surgically managed WHO grade I meningioma from a mixed retro-and prospective database with mean follow-up of 9.2 years ± 5.7 years (0.3–20.9 years) were reviewed. Recurring tumors at the site of initial surgery were considered as recurrence.</jats:p