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• 32 studies with 990 patients identified reporting elastography for neurosurgery. • Elastography can determine lesion stiffness and assist with diagnostic workup. • Quantitative measurements can help differentiate lesions pre-operatively. • Ultrasound elastography can provide real-time data to improve tumor resection. • Microscopic abnormalities and residual lesions can be identified on elastography. Elastography is an imaging technology capable of measuring tissue stiffness and consistency. The technology has achieved widespread use in the workup and management of diseases of the liver, breast, thyroid, and prostate. Although elastography is increasingly being applied in neurosurgery, it has not yet achieved widespread adoption and many clinicians remain unfamiliar with the technology. Therefore, we sought to summarize the range of applications and elastography modalities available for neurosurgery, report its effectiveness in comparison with conventional imaging methods, and offer recommendations. All full-text English-language manuscripts on the use of elastography for neurosurgical procedures were screened using the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science databases. Thirty-two studies were included with 990 patients, including 21 studies on intracranial tumors, 5 on hydrocephalus, 4 on epilepsy, 1 on spinal cord compression, and 1 on adolescent scoliosis. Twenty studies used ultrasound elastography (USE) whereas 12 used magnetic resonance elastography (MRE). MRE studies were mostly used in the preoperative setting for assessment of lesion stiffness, tumor–brain adherence, diagnostic workup, and operative planning. USE studies were performed intraoperatively to guide resection of lesions, determine residual microscopic abnormalities, assess the tumor–brain interface, and study mechanical properties of tumors. Elastography can assist with resection of brain tissue, detection of microscopic lesions, and workup of hydrocephalus, among other applications under investigation. Its sensitivity often exceeds that of conventional MRI and ultrasound for identifying abnormal tissue and lesion margins. [ABSTRACT FROM AUTHOR]

Spinal cord injury (SCI) is a devastating condition that affects about 17,000 individuals every year in the United States, with approximately 294,000 people living with the ramifications of the initial injury. After the initial primary injury, SCI has a secondary phase during which the spinal cord sustains further injury due to ischemia, excitotoxicity, immune-mediated damage, mitochondrial dysfunction, apoptosis, and oxidative stress. The multifaceted injury progression process requires a sophisticated injury-monitoring technique for an accurate assessment of SCI patients. In this narrative review, we discuss SCI monitoring modalities, including pressure probes and catheters, micro dialysis, electrophysiologic measures, biomarkers, and imaging studies. The optimal next-generation injury monitoring setup should include multiple modalities and should integrate the data to produce a final simplified assessment of the injury and determine markers of intervention to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies. [ABSTRACT FROM AUTHOR]

The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking. To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS. Systematic review and meta-analysis. Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence. The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=−0.31 [−3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= −3.30 [−8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=−2.94 days [−3.83, −2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=−0.69 days [−1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups. The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate. [ABSTRACT FROM AUTHOR]

The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery. A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies. A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine. PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging. [ABSTRACT FROM AUTHOR]

Lung cancer's propensity for spinal metastasis significantly impacts morbidity and mortality. The role of somatic mutations in determining the prognosis of these metastases is crucial for treatment optimization. To assess how somatic mutations affect survival and neurological outcomes in lung cancer patients with spinal metastases. A retrospective analysis was performed on 76 lung cancer patients at Johns Hopkins from 2013 to 2023 with spinal metastases to evaluate the impact of specific mutations and targeted therapy on prognosis. Inclusion criteria were based on a diagnosis of lung cancer with spinal metastasis and available genetic profiling data. The study focused on the correlation between survival and mutation status, the efficacy of targeted therapy, and postoperative neurological recovery. Data on demographics, tumor biomarkers, treatment modalities, and outcomes were collected and analyzed for each patient. In our study, 76 patients were analyzed, 95% with non-small-cell lung cancer (NSCLC), predominantly adenocarcinoma (83%). Genetic sequencing and immunohistochemical staining identified 61 unique biomarkers. EGFR mutations correlated with a notable increase in median overall survival (MOS) to 3.40 years from 1.39 years (p=0.014). KRAS+ patients had a significantly lower MOS at 0.71 years, compared to 2.60 years for those without KRAS mutations (p=0.03). Napsin A expression was associated with a substantial improvement in MOS to 5.41 years from 1.39 years (p=0.01), underscoring its prognostic value. The application of targeted therapy resulted in a MOS of 3.40 years, significantly better than 1.28 years observed without such treatment (p<0.01), indicating its efficacy in NSCLC management. Given that 95% of our study cohort were diagnosed with NSCLC, the observed improvement in MOS with targeted therapy primarily reflects outcomes in this population. Furthermore, Napsin A positively influenced postoperative neurological outcomes, as evidenced by improved Frankel scores (p=0.001), suggesting a role in patient recovery. In survival analysis, the overall median survival was 1.35 years (IQR 3.60 years), with the median time to first metastasis at 1.00 year (IQR 2.31 years) from diagnosis. The median time to spinal metastasis closely followed at 0.97 years (IQR 2.40 years), demonstrating the aggressive nature of NSCLC with spinal involvement. No significant difference was noted between the timing of the first and spinal metastases (p=0.71), nor between the median survival times post-first and spinal metastases (p=0.32). Accelerated Failure Time Model (AFT) analysis revealed immunotherapy (TR=2.15, p=0.007) and targeted therapy (TR=2.20, p=0.001) significantly improved survival, while radiotherapy to spinal metastasis was negatively associated with it (TR=0.46, p=0.015). Somatic mutations, especially EGFR, KRAS, and Napsin A, markedly influence survival in lung cancer patients with spinal metastases. Napsin A and targeted therapy were associated with better patient outcomes, underscoring the need for personalized treatment strategies to improve survival and neurological function. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population. [ABSTRACT FROM AUTHOR]