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Abstract Numerous materials of implants used for cranioplasty after decompressive craniectomy (DC) have been investigated to meet certain demanded key features, such as stability, applicability, and biocompatibility. We aimed to evaluate the feasibility and safety of biocompatible calcium-phosphate (CaP) implants for cranioplasty compared to polymethylmethacrylate (PMMA) implants. In this retrospective observational cohort study, the medical records of all patients who underwent cranioplasty between January 1st, 2015, and January 1st, 2022, were reviewed. Demographic, clinical, and diagnostic data were collected. Eighty-two consecutive patients with a mean age of 52 years (range 22–72 years) who received either a PMMA (43/82; 52.4%) or CaP (39/82; 47.6%) cranial implant after DC were included in the study. Indications for DC were equally distributed in both groups. Time from DC to cranioplasty was 143.8 ± 17.5 days (PMMA) versus 98.5 ± 10.4 days (CaP). The mean follow-up period was 34.9 ± 27.1 months. Postoperative complications occurred in 13 patients with PMMA and 6 in those with CaP implants (13/43 [30.2%] vs. 6/39 [15.4%]; p = 0.115). Revision surgery with implant removal was necessary for 9 PMMA patients and in 1 with a CaP implant (9/43 [20.9%] vs. 1/39 [2.6%]; p = 0.0336); 6 PMMA implants were removed due to surgical site infection (SSI) (PMMA 6/43 [14%] vs. CaP 0/39 [0%]; p = 0.012). In this study, a biocompatible CaP implant seems to be superior to a PMMA implant in terms of SSI and postoperative complications. The absence of SSI supports the idea of the biocompatible implant material with its ability for osseointegration.

This article outlines some promising future concepts against postoperative spinal implant infections on the basis of today available literature. The ever-adapting bacteria causing this common complication compel a corresponding continuous research about best effective treatment. The aim is to give a perspective on several future attack-points: surgical infection prevention strategies such as technical optimization of implants and surgical technique; faster diagnostic tools to detect infection, especially in the context of late infections with low-virulent germs and with regard to decision-making in the course of the surgical workflow; and combined surgical and medical treatment options against implant infections. The surgical treatment section will also state open issues concerning implant removal, and the medical treatment section will give an outlook to promising medical alternatives in a post-antibiotic era. To keep up in this field will be important to retain spine surgery in the future as the state-of-the-art treatment option for mandatory spinal interventions in the presence of tumor or trauma and even more so as an attractive option for patients with degenerative spinal disorder for improvement of their life quality.

Background After cranioplasty, in many cases a not negligible soft tissue defect remains in the temporozygomatical area, also referred to as a hollowing defect of the temple. Objective To assess the precise localization and volume of the hollowing defect, to optimize future cranioplasties. Methods CT data of patients who received craniectomy and conventional CAD cranioplasty in our institution between 2012 and 2018 were analyzed. CT datasets prior to craniectomy and after cranioplasty were subtracted to quantify the volume and localization of the defect. Results Out of 91 patients, 21 had suitable datasets. Five cases had good cosmetic results with no defect visible, 16 patients had an apparent hollowing defect. Their average defect volume was 5.0 cm3 ± 4.5 cm3. The defect localizations were in the area behind the zygomatic process and just below the superior temporal line, covering an area of app. 3x3 cm2. Surgical attempts of temporal muscle restoration were more often found in reports of good results (p Conclusion This work supplies evidence for the indication of a surgical corrective during cranioplasty in the small but cosmetically relevant area of the “frontozygomatic shadow”. Based on our 3D data analysis, future focused surgical strategies may obtain better aesthetical results here.

OBJECTIVESpinal ependymomas are rare glial neoplasms. Because their incidence is low, only a few larger studies have investigated this condition. There are no clear data concerning prognosis and therapy. The aim of the study was to describe the natural history, perioperative clinical course, and local tumor control of adult patients with spinal ependymomas who were surgically treated under modern treatment standards.METHODSThe authors performed a multicenter retrospective study. They identified 158 adult patients with spinal ependymomas who had received surgical treatment between January 2006 and June 2013. The authors analyzed the clinical and histological aspects of these cases to identify the predictive factors for postoperative morbidity, tumor resectability, and recurrence.RESULTSGross-total resection (GTR) was achieved in 80% of cases. At discharge, 37% of the patients showed a neurological decline. During follow-up the majority recovered, whereas 76% showed at least preoperative status. Permanent functional deterioration remained in 2% of the patients. Transient deficits were more frequent in patients with cervically located ependymomas (p = 0.004) and in older patients (p = 0.002). Permanent deficits were independently predicted only by older age (p = 0.026). Tumor progression was observed in 15 cases. The 5-year progression-free survival (PFS) rate was 80%, and GTR (p = 0.037), WHO grade II (p = 0.009), and low Ki-67 index (p = 0.005) were independent prognostic factors for PFS. Adjuvant radiation therapy was performed in 15 cases. No statistically relevant effects of radiation therapy were observed among patients with incompletely resected ependymomas (p = 0.079).CONCLUSIONSDue to its beneficial value for PFS, GTR is important in the treatment of spinal ependymoma. Gross-total resection is feasible in the majority of cases, with acceptable rates of permanent deficits. Also, Ki-67 appears to be an important prognostic factor and should be included in a grading scheme for spinal ependymomas.

Anaplastic meningioma is seldom encountered. Moreover, distant metastasis is extremely rare, with only a handful cases reported. Here, we report the case of a 74-year-old female patient who underwent a combined cranial and endonasal approach for an extensive spheno-orbital anaplastic meningioma (WHO grade III), followed by adjuvant radiotherapy. Although local tumor control was achieved, she presented with lung metastasis 2 years later. The patient then died from pulmonary complications related to chest metastasis.On the basis of this case, we discuss the available literature on metastatic meningiomas and radiologic follow-up strategies.

Background Cerebral cavernous malformations (CCM) can cause intracerebral hemorrhage. The lesions themselves are frequently associated with perifocal hemosiderin deposits caused by repetitive microhemorrhages. Main indications for a surgical treatment are recurrent symptomatic hemorrhages or cavernoma-related epilepsy. After surgical resection, follow-up magnetic resonance imaging (MRI) is usually performed to confirm 1) the complete resection of the CCM and, especially in cases of cavernoma-related epilepsy, 2) the complete resection of the hemosiderin deposits. Methods This prospective study evaluates the value of early postoperative MRI (within 72 hours) regarding the detection of CCM or hemosiderin remnants compared with a standard 3–6 months postoperative MRI control in 61 CCM cases. Results Sensitivity of early postoperative MRI for CCM remnant detection was 66.67% (95% confidence interval [CI], 9.43%–99.16%), specificity was 76.74% (95% CI, 61.37%–88.24%), positive predictive value was 16.67% (95% CI, 2.09%–48.41%), and negative predictive value was 97.06% (95% CI, 84.67%–99.93%). Because of the high number of patients who could not be evaluated because of imaging artifacts, sensitivity and specificity analysis was not performed for early postoperative MRI using T2*/susceptibility-weighted imaging to assess hemosiderin remnants. Sensitivity of early postoperative MRI for hemosiderin remnant detection using T2-weighted sequences was 85.71% (95% CI, 63.66%–96.95%), specificity was 66.67% (95% CI, 44.68%–84.37%), positive predictive value was 69.23% (95% CI, 55.45%–80.27%), and negative predictive value was 84.21% (95% CI, 64.31%–94.04%). Conclusions Our data suggest that early postoperative MRI after CCM surgery is often hampered by imaging artifacts creating false-positive results and therefore ineligible for a resection control. However, reliability of a negative result on early postoperative T2-weighted MRI is relatively high regarding both CCM and hemosiderin remnants.

Background Lateral approaches to treat anterior cranial fossa lesions have evolved since the first frontotemporal approach described by Dandy in 1918. We describe a less invasive approach to perform extradural anterior clinoidectomy through a lateral supraorbital (LSO) approach for anterior circulation aneurysms and anterolateral skull base lesions. Methods The extended LSO approach involves performing a standard lateral supraorbital craniotomy followed by drilling of the sphenoid wing and lateral wall of the orbit through the frontal bony opening of the LSO approach, without any temporal extension of the craniotomy. This creates a frontopterio-orbital window exposing the periorbita; superior, medial, and anterior aspect of the temporal dura mater; and superior orbital fissure. After unroofing the superior orbital fissure, the meningo-orbital fold is cut, and the temporal dura mater is peeled from the lateral wall of the cavernous sinus to expose the anterior clinoid process allowing a standard opening of the optic canal and anterior clinoidectomy. Results The extended LSO approach and extradural anterior clinoidectomy allowed access to 4 sphenoid wing/anterior clinoidal meningiomas, 5 anterior circulation aneurysms, 2 temporomesial lesions, and 1 orbital/cavernous sinus abscess. Postoperatively, 2 patients had transient hemiparesis, 2 patients had transient third nerve palsy, and 1 patient had minimal visual field deterioration. All patients had a modified Rankin Scale score ≤1 at 8-week follow-up. Conclusion The extended LSO approach opens a new route (frontopterio-orbital window) to perform extradural anterior clinoidectomy safely and increases surgical exposure, angles, and operability of a less invasive keyhole craniotomy (LSO approach) to treat anterior cranial fossa lesions.

OBJECTIVEAlthough several studies have suggested that the incidence of intracranial aneurysms (IAs) is higher in smokers, the higher prevalence of subarachnoid hemorrhage (SAH) in smokers remains uncertain. It is unclear whether smoking additionally contributes to the formation of multiple aneurysms and the risk of rupture. The aim of this study was to determine whether smoking is associated with IA formation, multiplicity, or rupture.METHODSPatients from the prospective multicenter @neurIST database (n = 1410; 985 females [69.9%]) were reviewed for the presence of SAH, multiple aneurysms, and smoking status. The prevalence of smokers in the population of patients diagnosed with at least one IA was compared with that of smokers in the general population.RESULTSThe proportion of smokers was higher in patients with IAs (56.2%) than in the reference population (51.4%; p < 0.001). A significant association of smoking with the presence of an IA was found throughout group comparisons (p = 0.01). The presence of multiple IAs was also significantly associated with smoking (p = 0.003). A trend was found between duration of smoking and the presence of multiple IAs (p = 0.057). However, the proportion of smokers among patients suffering SAH was similar to that of smokers among patients diagnosed with unruptured IAs (p = 0.48).CONCLUSIONSSmoking is strongly associated with IA formation. Once an IA is present, however, smoking does not appear to increase the risk of rupture compared with IAs in the nonsmoking population. The trend toward an association between duration of smoking and the presence of multiple IAs stresses the need for counseling patients with IAs regarding lifestyle modification.

Indications to emergency surgical treatment in degenerative spinal conditions are limited to those conditions where a delay in surgical management may lead to potentially catastrophic and irreversible sequelae. Indeed, those conditions are rarely encountered during clinical practice. The most typical scenarios in the thoraco-lumbar region are cauda equina syndrome (CES) and progressive radicular motor deficit (PRMD), both primarily caused by degenerative lumbar pathology. Early surgical treatment may influence the partial or full recovery and the long-term outcome of concerned patients.

BACKGROUND The treatment of clival chordomas remains challenging. Total tumour resection is often impossible without hampering adjacent anatomical structures and causing functional sequelae. On the other hand, chordomas show limited response to non-surgical treatment modalities. Up to now, no well-established interdisciplinary treatment algorithms for clival chordomas exist. In this regard, we analysed the data from all patients that underwent interdisciplinary treatment for clival chordoma in our institution over the last 10 years. METHOD Retrospective report of all patients treated at the authors' institution from 2005 to 2015. RESULTS Thirteen patients underwent 24 surgeries, of which 2 (8%) were gross total resections and 22 (92%) incomplete resections. Neurological deterioration, endocrinological disturbances and other surgical complications were observed in six (25%), three (13%) and nine (38%) cases, respectively. Three surgeries (13%) led to an improvement of the initial preoperative neurological condition. All patients were discussed on the interdisciplinary tumour board and all underwent one type of radiotherapy following initial surgery: proton beam in 11 cases (85%) and photon beam in two (15%) cases. In the course of their recurrent disease, three patients (23%) received systemic therapy (imatinib, pazopanib and nivolumab). One patient received a personalised cellular immunotherapy. One patient (8%) was lost to follow-up. Of the remaining 12 patients, four patients (33%) died in the period of analysis; all deaths were chordoma-related. The 5-year cumulative survival rate was 83% (52-97%, CI 95%), 5-year progression-free survival rate was 53% (26-79%, CI 95%). The eight patients (66%) still alive had favourable outcome (KPS, 90 ± 10.7%). SF36 analysis among the survivors revealed 43 points for the Physical Component Summary (12% above, 38% at and 50% below the general population norm) and 47 points for the Mental Component Summary (25% above, 38% at and 38% below). CONCLUSIONS Our patients show a low rate of gross total resection but an outcome well comparable to other published results. This emphasises the importance of interdispiplinary treatment strategies, with surgery supplying maximal safe resection and avoiding severe neurological deficit, allowing patients to undergo adjusted radiotherapy and other treatment options in a good condition.

Hybrid room treatment (HRT) provides the surgeon immediate intraoperative angiography control of aneurysm occlusion and vessel patency. Since it is relatively resource demanding, in clinical routine HRT is reserved for elective cases. However, since its introduction in our department in 2008, several random cases of ruptured intracranial aneurysms (IAs) have been treated in the HR. This study aims to compare the clinical and radiological outcomes of these cases with cases treated conventionally using a matched pair analysis. Twenty (20%) consecutive patients with ruptured IA treated by microsurgical clipping in the HR between 2009 and 2015 were retrospectively matched with “conventionally” (C) treated patients (overall n = 101). Clinical and radiological outcome variables were assessed and compared. Despite a trend in favor of the HR group, no significant difference between both matched groups (HR vs. C) could be demonstrated regarding the functional outcome (upper/lower good recovery 16/20 vs. 17/20, p > 0.05), frequency of clipping-related vascular insults on CT scans (0/20 vs. 3/20, p > 0.05), aneurysm remnant rate on postoperative angiography (1/20 vs. 4/20, p > 0.05) and retreatment rate (0/20 vs. 1/20, p > 0.05). When cumulating all outcome events by a scoring system, however, the HR cohort showed a significantly lower occurrence of events (p

OBJECTIVE: Quantitative comparison of minimally invasive and standard cranial approaches remains a methodologic challenge. The aim of this study was to apply a new digital, navigation-based method to quantify multiple parameters of the pterional, supraorbital, lateral supraorbital and mini-pterional approaches and to describe a target-specific maneuverability score. - METHODS: Supraorbital, lateral supraorbital, minipterional, and standard pterional craniotomies were performed on 8 sides in 4 cadaver heads. The limits of superficial and deep exposure and surgical target points were registered with image-guidance (Medtronic Stealth). A custom software (Guided Therapeutics Eyes II Software [GTxEyesII]) calculated superficial and deep surface areas,working volumes, and target distances. Volumeswere reconstructed digitally and visualized with GTxEyesII. Finally, we defined for each approach a targetspecific maneuverability score based on surface exposure, target distance, target position, and anatomical obstacles. - RESULTS: Surface exposure and volumes were significantly smaller for keyhole approaches compared with standard pterional craniotomy (P < 0.01). Maneuverability index scores showed the greatest values for standard pterional craniotomies, but nearly equally high scores could be achieved by one or several of the less-invasive approaches for most of the targets. - CONCLUSIONS: The combination of a navigation-based measurement method with custom software (GTxEyesII) provides a powerful tool for visualization and quantification of surgical approaches. Compared with standard pterional craniotomy, alternative keyhole craniotomies offer comparable deep exposure with smaller working volumes and relatively high maneuverability for specific targets.

To evaluate whether anterior lumbar interbody fusion (ALIF) is superior to transforaminal lumbar interbody fusion (TLIF) in cases of post-discectomy syndrome (PDS).In this retrospective study, we analyzed the consecutive results of 83 patients operated for PDS refractory to conservative treatment. A total of 46 patients underwent ALIF via a retroperitoneal approach; 37 patients underwent TLIF. Both fusion types were augmented by means of pedicle screw instrumentation. Early and delayed complications were registered within the course of hospitalization or outpatient clinical follow-up, respectively. Parameters such as patient satisfaction, current pain levels, pain medication, and change in work ability were obtained via telephone follow-up.Overall, 81.9% of patients were available for follow-up. Both ALIF and TLIF significantly improved back and leg pain (p0.01) and were described as satisfying operations by 75.8% and 73.3% of the patients, respectively. No significant difference between ALIF and TLIF results could be observed. Complications included dural tears, screw malposition, bleeding from major vessels (ALIF), abdominal wall insufficiency (ALIF), and nerve root injury (TLIF). One patient in the ALIF group and seven patients in the TLIF group required fusion extensions to adjacent levels within the observation period (observation period was 34 and 71 months, respectively).Both ALIF and TLIF techniques can be applied for PDS with equally good results. The technical advantages of ALIF have to be balanced with the additional morbidity and operation time owed to the additional approach. ALIF might be associated with a lower incidence of adjacent level disease compared with TLIF.

BACKGROUND Repair of the anterior skull base for cerebrospinal fluid leak requires either endoscopic endonasal approach or open transcranial approach. OBJECTIVE To present a less invasive surgical procedure for sealing of the entire anterior fossa floor for traumatic rhinoliquorrhea. METHODS Cadaver study in 3 head specimens. Endoscopic placement of a furled bovine pericardial patch bilaterally along the sphenoid ridge and planum in guidewire technique. Unfurling and spreading of the patch under endoscope assistance. RESULTS Patch placement was feasible in all 3 specimens without visible injuries to the frontal lobes. Dissection and preservation of the olfactory tracts was only possible for 50% of olfactory tracts. CONCLUSION Endoscopic transcranial keyhole duraplasty is a promising concept for traumatic rhinoliquorrhea.

A variety of implant-related short and long-term complications after lumbar fusion surgery are recognized. Mid to long-term complications due to cage migration and/or cage subsidence are less frequently reported. Here, we report a patient with a complete cage migration into the superior adjacent vertebral body almost 20 years after the initial posterior lumbar interbody fusion procedure. In this patient, the cage migration/subsidence was clinically silent, but a selective decompression for adjacent segment degenerative lumbar spinal stenosis was performed. We discuss the risk factors for cage migration/subsidence in view of the current literature.