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Andrew Kai-Hong Chan, Winward Choy, Catherine A. Miller, Leslie C. Robinson and Praveen V. Mummaneni

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is associated with improved patient-reported outcomes in well-selected patients. Recently, some neurosurgeons have aimed to further improve outcomes by utilizing multimodal methods to avoid the use of general anesthesia. Here, the authors report on the use of a novel awake technique for MI-TLIF in two patients. They describe the successful use of liposomal bupivacaine in combination with a spinal anesthetic to allow for operative analgesia.

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Winward Choy, Won Kim, Daniel Nagasawa, Stephanie Stramotas, Andrew Yew, Quinton Gopen, Andrew T. Parsa and Isaac Yang

Meningiomas are mostly benign, slow-growing tumors of the CNS that originate from arachnoidal cap cells. While monosomy 22 is the most frequent genetic abnormality found in meningiomas, a multitude of other aberrant chromosomal alterations, signaling pathways, and growth factors have been implicated in its pathogenesis. Losses on 22q12.2, a region encoding the tumor suppressor gene merlin, represent the most common genetic alterations in early meningioma formation. Malignant meningioma progression, however, is associated with more complex karyotypes and greater genetic instability. Cytogenetic studies of atypical and anaplastic meningiomas revealed gains and losses on chromosomes 9, 10, 14, and 18, with amplifications on chromosome 17. However, the specific gene targets in a majority of these chromosomal abnormalities remain elusive.

Studies have also implicated a myriad of aberrant signaling pathways involved with meningioma tumorigenesis, including those involved with proliferation, angiogenesis, and autocrine loops. Understanding these disrupted pathways will aid in deciphering the relationship between various genetic changes and their downstream effects on meningioma pathogenesis.

Despite advancements in our understanding of meningioma pathogenesis, the conventional treatments, including surgery, radiotherapy, and stereotactic radiosurgery, have remained largely stagnant. Surgery and radiation therapy are curative in the majority of lesions, yet treatment remains challenging for meningiomas that are recurrent, aggressive, or refractory to conventional treatments. Future therapies will include combinations of targeted molecular agents as a result of continued progress in the understanding of genetic and biological changes associated with meningiomas.