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Julia Onken, Bernhard Meyer, and Peter Vajkoczy

OBJECTIVE

Cervical artificial disc replacement (C-ADR) is a widely used procedure with low risk at implantation. Few cases have been reported about the surgical techniques of C-ADR revision. The authors describe their surgical experience with the explantation of a Galileo C-ADR.

METHODS

Revision surgery was performed in a 58-year-old patient. Patient positioning and surgical opening techniques were performed as appropriate for anterior cervical decompression.

RESULTS

Revision surgery via the initial anterior approach was successful following an atraumatic removal of the implant. Fusion of the C5–6 segment was performed without complications.

CONCLUSIONS

In general, the authors observed recurrent nerve palsy and malpositioning of the revised implant in C-ADR revision surgery. Problems with implant removal did not occur because the fusion rate was low due to the short time between initial surgery and C-ADR revision surgery.

The video can be found here: https://youtu.be/32CUEDquinc.

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Julia Onken, Kathrin Obermüller, Franziska Staub-Bartelt, Bernhard Meyer, Peter Vajkoczy, and Maria Wostrack

OBJECTIVE

Spinal meningiomas (sMNGs) are relatively rare in comparison to intracranial MNGs. sMNGs localized anterior to the denticulate ligament (aMNGs) represent a surgically challenging subgroup. A high perioperative complication rate due to the need for complex surgical approaches has been described. In the present study, the authors report on their surgical experience that involves two institutions in which 207 patients underwent surgery for sMNGs. Special focus was placed on patients with aMNGs that were treated via a unilateral posterior approach (ULPA).

METHODS

Between 2005 and 2017, 207 patients underwent resection of sMNGs at one of two institutions. The following characteristics were assessed: tumor size and localization, surgical approach, duration of surgery, grade of resection, peri- and postoperative complication rates, and neurological outcome. Data were compared between the subgroups of patients according to the lesion’s relationship to the denticulate ligament and to surgical approach.

RESULTS

The authors identified 48 patients with aMNGs, 86 patients with lateral MNGs, and 76 patients with posterior MNGs (pMNGs). Overall, 66.6% of aMNGs and 64% of pMNGs were reached via a ULPA. aMNGs that were approached via a ULPA showed reduced duration of surgery (131 vs 224 minutes, p < 0.0001) and had surgical complication rates and neurological outcomes comparable to those of lesions that were approached via a bilateral approach. No significant differences in complication rate, outcomes, and extent of resection were seen between aMNGs and pMNGs.

CONCLUSIONS

The duration of surgery, extent of resection, and outcomes are comparable between aMNGs and pMNGs when removed via a ULPA. Thus, ULPA represents a safe route to achieve a gross-total resection, even in cases of aMNG.

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Maria Wostrack, Florian Ringel, Sven O. Eicker, Max Jägersberg, Karl Schaller, Johannes Kerschbaumer, Claudius Thomé, Ehab Shiban, Michael Stoffel, Benjamin Friedrich, Victoria Kehl, Peter Vajkoczy, Bernhard Meyer, and Julia Onken

OBJECTIVE

Spinal 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.

METHODS

The 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.

RESULTS

Gross-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).

CONCLUSIONS

Due 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.

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Vanessa Hubertus, Jens Gempt, Michelle Mariño, Björn Sommer, Sven O. Eicker, Martin Stangenberg, Marc Dreimann, Insa Janssen, Christoph Wipplinger, Arthur Wagner, Nicole Lange, Ann-Kathrin Jörger, Marcus Czabanka, Veit Rohde, Karl Schaller, Claudius Thomé, Peter Vajkoczy, Julia S. Onken, and Bernhard Meyer

OBJECTIVE

Surgical management of spinal metastases at the cervicothoracic junction (CTJ) is highly complex and relies on case-based decision-making. The aim of this multicentric study was to describe surgical procedures for metastases at the CTJ and provide guidance for clinical and surgical management.

METHODS

Patients eligible for this study were those with metastases at the CTJ (C7–T2) who had been consecutively treated in 2005–2019 at 7 academic institutions across Europe. The Spine Instability Neoplastic Score, neurological function, clinical status, medical history, and surgical data for each patient were retrospectively assessed. Patients were divided into four surgical groups: 1) posterior decompression only, 2) posterior decompression and fusion, 3) anterior corpectomy and fusion, and 4) anterior corpectomy and 360° fusion. Endpoints were complications, surgical revision rate, and survival.

RESULTS

Among the 238 patients eligible for inclusion this study, 37 were included in group 1 (15%), 127 in group 2 (53%), 18 in group 3 (8%), and 56 in group 4 (24%). Mechanical pain was the predominant symptom (79%, 189 patients). Surgical complications occurred in 16% (group 1), 20% (group 2), 11% (group 3), and 18% (group 4). Of these, hardware failure (HwF) occurred in 18% and led to surgical revision in 7 of 8 cases. The overall complication rate was 34%. In-hospital mortality was 5%.

CONCLUSIONS

Posterior fusion and decompression was the most frequently used technique. Care should be taken to choose instrumentation techniques that offer the highest possible biomechanical load-bearing capacity to avoid HwF. Since the overall complication rate is high, the prevention of in-hospital complications seems crucial to reduce in-hospital mortality.