Aim:. Recent guidelines have been published by the Association of Neurophysiological Scientists / British Society for Clinical Neurophysiology (ANS/BSCN) regarding the use of intra-operative neurophysiological monitoring (IOM) during spinal deformity procedures. We present our unit's experience with IOM and the compliance with national guidelines. Method:. All patients undergoing intra-operative spinal cord monitoring during adult and paediatric spinal deformity surgery between Jan 2009 and Dec 2012 were prospectively followed. The use of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) was recorded and monitoring outcomes were compared to post-operative clinical neurological outcomes. Compliance with the national ANS/BSCN guidelines was assessed. Results:. 333 patients were included in this study. IOM was successful in 312 patients (94%), with both MEPs and SSEPs obtained in 282 patients (85%). SEPs were achieved in 91% and MEPs in 87%. Aetiology was idiopathic in 199 cases, 53 neuromuscular, 28 degenerative, 16 congenital, 16 other. Nine patients had changes in IOM related to surgical activity; six had MEP changes only, three had MEPs and SSEPs changes. All but one of these changes returned to baseline following surgical action; the one remaining patient had a temporary postoperative neurological deficit. One patient had a post-operative single radiculopathy requiring surgical exploration, without change in initial IOM. Final IOM findings demonstrated a positive predictive value (PPV) of 1 and a negative predictive value (NPV) of 0.996. Discussion:. IOM is essential during spinal deformity surgery and, using MEPs, has a high PPV and NPV. Our unit meets guidelines for MEP use and frequently meets guidelines for SSEP use. Conflict Of Interest Statement: No conflict of interest

Purpose: The purpose of this study was to assess the efficacy and safety of treating extra-foramen discal herniation via a microsurgical extra-foramen approach. Material and methods: Fourteen patients underwent this surgical procedure which enables release of the roots outside the foramen while preserving the vertebral isthma. The technique is described in detail together with the postoperative period. All patients were reviewed clinically and radiologically at at least one year. The PROLO score was used to assess results. Results: Among the 14 operated patients, good or excellent results were obtained in 13, fair results in one. There was no postoperative neurological deficit. The small number of cases in this series did not allow a statistical analysis of this uncommon clinical presentation. Discussion: The extra-formamen approach is an interesting alternative to isthmic resection requiring fixation for the treatment of disc-root conflicts in the extra-foramen position. With appropriate surgical skill, the technique is safe

Purpose of Study: To observe the efficiency of the combined motor-somatosensory monitoring and somatosensory-alone monitoring to identify the intra-operative neurologic changes. Methods and Results: We retrospectively assessed 123 cases in our centre, who had complete neurophysiological report while undergoing corrective spinal deformity surgery with spinal monitoring, from 2004 to 2008. Combined motor-somatosensory, somatosensory-alone and motor-alone monitoring were applied in sixty five, fifty and eight operations, respectively. We also looked at the factors that could potentially affect the neuro-physiologic monitoring, such as preoperative neurological status, anaesthetic method, blood loss, competency level of the monitoring team and the reaction of the surgical team to a significant monitoring event. In total, there were only two cases of true positive event, defined as a significant intraoperative event and postoperative neurological deficit. Both of these cases had combined monitoring during their procedures. No case of false negative was observed. There were also five cases with a significant intraoperative event without post operative neurologic sequel (false positive). Four of these had combined monitoring, with complete normal sensory monitoring and abnormal motor monitoring, which prompted the operating team to the appropriate action. Conclusion: Based on this observation, it is felt that the combined monitoring during spinal deformity correction procedures is superior to the sensory-alone monitoring for identifying the impending neurologic deficits. This is in accordance with the previous reports and recommendations

Sacrococcygeal chordoma is a slow growing, malignant tumour with a clinical poor outcome due to a high local recurrence (LR) rate. Several studies emphasize that margin-free tumour resection is the most important predictor of survival and LR in patients with sacrococcygeal chordoma. However, a high recurrence rate still remains. The purpose of this report is to define the role of postoperative radiotherapy (RT). 15 patients (7 females and 8 males) underwent surgical treatment for sacrococcygeal chordoma between 1981 and 2003. The mean age at surgery was 54 (range 31–70) years. The mean follow up was 8.5 (range 4 – 20) years. Most patients suffered from local swelling and pain; only one patient had a mild urinary continence being the only pre- and postoperative neurological deficit. Mean time of preoperative complaints was 4.5 (range 0.8 – 8) years. In 9 patients an en bloc resection was performed, in 6 patients a subtotal resection was achieved. Most patients with a subtotal resection received RT (5/6 patients) following surgery, patients with en bloc resection only received RT (> 50Gray) after LR (6/9 patients). After en bloc resection (no initial RT) all patients had local recurrence of the tumour with a mean time to recurrence of 3 (range 0.8 – 13) yrs. Only two patients in the group with subtotal resection had LR after 11 yrs. Six of 9 patients with LR after en bloc surgery received RT after recurrence and had a survival of at least 9 (range 5 – 20) years. There were no major complications. The time to recurrence was significantly longer in the group that received immediate RT after surgery, even after resection with irradical margins. There was no difference in survival between both surgical groups. Our results suggest that postoperative RT is more important in the prevention of local recurrence than margin-free tumour resection. This supports the strategy to add radiotherapy as a standard adjuvant therapy to tumour resection in patients with sacrococcygeal chordoma

Purpose: Isolated tumours of the peripheral nerves are exceptional and benign in 90% of the cases. They develop from the constitutive elements of the nerve and correspond to schwannomas in 80% of cases. Other tumours are much more rare and exhibit wide histological variability. Material and methods: Fifty-one patients were reviewed at mean 4.6 years. Forty-one had a resectable tumour: schwannoma (n=39), intranervous lipoma (n=2). Ten an unresectable tumour: solitary neurofibroma (n=5), peri-nervous hemangioma (n=3), neurofibrolipoma (n=2). We detailed the type of lesion, diagnostic elements, and results of complementary explorations. Enucleation was performed for resectable tumours. Epineurotomy for decompression with systematic interfascicular biopsy was performed in the event of an unresectable tumour. Results: Postoperative neurological deficits were exceptional and transient. In a first case, prognosis was excellent due to the absence of recurrence or degeneration. In the second, neurological disorders persisted but decreased (paraesthesia). The course remained stable. Discussion: Our findings are in line with reports in the literature. The diagnosis of nerve tumour should be entertained in the event of tumefaction along a nerve trajectory or if palpation triggers pain. MRI is the most powerful complementary exploration, particularly for deep tumours. The nature of the tumour, its benignity, and the possibility for resection can be suspected on the basis of clinical and complementary findings, but surgery and pathology examination of the surgical specimen are required for confirmation. Preservation of nerve continuity is the key to the therapeutic approach. For resectable tumours, exceptional persistence of symptoms should be followed by a new exploration to search for small unrecognised tumour(s) at the same operative site. For all other cases, recent and rapid changes in the clinical presentation is a sign of recurrence and requires appropriate intervention. To our knowledge, malignant degeneration has never been observed. Conclusion: First-intention resection of a nerve with a nerve tumour is never indicated

Introduction: Total en bloc spondylectomy (TES) as the only radical treatment option for sarcoma and solitary metastases of the spine was shown to markedly minimize local recurrences, improve patient quality of life and substantially increase overall survival rates. This study analyzes the onco-surgical results after multilevel thoracolumbar TES and reconstruction with a carbon composite vertebral body replacement system (CC-VBR) in a collective of patients. Methods: 26 patients (14f/12m; age 52±14y) treated with thoracolumbar multilevel TES (10x2, 12x3, 3x4, 1x5 segments) for spinal sarcomas (n=16), solitary metastases (n=5) and aggressive primary tumors (n=5) were retrospectively investigated. According to the classification system of Tomita et al. all patients were surgically staged as type 6 (multisegmental/extracom-partimental). Defect reconstruction (14 thoracic, 6 thoraco-lumbar and 6 lumbar) were performed with posterior stabilization and a CC-VBR. Patient charts and the current clinical follow-up results were analyzed for histopathological tumor type, pre- and postoperative data (symptoms, duration of surgery, blood loss, complications, intensive care, adjuvant therapies etc.) and course of disease. Latest radiographs and CT-scans were analyzed at follow up. Oncological status was evaluated using cumulative disease specific and metastases-free survival analysis. Results: With a mean follow up (100%) of 18 (4–44) months 24 patients (92%) were postoperatively ambulatory without any support. Postoperative neurological deficits were seen in two patient (8%). Wide resection margins were attained in 9, marginal in 17 patients. Depending on tumor biology/grading and/or resections margins an adjuvant therapy (radiation/chemotherapy) was performed in 18 (69%) patients. Local recurrence was found in two patient (8%). 19 (73%) patients showed no evidence of disease, 3 were alive with disease while 2 died of disease at 10 and 27 months postoperatively. Conclusion: In selected patients with multisegmental spinal tumor involvement oncological sufficient resections can be reached by multilevel TES. Although the surgical procedure is challenging and the patient’s stress is considerable our encouraging midterm results together with the low complication rate clearly favour and legitimate this technique. However, treatment success strongly depends on adjuvant therapies. Reconstruction with a CC-VBR showed low complication rates, promising biomechanical characteristics, increased volume for bone grafting and lower artefact rates in follow-up MR- and CT-imaging

Introduction: Total en bloc spondylectomy (TES) as the only radical treatment option for sarcoma and solitary metastases of the spine was shown to markedly minimize local recurrences, improve patient quality of life and substantially increase overall survival rates. Due to surgical difficulty of TES and complex biomechanical demands in defect reconstruction multisegmental tumor involvement of the spine has long been considered as a palliative situation, exceeding the limits of surgical feasibility. Thus, multilevel resections reports are very rare. For the first time, this study analyzes the onco-surgical results after multilevel thoracolumbar TES and reconstruction with a carbon composite vertebral body replacement system (CC-VBR) in a collective of patients. Methods: 18 patients (9f/9m; age 52±14y) treated with thoracolumbar multilevel TES (6x2, 9x3, 3x4 segments) for spinal sarcomas (n=9), solitary metastases (n=5) and aggressive primary tumors (n=3) were retrospectively investigated. According to the classification system of Tomita et al. all patients were surgically staged as type 6 (multisegmental/extracompartimental). Defect reconstruction (11 thoracic, 3 thoracolumbar and 4 lumbar) were performed with posterior stabilization and a CC-VBR. Patient charts and the current clinical follow-up results were analyzed for histopathological tumor type, pre- and postoperative data (symptoms, duration of surgery, blood loss, complications, intensive care, adjuvant therapies etc.) and course of disease. Latest radiographs and CT-scans were analyzed at follow up. Oncological status was evaluated using cumulative disease specific and metastases-free survival analysis. Results: With a mean follow up (100%) of 18 (4–44) months 17 patients (94%) were postoperatively ambulatory without any support. Postoperative neurological deficits were seen in one patient (6%). Wide resection margins were attained in 7, marginal in 11 patients. Depending on tumor biology/grading and/or resections margins an adjuvant therapy (radiation/chemotherapy) was performed in 12 (67%) patients. Local recurrence was found in one patient (6%). 13 (72%) patients showed no evidence of disease, 3 were alive with disease while 2 died of disease at 10 and 27 months postoperatively. Conclusion: In selected patients with multisegmental spinal tumor involvement oncological sufficient resections can be reached by multilevel TES. Although the surgical procedure is challenging and the patient’s stress is considerable our encouraging midterm results together with the low complication rate clearly favour and legitimate this technique. However, treatment success strongly depends on adjuvant therapies. Reconstruction with a CC-VBR showed low complication rates, promising biomechanical characteristics, increased volume for bone grafting and lower artefact rates in follow-up MR- and CT-imaging