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Extracellular vesicles (EVs) transport biomolecules that could serve as biomarkers for disease diagnosis and monitoring. The clinical utility of EVs derived from cerebrospinal fluid (CSF) in patients with intradural spinal tumors (IST) has not yet been investigated. Here, we obtained EVs from CSF of adult patients with intraspinal ependymoma (n = 9), meningioma (n = 9), hemangioma (n = 4) and schwannian tumors (n = 7), as well as comparison group (‘CG’, normal pressure hydrocephalus, n = 7), by ultrafiltration. CSF-EVs were characterized by electron microscopy and nanoparticle tracking analysis. EV populations according to the presence of tetraspanins (CD9, CD63, CD81) were measured by imaging flow cytometry (IFCM). CD81 + EVs were more prevalent in the comparison group, meningioma, ependymoma WHO grade 2, and hemangioma, whereas CD9 + EVs were predominant in ependymoma grade 1 and Schwannian tumors. CD63 + EVs per milliliter/CSF differed between ependymoma WHO grades 1 and 2 (FC = 24.6, AUC = 90%, p  < 0.05). Based on results from a bead-based multiplex profiling, we selected ITGB1, CD44, CD133 and HLA-DR/DQ/DP for further phenotyping in CSF-EVs using IFCM, in combination with each tetraspanin as double-positive subpopulations. Compared to CG, CD44 + EVs were the most relevant population in CSF from IST patients, followed by ITGB1. Notable differences in absolute (EVs/mL CSF) and relative (percentages of CSF-EVs) levels were: CD44 + /CD81 + for ependymoma grade 1 (FC = 196.5 and 34.5; p  < 0.01) and grade 2 (%FC = 6.1, p  < 0.05); CD44 + /CD63 + for meningioma (abs. and %FC > 1000, p  < 0.05); ITGB1 + /CD81 + for hemangioma (%FC = 4.8, p  < 0.05); and ITGB1 + /CD9 + for schwannian tumors (abs.FC = 19.8, p  < 0.01). In conclusion, we identified distinct EV subpopulations in the CSF of IST patients, potentially facilitating tumor classification.

Our aim was to identify the impact of different surgical strategies on the incidence of C5 palsy. Degenerative cervical spinal stenosis is a steadily increasing morbidity in the ageing population. Postoperative C5 nerve root palsy is a common complication with severe impact on the patients´ quality of life. We identified 1708 consecutive patients who underwent cervical decompression surgery due to degenerative changes. The incidence of C5 palsy and surgical parameters including type and level of surgery were recorded to identify predictors for C5 nerve palsy. The overall C5 palsy rate was 4.8%, with 18.3% of cases being bilateral. For ACDF alone the palsy rate was low (1.13%), compared to 14.0% of C5 palsy rate after corpectomy. The risk increased with extension of the procedures. Hybrid constructs with corpectomy plus ACDF at C3-6 showed significantly lower rates of C5 palsy (10.7%) than corpectomy of two vertebrae (p = 0.005). Multiple regression analysis identified corpectomy of C4 or C5 as a significant predictor. We observed a lower overall incidence for ventral (4.3%) compared to dorsal (10.9%) approaches (p<0.001). When imaging detected a postoperative shift of the spinal cord at index segment C4/5, palsy rate increased significantly (33.3% vs. 12.5%, p = 0.034). Extended surgical strategies, such as dorsal laminectomies, multilevel corpectomies and procedures with extensive spinal cord shift were shown to display a high risk of C5 palsy. The use of extended procedures should therefore be employed cautiously. Switching to combined surgical methods like ACDF plus corpectomy can reduce the rate of C5 palsy.

IntroductionPrimary malignant spinal astrocytomas present rare oncological entities with limited median survival and rapid neurological deterioration. Evidence on surgical therapy, adjuvant treatment, and neurological outcome is sparse. We aim to describe the treatment algorithm and clinical features on patients with infiltrating intramedullary astrocytomas graded WHO II–IV.MethodsThe following is a multicentered retrospective study of patients treated for spinal malignant glioma WHO II–IV in five high-volume neurosurgical departments from 2008 to 2019. Pilocytic astrocytomas were excluded. We assessed data on surgical technique, perioperative neurological status, adjuvant oncological therapy, and clinical outcome.Results40 patients were included (diffuse astrocytoma WHO II n = 11, anaplastic astrocytoma WHO III n = 12, WHO IV n = 17). Only 40% were functionally independent before surgery, most patients presented with moderate disability (47.5%). Most patients underwent a biopsy (n = 18, 45%) or subtotal tumor resection (n = 15, 37.5%), and 49% of the patients deteriorated after surgery. Patients with WHO III and IV tumors were treated with combined radiochemotherapy. Median overall survival (OS) was 46.5 months in WHO II, 25.7 months in WHO III, and 7.4 months in WHO IV astrocytomas. Preoperative clinical status and WHO significantly influenced the OS, and the extent of resection did not.ConclusionInfiltrating intramedullary astrocytomas WHO II–IV present rare entities with dismal prognosis. Due to the high incidence of surgery-related neurological impairment, the aim of the surgical approach should be limited to obtaining the histological tissue via a biopsy or, tumor debulking in cases with rapidly progressive severe preoperative deficits.

Cement augmentation via percutaneous vertebroplasty or kyphoplasty for treatment of spinal metastasis is a well-established treatment option. We assessed whether elevated intrametastatic pressure during cement augmentation results in an increased dissemination of tumour cells into the vascular circulation. We prospectively collected blood from patients with osteolytic spinal column metastases and analysed the prevalence of circulating tumour cells (CTCs) at three time-points: preoperatively, 20 minutes after cement augmentation, and 3–5 days postoperatively. Enrolling 21 patients, including 13 breast- (61.9%), 5 lung- (23.8%), and one (4.8%) colorectal-, renal-, and prostate-carcinoma patient each, we demonstrate a significant 1.8-fold increase of EpCAM+/K+ CTCs in samples taken 20 minutes post-cement augmentation ( P  < 0.0001). Despite increased mechanical CTC dissemination due to cement augmentation, follow-up blood draws demonstrated that no long-term increase of CTCs was present. Array-CGH analysis revealed a specific profile of the CTC collected 20 minutes after cement augmentation. This is the first study to report that peripheral CTCs are temporarily increased due to vertebral cement augmentation procedures. Our findings provide a rationale for the development of new prophylactic strategies to reduce the increased release of CTC after cement augmentation of osteolytic spinal metastases.

PurposeSpinal abnormalities frequently occur in patients with mucopolysaccharidosis (MPS) types I, II, IV, and VI. The symptoms are manifold, which sometimes prolongs the diagnostic process and delays therapy. Spinal stenosis (SS) with spinal cord compression due to bone malformations and an accumulation of storage material in soft tissue are serious complications of MPS disease. Data on optimal perioperative therapeutic care of SS is limited.MethodsA retrospective chart analysis of patients with MPS and SS for the time period 01/1998 to 03/2021 was performed. Demographics, clinical data, neurological status, diagnostic evaluations (radiography, MRI, electrophysiology), and treatment modalities were documented. The extent of the SS and spinal canal diameter were analyzed. A Cox regression analysis was performed to identify prognostic factors for neurological outcomes.ResultsOut of 209 MPS patients, 15 were included in this study. The most dominant type of MPS was I (–H) (n = 7; 46.7%). Preoperative neurological deterioration was the most frequent indication for further diagnostics (n = 12; 80%). The surgical procedure of choice was dorsal instrumentation with microsurgical decompression (n = 14; 93.3%). A univariate Cox regression analysis showed MPS type I (–H) to be associated with favorable neurological outcomes.ConclusionEarly detection of spinal stenosis is highly relevant in patients with MPS. Detailed neurological assessment during follow-up is crucial for timeous detection of patients at risk. The surgical intervention of choice is dorsal instrumentation with microsurgical decompression and resection of thickened intraspinal tissue. Patients with MPS type I (–H) demonstrated the best neurological course.

Purpose Intradural spinal hemangioblastomas are rare highly hypervascularized benign neoplasms. Surgical resection remains the treatment of choice, with a significant risk of postoperative neurological deterioration. Due to the tumor infrequency, scientific evidence is scarce and limited to case reports and small case series. Methods We performed a retrospective multicenter study including five high-volume neurosurgical centers analyzing patients surgically treated for spinal hemangioblastomas between 2006 and 2021. We assessed clinical status, surgical data, preoperative angiograms, and embolization when available. Follow-up records were analyzed, and logistic regression performed to assess possible risk factors for neurological deterioration. Results We included 60 patients in Germany and Austria. Preoperative angiography was performed in 30% of the cases; 10% of the patients underwent preoperative embolization. Posterior tumor location and presence of a syrinx favored gross total tumor resection (93.8% vs. 83.3% and 97.1% vs. 84%). Preoperative embolization was not associated with postoperative worsening. The clinical outcome revealed a transient postoperative neurological deterioration in 38.3%, depending on symptom duration and preoperative modified McCormick grading, but patients recovered in most cases until follow-up. Conclusion Spinal hemangioblastoma patients significantly benefit from early surgical treatment with only transient postoperative deterioration and complete recovery until follow-up. The performance of preoperative angiograms remains subject to center disparities.

Surgery for isthmic and degenerative spondylolisthesis (SL) in adults is carried out very frequently in everyday practice. However, it is still unclear whether the results of surgery are better than those of conservative treatment and whether decompression alone or instrumented fusion with decompression should be recommended. In addition, the role of reduction is unclear. Four clinically relevant key questions were addressed in this study: (1) Is surgery more successful than conservative treatment in relation to pain and function in adult patients with isthmic SL? (2) Is surgery more successful than conservative treatment in relation to pain and function in adult patients with degenerative SL? (3) Is instrumented fusion with decompression more successful in relation to pain and function than decompression alone in adult patients with degenerative SL and spinal canal stenosis? (4) Is instrumented fusion with reduction more successful in relation to pain and function than instrumented fusion without reduction in adult patients with isthmic or degenerative SL? A systematic PubMed search was carried out to identify randomized and nonrandomized controlled trials on these topics. Papers were analyzed systematically in a search for the best evidence. A total of 18 studies was identified and analyzed: two for question 1, eight for question 2, four for question 3, and four for question 4. Surgery appears to be better than conservative treatment in adults with isthmic SL (poor evidence) and also in adults with degenerative SL (good evidence). Instrumented fusion with decompression appears to be more successful than decompression alone in adults with degenerative SL and spinal stenosis (poor evidence). Reduction and instrumented fusion does not appear to be more successful than instrumented fusion without reduction in adults with isthmic or degenerative SL (moderate evidence).

Purpose 5-Aminolevulinic acid (5-ALA)-based fluorescence-guided surgery was shown to be beneficial for cerebral malignant gliomas. Extension of this technique for resection of meningiomas and cerebral metastasis has been recently evaluated. Aim of the present study is to evaluate the impact of fluorescence-guided surgery in spinal tumor surgery. Methods Twenty-six patients with intradural spinal tumors were included in the study. 5-ALA was administered orally prior to the induction of anesthesia. Intraoperative, 440 nm fluorescence was applied after exploration of the tumor and, if positive, periodically during and at the end of resection to detect tumor-infiltrated sites. Results Tumors of WHO grade III and IV were found in five patients. In detail intra- or perimedullary metastasis of malignant cerebral gliomas was found including glioblastoma WHO grade IV ( n  = 2), anaplastic astrocytoma WHO grade III ( n  = 1), anaplastic oligoastrocytoma WHO grade III ( n  = 1). In addition, one patient suffered from a spinal drop metastasis of a cerebellar medulloblastoma WHO grade IV. Tumors of WHO grade I were diagnosed in 18 patients: Eight cases of meningioma (two recurrences), six cases of neurinoma, one neurofibroma, two ependymoma and one plexus papilloma. At least, benign pathologies were histologically proven in three patients. All four spinal metastasis of malignant glioma (100 %), seven of eight meningiomas (87.5 %) and one of two ependymoma (50 %) were found to be ALA-positive. Conclusion The present study demonstrates that spinal intramedullary gliomas and the majority of spinal intradural meningiomas are 5-ALA positive. As a surgical consequence, especially in intramedullary gliomas, the use of 5-ALA fluorescence seems to be beneficial.

PurposeSpinal diseases requiring urgent surgical treatment are rare during pregnancy. Evidence is sparse and data are only available in the form of case reports. Our aim is to provide a comprehensive guide for spinal surgery on pregnant patients and highlight diagnostic and therapeutic aspects.MethodsThe study included a cohort of consecutive pregnant patients who underwent spinal surgery at five high-volume neurosurgical centers between 2010 and 2017. Perioperative and perinatal clinical data were derived from medical records.ResultsTwenty-four pregnant patients were included. Three underwent a preoperative cesarean section. Twenty-one patients underwent surgery during pregnancy. Median maternal age was 33 years, and median gestational age was 13 completed weeks. Indications were: lumbar disk prolapse (n = 14; including cauda equina, severe motor deficits or acute pain), unstable spine injuries (n = 4); intramedullary tumor with paraparesis (n = 1), infection (n = 1) and Schwann cell nerve root tumor presenting with high-grade paresis (n = 1). Two patients suffered transient gestational diabetes and 1 patient presented with vaginal bleeding without any signs of fetal complications. No miscarriages, stillbirths, or severe obstetric complications occurred until delivery. All patients improved neurologically after the surgery.ConclusionSpinal surgical procedures during pregnancy seem to be safe. The indication for surgery has to be very strict and surgical procedures during pregnancy should be reserved for emergency cases. For pregnant patients, the surgical strategy should be individually tailored to the mother and the fetus.