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Background: Massive intraoperative blood loss (IBL) is a serious complication in complex spine surgeries such as deformity correction, multilevel fusion, tumor resection, and revision procedures. While no strict definition exists, blood loss exceeding 1500 mL or 20% of estimated blood volume is generally considered clinically significant. Excessive bleeding increases the risk of hemodynamic instability, transfusion-related complications, postoperative infection, and prolonged hospitalization. Methods: This narrative review summarizes the current understanding of the incidence, risk factors, anatomical vulnerabilities, and evidence-based strategies for managing IBL in spine surgery through comprehensive literature analysis of recent studies and clinical guidelines. Results: Key risk factors include patient characteristics (anemia, obesity, advanced age, medication use), surgical variables (multilevel instrumentation, revision status, operative time), and pathological conditions (hypervascular tumors, severe deformity). Perioperative medication management is critical, requiring discontinuation of NSAIDs (5–7 days), antiplatelet agents (5–7 days), and NOACs (48–72 h) preoperatively to minimize bleeding risk. The thoracolumbar junction and hypervascular spinal lesions are especially prone to bleeding due to dense vascular anatomy. Evidence-based management strategies include comprehensive preoperative optimization, intraoperative hemostatic techniques, antifibrinolytic agents, topical hemostatic products, cell salvage technology, and structured transfusion protocols. Conclusions: Effective management of massive IBL requires a multimodal approach combining preoperative risk assessment and medication optimization, intraoperative hemostatic strategies including tranexamic acid administration, advanced monitoring techniques, and coordinated transfusion protocols. Particular attention to perioperative management of anticoagulant and antiplatelet medications is essential for bleeding risk mitigation. Understanding patient-specific risk factors, surgical complexity, and anatomical considerations enables surgeons to implement targeted prevention and management strategies, ultimately improving patient outcomes and reducing complications in high-risk spine surgery procedures.

Background: In recent decades, the adoption of minimally invasive (non-endoscopic) cervical techniques has grown significantly. Advancements in surgical instrumentation have broadened the spectrum of available percutaneous interventions, thus providing viable alternative treatment options for patients with prolonged, conservative treatment-resistant ailments due to contained cervical disc herniation. The aim of this study was to perform a systematic review and meta-analysis in order to evaluate the effectiveness and safety of minimally invasive percutaneous (non-endoscopic) cervical techniques. Methods: A comprehensive literature search was conducted using the PubMed, Cochrane Library, and SCOPUS databases up to July 2024, in accordance with the PRISMA guidelines. Outcomes measured included Visual Analogue Scale (VAS) scores, the Neck Disability Index (NDI), and MacNab scores, assessing pain relief and functional recovery. The risk of bias was evaluated using the Cochrane risk of bias tool (RoB 2) and the risk of bias in nonrandomized studies of interventions (ROBINS-I) tool, with statistical analyses conducted in R software (version 4.3.1). Results: Out of 847 records, 21 studies (covering 1580 patients) were included in the final analysis. Five different percutaneous minimally invasive cervical procedures were incorporated into this review: nucleoplasty (n = 973), discectomy (n = 311), a combination of nucleoplasty and discectomy (n = 98), annuloplasty (n = 33), and pulsed radiofrequency (n = 17). The mean patient age was 49.5, with a gender distribution of 47.7% male and 52.3% female. A meta-analysis of six studies on cervical nucleoplasty (400 patients) demonstrated a significant reduction in pain scores, with a standardized mean difference (SMD) of −4.68 (95% CI: −8.77; −0.59, p = 0.032). However, a high heterogeneity (I2 = 98.8%, Q = 407.31, p < 0.001) was observed, indicating significant variability across studies. The reoperation rate among patients was 3.4%, with discitis and device-related complications being the most frequently reported adverse events. Conclusions: Minimally invasive percutaneous cervical interventions provide effective pain relief and functional improvement for patients with cervical disc herniation, as evidenced by reductions in VAS scores and positive MacNab outcomes. The choice of the most appropriate technique should be based on individual clinical scenarios, surgeon expertise, and patient preferences, as no single method demonstrates clear superiority according to clinical outcomes or complication rates.

Background: Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) enables the intraoperative visualization of glioma. However, its effectiveness varies based on tumor subtype and molecular profile, posing challenges for achieving complete resection. Our systematic review aims to explore the relationship between IDH mutation status and intraoperative fluorescence visualization. Importantly, this is the first study to propose that vorasidenib, an emerging IDH-targeting agent, could enhance 5-ALA-guided surgery, marking a novel direction for translational research. Methods: A systematic literature search was conducted using the PubMed, Cochrane Library, Scopus and Web of Science databases up to May 2025, following PRISMA guidelines. The primary outcomes included fluorescence detection rates across different glioma subtypes and their correlation with IDH mutation status. Secondary outcomes comprised surgical efficacy measures such as gross total resection (GTR), overall survival (OS), and progression-free survival (PFS). Additionally, we analyzed the metabolic consequences of IDH mutations and evaluated the potential role of vorasidenib in enhancing 5-ALA-induced fluorescence. Results: Seven studies including 621 patients included in the final analysis. Fluorescence detection was nearly universal in WHO grade 4 gliomas (94–100%), but lower in grade 3 (43–85%) and rare in grade 2 (7–26%). Several cohorts reported reduced fluorescence in IDH-mutant gliomas, although this was not consistent across all studies. In high-grade gliomas, visible fluorescence correlated with higher GTR rates and, in some series, longer OS. Conversely, in lower-grade IDH-mutant gliomas, fluorescence did not increase GTR and was associated with worse PFS and OS. Conclusions: The effectiveness of 5-ALA-guided fluorescence in glioma surgery is significantly influenced by both tumor grade and IDH mutation status. Vorasidenib may represent a potential avenue for modulating tumor metabolism and enhancing intraoperative fluorescence in IDH-mutant gliomas, a hypothesis that warrants further experimental validation.

Background: Contained lumbar disc herniation is a prevalent cause of chronic low back pain and functional impairment. The Disc-FX system, a minimally invasive, percutaneous technique integrating nucleotomy, nucleus ablation, and annuloplasty, offers a multimodal approach to managing early degenerative disc disease. Despite promising short-term outcomes, evidence regarding long-term effectiveness remains limited. Methods: This single-center cohort study evaluated 197 patients (median age: 48 years; 56.85% female) who underwent the Disc-FX procedure between 2017 and 2024. Patients were followed for up to 84 months. Pain and disability were assessed using a Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI), respectively, while satisfaction was measured by the MacNab criteria. Multivariable models, including cumulative link models and linear mixed-effects models, were used to identify predictors of outcomes. Results: The Disc-FX procedure resulted in significant and sustained improvements in pain and function. Mean VAS scores decreased from 7.79 preoperatively to 4.31 at 12 months and remained below baseline at 84 months (5.05). ODI scores improved from 15.43 preoperatively to 9.62 at 36 months, rising slightly to 12.75 at 84 months. Good or excellent outcomes were reported in 66.9% of patients according to MacNab criteria. Male sex (OR = 0.41), longer symptom duration (OR = 0.85), and presence of radicular symptoms (OR = 0.39) were significantly associated with less favorable outcomes. Reoperation occurred in 26.4% of cases, predominantly within the first year and most frequently at L4/L5. Complications were rare (3.08%). Conclusions: This study provides robust evidence supporting the long-term clinical efficacy of the Disc-FX procedure in selected patients with contained lumbar disc herniation. While overall outcomes are favorable, optimal results depend on early intervention and careful patient selection, particularly in relation to symptom chronicity and the presence of radicular signs.

Introduction: The NF-κB signaling pathway is a key regulator of oncogenic processes; however, its systemic role in meningiomas remains poorly understood. The aim of this pilot study was to evaluate the expression of genes encoding NF-κB isoforms and IKK complex subunits in peripheral blood mononuclear cells (PBMCs) of patients with meningiomas prior to tumor resection. Methods: The study included 31 patients with meningiomas (WHO grades G1-G3) and 18 healthy volunteers. PBMCs were isolated using density gradient centrifugation, and total RNA was extracted. mRNA expression levels of NFKB1, NFKB2, RELA, RELB, c-REL, CHUK, IKBKB, and IKBKG were quantified by real-time PCR, with GAPDH used as the reference gene. Results: In patients with meningiomas, significantly lower expression of NFKB1 and higher expression of RELA, CHUK, and IKBKB were observed compared with the control group. NFKB1 expression was significantly higher in patients with higher tumor grades (WHO G2/G3) than in those with grade G1 tumors. Moreover, male patients exhibited higher expression levels of c-REL, CHUK, and IKBKB than female patients. Strong positive correlations were observed between components of the canonical NF-κB pathway. Discussion: The results may indicate systemic dysregulation of the NF-κB pathway in immune cells of patients with meningiomas, potentially characterized by activation of the canonical pathway and a shift toward p65/p65 homodimer formation. These alterations could reflect mechanisms associated with immunosuppression. NFKB1 expression may warrant further investigation as a candidate peripheral biomarker of tumor aggressiveness, while the observed sexual dimorphism in gene expression might suggest that sex could represent a relevant factor, requiring confirmation in prospective studies.

Proline metabolism has been identified as a significant player in several neoplasms, but knowledge of its role in gliomas is limited despite it providing a promising line of pursuit. Data on proline metabolism in the brain are somewhat historical. This study aims to investigate alterations of proline metabolism in gliomas of WHO grade 4 (GG4) in the context of the brain. A total of 20 pairs of samples were studied, consisting of excised tumor and unaffected brain tissue, obtained when partial brain resection was required to reach deep-seated lesions. Levels of proline oxidase/proline dehydrogenase (POX/PRODH), Δ1-pyrroline-5-carboxylate reductases (PYCR1/2/3), prolidase (PEPD), and metalloproteinases (MMP-2, MMP-9) were assessed, along with the concentration of proline and proline-related metabolites. In comparison to normal brain tissue, POX/PRODH expression in GG4 was found to be suppressed, while PYCR1 expression and activity of PEPD, MMP-2, and -9 were upregulated. The GG4 proline concentration was 358% higher. Hence, rewiring of the proline metabolism in GG4 was confirmed for the first time, with a low-POX/PRODH/high-PYCR profile. High PEPD and MMPs activity is in keeping with GG4-increased collagen turnover and local aggressiveness. Further studies on the mechanisms of the interplay between altered proline metabolism and the GG4 microenvironment are warranted.

Purpose While Ruptured Arteriovenous Malformation Grading Scale (RAGS) has recently been validated in children, the literature lacks validation on adults exclusively. Therefore, we aimed to determine the validity of RAGS on the external multicenter adult cohort and compare its accuracy with other scales. Methods A retrospective analysis was performed in five neurosurgical departments to extract patients who presented with the first episode of acute brain arteriovenous malformation (bAVM) rupture between 2012 and 2019. Standard logistic regression and area under the receiver operating curve (AUROC) calculations were performed to determine the value of the following scales: intracerebral hemorrhage (ICH), AVM-associated ICH (AVICH), Spetzler-Martin (SM), Supplemented SM (Supp-SM), Hunt and Hess (HH), Glasgow Coma Scale (GCS), World Federation of Neurological Surgeons (WFNS), and RAGS to predict change in categorical and dichotomized modified Rankin Scale (mRS) across three follow-up periods: within the 6 months, 6 months to 1 year, and above 1 year. Results Sixty-one individuals with a mean age of 43.6 years were included. The RAGS outperformed other grading scales during all follow-up time frames. It showed AUROC of 0.78, 0.74, and 0.71 at the first 6 months, between 6 and 12 months, and after 12 months of follow-up, respectively, when categorized mRS was applied, while corresponding values were 0.79, 0.76, and 0.73 for dichotomized mRS, respectively. Conclusion The RAGS constitutes a reliable scale predicting clinical outcomes following bAVM rupture among adults. Furthermore, the RAGS proved its generalizability across medical centers with varying treatment preferences.

Background: It is commonly believed that after successful clipping of unruptured cerebral aneurysms patients may be considered restored to normal life. Nonetheless, some 11% may develop stroke within a year of the procedure. Therefore the question arises as to whether this group of patients can be submitted to different medical procedures, including vaccination against COVID-19, which has been reported to incidentally elicit thromboembolic events, without the necessity of special precautions. Case presentation: A contribution to this debate was presented in the case-history of a 56-year-old woman who underwent clipping of 3 unruptured cerebral aneurysms and in whom CT 8 months postsurgery did not show any abnormalities. Fourteen months post procedure she developed headache,vomiting and hand numbness coincidentally with ChAdOx1 nCoV-19 vaccination. CT revealed a small hypodense region within the territory of the right middle cerebral artery (MCA). CT angiography demonstrated a gap in contrast enhancement of the MCA and of the left anterior cerebral artery (ACA), exactly at the sites corresponding to localization of the aneurysm clips. Conclusions: Following clipping of cerebral aneurysms, patients may be prone to developing stroke coincidental with anti-COVID-19 vaccination. They may require special care during the peri-vaccinate period.

Halophilic archaea are a group distinct from Bacteria and Eukarya, which belong to extremophiles living in highly saline environments. However, they can also exist in the human microbiome. Their impact on the human immune system is poorly known. In this study we examined the interaction of Halorhabdus rudnickae WSM-64 T , isolated from the Barycz area of the Wieliczka Salt-Mine in Poland, and of Natrinema salaciae MDB25 T from the brine of Lake Medee in Italy, with human monocyte-derived dendritic cells (Mo-DCs). We found that these halophilic archaea invade the cytoplasm and the nucleus of Mo-DCs, but, in contrast to intracellular bacterial pathogens, they do not cause cytotoxic effects on DCs, as no single- or double-stranded DNA breaks (SSB and DSB, respectively), nor chromatin aberrations were noted. Moreover, they did not induce cell cycle alterations, apoptosis or necrosis of DCs. Surprisingly, these halophiles were found to protect against genotoxic activities of Staphylococcus aureus enterotoxin B (SEB), as pre-incubation of the Mo-DCs with the halophilic archaea significantly reduced SEB-induced SSB and DSB, as well as cell cycle disturbance and apoptosis. Therefore, these halophilic archaea can be regarded as safe stimulators for the Mo-DCs to potentially be used as immunomodulators and protective agents for various disorders.