Eleftherios Archavlis

Background: Severe spinal cord injury (SCI) represents a debilitating condition with long-term physical and socioeconomic impacts. Understanding the pathophysiology of SCI and therapeutic interventions such as decompressive laminectomy and expansive duraplasty is crucial for optimizing patient outcomes. Objective: This systematic review explores the pathophysiology of SCI and evaluates evidence linking decompressive laminectomy and duraplasty to improved neuroplasticity and recovery. Methods: A comprehensive search was conducted in PubMed, Web of Science, and Cochrane Library for studies on decompressive surgery in SCI. Inclusion criteria were original articles investigating pathophysiology, neuroplasticity mechanisms, or surgical outcomes. Data on pathophysiological changes, molecular markers, and functional outcomes were extracted. Results: From 1240 initial articles, 43 studies were included, encompassing both animal models and human clinical data. Findings highlighted the role of inflammatory cascades, blood–spinal cord barrier disruption, and neurotrophic factor modulation in recovery. Decompressive duraplasty was associated with improved intrathecal pressure (ITP) management and neuroplasticity markers, such as BDNF and GAP-43. Conclusions: This review underscores the therapeutic potential of decompressive laminectomy and duraplasty in SCI. While evidence suggests benefits in promoting neuroplasticity, further research is needed to elucidate molecular mechanisms and refine interventions.

Background Severe spinal cord injury (SCI) represents a debilitating condition with long-term physical and socioeconomic impacts. Understanding the pathophysiology of SCI and therapeutic interventions such as decompressive laminectomy and expansive duraplasty is crucial for optimizing patient outcomes. Objective This systematic review explores the pathophysiology of SCI and evaluates evidence linking decompressive laminectomy and duraplasty to improved neuroplasticity and recovery. Methods A comprehensive search was conducted in PubMed, Web of Science, and Cochrane Library for studies on decompressive surgery in SCI. Inclusion criteria were original articles investigating pathophysiology, neuroplasticity mechanisms, or surgical outcomes. Data on pathophysiological changes, molecular markers, and functional outcomes were extracted. Results From 1,240 initial articles, 43 studies were included, encompassing both animal models and human clinical data. Findings highlighted the role of inflammatory cascades, blood-spinal cord barrier disruption, and neurotrophic factor modulation in recovery. Decompressive duraplasty was associated with improved intrathecal pressure (ITP) management and neuroplasticity markers, such as BDNF and GAP-43. Conclusions This review underscores the therapeutic potential of decompressive laminectomy and duraplasty in SCI. While evidence suggests benefits in promoting neuroplasticity, further research is needed to elucidate molecular mechanisms and refine interventions.

The classical supraorbital minicraniotomy (cSOM) constitutes a minimally invasive alternative for the resection of anterior skull base meningiomas (ASBM).

Aims Acute lower gastrointestinal bleeding (ALGIB) is associated with significant clinical and economic burden. We evaluated factors correlating with prolonged hospital stay (PHS) in patients with ALGIB. Methods Retrospective study through electronic medical record review of patients with a final diagnosis of ALGIB, admitted between 1/2019-6/2022. Factors associated with PHS (>5 days) were determined by multivariate regression analysis. Results Overall, 160 patients were included (mean age: 75.8±13.3 years, 53.5% females, 29.4% receiving antiplatelets, 30% anticoagulants, 13.1% hemodynamically unstable at admission, 32.5% receiving blood transfusion). A total of 152 (95%) underwent endoscopy after a median of 1 day (range: 0-6) from admission: flexible sigmoidoscopy was the first-line investigation in 97 (60.6%) and total colonoscopy in 55 (34.4%). Endoscopic treatment was performed in 17.5%, 10.6% underwent CT angiography and 2.5% required embolisation or surgery. Diverticular bleeding (43.3%) was the most common cause of ALGIB. The median length of hospital stay was 5 days (range: 1-29), with PHS observed in 60 (38.2%). By multivariate analysis, hemodynamic instability at admission (OR=4.51, 95%CI:1.58-12.86; p=0.005) was the only significant predictor of PHS, whereas endoscopic hemostasis showed a non-significant inverse correlation (OR=0.40, 95%CI:0.14-1.10; p=0.07). Conclusions Massive hemorrhage with hemodynamic instability at admission appears to be the main determinant of PHS in patients with ALGIB. The impact of endoscopic treatment on the length of hospital stay warrants further investigation in larger studies. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background No studies have directly and quantitatively compared two-dimensional (2D) and three-dimensional (3D) planning as applied during conventional percutaneous or navigated percutaneous pedicle screw placement. Study Aims This lumbar pedicle-based stabilization simulation study aimed to investigate the risk of upper facet joint violation (FJV) during posterior percutaneous pedicle screw placement with conventional 2D planning of screw implantation (as a model for fluoroscopically guided screws) compared with 3D planning (as used with navigation techniques). Methods The placement of monosegmental lumbar pedicle screws using the data sets of 250 consecutive patients was simulated. Conventional surgery (using 2D fluoroscopic images anteroposterior and lateral view) was compared with screw placement using the 3D reconstruction of the planning mode of the same software. Results The 2D planning resulted in 140 upper FJVs (28% of cases), whereas 3D planning resulted in only 24 upper FJVs (4.8% of cases) (p < 0.05). Among those spinal segments with severe facet joint arthropathy, Pathria grades 3 and 4, FJV was significantly higher (p < 0.05) in the 2D-planned screws (64.7%) than in the 3D-planned screws (11.2%). A more lateral (mean distance: 3.5 mm) and inferior (mean distance: 2.5 mm) offset of the pedicle entry point and a larger medial angulation of the trajectory (mean angle: 9 degrees) were observed for the 3D-planned screws at all levels. Conclusion This study demonstrates that the use of 2D planning is associated with a higher risk of upper FJV than when a 3D imaging data set is used. Using a more lateral and inferior entry point for fluoroscopically guided pedicle screws could reduce the rate of FJV in percutaneous pedicle screw placement.

Background Minimally invasive pedicle screw placement may have a higher incidence of violation of the superior cephalad unfused facet joint. Study Aims We investigated the incidence and risk factors of upper facet joint violation in percutaneous robot-assisted instrumentation versus percutaneous fluoroscopy-guided and open transpedicular instrumentation. Methods A retrospective study including all consecutive patients who underwent lumbar instrumentation, fusion, and decompression for spondylolisthetic stenosis and degenerative disk disease was conducted between January 2012 and January 2016. All operations were performed by the same surgeon; the patients were divided into three groups according to the method of instrumentation. Group 1 involved the robot-assisted instrumentation in 58 patients, group 2 consisted of 64 patients treated with a percutaneous transpedicular instrumentation using fluoroscopic guidance, and 72 patients in group 3 received an open midline approach for pedicle screw insertion. Results Superior segment facet joint violation occurred in 2 patients in the robot-assisted group 1 (7%), in 22 of the percutaneous fluoroscopy-guided group 2 (34%), and in 6 cases of the open group (8%). The incidence of facet joint violation was present in 5% (3) of the screws in group 1, 22% (28) of the screws in group 2, and 3% (4) of the screws in group 3. Conclusion Meticulous surgical planning of the appropriate entry site (Weinstein's method), trajectory planning, and proper robot-assisted instrumentation of pedicle screws reduced the risk of superior segment facet joint violation.

Salvage therapies in recurrent multifocal glioblastoma Background: Recurrent glioblastoma multiforme following multimodality therapy have limited palliative treatment options when the major modalities of therapy have been exhausted. Moreover, multifocal and multicentric bilateral patterns of recurrence is associated with worse prognosis and currently there is no specific treatment protocol for this patient population. The authors introduce a clinical and radiological indication-solving algorithm and provide outcome rates of a multifocal and multicentric glioblastoma recurrence cohort. Methods: Consecutive adult patients with multifocal and/or multicentric recurrence of glioblastoma who underwent a combined scheme of salvage treatments consisting of high dose rate (HDR) brachytherapy, stereotactic radiosurgery and chemotherapy were included in this retrospective study and were compared to a historical control group of 15 patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. All patients were previously treated with surgery of the primary pathology, concomitant and adjuvant radiochemotherapy with temozolomide. Results: Median survival was 6 months for the entire cohort after salvage treatment and can be translated into a 3 month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P=0.033). HDR-Brachytherapy combined with stereotactic radiosurgery and chemotherapy renders acceptable complication rates and seems to be a reasonable salvage option for patients with multifocal and/or multicentric recurrent glioblastoma. Conclusion: Our experience suggests that a combined salvage treatment plan appears to be either feasible or effective and can be considered in selected patients affected by multifocal and multicentric recurrence of glioblastoma. The authors' clinical and radiological indication-solving algorithm may assist in providing the best possible salvage treatment for this difficult population.

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Glioblastoma multiforme patients presenting with recurrence following multimodality therapy have limited palliative treatment options when the major modalities of therapy including surgery, radiochemotherapy and adjuvant chemotherapy have been exhausted. The authors introduce a clinical and radiological indication-solving algorithm and provide outcome rates of a glioblastoma recurrence cohort. Sixty six consecutive adult patients with recurrent glioblastoma who underwent a combined scheme of salvage treatments consisting of reoperation, high dose rate (HDR) brachytherapy and chemotherapy were included in this prospective study and were compared to a historical control group of 24 recurrent glioblastoma patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. Median follow-up was 32 months (range 28–36 months). Median survival was 9 months for the entire cohort after salvage treatment and can be translated into a 3-month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P = 0.043). Toxicity and adverse events of reoperation, HDR brachytherapy combined with chemotherapy were quite favourable compared to intensive temomozolomide chemotherapy as the only treatment. Our experience suggests that a combined salvage treatment plan appears to be both feasible and effective and can be considered in selected patients affected by recurrent high grade gliomas. The authors’ clinical and radiological indication-solving algorithm may assist in providing the best possible salvage treatment for this difficult population.