Jos M. A. Kuijlen

Transsphenoidal surgery (TSS) is the primary treatment of choice in acromegaly. Previous research on predicting remission after TSS was mainly based on clinical and radiological data, lacking histopathological evaluation. Our aim is to produce a clinicopathological prediction model for remission after TSS in acromegaly, enabling clinicians to better inform patients on expected treatment outcomes. This single-center study involved retrospective data collection in a large tertiary referral center in The Netherlands. One hundred patients in whom TSS was performed as primary therapy between January 2000 and July 2019 were included. Uni- and multivariate regression models were used to identify predictors of early biochemical remission according to the consensus criteria, long-term remission (defined as an age- and sex-normalized Insuline growth like factor 1and the absence of postoperative treatment (radiation therapy, repeat surgery, or medical therapy) at last follow-up, irrespective of residual tumor on postoperative magnetic resonance imaging ), and long-term remission without residual tumor (defined by the same biochemical and treatment criteria with the additional absence of residual tumor on postoperative magnetic resonance imaging ). In univariate logistic regression, a larger tumor volume, a larger maximum tumor diameter, a higher modified Knosp classification grade, the presence of cavernous sinus invasion, and a higher random growth hormone at diagnosis were significantly associated with lower remission rates. Tumor subtype and proliferation markers were not. In multivariate logistic regression, a simple model with only maximum tumor diameter as an independent variable predicted best for early biochemical remission (OR 0.85, 95% CI 0.78–0.93, P < .001, sensitivity 78.9%, specificity 71.8%), long-term remission (OR 0.79, 95% CI 0.70–0.88, P < .001, sensitivity 79.5%, specificity 73.7%), and long-term remission without residual tumor (OR 0.75, 95% CI 0.66–0.86, P < .001, sensitivity 79.4%, specificity 78.0%). Maximum tumor diameter was the best predictor, while histopathological characteristics were not predictive for remission after TSS in acromegaly in this cohort.

Background: Postoperative pain remains a serious concern after posterior lumbar interbody fusion (PLIF). Intraoperative epidural boluses of local anaesthetics (LA) have been proposed to reduce postoperative pain, but evidence is inconsistent. This study evaluated the association between an epidural bolus and pain in the post-anaesthesia care unit (PACU) following PLIF. Methods: A retrospective study was conducted including 147 PLIF patients. Patients were divided into the bolus ( n = 80) or control group ( n = 67) based on whether an epidural LA bolus was administered at the end of surgery. Primary outcomes: static (in rest) and dynamic (in movement) pain intensity (Numeric Rating Scale, NRS) in the PACU. Secondary outcomes: ward NRS, opioid consumption (Morphine Milligram Equivalents, MME), PACU and hospital length of stay (LOS), and analgesia- and surgery-related complications within 1 month. The multivariable regression models were adjusted for age, sex, BMI, ASA classification, preoperative opioid use, previous spinal surgery, and screw trajectory. Results: The groups were similar in age and sex, but differed in BMI, ASA classification, prior spinal surgery, and screw trajectory. Primary outcome : No significant differences were observed in static (Mann–Whitney U = 2439.0, p = 0.60) or dynamic (Mann–Whitney U = 1944.5, p = 0.48) NRS in the PACU. After adjustments, both static (MD -0.28, 95% CI -1.42 to 0.87, p = 0.63) and dynamic NRS (MD -0.51, 95% CI -1.69 to 0.67, p = 0.39) remained similar. Secondary outcomes : Ward NRS and opioid consumption in the PACU did not differ, but MME/hour on postoperative day 1 was lower in the bolus group (MD -0.34, 95% CI -0.57 to -0.11, p = 0.004). PACU LOS, hospital LOS, and analgesia-related complications were similar. Surgery-related complications < 1 month were not increased in the bolus group. Conclusions: This retrospective study found no association between epidural LA bolus administration and lower postoperative pain or opioid consumption in the PACU after PLIF. However, secondary analyses suggested lower opioid consumption on postoperative day 1.

Study Design: Experimental human specimen study. Objective: To evaluate the surgical accuracy of pedicle screw placement in preserved human specimens using an in-house mixed reality (MR) navigation system compared with conventional computer-assisted navigation. Summary of Background Data: Pedicle screw fixation was used to obtain spinal stability and fusion in spinal conditions. Traditional surgical methods carry risks of screw malpositioning, radiation exposure, and reliance on two-dimensional navigation monitors. MR navigation enables real-time three-dimensional projection in the surgical field, potentially improving spatial orientation and surgical accuracy. Materials and Methods: Three Thiel-embalmed human specimens underwent CT-based pedicle screw virtual surgical planning with 3D technology. On the left side of accessible vertebral levels, 26 pedicle trajectories were drilled using conventional navigation, and 25 on the right side using MR navigation. The in-house MR navigation system superimposes color-coded circular markers directly onto the surgical field, providing immediate, monitor-free, intuitive feedback. Accuracy and efficiency were assessed using postprocedural CT-based deviation analysis (3D deviation angle and entry-point deviation), Gertzbein-Robbins classification by two observers, and navigation time. Both groups were tested for statistical significance using the independent-samples t test and the Mann-Whitney U test. Results: No statistically significant differences were found between the conventional and MR groups for the 3D deviation angle (4.58±2.43 vs. 4.05±2.52°, P =0.618), entry point deviation [median: 2.70 mm (IQR: 1.63–2.99) vs . 2.10 mm (IQR: 1.39–2.65), P =0.127], or navigation time [median: 2:16 min (IQR: 0:58–4:20) vs . 1:16 min (IQR: 0:55–2:48), P =0.198]. The Gertzbein-Robbins classification showed 90.2% grade A/B trajectories overall, with substantial interobserver agreement (κ=0.692) and similar distribution between groups. Conclusions: MR navigation achieved surgical accuracy comparable to conventional computer-assisted navigation, indicating no concessions in safety. MR navigation reduced the median navigation time by ∼1 minute and eliminated the constant attention shift between the surgical field and the external 3D navigation monitor, offering meaningful workflow benefits. Future studies with larger cohorts and prospective clinical trials are warranted to further establish accuracy and efficacy before clinical implementation.

Study Design: Proof-of-concept study. Background: Optimal cervical screw placement is a complex, user-dependent procedure. While advanced techniques, including image-guided surgery and 3D-printed guides, have shown to improve accuracy of this procedure, their success depends on the quality of preoperative planning. However, traditional preoperative planning is labor-intensive, user-dependent, and may overlook patient-specific anatomic nuances. Objective: To develop and evaluate an AI-guided method for planning atlantoaxial and subaxial lateral mass screw trajectories in the cervical spine. Methods: The training of the AI model involved defining the orientation of the atlantoaxial and subaxial screws in all cervical levels on preoperative CT imaging of 41 patients who underwent cervical spine surgery. The model’s performance was evaluated using ten thin-sliced head and neck CT images, effectively simulating clinical applications for various anatomic scenarios. Results: Qualitative evaluation of the AI model demonstrated a 99.3% success rate for defining an identifiable screw trajectory and a 98.6% success rate for identification of the correct vertebral level. Quantitative evaluation of the AI model showed an overall mean screw length of 19.2±3.9 mm, bicortical purchase achievement in 84% of the subaxial screws, an adequate head-to-rod distance in 95.8% of all screws, and a mean runtime of 13.4±4.7 minutes. Conclusions: The developed model represents a valuable step toward the clinical implementation of AI-guided, human-monitored surgical planning for cervical screw placement. By enabling clinicians to primarily verify and fine-tune automated plans, the model reduces workload, saves time, improves accuracy, and minimizes user dependency, which supports safer and more efficient cervical procedures. Further expanding the training dataset to encompass broader spinal pathologies and screw insertion techniques is expected to enhance its clinical value even more.

Background: To evaluate postoperative health‐related quality of life (HRQoL) for pituitary adenoma patients, multidimensional assessment is important. Available data is limited on long‐term follow‐up. Methods: Prospectively, 52 nonfunctioning (NFA) and functioning (FA) pituitary adenoma patients were included. The Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES‐Q) was completed preoperatively and postoperatively (2 weeks, 3 months, 1 year, 8.5 years). Generalized estimating equations identified variables associated with HRQoL changes over time. Results: Psychological ( p = 0.006) and social HRQoL ( p = 0.026) significantly improved after very long‐term follow‐up, while physical HRQoL and EES‐Q scores normalized. Pre‐ and postoperatively, most inconveniences were reported in the social domain, with a noticeable difference between NFA and FA patients. Female gender negatively impacted physical HRQoL. Conclusions: Endoscopic endonasal surgery has no very long‐term negative impact on HRQoL. Social functioning remained the most affected throughout follow‐up. These results highlight the importance of this multidimensional HRQoL tool to improve patient‐centered health care.

Purpose: Symptomatic lumbar spondylolisthesis is usually treated with fusion surgery when conservative methods fail. However, traditional open decompression and fusion involves a large skin incision and muscle detachment. Therefore, minimally invasive techniques have been developed to reduce tissue damage, potentially leading to less postoperative pain and earlier resumption of activities. The purpose of this study was to compare percutaneous versus open pedicle screw placement in patients receiving lumbar midline decompression due to symptomatic lumbar spondylolisthesis focusing on short-term low back pain. Methods: A randomised controlled trial was conducted in 2 Dutch hospital from 2015 to 2020. Participants with spondylolytic or degenerative lumbar spondylolisthesis were randomised into percutaneous pedicle screw placement with a mini-open decompression (mini-open), or conventional open surgery with instrumented fusion (open). The primary outcome measure was short-term low back pain after 2 weeks, measured by a visual analogue scale. Leg pain, disability and quality of life were recorded at 2 and 6 weeks, 3 and 6 months and 1 year. Surgical variables, including complications, were recorded. Analyses were performed in the intention-to-treat population. Results: In total, 169 participants were included and randomised to mini-open (n = 81) or standard open surgery (n = 88). No statistically or clinically significant differences were found between groups in terms of primary or secondary outcomes. Surgery duration, blood loss, hospital stay, and complications were also similar between groups. Conclusions: This study detected no difference in outcome between mini-open compared to open surgery in patients with spondylolisthesis. The hypothetical advantage of reduced short-term low back pain, less blood loss and better clinical outcome could not be confirmed.

In recent years, patient-specific spinal drill guides (3DPGs) have gained widespread popularity. Several studies have shown that the accuracy of screw insertion with these guides is superior to that obtained using the freehand insertion technique, but there are no studies that make a comparison with computer-assisted surgery (CAS). The aim of this study was to determine whether the accuracy of insertion of spinal screws using 3DPGs is non-inferior to insertion via CAS. A randomized controlled split-spine study was performed in which 3DPG and CAS were randomly assigned to the left or right sides of the spines of patients undergoing fixation surgery. The 3D measured accuracy of screw insertion was the primary study outcome parameter. Sixty screws inserted in 10 patients who completed the study protocol were used for the non-inferiority analysis. The non-inferiority of 3DPG was demonstrated for entry-point accuracy, as the upper margin of the 95% CI (−1.01 mm–0.49 mm) for the difference between the means did not cross the predetermined non-inferiority margin of 1 mm (p < 0.05). We also demonstrated non-inferiority of 3D angular accuracy (p < 0.05), with a 95% CI for the true difference of −2.30°–1.35°, not crossing the predetermined non-inferiority margin of 3° (p < 0.05). The results of this randomized controlled trial (RCT) showed that 3DPGs provide a non-inferior alternative to CAS in terms of screw insertion accuracy and have considerable potential as a navigational technique in spinal fixation.

Differentiation of pituitary neuroendocrine tumor (PitNET) tissue from surrounding normal tissue during surgery is challenging. A number of fluorescent agents is available for visualization of tissue discrepancy, with the potential of improving total tumor resection. This review evaluates the availability, clinical and technical applicability of the various fluorescent agents within the field of pituitary surgery. According to PRISMA guidelines, a systematic review was performed to identify reports describing results of in vivo application of fluorescent agents. In this review, 15 publications were included. Sodium Fluorescein (FNa) was considered in two studies. The first study reported noticeable fluorescence in adenoma tissue, the second demonstrated the strongest fluorescence in non-functioning pituitary adenomas. 5-Aminolevulinic acid (5-ALA) was investigated in three studies. One study compared laser-based optical biopsy system (OBS) with photo-diagnostic filter (PD) and found that the OBS was able to detect all microadenomas, even when MRI was negative. The second study retrospectively analyzed twelve pituitary adenomas and found only one positive for fluorescence. The third investigated fifteen pituitary adenomas of which one displayed vague fluorescence. Indocyanine green (ICG) was researched in four studies with variable results. Second-Window ICG yielded no significant difference between functioning and non-functioning adenomas in one study, while a second study displayed 4 times higher fluorescence in tumor tissue than in normal tissue. In three studies, OTL38 showed potential in non-functioning pituitary adenomas. At present, evidence for fluorescent agents to benefit total resection of PitNETs is lacking. OTL38 can potentially serve as a selective fluorescent agent in non-functioning pituitary adenomas in the near future.

Background: The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs). Methods: A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I ² ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias. Results: A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity. Conclusions: This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.