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Orbital approaches for targeting intracranial, orbital, and infratemporal disease have evolved over the years in an effort to discover safe, reliable, effective, and cosmetically satisfying surgical corridors. The surgical goals of these approaches balance important factors such as proximity of the lesion to the optic nerve, the degree of anticipated manipulation and required space for surgical maneuverability, and the type of disease. The authors provide a comprehensive review of the most commonly used periorbital approaches in the management of intra-and extracranial disease, with emphasis on the advantages and limitations of each approach.

BACKGROUND For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required. RESULTS A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

BACKGROUND In patients with locally recurrent brain metastases (LRBMs), the role of (repeat) craniotomy is controversial. This study aimed to analyze long-term oncological outcomes in this heterogeneous population. METHODS Craniotomies for LRBM were identified from a tertiary neuro-oncological institution. First, we assessed overall survival (OS) and intracranial control (ICC) stratified by molecular profile, prognostic indices, and multimodality treatment. Second, we compared LRBMs to propensity score-matched patients who underwent craniotomy for newly diagnosed brain metastases (NDBM). RESULTS Across 180 patients, median survival after LRBM resection was 13.8 months and varied by molecular profile, with >24 months survival in ALK/EGFR+ lung adenocarcinoma and HER2+ breast cancer. Furthermore, 102 patients (56.7%) experienced intracranial recurrence; median time to recurrence was 5.6 months. Compared to NDBMs (n = 898), LRBM patients were younger, more likely to harbor a targetable mutation and less likely to receive adjuvant radiation (p < 0.05). After 1:3 propensity matching stratified by molecular profile, LRBM patients generally experienced shorter OS (hazard ratio 1.67 and 1.36 for patients with or without a mutation, p < 0.05) but similar ICC (hazard ratio 1.11 in both groups, p > 0.20) compared to NDBM patients with similar baseline. Results across specific molecular subgroups suggested comparable effect directions of varying sizes. CONCLUSIONS In our data, patients with LRBMs undergoing craniotomy comprised a subgroup of brain metastasis patients with relatively favorable clinical characteristics and good survival outcomes. Recurrent status predicted shorter OS but did not impact ICC. Craniotomy could be considered in selected, prognostically favorable patients.

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OBJECTIVEMetastatic spinal cord compression (MSCC) imposes significant impairment on patient quality of life and often requires immediate surgical intervention. In this study the authors sought to estimate the impact of surgical intervention on patient quality of life in the form of mean quality-adjusted life years (QALY) gained and identify factors associated with positive outcomes.METHODSThe authors performed a retrospective chart review and collected data for patients who had neurological symptoms resulting from radiologically and histologically confirmed MSCC and were treated with surgical decompression during the last 12 years.RESULTSA total of 151 patients were included in this study (mean age 60.4 years, 57.6% males). The 5 most common metastatic tumor types were lung, multiple myeloma, renal, breast, and prostate cancer. The majority of patients had radioresistant tumors (82.7%) and had an active primary site at presentation (67.5%). The median time from tumor diagnosis to cord compression was 12 months and the median time from identification of cord compression to death was 4 months. Preoperative presenting symptoms included motor weakness (70.8%), pain (70.1%), sensory disturbances (47.6%), and bowel or bladder disturbance (31.1%). The median estimated blood loss was 500 mL and the average length of hospital stay was 10.3 days. About 18% of patients had postoperative complications and the mean follow-up was 7 months. The mean pre- and postoperative ECOG (Eastern Cooperative Oncology Group) performance status grades were 3.2 and 2.4, respectively. At follow-up, 58.3% of patients had improved status, 31.5% had no improvement, and 10.0% had worsening of functional status. The mean QALY gained per year in the entire cohort was 0.55. The mean QALY gained in the first 6 months was 0.1 and in the first year was 0.4. For patients who lived 1–2, 2–3, 3–4, or 4–5 years, the mean QALY gained were 0.8, 1.4, 1.7, and 2.3, respectively. Preoperative motor weakness, bowel dysfunction, bladder dysfunction, and ASA (American Society of Anesthesiologists) class were identified as independent predictors inversely associated with good outcome.CONCLUSIONSThe mean QALY gained from surgical decompression in the first 6 months and first year equals 1.2 months and 5 months of life in perfect health, respectively. These findings suggest that surgery might also be beneficial to patients with life expectancy < 6 months.

BACKGROUND Surgical management of spine deformity is associated with significant morbidity. Recent literature has inconsistently demonstrated better outcomes after utilizing 2 attending surgeons for spine deformity. OBJECTIVE To conduct a systematic review and meta-analysis on studies reporting outcomes following single- vs dual-attending surgeons for spine deformity. METHODS MEDLINE, Embase, Web of science, and Cochrane databases were last searched on July 16, 2020. A total of 1013 records were identified excluding duplicates. After screening, 10 studies (4 cohort, 6 case series) were included in the meta-analysis. Random-effect models were used to pool the effect estimates by study design. When feasible, further subgroup analysis by deformity type was conducted. RESULTS A total of 953 patients were analyzed. Pooled results from propensity score-matched cohort studies revealed that the single-surgeon approach was unfavorably associated with a nonstatistically significant higher blood loss (mean difference = 421.0 mL; 95% CI: −28.2, 870.2), a statistically significant higher operative time (mean difference = 94.3 min; 95% CI: 54.9, 133), length of stay (mean difference = 0.84 d; 95% CI: 0.46, 1.22), and an increased risk of complications (Mantel-Haenszel risk ratio = 2.93; 95% CI: 1.12, 7.66). Data from pooled case series demonstrated similar results for all outcomes. Moreover, these results did not differ significantly between deformity types (adolescent idiopathic scoliosis and adult spinal deformity). CONCLUSION Dual-attending surgeon approach appeared to be associated with reduced operative time, shorter hospital stays, and reduced risk of complications. These findings may potentially improve outcomes in surgical treatment of spine deformity.