The use of the O-arm in combination with a navigation system increases the accuracy of pedicle screw placement. The accuracy of the surgeon's perception and the need to limit the radiation dose for the patient justify an additional CT scan only after careful assessment of the potential additional value.

Pulsed radiofrequency treatment has been described as a minimal invasive alternative to radiofrequency thermocoagulation for the management of chronic pain syndromes. We present here our first five high-risk patients with idiopathic trigeminal neuralgia who were treated with pulsed radiofrequency after multidisciplinary assessment; with a mean follow-up of 19.2 months (range 10-26). These patients were at high risk due to age, co-morbidities or previous interventional and surgical treatments. An excellent long-term effect was achieved in three of the five patients, a partial effect in one patient and a short-term effect in one patient. No neurological side effects or complications were reported.

In patients at high risk of herniation recurrence after lumbar microdiscectomy, annular closure with a bone-anchored implant lowers the risk of symptomatic recurrence and reoperation. Additional study to determine outcomes beyond 2 years with a bone-anchored annular closure device is warranted.

Prognosis of glioblastoma remains dismal, underscoring the need for novel therapies. Immunotherapy is generating promising results, but requires combination strategies to unlock its full potential. We investigated the immunomodulatory capacities of poly(I:C) on primary human glioblastoma cells and its combinatorial potential with programmed death ligand (PD-L) blockade. In our experiments, poly(I:C) stimulated expression of both PD-L1 and PD-L2 on glioblastoma cells, and a pro-inflammatory secretome, including type I interferons (IFN) and chemokines CXCL9, CXCL10, CCL4 and CCL5. IFN-β was partially responsible for the elevated PD-1 ligand expression on these cells. Moreover, real-time PCR and chloroquine-mediated blocking experiments indicated that poly(I:C) triggered Toll-like receptor 3 to elicit its effect. Cocultures of poly(I:C)-treated glioblastoma cells with peripheral blood mononuclear cells enhanced lymphocytic activation (CD69, IFN-γ) and cytotoxic capacity (CD107a, granzyme B). Additional PD-L1 blockade further propagated immune activation. Besides activating immunity, poly(I:C)-treated glioblastoma cells also doubled the attraction of CD8 T cells, and to a lesser extent CD4 T cells, via a mechanism which included CXCR3 and CCR5 ligands. Our results indicate that by triggering glioblastoma cells, poly(I:C) primes the tumor microenvironment for an immune response. Secreted cytokines allow for immune activation while chemokines attract CD8 T cells to the front, which are postulated as a prerequisite for effective PD-1/PD-L1 blockade. Accordingly, additional blockade of the concurrently elevated tumoral PD-L1 further reinforces the immune activation. In conclusion, our data proposes poly(I:C) treatment combined with PD-L1 blockade to invigorate the immune checkpoint inhibition response in glioblastoma.

Seven patients with the co-occurrence of meningioma and pituitary adenoma are reported. Diagnosis was based on histological examination and if not available on MR imaging. Extensive review of the literature reveals only 18 other cases with this association if meningiomas appearing after radiation therapy for pituitary tumors are excluded. As in isolated meningiomas, the female-to-male ratio is high. A preponderance of perisellar meningiomas is apparent. Another distinct characteristic of this combination is not revealed, since no specific typing of the meningioma and no specific endocrine syndrome is uncovered. Two patients presented with multiple meningiomas, of which one showed two histologically different tumor types. The presence of other tumors in association with pituitary adenomas and meningiomas in our series is striking and could suggest a genetic dysregulation leading to the development of these tumors.

Our aim was to establish the normal range of MRI findings after successful lumbar discectomy. We prospectively examined 34 consecutive patients with an excellent clinical outcome by MRI 6 weeks and 6 months after surgery. All examinations included sagittal and axial spin-echo (SE) T1-weighted images before and after intravenous gadolinium-DTPA and fast SE T2-weighted images. Contrast enhancement along the surgical tract was seen in all patients 6 weeks and 6 months after surgery. After 6 months minimal or no mass effect on the dural sac by epidural scar was seen. In 20% of patients there was recurrent disc herniation, with mass effect. Enhancing nerve roots were seen in 20% of patients 6 weeks postoperatively, and half of these were associated with recurrent disc herniation at the same side. None of these patients still showed nerve root enhancement 6 months after surgery. Postoperative MRI studies must be interpreted with great care since the features described in the failed back surgery syndrome are also found, to some extent, in asymptomatic postoperative patients.

We evaluated the role of MRI in the diagnosis of postoperative spondylodiscitis. Spondylodiscitis is a serious complication of surgery, and the diagnosis frequently depends on a combination of clinical, laboratory and imaging findings. We compared the MRI findings in six patients with biopsy- or surgery-proven spondylodiscitis with those in 38 asymptomatic postoperative patients. Contrast enhancement and signal changes in the intervertebral disc or the vertebral endplates are not specific for spondylodiscitis, being also seen in the asymptomatic patients. However, absence of Modic type 1 changes, of contrast enhancement of the disc or of enhancing paravertebral soft tissues suggests that the patient does not have spondylodiscitis. MRI appears more useful for exclusion than for confirmation of postoperative spondylodiscitis.

<p class="abstract"><strong>Background:</strong> Same-level reherniation and progressive degeneration with disc height loss are main causes of poor outcome after discectomy and may necessitate reoperation.  A novel prosthesis for anular closure was developed to address these causes.</p><p class="abstract"><strong>Methods:</strong> The design of a multicenter, prospective, randomized, post-market superiority trial comparing limited lumbar discectomy augmented with this device (intervention group) with limited lumbar discectomy alone (control group) is presented.</p><p class="abstract"><strong>Results:</strong> Patients with single-level (L1-S1) posterior or posterolateral disc herniation and radiologic confirmation of neural compression for whom at least six weeks of conservative treatment has failed are eligible.  Patients must have posterior disc height ≥5 mm at index level and baseline Oswestry and VAS leg pain scores of ≥40/100.  Intraoperatively, subjects meeting anular defect size criteria post-discectomy (4-6 mm tall and 6-10 mm wide) will be randomized to study groups in a 1:1 ratio using centralized, web-based software. A Bayesian statistical approach will be used to enroll 400 to 800 subjects who will be followed for at least 24 months.  Two co-primary endpoints will be assessed at 24 months: 1) a composite of leg pain, clinical function, disc height maintenance, and absence of reherniation, reoperation, and device failure; and 2) absence of reherniation based upon independent radiologic analysis.  </p><strong>Conclusions:</strong> This type of analysis is becoming increasingly important as governments and health insurers continue to be pressured to spend limited healthcare funding wisely.