Object. The authors undertook a study to explore the predisposing risk factors, frequency of occurrence, and clinical implications of kyphosis following laminectomy for cervical spondylotic myelopathy (CSM). Methods. Preoperative radiological studies were available in 46 patients with CSM who had undergone laminectomy. Records were reviewed to obtain demographic data and operative reports. Preoperative radiographs were assessed to determine spinal alignment. In a follow-up interview the authors established clinical outcome and patient satisfaction. Postoperative cervical alignment and mobility was also determined by assessing lateral neutral, flexion, and extension x-ray films. Preoperatively, the cervical spine was shown to be kyphotic in four (9%) of 46, straight in 20 (43%) of 46, and lordotic in 22 (48%) of 46 patients. Nine (21%) of 42 patients with either straight or lordotic alignment demonstrated in the preoperative period developed kyphosis after surgery. Kyphosis developed in six (30%) of 20 patients in whom straight spinal alignment was demonstrated preoperatively and in only three (14%) of 22 patients in whom lordosis was found preoperatively. Clinically, 13 (29%) of 45 patients improved and 19 (42%) of 45 remained unchanged after an average 4-year follow-up period; 36 (80%) patients believed that their surgery was successful (one patient, who was mentally retarded, could not respond to the follow-up questionnaire). Spinal alignment was not predictive of outcome; cervical mobility as demonstrated on flexion and extension, however, correlated with improved functional performance (p = 0.005). Conclusions. Kyphosis may develop in up to 21% of patients who have undergone laminectomy for CSM. Progression of the deformity appears to be more than twice as likely if preoperative radiological studies demonstrate a straight spine. In this study, clinical outcome did not correlate with either pre- or postoperative sagittal alignment.

Object. The authors reviewed their series of patients to quantify clinical and radiographic complications in those who underwent a posterior lumbar interbody fusion (PLIF) procedure in which a threaded interbody cage (TIC) was implanted. Methods. Sixty-seven patients underwent a posterior lumbar interbody fusion procedure in which a TIC was used. The authors excluded patients who underwent procedures in which other instrumentation was used or a nondorsal approach was performed. Fifteen percent of the cases (10 patients) were complicated by laceration of the dura. In three cases, bilateral implantation could not be performed. The average blood loss was 670 ml for all cases, and blood transfusion was required in 25% of the cases (17 patients). The rate of minor wound complication was 4.5% (three patients). One patient died. The average period of hospitalization was 4.25 days. Twenty-eight patients (42%) experienced significant low-back pain 3 months postoperatively, and in 10 (15%) of these cases it persisted beyond 1 year. In 10 patients postoperative radiculopathy was demonstrated, and magnetic resonance imaging revealed epidural fibrosis in six patients, arachnoiditis in one, and a recurrent disc herniation in one. One patient incurred a permanent motor deficit with sexual dysfunction. Pseudarthrosis was suggested radiographically with evidence of motion on lateral flexion—extension radiographs (10 cases), lucencies around the implants (seven cases), and posterior migration of the cage (two cases). Additional procedures (in 14 patients) consisted primarily of transverse process fusion with pedicle screw and plate augmentation for persistent back pain and radiographically demonstrated signs of spinal instability. In two patients with radiculopathy, migration of the TIC required that it be removed. Graft material that extruded from one implant necessitated its removal. In one patient scarectomy was performed. Conclusions. Our high incidence of TIC-related complications in PLIF is inconsistent with that reported in previous studies.

IMPORTANCE New treatments are needed to improve the prognosis of patients with recurrent high-grade glioma.OBJECTIVE To compare overall survival for patients receiving tumor resection followed by vocimagene amiretrorepvec (Toca 511) with flucytosine (Toca FC) vs standard of care (SOC). DESIGN, SETTING, AND PARTICIPANTSA randomized, open-label phase 2/3 trial (TOCA 5) in 58 centers in the US, Canada, Israel, and South Korea, comparing posttumor resection treatment with Toca 511 followed by Toca FC vs a defined single choice of approved (SOC) therapies was conducted from November 30, 2015, to December 20, 2019. Patients received tumor resection for first or second recurrence of glioblastoma or anaplastic astrocytoma.INTERVENTIONS Patients were randomized 1:1 to receive Toca 511/FC (n = 201) or SOC control (n = 202). For the Toca 511/FC group, patients received Toca 511 injected into the resection cavity wall at the time of surgery, followed by cycles of oral Toca FC 6 weeks after surgery. For the SOC control group, patients received investigators' choice of single therapy: lomustine, temozolomide, or bevacizumab. MAIN OUTCOMES AND MEASURESThe primary outcome was overall survival (OS) in time from randomization date to death due to any cause. Secondary outcomes reported in this study included safety, durable response rate (DRR), duration of DRR, durable clinical benefit rate, OS and DRR by IDH1 variant status, and 12-month OS. RESULTSAll 403 randomized patients (median [SD] age: 56 [11.46] years; 62.5% [252] men) were included in the efficacy analysis, and 400 patients were included in the safety analysis (3 patients on the SOC group did not receive resection). Final analysis included 271 deaths (141 deaths in the Toca 511/FC group and 130 deaths in the SOC control group). The median follow-up was 22.8 months. The median OS was 11.10 months for the Toca 511/FC group and 12.22 months for the control group (hazard ratio, 1.06; 95% CI 0.83, 1.35; P = .62). The secondary end points did not demonstrate statistically significant differences. The rates of adverse events were similar in the Toca 511/FC group and the SOC control group.CONCLUSIONS AND RELEVANCE Among patients who underwent tumor resection for first or second recurrence of glioblastoma or anaplastic astrocytoma, administration of Toca 511 and Toca FC, compared with SOC, did not improve overall survival or other efficacy end points.

Gross total extracapsular resection of midline suprasellar tumors via a transsphenoidal approach is possible but is associated with a higher risk of complications than is standard transsphenoidal surgery.