The first evidence of spinal surgery was found in Egyptian mummies 2900 BC [1]. In the antiquity,... more The first evidence of spinal surgery was found in Egyptian mummies 2900 BC [1]. In the antiquity, about 2500 years later, Hippocrates who is considered “The father of spine surgery” collected a valuable heritage of knowledge and methodology about the human body. He was the first who described sciatica and low-back pain. He also proposed a traction procedure and invented devices based on his fundamental principle [2]. Concerning the cervical spine, Aulus Celsus was the first who noted death following injury of the cervical spinal cord [3]. Paulus of Aegina performed the first operative repair of injured spinal cord by removing bony fragments which irritated the spinal cord and caused consecutive paralysis in the seventh century [3]. It took spinal surgery about 1900 years until an endoscope was applied. In 1983, the first report of an examination technique for intervertebral disc space after nucleotomy via endoscopy/arthroscopy was described by Frost and Hausmann [4]. Since then new surgical technology and techniques for minimally invasive approaches have revolutionized the work of surgeons of all subspecialties. Procedures such as laparoscopic cholecystectomy and orthopedic arthroscopy have proven to decrease surgically related morbidity, shorten postoperative hospital time and improve clinical outcomes [5–7]. In spinal surgery, morbidity is associated with iatrogenic muscle and soft tissue injury due to approach and exposure of the surgical field. Particularly in lumbar spine surgery, the standard open approach leads to iatrogenic injury of the paraspinal muscles which might result in decreased muscle strength and muscle atrophy after extensive muscle retraction [8, 9]. Biomechanical studies have investigated the function of the posterior column and its importance in maintaining lumbar spinal stability [10, 11]. Serial tube dilators and retractors were designed to split the back muscle gently and thus made to minimize retraction and disruption of the paraspinal muscular integrity. Further, other studies demonstrated that the postoperative recovery of CK and CRP levels occurred within 1 week and that the intensity of low back pain was mild [12, 13]. Mayer et al. studied the postoperative muscle architecture on CT scan and its relevance for failed-back syndrome [8]. They found that the integrity of paraspinal muscles might be of utmost importance for the postoperative result. A tubular retraction system provides direct and focal access to the diseased anatomy via a less invasive approach [14, 15]. Surgery can be done by using either an endoscope or using a microscope for visualization. The microendoscopic technique for interlaminar fenestration is considered safe and effective treatment of degenerative lumbar spine diseases and makes this to be seen as an option along with the traditional technique for every spine surgeon [16].
Introduction The surgical management of third ventricular lesions poses unique challenges, requir... more Introduction The surgical management of third ventricular lesions poses unique challenges, requiring careful consideration of various approaches and techniques. This study focuses on the transventricular transforaminal endoscopic approach and aims to provide insights into its indications, limitations, technical nuances, and potential complications in pediatric patients. Methods A retrospective analysis was conducted using data from a 13-year period on pediatric patients who were subjected to transforaminal endoscopic surgery for third ventricular lesions. The study utilized a prospectively maintained internal database, extracting demographic data, preoperative assessment, surgical details, and postoperative follow-up information. The surgical technique is presented in detail, and exemplary case reports highlight relevant surgical considerations. Results Out of 578 endoscopic transforaminal procedures, 24 surgeries were performed on pediatric patients with third ventricular lesions. ...
Personalized care models are dominating modern medicine. These models are rooted in teaching futu... more Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work–life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, wha...
Matrix metalloproteinases (MMPs) are endopeptidases participating in physiological processes of t... more Matrix metalloproteinases (MMPs) are endopeptidases participating in physiological processes of the brain, maintaining the blood–brain barrier integrity and playing a critical role in cerebral ischemia. In the acute phase of stroke activity, the expression of MMPs increase and is associated with adverse effects, but in the post-stroke phase, MMPs contribute to the process of healing by remodeling tissue lesions. The imbalance between MMPs and their inhibitors results in excessive fibrosis associated with the enhanced risk of atrial fibrillation (AF), which is the main cause of cardioembolic strokes. MMPs activity disturbances were observed in the development of hypertension, diabetes, heart failure and vascular disease enclosed in CHA2DS2VASc score, the scale commonly used to evaluate the risk of thromboembolic complications risk in AF patients. MMPs involved in hemorrhagic complications of stroke and activated by reperfusion therapy may also worsen the stroke outcome. In the presen...
With 2-3%, the initial haemorrhagic presentation of patients with pituitary adenomas is a rare fi... more With 2-3%, the initial haemorrhagic presentation of patients with pituitary adenomas is a rare finding [2]. Khawari and colleagues present interesting data of a retrospective multicentre cohort study on management, clinical and oncologic outcomes in such cases. In this study, patients with immediate surgical intervention were compared to those who underwent surgery within three months and with only conservative treatment. Subgroup analysis revealed comparable outcomes for all groups regarding visual and endocrinological findings. Interestingly, patients with subacute surgical therapy within three months showed higher rates of further oncological treatment-but without reaching statistical significance. However, 76% of the patients treated conservatively only did not require any additional treatment at all. Consequently, the authors suggest decision-making on the treatment modality based on visual symptoms rather than oncological aspects. Surgery in the acute phase is mainly aimed at an early decompression of the visual apparatus or cranial nerves [1]. Reported outcomes prove an effective recovery of up to 94% of visual symptoms depending on surgical timing [3, 8, 9]. Endocrinological improvement is less pronounced with partial recovery rates of up to 23% [7, 8]. However, in our opinion, devastating headaches-as the main symptom of pituitary apoplexy-tend to move into the background in scientific reports. This may be attributed to the limited prospective long-term relevance for the patient. However, in our experience, early surgery is the most effective strategy for pain relief in these patients. Regarding low surgery-related complication rates in experienced high-volume centres,
Background Navigated transcranial magnetic stimulation (nTMS) of the motor cortex has been succes... more Background Navigated transcranial magnetic stimulation (nTMS) of the motor cortex has been successfully implemented into radiotherapy planning by a number of studies. Furthermore, the hippocampus has been identified as a radiation-sensitive structure meriting particular sparing in radiotherapy. This study assesses the joint protection of these two eloquent brain regions for the treatment of glioblastoma (GBM), with particular emphasis on the use of automatic planning. Patients and Methods Patients with motor-eloquent brain glioblastoma who underwent surgical resection after nTMS mapping of the motor cortex and adjuvant radiotherapy were retrospectively evaluated. The radiotherapy treatment plans were retrieved, and the nTMS-defined motor cortex and hippocampus contours were added. Four additional treatment plans were created for each patient: two manual plans aimed to reduce the dose to the motor cortex and hippocampus by manual inverse planning. The second pair of re-optimized plan...
Meningiomas are mostly benign tu- mours that originate from the coverings of brain and spinal cor... more Meningiomas are mostly benign tu- mours that originate from the coverings of brain and spinal cord. Only a minority of cases show progression to an anaplastic tumour (WHO grades II and III). Multiple and familial cases are rare and mostly associated with (hereditary) neurofibroma- tosis 2 (NF2). Meningiomas show an unexpectedly high recurrence rate. Also, completely removed low-grade tumours can recur. On a cytogenetic level, meningiomas are the best-studied tumours in humans. The majority of high-grade but only a minority of low-grade meningiomas show loss of merlin, a cytoskeleton-cytoplasm-linker protein. Merlin is the product of the NF2 gene located on chromosome 22. A second tumour suppressor gene on chromosome 22 on 22q12.3 is the gene for the tissue inhibitor of metalloproteinase 3 (TIMP3), which appears to be involved in meningioma pro- gression and a high-grade meningioma pheno- type. In contrast to other solid tumours, progres- sion of meningiomas is correlated with increa...
Brain metastases can effectively be treated with surgical resection and adjuvant stereotactic rad... more Brain metastases can effectively be treated with surgical resection and adjuvant stereotactic radiotherapy (SRT). Navigated transcranial magnetic stimulation (nTMS) has been used to non-invasively map the motor cortex prior to surgery of motor eloquent brain lesions. To date, few studies have reported the integration of such motor maps into radiotherapy planning. The hippocampus has been identified as an additional critical structure of radiation-induced deficits. The aim of this study is to assess the feasibility of selective dose reduction to both the nTMS-based motor cortex and the hippocampi in SRT of motor-eloquent brain metastases. Patients with motor-eloquent brain metastases undergoing surgical resection and adjuvant SRT between 07/2014 and 12/2018 were retrospectively analyzed. The radiotherapy treatment plans were retrieved from the treatment planning system (“original” plan). For each case, two intensity-modulated treatment plans were created: the “motor” plan aimed to re...
Background: Here, we present the case of a 32-year-old female with a progressing history of menin... more Background: Here, we present the case of a 32-year-old female with a progressing history of meningioma for 16 years starting with an ethmoidal lesion in 2002. The initial tumor specimen of this patient showed a deletion of the short arm of chromosome 1 through a translocation between chromosomes 1 and 11 (t[1; 11]) as well as additional chromosomal aberrations, including partial or complete monosomy of chromosomes 2, 6, 7, 11, 13, and 22. These molecular characteristics were already known to be associated with an aggressive course of the disease, and the patient was, therefore, included in a strict follow-up regime. From 2003 to 2019, the patient suffered multiple relapses and consecutive tumor resections. Methods: Tumor specimen from 2017 was examined using a genome-wide methylation analysis as well as a whole-genome sequencing. Results: These analyses confirmed the findings of 2002 and proved genetic alteration in the meningioma to be very stable over the time. Yet SMO and AKT1 mu...
Background: Endoscopic techniques are well accepted as surgical technique for decompression of lu... more Background: Endoscopic techniques are well accepted as surgical technique for decompression of lumbar lateral recess stenosis (LRS). It is uncertain if there is a difference in clinical outcome for decompression alone (DA) or decompression with partial discectomy (DPD) for the treatment of LRS. Methods: All files of patients who underwent an endoscopic procedure for lumbar LRS were identified from a prospectively collected database. Preoperative magnetic resonance imaging and endoscopic video were analyzed with special focus on the technique of nerve root decompression. Clinical outcome was assessed via a personal examination, a standardized questionnaire including the numeric rating scale (NRS) for leg and back pain, the Oswestry disability index (ODI), and the modified MacNab criteria to assess functional outcome and clinical success. Results: Sixty-six patients were identified of which 57 attended for evaluation (86.4%). DA was performed in 15 (26.3%) patients and DPD in 42 patients (73.7%). The mean follow-up was 45.0 months (range: 16-82 months). Fifty-two patients reported to be free of leg pain (91.1%), 42 patients had no noticeable back pain (73.7%), 49 patients had full muscle strength (85.9%), and 48 patients had no sensory disturbance (84.2%). The mean NRS for leg pain was 1, the mean NRS for back pain was 2, mean ODI was 16% (range: 0%-60%). Clinical success was noted in 49 patients (85.9%) and it was significantly higher for patients following DPD (P ¼ .024). The overall repeat procedure rate was 12% with reoperation rate at the index segment in 10.5% of cases. There were no significant differences with respect to leg and back pain, ODI, and reoperation between both groups. Conclusion: Microendoscopic DPD of LRS achieves a 92% clinical success rate which is significantly higher compared to 67% clinical success achieved by DA. There was no significant difference for the rate of reoperation, leg and back pain, and ODI.
Vulnerable). RESULTS: 113 PTS were enrolled: 72 (64%) were male, KPS were ≥ 70 in 90 PTS (80%); 3... more Vulnerable). RESULTS: 113 PTS were enrolled: 72 (64%) were male, KPS were ≥ 70 in 90 PTS (80%); 37 PTS (33%) had a radical surgery, 63% partial surgery and 4% received a biopsy. 90 PTS (80%) received Stupp treatment, 16 (14%) temozolomide or radiotherapy alone and, only 7 (6%) received no treatment. MGMT methylation status was analyzed in 96 PTS: 44% were metMGMT. According to CGA evaluation: 40 PTS (35.4%) were classified as Fit and 73 PTS (64.6%) Unfit. PFS was 11.2 (95% CI 6.0-16.4) and 7.2 (95% CI 5.8-8.6) months for Fit and Unfit PTS (p=0.1). On multivariate analysis, adjusted for type of surgery, MGMT methylation status and type of therapy, PFS wassignificantly different between the two groups (HR=0.6, 95% CI 0.2-0.9; p=0.04). OS was 16.4 (95% CI 14.6-18.2) and 10.6 (95% CI 8.3-12.8) ms for Fit and Unfit PTS (p=0.04); on multivariate analysis the HR was 0.51 (95% CI 0.2-0.9; p=0.04). CONCLUSION: CGA demonstrated significant outcome prediction in terms of OS and PFS, regardless of therapy. It could be a useful treatment decision-tool suggesting to treat FIT PTS with radiochemotherapy while a prospective study to evaluate the best treatment in Unfit PTS should be warrant.
Background: Meningiomas are mostly benign tumors that originate from the coverings of the brain a... more Background: Meningiomas are mostly benign tumors that originate from the coverings of the brain and spinal cord. Compared to malignant glial tumors, meningiomas are relatively understudied with regard to their risk factors and epidemiology. In particular, population-based data on cancer burden and patient outcomes are scant. Methods: Population-based data from Saarland, a federal state in SouthWestern Germany, were used; the data included 992 patients diagnosed with a first meningioma between 2000 and 2015. Incidence and mortality rates-as well as estimates of observed and relative survival and cumulative incidence of tumor recurrence up to 10 years after diagnosis-were derived by sex, age, WHO grade, and whether or not the patient had undergone surgery. Results: This population-based study not only included patients treated in the regional university hospital but also those treated elsewhere or patients without any surgical treatment. The mean age of the patients at diagnosis was 63 years, and 70%, 28% and 3% had WHO grade I, II and III meningiomas, respectively. Ten-year observed and relative survival of all patients combined was 72% and 91% respectively. Tumor-related mortality varied by sex and increased with age at diagnosis and the WHO grade of the tumor. The overall 10-year cumulative incidence of meningioma recurrence was 9%. Conclusion: This analysis represents the first modern population-based analysis of meningioma incidence and mortality and outcomes of patients with such neoplasms in Germany. Derived from an unselected sample of patients, this study may fill a hitherto existing gap in the literature on meningiomas.
Objective: Meningiomas are among the most frequent intracranial tumors. Although the majority of ... more Objective: Meningiomas are among the most frequent intracranial tumors. Although the majority of meningiomas can be cured by surgical resection, up to 20% of the patients develop an aggressive clinical course with tumor recurrence or progressive disease. Cytogenetically, meningiomas frequently harbour a normal karyotype or monosomy of chromosome 22 as the sole anomaly. However, progression of meningiomas is associated with a non-random pattern of secondary losses of the chromosomes and chromosomal regions 1p, 6, 10, 14, 18, and 19. There is evidence, that loss of chromosome 17 might be involved in the clonal cytogenetic evolution of recurrent meningiomas. The aim of this study was to determine the role of deletions in the 17q chromosomal region in patients with recurrent meningiomas. Results: The authors retrospectively reviewed all patients that underwent repeated surgery for recurrent meningiomas between 1999 and 2015 at the Department of Neurosurgery of the Saarland University Hospital. Patients were included in this study if tumor samples from two or more different meningiomas were available. A total of 7 patients underwent repeated surgery for recurrent meningiomas (4 males, 3 females, mean age: 45.4 years at the date of surgery) between 1999 and 2015. Collectively, 22 biopsies were analyzed with FISH (fluorescence-in-situhybridization) for the chromosomal region 17q23.3. In 20/22 (90.1%) specimens, the tumor samples harboured a significant deletion in the chromosomal region 17q (range: 10 to 63% of the cells). In 3/3 (100%) cases, deletion in the 17q chromosomal region was detectable in the primary tumor. In the tumor evolution, there was no steady in-or decrease in the percentage of this deletion. Conclusion: Deletion in the 17q chromosomal region was present in the patients' primary tumors as well as in late recurrences. Overall, a significant deletion in the 17q chromosomal region was detected in 90.1% of the tumors. Thus, the authors assume that deletion in the 17q chromosomal region displays rather an early event in meningioma progression. Accordingly, deletion in the 17q chromosomal region might clinically serve as a potential early marker for malignancy and a higher risk for recurrence in meningiomas.
Objective: The safety of endoscopic skull base surgery can be enhanced by accurate navigation in ... more Objective: The safety of endoscopic skull base surgery can be enhanced by accurate navigation in preoperative computed tomography (CT) and magnetic resonance imaging (MRI). Here, we report our initial experience of real-time intraoperative CT-guided navigation surgery for pituitary tumors in childhood. Materials and Methods: We report the case of a 15-year-old girl with a huge growth hormone-secreting pituitary adenoma with supra- and perisellar extension. Furthermore, the skull base was infiltrated. In this case, we performed an endonasal transsphenoidal approach for debulking the adenoma and for chiasma decompression. We used an MRI neuronavigation (Medtronic Stealth Air System) which was registered via intraoperative CT scan (Siemens CT Somatom). Preexisting MRI studies (navigation protocol) were fused with the intraoperative CT scans to enable three-dimensional navigation based on MR and CT imaging data. Intraoperatively, we did a further CT scan for resection control. Results: ...
Current Directions in Biomedical Engineering, 2016
For the treatment of intracranial aneurysms with aneurysm clips, usually a follow-up inspection i... more For the treatment of intracranial aneurysms with aneurysm clips, usually a follow-up inspection in MRI is required. To avoid any artifacts, which can make a proper diagnosis difficult, a new approach for the manufacturing of an aneurysm clip entirely made from fiber-reinforced plastics has been developed. In this paper the concept for the design of the clip, the development of a new manufacturing technology for the fiber-reinforced components as well as first results from the examination of the components in phantom MRI testing is shown.
The first evidence of spinal surgery was found in Egyptian mummies 2900 BC [1]. In the antiquity,... more The first evidence of spinal surgery was found in Egyptian mummies 2900 BC [1]. In the antiquity, about 2500 years later, Hippocrates who is considered “The father of spine surgery” collected a valuable heritage of knowledge and methodology about the human body. He was the first who described sciatica and low-back pain. He also proposed a traction procedure and invented devices based on his fundamental principle [2]. Concerning the cervical spine, Aulus Celsus was the first who noted death following injury of the cervical spinal cord [3]. Paulus of Aegina performed the first operative repair of injured spinal cord by removing bony fragments which irritated the spinal cord and caused consecutive paralysis in the seventh century [3]. It took spinal surgery about 1900 years until an endoscope was applied. In 1983, the first report of an examination technique for intervertebral disc space after nucleotomy via endoscopy/arthroscopy was described by Frost and Hausmann [4]. Since then new surgical technology and techniques for minimally invasive approaches have revolutionized the work of surgeons of all subspecialties. Procedures such as laparoscopic cholecystectomy and orthopedic arthroscopy have proven to decrease surgically related morbidity, shorten postoperative hospital time and improve clinical outcomes [5–7]. In spinal surgery, morbidity is associated with iatrogenic muscle and soft tissue injury due to approach and exposure of the surgical field. Particularly in lumbar spine surgery, the standard open approach leads to iatrogenic injury of the paraspinal muscles which might result in decreased muscle strength and muscle atrophy after extensive muscle retraction [8, 9]. Biomechanical studies have investigated the function of the posterior column and its importance in maintaining lumbar spinal stability [10, 11]. Serial tube dilators and retractors were designed to split the back muscle gently and thus made to minimize retraction and disruption of the paraspinal muscular integrity. Further, other studies demonstrated that the postoperative recovery of CK and CRP levels occurred within 1 week and that the intensity of low back pain was mild [12, 13]. Mayer et al. studied the postoperative muscle architecture on CT scan and its relevance for failed-back syndrome [8]. They found that the integrity of paraspinal muscles might be of utmost importance for the postoperative result. A tubular retraction system provides direct and focal access to the diseased anatomy via a less invasive approach [14, 15]. Surgery can be done by using either an endoscope or using a microscope for visualization. The microendoscopic technique for interlaminar fenestration is considered safe and effective treatment of degenerative lumbar spine diseases and makes this to be seen as an option along with the traditional technique for every spine surgeon [16].
Introduction The surgical management of third ventricular lesions poses unique challenges, requir... more Introduction The surgical management of third ventricular lesions poses unique challenges, requiring careful consideration of various approaches and techniques. This study focuses on the transventricular transforaminal endoscopic approach and aims to provide insights into its indications, limitations, technical nuances, and potential complications in pediatric patients. Methods A retrospective analysis was conducted using data from a 13-year period on pediatric patients who were subjected to transforaminal endoscopic surgery for third ventricular lesions. The study utilized a prospectively maintained internal database, extracting demographic data, preoperative assessment, surgical details, and postoperative follow-up information. The surgical technique is presented in detail, and exemplary case reports highlight relevant surgical considerations. Results Out of 578 endoscopic transforaminal procedures, 24 surgeries were performed on pediatric patients with third ventricular lesions. ...
Personalized care models are dominating modern medicine. These models are rooted in teaching futu... more Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work–life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, wha...
Matrix metalloproteinases (MMPs) are endopeptidases participating in physiological processes of t... more Matrix metalloproteinases (MMPs) are endopeptidases participating in physiological processes of the brain, maintaining the blood–brain barrier integrity and playing a critical role in cerebral ischemia. In the acute phase of stroke activity, the expression of MMPs increase and is associated with adverse effects, but in the post-stroke phase, MMPs contribute to the process of healing by remodeling tissue lesions. The imbalance between MMPs and their inhibitors results in excessive fibrosis associated with the enhanced risk of atrial fibrillation (AF), which is the main cause of cardioembolic strokes. MMPs activity disturbances were observed in the development of hypertension, diabetes, heart failure and vascular disease enclosed in CHA2DS2VASc score, the scale commonly used to evaluate the risk of thromboembolic complications risk in AF patients. MMPs involved in hemorrhagic complications of stroke and activated by reperfusion therapy may also worsen the stroke outcome. In the presen...
With 2-3%, the initial haemorrhagic presentation of patients with pituitary adenomas is a rare fi... more With 2-3%, the initial haemorrhagic presentation of patients with pituitary adenomas is a rare finding [2]. Khawari and colleagues present interesting data of a retrospective multicentre cohort study on management, clinical and oncologic outcomes in such cases. In this study, patients with immediate surgical intervention were compared to those who underwent surgery within three months and with only conservative treatment. Subgroup analysis revealed comparable outcomes for all groups regarding visual and endocrinological findings. Interestingly, patients with subacute surgical therapy within three months showed higher rates of further oncological treatment-but without reaching statistical significance. However, 76% of the patients treated conservatively only did not require any additional treatment at all. Consequently, the authors suggest decision-making on the treatment modality based on visual symptoms rather than oncological aspects. Surgery in the acute phase is mainly aimed at an early decompression of the visual apparatus or cranial nerves [1]. Reported outcomes prove an effective recovery of up to 94% of visual symptoms depending on surgical timing [3, 8, 9]. Endocrinological improvement is less pronounced with partial recovery rates of up to 23% [7, 8]. However, in our opinion, devastating headaches-as the main symptom of pituitary apoplexy-tend to move into the background in scientific reports. This may be attributed to the limited prospective long-term relevance for the patient. However, in our experience, early surgery is the most effective strategy for pain relief in these patients. Regarding low surgery-related complication rates in experienced high-volume centres,
Background Navigated transcranial magnetic stimulation (nTMS) of the motor cortex has been succes... more Background Navigated transcranial magnetic stimulation (nTMS) of the motor cortex has been successfully implemented into radiotherapy planning by a number of studies. Furthermore, the hippocampus has been identified as a radiation-sensitive structure meriting particular sparing in radiotherapy. This study assesses the joint protection of these two eloquent brain regions for the treatment of glioblastoma (GBM), with particular emphasis on the use of automatic planning. Patients and Methods Patients with motor-eloquent brain glioblastoma who underwent surgical resection after nTMS mapping of the motor cortex and adjuvant radiotherapy were retrospectively evaluated. The radiotherapy treatment plans were retrieved, and the nTMS-defined motor cortex and hippocampus contours were added. Four additional treatment plans were created for each patient: two manual plans aimed to reduce the dose to the motor cortex and hippocampus by manual inverse planning. The second pair of re-optimized plan...
Meningiomas are mostly benign tu- mours that originate from the coverings of brain and spinal cor... more Meningiomas are mostly benign tu- mours that originate from the coverings of brain and spinal cord. Only a minority of cases show progression to an anaplastic tumour (WHO grades II and III). Multiple and familial cases are rare and mostly associated with (hereditary) neurofibroma- tosis 2 (NF2). Meningiomas show an unexpectedly high recurrence rate. Also, completely removed low-grade tumours can recur. On a cytogenetic level, meningiomas are the best-studied tumours in humans. The majority of high-grade but only a minority of low-grade meningiomas show loss of merlin, a cytoskeleton-cytoplasm-linker protein. Merlin is the product of the NF2 gene located on chromosome 22. A second tumour suppressor gene on chromosome 22 on 22q12.3 is the gene for the tissue inhibitor of metalloproteinase 3 (TIMP3), which appears to be involved in meningioma pro- gression and a high-grade meningioma pheno- type. In contrast to other solid tumours, progres- sion of meningiomas is correlated with increa...
Brain metastases can effectively be treated with surgical resection and adjuvant stereotactic rad... more Brain metastases can effectively be treated with surgical resection and adjuvant stereotactic radiotherapy (SRT). Navigated transcranial magnetic stimulation (nTMS) has been used to non-invasively map the motor cortex prior to surgery of motor eloquent brain lesions. To date, few studies have reported the integration of such motor maps into radiotherapy planning. The hippocampus has been identified as an additional critical structure of radiation-induced deficits. The aim of this study is to assess the feasibility of selective dose reduction to both the nTMS-based motor cortex and the hippocampi in SRT of motor-eloquent brain metastases. Patients with motor-eloquent brain metastases undergoing surgical resection and adjuvant SRT between 07/2014 and 12/2018 were retrospectively analyzed. The radiotherapy treatment plans were retrieved from the treatment planning system (“original” plan). For each case, two intensity-modulated treatment plans were created: the “motor” plan aimed to re...
Background: Here, we present the case of a 32-year-old female with a progressing history of menin... more Background: Here, we present the case of a 32-year-old female with a progressing history of meningioma for 16 years starting with an ethmoidal lesion in 2002. The initial tumor specimen of this patient showed a deletion of the short arm of chromosome 1 through a translocation between chromosomes 1 and 11 (t[1; 11]) as well as additional chromosomal aberrations, including partial or complete monosomy of chromosomes 2, 6, 7, 11, 13, and 22. These molecular characteristics were already known to be associated with an aggressive course of the disease, and the patient was, therefore, included in a strict follow-up regime. From 2003 to 2019, the patient suffered multiple relapses and consecutive tumor resections. Methods: Tumor specimen from 2017 was examined using a genome-wide methylation analysis as well as a whole-genome sequencing. Results: These analyses confirmed the findings of 2002 and proved genetic alteration in the meningioma to be very stable over the time. Yet SMO and AKT1 mu...
Background: Endoscopic techniques are well accepted as surgical technique for decompression of lu... more Background: Endoscopic techniques are well accepted as surgical technique for decompression of lumbar lateral recess stenosis (LRS). It is uncertain if there is a difference in clinical outcome for decompression alone (DA) or decompression with partial discectomy (DPD) for the treatment of LRS. Methods: All files of patients who underwent an endoscopic procedure for lumbar LRS were identified from a prospectively collected database. Preoperative magnetic resonance imaging and endoscopic video were analyzed with special focus on the technique of nerve root decompression. Clinical outcome was assessed via a personal examination, a standardized questionnaire including the numeric rating scale (NRS) for leg and back pain, the Oswestry disability index (ODI), and the modified MacNab criteria to assess functional outcome and clinical success. Results: Sixty-six patients were identified of which 57 attended for evaluation (86.4%). DA was performed in 15 (26.3%) patients and DPD in 42 patients (73.7%). The mean follow-up was 45.0 months (range: 16-82 months). Fifty-two patients reported to be free of leg pain (91.1%), 42 patients had no noticeable back pain (73.7%), 49 patients had full muscle strength (85.9%), and 48 patients had no sensory disturbance (84.2%). The mean NRS for leg pain was 1, the mean NRS for back pain was 2, mean ODI was 16% (range: 0%-60%). Clinical success was noted in 49 patients (85.9%) and it was significantly higher for patients following DPD (P ¼ .024). The overall repeat procedure rate was 12% with reoperation rate at the index segment in 10.5% of cases. There were no significant differences with respect to leg and back pain, ODI, and reoperation between both groups. Conclusion: Microendoscopic DPD of LRS achieves a 92% clinical success rate which is significantly higher compared to 67% clinical success achieved by DA. There was no significant difference for the rate of reoperation, leg and back pain, and ODI.
Vulnerable). RESULTS: 113 PTS were enrolled: 72 (64%) were male, KPS were ≥ 70 in 90 PTS (80%); 3... more Vulnerable). RESULTS: 113 PTS were enrolled: 72 (64%) were male, KPS were ≥ 70 in 90 PTS (80%); 37 PTS (33%) had a radical surgery, 63% partial surgery and 4% received a biopsy. 90 PTS (80%) received Stupp treatment, 16 (14%) temozolomide or radiotherapy alone and, only 7 (6%) received no treatment. MGMT methylation status was analyzed in 96 PTS: 44% were metMGMT. According to CGA evaluation: 40 PTS (35.4%) were classified as Fit and 73 PTS (64.6%) Unfit. PFS was 11.2 (95% CI 6.0-16.4) and 7.2 (95% CI 5.8-8.6) months for Fit and Unfit PTS (p=0.1). On multivariate analysis, adjusted for type of surgery, MGMT methylation status and type of therapy, PFS wassignificantly different between the two groups (HR=0.6, 95% CI 0.2-0.9; p=0.04). OS was 16.4 (95% CI 14.6-18.2) and 10.6 (95% CI 8.3-12.8) ms for Fit and Unfit PTS (p=0.04); on multivariate analysis the HR was 0.51 (95% CI 0.2-0.9; p=0.04). CONCLUSION: CGA demonstrated significant outcome prediction in terms of OS and PFS, regardless of therapy. It could be a useful treatment decision-tool suggesting to treat FIT PTS with radiochemotherapy while a prospective study to evaluate the best treatment in Unfit PTS should be warrant.
Background: Meningiomas are mostly benign tumors that originate from the coverings of the brain a... more Background: Meningiomas are mostly benign tumors that originate from the coverings of the brain and spinal cord. Compared to malignant glial tumors, meningiomas are relatively understudied with regard to their risk factors and epidemiology. In particular, population-based data on cancer burden and patient outcomes are scant. Methods: Population-based data from Saarland, a federal state in SouthWestern Germany, were used; the data included 992 patients diagnosed with a first meningioma between 2000 and 2015. Incidence and mortality rates-as well as estimates of observed and relative survival and cumulative incidence of tumor recurrence up to 10 years after diagnosis-were derived by sex, age, WHO grade, and whether or not the patient had undergone surgery. Results: This population-based study not only included patients treated in the regional university hospital but also those treated elsewhere or patients without any surgical treatment. The mean age of the patients at diagnosis was 63 years, and 70%, 28% and 3% had WHO grade I, II and III meningiomas, respectively. Ten-year observed and relative survival of all patients combined was 72% and 91% respectively. Tumor-related mortality varied by sex and increased with age at diagnosis and the WHO grade of the tumor. The overall 10-year cumulative incidence of meningioma recurrence was 9%. Conclusion: This analysis represents the first modern population-based analysis of meningioma incidence and mortality and outcomes of patients with such neoplasms in Germany. Derived from an unselected sample of patients, this study may fill a hitherto existing gap in the literature on meningiomas.
Objective: Meningiomas are among the most frequent intracranial tumors. Although the majority of ... more Objective: Meningiomas are among the most frequent intracranial tumors. Although the majority of meningiomas can be cured by surgical resection, up to 20% of the patients develop an aggressive clinical course with tumor recurrence or progressive disease. Cytogenetically, meningiomas frequently harbour a normal karyotype or monosomy of chromosome 22 as the sole anomaly. However, progression of meningiomas is associated with a non-random pattern of secondary losses of the chromosomes and chromosomal regions 1p, 6, 10, 14, 18, and 19. There is evidence, that loss of chromosome 17 might be involved in the clonal cytogenetic evolution of recurrent meningiomas. The aim of this study was to determine the role of deletions in the 17q chromosomal region in patients with recurrent meningiomas. Results: The authors retrospectively reviewed all patients that underwent repeated surgery for recurrent meningiomas between 1999 and 2015 at the Department of Neurosurgery of the Saarland University Hospital. Patients were included in this study if tumor samples from two or more different meningiomas were available. A total of 7 patients underwent repeated surgery for recurrent meningiomas (4 males, 3 females, mean age: 45.4 years at the date of surgery) between 1999 and 2015. Collectively, 22 biopsies were analyzed with FISH (fluorescence-in-situhybridization) for the chromosomal region 17q23.3. In 20/22 (90.1%) specimens, the tumor samples harboured a significant deletion in the chromosomal region 17q (range: 10 to 63% of the cells). In 3/3 (100%) cases, deletion in the 17q chromosomal region was detectable in the primary tumor. In the tumor evolution, there was no steady in-or decrease in the percentage of this deletion. Conclusion: Deletion in the 17q chromosomal region was present in the patients' primary tumors as well as in late recurrences. Overall, a significant deletion in the 17q chromosomal region was detected in 90.1% of the tumors. Thus, the authors assume that deletion in the 17q chromosomal region displays rather an early event in meningioma progression. Accordingly, deletion in the 17q chromosomal region might clinically serve as a potential early marker for malignancy and a higher risk for recurrence in meningiomas.
Objective: The safety of endoscopic skull base surgery can be enhanced by accurate navigation in ... more Objective: The safety of endoscopic skull base surgery can be enhanced by accurate navigation in preoperative computed tomography (CT) and magnetic resonance imaging (MRI). Here, we report our initial experience of real-time intraoperative CT-guided navigation surgery for pituitary tumors in childhood. Materials and Methods: We report the case of a 15-year-old girl with a huge growth hormone-secreting pituitary adenoma with supra- and perisellar extension. Furthermore, the skull base was infiltrated. In this case, we performed an endonasal transsphenoidal approach for debulking the adenoma and for chiasma decompression. We used an MRI neuronavigation (Medtronic Stealth Air System) which was registered via intraoperative CT scan (Siemens CT Somatom). Preexisting MRI studies (navigation protocol) were fused with the intraoperative CT scans to enable three-dimensional navigation based on MR and CT imaging data. Intraoperatively, we did a further CT scan for resection control. Results: ...
Current Directions in Biomedical Engineering, 2016
For the treatment of intracranial aneurysms with aneurysm clips, usually a follow-up inspection i... more For the treatment of intracranial aneurysms with aneurysm clips, usually a follow-up inspection in MRI is required. To avoid any artifacts, which can make a proper diagnosis difficult, a new approach for the manufacturing of an aneurysm clip entirely made from fiber-reinforced plastics has been developed. In this paper the concept for the design of the clip, the development of a new manufacturing technology for the fiber-reinforced components as well as first results from the examination of the components in phantom MRI testing is shown.
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Papers by Joachim Oertel