Purpose: Carbon-fiber reinforced polyetheretherketone (CFRP)-based spinal implants are an alternative to titanium, offering less image artifact as their metallic counterparts while maintaining similar biomechanical and biocompatibility properties. Its use in the management of spinal tumors has been reported, however the perceived advantages related to improved imaging quality, radiation treatment planning, and detection of tumor recurrence have not been fully assessed.Methods: We performed a retrospective review of medical records amongst oncologic patients treated at MD Anderson Cancer Center with CFRP implants. Histology, tumor location, construct features, time of follow-up, adjuvant radiation, recurrences, overall survival, and hardware-related complications were recorded.Results: Sixty-nine consecutive patients were assessed (22 primary tumors, 47 metastases) and the median time for follow-up was 5.4 months. Amongst the cohort, a total of 491 CFRP pedicle screws were implanted. Hardware complications were observed in 5 cases (7.04%). Adjuvant radiation was completed in 8 patients with primary tumors and 29 patients with spinal metastases. A total of 28 patients (40.5%) from the combined primary and metastatic cohorts experienced systemic disease progression, with 12 patients (17.3%) demonstrating local recurrences. Amongst primary and metastatic tumors, overall survival (p = 0.363) and rate of local recurrence (p = 0.112) were similar.Conclusion: This largest series of CFRP implants demonstrates safe and effective spinal stabilization for patients with both primary and metastatic tumors. Enhanced postoperative imaging led to minimal imaging artifacts which facilitated postoperative radiation planning and the ability to detect local recurrence.

Surgeons must optimize the onco-functional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Optimal patient selection and surgical planning requires preoperative identification of nonresectable structures. Transcranial magnetic stimulation is a method of noninvasively mapping the cortical representations of the speech and motor systems. Despite recent promising data, its clinical relevance and appropriate role in a comprehensive mapping approach remains unknown. In this study, we aim to provide direct evidence regarding the clinical utility of transcranial magnetic stimulation by interrogating the eloquence of TMS points. Forty-two glioma patients were included in this retrospective study. We collected motor function outcomes 3 months postoperatively. We overlayed the postoperative MRI onto the preoperative MRI to visualize preoperative TMS points in the context of the surgical cavity. We then generated diffusion tensor imaging tractography to identify meaningful subsets of TMS points. We correlated the resection of preoperative imaging features with clinical outcomes. The resection of TMS-positive points was significantly predictive of permanent deficits (p = 0.05). However, four out of eight patients had TMS-positive points resected without a permanent deficit. DTI tractography at a 75% FA threshold identified which TMS points are essential and which are amenable to surgical resection. TMS combined with DTI tractography shows a significant prediction of postoperative neurological deficits with both a high positive predictive value and negative predictive value.

BACKGROUND AND PURPOSE: Tumor recurrence is difficult to predict in patients receiving laser ablation for intracranial malignancy. We assessed the efficacy of the initial area under the time-to-signal intensity curve at 60 seconds (iAUC(60)) from dynamic contrast-enhanced MR imaging in predicting progression-free survival in patients with brain metastases following laser interstitial thermal therapy. MATERIALS AND METHODS: The study population was a consecutive series of patients undergoing laser interstitial thermal therapy for brain metastases. Patient demographics including age, sex, tumor histology, and Karnofsky Performance Scale were collected prospectively. Preoperative, postoperative, and 1-month follow-up dynamic contrast-enhanced MRIs were analyzed. Values of iAUC(60) were computed using a trapezoidal rule applied to the time history of contrast uptake over the first 60 seconds postenhancement. The change in iAUC(60) (Delta iAUC(60)) was calculated by taking the difference between the values of iAUC(60) from 2 time points. Pearson correlation coefficients were calculated between progression-free survival, defined as the time from laser interstitial thermal therapy to tumor recurrence, and iAUC(60) or Delta iAUC(60) values. RESULTS: Thirty-three cases of laser interstitial thermal therapy for 32 brain metastases in a cohort of 27 patients were prospectively analyzed. A significant relationship was observed between the values of iAUC(60) from postoperative dynamic contrast-enhanced MR imaging and progression-free survival with Pearson correlation (P = .03) and Cox univariate analysis (P = .01). The relationship between preoperative and 1-month follow-up dynamic contrast-enhanced MR imaging was not significantly correlated with progression-free survival. Similarly, no statistically significant relationship was observed with Delta iAUC(60) and progression-free survival between any time points. CONCLUSIONS: Progression-free survival is difficult to predict in patients undergoing laser interstitial thermal therapy for brain metastases due to confounding with posttreatment change. iAUC(60) extracted from postoperative dynamic contrast-enhanced MR imaging shows promise for accurately prognosticating patients following this operative therapy.

BACKGROUND: In patients with perieloquent tumors, neurosurgeons must use a variety of techniques to maximize survival while minimizing postoperative neurological morbidity. Recent publications have shown that conventional anatomical features may not always predict postoperative deficits. Additionally, scientific conceptualizations of complex brain function have shifted toward more dynamic, neuroplastic theories instead of traditional static, localizationist models. Functional imaging techniques have emerged as potential tools to incorporate these advances into modern neurosurgical care. In this case report, we describe our observations using preoperative transcranial magnetic stimulation data combined with tractography to guide a nontraditional surgical approach in a patient with a motor eloquent glioblastoma. OBSERVATIONS: The authors detail the use of preoperative functional and structural imaging to perform a gross total resection despite tumor infiltration of conventionally eloquent anatomical structures. The authors resected the precentral gyrus, specifically the paracentral lobule, localized using intraoperative mapping techniques. The patient demonstrated mild transient postoperative weakness and made a full neurological recovery by discharge 1 week later. LESSONS: Preoperative functional and structural imaging has potential to not only optimize patient selection and surgical planning, but also facilitate important intraoperative decisions. Innovative preoperative imaging techniques should be optimized and used to identify safely resectable structures.

BACKGROUND AND OBJECTIVES: Achieving maximal safe resections is critical for patients with language-eloquent gliomas. White matter tracts (WMTs) may offer valuable insights for surgical decision making, but the resectability of specific tracts remains unclear. In this study, we aim to identify predictors of permanent postoperative language deficits (PLDs) using resections of WMTs, illuminating the functional relevance of specific white matter segments. METHODS: This retrospective cohort study analyzed 78 consecutive glioma patients undergoing resection of language-eloquent tumors. WMT reconstructions were performed for 6 language-associated tracts. Tracts were parcellated according to anatomic location. The positive predictive value (PPV—tract resections with PLDs divided by total tract resections) was calculated for each tract segment. Resected tract segments (RTS) were normalized to Montreal Neurological Institute space. RESULTS: WMT resection strongly predicted PLDs (odds ratio = 16.00, P = .0115), with high negative predictive value (NPV, 97.4%), but low PPV (29.6%). RTS in patients with PLDs clustered within the white matter of the temporoparietal junction and middle temporal lobe. RTS without sequela localized more diffusely, with notable concentrations in the frontal operculum, anterior temporal lobe, and orbitofrontal region. Tract segments in the frontal lobe demonstrated near-complete resectability (frontal arcuate fasciculus [AF], frontal inferior fronto-occipital fasciculus, frontal uncinate fasciculus, frontal superior longitudinal fasciculus PPV = 0). Tract segments in the parietal and temporal lobe demonstrated significantly less resectability (parietal AF PPV = 0.4; temporal AF PPV = 1; temporal inferior fronto-occipital fasciculus PPV = 0.5; temporal inferior longitudinal fasciculus PPV = 0.5). The volume of tract resected did not significantly differ according to functional outcome (U = 84.0, P = .70). Resections of parietal and temporal tract segments robustly predicted PLDs (odds ratio = 29.4, P < .001), with a notable increase in PPV (50%) compared with the generalized model. CONCLUSION: This study demonstrates that resecting WMTs is a robust predictor of PLDs. WMTs in the orbitofrontal region, anterior temporal lobe, and frontal operculum were resectable whereas tract resections in the parietal and temporal lobes significantly increased risk of PLDs.