Glioblastoma is a highly malignant brain tumor, for which standard treatment consists of surgery, radiotherapy, and chemotherapy. Increasing extent of tumor resection (EOTR) is associated with prolonged survival. Intraoperative magnetic resonance imaging (iMRI) is used to increase EOTR, based on contrast enhanced MR images. The correlation between intraoperative contrast enhancement and tumor has not been studied systematically. For this prospective cohort study, we recruited 10 patients with a supratentorial brain tumor suspect for a glioblastoma. After initial resection, a 0.15 Tesla iMRI scan was made and neuronavigation-guided biopsies were taken from the border of the resection cavity. Scores for gadolinium-based contrast enhancement on iMRI and for tissue characteristics in histological slides of the biopsies were used to calculate correlations (expressed in Kendall's tau). A total of 39 biopsy samples was available for further analysis. Contrast enhancement was significantly correlated with World Health Organization (WHO) grade (tau 0.50), vascular changes (tau 0.53), necrosis (tau 0.49), and increased cellularity (tau 0.26). Specificity of enhancement patterns scored as "thick linear" and "tumor-like" for detection of (high grade) tumor was 1, but decreased to circa 0.75 if "thin linear" enhancement was included. Sensitivity for both enhancement patterns varied around 0.39-0.48 and 0.61-0.70, respectively. Presence of intraoperative contrast enhancement is a good predictor for presence of tumor, but absence of contrast enhancement is a bad predictor for absence of tumor. The use of gadolinium-based contrast enhancement on iMRI to maximize glioblastoma resection should be evaluated against other methods to increase resection, like new contrast agents, other imaging modalities, and "functional neurooncology" - an approach to achieve surgical resection guided by functional rather than oncological-anatomical boundaries.

Background: Posterior cervical foraminotomy (posterior surgery) is a valid alternative to anterior discectomy with fusion (anterior surgery) as a surgical treatment of cervical radiculopathy, but the quality of evidence has been limited. The purpose of this study was to compare the clinical outcome of these treatments after 2 years of follow-up. We hypothesized that posterior surgery would be noninferior to anterior surgery. Methods: This multicenter, randomized, noninferiority trial assessed patients with single-level cervical radiculopathy in 9 Dutch hospitals with a follow-up duration of 2 years. The primary outcomes measured reduction of cervical radicular pain and were the success ratio based on the Odom criteria, and arm pain and decrease in arm pain, evaluated with the visual analog scale, with a 10% noninferiority margin, which represents the maximum acceptable difference between the new treatment (posterior surgery) and the standard treatment (anterior surgery), beyond which the new treatment would be considered clinically unacceptable. The secondary outcomes were neck pain, Neck Disability Index, Work Ability Index, quality of life, complications (including reoperations), and treatment satisfaction. Generalized linear mixed effects modeling was used for analyses. The study was registered at the Overview of Medical Research in the Netherlands (OMON), formerly the Netherlands Trial Register (NTR5536). Results: From January 2016 to May 2020, 265 patients were randomized (132 to the posterior surgery group and 133 to the anterior surgery group). Among these, 25 did not have the allocated intervention; 11 of these 25 patients had symptom improvement, and the rest of the patients did not have the intervention due to various reasons. At the 2-year follow-up, of 243 patients, primary outcome data were available for 236 patients (97%). Predicted proportions of a successful outcome were 0.81 after posterior surgery and 0.74 after anterior surgery (difference in rate, −0.06 [1-sided 95% confidence interval (CI), −0.02]), indicating the noninferiority of posterior surgery. The between-group difference in arm pain was −2.7 (1-sided 95% CI, 7.4) and the between-group difference in the decrease in arm pain was 1.5 (1-sided 95% CI, 8.2), both confirming the noninferiority of posterior surgery. The secondary outcomes demonstrated small between-group differences. Serious surgery-related adverse events occurred in 9 patients (8%) who underwent posterior surgery, including 9 reoperations, and 11 patients (9%) who underwent anterior surgery, including 7 reoperations (difference in reoperation rate, −0.02 [2-sided 95% CI, −0.09 to 0.05]). Conclusions: This trial demonstrated that, after a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction in patients with cervical radiculopathy. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

When surgically treating cervical degenerative disc disease, the most commonly performed procedure is anterior cervical discectomy. This procedure is performed with, or without fusion promoting methods. For both options the rate of fusion is high and there is much debate whether fusion of the treated segment is a contributing factor to accelerated degeneration of adjacent motion segments. In an effort to prevent degeneration of adjacent segments (ASDeg) due to loss of mobility at the operated level, cervical disc arthroplasty (CDA) was introduced. To evaluate the effectiveness of CDA in preventing ASDeg long term studies are necessary. However, prevention of ASDeg is based on the premise that mobile disc prostheses preserve cervical spine motion in a physiological way. In this article the authors describe a short term protocol for a study that aims to investigate whether CDA reaches the intended goal: restoration or preservation of physiological cervical spine motion. To this end, a technique is used to establish the sequence of contributions of cervical motion segments to flexion/extension of the spine. 24 subjects between 18 and 55 years old, with radicular symptoms due to a herniated disc between C5 and C7, refractory to conservative therapy are randomized to simple discectomy, or CDA. These groups are preceded by a pilot group of three subjects receiving CDA. Fluoroscopic flexion-extension recordings are acquired preoperatively, and at three and 12 months postoperative. At these same time points, patient reported outcomes are collected, and a neurological examination is performed by and independent physician. Studies investigating arthroplasty determine mobility by measuring segmental range of motion (sROM), which gives no information other than presence, and quantity, of mobility. SROM suffer from high variability. The authors therefore chose to use a method previously used in healthy controls, to describe the dynamic process of cervical spine motion in more detail. Determining cervical spine motion patterns has been reported to be more consistent than sROM. If a physiological motion pattern is absent after surgery in the CDA group, prevention of future ASDeg is less likely. Radiological outcomes will be correlated to clinical outcomes. NCT00868335

Bringing evidence to practice is a key issue in modern medicine. The key barrier to information searching is time. Clinical decision support systems (CDSS) can improve guideline adherence. Mounting evidence exists that mobile CDSS on handheld computers support physicians in delivering appropriate care to their patients. Subaxial cervical spine injuries account for almost half of spine injuries, and a majority of spinal cord injuries. A valid and reliable classification exists, including evidence-based treatment algorithms. A mobile CDSS on this topic was not yet available. We developed and tested an iPhone application based on the Subaxial Injury Classification (SLIC) and 5 evidence-based treatment algorithms for the surgical approach to subaxial cervical spine injuries. The application can be downloaded for free. Users are cordially invited to provide feedback in order to direct further development and evaluation of CDSS for traumatic lesions of the spinal column.