Objectives: Raynaud's phenomenon (RP) is a vascular disorder characterized by episodic peripheral artery vasospasms, resulting in paleness, cyanosis, and/or erythema. There are few reports, mostly case reports, on the benefits of spinal cord stimulation (SCS) for the treatment of RP. However, there is a lack of objective evidence on SCS-induced modulation of the sympathetic system (eg, vasodilation) in this condition. We hypothesize that evoked compound action potential- controlled closed-loop SCS may relieve pain, reduce the severity and frequency of Raynaud attacks, and improve peripheral blood flow. Materials and Methods: This prospective, observational, single-center pilot study aimed to evaluate the effectiveness of SCS in treating primary and secondary RP. Patient outcomes such as pain, Raynaud severity/condition score, Cochin Hand Function Scale, Scleroderma Health Assessment Questionnaire RP visual analog scale, EQ-5D-5L, Patient Global Impression of Change, blood fl ow assessments, and neurophysiological measurements were collected at baseline, trial end, one month, three months, and six months. Results: Ten patients were successfully enrolled in the study and underwent epidural electrode placement for SCS. SCS resulted in a significant improvement in the severity of RP attacks (severity difference from baseline at trial end: - 1.8, 95% CI, - 3.1 to - 0.5; p = 0.01; at one month: - 2.1; 95% CI, - 3.4 to - 0.8; p = 0.004; at three months: - 2.9; 95% CI, - 4.2 to - 1.6; p = 0.0002) and Raynaud condition score (difference from baseline at trial end: - 2.1; 95% CI, - 3.3 to - 0.9; p = 0.002; at one month: - 2.2; 95% CI, - 3.4 to - 1.0; p = 0.002; at three months: - 3.3; 95% CI, - 4.6 to - 2.1; p = 0.00002; at six months: - 4.1; 95% CI, - 5.4 to - 2.8; p = 0.0000008), and an objective reduction in peripheral occlusion and ulceration. While one of the combined primary end points was successfully achieved in terms of severity at the three-month follow-up, it is worth noting that the primary end point related to frequency improvement was not met during the same time frame. Conclusions: This pilot study offers evidence linking SCS with the activation of large, myelinated fi bers within the dorsal column in patients with RP. This activation is associated with improvement in the number of patient-related outcomes and enhanced peripheral circulation.

We depict the rare case of a patient with aneurysmatic subarachnoid hemorrhage previously treated with deep brain stimulation for Parkinson's disease. Initial CT scans showed a Fisher grade 4 subarachnoid hemorrhage with lead displacement due to midline-shift. CT angiogram revealed a supra-ophthalmic aneurysm of the internal carotid artery. The patient subsequently underwent clipping of the aneurysm and decompressive hemicraniecomy.

Background: Sacral neuromodulation is an established minimally invasive therapy indicated for the treatment of functional pelvic floor disorders. While it received its original US Food and Drug Administration (FDA) approval for the treatment of overactive bladder symptoms, it is now regarded as a therapeutic option to treat both urinary/fecal incontinence and retention. In addition, it has proven to be a valuable tool in the treatment of chronic pelvic pain, and preliminary results indicate a potential to elicit improvements in sexual functioning. Objective: This article serves to provide a summary of the therapy and its applications. Method: Selective literature review. Results: Sacral neuromodulation implants allow for the controlled shifting of the autonomic control of bladder and rectum towards an inhibition or facilitation of voiding, dependent on the patient's needs and under the patient's control. At the same time and depending on the applied stimulation, the implants can interfere with the nerve's conduction of pain signals. This makes them a therapeutic option for pelvic pain that fails to respond to conventional treatment. Finally, there have been first reports suggesting improvements in sexual dysfunction under sacral neuromodulation, thus, potentially opening up a new line of therapy for those disorders. Discussion: Sacral neuromodulation is a flexible and efficient form of therapy for functional disorders of the pelvic floor. Specifically, the same intervention can treat seemingly contradictory disorders such as urinary/fecal incontinence and retention as well as chronic pain.

Die sakrale Neuromodulation (SNM) stellt eine etablierte minimal-invasive Therapiemöglichkeit bei Funktionsstörungen des Beckenbodens dar. Ursprünglich zur Therapie von Blasenentleerungsstörung zugelassen, dient sie heute auch der Therapie von Mastdarmentleerungsstörung sowie chronischer Schmerzen im Bereich des Beckenbodens und, wenn auch noch experimentell, sexuellen Funktionsstörungen. Das folgende Kapitel gibt einen Überblick über das Verfahren der SNM. Selektiver Literaturreview. Durch die Implantation von Sakralelektroden kann mittels elektrischer Stimulation die autonome Kontrolle der Blase und des Mastdarms beeinflusst werden, so dass je nach Stimulation eine vom Patienten kontrollierbare Hemmung oder Förderung der Entleerung erzielt werden kann. Gleichzeitig kann über diese Elektroden die Schmerzweiterleitung aus der Gegend des Beckenbodens beeinflusst werden, so dass derselbe Eingriff auch zur Schmerztherapie bei sonst therapierefraktären Schmerzen verwendet werden kann. Zuletzt werden in der Literatur Verbesserungen bei sexuellen Funktionsstörungen beschrieben, so dass sich hier potenziell eine weitere Therapieoption ergibt. Die SNM stellt eine flexible und effiziente Therapieform bei Funktionsstörungen des Beckenbodens dar. Sie kann mit der gleichen Intervention, der Implantation von Sakralelektroden, gegensätzliche Störungen wie Harn‑/Stuhlverhalt und Harn‑/Stuhlinkontinenz sowie chronische, medikamentös nichttherapierbare Schmerzen behandeln.

Raynaud's phenomenon (RP) is an episodic vasospasm of the peripheral arteries that causes cyanosis, erythema, pain, paraesthesia's, and sometimes ulceration of the fingers and/or toes1. There are few reports, mostly case series, on the benefits of spinal cord stimulation (SCS) for the treatment of RP2–19. However, there is a lack of objective evidence on SCS induced modulation of the sympathetic system (e.g., vasodilation) in this condition. We hypothesize that evoked compound action potential-(ECAP)-controlled closed-loop-SCS may relieve pain and reduce the severity and frequency of Raynaud's attacks. Furthermore, we hypothesize that the retrograde effects of ECAP-controlled closed-loop-SCS may improve peripheral blood flow. Here, objective results on the effects on peripheral circulation and subjective changes in the frequency and severity of Raynaud's attacks will be presented. Full cohort data will be introduced at eINS.

In recent times, widely understood spine diseases have advanced to one of the most urgetn problems where quick diagnosis and treatment are needed. To diagnose its specifics (e.g. to decide whether this is a scoliosis or sagittal imbalance) and assess its extend, various kind of imaging diagnostic methods (such as X-Ray, CT, MRI scan or ST) are used. However, despite their common use, some may be regarded as (to a level) invasive methods and there are cases where there are contraindications to using them. Besides, which is even more of a problem, these are very expensive methods and whilst their use for pure diagnostic purposes is absolutely valid, then due to their cost, they cannot rather be considered as tools which would be equally valid for bad posture screening programs purposes. This paper provides an initial evaluation of the alternative approach to the spine diseases diagnostic/screening using inertial measurement unit and we propose policy-based computing as the core for the inference systems. Although the methodology presented herein is potentially applicable to a variety of spine diseases, in the nearest future we will focus specifically on sagittal imbalance detection.

Objective Antithrombotic therapy is common in older patients to avoid thromboembolic events. Careful planning is required, particularly in the perioperative environment. There are no clearly date guidelines on the best timing for interrupting the use of anticoagulation in the case of spinal surgery. This study evaluates early per procedural clinical outcomes in patients whose antithrombotic therapy was interrupted for spinal surgery. Methods This is a retrospective cohort study. All patients who underwent dorsal instrumentation from January 1, 2019 to December 31, 2020 were included. In group A, vitamin K antagonists (VKA) were suspended for 5 days and direct oral anticoagulants (DOAC) for 3 days. In group B, antiplatelet agents (APA) were paused for at least 7 days before surgery to prevent perioperative bleeding. Patients not taking anticoagulation medication were gathered into control group C. We analyzed demographic data, ASA status, blood loss, comorbidities, duration of surgery, blood transfusion, length of hospital stay, complications, thromboembolism, and 30 day in-hospital mortality. Multivariate analyses from the three groups were further analyzed and conducted. Results A total of 217 patients were operated and included. Twenty-eight patients taking VKA/DOAC (group A), 37 patients using APA (group B), and 152 patients without anticoagulation (group C) underwent spinal surgery. Those using anticoagulants were significantly older and often with multimorbidity, but did not differ significantly in procedural bleeding, time of surgery, length of hospital stay, complication rate, thromboembolism, or 30 day in-hospital mortality ( p > 0.05). Conclusion Our data show that dorsal instrumentation safely took place in patients whose antithrombotic therapy was interrupted.

Study design Retrospective single-center cohort study. Background The spine is the most common anatomic site for osteoporotic fractures. Osteoporotic vertebral fractures play an increasingly important role in geriatric patients and percutaneous vertebroplasty (PVP) constitutes a common treatment option. The aim of this study was to evaluate the safety and efficacy of PVP in geriatric patients with cardiovascular comorbidities at our center. Methods In this retrospective single-center study, 49 patients aged ≥ 65 with a total of 88 vertebral fractures underwent vertebroplasty. MRI and CT scans of the spine were performed in all patients prior to surgery. All patients were evaluated 4 weeks after surgery as part of their clinical follow-up. VAS scores were recorded before and after the operation. Postoperative complications within 30 days of the initial surgery were analyzed. Results The mean age of patients was 77 years (± 6.4). Of the 49 patients, 39 (80%) were female, and 36 (76%) had cardiovascular comorbidities. The most frequent postoperative complications were cement leakage with no new neurological postoperative deficits (14.3%). The in-hospital mortality rate was 1 out of 49 patients (2%). VAS scores revealed an overall pain reduction of > 97%. None of the following affected patient safety: ASA, BMI, duration of surgery, or the level or localization of vertebroplasty. Conclusions Our data demonstrate that vertebroplasty was a feasible and effective treatment for pain reduction in geriatric patients with osteoporotic fractures despite cardiovascular comorbidities. Level of evidence 3.

Introduction: Dorsal root ganglion (DRG) stimulation demonstrated superiority over traditional spinal cord stimulation with better pain relief and greater improvement of quality of life. However, leads specifically designed for DRG stimulation are difficult to implant in patients who previously underwent spinal surgery and show epidural scarring at the desired site of implantation because of the reduced stiffness of the lead. Nevertheless, recurrent leg or arm pain after spinal surgery usually manifests as a single level radiculopathy, which should theoretically be amenable to DRG stimulation. Materials and Methods: We present the percutaneous transforaminal placement of cylindrical leads through a lateral endo-scopic approach for DRG stimulation in burst mode. Results: We could successfully show that percutaneous transforaminal lead placement is feasible in three illustrative cases. Conclusion: This technical note combines two innovations, one linked to the other. The first innovation involves a novel endoscopic lateral transforaminal approach to insert a cylindrical lead to the DRG. Because this electrode is compatible with burst stimulation-enabled devices, a second innovation consists of the application of burst stimulation on the DRG.

Raynaud's phenomenon (RP) is an episodically occurring vasospasm of the peripheral arteries that causes cyanosis, erythema, pain, paresthesia, and sometimes ulceration of the fingers and/or toes [1]. In severe cases, RP patients have physical and functional impairments that substantially affect their ability to work. There are few reports, mostly case series, on the utility of spinal cord stimulation (SCS) to treat RP [2]–[9]. However, there is a lack of objective evidence on the physiological effects (e.g., vasodilation) of SCS in this condition. Here, we present clinical outcomes of severe RP patients treated with evoked compound action potential (ECAP)-controlled closed-loop SCS. We hypothesize that ECAP-controlled closed-loop SCS can alleviate pain and decrease the severity and frequency of Raynaud attacks. We further hypothesize that the retrograde effects of ECAP-controlled closed-loop SCS can potentially improve peripheral circulation. Therefore, we will present here an objective peripheral circulation measurement as an unbiased tool to assess the patient outcome.

Spinal cord stimulation (SCS) for intractable pain syndromes has become a pillar of modern pain management. Common complications include lead migration, implant infection, cerebral spinal fluid leak, and lead fracture. Spinal epidural abscess due to spinal cord stimulator implantation is a very rare occurrence with only two cases reported in the literature so far. We present an illustrative case and discuss the pathophysiology and best clinical management for this very rate entity.

Leksell stereotactic system-based aspiration biopsy is a common procedure in the neurosurgical treatment of deep-seated or multiple brain lesions. This study aimed to evaluate the benefit of frameless biopsy using VarioGuide compared to frame-based biopsy using the Leksell stereotactic system (LSS). We analyzed all brain biopsies using VarioGuide or LSS at our neurooncological Department of Neurosurgery in the University Hospital of Bonn between January 2018 and August 2020. We analyzed demographic data, duration of surgery, size of lesion, localization, and early complications. Uni-variable analyses were carried out on data from both groups. In total, 109 biopsies were compared (40 VarioGuide vs. 69 LSS). Patients with VarioGuide were significant older (74 (62–80) years vs. 67 (57–76) years; p = 0.03) and had a shorter duration of general anesthesia (163 (138–194) min vs. 193 (167–215) min, p < 0.001). We found no significant differences in surgery duration (VarioGuide median 28 min (IQR 20–38); LSS: median 30 min (IQR 25–39); p = 0.1352) or in early complication rates (5% vs. 7%; p = 0.644). A slightly higher false negative biopsy rate was registered in the LSS group (3 vs. 1; p = 0.1347). The size of the lesions also did not differ significantly between the two groups (18.31 ± 26.35 cm3 vs. 12.63 ± 14.62; p = 0.15). Our data showed that biopsies performed using VarioGuide took significantly less time than LSS biopsies and did not differ in complication rates. Both systems offered a high degree of patient safety.

Objective Dorsal instrumentation of the cervical spine is an established treatment in spine surgery. However, careful planning is required, particularly in elderly patients. This study evaluates early clinical outcomes in geriatric patients undergoing complex spine surgery. Methods In this retrospective, single center cohort study, we included all geriatric patients (aged ≥65 years) who underwent dorsal instrumentation between January 2013 and December 2020. We analyzed postoperative complications and the 30-day in-hospital mortality rate. Furthermore, the Charlson comorbidity index (CCI) and Clavien-Dindo grading system (CDG) were used to assess the patients' comorbidity burden. Results In total, 153 patients were identified and included. The mean age of patients was 78 years ( SD ± 7). Traumatic injury (53.6%) was the most common reason for surgery. 60.8% of the patients underwent dorsal instrumentation with 3 or more levels. The most common comorbidities were arterial hypertension (64%), diabetes mellitus (22.2%), coronary heart disease and atrial fibrillation (19.6%). The most common adverse event (AE) was pneumonia (4%) and the most common surgery-related complication was wound infection (5.2%). Among patients categorized as high risk for AE (CCI > 5), 14.6% suffered a postoperative AE. In our univariate analysis, we found no risk factors for high rates of complications or mortality. Conclusion Our data demonstrates that older patients were at no significant risk of postoperative complications. The CCI/CDG scores may identify patients at higher risk for adverse events after dorsal instrumentation, and these assessments should become an essential component of stratification in this older patient population.

Chronic axial lower back pain is one of the most common conditions that patients seek medical attention for in pain practices. About 15 to 40% of axial lower back pain is due to facet-mediated pain. Diagnostic blocks of the medial branch reliably identify the facet joint as the pain generator and offer a prognostic factor for response to radiofrequency neurotomy of the identified facet joints resulting in profound pain relief. However, deep brain stimulation implants have been considered a contraindication for neurotomy. We present an illustrative case of a patient with deep brain stimulation system treated with bipolar medial branch neurotomy using a two-needle technique.

Posterior instrumentation is an established treatment for a range of spinal disorders. Material failure is not uncommon, and the indications for a revision are very heterogeneous. This study aimed to evaluate the indications and timing for early revision spinal surgery due to material failure. In this retrospective, single-center cohort study, patients underwent spinal posterior instrumentation between January 2017 and July 2019. They were followed up at 3, 12, and 18 months postoperatively. The time of onset of material failure which led to revision surgery was analyzed. In addition, the relationship between the indications for revision surgery and independent variables was examined using a multivariate logistic regression model. A total of one hundred thirty-five patients were enrolled. Radiolucent zones were found in 30 patients (20%) after 3 months, whereas 48 patients (31%) had radiolucent zones after 12 months. Revision surgery was performed in 13 patients (8.5%). The peak time for revision due to instability was within the first four months of the primary surgery. Multivariate analysis revealed that location, pathology, ASA score, and smoking had no significant impact on the indication for revision surgery, and neither did BMI (P = .042). Non-fusion (P = .007) and radiolucent zones (P = .004), in combination with increased pain (P = .006), were predictors for revision. Our data show that the peak time for early revision of material failure after posterior instrumentation was within the first 4 months of primary surgery. The abnormalities (e.g., radiolucent zones) surrounding the screws without fusion, including persistence of pain, were predictors for revision surgery.