BACKGROUND: Both bone forearm fractures (BBFFs) are a common injury amongst the pediatric population. The main indications of surgical fixation are open, irreducible, or unstable fractures. The two most commonly used surgical techniques are closed or open reduction with intramedullary fixation (IMF) and open reduction with plate fixation (PF). The aim of this systematic review and meta-analysis was to determine which fixation method is superior for BBFFs.
METHODS: PubMed, Scopus, Web of Science, and CENTRAL were searched to identify studies comparing IMF and PF. We extracted data on union rates, complications, early hardware removal rates, reoperation rates, and radiographic, clinical, and perioperative outcomes.
RESULTS: Sixteen studies were included in the analysis, with a total of 922 patients (539 IMF and 383 PF). Similar union rates were achieved by both fixation technique. IMF was associated with a higher incidence of symptomatic hardware, and early hardware removal. Better restoration of the radial bow was observed with the PF group, especially in older children and adolescents. The rate of excellent function was comparable between groups, whereas better cosmesis was reported with the IMF group. Despite shorter fluoroscopy time and immobilization time, PF demonstrated longer tourniquet time, operating time, and hospital stay compared to IMF.
CONCLUSIONS: We found no significant difference between IMF and PF in terms of union rates and functional outcomes taking in consideration the merits and demerits of each technique. High-quality randomized controlled trials are, therefore, necessary to determine the superiority of one fixation technique over the other.
METHODS: III.

BACKGROUND: Intramedullary meningiomas are an exceptionally rare subtype of spinal tumors, accounting for only 5% of primary spinal neoplasms. Given their scarcity and unique characteristics, understanding optimal management approaches is crucial for improved clinical decision-making. This systematic review aims to consolidate existing literature and present a detailed case illustration to enhance understanding of this uncommon spinal tumor entity.
METHODS: A systematic search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Eligible studies included case reports, case series, cohort studies, reviews, and meta-analyses. Data extraction and synthesis focused on demographic characteristics, tumor location, clinical presentation, imaging findings, surgical interventions, histopathological features, and outcomes.
RESULTS: A total of 15 high-quality scientific articles were included in the systematic review, providing insights into various aspects of intramedullary meningiomas. Demographic analysis revealed a broad age distribution with an equal gender distribution among affected patients. Common clinical presentations included difficulty walking, sensory disturbances, spastic paraparesis, and urinary incontinence. Neuroimaging findings demonstrated heterogeneous signal intensity variations on T1- and T2-weighted images, with variable enhancement patterns on gadolinium-enhanced images. Surgical interventions, predominantly total resection, resulted in favorable postoperative outcomes in most cases.
CONCLUSIONS: Intramedullary meningiomas pose diagnostic and therapeutic challenges due to their rarity and unique characteristics. Tailored surgical approaches, incorporating techniques such as intraoperative neurophysiological monitoring and fluorescence-aided resection, are crucial for minimizing neurological deficits and optimizing patient outcomes. Despite their infrequency, recognizing intramedullary meningiomas in the differential diagnosis of spinal tumors is essential for prompt diagnosis and timely intervention, ultimately improving patient prognosis.

BACKGROUND: Spinal tumors comprise 15 % of all central nervous system tumors, with schwannomas accounting for 30 % of primary intraspinal neoplasms. While predominantly extramedullary-intradural, spinal schwannomas rarely manifest intramedullary occurrences (0.3 % of intraspinal tumors). This study sheds light on two rare cases of thoracic intramedullary schwannomas, emphasizing their diagnostic complexities and surgical management, alongside a literature review.
METHODS: Case 1 involves a 50-year-old female presenting with worsening back pain, right lower limb weakness, and urinary incontinence. MRI revealed an intradural intramedullary soft tissue mass, diagnosed as a schwannoma with an associated organizing hematoma. Surgical removal led to gradual improvement. Case 2 features a 25-year-old male with back pain, partial foot drop, and weakness in the right knee and hip. MRI demonstrated an intradural intramedullary lesion, later confirmed as an intradural intramedullary schwannoma. Surgery resulted in a smooth recovery without adverse effects.
CONCLUSIONS: This article presents two cases of intradural intramedullary thoracic schwannomas initially misdiagnosed as astrocytomas. Surgical resection confirmed the diagnosis, underscoring challenges in preoperative MRI diagnosis. The review of 174 reported cases reveals an equal distribution between the cervical and thoracic regions, with males affected 1.5 times more frequently than females. The average age of onset is 40, and surgical treatment demonstrates a 90 % improvement rate. The complex pathogenesis encompasses six proposed explanations. Clinical suspicion, considering pain and neurological symptoms, is paramount due to potential misdiagnosis and the imperative for histological confirmation.
CONCLUSIONS: Although rare, intramedullary schwannomas (IMS) have significant clinical implications, necessitating precise treatment. Surgical resection yields favorable outcomes, with subtotal resection considered based on adhesion factors. Pre-surgical diagnosis requires a comprehensive integration of radiological and clinical data, with intraoperative analysis ensuring optimal treatment strategies.

OBJECTIVE: To systematically review the clinical features, management, and outcomes of diffuse midline H3K27-altered gliomas of the spinal cord (DMG-SCs).
METHODS: PubMed, Ovid EMBASE, Scopus, and Web of Science were searched from database inception to 23 September 2023 for histologically confirmed cases of DMG-SC. Patient demographics, tumor characteristics, management information, and survival outcomes were extracted and analyzed.
RESULTS: A total of 279 patients from 39 studies were collected. Patients were mostly male (61%), with an average age of 32 years. Patients were treated with surgery, radiotherapy, and chemotherapy combined (31%) or surgery only (24%), and extent of resection was most often subtotal (38%). Temozolomide was the most common chemotherapeutic agent (81%). Radiation therapy was delivered with mean dose of 47 Gy in 23 fractions. At mean follow-up time of 21 months, 13% of patients were alive. Average median overall survival was 24 months (range of 13 to 40 months) with a median progression-free survival of 14 months. Historical WHO grades of 2 or 3 appeared to exhibit a longer average median overall survival time than that of grade 4 DMG-SCs (32 vs. 23 months, p = 0.009).
CONCLUSIONS: Outcomes for DMG-SCs are poor overall but appear to be favorable compared to intracranial DMGs. Despite the recent WHO 2021 grade 4 classification for all DMGs, given the differences in overall survival reported based on historical grading systems, future studies on DMG-SCs are needed to further define if DMG-SCs may represent a heterogeneous group of tumors with different prognoses.

Intramedullary spinal cord metastasis (ISCM), though rare, represents a potentially debilitating manifestation of systemic cancer. With emerging advances in cancer care, ISCMs are increasingly being encountered in clinical practice. Herein, we describe one of the larger retrospective single institutional case series on ISCMs, analyze survival and treatment outcomes, and review the literature. All surgically evaluated ISCMs at our institution between 2005 and 2023 were retrospectively reviewed. Demographics, tumor features, treatment, and clinical outcome characteristics were collected. Neurological function was quantified via the Frankel grade and the McCormick score (MCS). The pre- and post-operative Karnofsky performance scores (KPS) were used to assess functional status. Descriptive statistics, univariate analysis, log-rank test, and the Kaplan-Meier survival analysis were performed. A total of 9 patients were included (median age 67 years (range, 26-71); 6 were male). Thoracic and cervical spinal segments were most affected (4 patients each). Six patients (75%) underwent surgical management (1 biopsy and 5 resections), and 3 cases underwent chemoradiation only. Post-operatively, 2 patients had an improvement in their neurological exam with one patient becoming ambulatory after surgery; three patients maintained their neurological exam, and 1 had a decline. There was no statistically significant difference in the pre- and post-operative MCS and median KPS scores in surgically treated patients. Median OS after ISCM diagnosis was 7 months. Absence of brain metastasis, tumor histology (renal and melanoma), cervical/thoracic location, and post-op KPS ≥ 70 showed a trend toward improved overall survival. The incidence of ISCM is increasing, and earlier diagnosis and treatment are considered key for the preservation of neurological function. When patient characteristics are favorable, surgical resection of ISCM can be considered in patients with rapidly progressive neurological deficits. Surgical treatment was not associated with an improvement in overall survival in patients with ISCMs.

OBJECTIVE: The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs.
METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI).
RESULTS: Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available.
CONCLUSIONS: Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

Intramedullary K-wire (IMKW) fixation is one of the mainstays for surgically treating metacarpal shaft and neck fractures. However, there remains a lack of literature comparing outcomes of the various available surgical repair techniques in all indicated metacarpals. Therefore, we conducted a systematic review and meta-analysis to investigate the clinical advantages and drawbacks of IMKW compared with alternate fracture repair techniques. A comprehensive systematic literature review was performed to identify studies that compared clinical outcomes of IMKW to alternate metacarpal fixation modalities. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH/ quick DASH) scores, grip strength, union rate, visual analog scale pain, operative time, and complications. A random-effects model was used to compare IMKW to the pooled effect of other fixation techniques. A total of 10 studies were included in our analysis, comprising 497 metacarpal fractures (220 shafts and 277 necks). IMKW fixation was identified as the control group in all studies. The pooled experimental group included plates, transverse K-wires (TKWs), interfragmentary screws (IFSs), and K-wire cross-pinning (CP). In treating metacarpal shaft fractures, IMKW showed significantly shorter operative time ( p  = 0.04; mean difference = - 13; 95% confidence interval = -26 to -0.64). No significant differences were observed in treating metacarpal neck fractures for disability, grip strength, healing rate, pain, operative time, or complication rate. This systematic review and meta-analysis found no difference in clinical outcomes among various surgical techniques for treating metacarpal shaft and neck fractures. Further high evidence studies are required that investigate the efficacy and safety of IFS, CP, TKW, and intramedullary screws versus IMKW for treating closed, unstable metacarpal fractures.

Sarcoidosis is a multisystemic inflammatory granulomatosis disease that rarely involves the central nervous system (CNS) and is even more so rarely isolated to the intramedullary thoracic spine. In isolated CNS sarcoidosis cases, surgical treatment is debated. We present here a case report and literature review on intramedullary thoracic spine sarcoidosis to evaluate potential portents of spine involvement and indications for surgical intervention. A 47-year-old female with a prior history of renal cell carcinoma presented with a week-long history of urinary retention and bilateral lower extremity numbness, and a 24-hour history of left lower extremity (LLE) weakness with saddle anesthesia. Magnetic resonance imaging demonstrated a syrinx spanning the spinal cord to the conus medullaris and a contrast-enhancing, expansile intramedullary thoracic lesion at T6-T7 with a non-enhancing, cystic right paraspinal lesion at T5. Given the patient\'s history of a kidney neoplasm, a metastatic work-up was completed. Biopsy of the T5 lesion was consistent with endometriosis. The patient underwent a T6-8 laminectomy with excisional biopsy and gross total resection of the intramedullary mass. Initial pathology was notable for lymphohistiocytic infiltrate with coagulative necrosis and rare multinucleated giant cells. At the one-month follow-up, the patient had improving LLE weakness and continued impairment of gait, balance, and coordination, but her symptoms of urinary retention, paresthesia, and numbness were resolved. Final pathology supported a diagnosis of sarcoidosis. At the three-month follow-up, the patient reported intermittent surgical site pain, but no other symptoms. She is followed up by her primary care consultant for symptom management and recurrence monitoring. Apart from the presented case, only one case of isolated intramedullary thoracic spine sarcoidosis was identified in the literature. The only case, of both review and presented, without significant symptom improvement did not undergo surgery. The available literature is limited; however, early surgical intervention may be indicated in isolated thoracic spine sarcoidosis.

UNASSIGNED: Central nervous system tumors are usually located in the brain, and spinal cord tumors account for approximately 20% of central nervous system tumors. Epidermoid cysts constitute <1% of all intraspinal tumors. It consists of squamous epithelial-lined cysts containing keratin, cholesterol, and cellular granules. Epidermoid cysts can be classified as congenital, acquired, extradural, extramedullary, or intramedullary according to etiology and location. The intradural intramedullary type is uncommon.
UNASSIGNED: An 11-year-old female patient had back pain with radiation to both lower extremities but worsened on the left side for 5 years. On neurological examination, motor strength was 3/5 for hip flexion and knee extension bilaterally and 5/5 for other key muscle groups. Contrast-enhanced lumbosacral magnetic resonance imaging (MRI) revealed T1 hypointense and T2 hyperintense lesions in the L2-L4 intramedullary conus and cauda equina. Laminectomy and near total resection were done, and histopathological examination revealed an epidermoid cyst. On the third postoperative day, the patient was discharged with completely resolved back pain and an improvement in lower extremity motor power. At monthly follow-up visits for a further 6 months, her back pain and weakness completely resolved, and she had no neurologic deficits. A postoperative lumbosacral MRI was done and confirmed near total excision of the tumor.
UNASSIGNED: Intramedullary conus epidermoid cysts are rare but not unknown to neurosurgeons. MRI with diffusion-weighted images (DWI) is an imaging modality of choice. Asymptomatic patients can be conservatively treated. Once the patient has progressive symptoms and signs of compression, surgical excision is recommended. Meticulous electrocauterization may help decrease tumor regrowth in the remnant capsule, which is recommended. Avoiding leakage of cyst fluid into the subarachnoid space helps to avoid postoperative chemical meningitis. Radiotherapy is an option for the management of multiple recurrences.

UNASSIGNED: Intertrochanteric Femur Fractures (IFF) fixation could be done with short or long Cephalomedullary Nails (CMNs). Nevertheless, despite several studies in the literature, there has been a continued lack of consensus on which design of CMN is better than the other. Hence, the current review aimed to evaluate the evidence about short versus long CMNs for the fixation of IFF.
UNASSIGNED: PRISMA guidelines were followed, and the protocol for the study was registered to PROSPERO. Four databases, Medline/PubMed, Embase, Scopus, and Cochrane Library, were searched. A total of 31 studies with 6 randomized trials (RCTs) and 25 non-randomized studies were included. Demographic data, follow-up period, and primary and secondary outcomes were extracted and evaluated from each of the included studies; statistical analysis was done by Review Manager Software version 5.4.1.
UNASSIGNED: Fourteen thousand five hundred forty-seven patients were included in this review.
UNASSIGNED: Long CMNs showed statistically significant lower rates of ipsilateral shaft femur refracture (OR 1.60, 95% CI 1.14, 2.24, p = 0.007); however, the difference was not statistically significant between the two groups for mortality at 30 days and within 1 year.
UNASSIGNED: Statistically significant shorter duration of surgery (MD-17.83 (95% CI - 22.03, - 13.63, p < 0.05), less intra-operative blood loss (MD - 62.65, 95% CI - 97.13 to - 28.17, p =  < 0.05), and lower blood transfusion rates (OR 0.71, 95% CI 0.62, 0.83, p < 0.05) for short CMNs; no statistically significant difference for the length of hospital stay, implant-related complications, overall complications, re-operation rates, fluoroscopy time, and functional outcome between two groups of CMNs was seen.
UNASSIGNED: With shorter operative time, lesser intra-operative blood loss, and lower postoperative transfusion rates for short CMNs, they have certain benefits over longer CMNs. However, more distal shaft femur fractures were seen in the shorter version of nail, which should be considered before offering these nails to a patient; careful and individualized postoperative weight-bearing protocol could minimize the same.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s43465-023-00915-5.