BACKGROUND: This systematic review and meta-analysis aimed to compare the effects of using phenylephrine or norepinephrine on the pH and base excess (BE) of the umbilical artery and vein in parturients undergoing cesarean section.
METHODS: The study protocol was registered in INPLASY. Independent researchers searched Ovid-Medline, Ovid-EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases and Google Scholar for relevant randomized controlled trials (RCTs). The primary outcome of this study was the umbilical artery (UA) or umbilical vein (UV) pH as neonatal condition at birth, and the secondary outcome was the UA or UV BE as an additional prognostic value over the measurement of umbilical pH.
RESULTS: There was no evidence of a difference between phenylephrine and norepinephrine for overall, UA, and UV pH (mean difference (MD) -0.001, 95% confidence interval (CI) -0.004 to 0.007; MD 0.000, 95%CI -0.004 to 0.004; and MD 0.002, 95%CI -0.013 to 0.017). There was also no evidence of a difference between phenylephrine and norepinephrine for overall, UA, and UV BE (MD 0.096, 95% CI -0.258 to 0.451; MD 0.076, 95%CI -0.141 to 0.294; and MD 0.121, 95%CI; -0.569 to 0.811). A meta-regression showed that factors such as umbilical artery or vein, infusion method, single or twin, and the number of parturients per study had no effect on the UA pH, UV pH, UA BE, or UV BE. No evidence of publication bias was detected.
CONCLUSIONS: There was no evidence of a difference between phenylephrine and norepinephrine for umbilical pH and BE. A subgroup analysis and meta-regression also did not show evidence of differences.

The use of intrathecal (IT) dexamethasone during subarachnoid block (SAB) has not been evaluated. There are no pooled data available to decide on the optimal regimen of IT dexamethasone during SAB, irrespective of the type of surgery. There is uncertainty about its dosage, effectiveness, and safety, and a need to establish clear guidelines on its use. Our objective was to evaluate the effectiveness and safety of use of IT dexamethasone during SAB. We performed a meta-analysis (PROSPERO, CRD42022304944) of trials that included patients who underwent a variety of surgical procedures under SAB. Patients received concomitant IT dexamethasone as an adjuvant to spinal local anesthetics. The analyzed outcomes included sensory and motor effects as well as adverse and/or beneficial side effects. Subgroup analysis was planned based on different doses used. Trial sequential analysis (TSA) was used to estimate the required sample size information (RIS) for each outcome. Eighteen studies (2531 participants) were included in this analysis. Addition of IT dexamethasone (4-8 mg) to heavy bupivacaine effectively prolonged the duration of sensory blockade (mean difference, MD = 63.8 minutes; [95% confidence interval, CI, 33.1-94.5], P < 0.0001), two-segment regression time (MD = 20.1[95% CI, 0.96-39.2], P = 0.04) and first rescue analgesic time (MD = 143.3 [95% CI, 90.3-196.0], P = 0.001). Subgroup analyses revealed superior effects of 8 mg dose over 4 mg for sensory and analgesic effects. The effect of dexamethasone on duration of motor blockade was inconclusive. Additionally, lower risk ratios (RRs) were recorded for spinal anesthesia-related hypotension (RR = 0.74 [95% CI, 0.6-0.9], P = 0.0003) and nausea/vomiting (RR = 0.62 [95% CI, 0.41-0.93], P = 0.02) in the dexamethasone group. For outcomes such as sensory blockade, analgesia, and hypotension, the required information size was reached during TSA. In conclusion, IT dexamethasone, used as an adjuvant to spinal local anesthetic, especially at the dose of 8 mg, increases sensory blockade duration and the time for request of the first rescue analgesic. SAB-induced side effects such as hypotension, nausea, and vomiting are lesser with the use of IT dexamethasone. However, further studies are necessary to draw meaningful conclusions on its safety profile.

BACKGROUND: Adult hemangioblastomas (HBs) are rare World Health Organization central nervous system (CNS) grade 1 tumors, particularly affecting the posterior cranial fossa. They exhibit a gender bias, impacting men in their fifth and sixth decades of life and manifesting sporadically or as part of von Hippel Lindau disease. Understanding the intricacies of CNS HBs is crucial for clinical decision-making.
METHODS: A systematic review of 576 articles was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Eligibility criteria included 3189 adult cases of CNS HBs. Data on patient demographics, tumor characteristics, symptoms, treatment modalities, complications, and outcomes were systematically extracted and synthesized.
RESULTS: The review revealed a heterogeneous demographic distribution, with a male predominance. The median age at diagnosis was 44.7 years. Cranial HBs were more commonly located in the infratentorial (73%) than supratentorial (27%) compartments. Spinal HBs were mostly located in the cervical spine (44.3%), followed by thoracic (36.7%) and lumbar spine (12%). Clinical symptoms varied by location, emphasizing the importance of anatomical considerations. Surgical intervention-total resection (82% of cases)-was the preferred treatment modality, while radiotherapy was less common. Histological examination and immunohistochemistry aided in accurate diagnosis. Complications were location-specific, with intracranial complications more common in infratentorial tumors. Overall, favorable outcomes were prevalent (78% of cases), with low mortality rates.
CONCLUSIONS: Adult CNS HBs present with diverse characteristics and clinical manifestations. Surgical intervention remains the mainstay treatment; ongoing research into genetic and molecular mechanisms may enhance our understanding of tumor pathology and lead to improved management strategies in the future.

BACKGROUND: Extensive spinal epidural abscess (ESEA) is a rare clinical entity subject to delayed diagnosis, which can be explained by the extension of the epidural collection, thereby delaying the mass effect responsible for its clinical manifestations.
METHODS: We report a rare case of an extensive C7-T10 epidural abscess in a 54-year-old man treated with antibiotics, laminectomy, and abscess drainage. In addition, we conducted a systematic literature search according to the \"Preferred Reporting Items for Systematic Reviews\" guidelines. Relevant studies (1980-2023) reporting patients with ESEA were identified from PubMed databases.
RESULTS: A total of 48 studies reporting 55 patients were included in this study with a mean age of 55.7 ± 14.6 years with a male predominance of 61.8% (n = 34). The median duration of follow-up was 38 months (21.5-64.3). The mortality rate of ESEA was 1.8% for a 21.8% morbidity rate with 76.4% (n = 42) reported to have been improved after surgery.
CONCLUSIONS: Both single and multilevel laminectomy with abscess drainage for ESEA leads to patient recovery from this devastating condition. Evaluation of the outcome with data on time-to-Nadir and Nadir-to-surgery is needed to codify ESEA management.

OBJECTIVE: Spinal chordoma treatment guidelines recommend resection. However, in patients in whom gross-total resection (GTR) is achieved, the benefits of radiation therapy (RT) are unclear. Therefore, the authors performed a systematic review to determine if RT is associated with postoperative progression-free survival (PFS) or overall survival (OS) after achieving GTR of spinal chordoma.
METHODS: The PubMed database was searched for studies including individualized data of patients undergoing GTR with or without RT for spinal chordoma. Patients < 18 years of age or those who underwent stereotactic body RT were excluded. Qualitative assessment was performed using Newcastle-Ottawa Scale guidelines. Log-rank tests for time-to-event data and a Cox proportional-hazards model were generated for a multivariable statistical model.
RESULTS: Complete data of 132 patients were retrieved, with 37 (28%) patients receiving adjuvant RT and 95 (72%) not receiving adjuvant RT. The mean follow-up was not statistically significantly different between those undergoing RT and not undergoing RT (54.02 months and 65.43 months, respectively). Patients were more likely not to undergo RT if their disease was located in the sacrum versus the mobile spine (p < 0.001). When controlling for age ≥ 65 years, male sex, disease location, and treatment year ≥ 2010, patients undergoing RT had similar PFS and OS when compared with those not undergoing RT on multivariable survival analysis (HR 0.935 [95% CI 0.703-2.340], p = 0.844 and HR 2.078 [95% CI 0.848-5.090], p = 0.110, respectively). However, age ≥ 65 years was associated with poorer OS in adjusted analyses (HR 2.761 [95% CI 1.185-6.432], p = 0.018) relative to patients < 65 years of age.
CONCLUSIONS: After achieving GTR of spinal chordoma, the utility of RT on PFS and OS remains unclear. Age ≥ 65 years appears to be associated with OS in spinal chordoma patients. Additional multicenter prospective studies are needed to determine the utility of RT in this patient population.

OBJECTIVE: This study aims to systematically collect data on cost-effectiveness analyses that assess technologies to treat type I and II spinal muscular atrophy and evaluate their recommendations.
METHODS: A structured electronic search was conducted in 4 databases. Additionally, a complementary manual search was conducted. Complete economic studies that evaluated nusinersen, risdiplam, onasemnogene abeparvovec (OA), and the best support therapy (BST) from the health system\'s perspective were selected. The incremental cost-effectiveness ratios were compared with various thresholds for the analysis. The review was registered a priori in PROSPERO (CRD42022365391).
RESULTS: Twenty studies were included in the analyses. They were all published between 2017 and 2022 and represent the recommendations in 8 countries. Most studies adopted 5, 6, or 10-state Markov models. Some authors took part in multiple studies. Four technologies were evaluated: BST (N = 14), nusinersen (N = 19), risdiplam (N = 5), and OA (N = 9). OA, risdiplam, and nusinersen were considered inefficient compared with the BST. Risdiplam and OA were generally regarded as cost-effective when compared with nusinersen. Because nusinersen is not a cost-effective drug, no recommendation can be derived from this result. Risdiplam and OA were compared in 2 studies that presented opposite results.
CONCLUSIONS: Nusinersen, risdiplam, and OA are being adopted worldwide as a treatment for spinal muscular atrophy. Despite that, the pharmacoeconomic analyses show that the technologies are not cost-effective compared with the BST. The lack of controlled studies for risdiplam and OA hamper any conclusions about their face-to-face comparison.

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.

The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain.
A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators.
The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures.
Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB.
A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study.
Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing.
Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.