The infiltrative character of supratentorial lower grade glioma makes it possible for eloquent neural pathways to remain within tumoural tissue, which renders complete surgical resection challenging. Neuromodulation-Induced Cortical Prehabilitation (NICP) is intended to reduce the likelihood of premeditated neurologic sequelae that otherwise would have resulted in extensive rehabilitation or permanent injury following surgery. This review aims to conceptualise current approaches involving Repetitive Transcranial Magnetic Stimulation (rTMS-NICP) and extraoperative Direct Cortical Stimulation (eDCS-NICP) for the purposes of inducing cortical reorganisation prior to surgery, with considerations derived from psychiatric, rehabilitative and electrophysiologic findings related to previous reports of prehabilitation. Despite the promise of reduced risk and incidence of neurologic injury in glioma surgery, the current data indicates a broad but compelling possibility of effective cortical prehabilitation relating to perisylvian cortex, though it remains an under-explored investigational tool. Preliminary findings may prove sufficient for the continued investigation of prehabilitation in small-volume lower-grade tumour or epilepsy patients. However, considering the very low number of peer-reviewed case reports, optimal stimulation parameters and duration of therapy necessary to catalyse functional reorganisation remain equivocal. The non-invasive nature and low risk profile of rTMS-NICP may permit larger sample sizes and control groups until such time that eDCS-NICP protocols can be further elucidated.

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Background: Adjacent segment disease (ASD) above a previous posterior lumbar instrumented fusion can be managed with minimally invasive lateral lumbar interbody fusion. Earlier procedures with stand-alone lateral cages risked nonunion, and lateral cages with separate lateral plates risked lumbar plexus injury and vertebral fracture. We investigated clinical and radiographic outcomes of an expandable lateral titanium interbody cage with an integrated lateral fixation (eLLIFp) device as a stand-alone treatment for symptomatic ASD above a previous posterior lumbar fusion and performed a comparative cost analysis of eLLIFp to alternative operations for ASD.Methods: In this prospective, observational study, patients with ASD above 1-, 2-, 3-, or 4-level instrumented posterior fusions underwent surgery with lateral expandable titanium cage(s) with an integrated lateral plate with single screws into each adjacent vertebra from August 2017 to August 2019. Multimodality intraoperative neural monitoring was performed. Patientreported outcomes, computed tomography outcomes, and total costs were analyzed.Results: A total of 33 patients received 35 eLLIFp cages. All clinical outcomes improved significantly. The eLLIFp cages added 2.2° segmental lordosis and 2.7 mm posterior disc height. Interbody fusion rate was 94% at 12 months. There were 2 neurologic complications (6%): 1 patient reported transient anterior thigh numbness and 1 had mild persistent L4 radiculopathy. No cage subsidence, cage migration, screw loosening, or vertebral fracture occurred. No revision lateral surgery, posterior decompression, or supplemental posterior fixation was required. The total eLLIFp cost (AU$19,715) was lower than the cost for all other procedures.Conclusions: eLLIFp provided a minimally invasive, low morbidity, cost-effective, and robust alternative to traditional posterior construct extension surgery for rostral lumbar ASD in selected patients with 1-to 2-level stenosis and minimal deformity.Clinical Relevance: Traditional ASD treatment involves substantial risks and expense. eLLIFp should be considered a safe, effective, and lower cost alternative to posterior construct extension surgery.

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