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Study Design Literature review with clinical recommendation.Objective A concise curation of the latest spine literature exploring the relationship between expectations and satisfaction for patients with metastatic spinal disease (MSD). Deliver recommendations to practicing clinicians regarding interpretation and utilisation of this evidence.Methods The latest spine literature in the topic of factors affecting the expectations of patients with MSD was reviewed and clinical recommendations were formulated. Recommendations are graded as strong or Conditional.Results 5 articles were selected. Article 1: risk factors for the development of dissatisfaction from a cohort of 362 MSD patients. Strongrecommendation to incorporate risk factor assessment when considering treatment. Article 2: systematic review assessing the relationship between pre-operative patient expectations and subsequent satisfaction in allied disciplines. Conditionalrecommendation to optimize patient expectation to positively modify patient satisfaction. Article 3: qualitative study of how clinicians, from different specialties, counsel patients with MSD pre-treatment. Strongrecommendation to use a multidisciplinary approach. Article 4 qualitative study of how MSD patients experience their pre-treatment counselling and how that affected their appreciation of treatment success. Conditionalrecommendation to furnish patients with tailored, expected outcomes in the context of systemic progression. Article 5 Design and validation of a pre-treatment questionnaire specific to MSD. A conditionalrecommendation to incorporate this questionnaire in clinical and research MSD practice.Conclusion Patients with MSD are approaching end of life care and high levels of treatment satisfaction are crucial at this juncture. The role of expectation management and comprehensive counselling is critical.

Study design Prospective observational studyObjective The population of patients with advanced stages of cancer, including metastatic spinal disease, is growing because of better treatment options allowing for longer control of disease. The main goal of treatment for these patients is to improve or maintain their health-related quality of life (HRQOL). A spine oncology-specific outcome measure has been developed by the Spine Oncology Study Group and validated through international studies. We proposed to translate and validate the questionnaire in Italian language.Methods The cross-cultural adaptation of the questionnaire has been performed according to guidelines previously proposed. After this process, an observational prospective study has been conducted to validate the efficacy of SOSGOQ in Italian language. SOSGOQ has been compared to SF-36 (Short Form Health Survey-36), a generic validated questionnaire to assess HRQOL. Starting from January 2020, SOSGOQ and SF-36 questionnaires were auto-administered to 150 patients affected by spinal metastases who provided written informed consent for study participation.Results The confirmatory factor analysis on the 4 domains examined showed a good model fit (comparative fit index, .95; RMSEA .07 (90% CI, .05-.09) and SRMR, .05), endorsing construct validity. The analysis of concurrent validity demonstrated strong correlation for physical function, pain and mental health domains with the corresponding domain scores of SF-36. The reliability across item was high with a Cronbach’s alpha coefficient of .91.Conclusions The statistical analysis of the results will allow to accept the Italian version of SOSGOQ as a specific and efficient tool to measure HRQOL in Italian-speaking patients affected by spinal metastases.

Study Design Questionnaire-based survey.Objectives Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research.Methods An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy.Results Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus(SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions.Conclusions With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.

Study design Retrospective cohort study.Objectives This study aimed to investigate the failure of the caudal end of lumbar posterior fixation in terms of pre-operative and post-operative spinopelvic parameters, correction performed, demographic and clinical data.Methods The lumbar, thoraco-lumbar and lumbo-sacral posterior fixations performed with pedicle screws and rods in 2017-2019 were retrospectively analyzed. As 81% failures occurred within 4 years, an observational period of 4 years was chosen. The revision surgeries due to the failure in the caudal end were collected in the junctional group. Fixations which have not failed were gathered in the control group. The main spinopelvic parameters were measured for each patient on standing lateral radiographs with the software Surgimap. Demographic and clinical data were extracted for both groups.Results Among the 457 patients who met the inclusion criteria, the junctional group included 101 patients, who required a revision surgery. The control group collected 356 primary fixations. The two most common causes of revision surgeries were screws pullout (57 cases) and rod breakage (53 cases). SVA, PT, LL, PI-LL and TPA differed significantly between the two groups (P= .021 for LL, P< .0001 for all the others). The interaction between the two groups and the pre-operative and post-operative conditions was significant for PT, SS, LL, TK, PI-LL and TPA (P< .005). Sex and BMI did not affect the failure onset.Conclusions Mechanical failure is more likely to occur in patients older than 40 years with a thoraco-lumbar fixation where PT, PI-LL and TPA were not properly restored.

Study Design: Secondary analysis of data from a randomized controlled trial.Objectives: To identify risk factors for continued opioid use after conservative management (CM) or minimally invasive surgical management (MISM) of low back pain (LBP) originating from the sacroiliac joint.Methods: Patients were randomized either to CM (n = 49) or MISM (n = 52). We documented opioid use, pain intensity (visual analogue scale [VAS]), Oswestry Disability Index (ODI), and the Zung depression score (Zung Self-Rating Depression Scale) at baseline and at months 3 and 6 after treatment initiation.Results: Compared with opioid nonusers, opioid users at baseline had higher mean levels of disability (ODI 61.5, standard deviation [SD] 13.3 vs ODI 51.5, SD 12.8; P< .01) and higher depression scores (Zung 48.5, SD 8.5, vs Zung 42.2, SD 7.2; P< .01). At 6 months, opioid users had higher 6-month pain levels (VAS 60.4, SD 24.0, vs VAS 42.4, SD 28.2; P< .01), higher disability scores (ODI 50.5, SD 16.2, vs ODI 32.7, SD 19.3; P< .01) and higher depression scores (Zung 47.6, SD 8.0, vs Zung 38.8, SD 8.9; P< .01). Risk factors for continued opioid use at 6 months were patient age (odds ratio [OR] for age = 0.91; P= .02) and an increase in LBP (OR 1.08; P= .02) in the CM group and a lack of improvement in depression scores (OR 1.12; P= .03) in the MISM group.Conclusions: In our patient cohort, the risk of continued opioid use in the treatment of LBP increased not only with pain intensity but also with levels of depression during the course of treatment.

Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) restores the stiffness and the strength of fractured vertebral bodies, but changes the pattern of the stress transfer. This effect may cause a secondary fracture of the adjacent vertebrae. Elastoplasty has emerged as a new technique to overcome this complication. The aim of this study is to retrospectively evaluate the clinical results of the elastoplasty procedure.

Skeletal metastases are a common cause of severe morbidity, reduction in quality of life and often early mortality. Consequently, improvements in therapies are necessary. Electroporation uses electric energy to alter cancer cell membrane permeability and enhance the local uptake of chemotherapeutics, thus leading to local tumor control. The aim of this study was to investigate the feasibility and safety of delivering electric field protocols causing electroporation of healthy bone and structures of clinical relevance using small and large animal models. Reversible electroporation was used in the rabbit sciatic nerve by applying 2 series of 8 pulses 100ms long at 1000 V/cm. Irreversible electroporation was used in rabbit distal femur condyles and in sheep vertebral body by applying 120 pulses 100ms long at 1750 V/cm. Any effect on surrounding sensitive structures was investigated. Reversible electroporation of sciatic nerve was associated with transient foot functional deficit that completely recovered at 30 days. Irreversible electroporation removed cells from trabeculae in the femurs of rabbits and in the vertebral body of sheep. After irreversible protocol, histology and microtomography demonstrated that the trabecular structure was maintained, the presence of new bone marrow cells, osteoblasts, and mineral apposition characterized by new trabeculae thinner than controls (P= .005) and a significant reduction in the ablated areas (−225%, P= .0219). Spinal cord, vertebral pedicles and spinal nerves showed transient edema in the absence of functional or structural alterations. Collectively, these results show that electroporation can be safely applied to bone even in the proximity of neuronal structures.

Study Design Case report and literature review.Objective To present the first case of metastatic adamantinoma of the spine with immunohistochemical confirmation and an updated literature review.Summary of Background Data Spinal metastatic disease could be difficult to diagnose because of the multiple differential diagnoses involved. Spinal surgeons must be aware of unusual primary extra-axial tumors that metastasize to the spine because in certain cases the primary surgery must determine the prognosis of this lesion.Methods We present a fully documented case of a middle-aged man with tibial adamantinoma who developed spine metastasis, confirmed by immunohistochemistry. A literature review was done.Results Based on clinical, imaging, and pathology findings, we provide evidence for the first proven metastatic adamantinoma of the spine, adding this condition to the long list of differential diagnoses of secondary spinal disease.Conclusions Adamantinoma is a very rare bone tumor representing ~1% of primary bone tumors. Spinal metastatic adamantinoma with immunohistochemical confirmation has not been described previously. Due to the lack of specific image findings or serum markers and multiple differential diagnoses, biopsy with immunohistochemical confirmation is mandatory, because “en block resection” might prove to be curative treatment.

Minimally invasive stabilization of thoracic and lumbar fractures without neurologic involvement is becoming a more frequent alternative to open fusion and conservative treatment.The authors analyzed the complication rate and limits of this technique in a consecutive series of 99 patients (127 thoracolumbar vertebral fractures) who underwent this technique between May 2005 and November 2009. Eighty-three patients had only spine injuries, whereas 16 had polytrauma injuries (mean Injury Severity Score, 25.2). In these 16 patients, percutaneous fixation was performed as a damage control procedure. The most frequent construct was monosegmental: 1 level above and 1 level below the fractured vertebra. In the remaining 21 patients, multilevel construction was performed for multiple injuries. Complications were analyzed according to the period of onset (intra- and postoperative) and the severity (major and minor). Twelve (12%) complications were recorded: 4 (4%) were intraoperative, 6 (6%) were early postoperative, and 2 (2%) were late postoperative; 4 (4%) were minor and 8 (8%) were major. Mean follow-up was 52 months (range; 36–90 months). All patients except 1 were considered healed after 6-month follow-up. The failed patient had an initial kyphosis greater than 20°, and a posterior open reduction and fusion would have been more appropriate.Minimally invasive stabilization of selected spine injuries is a safe technique with a low complication rate. The main goal of this approach is a fast recovery time, so any complication leading to an extended length of stay should be considered severe. An adequate learning curve is important to minimize complications.

Retrospective cohort study.

We investigated predictive factors for local recurrence in 540 patients with non-metastatic osteosarcoma of the extremity treated with surgery and neoadjuvant chemotherapy, between March 1983 and October 1994. The median follow-up was 7.5 (2.5-15) years. Local recurrences developed in 31 (6%) patients after a median time of 2 (0.5-7) years. Local recurrence did not correlate with patients' age and sex, histologic subtype, site and tumor volume, presence of pathologic fracture, chemotherapy regimen and type of surgery. Local recurrence-free survival (LRFS) correlated with the quality of surgical margins and response to chemotherapy: the 7-year LRFS was 97% after adequate surgical margins and 71 % after inadequate surgical margins (p < 0.0001), and was 95% in good respondent and 90% in poor responders (p = 0.001). Only 1 of 31 patients with local recurrence was free of disease 15 months after the last treatment, 3 were alive with uncontrolled disease and 27 died. This post-relapse outcome is significantly worse than in patients who relapsed with metastases only (25% free of disease, 0.5-9 years after the last treatment). We conclude that, in osteosarcoma of the extremity, limb-salvage procedures should be planned only when the preoperative staging indicates that it is possible to achieve adequate surgical margins. If the pathologic examination of the surgical specimen shows inadequate surgical margins, an immediate amputation should be considered, especially if the histologic response to preoperative chemotherapy was poor.

To evaluate the frequency of osteosarcoma involving the foot and determine the clinical outcome of affected patients.

Iatrogenic aortic injuries by pedicle screws are rare but serious complications of spinal fixation surgery. We report the case of a 55-year-old man who underwent surgical correction of traumatic thoracic vertebral fractures at another institution. At 6-month follow-up, computed tomography revealed a nonhealing of the fractures, and a T4 misplaced pedicle screw penetrating the descending thoracic aorta. The patient underwent open aortic repair associated with the anterior vertebral column reconstruction and posterior arthrodesis revision by a vascular and orthopedic surgery team simultaneously.

Vertebral column is the most frequent site for bone metastases. It has been demonstrated in previous studies that bone metastases can be efficiently treated by electrochemotherapy. We developed a novel approach to treat spinal metastases, that is, transpedicular approach that combines electrochemotherapy with already established technologies for insertion of fixation screws in spinal surgery. In the transpedicular approach, needle electrodes are inserted into the vertebral body through pedicles and placed around the tumor. The main goal of our study was to numerically investigate the feasibility of the proposed treatment approach. Three clinical cases were used in this study—1 with a tumor completely contained within the vertebral body and 2 with tumors spread also to the pedicles and spinal canal. Anatomically accurate numerical models were built for all 3 cases, and numerical computations of electric field distribution in tumor and surrounding tissue were performed to determine the treatment outcome. Complete coverage of tumor volume with sufficiently high electric field is a prerequisite for successful electrochemotherapy. Close to 100% tumor coverage was obtained in all 3 cases studied. Two cases exhibited tumor coverage of >99%, while the coverage in the third case was 98.88%. Tumor tissue that remained untreated was positioned on the margin of the tumor volume. We also evaluated hypothetical damage to spinal cord and nerves. Only 1 case, which featured a tumor grown into the spinal canal, exhibited potential risk of neural damage. Our study shows that the proposed transpedicular approach to treat spinal metastases is feasible and safe if the majority of tumor volume is contained within the vertebral body. In cases where the spinal cord and nerves are contained within the margin of the tumor volume, a successful and safe treatment is still possible, but special attention needs to be given to evaluation of potential neural damage.

Introduction. Biopsy of affected tissue is required for lymphoma diagnosis at onset and relapse and to plan an adequate treatment. Open incisional biopsy is traditionally the method of choice, with an accuracy of approximately 100%. Nevertheless, it requires hospitalization, availability of an operating room and sometimes general anesthesia and is associated with several drawbacks (morbidity, surgical complications, tumor contamination of surrounding tissues). The development of ultrasound and computed tomography (CT)-guided fine-needle biopsies has almost overcome these disadvantages. However, a variable proportion of non-diagnostic procedures is reported, leading to an accuracy that ranges between 50% and 80%. Functional imaging, such as fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is a procedure which can potentially be used to drive biopsy to the most metabolically active area within a lymph node or to extranodal masses which sometimes show no morphologically detectable changes on CT scan.

Introduction Spinal infections are rare diseases, whose management highlights the importance of a multidisciplinary approach. Although treatment is based on antibiotics, always selected on coltural and antibiogram tests, surgery is required in case of development of spinal instability or deformity, progressive neurological deficits, drainage of abscesses, or failure of medical treatment. The first step of the algorithm is diagnosis, which is established on MRI with contrast, PET/CT scan, blood tests (CRP and ESR) and CT-guided needle biopsy. Evaluation of response to the specific antibiotic therapy is based on variations in Maximum Standardized Uptake Value (SUVmax) after 2 to 4 weeks of treatment. In selected cases, early minimally invasive surgery was proposed to provide immediate stability and avoid bed-rest.Material and Methods From 1997 to 2014, 182 patients affected by spinal infections have been treated at the same institution (Istituto Ortopedico Rizzoli – Bologna, Italy) according to the proposed algorithm. Mean age was 56 years (range 1 - 88). Male to female ratio was 1,46.Results Minimum follow-up was 1 year. Infections were mostly located in the lumbar spine (57%) followed by thoracic (37%) and cervical spine (6%). Conservative treatment based on antibiotics needed surgery (open and/or percuteneous minimally invasive) as an adjuvant in 83 patients out of 182 (46%).Conclusion Management of spinal infections still remains a challenge in spinal surgery and multisciplinary approach is mandatory. This algorithm represents the shared decision making process from diagnosis to the most appropriate treatment, led to successful outcomes with a low-complication rate.

Introduction The surgical treatment of complex spinal deformity and vertebral oncological diseases is becoming more common. The aim of this study was to prospectively record all the major complications observed in the perioperative and postoperative period for surgeries performed at our Division of Spine Surgery in the 2010 to 2012 period, correlating this score with different parameters to determine possible risk factors.Material and Methods A total of 285 surgeries were registered in 2010, 324 in 2011, and 308 in 2012. All the complications observed during the procedure and the follow-up period were recorded and classified according to the type (mechanical complications, neurological complications, infection, hematoma, cerebrospinal fluid fistula, systemic complications, and death related to the surgery).Results In 2010, on 285 surgeries 47 patients (16.5%) had 69 complications (24.2%): 25.7% for the treatment of oncological diseases, 23% for the treatment of degenerative diseases, 27% for the treatment of pathologies of traumatic origin, and 11% for the treatment of spondylodiscitis (infectious diseases). In 2011, on 324 surgeries 35 patients (10.8%) had 54 complications (16.7%): 16.3% for the treatment of oncological diseases, 16.3% for the treatment of degenerative diseases, 20% for the treatment of pathologies of traumatic origin, 28.6% for the treatment of spondylodiscitis. In 2012, on 308 surgeries, 25 patients (8.1%) had 36 complications (11.7%): 14.4% for the treatment of oncological diseases, 7.2% for the treatment of degenerative diseases, 16.7% for the treatment of pathologies of traumatic origin, and 20% for the treatment of spondylodiscitis.Conclusion On 917 spinal surgeries performed from January 2010 to December 2012, 159 complications (17.3%) were recorded, with a prevalence of mechanical complications and infections. The correlation of these complications with different parameters, such as age, sex, presence of comorbidities, previous spine surgery, type of surgery, will be analyzed to detect potential risk factors to be taken into consideration in the decision-making process for complex spinal surgery.

Introduction The surgical approach to adult deformities is challenging both in terms of surgical planning and of amount of complications. Current literature shows potential benefits in surgical correction of adult deformities; recovery of both frontal and sagittal balance seems to be the key for satisfactory outcomes.Patients and Methods In this retrospective study, from an initial pattern of 30 patients, 12 selected patients were considered. All patients, average age 57 years, underwent adult scoliosis surgical correction. We evaluated the clinical outcomes in correlation with restoring of the sagittal balance and the rate of complications and mechanical failure. Previous surgery was not an exclusion criteria. Average follow-up was 8.2 months (range, 3–20 months). Clinical evaluation was performed by using Visual Analog Score test, Oswestry Disability Index, and Quality of Life test. Radiological measures were performed by software Surgimap Spine.Results In 10 cases (83% of patients), we observed agreement between clinical and radiological outcomes (we focused in particular on sagittal balance). To a satisfactory recovery of sagittal balance, in eight cases we found improvement at clinical tests while in two cases to a poor balance correction, the patients' quality of life did not improve. In only two cases (16% of patients), we found disagreement between the two parameters indicated (sagittal balance and quality of life). In our series, five patients had mechanical failures: four of them did not improve their sagittal balance at postoperative X-ray.Conclusion The purpose of this study was to validate the hypothesis that good clinical results in adult deformities correction are better achieved when restoration of sagittal balance is obtained. The large agreement among quality of life evaluation and recovery of sagittal balance we observed in this preliminary series of selected patients seems to hold it up. Moreover, the respect of physiological pelvic parameters seems to reduce the number of adverse events in terms of mechanical failures and consequently the number of reoperations; its indeed necessary to underline how 100% of patients whose sagittal balance did not improve with surgery had mechanical failure of instrumentation. Only one patient with acceptable sagittal parameters needed reoperation because of breaking of the rods.