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Background Context: Surgical decompression and stabilization followed by radiosurgery represents an effective method for local tumor control and neurologic preservation for patients with metastatic epidural spinal cord compression (MESCC). We have previously demonstrated improvement in health-related quality of life (HrQOL) after this combined modality treatment ("hybrid therapy").Purpose: The current analysis focuses on delineation of patient-specific prognostic factors predictive of HrQOL change after combined surgery-stereotactic radiosurgery (SRS) treatment of MESCC.Study Design: This is a prospective, single-center, cohort study.Patient Sample: One hundred and eleven patients with MESCC who underwent separation surgery followed by SRS were included.Outcome Measures: Prognostic factors associated with improved patient-reported outcome (PRO) measures.Methods: Patient-reported outcome tools, that is, Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP), both validated in the cancer population, were prospectively collected. Numeric prognostic factors were correlated with PRO measures using the Spearman rank correlation coefficient. Categorical prognostic factors were correlated with PRO measures using the Wilcoxon two-sample test (for two categories) or the Kruskal-Wallis test (for three or more categories). All statistical tests were two-sided with a level of significance <.05 for correlation of prognostic factors with PRO constructs and a level of significance <.0014 for correlation of prognostic factors with PRO items. Statistical analyses were done in SAS (version 9.4, Cary, NC, USA).Results: One hundred and eleven patients were included in this analysis. Patients with lower preoperative Medical Research Council (MRC) motor scores experienced a greater decrease in symptom interference (BPI interference construct (p=.03) and individual functional measures including general activity (p=.001), walking (p=.001), and normal work (p=.006)). Lumbar location was associated with better outcomes than cervical or thoracic as noted on the BPI pain experience construct (p=.03) and MDASI-SP interference (p=.01) and core symptom (p=.002) constructs. Patients with American Spinal Injury Association (ASIA) scores of C or D benefit more than those with ASIA E on BPI interference construct (p=.04). Patients with higher Eastern Cooperative Oncology Group (ECOG) scores at presentation benefit more than those with low ECOG scores on MDASI-SP interference construct (p=.03). Women benefit more than men on BPI interference (p=.03) and pain experience (p=.04) constructs. Patients with prior spinal surgery at the current level of interest benefit less than those who are naïve surgical patients in MDASI-SP interference construct (p=.04).Conclusions: Delineation of patient characteristics associated with HrQOL improvement provides crucial information for patient selection, patient education, and setting treatment expectations. For patients with MESCC treated with hybrid therapy using surgery and radiosurgery, the presence of neurologic deficits and diminished performance status, lumbar tumor level, and female gender were associated with greater PRO improvement. [ABSTRACT FROM AUTHOR]

Background and Context: Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management.Purpose: Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC.Study Design/setting: Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015.Patient Sample: Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression.Outcome Measures: Duration of ambulation and survival.Methods: Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis.Results: Forty patients were included (21 male, 54%; mean age 74 years, range 65-87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0-1662) and 525 days (range 11-1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65-69, 70-79, or 80-89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0-11.Conclusions: Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery. [ABSTRACT FROM AUTHOR]

Background Context: Bioresorbable calcium phosphate cement (CPC) may be suitable for vertebroplasty/kyphoplasty of osteoporotic vertebral fractures. However, additional targeted delivery of osteoinductive bone morphogenetic proteins (BMPs) in the CPC may be required to counteract the augmented local bone catabolism and support complete bone regeneration.Purpose: This study aimed at testing an injectable, poly (l-lactide-co-glycolide) acid (PLGA) fiber-reinforced, brushite-forming cement (CPC) containing low-dose bone morphogenetic protein BMP-2 in a sheep lumbar osteopenia model.Study Design/ Setting: This is a prospective experimental animal study.Methods: Bone defects (diameter 5 mm) were generated in aged, osteopenic female sheep and filled with fiber-reinforced CPC alone (L4; CPC+fibers) or with CPC containing different dosages of BMP-2 (L5; CPC+fibers+BMP-2; 1, 5, 100, and 500 µg BMP-2; n=5 or 6 each). The results were compared with those of untouched controls (L1). Three and 9 months after the operation, structural and functional effects of the CPC (±BMP-2) were analyzed ex vivo by measuring (1) bone mineral density (BMD); (2) bone structure, that is, bone volume/total volume (assessed by micro-computed tomography [micro-CT] and histomorphometry), trabecular thickness, and trabecular number; (3) bone formation, that is, osteoid volume/bone volume, osteoid surface/bone surface, osteoid thickness, mineralizing surface/bone surface, mineral apposition rate, and bone formation rate/bone surface; (4) bone resorption, that is, eroded surface/bone surface; and (5) compressive strength.Results: Compared with untouched controls (L1), CPC+fibers (L4) and/or CPC+fibers+BMP-2 (L5) significantly improved all parameters of bone formation, bone resorption, and bone structure. These effects were observed at 3 and 9 months, but were less pronounced for some parameters at 9 months. Compared with CPC without BMP-2, additional significant effects of BMP-2 were demonstrated for bone structure (bone volume/total volume, trabecular thickness, trabecular number) and formation (osteoid surface/bone surface and mineralizing surface/bone surface), as well as for the compressive strength. The BMP-2 effects on bone formation at 3 and 9 months were dose-dependent, with 5-100 µg as the optimal dosage.Conclusions: BMP-2 significantly enhanced the bone formation induced by a PLGA fiber-reinforced CPC in sheep lumbar osteopenia. A single local dose as low as ≤100 µg BMP-2 was sufficient to augment middle to long-term bone formation. The novel CPC+BMP-2 may thus represent an alternative to the bioinert, supraphysiologically stiff polymethylmethacrylate cement presently used to treat osteoporotic vertebral fractures by vertebroplasty/kyphoplasty. [ABSTRACT FROM AUTHOR]

Background Context: A number of studies have reported favorable surgical results for metastatic spinal tumors from various solid tumors. However, there are few data available on metastatic spinal cord compression (MSCC) from lung cancer despite its considerable frequency.Purpose: The study aims to present the functional outcomes, survival time, and complications after surgical treatment for MSCC from non-small cell lung cancer (NSCLC).Study Design/setting: This is a longitudinal observational study.Patient Sample: The study includes 50 patients who had neurologic deficit and underwent surgical treatment for MSCC from NSCLC.Outcome Measures: The Eastern Cooperative Oncology Group performance status (ECOG-PS), ambulatory status, overall survival, factors associated with survival time, and perioperative complications were analyzed.Methods: The postoperative changes of ECOG-PS and ambulatory status were assessed. The factors affecting postoperative ambulatory status were evaluated using logistic regression analysis. Survival time was calculated using the Kaplan-Meier method. To identify the prognostic factors, log-rank test and Cox hazards regression model were used for univariate and multivariate analyses, respectively. Major complications within postoperative 30 days and mortality rate were recorded.Results: The study cohort consisted of 27 males and 23 females with a mean age of 58.0±11.3 years at the time of surgery. An ECOG-PS improvement by at least one grade was observed in 33 of 50 cases (66.0%). Among 39 patients who were not ambulatory before surgery, 23 patients (59.0%) regained ambulatory ability after surgery. Patients who were preoperatively ambulant and those who underwent surgery within 72 hours from neurologic deficit had an increased chance of postoperative ambulation. The median for overall survival after surgery was 5.2 months. Five prognostic factors were identified on univariate analysis: time from neurologic deficit, responsiveness to preoperative chemotherapy, postoperative chemotherapy, postoperative ECOG-PS, and postoperative ambulatory status. Multivariate analysis revealed that time to neurologic deficit (risk ratio [RR]: 2.28, p=.023), postoperative chemotherapy (RR: 6.58, p<.001), and postoperative ECOG-PS (RR: 2.73, p=.040) were independent prognostic factors of survival time. Major complications developed in 34.0% of patients (17 of 50), and the 30-day mortality rate was 10.0% (5 of 50).Conclusions: Functional improvements were observed through surgical treatment even with relatively high complication rates for MSCC from NSCLC. Earlier surgical treatment could act as an adjuvant therapy for prolonging survival by improving functional status. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Primary non-Hodgkin lymphoma of the spine (PNHLS) with spinal cord compression is an extremely rare disease in clinical practice. The optimal treatment options for this disease have been controversial and pose a challenge for the clinicians. Purpose: To provide some useful insight into the treatments, outcomes, and prognostic factors of PNHLS. Study design: Retrospective analysis. Patient sample: The authors collected 40 patients’ data with primary non-Hodgkin lymphoma at the mobile spine, and these patients presented with spinal cord compression as a first symptom between 1998 and 2010. Outcome measures: The posttreatment neurologic status, general status, local recurrence, and survival were noted according to the telephone calls, letters, or follow-up visits in the outpatient department. Methods: Multidisciplinary treatments, including surgical intervention, chemotherapy, and radiotherapy, were performed in this series. Follow-ups regarding treatment outcomes, local recurrence, and survival rates were carried out and analyzed. The prognostic factors including age, neurologic status, general status, vertebrae involvement, and treatment outcomes were determined. Results: The median age of the patients was 52 years (range, 13–79 years). After treatments, 30 patients (75%) reached a complete remission (CR). The 5-year overall survival (OS) of all patients was 72.9%. Patients who were younger than 60 years, with single vertebra involvement, or had CR after treatment had higher 5-year OS (p<.05). In multivariate analysis, CR after treatment and involvement of a single vertebra were identified as favorable prognostic factors for OS. Conclusions: Patients with PNHLS with neurologic compression had distinct clinical features. Regarding treatment, the authors emphasized the importance of multidisciplinary management and the optimal operating juncture. Patients with excellent response to the treatment and single vertebra involvement had better survival. [Copyright &y& Elsevier]

Background Context: Multiple myeloma (MM) with spinal involvement may present with spinal cord or cauda equina compression, with or without neurological impairment. This occurs when a soft-tissue myelomatous mass extends into the epidural space (Barron et al., 1959 [1]). The mainstay of management for such lesions in patients with normal neurology is chemotherapy and radiotherapy or radiotherapy alone, but those with neurological compromise require surgical decompression with adjuvant therapy (Patchell et al., 2005 [2]). Infrequently, patients with MM present with spinal cord compression and neurological impairment due to bony encroachment from vertebral translation and kyphosis where significant lytic bone disease has rendered the spine mechanically unstable. The standard management for these patients is surgical decompression and internal fixation.Purpose: This study aimed to report a high-risk myeloma patient with a mechanically unstable spine, acute spinal cord compression, and neurologic deficit that was treated successfully using nonoperative means.Study Design: Case report.Methods: A 37-year-old male patient with MM was referred to our tertiary referral spinal unit with acute bony spinal cord compression and neurological impairment. Computer tomography revealed lytic lesions of T2 and T3 and anterolisthesis of T1 on T2 producing mechanical instability and magnetic resonance imaging confirmed extension of disease into the epidural space and cord compression. This was successfully managed with nonoperative treatment using a brace.Results: Management in a brace restored clinical and radiological stability and normal neurological function.Conclusion: Certain high-risk myeloma patients with a mechanically unstable spine, acute spinal cord compression and neurologic deficit can be treated effectively in an appropriate brace when managed by a tertiary referral spinal unit. [ABSTRACT FROM AUTHOR]