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Background Context: Coexisting Parkinson's disease (PD) and cervical spondylotic myelopathy (CSM) presents a diagnostic and therapeutic challenge due to symptomatic similarities between the diseases. Whereas CSM patients are routinely treated with surgery, PD patients face poorer outcomes following spine surgery. No studies have investigated the quality of life (QOL) outcomes following decompression in coexisting PD and CSM.Purpose: The purpose of the present study was to characterize QOL outcomes for patients with coexisting PD and CSM following cervical decompression.Study Design/setting: This is a matched cohort study at a single tertiary-care center.Patient Sample: Patients with coexisting PD and CSM undergoing cervical decompression between June 2009 and December 2014 were included. These patients were matched to controls with CSM alone by age, gender, American Society of Anesthesiologists classification, Modified Japanese Orthopaedic Association scores, and operative parameters.Outcome Measures: The primary outcome measure was QOL outcomes assessed by change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9) at last follow-up (LFU). Change in QOL exceeding the minimal clinically important difference (MCID) was secondary.Methods: QOL data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable regressions were used to assess the impact of PD upon change in QOL.Results: Eleven PD patients were matched to 44 controls. Control patients experienced QOL improvement across all three measures, whereas PD patients only improved with respect to PDQ(89.9-80.7, p=.03). Despite no significant differences in preoperative QOL, PD patients experienced poorer QOL at LFU in EQ-5D (0.526 vs. 0.707, p=.01) and PDQ (80.7 vs. 51.4, p=.03), and less frequently achieved an EQ-5D MCID (18% vs. 57%, p=.04). However, no differences in the achievement of an MCID in PDQ or PHQ-9 were observed between cohorts. Multivariable regression identified PD as a significant independent predictor of poorer improvement in EQ-5D (β=-0.09, p<.01) and failure to achieve an EQ-5D MCID (odds ratio: 0.08, p<.01).Conclusions: This is the first study to characterize QOL outcomes following cervical decompression for patients with coexisting PD and CSM. Although myelopathy may have been less severe among PD patients, a significant reduction in pain-related disability was observed following decompression. However, PD predicted diminished improvement in overall QOL measured by the EQ-5D. [ABSTRACT FROM AUTHOR]

Background Context: Nearly 70% of patients with multiple myeloma (MM) experience vertebral fracture. As a consequence, these patients suffer significantly poorer quality of life. However, no studies have characterized the natural progression of these fractures.Purpose: The purpose of this study was to characterize the progression of MM-associated vertebral fractures.Study Design/setting: A consecutive retrospective chart review at a single tertiary-care center was carried out.Patient Sample: Patients with MM and pathologic vertebral fracture with at least one follow-up between January 2007 and December 2013 were included. Radiographic measurements were recorded until last follow-up (LFU) or until surgical intervention or patient death. Patients with a history of vertebral fracture not associated with MM were excluded.Outcome Measures: The primary outcome measure was change in height of the fractured vertebrae. Fractures were characterized by Genant grade and morphology.Methods: At baseline and each follow-up, anterior, middle, and posterior vertebral body heights were measured from midline sagittal T1-weighted magnetic resonance imaging. Student t tests and Fisher exact tests were performed to identify variables associated with fracture progression.Results: Among 33 patients, 67 fractures were followed. Sixty-four percent of patients were female, with a mean age of 66. Baseline mean anterior, middle, and posterior vertebral body height losses were 30%, 36%, and 15%, respectively. Forty-three percent of fractures were Genant grade 3, and 57% were biconcave. Mean time to LFU was 40 months. At LFU, mean anterior, middle, and posterior vertebral body height losses increased to 47% (p<.01), 49% (p<.01), and 28% (p<.01), respectively. More fractures became Genant grade 3 (75%, p<.01) and wedge (54%, p=.03). On average, patients lost 0.83% in vertebral body height per month, with initial Genant grade 1 fractures progressing most rapidly (1.69%/month, p<.01). Patients treated with bisphosphonates suffered less additional height loss compared with untreated patients (14% vs. 24%, p=.07).Conclusions: We observed significant fracture progression despite high utilization of bisphosphonates. Patients lost nearly 1% of additional vertebral body height per month, with the least severe presenting fractures progressing most rapidly, highlighting the necessity for early referral to spine specialists and evidence-based guidelines for surveillance and treatment in the myeloma population. [ABSTRACT FROM AUTHOR]

Background Context: Patients with multiple myeloma (MM) incur significant degradation in quality of life because of progressive osteolytic vertebral fractures. No studies have investigated predictors of fracture progression, and limited data are available for predicting the development of future fractures.Purpose: The purpose of this study was to identify independent predictors of vertebral fracture progression and the development of future vertebral fracture.Study Design/setting: This is a consecutive retrospective chart review at a single tertiary-care center.Patient Sample: Patients with MM and pathologic vertebral fracture with radiographic follow-up between January 2007 and December 2013 were included. Radiographic measurements were recorded at presentation with fracture and first follow-up (FFU) after at least three months. Patients with a history of vertebral fracture not associated with MM were excluded.Outcome Measures: The primary outcome measure was the rate of vertebral body height loss. The development of future vertebral fracture was secondary.Methods: Anterior, middle, and posterior vertebral body heights were measured from midline sagittal T1-weighted magnetic resonance imaging (MRI). Future fracture-free survival was calculated using Kaplan-Meier analysis. Multivariable regression was used to identify independent predictors of the rate of vertebral height loss. Multivariable Cox proportional hazards modeling was used to identify predictors of developing future vertebral fracture.Results: Thirty-three patients with 67 fractures were followed for a median of 10.8 months to FFU. Sixty-four percent of the patients were female and the median age was 66. The median additional vertebral height loss between presentation and FFU was 15%, whereas the median rate of vertebral height loss was 1.01%/month. More rapid vertebral height loss was predicted by dyslipidemia (β=0.36, p=.05), previous non-vertebral pathologic fracture related to MM (β=0.51, p=.01), and Durie-Salmon Stage III (β=0.66, p=.06). The median time to future fracture was 25.1 months; the 5-year future fracture-free survival rate was 34%. Osteopenia/osteoporosis (hazard ratio [HR]: 9.28, p<.01), serum light chains (HR: 1.37, p=.06), and serum calcium (HR: 1.62, p=.05) predicted the development of future vertebral fracture.Conclusions: We observed significant fracture progression over a short follow-up period. Several comorbidities and laboratory measures predicted more rapid vertebral height loss and the development of future fracture. Identifying risk factors for increased fracture burden may allow spine specialists to pursue earlier and appropriate intervention to optimize function and minimize morbidity. [ABSTRACT FROM AUTHOR]

Objectives: Prior studies suggest that oxaliplatin is unique among platinum chemotherapy drugs in its ability to enhance anti-tumor immunity, but the immune mechanisms of different platinum chemotherapy drugs have not been previously compared in preclinical models of head and neck squamous cell carcinoma (HNSCC).Materials and Methods: Human HNSCC cell lines were treated with cisplatin or oxaliplatin, then assessed for markers associated with immunogenic cell death (ICD) and antigen processing. A syngeneic mouse model of oral cancer was then used to compare the effects of cisplatin vs. oxaliplatin, alone or in combination with anti-PD-1 immunotherapy, on tumor growth and survival. A subset of spleens and tumors were analyzed for ICD markers and immune cell infiltrates by flow cytometry.Results: Cisplatin and oxaliplatin both increased cell surface levels of calreticulin, HSP70, MHC class I and PD-L1 in multiple cell lines. Inoculation of immunocompetent mice with cells killed in vitro by either drug resulted in failure of subsequently-injected live tumor cells to establish and grow in a small proportion of animals. Systemic cisplatin and oxaliplatin induced similar tumor growth delay when combined with anti-PD-1 therapy.Conclusions: Treatment of HNSCC cells with platinum chemotherapy appears to induce some features of anti-tumor immunity, which may be enhanced by anti-PD-1 therapy. Cisplatin, the standard drug for HNSCC, appears to affect anti-tumor immunity in a similar fashion to oxaliplatin in these preclinical models. [ABSTRACT FROM AUTHOR]

Background Context: Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.Purpose: The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery.Study Design/setting: This is a retrospective cohort study at a single tertiary care institution.Patient Sample: The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014.Outcome Measures: The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission.Methods: Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes.Results: A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1-58.2 for cervical patients and 79.4-58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05-4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03-1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10).Conclusions: Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year. [ABSTRACT FROM AUTHOR]

Background: The primary dose-limiting toxicity of stereotactic radiosurgery (SRS) is radiation necrosis (RN), which occurs after approximately 5% to 10% of treatments. This adverse event may worsen neurologic deficits, increase the frequency and cost of imaging, and necessitate prolonged treatment with steroids or antiangiogenic agents. Previous investigations have primarily identified lesion size and dosimetric constraints as risk factors for RN in small populations. We hypothesized that disease histology, receptor status, and mutational status are associated with RN.Methods and Materials: All patients presenting with brain metastasis between 1997 and 2015 who underwent SRS and subsequent radiographic follow-up at a single tertiary-care institution were eligible for inclusion. The primary outcome was the cumulative incidence of radiographic RN. Multivariate competing risks regression was used to identify biological risk factors for RN.Results: 1939 patients (5747 lesions) were eligible for inclusion; 285 patients (15%) experienced radiographic RN after the treatment of 427 (7%) lesions. After SRS, the median time to RN was 7.6 months. After multivariate analysis, graded prognostic assessment, renal pathology, lesion diameter, and the heterogeneity index remained independently predictive of RN in the pooled cohort. In subset analyses of individual pathologies, HER2-amplified status (hazard ratio [HR] 2.05, P=.02), BRAF V600+ mutational status (HR 0.33, P=.04), lung adenocarcinoma histology (HR 1.89, P=.04), and ALK rearrangement (HR 6.36, P<.01) were also associated with RN.Conclusions: In the present investigation constituting the largest series of RN, several novel risk factors were identified, including renal histology, lung adenocarcinoma histology, HER2 amplification, and ALK/BRAF mutational status. These risk factors may be used to guide clinical trial design incorporating biological risk stratification or dose escalation. Future studies determining the optimal timing of targeted therapies are warranted to further define the risk of RN. [ABSTRACT FROM AUTHOR]

Background Context: Patients with comorbid disease may experience suboptimal quality of life (QOL) improvement following decompression spinal surgery. Prior studies have suggested the deleterious effect of diabetes upon postoperative QOL; however, these studies have not used minimal clinically important differences (MCIDs) or multivariable statistical techniques.Purpose: The purpose of this study was to assess the effect of preoperative diabetes upon postoperative change in QOL.Study Design/setting: A retrospective cohort study at a single tertiary-care center was carried out.Patient Sample: Patients who underwent lumbar decompression between 2008 and 2014 were included in the study. Inclusion necessitated a minimum follow-up of 6 months.Outcomes Measures: Postoperative changes in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire 9 (PHQ-9) at last follow-up were the primary outcome measures. The secondary outcome variable was postoperative change in QOL measures exceeding the MCID.Methods: Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. Simple and multivariable logistic regressions were used to assess the impact of diabetes upon normalized change in QOL and improvement exceeding the MCID.Results: There were 212 patients who met inclusion criteria. Whereas non-diabetics experienced significant improvements in EQ-5D, PDQ, and PHQ-9 (p<.01), diabetics experienced no significant changes in any measures. More non-diabetics achieved the EQ-5D MCID compared with diabetics (55% vs. 23%, p<.01). Following multivariable regression, chronic kidney disease (CKD, β=-0.15, p=.04) and diabetes (β=-0.05, p=.04) were identified as significant independent predictors of diminished improvement in EQ-5D postoperatively. Furthermore, diabetes was also identified as a significant independent predictor of failure to achieve an EQ-5D MCID (OR 0.20, p<.01), whereas CKD trended toward predicting diminished improvement (OR<0.01, p=.09).Conclusion: The burden of comorbidities may impact the QOL benefit of decompression spine surgery. In the present study, diabetes was found to independently predict diminished improvement in QOL after lumbar decompression. [ABSTRACT FROM AUTHOR]

Background Context: Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5-S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques.Purpose: To define the clinical, radiographic, and financial differences between TLIF and ALIFPS for L5-S1 IS.Design/setting: A retrospective cohort study conducted at a single tertiary care center.Patient Sample: Sixty-six patients who underwent either TLIF or ALIPFS for L5-S1 IS at a single tertiary care center between 2009 and 2014.Outcome Measures: Quality of life outcome scores including the EuroQol-5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Sagittal balance parameters including: pelvic incidence, pelvic tilt, sacral slope, segmental lordosis, total lordosis, degree of slip, disc height, and L1-axis S1 distance (LASD). Cost measures included in-hospital charges, hospital length of stay (LOS), and post-admission costs accrued over 1 year.Methods: Quality of life (QoL) outcome scores, radiographic data, and financial data were collected with a minimum of 1-year follow-up. Clinical results were investigated using the PDQ, PHQ-9, and EQ-5D. Radiographic measurements included lumbar lordosis, segmental lordosis, pelvic tilt, pelvic incidence, height of disc, L-1 axis S-1 distance, and the degree of slip. Cost data were generated based on patient-level resource utilization. Comparative data were presented as median with interquartile range (IQR). Continuous variables were compared using either independent Student t tests assuming unequal variance or Mann-Whitney U tests for parametric and nonparametric variables, respectively. The minimally clinical important difference (MCID) used for each questionnaire was as follows: PDQ (26), PHQ-9 (5), and EQ-5D (0.4).Results: A total of 66 patients met inclusion criteria. In the ALIFPS cohort, PDQ scores improved from 69 [47, 82] to 26 [18.2, 79.7], p=.02. In the TLIF cohort, PDQ scores improved from 73 [46, 85] to 48.5 [23, 67.5], p=.01. Both groups also showed a significant improvement in EQ-5D scores at 1 year, but the ALIFPS group showed a significantly greater improvement in EQ-5D scores at 1 year (0.1 [0,0.2] vs. 0.2 [0.1, 0.4], p=.02). Furthermore, only the ALIFPS cohort showed a significant improvement in segmental lordosis. The ALIFPS cohort showed a significantly greater improvement in disc height than did TLIF (3.5 [2, 5.5] vs. 6.7 [4.1, 10], p=.01). No significant differences were found in the direct costs of both procedures.Conclusions: Our findings suggest that anterior lumbar interbody fusion with percutaneous pedicle screws can achieve better clinical outcomes compared with TLIF for the treatment of IS. We believe the superior radiographic outcomes achieved through ALIFPS, namely a greater restoration of segmental lordosis and disc height, may have contributed to the improved clinical outcomes presented in the current study. [ABSTRACT FROM AUTHOR]

Background: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys are used to assess the quality of the patient experience following an inpatient stay. Hospital Consumer Assessment of Healthcare Providers and Systems scores are used to determine reimbursement for hospital systems and incentivize spine surgeons nationwide. There are conflicting data detailing whether early readmission or other postdischarge complications are associated with patient responses on the HCAHPS survey. Currently, the association between postdischarge emergency department (ED) visits and HCAHPS scores following lumbar spine surgery is unknown.Purpose: To determine whether ED visits within 30 days of discharge are associated with HCAHPS scores for patients who underwent lumbar spine surgery.Study Design: Retrospective cohort study.Patient Sample: A total of 453 patients who underwent lumbar spine surgery who completed the HCAHPS survey between 2013 and 2015 at a single tertiary care center.Outcome Measures: The HCAHPS survey-the Centers for Medicare and Medicaid Services' official measure of patient experience-results for each patient were analyzed as the primary outcome of this study.Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy or scoliosis. Patients who had an ED visit at our institution within 30 days of discharge were included in the ED visit cohort. The primary outcomes of this study include 21 measures of patient experience on the HCAHPS survey. Statistical analysis included Pearson chi-square for categorical variables, Student t test for normally distributed continuous variables, and Mann-Whitney U test for nonparametric variables. Additionally, log-binomial regression models were used to analyze the association between ED visits within 30 days after discharge and odds of top-box HCAHPS scores. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.Results: After adjusting for patient-level covariates using log-binomial regression models, we found postdischarge ED visits were independently associated with lower likelihood of top-box score for several individual questions on HCAHPS. Emergency department visits within 30 days of discharge were negatively associated with perceiving your doctor as "always" treating you with courtesy and respect (risk ratio [RR] 0.26, p<.001), as well as perceiving your doctor as "always" listeningcarefully to you (RR 0.40, p=.003). Also, patients with an ED visit were less likely to feel as if their preferences were taken into account when leaving the hospital (RR 0.61, p=.008), less likely to recommend the hospital to family or friends (RR 0.46, p=.020), and less likely to rate the hospital as a 9 or a 10 out of 10, the top-box score (RR 0.43, p=.005).Conclusions: Our results demonstrate a strong association between postdischarge ED visits and low HCAHPS scores for doctor communication, discharge information, and global measures of hospital satisfaction in a lumbar spine surgery population. [ABSTRACT FROM AUTHOR]