Search

Background: Effective management of metastatic disease requires multidisciplinary input and entails high risk of disease-related and treatment-related morbidity and mortality. The factors that influence clinician decision-making around spinal metastases are not well understood. We conducted a qualitative study that included a multidisciplinary cohort of physicians to evaluate the decision-making process for treatment of spinal metastases from the clinician's perspective.Methods: We recruited operative and nonoperative clinicians, including orthopaedic spine surgeons, neurosurgeons, radiation oncologists, and physiatrists, from across North America to participate in either a focus group or a semistructured interview. All interviews were audiorecorded and transcribed verbatim. We then performed a thematic analysis using all of the available transcript data. Investigators sequentially coded transcripts and identified recurring themes that encompass overarching patterns in the data and directly bear on the guiding study question. This was followed by the development of a thematic map that visually portrays the themes, the subthemes, and their interrelatedness, as well as their influence on treatment decision-making.Results: The thematic analysis revealed that numerous factors influence provider-based decision-making for patients with spinal metastases, including clinical elements of the disease process, treatment guidelines, patient preferences, and the dynamics of the multidisciplinary care team. The most prominent feature that resonated across all of the interviews was the importance of multidisciplinary care and the necessity of cohesion among a team of diverse health-care providers. Respondents emphasized aspects of care-team dynamics, including effective communication and intimate knowledge of team-member preferences, as necessary for the development of appropriate treatment strategies. Participants maintained that the primary role in decision-making should remain with the patient.Conclusions: Numerous factors influence provider-based decision-making for patients with spinal metastases, including multidisciplinary team dynamics, business pressure, and clinician experience. Participants maintained a focus on shared decision-making with patients, which contrasts with patient preferences to defer decisions to the physician, as described in prior work.Clinical Relevance: The results of this thematic analysis document the numerous factors that influence provider-based decision-making for patients with spinal metastases. Our results indicate that provider decisions regarding treatment are influenced by a combination of clinical characteristics, perceptions of patient quality of life, and the patient's preferences for care. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective study.Objective: The aim of this study was to describe the association between storage duration of packed red blood cells (PRBCs) and perioperative adverse events in patients undergoing spine surgery at a tertiary care center.Summary Of Background Data: Despite retrospective studies that have shown that longer PRBC storage duration worsens patient outcomes, randomized clinical trials have found no difference in outcomes. However, no studies have examined the impact of giving the oldest blood (28 days old or more) on morbidity within spine surgery.Methods: The surgical administrative database at our institution was queried for patients transfused with PRBCs who underwent spine surgery between December 4, 2008, and June 26, 2015. Patients undergoing spinal fusion, tumor-related surgeries, and other identified spine surgeries were included. Patients were divided into two groups on the basis of storage duration of blood transfused: exclusively ≤28 days' storage or exclusively >28 days' storage. The primary outcome was composite in-hospital morbidity, which included (1) infection, (2) thrombotic event, (3) renal injury, (4) respiratory event, and/or (5) ischemic event.Results: In total, 1141 patients who received a transfusion were included for analysis in this retrospective study; 710 were transfused exclusively with PRBCs ≤28 days' storage and 431 exclusively with PRBCs >28 days' storage. Perioperative complications occurred in 119 patients (10.4%). Patients who received blood stored for >28 days had higher odds of developing any one complication [odds ratio (OR) = 1.82; 95% confidence interval (95% CI), 1.20-2.74; P = 0.005] even after adjusting for competing perioperative risk factors.Conclusion: Blood stored for >28 days is independently associated with higher odds of developing perioperative complications in patients transfused during spinal surgery. Our results suggest that blood storage duration may be an appropriate parameter to consider when developing institutional transfusion guidelines that seek to optimize patient outcomes.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study of a nationwide database.Objective: To compare in-hospital outcomes for pediatric patients who underwent primary versus revision spinal fusion.Summary Of Background Data: There is limited data on outcomes after primary versus revision spinal fusion in children.Methods: Data from the Nationwide Inpatient Sample from 2002 to 2011 were analyzed. Pediatric patients (age <18 yr) who underwent ≥3 level spinal fusion were identified. Demographics, in-hospital complications, length of stay, and hospital charges were compared between primary and revision (refusion) procedures. All analyses were performed after application of discharge weights.Results: Data from 72,483 primary fusion and 2042 revision fusion procedures (2.7%) were analyzed. Average length of stay was 7.9 days for the revision group and 6.6 for the primary group (P = 0.022). Average total charges were $135,644 and $142,029 for the revision and primary fusion groups, respectively (P = 0.252). The percentage of patients who developed at least one in-hospital complication was 16.7% in the revision group and 8.6% in the primary fusion group (P < 0.001). Specific complications that were more common in the revision group were reintubation (4.3% vs. 2.3%, P = 0.008), hemorrhage/hematoma (5.0% vs. 2.5%, P = 0.001), wound complications (4.0% vs. 1.1%, P < 0.001), accidental vessel/nerve puncture (2.6% vs. 0.8%, P < 0.001), implant-related complications (5.3% vs. 0.4%, P < 0.001), and incidental durotomy (2.1% vs. 0.3%, P < 0.001). On multivariate analysis, revision procedures (odds ratio [OR] 2.64; 95% confidence interval [CI] 1.93-3.59; P < 0.001), male sex (OR 1.73; 95% CI 1.52-1.98; P < 0.001), and fusion of eight or more spinal levels (OR 1.27; 95% CI 1.09-1.47; P = 0.001) were risk factors for complication development.Conclusion: In the present study, pediatric patients who underwent spinal refusion had significantly higher complication rates compared to patients who underwent primary fusion, consistent with previous investigations. Male patients and patients who underwent fusion of eight or more spinal levels also had higher complication rates.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Type: A review of the literature.Objective: The aim of this study was to discuss the evolution of molecular signatures and the history and development of targeted therapeutics in metastatic tumor types affecting the spinal column.Summary Of Background Data: Molecular characterization of metastatic spine tumors is expected to usher in a revolution in diagnostic and treatment paradigms. Molecular characterization will provide critical information that can be used for initial diagnosis, prognosticating the ideal treatment strategy, assessment of treatment efficacy, surveillance and monitoring recurrence, and predicting complications, clinical outcome, and overall survival in patients diagnosed with metastatic cancers to the spinal column.Methods: A review of the literature was performed focusing on illustrative examples of the role that molecular-based therapeutics have played in clinical outcomes for patients diagnosed with metastatic tumor types affecting the spinal column.Results: The impact of molecular therapeutics including receptor tyrosine kinases and immune checkpoint inhibitors and the ability of molecular signatures to provide prognostic information are discussed in metastatic breast cancer, lung cancer, prostate cancer, melanoma, and renal cell cancer affecting the spinal column.Conclusion: For the providers who will ultimately counsel patients diagnosed with metastases to the spinal column, molecular advancements will radically alter the management/surgical paradigms utilized. Ultimately, the translation of these molecular advancements into routine clinical care will greatly improve the quality and quantity of life for patients diagnosed with spinal malignancies and provide better overall outcomes and counseling for treating physicians.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Study Design: Literature review.Objective: To describe advancements in molecular techniques, biomarkers, technology, and targeted therapeutics and the potential these modalities hold to predict treatment paradigms, clinical outcomes, and/or survival in patients diagnosed with primary spinal column tumors.Summary Of Background Data: Advances in molecular technologies and techniques have influenced the prevention, diagnosis, and overall management of patients diagnosed with cancer. Assessment of genomic, proteomic alterations, epigenetic, and posttranslational modifications as well as developments in diagnostic modalities and targeted therapeutics, although the best studied in nonspinal metastatic disease, have led to increased understanding of spine oncology that is expected to improve patient outcomes. In this manuscript, the technological advancements that are expected to change the landscape of spinal oncology are discussed with a focus on how these technologies will aid in clinical decision-making for patients diagnosed with primary spinal tumors.Methods: A review of the literature was performed focusing on studies that integrated next-generation sequencing, circulating tumor cells/circulating tumor DNA, advances in imaging modalities and/or radiotherapy in the diagnosis and treatment of cancer.Results: We discuss genetic and epigenetic drivers, aberrations in receptor tyrosine kinase signaling, and emerging therapeutic strategies that include receptor tyrosine kinase inhibitors, immunotherapy strategies, and vaccine-based cancer prevention strategies.Conclusion: The wide range of approaches currently in use and the emerging technologies yet to be fully realized will allow for better development of rationale therapeutics to improve patient outcomes.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Pediatric spinal trauma is relatively rare with roughly 5% of injuries occurring in this group. Cervical spinal trauma is most common in the pediatric population, followed by thoracic and lumbar injuries. The biomechanics of the evolving pediatric anatomy alter the injury characteristics and radiographic interpretation of pediatric spinal trauma patients. Systematic assessment paradigms are necessary in the evaluation and treatment of pediatric spinal cord trauma patients. Common treatment modalities for this subgroup of patients include halo fixation, bracing, and surgical instrumentation. While the surgical management options for pediatric spinal injuries have improved, the anatomical considerations associated with the size and growth potential of pediatric patients provide room for improvement of these modalities. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of prospective, multicenter and international cohort study., Objective: To describe the effect of gender on HRQoL, clinical outcomes and survival for patients with spinal metastases treated with either surgery and/or radiation., Summary of Background Data: Gender differences in health-related outcomes are demonstrated in numerous studies, with women experiencing worse outcomes and receiving lower standards of care than men, however, the influence that gender has on low health-related quality of life (HRQoL) and clinical outcomes after spine surgery remains unclear., Methods: Patient demographic data, overall survival, treatment details, perioperative complications, and HRQoL measures including EQ-5D, pain NRS, the short form 36 version 2 (SF-36v2) and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) were reviewed. Patients were stratified by sex, and a separate sensitivity analysis that excluded gender-specific cancers (i.e., breast, prostate, etc.) was performed., Results: The study cohort included 207 female and 183 male patients, with age, smoking status, and site of primary cancer being significantly different between the two cohorts (P<0.001). Both males and females experienced significantly improved SOSGOQ2.0, EQ-5D, and pain NRS scores at all study time points from baseline (P<0.001). Upon sensitivity analysis, (gender-specific cancers removed from analysis), the significant improvement in SOSGOQ physical, mental, and social subdomains and on SF-36 domains disappeared for females. Males experienced higher rates of postoperative complications. Kaplan-Meier survival analysis of both the overall and sensitivity analysis cohorts showed females lived longer than males after treatment (P=0.001 and 0.043, respectively)., Conclusion: Both males and females experienced significantly improved HRQoL scores after treatment, but females demonstrated longer survival and a lower complication rate. This study suggests that gender may be a prognostic factor in survival and clinical outcomes for patients undergoing treatment for spine metastases and should be taken into consideration when counseling patients accordingly., Competing Interests: Conflict of Interest: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Mutations/deletions of the tumor-suppressor phosphatase and tensin homolog PTEN result in PI3K/Akt pathway hyperactivation and potentially alter oncogenic responses to targeted receptor tyrosine kinase inhibitors. We previously showed that hepatocyte growth factor (HGF):c-Met pathway inhibition decreases tumor growth and oncogenic signaling responses in PTEN-null/Met+ gliomas. Here, we use two tet-on PTENwt-inducible glioma cell lines and xenograft models to examine the influence of PTEN on oncogenic signaling responses to HGF:c-Met pathway inhibitors. Reconstitution of PTEN inhibited Akt by more than 80% and inhibited cell growth by approximately 70-75% in both cell lines in vitro. C-Met inhibition alone inhibited in-vitro cell growth by approximately 80-85% and the magnitude of growth inhibition was not altered by combining PTEN reconstitution with c-Met inhibition. Combining PTEN reconstitution with Met inhibition arrested a higher percentage of cells in G(1)/G(0) phase of the cell cycle when compared with either PTEN reconstitution or c-Met inhibition alone. Both PTEN reconstitution alone and inhibiting autocrine HGF:c-Met signaling alone, using anti-HGF mAb, robustly inhibited the growth of subcutaneous and intracranial glioma xenografts. Combining anti-HGF therapy with PTEN reconstitution did not significantly alter the magnitude of xenograft growth inhibition. Semiquantitative immunohistopathological analyses revealed that the inhibition of glioma xenograft angiogenesis and cell proliferation by anti-HGF mAb was greatest in conjunction with PTEN reconstitution. In contrast, xenograft cell apoptosis was greatest in response to anti-HGF therapy alone and PTEN reconstitution abrogated the apoptotic response to anti-HGF therapy. These results provide new insights into how PTEN modulates glioma responses to the inhibition of HGF:c-Met signaling and possibly other receptor tyrosine kinase pathways.