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Background: Incidental intradural tumors of the spine in the pediatric population are rare lesions whose management remains unclear. Surgeons must balance the risks of iatrogenic deficits and complications after surgical resection against the risks from progressive growth of the tumor. Moreover, the natural history of an incidental finding can be difficult to predict. Here, we review the literature on incidental intradural tumors of the spine and present considerations for their management. Summary: Growth of the tumor or changes in radiographic features are usually indications for resection. Asymptomatic lesions can be found in patients with genetic syndromes that predispose to tumor formation, such as neurofibromatosis type 1 and 2, schwannomatosis, and Von-Hippel-Lindau syndrome, and careful workup of a genetic cause is warranted in any patient presenting with multiple tumors and/or cutaneous features. Close follow-up is generally favored given the heavy tumor burden; however, some recommend pre-emptive resection to prevent permanent neurological deficits. Incidental intradural tumors can also occur in association with hydrocephalus, significant syringomyelia, and cord compression, and surgical treatment is usually warranted. Tumors may also be discovered as part of the workup for scoliosis, where they are not truly incidental to the scoliosis but rather are contributing to curve deformation. Key Messages: Thorough workup of patients for associated genetic syndromes or comorbidities should be undertaken in pediatric patients with incidental intradural tumors. Further research is needed into the natural history of these incidental lesions. Incidental tumors can often be managed conservatively with close follow-up, with surgical intervention warranted for expanding tumors or new-onset symptoms. [ABSTRACT FROM AUTHOR]

Metastatic glioblastoma to the vertebral spine is rarely encountered. The decision to intervene surgically must consider the poor prognosis in these patients. Here we report the case of a 46-year-old woman who presented with sudden weakness of the lower extremities 10 months after diagnosis of a left parietal glioblastoma. Imaging revealed osseous metastases to the thoracic and lumbosacral vertebral bodies. She initially underwent vertebroplasty with symptomatic improvement, but the progression of disease precluded further surgical interventions, and the patient was referred for chemotherapy and radiotherapy. The case illustrates that the choice of treatment modality varies throughout the time course of the disease—patients with spinal instability or few solitary metastases may benefit from intervention, but as the disease burden increases, palliative radiotherapy and chemotherapy may offer greater benefit. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Decompressive procedures such as laminectomy, facetectomy, and costotransversectomy are routinely performed for various pathologies in the thoracic spine. The thoracic spine is unique, in part, because of the sternocostovertebral articulations that provide additional strength to the region relative to the cervical and lumbar spines. During decompressive surgeries, stability is compromised at a presently unknown point. Purpose: To evaluate thoracic spinal stability after common surgical decompressive procedures in thoracic spines with intact sternocostovertebral articulations. Study design: Biomechanical cadaveric study. Methods: Fresh-frozen human cadaveric spine specimens with intact rib cages, C7–L1 (n=9), were used. An industrial robot tested all spines in axial rotation (AR), lateral bending (LB), and flexion-extension (FE) by applying pure moments (±5 Nm). The specimens were first tested in their intact state and then tested after each of the following sequential surgical decompressive procedures at T4–T5 consisting of laminectomy; unilateral facetectomy; unilateral costotransversectomy, and subsequently instrumented fusion from T3–T7. Results: We found that in all three planes of motion, the sequential decompressive procedures caused no statistically significant change in motion between T3–T7 or T1–T12 when compared with intact. In comparing between intact and instrumented specimens, our study found that instrumentation reduced global range of motion (ROM) between T1–T12 by 16.3% (p=.001), 12% (p=.002), and 18.4% (p=.0004) for AR, FE, and LB, respectively. Age showed a negative correlation with motion in FE (r=−0.78, p=.01) and AR (r=−0.7, p=.04). Conclusions: Thoracic spine stability was not significantly affected by sequential decompressive procedures in thoracic segments at the level of the true ribs in all three planes of motion in intact thoracic specimens. Age appeared to negatively correlate with ROM of the specimen. Our study suggests that thoracic spinal stability is maintained immediately after unilateral decompression at the level of the true ribs. These preliminary observations, however, do not depict the long-term sequelae of such procedures and warrant further investigation. [Copyright &y& Elsevier]

The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking. To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS. Systematic review and meta-analysis. Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence. The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=−0.31 [−3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= −3.30 [−8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=−2.94 days [−3.83, −2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=−0.69 days [−1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups. The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate. [ABSTRACT FROM AUTHOR]

Poor bone quality and low bone mineral density (BMD) have been previously tied to higher rates of postoperative mechanical complications in patients undergoing spinal fusion. These include higher rates of proximal junctional kyphosis, screw pullout, pseudoarthrosis, and interbody subsidence. For these reasons, accurate preoperative assessment of a patient's underlying bone quality is paramount for all elective procedures. Dual-energy X-ray absorptiometry (DXA) is currently considered to be the gold standard for assessing BMD. However, a growing body of research has suggested that in vivo assessments of BMD using DXA are inaccurate and have, at best, moderate correlations to postoperative mechanical complications. Consequently, there have been investigations into using alternative methods for assessing in vivo bone quality, including using computed tomography (CT) and magnetic resonance imaging (MRI) volumes that are commonly obtained as part of surgical evaluation. Here we review the data regarding the accuracy of DXA for the evaluation of spine bone quality and describe the alternative imaging modalities currently under investigation. [ABSTRACT FROM AUTHOR]

Chondrosarcoma is an uncommon primary bone tumor with an estimated incidence of 0.5 per 100,000 patient-years. Primary chondrosarcoma of the mobile spine and sacrum cumulatively account for less than 20% of all cases, most .commonly causing patients to present with focal pain with or without radiculopathy, or myelopathy secondary to neural element compression. Because of the rarity, patients benefit from multidisciplinary care at academic tertiary-care centers. Current standard-of-care consists of en bloc surgical resection with negative margins; for high grade lesions adjuvant focused radiation with ≥60 gray equivalents is taking an increased role in improving local control. Prognosis is dictated by lesion grade at the time of resection. Several groups have put forth survival calculators and epidemiological evidence suggests prognosis is quite good for lesions receiving R0 resection. Future efforts will be focused on identifying potential chemotherapeutic adjuvants and refining radiation treatments as a means of improving local control. [ABSTRACT FROM AUTHOR]

In the present study, we identified the risk factors for wound complications, wound infection, and reoperation for wound complications after spine metastasis surgery and deployed the resultant model as a web-based calculator. Patients treated at a single comprehensive cancer center during a 7-year period were included. The demographics, pathology, comorbidities, laboratory values, and operative details were collected. Factors with P < 0.15 on univariable regression were entered into multivariable logistic regression to generate predictive models internally validated using 1000 bootstrapped samples. Of the 330 patients included, 29 (7.6%) had experienced a surgical site infection. The independent predictive factors for wound-related complications were a higher Charlson comorbidity index (CCI; odds ratio [OR], 1.41 per point; P < 0.01), Karnofsky performance scale score ≤70 (OR, 2.14; P = 0.04), lower platelet count (OR, 0.49 per 105/μL; P < 0.01), revision versus index surgery (OR, 3.10; P = 0.02), and increased incision length (OR, 1.21 per level; P = 0.02). Wound infection was associated with a higher CCI (OR, 1.60 per point; P < 0.01), a lower platelet count (OR, 0.35 per 105/μL; P < 0.01), revision surgery (OR, 4.63; P = 0.01), and a longer incision length (OR, 1.25 per level; P = 0.03). Unplanned reoperation for wound complications was predicted by a higher CCI (OR, 1.39 per point; P = 0.003), prior irradiation (OR, 2.52; P = 0.04), a lower platelet count (OR, 0.57 per 105/μL; P = 0.02), and revision surgery (OR, 3.34; P = 0.03), The optimism-corrected areas under the curve were 0.75, 0.81, and 0.72 for the wound complication, infection, and reoperation models, respectively. Low platelet counts, poorer health status, more invasive surgery, and revision surgery all independently predicted the risk of wound complications, including infection and unplanned reoperation for infection. Validation of the calculators in a prospective study is merited. [ABSTRACT FROM AUTHOR]

To determine those clinical, demographic, and operative factors that predict 30-day unplanned reoperation and readmission within a population of adults who underwent spinal metastasis surgery at a comprehensive cancer center. Adults who underwent spinal metastasis surgery at a comprehensive cancer center were analyzed. Data included baseline laboratory values, cancer history, demographics, operative characteristics and medical comorbidities. Medical comorbidities were quantified using the modified Charlson Comorbidity Index (CCI). Values associated with the outcomes of interest were then subjected to multivariable logistic regression to identify independent predictors of readmission and reoperation. A total of 345 cases were identified. Mean age was 59.4 ± 11.7 years, 56% were male, and the racial makeup was 64% white, 29% black, and 7.3% other. Forty-two patients (12.2%) had unplanned readmissions, most commonly for wound infection with dehiscence (14.2%), venous thromboembolism (14.2%), and bowel obstruction/complication (11.9%). Thirteen patients required reoperation (4%), most commonly for wound infection with dehiscence (39%) or local recurrence (23%). Multivariable analysis showed that the modified CCI (odds ratio [OR], 1.25; 95% confidence interval [CI] 1.03–1.52; P = 0.03) was an independent predictor of 30-day readmission. Independent predictors of 30-day unplanned reoperation were: black (vs. white) race (OR, 0.08; 95% CI, 0.01–0.41; P < 0.01), length of stay (OR, 1.05 per day; 95% CI, 1.00–1.09; P = 0.04), and CCI (OR, 1.72 per point; 95% CI, 1.29–2.28; P < 0.01). Increasing medical comorbidities is independently predictive of both 30-day unplanned readmission and reoperation after spinal metastasis surgery. Unplanned reoperation is also positively predicted by a longer index admission. Neither tumor pathology nor age predicted outcome, suggesting that poor wound-healing factors and increased surgical morbidity may best predict these adverse outcomes. [ABSTRACT FROM AUTHOR]

Chordoma is a notochord-derived primary tumor of the skull base and vertebral column known to affect 0.08 to 0.5 per 100,000 persons worldwide. Patients commonly present with mechanical, midline pain with or without radicular features secondary to nerve root compression. Management of these lesions has classically revolved around oncologic resection, defined by en bloc resection of the lesion with negative margins as this was found to significantly improve both local control and overall survival. With advancement in radiation modalities, namely the increased availability of focused photon therapy and proton beam radiation, high-dose (>50 Gy) neoadjuvant or adjuvant radiotherapy is also becoming a standard of care. At present chemotherapy does not appear to have a role, but ongoing investigations into the ontogeny and molecular pathophysiology of chordoma promise to identify therapeutic targets that may further alter this paradigm. In this narrative review we describe the epidemiology, histopathology, diagnosis, and treatment of chordoma. [ABSTRACT FROM AUTHOR]

Background Context: Surgery for vertebral column tumors is commonly associated with intraoperative blood loss (IOBL) exceeding 2 liters and the need for transfusion of allogeneic blood products. Transfusion of allogeneic blood, while necessary, is not benign, and has been associated with increased rates of wound complication, venous thromboembolism, delirium, and death.Purpose: To develop a prediction tool capable of predicting IOBL and risk of requiring allogeneic transfusion in patients undergoing surgery for vertebral column tumors.Study Design/setting: Retrospective, single-center study.Patient Sample: Consecutive series of 274 patients undergoing 350 unique operations for primary or metastatic spinal column tumors over a 46-month period at a comprehensive cancer center OUTCOME MEASURES: IOBL (in mL), use of intraoperative blood products, and intraoperative blood products transfused.Methods: We identified IOBL and transfusions, along with demographic data, preoperative laboratory data, and surgical procedures performed. Independent predictors of IOBL and transfusion risk were identified using multivariable regression.Results: Mean age at surgery was 57.0±13.6 years, 53.1% were male, and 67.1% were treated for metastatic lesions. Independent predictors of IOBL included en bloc resection (p<.001), surgical invasiveness (β=25.43 per point; p<0.001), and preoperative albumin (β=-244.86 per g/dL; p=0.011). Predictors of transfusion risk included preoperative hematocrit (odds ratio [OR]=0.88 per %; 95% confidence interval [CI, 0.84, 0.93]; p<0.001), preoperative MCHgb (OR=0.88 per pg; 95% CI [0.78, 1.00]; p=0.048), preoperative red cell distribution width (OR=1.32 per %; 95% CI [1.13, 1.55]; p<0.001), en bloc resection (OR=3.17; 95%CI [1.33, 7.54]; p=0.009), and surgical invasiveness (OR=1.08 per point; [1.06; 1.11]; p<0.001). The transfusion model showed a good fit of the data with an optimism-corrected area under the curve of 0.819. A freely available, web-based calculator was developed for the transfusion risk model (https://jhuspine3.shinyapps.io/TRUST/).Conclusions: Here we present the first clinical calculator for intraoperative blood loss and transfusion risk in patients being treated for primary or metastatic vertebral column tumors. Surgical invasiveness and preoperative microcytic anemia most strongly predict transfusion risk. The resultant calculators may prove clinically useful for surgeons counseling patients about their individual risk of requiring allogeneic transfusion. [ABSTRACT FROM AUTHOR]

Pharmacogenomics may help personalize medicine and improve therapeutic selection. This is the first study investigating how pharmacogenomic testing may inform analgesic selection in patients with spine disease. We profile pharmacogenetic differences in pain medication–metabolizing enzymes across patients presenting at an outpatient spine clinic and provide preliminary evidence that genetic polymorphisms may help explain interpatient differences in preoperative pain refractory to conservative management. Adults presenting to our outpatient spine clinic with chief symptoms of neck and/or back pain were prospectively enrolled over 9 months. Patients completed the Wong-Baker FACES and numeric pain rating scales for their chief pain symptom and provided detailed medication histories and cheek swab samples for genomic analysis. Thirty adults were included (mean age, 60.6 ± 15.3 years). The chief concern was neck pain in 23%, back pain in 67%, and combined neck/back pain in 10%. At enrollment, patient analgesic regimens comprised 3 ± 1 unique medications, including 1 ± 1 opioids. After genomic analysis, 14/30 patients (47%) were identified as suboptimal metabolizers of ≥1 medications in their analgesic regimen. Of these patients, 93% were suboptimal metabolizers of their prescribed opioid analgesic. Nonetheless, pain scores were similar between optimal and suboptimal metabolizer groups. This pilot study shows that a large proportion of the spine outpatient population may use pain medications for which they are suboptimal metabolizers. Further studies should assess whether these pharmacogenomic differences indicate differences in odds of receiving therapeutic benefit from surgery or if they can be used to generate more effective postoperative analgesic regimens. [ABSTRACT FROM AUTHOR]

Good bone quality is key in avoiding a multitude of afflictions, including osteoporotic fragility fractures and poor outcomes after spine surgery. In patients undergoing instrumented spine fusion, bone quality often dictates screw pullout strength, insertional torque, and vertebral body loading properties. While dual-energy X-ray absorptiometry (DEXA) screening is the current method of assessing bone mineral density, the majority of patients do not have DEXA measurements available before undergoing surgical instrumentation. To create a simple magnetic resonance imaging (MRI)-based score to evaluate bone quality and evaluate the degree to which it correlates with conventional DEXA scores. Retrospective cohort. Patients ≥18 years of age undergoing spine surgery for degenerative conditions between 2013 and 2018. Correlation of the vertebral bone quality (VBQ) score with DEXA T-scores, and association between VBQ score and presence of osteopenia/osteoporosis. Using noncontrast T1-weighted MRIs of the lumbar spine, the novel VBQ score was calculated for each patient. DEXA T-scores of the femoral neck and total hip were obtained and were compared with patient VBQ scores using linear regression and Pearson's correlation. Among 68 patients included in this study, 37 were found to have osteopenia/osteoporosis (T-score < −1.0) based on DEXA. A greater VBQ score was significantly associated with the presence of osteopenia/osteoporosis with a predictive accuracy of 81%. VBQ scores correlated moderately with femoral neck T-scores, the lowest overall T-scores of each patient, and correlated fairly with total hip T-scores. This is the first study to correlate the novel VBQ score obtained from MRIs with DEXA T-score. We found this score to be a significant predictor of healthy versus osteopenic/osteoporotic bone with an accuracy of 81%, and found that VBQ score was moderately correlated with femoral neck and overall lowest T-score. [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]

We systematically reviewed the literature to compare risk factors for postoperative complications at the surgical wound site in primary and metastatic tumor operations. We screened English-language publications on the outcomes of primary and metastatic spinal tumor operations. Pooled analyses and meta-analyses with random-effects modeling were performed comparing patients with and without wound complications, which were defined as surgical site infection or sterile wound dehiscence. Our search identified 5471 unique citations, from which we included 23 studies describing 5104 patients. A total of 1936 patients underwent surgery for primary tumors, with a wound complication rate of 8.1%. Subgroup analysis of benign and malignant primary tumors yielded significantly different wound complication rates of 7.8% and 26.9%, respectively. The metastatic tumor cohort included 168 patients and a complication rate of 6.6%. In a pooled analysis of primary tumors, higher wound complication rates were associated with sacral operations and the use of instrumentation. In the metastatic tumor cohort, higher complication rates were associated with female sex, smoking history, preoperative chemotherapy, preoperative radiotherapy, corticosteroid use, and previous spine surgery. Instrumentation remained a statistically significant risk factor for primary tumors with the addition of random-effects meta-analysis. Risk factors for wound complications after primary tumor operations were related to tumor histology and the spinal location of the operation. Risk factors for metastatic tumors may be related to several systemic preoperative treatments and baseline comorbidities. Random-effects meta-analysis showed the limited generalizability of these findings because of the small heterogenous primary literature. [ABSTRACT FROM AUTHOR]