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OBJECTIVE Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified. METHODS Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis. RESULTS A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission. CONCLUSIONS Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.

OBJECTIVE The goal of this study was to use a large national registry to evaluate the 30-day cumulative incidence and predictors of adverse events, readmissions, and reoperations after surgery for primary and secondary spinal tumors. METHODS Data from adult patients who underwent surgery for spinal tumors (2011-2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition. RESULTS Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12-23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8-20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4-5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4-19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14-25 days), and sepsis (2.9%) at 13 days (IQR 7-21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3-5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3-9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5-26 days). CONCLUSIONS In this NSQIP analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA classification. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge.

Purpose: Spinal lipoma of the filum terminale (LFT) is a congenital lumbosacral anomaly that can cause tethered cord syndrome. Purposes of this study are to clarify preoperative characteristics of LFT, to elucidate surgical effects, and to discuss the rationale of prophylactic surgery for LFT., Methods: Medical data of 174 children (2008-2014) who underwent section of LFT were prospectively recorded for prevalence of symptoms, skin stigmas, and associated malformations, motivator of diagnosis, conus level, and surgical outcome. Mean age at surgery was 4.1 ± 4.2 years (37 days to 17.7 years)., Results: Ninety-four children (54.0 %) had skin stigmas and 60 (34.5 %) had certain perineal malformations. Seventy-nine children (45.4 %) were symptomatic. The most common motivator for diagnosis was skin stigmas (44.3 %), followed by associated malformations (33.3 %), and symptoms (20.1 %). The age at surgery was significantly older in symptomatic patients than in asymptomatic patients (p < 0.001). Surgery improved symptoms in 50 % of patients at 2.1-year follow-up period. Of 85 asymptomatic patients, all except one remained asymptomatic postoperatively and none of the symptomatic patients deteriorated. The presence of associated malformations and the conus level did not affect surgical outcome. Postoperative complications developed in nine patients (5.2 %): seven transient local problems, one definitive urological deterioration, and one transient respiratory problem., Conclusions: Surgery for LFT was a simple and safe procedure. It improved half of symptomatic patients and stopped the deterioration of the others. Even if only one of the asymptomatic patients deteriorated at maximum follow-up, the role of prophylactic surgery remains a point of discussion.

OBJECTIVE The purpose of this study was to identify factors contributing to an increased risk for vertebral compression fracture (VCF) following stereotactic body radiation therapy (SBRT) for spinal tumors. METHODS A total of 594 tumors were treated with spinal SBRT as primary treatment or re-irradiation at 8 different institutions as part of a multi-institutional research consortium. Patients underwent LINAC-based, image-guided SBRT to a median dose of 20 Gy (range 8-40 Gy) in a median of 1 fraction (range 1-5 fractions). Median patient age was 62 years. Seventy-one percent of tumors were osteolytic, and a preexisting vertebral compression fracture (VCF) was present in 24% of cases. Toxicity was assessed following treatment. Univariate and multivariate analyses were performed using a logistic regression method to determine parameters predictive for post-SBRT VCF. RESULTS At a median follow-up of 10.1 months (range 0.03-57 months), 80% of patients had local tumor control. At the time of last imaging follow-up, at a median of 8.8 months after SBRT, 3% had a new VCF, and 2.7% had a progressive VCF. For development of any (new or progressive) VCF following SBRT, the following factors were predictive for VCF on univariate analysis: short interval from primary diagnosis to SBRT (less than 36.8 days), solitary metastasis, no additional bone metastases, no prior chemotherapy, preexisting VCF, no MRI used for target delineation, tumor volume of 37.3 cm(3) or larger, equivalent 2-Gy-dose (EQD2) tumor of 41.8 Gy or more, and EQD2 spinal cord Dmax of 46.1 Gy or more. Preexisting VCF, solitary metastasis, and prescription dose of 38.4 Gy or more were predictive on multivariate analysis. The following factors were predictive of a new VCF on univariate analysis: solitary metastasis, no additional bone metastases, and no MRI used for target delineation. Presence of a solitary metastasis and lack of MRI for target delineation remained significant on multivariate analysis. CONCLUSIONS A VCF following SBRT is more likely to occur following treatment for a solitary spinal metastasis, reflecting a more aggressive treatment approach in patients with adequately controlled systemic disease. Higher prescription dose and a preexisting VCF also put patients at increased risk for post-SBRT VCF. In these patients, pre-SBRT cement augmentation could be considered to decrease the risk of subsequent VCF.

Study Design: Retrospective case series., Objective: To report on the natural history and long-term outcome of a large series of consecutive primary sacral chordoma patients surgically treated at two reference centers., Summary of Background Data: Sacral chordomas are rare tumors with poor long-term prognosis mainly caused by local failure. Till date, a few large series with long follow up are available in literature., Methods: All consecutive patients affected by primary localized sacral chordoma operated on at two Italian reference centers between 1981 and 2012 were included. Overall survival (OS), disease free survival (DFS), crude cumulative incidence (CCI) of local recurrence (LR), and distant metastases (DM) were calculated. Multivariable analyses for OS, DFS, LR, and DM were performed., Results: A total of 99 patients were identified: 65 males and 34 females. Median age was 59 years (range 22-77 yrs), median tumor size was 9 cm (range 4-22). Nineteen patients received pre- or postoperative radiotherapy (RT). Wide (R0) surgical margins were achieved in 46 patients, marginal (R1) margins in 43 patients and intralesional (R2) margins in 10 patients. At a median follow up of 8.7 years (range 1-23.8 yrs) 30 patients died of disease, 31 patients developed local relapse, 16 patients developed distant metastasis, whereas 51 patients are alive without disease. OS and DFS at 5, 10, and 15 year were 92% and 63%, 45% and 62%, 36% and 21%, respectively, without any evidence of a plateau in the curves.CCI of LR and DM were 30% and 9% at 5 years, 46% and 18% at 10 years, 56% and 23% at 15 years. Size of the tumor and quality of surgical margins were the only significant predictors of long-term outcome. DFS for 15 years was, in fact, 49% for R0 and 7% for R1, respectively., Conclusion: In this series, long-term outcome of resected sacral chordoma was poor, with less than 25% patients were disease-free at 15 years. Interestingly, only half of the patients treated with R0 resection had no evidence of recurrence at 15 years. When surgical margins are expected to be positive other treatment modalities should be considered, especially when expected sequelae are substantial as in the case of more cephalad levels of resection., Level of Evidence: 3.

Study Design: An ambispective cohort study., Objective: The aim of this study was to determine whether the application of the Enneking classification in the management of spinal chondrosarcomas influences local recurrence and survival., Summary of Background Data: Primary spinal chondrosarcomas are rare. Best available evidence is based on small case series, thus making it difficult to determine optimal management and risk factors for local recurrence and survival., Methods: The AOSpine Knowledge Forum Tumor developed a multicenter ambispective database of surgically treated patients with spinal chondrosarcoma. Patient data pertaining to demographics, diagnosis, treatment, cross-sectional survival, and local recurrence were collected. Tumors were classified according to the Enneking classification. Patients were divided into two cohorts: Enneking appropriate (EA) and Enneking inappropriate (EI). They were categorized as EA when the final pathological assessment of the margin matched the Enneking recommendation, and otherwise, they were categorized as EI., Results: Between 1987 and 2011, 111 patients (37 female; 74 male) received surgical treatment for a primary spinal chondrosarcoma at a mean age of 47.4 ± 15.8 years. Patients were followed for a median period of 3.1 years (range = 203 d-18.7 yrs). Median survival for the entire cohort was 8.4 years postoperative. After 10 years postoperative, 36 (32%) patients died and 37 (35%) patients suffered a local recurrence. Twenty-three of these 37 patients who suffered a local recurrence died. Sixty (58%) patients received an EA procedure while 44 (42%) received an EI procedure. EI patients had a higher hazard ratio for local recurrence than those who received an EA procedure (P = 0.052). Local recurrence was strongly associated with chondrosarcoma-related death (risk ratio = 3.6, P < 0.010)., Conclusion: This is the largest multicenter cohort of spinal chondrosarcomas. EA surgical management appeared to correlate with a decreased risk of local recurrence, yet no relationship with survival was found. Where possible, surgeons should strive to achieve EA margins to minimize the risk of local recurrence., Level of Evidence: 4.

Study Design: This cross-sectional study was carried out on 196 adults (98 men and 98 women), aged between 18 and 91 years., Objective: To examine whether vertebral hemangiomas (VHs) are associated with other spinal pathologies, metabolic diseases, cardiovascular diseases, cancer and past trauma, to shed light on their possible pathophysiology., Summary of Background Data: VHs are the most common form of benign tumors in the spine. Their association with spinal and systemic pathologies has not yet been systematically studied., Methods: Clinical data were gathered from full spine CT scans and medical records., Results: VHs were significantly associated with disc lesions (P = 0.004), past trauma (P = 0.037), diabetes (χ = 5.179, P = 0.023), cardio-vascular diseases (χ = 8.625, P = 0.003), and cancer (χ = 5.820, P = 0.016), but not with obesity. Only medium-large size VHs were significantly associated with osteoporosis (χ = 6.695, P = 0.010)., Conclusion: The pattern of diseases related to VHs suggests a common cause for VH, namely, a disruption of vascular flow in the microvessels (accompanied by endothelium damage) within the vertebral body, eventually resulting in hypervascularization., Level of Evidence: 4.

Study Design: A retrospective study., Objective: Aim of the study was to investigate morphological differences in the vertebrae of scoliosis secondary to neurofibromatosis type 1 (NF1-S) with and without paraspinal neurofibromas and to identify the relationship between paraspinal neurofibromas and vertebral deformity., Summary of Background Data: Scoliosis is the most common orthopedic manifestation of NF1. Erosion or infiltration of the bone by localized neurofibromas was suggested as one of the primary etiology for the vertebral deformity., Methods: One hundred fourteen patients with NF1-S were classified into spinal tumor (ST) group and nontumor (NT) group with respect to the presence of paraspinal neurofibromas. The curve pattern, curve magnitude, the shape and location of paraspinal neurofibromas, and various kinds of morphological changes of vertebrae were evaluated by complete radiographs were compared between the two groups to determine whether the presence of paraspinal neurofibromas could be associated with a more severe vertebral deformity., Results: The ST and NT groups included 54 patients (age, 16.8 ± 5.5 years) and 60 patients (age, 17.3 ± 4.2 years), respectively. The Cobb angles of the main curve were 72.3° ± 20.6° and 65.4° ± 19.4° for the ST and NT groups, respectively. No significant differences were observed between the two groups in age, sex ratio, and Cobb angle. There were significant differences between the ST and NT groups in apical vertebral rotation (36.8° ± 7.2° vs. 27.5° ± 6.8°; P < 0.001) and the prevalence of rotatory subluxation (66.1% vs. 35.0%; P = 0.04). Most of the paraspinal neurofibromas (70.4%) developed within the apical region, with the majority (29/38) located on the concave side., Conclusion: The NF1-S patients with paraspinal neurofibromas had significantly higher prevalence of morphological changes of vertebrae. The paraspinal neurofibromas, most of which were located on the concave side of the apical region, could be associated with more severe vertebral deformities., Level of Evidence: 3.

Study Design: A retrospective review., Objective: We sought to use data from 4 tertiary medical centers to explore surgical, medical, and demographic factors that influence survival within the first 90 days following surgery for spinal metastases., Summary of Background Data: Over the last 2 decades, patients with spinal metastases have become more likely to receive surgical intervention. The impact of surgical intervention and its potential benefits must be weighed against the risk of complications and peri-operative mortality. Risk factors that elevate the risk of mortality in the acute postoperative period are not well understood., Methods: All records of patients who underwent surgery for metastatic spinal disease at 1 of 4 academic medical centers in New England from 2007 to 2013 were obtained. Patient demographics, tumor characteristics, medical comorbidities, nutritional and functional status, as well as surgical variables were abstracted. Mortality was assessed for patients at 30 and 90 days following the procedure. Factors predictive of survival were assessed using bivariate logistic regression. Those factors with P values < 0.20 in the bivariate assessment were included in a final multivariable model that adjusted for confounders., Results: Between 2007 and 2013, 318 patients received surgical intervention for metastatic disease involving the spine. Cancer type did not influence the odds of survival at 30 days, while nutritional status and ambulatory capacity increased survival. Lung cancer significantly decreased the odds of survival at 90 days following surgery (odds ratio 0.36; 95% confidence interval 0.18-0.72), while ambulatory function and nutritional status remained significantly associated with improved survival., Conclusion: This effort is one of the first to identify predictors of acute postoperative survival in a large series of patients treated for spinal metastases. Improved nutritional status and ambulatory function may enhance postoperative survival among individuals who undergo surgical intervention for spinal metastases., Level of Evidence: 3.

Background: Sacrococcygeal teratoma (SCT) is a rare congenital tumor associated with high rates of perinatal mortality and morbidity. This study evaluated the incidence, prenatal detection rate, and early predictors of a complicated outcome following diagnosis of SCT., Methods: We retrospectively identified all fetuses and newborns diagnosed with SCT in southern Sweden from 2000 to 2013. Prenatal sonograms, charts, and pathology reports were reviewed and analyzed. Each case of SCT was defined as complicated or uncomplicated based on the postnatal outcome. All cases with a fatal outcome or that required cardiac resuscitation during birth or surgery were classified as complicated., Results: The overall incidence of SCT was 1:13,982 (19 children in a cohort of 265,658 live births). A prenatal diagnosis was made in 74% of cases, there were no stillbirths or intrauterine deaths, and the overall mortality rate was 11%. Four cases of SCT (21%) were classified as complicated, and these cases had a significantly larger tumor size at gestational week 20 (P=0.048), had a significantly higher tumor growth rate (P=0.003), and were more often associated with polyhydramnios (P=0.01), and mainly solid/mixed morphology (P=0.001)., Conclusions: The incidence of SCT in southern Sweden was higher than those reported in most previous studies; however, the associated mortality rate was relatively low. Fetuses with large tumors, rapidly growing tumors, and polyhydramnios were more likely to experience a complicated outcome during the postnatal period., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Stereotactic body radiotherapy (SBRT) is becoming widely adopted in the treatment of primary and secondary tumors. Spinal bone metastases are frequently discovered in cancer patients, and in the past have been usually treated with a palliative goal. Nevertheless, in some particular clinical settings, such as oligometastatic patients and/or those with a long life expectancy, spinal SBRT could be considered a valid therapeutic option to obtain long-lasting palliation and, when possible, with a curative goal. This review aims to summarize available clinical and dosimetric data of published studies about spinal SBRT., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background/aims: Primary chordomas, rare cancers arising from the notochord remnants, are extremely rare in the pediatric population. This study examined a large cohort of primary chordoma patients to determine factors impacting prognosis and survival., Methods: Demographic and clinical data on 1,358 primary chordoma patients (86 pediatric patients ≤19 years of age and 1,272 adult patients ≥20 years of age) were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1973-2011)., Results: Pediatric primary chordomas present most often as small tumors <4 cm in the cranium of male Caucasians. Despite the majority of primary chordomas presenting with locoregional involvement (90.4%), pediatric patients had more distant disease (14.8 vs. 9.2%, p < 0.05). Survival among pediatric patients having surgery only was significantly longer than for adults (22.5 vs. 14.3 years, p < 0.001). Overall survival was longer (17.2 vs. 12.6 years) and overall mortality was lower in pediatric patients (38.4 vs. 49.8%), but cancer-specific mortality was higher (37.2 vs. 28.6%, p < 0.005)., Conclusions: Pediatric primary chordomas present most often as small tumors <4 cm in the cranium of male Caucasians. Despite having a higher rate of metastasis, they have prolonged survival compared to adults. Surgical resection significantly improves survival in pediatric primary chordoma patients, and should be considered as first-line therapy in all eligible children., (© 2016 S. Karger AG, Basel.)

Purpose: En bloc sacrectomy is a demanding surgical procedure to remove tumors from the sacrum. Comprehensive data on readmissions for complications endured months to years after initial discharge are scant. The purpose of this study is to present the long-term complications, readmissions and secondary interventions for patients having undergone en bloc sacrectomy., Methods: Patients were included if en bloc sacrectomy and follow-up were conducted in the authors institution. Correspondence from all specialties involved in the treatment of patients was retrieved. Predefined parameters were scored and assigned to five distinct phases: diagnostic phase; surgery; postoperative period to 1 year after surgery; second year after surgery until follow-up and last follow-up., Results: Sixteen patients underwent anterior-posterior en bloc sacrectomy for a locally aggressive tumor (n=2); malignant tumor (n=13) or solitary metastasis (n=1). The type of resection was low (n=1); middle (n=3); high (n=4); total (n=3) and hemisacrectomy (n=5). The median surgical duration was 12.7 h and median blood lost was 12 l. A total of 73 major complications (average per patient 5; median 4; range 0-12) were recorded and 73 secondary interventions (average per patient 5; median 5; range 0-11) were performed in the first year postsurgery. From the second year until follow-up complications and secondary interventions markedly decreased. At final follow-up (65-266 months), considerable morbidity was found for the eleven patients still alive., Conclusions: En bloc sacrectomy is a procedure with a high rate of major complications, regardless of tumor histology, often necessitating readmissions and secondary interventions. Long-term survival is associated with considerable morbidity and extensive preoperative counseling should be conducted to discuss the risks and outcome of the procedure.

Purpose: To determine the frequency of major complications and identify related risk factors in surgery for hypervascular spinal tumors after preoperative selective arterial embolization., Methods: Patients with spinal tumors who underwent preoperative embolizations between January 2010 and March 2013 were retrospectively reviewed. Perioperative complications were classified as either major or minor. Preoperative and intraoperative factors were analyzed for any association with major complications using univariate and multivariate regression analysis., Results: There were 120 embolizations with subsequent 120 spine operations that met the inclusion and exclusion criteria. Overall, 27.5% (33/120) experienced major complications and 11.7% (14/120) had at least two major complications. Respiratory complications were the most commonly seen with a rate of 10.8% (13/120). Multivariate regression analysis identified two risk factors for major complications: reoperation and higher score of surgical invasiveness index. Two risk factors were identified for two or more major complications: age≥65 years and higher score of surgical invasiveness index. Two risk factors were identified for major respiratory complications: thoracic surgery and higher score of surgical invasiveness index. However, embolization-related factors did not reach significance in the multiple regression model., Conclusion: Major complications in surgery for hypervascular spinal tumors after embolization are prevalent. Risk factors identified in this study are useful prognostic indicators when considering surgical treatment combined with embolization.

Purpose: Vertebral hemangiomas (VHs) are the most common form of benign tumors in the spine. The aim of this research was to study the prevalence of VHs in the human population, their distribution along the spine and their location in the vertebral body., Methods: The presence of VHs was assessed in full spine CT scans of 196 adults. Demographic data were gathered from medical records., Results: VHs were present in 26.0% of the individuals studied, a rate significantly higher (χ2=43.338, p<0.001) than the prevalence reported in the literature (10.7%). Multiple VHs (≥2) appeared in 7.2% of the population studied. VHs prevalence is sex-independent, appearing in 28.6% of females and 23.5% of males (χ2=0.663, p=0.416); and age-dependent: the mean age of affected individuals (65.8 years) was significantly higher (p<0.001) than unaffected individuals (56.2 years). VH size was also age-dependent (p=0.023). No vertebra was significantly more prone to be affected by a hemangioma. T11 and T12 show the highest prevalence of VHs (3.57% of vertebrae affected). VHs were found in similar percentages in the anterior and posterior parts of the vertebral body (52.8 vs. 47.2%, respectively); and at its center and periphery (50.1 and 49.9%, respectively). VHs usually appeared at mid-height of the vertebral body or slightly higher., Conclusions: The reported prevalence of VHs is dependent on the demographic structure of the population studied, the size of the VHs and the method used to identify them. Overall, the phenomenon is more frequent than usually reported. VHs may appear at all vertebral levels and in all areas of the vertebral body.

Background: Radical surgery for metastases in the spine is in many cases not possible, includingthe higher risk of surgery in older patients with co-morbidities. The aims of treatment are: minimally invasive and maximally effective tumour removal, fracture position, stabilization, pain reduction, and improved quality of life. The specific features and problems of diagnosis and treatment using the cavity/coblation method, , the surgical technique, and the results of the treatment of 250 patients with spinal tumours/metastases are presented., Materials and Methods: Tumour resection is carried out by plasma field, via percutaneous trans-/extrapedicular access, followed by kyphoplasty. Clinical and radiological follow-up was carried out postoperatively, including data on pain reduction and improvement of quality of life., Results: Within 6 years (March 2008t February 2014) a total of 250 patients, or 812 spines were treated. In 59 cases dorsal percutaneous instrumentation and straightening were carried out. Minimal blood loss and a very low complication rate were recorded. After surgery, significant pain reduction, satisfaction, early mobilization, and improvement in quality of life were demonstrated in all patients. Immediate radio- and chemotherapy could be carried out. In 38 cases cement escaped laterally into the intervertebral space, but this had no clinical relevance. 188 patients have since died because of tumour manifestations., Conclusions: The cavity/coblation method has been demonstrated to be a safe, minimally invasive procedure, with good short- and long-term results and lower complication rates. A comprehensive diagnostic, including tumour staging, the correct indication, and prognosis estimation, is important.

Study Design: Multicenter, ambispective observational study., Objective: To quantify local recurrence and mortality rates after surgical treatment of symptomatic spinal hemangiomas and identify prognostic variables for local disease control., Summary of Background Data: Spinal hemangiomas are the most common primary tumors of the spine and are generally benign and usually asymptomatic. Because of the rarity of symptomatic spinal hemangiomas, optimal surgical treatment remains unclear., Methods: AOSpine Knowledge Forum Tumor Investigators created a multicenter database of primary spinal tumors including demographics, presentation, diagnosis, treatment, survival, and recurrence data. Tumors were classified according to Enneking and Weinstein-Boriani-Biagini. Descriptive statistics were summarized and time to mortality and recurrence was determined., Results: Between 1996 and 2012, 68 patients (mean age = 51 yr, SD = 16) underwent surgical treatment of a spinal hemangioma. Epidural disease was present in 55% of patients (n = 33). Pain and neurological compromise were presenting symptoms in 82% (n = 54) and 37% (n = 24) of patients, respectively. Preoperative embolization was performed in 35% of patients (n = 23), 10% (n = 7) had adjuvant radiotherapy, and 81% (n = 55) underwent posterior-alone surgery. The local recurrence rate was 3% (n = 2). Mortality secondary to spinal hemangioma was not observed (mean follow-up = 3.9 yr, SD = 3.8)., Conclusion: This is the largest multicenter surgical cohort of spinal hemangiomas. Symptomatic spinal hemangiomas are a benign tumor despite frequently presenting with epidural disease and neurological compromise. Thus, formal en bloc resection is not required, and excellent rates of local control and long-term survival can result from aggressive intralesional resection during index surgery., Level of Evidence: 3.

This study evaluated the secondary cancer risk from volumetric-modulated arc therapy (VMAT) for spine radiotherapy compared with intensity-modulated radiotherapy (IMRT) and 3-dimensional conformal radiotherapy (3DCRT). Computed tomography images of an Radiological Physics Center spine anthropomorphic phantom were exported to a treatment planning system (Pinnacle(3), version 9.4). Radiation treatment plans for spine were prepared using VMAT (dual-arc), 7-field IMRT (beam angles: 110°, 130°, 150°, 180°, 210°, 230°, and 250°), and 4-field 3DCRT technique. The mean and maximum doses, dose-volume histograms, and volumes receiving more than 2 and 4Gy to organs at risk (OARs) were calculated and compared. The lifetime risk for secondary cancers was estimated according to the National Cancer Registry Programme Report 116. VMAT delivered the lowest maximum dose to the esophagus (4.03Gy), bone (8.11Gy), heart (2.11Gy), spinal cord (6.45Gy), and whole lung (5.66Gy) as compared with other techniques (IMRT and 3DCRT). The volumes of OAR (esophagus) receiving more than 4Gy were 0% for VMAT, 27.06% for IMRT, and up to 32.35% for 3DCRT. The estimated risk for secondary cancer in the respective OAR is considerably lower in VMAT compared with other techniques. The results of maximum doses and volumes of OARs suggest that the risk of secondary cancer induction for the spine in VMAT is lower than IMRT and 3DCRT, whereas VMAT has the best target coverage compared with the other techniques., (Copyright © 2015 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Background: Postural orthostatic tachycardia syndrome (POTS) is the most common of several types of dysautonomia, characterized by dysfunction of the autonomic nervous system manifesting with symptoms of orthostatic intolerance with or without associated orthostatic hypotension and excessive autonomic excitation. Given the numerous presenting musculoskeletal symptoms of POTS and its known associations with other clinical entities like Ehlers-Danlos syndrome, POTS constitutes an unusual treatment challenge of which the orthopaedic surgeon and other related healthcare providers should be aware., Case Description: We describe two patients with a diagnosis of POTS and musculoskeletal manifestations. The first is a 13-year-old boy with a concurrent diagnosis of Ehlers-Danlos syndrome and worsening back pain. The patient had resolution of his musculoskeletal symptoms after treatment with a Boston Overlap LSO brace and physical therapy and resolution of his cardiovascular symptoms after pharmacologic treatment. The second patient is a 17-year-old girl with an L1 vertebral hemangioma and pain of sudden onset radiating to her lower extremities. Her symptoms were controlled with therapy and gabapentin., Literature Review: POTS is a poorly understood and controversial clinical entity with lack of awareness and knowledge regarding the syndrome by the majority of medical specialists. Its complex and wide range of clinical presentation has led to being commonly mistaken with malingering, depression and anxiety disorders. Review of the literature did not yield any previous studies addressing POTS and the special considerations for the orthopaedic surgeon caring for these patients; previous studies of large patient series focus on investigating the pathologic substrate of POTS and the efficacy of various treatment modalities on the cardiovascular dysregulation., Clinical Relevance: These two cases show that understanding and knowledge of this syndrome and its comorbidities should guide any diagnostic approach or therapeutic intervention by the orthopaedic surgeon caring for patients with this syndrome. It is important that the surgeon is aware of the benefits of detailed patient education and physical conditioning, the increased perioperative complications, and the need for specialized anesthesia.

Background Context: Spinal cord compression and fracture are possible complications of spine metastasis and multiple myeloma. Prompt diagnosis and treatment of threatening lesions are likely to reduce the frequency of these dreaded complications., Purpose: To evaluate the proportion of neoplastic spine lesions operated on emergency., Study Design: Retrospective study., Patient Sample: All patients who underwent palliative surgery for the treatment of a neoplastic spine lesion in our institution between 2005 and 2012., Outcome Measures: Percentage of patients who underwent surgery as an emergency for acute fracture or rapid neurological decline., Methods: We retrospectively reviewed the data of all patients who underwent palliative surgery for the treatment of a neoplastic spine lesion from solid cancer or multiple myeloma, in our institution between January 2005 and December 2012. The study was supported by grant from our institution., Results: A total of 317 patients were included in the study. There were 166 men and 151 women and the mean age was 57.97 years (range 26-88; SD 12.45). The cancer was known for 224 patients, while the lesion revealed the disease for the other 93 patients. The percentage of patients with known cancer operated as an emergency in our institution decreased significantly between 2005 and 2012 (p = 0.0006)., Conclusion: Due to the variability of clinical and radiological presentations, best care requires a truly multidisciplinary approach, to offer each patient a prompt and individualized treatment option, which is likely to reduce the incidence of emergency surgeries., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Object: The National Institutes of Health recommends strategies to obtain evidence for the treatment of rare conditions such as primary tumors of the spine (PTSs). These tumors have a low incidence and are pathologically heterogeneous, and treatment approaches are diverse. Appropriate evidence-based care is imperative. Failure to follow validated oncological principles may lead to unnecessary mortality and profound morbidity. This paper outlines a scientific model that provides significant evidence guiding the treatment of PTSs., Methods: A four-stage approach was used: 1) planning: data from large-volume centers were reviewed to provide insight; 2) recruitment: centers were enrolled and provided the necessary infrastructure; 3) retrospective stage: existing medical records were reviewed and completed with survival data; and 4) prospective stage: prospective data collection has been implemented. The AOSpine Knowledge Forum Tumor designed six modules: demographic, clinical, diagnostic, therapeutic, local recurrence, survival, and perioperative morbidity data fields and provided funding., Results: It took 18 months to implement Stages 1-3, while Stage 4 is ongoing. A total of 1495 tumor cases were captured and diagnosed as one of 18 PTS histotypes. In addition, a PTS biobank network has been created to link clinical data with tumor pathology and molecular analysis., Conclusions: This scientific model has not only aggregated a large amount of PTS data, but has also established an international collaborative network of spine oncology centers. Access to large volumes of data will generate further research to guide and enhance PTS clinical management. This model could be applied to other rare neoplastic conditions. Clinical trial registration no.: NCT01643174 (ClinicalTrials.gov).

Involvement of osteochondromas in the spinal canal occurs in patients with multiple hereditary exostosis, but the exact prevalence is unknown. A recent study found an incidence of 68%, with 27% of these lesions encroaching into the spinal canal. We studied MRI findings of 27 patients with multiple hereditary exostosis and found only six (23.1%) patients with osteochondromas arising from the spinal column and three (11.5%) patients with encroachment into the spinal canal. We also found three (11.5%) patients with an incidental syringomyelia. Only five of the nine (55.6%) patients with positive findings on MRI had symptoms prompting the MRI and two patients had significant symptoms that required surgical excision. Although the incidence of spinal osteochondroma in our population is lower than that of previous studies, we found a relatively high incidence of syringomyelia in these patients, which has not been previously reported.

Objective: To determine prevalence, demographic data and clinical presentation of primary vertebral tumors., Material and Method: A retrospective study of the primary spine tumor specimens from Siriraj bone tumor registry from 1996 to 2010., Results: From the study, primary spinal tumors constituted 85 of 1,679 bone tumor cases (5.06%). The common benign spinal tumors were giant cell tumor and hemangioma. The common malignant spinal tumors were chordoma, chondrosarcoma, and osteosarcoma. The mean age ofpresentation was 44.68 years. Fifty-three percent of tumors occurred in females. Pain was the most common presenting symptom, occurring in 73.53% of malignant and 52.94% of benign tumors. Neurological involvement occurred in 25% of malignant tumor Malignant lesions predominated in the sacral region while the most common location ofbenign specimens was thoracic region., Conclusion: The present study was the first demographic study ofprimary spinal tumor in Thai showed variety of prevalence when compared with similar studies based on Western patients. Whether these results reflect differences in the population, race and data collection method.

Opinion Statement: Primary sarcomas of the spine are rare diseases and include osteosarcoma, chondrosarcoma, chordoma, and Ewing's sarcoma. Surgery for these lesions remains an important part of their treatment. Strong evidence exists for the en bloc resection of chondrosarcoma and chordoma since these lesions respond poorly to both chemotherapy and radiation. Weaker but important evidence suggests that osteosarcoma and Ewing's sarcoma may also benefit from wide excisions, but after the application of neoadjuvant therapy, which may significantly aid the surgical process as well as independently prolong the survival. The unacceptable morbidity associated with damage to the neural elements makes resection with wide margins difficult in the spine. Nevertheless, this can be achieved in many circumstances and can, on occasion, lead to long term disease-free survival and even cure. There are numerous techniques described for en bloc resections in the mobile spine and pelvis and these vary widely for the region of the spine involved and the preferences of the surgeon. There are constant principles that do apply to all cases. We think of these surgeries as consisting of 2 stages which can be done in 1 or multiple operations. In the first phase, a corridor free of tumor is removed from the bone and the neural elements to be protected are dissected free from surrounding tissues. In the second phase, the tumor and a margin of normal tissue is circumferentially dissected and delivered while sparing the neural structures. Patient selection, in terms of age, overall disease burden, personal preferences, and comorbidities need to be carefully taken into account to optimize the risk benefit ratio. Sarcomas of the spine are a challenging group of lesions to treat but they can also be the most rewarding. Our newly acquired insight into the pathogenesis of these lesions, as well as improved surgical techniques combined with better neoadjuvant and adjuvant therapies are leading to longer survival times as well as long term disease free survivors.

Background Context: Surgical treatment for spinal metastasis is still controversial. However, with the improvements in treatment for primary tumors, the survival rate of patients with spinal metastasis is enhanced. At the same time, surgical technique for spinal metastasis has also improved., Purpose: The purpose of this study was to examine trends in the surgical treatment for spinal metastasis and in-hospital patient outcomes on a national level., Study Design/setting: This was an epidemiologic study using national administrative data from the Nationwide Inpatient Sample (NIS) database., Patient Sample: All discharges in the NIS with a diagnosis code of secondary malignant neoplasm of the spinal cord/brain, meninges, or bone who also underwent spinal surgery from 2000 to 2009 were included., Outcome Measures: Trends in the surgical treatment for spinal metastasis, in-hospital complications and mortality, and resource use were analyzed., Methods: The NIS was used to identify patients who underwent surgical treatment for spinal metastasis from 2000 to 2009, using the International Classification of Diseases, Ninth revision, Clinical Modification codes. Trends in the surgical treatment for spinal metastasis and in-hospital patient outcomes were analyzed., Results: From 2000 to 2009, there was an increasing trend in the population growth-adjusted rate of surgical treatment for spinal metastasis (1.15-1.77 per 100,000; p<.001). Average Elixhauser comorbidity score increased over time (2.6-3.8; p<.001), and the overall in-hospital complication rate increased over time (14.8%-27.7%; p<.001), whereas in-hospital mortality rate and length of hospital stay remained stable over time (5.2%-4.6%, p=.413; 10.6-10.8 days, p=.626). Inflation-adjusted mean hospital charges increased more than two-fold over time ($50,390-$110,173; p<.001)., Conclusions: During the last decade, surgical treatment for spinal metastasis has increased in the United States. The overall in-hospital complication rate and hospital charges increased, whereas the in-hospital mortality rate and length of hospital stay remained stable., (Copyright © 2014 Elsevier Inc. All rights reserved.)

From 100,000 people in Germany, statistically calculated, 441 males and 350 females suffer from a cancer disease. In about 50 to 80 % of patients with breast or prostate carcinoma bone metastases are registered, which is connected, among others, with a high risk for pathological fractures and other debilitating diseases. The diagnosis of bone metastases is done by conventional X-ray equipment, CT, MRI, and especially with the help of skeletal scintigraphy. For therapy bisphosphonates, anti-hormones and chemotherapeutic agents as drugs are used. Furthermore, radiotherapy, radionuclides, surgery and ablative procedures are applied. A more recent technical method is the STAR™ Tumour Ablation System (RFA), by which minimally invasively an electrode is introduced into the vertebral bodies. The system ensures precise control and thus a targeted ablation of the metastases. Several publications and reports describing a combined application demonstrate the synergistic effectiveness of RFA and radiofrequency kyphoplasty., (Georg Thieme Verlag KG Stuttgart · New York.)

Study Design: Prospective national population-based cohort study., Objective: To evaluate national population-based data on histopathologically verified intraspinal tumors and explore time trends in incidence and surgery rates and associations with the increased availability of magnetic resonance imaging (MRI) during 1993 and 2011., Summary of Background Data: There is a relative lack of updated epidemiological data on primary intraspinal tumors and most previous studies do not capture the advances in diagnostics and surgical treatment in the era of modern neuroimaging. The possible effect of the increasing availability of MRI on incidence rates and clinical management of primary intraspinal tumors is not known., Methods: We included all patients with a histologically verified intraspinal tumor diagnosed between 1993 and 2011 in a population-based cohort based on data from the Cancer Registry of Norway. The incidence and surgery rates were calculated and compared with the number of available MRI scanners in Norway., Results: We identified 1104 patients diagnosed with a primary intraspinal tumor. The incidence rate based on the Norwegian population between 1993 and 2011 was 1.28 per 100,000. In 1993, there were 8 MRI scanners in Norway increasing to 125 in 2011. There seems to be a plateau in the increase in incidence rates after 2002 where the subsequent increase in the number of MRI scanners did not seem to be followed by further increases of intraspinal tumor surgery., Conclusion: The incidence rate of primary intraspinal tumors in Norway changed dramatically during the study period, stabilizing around 1.5 per 100,000 per year since 2002. There was an increase in surgery for all major subgroups. This increase in surgical activity seems to correlate with the simultaneous large increase in the availability of diagnostic magnetic resonance imaging.

Computed tomography has become an important component in the initial assessment of severely injured patients over the last years. The liberal use coupled with advances in imaging technology often result in incidental findings. In our present investigation, the prevalence incidence of incidental findings of the spine and skull amounted to 58% of all patients with trauma. Degenerative changes were most commonly found, followed by congenital defects and neoplasms. Within the latter, further investigation was necessary in six cases, of which two findings proved to be malignant neoplasms. The high incidence of incidental findings calls for a uniform documentation, handling and clarification of responsibility in treatment and insurance-related competence.

Peripheral nerve sheath tumors are uncommon neoplasms that can affect any area of the body. Spinal lesions, especially those that are malignant, pose difficult management challenges, and data regarding these lesions are limited by the disease rarity. This study provides a population-based analysis using the Surveillance, Epidemiology, and End Results (SEER) database, focusing on patient characteristics and treatments. Surgery is associated with improved survival, whereas radiation therapy is associated with decreased survival in this cohort with malignant peripheral nerve sheath tumor in the spine., (Copyright © 2014. Published by Elsevier Ltd.)

Background: A recent randomized trial demonstrated that for metastatic epidural spinal cord compression (MESCC), a complication of advanced prostate cancer, surgical decompression may be more effective than external beam radiation therapy (RT). We investigated predictors of MESCC, its treatment, and its impact on hospital length of stay for patients with advanced prostate cancer., Methods: We used the SEER-Medicare database to identify patients >65 years with stage IV (n = 14,800) prostate cancer. We used polytomous logistic regression to compare those with and without MESCC and those hospitalized for treatment with surgical decompression and/or RT., Results: MESCC developed in 711 (5 %) of patients, among whom 359 (50 %) received RT and 107 (15 %) underwent surgery ± RT. Median survival was 10 months. MESCC was more likely among patients who were black (OR 1.75, 95 %CI 1.39-2.19 vs. white) and had high-grade tumors (OR 3.01, 95 %CI 1.14-7.94), and less likely in those younger; with prior hormonal therapy (OR 0.73, 95 %CI 0.62-0.86); or with osteoporosis (OR 0.63, 95 %CI 0.47-0.83). Older patients were less likely to undergo either RT or surgery, as were those with ≥1 comorbidity. Patients with high-grade tumors were more likely to undergo RT (OR 1.92, 95 %CI 1.25-2.96). Those who underwent RT or surgery spent an additional 11 and 29 days, respectively, hospitalized., Conclusions: We found that black men with metastatic prostate cancer are more likely to develop MESCC than whites. RT was more commonly utilized for treatment than surgery, but the elderly and those with comorbidities were unlikely to receive either treatment.

Objectives: We aimed to describe surgical planning, technique, and complications of en bloc resection in the thoracic spine in patients who opted for surgery with en bloc resection and a tumor-free margin., Methods: Oncologic and functional results were recorded for 134 patients (53% male, age 44 ± 18 years) who had undergone en bloc resection for primary tumors (90 cases) and bone metastases (44 cases). Patients were followed until death or the latest follow-up examination (0-211 months, median 47 months). Surgeries were performed from 1990 to 2007 by the same team. An ongoing critical analysis of local control rates, surgical complications, and expected versus actual loss of function enabled the authors to refine the surgical technique and propose seven different types of resection., Results and Discussion: En bloc resection is a demanding procedure and requires careful planning after a careful decision-making process. The patient has to correctly understand the purpose of the surgery, based on oncological staging, in order to accept or decide against the procedure after weighing the possible morbidity and functional loss against the expected final result. TECHNIQUES OF EN BLOC RESECTION: Seven different strategies to perform en bloc resection in the thoracic spine, based on four combinations of surgical approaches (anterior, posterior, anterior followed by posterior, and posterior followed by simultaneous anterior and posterior) are identified and proposed. This planning is based on Weinstein-Boriani-Biagini (WBB) surgical staging. The surgical plan was designed to achieve the required oncologic margin with the minimum achievable morbidity.

Objectives: The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis, and surgical management of the malignant primary sacral tumors., Methods: A PubMed search was conducted using a combination of the following items: (('Spinal Neoplasms'[Mesh]) AND 'Sacrum'[Mesh]) NOT ('Metastasis' OR 'Metastases' OR 'Benign'). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors., Results: Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and oncologic outcome, and the recurrence-free and disease-specific survival of this rare patient category., Discussion: Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols.

Primary spinal tumors are rare diseases. Primary spinal tumor registry would be useful to help decision making in this complex field of spine surgery. In this article the authors present the latest findings from the Primary Spinal Tumor Registry at the National Centre for Spinal Disorders, Hungary. The registry is based on a novel database management software, the REDCap electronic data capture system. It contains data of 323 patients treated surgically during an 18-year period. Among the 126 malignant tumors, the most frequent was chordoma (61 cases). In the case of benign tumors schwannoma showed the largest prevalence (45 cases). The authors conclude that due to the rarity of the disease and the complexity of the management, multicenter, prospective registries are required to provide high level of evidence. The structure of the Primary Spinal Tumor Registry in the National Centre for Spinal Disorders in Hungary is optimal for user-friendly, fast and secure data collection providing a prospective database for scientific researches and clinical follow-up.

Objective: The aim of the present study was to analyze the practice patterns, complications and outcome following surgery for spinal meningioma in the United States., Patients and Methods: We performed a retrospective cohort study using the Nationwide Inpatient Sample database from 2003 to 2010. In-patient mortality and discharge disposition were the outcome predictors., Results: A total of 13,792 admissions for surgically managed spinal meningioma were identified. The number of admissions increased from 12.6% in 2003 to 14.7% in 2010. 1.2% patients were ≤18 years and 28.4% ≥70 years. 8.3% patients had high co-morbidity score. The total in-hospital complication rate was 6.4%. 42% of the admissions were discharged to facilities other than home or self-care. Patients in the pediatric and adult age groups had a significantly higher rate of adverse outcome. There was no difference in complication rates and adverse discharge disposition between the hospitals with varying case volumes., Conclusions: Caucasian patients with private insurance without co-morbidity had significantly lower complication rate and good outcome. Occurrence of spinal meningioma in the pediatric and adult age groups does not carry worse prognosis., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Purpose: The phase 2 component of Radiation Therapy Oncology Group (RTOG) 0631 assessed the feasibility and safety of spine radiosurgery (SRS) for localized spine metastases in a cooperative group setting., Methods and Materials: Patients with 1-3 spine metastasis with a Numerical Rating Pain Scale (NRPS) score ≥5 received 16 Gy single fraction SRS. The primary endpoint was SRS feasibility: image guidance radiation therapy (IGRT) targeting accuracy ≤2 mm, target volume coverage >90% of prescription dose, maintaining spinal cord dose constraints (10 Gy to ≤10% of the cord volume from 5-6 mm above to 5-6 mm below the target or absolute spinal cord volume <0.35 cc) and other normal tissue dose constraints. A feasibility success rate <70% was considered unacceptable for continuation of the phase 3 component. Based on the 1-sample exact binomial test with α = 0.10 (1-sided), 41 patients were required. Acute toxicity was assessed using the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0., Results: Sixty-five institutions were credentialed with spine phantom dosimetry and IGRT compliance. Forty-six patients were accrued, and 44 were eligible. There were 4 cervical, 21 thoracic, and 19 lumbar sites. Median NRPS was 7 at presentation. Final pretreatment rapid review was approved in 100%. Accuracy of image guided SRS targeting was in compliance with the protocol in 95%. The target coverage and spinal cord dose constraint were in accordance with the protocol requirements in 100% and 97%. Overall compliance for other normal tissue constraints was per protocol in 74%. There were no cases of grade 4-5 acute treatment-related toxicity., Conclusions: The phase 2 results demonstrate the feasibility and accurate use of SRS to treat spinal metastases, with rigorous quality control, in a cooperative group setting. The planned RTOG 0631 phase 3 component will proceed to compare pain relief and quality of life between SRS and external beam radiation therapy., (Copyright © 2014 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Studies examining the efficacy of vertebroplasty and kyphoplasty in patients with vertebral fractures from multiple myeloma are limited. We sought to perform a systematic review of published case studies examining changes in pain, disability, and analgesic drug use in patients with multiple myeloma who have undergone vertebral augmentation., Materials and Methods: We performed a pooled analysis of published case series of vertebral augmentation in patients with multiple myeloma. Twenty-three studies (9 kyphoplasty, 12 vertebroplasty, and 2 of both) with data on 923 patients were identified from a PubMed search. Quantitative outcome data included the Visual Analog Scale, the Brief Pain Inventory, the Short Form 36 Health Survey, and the Owestry Disability Index. Time periods were consolidated into 3: postoperatively ≤1 week, 1 week to 1 year, and ≥1 year. Change in analgesic use was also studied. Data were compared by using nonparametric tests and matched t tests for temporally linked data., Results: Patients achieved a decrease in pain across all consolidated time periods. Pain, as measured on a 10-point scale, decreased by 4.8 points up to 1 week, 4.6 points up to 1 year, and 4.4 points after a year (P < .001). Decrease in pain was apparent early after treatment and was sustained with time. Kyphoplasty and vertebroplasty were equally effective in reducing pain scores because differences between procedures for each time period were insignificant (P < .9 for <1 week, P < 1.0 for ≤1 year, and P < .9 for >1 year., Conclusions: Our analysis demonstrates that vertebral augmentation is effective in patients with multiple myeloma.

Central neurocytoma is a rare neuroectodermal tumor found in young adults. These tumors are generally located in the lateral or third ventricles. Extraventricular neurocytoma in the spinal cord is extremely rare. We report on two patients with primary spinal neurocytomas who presented with progressive numbness and weakness in the limbs. Both patients had intramedullary masses between the medulla and the upper thoracic levels. The clinical, radiological, surgical, and pathological features of this abnormality are discussed, and all 20 reported cases were reviewed. In conclusion, neurocytoma should be included in the differential diagnosis of a spinal intramedullary tumor, and subtotal resection is acceptable for a relatively favorable prognosis if gross total removal is unachievable. The efficacy of adjuvant radiochemotherapy to control tumor recurrence is unknown.

Direct single fields are commonly used in radiotherapy for spinal bone metastases, and it is crucial to define the point for which the dose is prescribed. According to the guidelines from the International Bone Metastases Consensus Working Party (IBMCWP) updated in 2010, different opinions exist on whether this therapy should be prescribed to the mid-vertebral or anterior vertebral body. To our knowledge, no previous studies have surveyed practice patterns regarding this discrepancy. Therefore, we performed an Internet-based survey of members of the Japanese Radiation Oncology Study Group (JROSG) to investigate the current practice patterns in Japan. The respondents mentioned the point to which they prescribed radiotherapy for a single direct field. A total of 52 radiation oncologists from 50 institutions (36% of JROSG institutions) responded. Respondent prescription for radiotherapy varied widely. Only 21% and 6% of respondents prescribed irradiation to the mid-vertebral body and anterior vertebral body, respectively. A larger proportion of respondents (27%) prescribed irradiation to the spinal cord (center of the spinal canal). Still another group of respondents (27%) stated that they never use a single direct field. In conclusion, the point to which irradiation dosages are prescribed varies widely for a single direct field in cases of spinal bone metastases. This variation may lead some radiation oncologists to misunderstand the tolerance dosage of the spinal cord, especially in cases of re-irradiation. Thus, careful consideration is required before any prescriptions are made.

Objectives: There have been several modifications to the classification of childhood cancers since the first report (1968-1981) specific to the Jamaican paediatric population was published in 1988. This paper reports on paediatric cancer incidence in Kingston and St Andrew, Jamaica, for the 20-year period 1983-2002 based on these modifications., Methods: All cases of cancer diagnosed in children (0-14 years), between 1983 and 2002 were extracted from the Jamaica Cancer Registry archives and classified using the International Classification of Childhood Cancer, third edition. Incidence figures were calculated as per the International Agency for Research on Cancer (IARC) reporting format for childhood cancer., Results: There were 272 cases (133 males, 139 females) of childhood cancer identified in the 20-year period. The overall age standardized rate (ASR) was 69.4 per million; that for males was 67.8 per million, and for females, 70.9 per million. The three most common malignancies overall were leukaemia (21.3%), lymphoma (15.8%) and brain and spinal neoplasms (14.0%). In males, the highest ASRs were seen for leukaemia (14.8 per million), lymphoma (12.7 per million), and brain and spinal neoplasms (8.2 per million), and in females, leukaemia (14.4 per million), nephroblastoma (11.3 per million), and brain and spinal neoplasms (10.6 per million)., Conclusions: The rankings of the most common childhood malignancies in Jamaica (leukaemia, brain and spinal neoplasms and lymphomas) have shown few changes since the last review. However, there are differences in frequency and gender distribution of nephroblastoma and brain and spinal neoplasms.

The treatment of spinal metastasis has considerably improved with the advent of stereotactic body radiotherapy. Technological advances have enabled the precise delivery of high-dose radiation that may supplant surgery and standard fractionation postoperative radiation as a treatment for spinal metastasis without cord compression. Unfortunately, the higher biologically equivalent doses conferred by stereotactic body radiotherapy can also result in radiation toxicity, notably myelitis and vertebral body fracture. These are toxicities that the radiation oncologist must be able to anticipate, mitigate and manage. Although myelitis can be prevented largely by instituting dose constraints, it is less clear what the fracture risk of a structurally compromised vertebra is, and what should be done in terms of stabilization and dosimetry to mitigate this risk. This review answers these questions by defining the appropriate patient for stereotactic body radiotherapy, and what dose, fractionation and spinal stabilization should be used for potentially unstable spines.

The existing literature on preoperative spine tumor embolization is limited in size of patient cohorts and diversity of tumor histologies. This report presents our experience with preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors in the largest series to date. We conducted a retrospective review of 228 angiograms and 188 pre-operative embolizations for tumors involving thoracic, lumbar and sacral spinal column. Tumor vascularity was evaluated with conventional spinal angiography and was graded from 0 (same as normal adjacent vertebral body) to 3 (severe tumor blush with arteriovenous shunting). Embolic materials included poly vinyl alcohol (PVA) particles and detachable platinum coils and rarely, liquid embolics. The degree of embolization was graded as complete, near-complete, or partial. Anesthesia records were reviewed to document blood loss during surgery. Renal cell carcinoma (44.2%), thyroid carcinoma (9.2%), and leiomyosarcoma (6.6%) were the most common tumors out of a total of 40 tumor histologies. Hemangiopericytoma had the highest mean vascularity (2.6) of all tumor types with at least five representative cases followed by renal cell carcinoma (2.0) and thyroid carcinoma (2.0). PVA particles were used in 100% of cases. Detachable platinum coils were used in 51.6% of cases. Complete, near-complete, and partial embolizations were achieved in 86.1%, 12.7%, and 1.2% of all cases, respectively. There were no new post-procedure neurologic deficits or other complications with long-term morbidity. The mean intra-operative blood loss for the hypervascular tumors treated with pre-operative embolization was 1745 cc. Preoperative embolization of hypervascular thoracic, lumbar, and sacral spine tumors can be performed with high success rates and a high degree of safety at high volume centers.

Advances in early detection and therapy of spinal metastasis have improved life expectancy of patients with various tumor entities. However, this and the demographic development have led to an increased risk for developing spinal metastases. Numerous prognostic factors have been determined to allow an assessment of outcome and survival time of patients with metastatic spinal tumors. The implementation of these factors into different scoring systems has been encouraging in the decision making process of spinal surgery. This overview highlights some of the most important prognostic factors and scores which may facilitate surgical considerations.

Purpose: The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence., Methods: The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for ≥ 12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors., Results: Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age <40 years, history of diabetes mellitus, maximum tumor diameter ≥ 10 cm, and instrumentation used were risk factors for wound complications., Conclusions: The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.

Background: The spinal injuries in workers have become a large scale health problem. The purpose of this study is to review the differences in the spine pathologies from incapacity to work, as well as factors that could alter the recovery time and the possibility of returning the patient to work., Methods: Statistical preliminary review study in 37 patients enrolled in the Instituto Mexicano del Seguro Social, workers, undertaken to spinal pathology surgery, comparing days of incapacity with proposed internationally, as well as his return to work., Results: The results show that 37% of the patients studied are still active in the social security, 2 years after surgery. The days of disability generated by the pathology in this study group (212.3 days) are significantly higher than what is set on the Medical Disability Advisor (56 days, almost 4 times more)., Conclusion: The study shows the need to develop the same analysis in other hospitals, comparing the proportion of cases that return to the work and total disability times for diagnostics.

Three Epstein-Barr virus-associated smooth muscle tumors (intracranial, endobronchial, and paraspinal) in 2 patients are presented. The patient with the intracranial tumor had no concurrent or previous manifestation of this neoplasm and was immunosuppressed because of a renal transplant. The other patient had AIDS and radiologic evidence of involvement of multiple other sites. Although mitotic activity was present, none of the tumors displayed any high-grade malignant histologic features. All tumors were strongly positive for smooth muscle actin and variably expressed h-caldesmon. Desmin was negative in all 3 tumors. The intracranial tumor was associated with prominent intracerebral edema and displayed, in addition to a prominent intratumoral T-cell component, a hitherto unreported component of prominent intratumoral B cells and plasma cells., (Copyright © 2013 Elsevier Inc. All rights reserved.)

In the pediatric population, malignant osseous tumors of the spine include osteosarcoma, Ewing sarcoma, lymphoma, and metastatic neuroblastoma. Although these tumors are rare, prompt diagnosis and recognition are critical to the overall prognosis. Improved understanding of the natural history of spine deformity, combined with advances in imaging, surgical technology, radiation therapy, and chemotherapeutic regimens, has improved survival rates and decreased rates of local recurrence-especially recurrence of low-grade lesions. Prognosis for patients with high-grade lesions with distant metastasis on presentation remains exceedingly poor. Recognition of these spine tumors and prompt referral to a tertiary care center that specializes in oncology can optimize patient outcomes.