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BackgroundCauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.MethodsThis is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.FindingsIn 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.InterpretationPost-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.FundingDCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

Cervical disc arthroplasty is a treatment option for symptomatic cervical disc disease. There is a paucity of literature on long-term safety outcomes, durability, and device-related failure rates. The M6-C artificial cervical disc is a device with titanium alloy endplates and a complex polymeric centerpiece. To date, trials have exhibited acceptable safety profiles.This case series describes the presentation, management, and pathological findings of a delayed prevertebral periprosthetic mass anterior to the M6-C disc. Four patients at 3 different institutions underwent cervical disc replacement with the M6-C disc. Two to seven years postoperatively, they presented with dysphagia secondary to a compressive mass anterior to the disc. Case notes were reviewed to collect data on symptoms, management, and outcomes. The patients were systemically well and presented with progressive dysphagia. They had imaging findings of a mass anterior to the disc. They underwent a decompressive procedure, with 2 patients undergoing device removal and fusion. In 2 cases, a soft-tissue mass was seen intraoperatively, with frank pus. In 3 cases, Propionibacterium acnes was identified and antibiotic treatment given. Histopathology demonstrated mixed inflammatory infiltrates with foreign body–type granulomas. Postoperatively, the dysphagia resolved.The development of delayed dysphagia in a patient with an M6-C disc should prompt investigation to identify a mass lesion. To the authors’ knowledge, this is the first report of delayed infection, or suspected delayed-type hypersensitivity reaction, following M6-C disc implantation. It is important for this to be added to the device safety concerns. Further prospective studies are needed to establish the incidence and the long-term safety and failure rates of the M6-C disc.

Study Design:Prospective cohort study.Objective:To evaluate the long-term effectiveness of a posterior dynamic spine stabilization (PDS) System called PercuDyn system as a treatment for low back pain (LBP) in patients with degenerative disc disease who have failed conservative treatment.Methods:Thirty-five patients (21 males, 14 females, mean age 36 years) with chronic LBP due to degenerative disc disease underwent percutaneous facet augmentation with the PercuDyn system. Indications for implanting the PercuDyn device were chronic LBP without sciatica, significant disc degeneration, and who failed conservative treatment. Follow-up after surgery ranged from 4 to 8 years. Patients were clinically evaluated using visual analogue scale (VAS), Oswestry Disability Index (ODI) questionnaire, and the EQ-5D3L.Results:The VAS scale and ODI scores improved at 6 months, 1 year, 2 years, and 4 to 8 years in comparison with the baseline values ( P < .001 and P < .01, respectively). Equally, data from the EQ-5D-3L questionnaire suggested improvements in all domains, including pain and discomfort, over the follow-up period. However, during follow-up, 16 patients (46%) have had unsatisfactory outcome including failure of implant to resolve symptoms (n = 8), developed symptomatic disc protrusion (n = 4), and loosening of the screws (n = 4).Conclusion:Our clinical experience highlights the rather high overall failure rate of this system. Although, some patients show significant improvement in their symptoms, we believe that patients with LBP related to degenerative disc disease are a poor indication for this PDS device.However, large scale studies, with optimised selection criteria are needed to demonstrate the exact role of this device in spinal patients.

AIM: Surgery for spinal metastases can improve symptoms, but sometimes complications can negate the benefits. Operations may have different indications, complexities and risks, and the choice for an individual is a tailor-made personalised decision. Previous prognostic scoring systems are becoming out of date and inaccurate. We designed a risk calculator to estimate survival after surgery, to inform clinicians and patients when making management decisions. METHODS: A prospective cohort study was performed, including 1430 patients with spinal metastases who underwent surgery. Of them, 1264 patients from 20 centres were used for model development using a Cox frailty model. Calibration slope, D-statistic and C-index were used for model validation based on 166 patients. Follow-up was to death or minimum of 2 years after surgery. Pre-operative indices (examination findings, pain, Karnofsky physical functioning score, and radiology) were assessed. RESULTS: An algorithm to predict survival was constructed including the tumour type, ambulatory status, analgesic use, American Society of Anesthesiologists score, number of spinal metastases, previous radiotherapy or chemotherapy, presence of visceral metastases, cervical or thoracic spine involvement, as predictors. An Internet-based risk calculator was developed based on this algorithm, with similar or improved accuracy compared to other validated prognostic scoring systems (C-index, 0.68; 95% confidence interval, 0.63--0.73, and calibration slope, 1.00; 95% confidence interval, 0.68--1.32). CONCLUSION: A large, prospective, surgical series of patients with symptomatic spinal metastases was used to create a validated risk calculator that can help clinicians to inform patients about the most appropriate treatment plan. The calculator is available at www.spinemet.com. ispartof: EUROPEAN JOURNAL OF CANCER vol:107 pages:28-36 ispartof: location:England status: published

Study Design. A prospective multicenter cohort study.Objective. To assess the clinical accuracy of six commonly cited prognostic scoring systems for patients with spinal metastases.Summary of Background Data. There are presently several available methods for the estimation of prognosis in metastatic spinal disease, but none are universally accepted by surgeons for clinical use. These scoring systems have not been rigorously tested and validated in large datasets to see if they are reliable enough to inform day-to-day patient management decisions. We tested these scoring systems in a large cohort of patients. A total of 1469 patients were recruited into a secure internet database, and prospectively collected data were analyzed to assess the accuracy of published prognostic scoring systems.Methods. We assessed six prognostic scoring systems, described by the first authors Tomita, Tokuhashi, Bauer, van der Linden, Rades, and Bollen. Kaplan-Meier survival estimates were created for different patient subgroups as described in the original publications. Harrell's C-statistic was calculated for the survival estimates, to assess the concordance between estimated and actual survival.Results. All the prognostic scoring systems tested were able to categorize patients into separate prognostic groups with different overall survivals. However none of the scores were able to achieve "good concordance" as assessed by Harrell's C-statistic. The score of Bollen and colleagues was found to be the most accurate, with a Harrell's C-statistic of 0.66.Conclusion. No prognostic scoring system was found to have a good predictive value. The scores of Bollen and Tomita were the most effective with Harrell's C-statistic of 0.66 and 0.65, respectively. Prognostic scoring systems are calculated using data from previous years, and are subject to inaccuracies as treatments advance in the interim. We suggest that other methods of assessing prognosis should be explored, such as prognostic risk calculation.

In this paper, a surgical robot platform with a novel concentric connector joint (CCJ) is presented. The surgical robot is a parallel robot platform comprised of multiple struts, arranged in a geometrically stable array, connected at their end points via the CCJ. The CCJ joints have near-perfect concentricity of rotation around the node point, which enables the tension and compression forces of the struts to be resolved in a structurally-efficient manner. The preliminary feasibility tests, modeling and simulations were introduced.

There is a lively discussion in science about the question who supports right-wing populist parties and why. The aim of the article is to understand how the scientific conceptualization of the electorate of right-wing populist parties has evolved since the 1990s based on the losers of modernization thesis. The brief historization of the scientific category losers of modernization should lay the foundation to understand the mutual, constitutive relationship between science and society with regard to this category., In der Wissenschaft existiert eine lebhafte Diskussion darüber, wer rechtspopulistische Parteien wählt und warum sie unterstützt werden. Ziel des Beitrags ist es zu verstehen, wie sich das „Begriffenwerden“ des Elektorats von rechtspopulistischen Parteien anhand der Modernisierungsverlierer-These seit den 1990er entwickelt hat. Mit Hilfe dieser kurzen Begriffsgeschichte zu der wissenschaftlichen Kategorie der Modernisierungsverlierer soll ein Grundstein zum besseren Verständnis für das wechselseitige konstituierende Verhältnis von Wissenschaft und Gesellschaft bezüglich der Modernisierungsverlierer gelegt werden.

BACKGROUND: As survival after treatment for symptomatic spinal metastases increases, the incidence of local tumor recurrence also may increase. However, data regarding incidence and timing of recurrence or duration of survival after second surgeries are not readily available and may help to inform clinicians when to perform second surgeries. OBJECTIVE: To identify features associated with loss of local control (LLC) at a previously treated or new spinal level. METHODS: Clinical and surgical data were collected from a prospective cohort of 1421 patients who had surgery for symptomatic spinal metastases. Patients undergoing repeat spinal surgery for symptomatic LLC at the same or a different level were identified and analyzed. RESULTS: In total, 3.0% patients underwent repeat surgery for symptomatic LLC after a median interval of 184 days from the first surgery; median survival was 6.1 months after second surgery. Factors associated with second surgery for LLC were the primary tumor type, number of spinal levels, Tomita staging, Tokuhashi and Karnofsky scores, anterior surgical approach, more aggressive surgical resection, and postoperative radiotherapy. In total, 1.5% patients were admitted for surgery for a different spinal level than the index operation after median 338 days from the first operation. CONCLUSIONS: The likelihood for repeat surgery due to LLC cannot be accurately predicted at the time of initial presentation. Factors associated with second surgery for LLC relate to less aggressive tumor biology and better survival. Most patients had a reasonable duration of survival after second surgery. ispartof: WORLD NEUROSURGERY vol:117 pages:E8-E16 ispartof: location:United States status: published

Purpose Survival after metastatic cancer has improved at the cost of increased presentation with metastatic spinal disease. For patients with pathologic spinal fractures and/or spinal cord compression, surgical intervention may relieve pain and improve quality of life. Surgery is generally considered to be inappropriate if anticipated survival is < 3 months. The aim of this international multicenter study was to analyze data from patients who died within 3 months or 2 years after surgery, to identify preoperative factors associated with poor or good survival, and to avoid inappropriate selection of patients for surgery in the future. Patients and Methods A total of 1,266 patients underwent surgery for impending pathologic fractures and/or neurologic deficits and were prospectively observed. Data collected included tumor characteristics, preoperative fitness (American Society of Anesthesiologists advisory [ASA]), neurologic status (Frankel scale), performance (Karnofsky performance score [KPS]), and quality of life (EuroQol five-dimensions questionnaire [EQ-5D]). Outcomes were survival at 3 months and 2 years postsurgery. Univariable and multivariable logistic regression analyses were used to find preoperative factors associated with short-term and long-term survival. Results In univariable analysis, age, emergency surgery, KPS, EQ-5D, ASA, Frankel, and Tokuhashi/Tomita scores were significantly associated with short survival. In multivariable analysis, KPS and age were significantly associated with short survival (odds ratio [OR], 1.36; 95% CI, 1.15 to 1.62; and OR, 1.14; 95% CI, 1.02 to 1.27, respectively). Associated with longer survival in univariable analysis were age, number of levels included in surgery, KPS, EQ-5D, Frankel, and Tokuhashi/Tomita scores. In multivariable analysis, the number of levels included in surgery (OR, 1.21; 95% CI, 1.06 to 1.38) and primary tumor type were significantly associated with longer survival. Conclusion Poor performance status at presentation is the strongest indicator of poor short-term survival, whereas low disease load and favorable tumor histology are associated with longer-term survival.

BACKGROUND: Indications for surgery for symptomatic spinal metastases have become better defined in recent years, and suitable outcome measures have been established against a changing backdrop of patient characteristics, tumor behavior, and oncologic treatments. Nonetheless, variations still exist in the local management of patients with spinal metastases. In this study, we aimed to review global trends and habits in the surgical treatment of symptomatic spinal metastases, and to examine how these have changed over the last 25 years. METHODS: In this cohort study of consecutive patients undergoing surgery for symptomatic spinal metastases, data were collected using a secure Internet database from 22 centers across 3 continents. All patients were invited to participate in the study, except those unable or unwilling to give consent. RESULTS: There was a higher incidence of colonic, liver, and lung carcinoma metastases in Asian countries, and more frequent presentation of breast, prostate, melanoma metastases in the West. Trends in surgical technique were broadly similar across the centers. Overall survival rates after surgery were 53% at 1 year, 31% at 2 years, and 10% at 5 years after surgery (standard error 0.013 for all). Survival improved over successive time periods, with longer survival in patients who underwent surgery in 2011-2016 compared with those who underwent surgery in earlier time periods. CONCLUSIONS: Surgical habits have been fairly consistent among countries worldwide and over time. However, patient survival has improved in later years, perhaps due to medical advances in the treatment of cancer, improved patient selection, and operating earlier in the course of disease. ispartof: WORLD NEUROSURGERY vol:114 pages:E809-E817 ispartof: location:United States status: published

There are current trends in public and academic debates which point toward a wish of some analysts and observers to “de-culturalize” debates on international migration. In German debates, it is the term “integration” which has an alleged culturalizing effect and which therefore should be avoided and discarded as a concept of practice and as a concept of theory. In contrast to these positions we argue that there is a fundamental nexus between communal relations (Vergemeinschaftung or integration) and sociation (Vergesellschaftung). It is only by relating communal relations and sociation that we can understand the logics of important institutions such as citizenship and welfare states. Analytical concepts such as Vergemeinschaftung and Vergesellschaftung are necessary because they help us to account for fundamental changes. We find that in recent decades the meaning of integration connected to nationhood in public debates has changed from an ethno-cultural understanding to a republican one which is simultaneously characterized by increasing demands upon individuals who are conceptualized as autonomous persons (individualization). Full text available at: https://doi.org/10.22215/rera.v11i1.252

We report a case of primary leptomeningeal gliomatosis limited to the spinal cord occurring in a 52 years-old patient, who presented with back pain and leg weakness. MRI-scan of the craniospinal axis revealed an enhancing cervicothoracic lesion confined to the leptomeninges. A diagnostic biopsy was taken followed by a six level cervicothoracic laminoplasty with the aim of debulking of the dorsal portion of the tumour and relieving cord compression. Two weeks following surgery, the patient developed bilateral arm weakness. Repeat imaging revealed extension of the lesion to the level of the lower medulla. This patient underwent spinal radiotherapy and concomitant chemotherapy with Temozolomide, but she died of pneumonia 8.5 months after the time of diagnosis. No post-mortem was performed. Primary leptomeningeal gliomatosis exclusively involving the spinal cord is an extremely rare condition bearing a dismal prognosis. It can be suspected on neuroimaging, but histopathological examination is required for the final diagnosis. No current treatment protocols are available. Decompressive surgery may have a role in relieving symptoms, but no substantial benefit has been proven in administering radio-chemotherapy.

BACKGROUND: With recent advances in oncologic treatments, there has been an increase in patient survival rates and concurrently an increase in the number of incidence of symptomatic spinal metastases. Because elderly patients are a substantial part of the oncology population, their types of treatment as well as the possible impact their treatment will have on healthcare resources need to be further examined.PURPOSE: We studied whether age has a significant influence on quality of life and survival in surgical interventions for spinal metastases.STUDY DESIGN: We used data from a multicenter prospective study by the Global Spine Tumor Study Group (GSTSG). This GSTSG study involved 1,266 patients who were admitted for surgical treatments of symptomatic spinal metastases at 22 spinal centers from different countries and followed up for 2 years after surgery.PATIENT SAMPLE: There were 1,266 patients recruited between March 2001 and October 2014.OUTCOME MEASURES: Patient demographics were collected along with outcome measures, including European Quality of Life-5 Dimensions (EQ-5D), neurologic functions, complications, and survival rates.METHODS: We realized a multicenter prospective study of 1,266 patients admitted for surgical treatment of symptomatic spinal metastases. They were divided and studied into three different age groups: 80 years.RESULTS: Despite a lack of statistical difference in American Society of Anesthesiologists (ASA) score, Frankel neurologic score, or Karnofsky functional score at presentation, patients >80 years were more likely to undergo emergency surgery and palliative procedures compared with younger patients. Postoperative complications were more common in the oldest age group (33.3% in the >80, 23.9% in the 70-80, and 17.9% for patients 80 years old.CONCLUSIONS: Surgeons should not be biased against operating elderly patients. Although survival rates and neurologic improvements in the elderly patients are lower than for younger patients, operating the elderly is compounded by the fact that they undergo more emergency and palliative procedures, despite good ASA scores and functional status. Age in itself should not be a determinant of whether to operate or not, and operations should not be avoided in the elderly when indicated.

The present generation of surgical tools is reliant on drills and cutting tools that cannot navigate through small corners present in complex bones such as the spinal column. This paper summarizes the development of a flexible robotic surgical system to be used in minimally invasive spinal surgery (MISS), targeting the removal of cancerous tissue. The cutting system consists of a flexible drill and a water-jet cutter which may be used interchangeably; each capable of bending around the spinal column for tissue removal. A robot platform has been designed and fabricated that acts as a mount for the cutting system, and produces the desired range of movements. A graphical user interface (GUI) has been created to analyze the working envelope of the platform and provide an interface for control by a surgeon. Experimental testing shows that prototypes of both the drill and water jet cutter are able to go around angles up to 120° and remove soft tissues off the bone. The developed systems could be used to remove cancerous tumors surrounding the spinal column in MISS procedures.

Instrumented spinal fixations are an important tool in the management of traumatic conditions and delayed complications are rare. We present a case of open reduction and fixation of traumatic C5/6 facet fracture dislocation with late complication in the form of intradural hardware migration. To our knowledge, this is the first report of an intradural rod migration distant to the initial surgery in a patient without posterior decompression. This highlights the need for long-term follow-up of patients with spinal instrumentation.

Die aktuelle Teilhabe-Diskussion in Politik, Medien und Wissenschaft hegt den Wunsch nach einer Art Entkulturalisierung der Migrationsdebatte. In Deutschland wird Vergemeinschaftung über das bedenkliche Zauberwort Integration ausgemacht, und dieses gilt es nun zu entfernen. In diesem Artikel argumentieren wir am Beispiel von Bürgerschaft, dass ein fundamentaler Zusammenhang zwischen Vergemeinschaftung (Integration) und Vergesellschaftung (Teilhabe) besteht. Diesen nicht zu verabschieden, sondern zu erkennen und neue Formen der Vergemeinschaftung in der Migrationsdebatte zu bestimmen, ist Ziel dieser Intervention. Die These lautet, dass die ethno-kulturelle Vergemeinschaftung in der Öffentlichkeit einem republikanischen Verständnis gewichen ist, welches das eigenverantwortliche Individuum hervorhebt. There are current trends in public and academic debates which point towards a wish of some analysts and observer to sort of de-culturalize debates on international migration. In German debates, it is the term "integration" which has an alleged culturalizing effect and which therefore should be avoided and discarded as a concept of practice and as a concept of theory. In contrast to these positions we argue that there is a fundamental nexus between communal relations (Vergemeinschaftung or integration) and sociation (Vergesellschaftung). It is only by relating communal relations and sociation that we can understand the logics of important institutions such as citizenship and welfare states. Analytical concepts such as Vergemeinschaftung and Vergesellschaftung are necessary because they help us to account for fundamental changes. We find that in recent decades the meaning of integration connected to nationhood in public debates has changed from an ethno-cultural understanding to a republican one which is simultaneously characterized by increasing demands upon individuals who are conceptualized as autonomous persons (individualization).