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Purpose Surgical indications for lumbar spinal stenosis are controversial, but most agree that leg dominant pain is a better predictor of success after decompression surgery. The objective of this study is to analyze the ability of the Nerve Root Sedimentation Sign (SedSign) on MRI to differentiate leg dominant symptoms from non-specific low back pain. Methods This was a retrospective review of 367 consecutive patients presenting with back and/or leg pain. Baseline clinical characteristics included Oswestry disability index (ODI), visual analog pain scores, EuroQol Group 5-Dimension Self-Report (EQ5D) and Saskatchewan Spine Pathway Classification (SSPc). Inter- and intra-rater reliability for SedSign was 73% and 91%, respectively (3 examiners). Results SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. On univariate analysis, a positive SedSign was correlated with age, male sex, several ODI components, EQ5D mobility, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and SSPc pattern 4 (intermittent leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI walking distance. Patients with a positive SedSign were more likely to be offered surgery after referral (OR 2.65). The sensitivity and specificity for detecting all types of leg dominant pain were 37.4 and 82.8, respectively (ppv 77.5%, npv 43.8%). Conclusions Patients with a positive SedSign were more likely to be offered surgery, in particular non-instrumented decompression. The SedSign has high specificity for leg dominant pain, but the sensitivity is poor. As such, its use in triaging appropriate surgical referrals is limited.

Systemic assessment is a pillar in the neurological, oncological, mechanical, and systemic (NOMS) decision-making framework for the treatment of patients with spinal metastatic disease. Despite this importance, emerging evidence relating systemic considerations to clinical outcomes following surgery for spinal metastatic disease has not been comprehensively summarised. We aimed to conduct a scoping literature review of this broad topic. We searched MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL databases from Jan 1, 2000, to July 31, 2021. 61 articles were included, accounting for a total of 22 335 patients. Preoperative systemic variables negatively associated with postoperative clinical outcomes included demographics (eg, older age [>60 years], Black race, male sex, low or elevated body-mass index, and smoking status), medical comorbidities (eg, cardiac, pulmonary, hepatic, renal, endocrine, vascular, and rheumatological), biochemical abnormalities (eg, hypoalbuminaemia, atypical blood cell counts, and elevated C-reactive protein concentration), low muscle mass, generalised motor weakness (American Spinal Cord Injury Association Impairment Scale grade and Frankel grade) and poor ambulation, reduced performance status, and systemic disease burden. This is the first comprehensive scoping review to broadly summarise emerging evidence relevant to the systemic assessment component of the widely used NOMS framework for spinal metastatic disease decision making. Medical, surgical, and radiation oncologists can consider these findings when prognosticating spinal metastatic disease-related surgical outcomes on the basis of patients’ systemic condition. These factors might inform a shared decision-making approach with patients and their families.

Background Evoked electromyographic (EMG) monitoring of pedicle screws has been shown to be an effective adjuvant to image guidance or direct visualization of pedicle screw placement. Electrical stimulation is delivered to the head of the screw at various intensities until a muscle potential is evoked. This practice is based on the fact that an intact pedicle effectively shields nerve roots from electrical stimulus. Several factors have been debated that may affect the interpretation of results; however, to the best of our knowledge, the electrical resistance of modern manufactured pedicle screws and stimulation devices has not been studied. Objective To determine if pedicle screw resistances affect triggered EMG. Methods Samples of the most commonly implanted pedicle screws in Canada were obtained, with diameters ranging from 4.5 to 7 mm. The resistance between the screw head and thread and core at the midpoint and tip of the screw was recorded using a Multimeter in accordance with IEEE standards. For screws with variable threads, the midpoint was considered the point at which the thread pitch changed. Results All screws had low impedances when tested at the point of the screw, but much higher when the cup is tested. The resistance of different manufactures' screws was significantly different, ranging from 0.514 to 2156 Ohms. Conclusion Despite differences in resistance, most screws had resistances in ranges that allow for triggered EMG pedicle integrity testing. Resistance from pedicle screws is an important consideration in EMG monitoring of the spine.

"After-hours" non-elective spine surgery is associated with increased morbidity. Decision-making may be enhanced by collaborative input from experienced local colleagues. At our center, we implemented routine use of a cross-platform messaging system (CPMS; WhatsApp Inc., Mountain View, California) to facilitate quality care discussions and collaborative surgical decision-making between spine surgeons prior to booking cases with the operating room. Our aim is to determine whether encrypted text messaging for shared decision-making between spine surgeons affects the number or type of after-hours spine procedures.We retrospectively compared the number, type and length of after-hours spine surgery over three time periods: (A) June 1, 2016-May 31, 2017 (baseline control); (B) June 1, 2017-May 31, 2018 (implementation of retrospective quality care spine rounds); and (C) June 1, 2018-May 31, 2019 (implementation of CPMS). A qualitative analysis of the CPMS transcripts was also performed to assess the rate of between-surgeon agreement for timing and type of procedure.The mean number of after-hours spine surgeries/month over the three study periods (A, B, C) was 10.83, 9.75 and 7.58 (p = 0.014); length of surgery was 41.82, 33.14 and 25.37 h/month (p = 0.001). Group agreement with the attending spine surgeon plan was 74.3% overall and was highest for the most urgent and least urgent types of indications.Prospective (i.e., prior to booking surgery) quality care discussion for joint decision-making among spine surgeons using CPMS may reduce both the number and complexity of after-hours procedures.

Acute traumatic spinal cord injury (SCI) can result in severe, lifelong neurological deficits. After SCI, Rho activation contributes to collapse of axonal growth cones, failure of axonal regeneration, and neuronal loss. This randomized, double-blind, placebo-controlled phase 2b/3 study evaluated the efficacy and safety of Rho inhibitor VX-210 (9 mg) in patients after acute traumatic cervical SCI. The study enrolled patients 14-75 years of age with acute traumatic cervical SCIs, C4-C7 (motor level) on each side, and American Spinal Injury Association Impairment Scale (AIS) Grade A or B who had spinal decompression/stabilization surgery commencing within 72 h after injury. Patients were randomized 1:1 with stratification by age (

Background: despite the efforts of multiple stakeholders to promote appropriate care throughout the healthcare system, studies show that two out of three lower back pain (LBP) patients expect to receive imaging. We used the Choosing Wisely Canada patient-oriented framework, prioritizing patient engagement, to develop an intervention that addresses lower back pain imaging overuse. Methods: to develop this intervention, we collaborated with a multidisciplinary advisory team, including two patient partners with lower back pain, researchers, clinicians, healthcare administrators, and the Choosing Wisely Canada lead for Saskatchewan. For this qualitative study, data were collected through two advisory team meetings, two individual interviews with lower back pain patient partners, and three focus groups with lower back pain patient participants. A lower back pain prescription pad was developed as an outcome of these consultations. Results: participants reported a lack of interactive and informative communication was a significant barrier to receiving appropriate care. The most cited content information for inclusion in this intervention was treatments known to work, including physical activity, useful equipment, and reliable sources of educational material. Participants also suggested it was important that benefits and risks of imaging were explained on the pad. Three key themes derived from the data were also used to guide development of the intervention: (a) the role of imaging in LBP diagnosis, (b) the impact of the patient-physician relationship on LBP diagnosis and treatment, and (c) the lack of patient awareness of Choosing Wisely Canada and their recommendations. Conclusions: the lower back pain patient-developed prescription pad may help patients and clinicians engage in informed conversations and shared decision making that could support reduce unnecessary lower back pain imaging.

As the incidence of traumatic spinal cord injury (tSCI) in the elderly rises, clinicians are increasingly faced with difficult discussions regarding aggressiveness of management, likelihood of recovery, and survival. Our objective was to outline risk factors associated with in-hospital mortality in elderly surgical and non-surgical patients following tSCI and to determine those unlikely to have a favorable outcome. Data from elderly patients (≥ 65 years of age) in the Canadian Rick Hansen SCI Registry from 2004 to 2017 were analyzed using descriptive analysis. Survival and mortality groups in each of the surgical and non-surgical group were compared to explore factors associated with in-hospital mortality and their impact, using logistical regression. Of 1340 elderly patients, 1018 had surgical data with 826 having had surgery. In the surgical group, the median time to death post-injury was 30 days with 75% dying within 50 days compared with 7 days and 20 days, respectively, in the non-surgical group. Significant predictors for in-hospital mortality following surgery are age, comorbidities, neurological injury severity (American Spinal Injury Association [ASIA] Impairment Scale [AIS]), and ventilation status. The odds of dying 50 days post-surgery are six times higher for patients ≥77 years of age versus those 65-76 years of age, five times higher for those with AIS A versus those with AIS B/C/D, and seven times higher for those who are ventilator dependent. An expected probability of dying within 50 days post-surgery was determined using these results. In-hospital mortality in the elderly after tSCI is high. The trend with age and time to death and the significant predictors of mortality identified in this study can be used to inform clinical decision making and discussions with patients and their families.

Summary Background Degenerative cervical myelopathy represents the most common form of non-traumatic spinal cord injury. This trial investigated whether riluzole enhances outcomes in patients undergoing decompression surgery for degenerative cervical myelopathy. Methods This multicentre, double-blind, placebo-controlled, randomised, phase 3 trial was done at 16 university-affiliated centres in Canada and the USA. Patients with moderate-to-severe degenerative cervical myelopathy aged 18–80 years, who had a modified Japanese Orthopaedic Association (mJOA) score of 8–14, were eligible. Patients were randomly assigned (1:1) to receive either oral riluzole (50 mg twice a day for 14 days before surgery and then for 28 days after surgery) or placebo. Randomisation was done using permuted blocks stratified by study site. Patients, physicians, and outcome assessors remained masked to treatment group allocation. The primary endpoint was change in mJOA score from baseline to 6 months in the intention-to-treat (ITT) population, defined as all individuals who underwent randomisation and surgical decompression. Adverse events were analysed in the modified intention-to-treat (mITT) population, defined as all patients who underwent randomisation, including those who did not ultimately undergo surgical decompression. This study is registered with ClinicalTrials.gov , NCT01257828 . Findings From Jan 31, 2012, to May 16, 2017, 408 patients were screened. Of those screened, 300 were eligible (mITT population); 290 patients underwent decompression surgery (ITT population) and received either riluzole (n=141) or placebo (n=149). There was no difference between the riluzole and placebo groups in the primary endpoint of change in mJOA score at 6-month follow-up: 2·45 points (95% CI 2·08 to 2·82 points) versus 2·83 points (2·47 to 3·19), difference −0·38 points (−0·90 to 0·13; p=0·14). The most common adverse events were neck or arm or shoulder pain, arm paraesthesia, dysphagia, and worsening of myelopathy. There were 43 serious adverse events in 33 (22%) of 147 patients in the riluzole group and 34 serious adverse events in 29 (19%) of 153 patients in the placebo group. The most frequent severe adverse events were osteoarthrosis of non-spinal joints, worsening of myelopathy, and wound complications. Interpretation In this trial, adjuvant treatment for 6 weeks perioperatively with riluzole did not improve functional recovery beyond decompressive surgery in patients with moderate-to-severe degenerative cervical myelopathy. Whether riluzole has other benefits in this patient population merits further study. Funding AOSpine North America.

People of Aboriginal (Indigenous) ancestry are more likely to experience traumatic spinal cord injury (TSCI) than other Canadians; however, outcome studies are limited. This study aims to compare Aboriginal and non-Aboriginal populations with acute TSCI with respect to preinjury baseline characteristics, injury severity, treatment, outcomes and length of stay.This was a retrospective analysis of participants with a TSCI who were enrolled in the prospective Rick Hansen Spinal Cord Injury Registry (RHSCIR), Saskatoon site (Royal University Hospital), between Feb. 13, 2010, and Dec. 17, 2016. Demographic, injury and management data were assessed to identify any differences between the populations.Of the 159 patients admitted to Royal University Hospital with an acute TSCI during the study period, 62 provided consent and were included in the study. Of these, 21 self-identified as Aboriginal (33.9%) and 41 as non-Aboriginal (66.1%) on treatment intake forms. Compared with non-Aboriginal participants, Aboriginal participants were younger, had fewer medical comorbidities, had a similar severity of neurologic injury and had similar clinical outcomes. However, the time to discharge to the community was significantly longer for Aboriginal participants (median 104.0 v. 34.0 d, p = 0.016). Although 35% of non-Aboriginal participants were discharged home from the acute care site, no Aboriginal participants were transferred home directly.This study suggests a need for better allocation of resources for transition to the community for Aboriginal people with a TSCI in Saskatchewan. We plan to assess outcomes from TSCI for Aboriginal people across Canada.Au Canada, les personnes d’origine autochtone sont plus susceptibles que les autres de vivre un traumatisme médullaire. Malgré cela, il y a peu d’études sur les conséquences de cet événement. Notre étude visait à comparer les cas de traumatisme médullaire aigu dans les populations autochtones et non autochtones sur plusieurs plans : les caractéristiques initiales des patients, la gravité du traumatisme, la nature du traitement, les issues cliniques et la durée de séjour.Nous avons fait une analyse rétrospective des dossiers de personnes ajoutées au Rick Hansen Spinal Cord Injury Registry (RHSCIR) [Registre des traumatismes médullaires Rick Hansen] entre le 13 février 2010 et le 17 décembre 2016 pour l’établissement de Saskatoon (l’Hôpital universitaire Royal). Nous avons comparé les renseignements de base des patients ainsi que les données sur le traumatisme et la prise en charge afin de cerner toute différence entre les populations.Sur les 159 traumatisés médullaires admis à l’Hôpital universitaire Royal pendant la période à l’étude, 62 ont consenti à l’utilisation de leurs données. Parmi eux, 21 s’étaient identifiés comme Autochtones (33,9 %) sur le formulaire d’hospitalisation, et 41 comme non-Autochtones (66,1 %). Par rapport aux non-Autochtones, les Autochtones étaient plus jeunes, avaient moins de comorbidités, présentaient une atteinte neurologique de gravité comparable et connaissaient à peu près le même tableau clinique. Toutefois, le délai avant leur retour en communauté était significativement plus long (médiane : 104,0 jours contre 34,0 jours; p = 0,016). Aucun participant autochtone n’a été renvoyé directement à la maison, alors que 35 % des participants non autochtones sont retournés chez eux en quittant les soins de première ligne.Cette étude montre qu’il faut améliorer la répartition des ressources de retour dans la communauté pour les traumatisés médullaires autochtones de la Saskatchewan. Enfin, nous comptons examiner les répercussions cliniques du traumatisme médullaire chez les Autochtones de partout au Canada.

Systematic review.The objective of this systematic review was to answer 2 key questions: (1) What is the clinical presentation and probability of symptomatic improvement following treatment for patients with renal cell carcinoma (RCC) of the spine? (2) What is the overall survival of patients diagnosed with spinal metastases from RCC?A literature review was performed to identify articles that reported on survival, clinical outcomes, and/or prognostic factors in the RCC population with spinal metastases from 1986 to 2016.Forty-eight articles (807 patients) were included. The Fuhrman Nuclear Grade has been significantly associated with survival in previous studies but was underpowered in the current study. The Memorial Sloan-Kettering Cancer Center Score (MSKCC/Motzer) was also underpowered in the current study. From the time of spinal metastasis, the mean and median survival for patients with previously diagnosed primary RCC was 8.75 and 11.7 months, respectively, whereas synchronously diagnosed patients (primary RCC and spinal metastasis) had a mean and median survival of 6.75 and 11 months, respectively. Patients with a "low" (0-8), "intermediate" (9-11), or "high" (12-15) revised Tokuhashi score at initial presentation had a median survival of 5.4, 11.7, and 32.9 months, respectively.Patients with either a synchronous or latent diagnosis of RCC survived greater than 6 months from the time of presentation. Initial Furhman grade, Tokuhashi score, and MSKCC/Motzer can be useful tools in informing patient-specific prognosis for those with metastatic RCC of the spine.

Current research indicates that more than half of patients with traumatic spinal cord injury (tSCI) experience delays in transfer and receive surgery >24 h post-injury. The objectives of this study were to determine the geographic distribution of tSCI in Canada relative to specialized treatment facilities, to assess clinical and logistical factors at play for indirect admissions to those facilities, and to explore differences in current time to admission and simulated scenarios in an attempt to assess the potential impact of changes to triage protocols. This study included data from 876 patients with tSCI enrolled in the prospectively collected acute Rick Hansen Spinal Cord Injury Registry (RHSCIR) between January 1, 2010 and December 31, 2013 for whom there were data on the location of their injury. Patients transported directly to a RHSCIR acute facility were more likely to reach the facility within 1 h of injury, whereas those transported indirectly were more likely to arrive 7 h later. Considering the injuries occurring within 40 km of a RHSCIR acute facility (n = 323), 249 patients (77%) were directly and 74 (23%) were indirectly admitted. In the multivariate regression analysis, only older age and longer road distance remained significantly associated with being indirectly admitted to a RHSCIR facility. Compared with the current status, the median time to admission decreased by 20% (3.5 h) in the 100% direct admission scenario, and increased by 102% (8.9 h) in the 100% indirect admission scenario.

Study Design: Reliability analysis. Objectives: The Spinal Instability Neoplastic Score (SINS) was developed for assessing patients with spinal neoplasia. It identifies patients who may benefit from surgical consultation or intervention. It also acts as a prognostic tool for surgical decision making. Reliability of SINS has been established for spine surgeons, radiologists, and radiation oncologists, but not yet among spine surgery trainees. The purpose of our study is to determine the reliability of SINS among spine residents and fellows, and its role as an educational tool. Methods: Twenty-three residents and 2 spine fellows independently scored 30 de-identified spine tumor cases on 2 occasions, at least 6 weeks apart. Intraclass correlation coefficient (ICC) measured interobserver and intraobserver agreement for total SINS scores. Fleiss’s kappa and Cohen’s kappa analysis evaluated interobserver and intraobserver agreement of 6 component subscores (location, pain, bone lesion quality, spinal alignment, vertebral body collapse, and posterolateral involvement of spinal elements). Results: Total SINS scores showed near perfect interobserver (0.990) and intraobserver (0.907) agreement. Fleiss’s kappa statistics revealed near perfect agreement for location; substantial for pain; moderate for alignment, vertebral body collapse, and posterolateral involvement; and fair for bone quality (0.948, 0.739, 0.427, 0.550, 0.435, and 0.382). Cohen’s kappa statistics revealed near perfect agreement for location and pain, substantial for alignment and vertebral body collapse, and moderate for bone quality and posterolateral involvement (0.954, 0.814, 0.610, 0.671, 0.576, and 0.561, respectively). Conclusions: The SINS is a reliable and valuable educational tool for spine fellows and residents learning to judge spinal instability.

Study Design: Systematic review. Objective: Surgical decompression and reconstruction of symptomatic spinal metastases has improved the quality of life in cancer patients. However, most data has been collected on cohorts of patients with mixed tumor histopathology. We systematically reviewed the literature for prognostic factors specific to the surgical treatment of prostate metastases to the spine. Methods: A systemic review of the literature was conducted to answer the following questions: Question 1. Describe the survival and functional outcomes of surgery or vertebral augmentation for prostate metastases to the spine. Question 2. Determine whether overall tumor burden, Gleason score, preoperative functional markers, and hormonal naivety favor operative intervention. Question 3. Establish whether clinical outcomes vary with the evolution of operative techniques. Results: A total of 16 studies met the preset inclusion criteria. All included studies were retrospective series with a level of evidence of IV. Included studies consistently showed a large effect of hormone-naivety on overall survival. Additionally, studies consistently demonstrated an improvement in motor function and the ability to maintain/regain ambulation following surgery resulting in moderate strength of recommendation. All other parameters were of insufficient or low strength. Conclusions: There is a dearth of literature regarding the surgical treatment of prostate metastases to the spine, which represents an opportunity for future research. Based on existing evidence, it appears that the surgical treatment of prostate metastases to the spine has consistently favorable results. While no consistent preoperative indicators favor nonoperative treatment, hormone-naivety and high Karnofsky performance scores have positive effects on survival and clinical outcomes.

Retrospective analysis of a prospective registry and surgeon survey. To identify surgeon opinion on ideal practice regarding the timing of decompression/stabilization for spinal cord injury and actual practice. Discrepancies in surgical timing and barriers to ideal timing of surgery were explored. Canada. Patients from the Rick Hansen Spinal Cord Registry (RHSCIR, 2004-2014) were reviewed to determine actual timing of surgical management. Following data collection, a survey was distributed to Canadian surgeons, asking for perceived to be the optimal and actual timings of surgery. Discrepancies between actual data and surgeon survey responses were then compared using χ2 tests and logistic regression. The majority of injury patterns identified in the registry were treated operatively. ASIA Impairment Scale (AIS) C/D injuries were treated surgically less frequently in the RHSCIR data and surgeon survey (odds ratio (OR)= 0.39 and 0.26). Significant disparities between what surgeons identified as ideal, actual current practice and RHSCIR data were demonstrated. A great majority of surgeons (93.0%) believed surgery under 24 h was ideal for cervical AIS A/B injuries and 91.0% for thoracic AIS A/B/C/D injuries. Definitive surgical management within 24 h was actually accomplished in 39.0% of cervical and 45.0% of thoracic cases. Ideal surgical timing for traumatic spinal cord injury (tSCI) within 24 h of injury was identified, but not accomplished. Discrepancies between the opinions on the optimal and actual timing of surgery in tSCI patients suggest the need for strategies for knowledge translation and reduction of administrative barriers to early surgery.

STUDY DESIGN.: Systematic literature review OBJECTIVE.: To address the following questions in a systematic literature review: 1. How is spinal neoplastic instability defined or classified in the literature before and after the introduction of the Spinal Instability Neoplastic Score (SINS)? 2. How has SINS affected daily clinical practice? 3. Can SINS be used as a prognostic tool? SUMMARY OF BACKGROUND DATA.: Spinal neoplastic-related instability was defined in 2010 and simultaneously SINS was introduced as a novel tool with criteria agreed upon by expert consensus to assess the degree of spinal stability. METHODS.: Pubmed, Embase, and clinical trial databases were searched with the key words “spinal neoplasm”, “spinal instability”, “spinal instability neoplastic score”, and synonyms. Studies describing spinal neoplastic-related instability were eligible for inclusion. Primary outcomes included studies describing and/or defining neoplastic-related instability, SINS, and studies using SINS as a prognostic factor. RESULTS.: The search identified 1414 articles, of which 51 met the inclusion criteria. No precise definition or validated assessment tool was used specific to spinal neoplastic-related instability prior to the introduction of SINS. Since the publication of SINS in 2010, the vast majority of the literature regarding spinal instability has used SINS to assess or describe instability. Twelve studies specifically investigated the prognostic value of SINS in patients who underwent radiotherapy or surgery. CONCLUSION.: No consensus could be determined regarding the definition, assessment, or reporting of neoplastic-related instability before introduction of SINS. Defining spinal neoplastic-related instability and the introduction of SINS have led to improved uniform reporting within the spinal neoplastic literature. Currently, the prognostic value of SINS is controversial.Level of Evidence: N/A

Background We report the case of a 40-year-old patient with a large, World Health Organization grade III oligodendroglioma in the left parietal lobe. Case Description Presurgical planning included functional magnetic resonance imaging (fMRI) localization of language, motor, and somatosensory processing. fMRI results for motor and somatosensory tasks revealed activation in perilesional regions near the surgical resection as well as deactivation in the tumor for the sensory task, suggesting decreased autoregulation in the region owing to the glioma. fMRI results showed left-hemisphere dominance for language and activation in perilesional regions for all 3 speech tasks (i.e., word reading, picture naming, and semantic questions). In addition, the results demonstrated that the high vascularity of the lesion altered the blood oxygen level–dependent function, resulting in false-positive and false-negative activation in the semantic questions and leg/foot rubbing task, respectively. Intraoperative direct cortical stimulation was conducted in the regions corresponding to fMRI activation while the patient performed motor, sensory, and language tasks and showed no loss of function. Follow-up fMRI revealed that there was no longer activation in the tumor or in perilesional regions, presumably owing to the resection of the vascularized tumor. Conclusions This case highlights the importance of presurgical fMRI to inform the neurosurgical approach and emphasizes the need for careful interpretation of fMRI data, especially in cases of malignant glioma, which can decrease autoregulation in surrounding regions, affecting fMRI blood oxygen level–dependent signal.

The subaxial cervical spine has unique anatomical features that affect the clinical manifestations and treatment of metastatic tumors. In this chapter, we review the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of this condition. The importance of understanding the histopathology prior to making treatment decisions is emphasized. A treatment decision-making framework called LMNOP is reviewed. The rationale and methods of anterior, posterior, and combined surgical approaches are outlined. Lastly, we touch on perioperative complication avoidance.

In prior analyses of the effectiveness of methylprednisolone for the treatment of patients with acute traumatic spinal cord injuries (TSCIs), the prognostic importance of patients' neurological levels of injury and their baseline severity of impairment has not been considered. Our objective was to determine whether methylprednisolone improved motor recovery among participants in the Rick Hansen Spinal Cord Injury Registry (RHSCIR). We identified RHSCIR participants who received methylprednisolone according to the Second National Spinal Cord Injury Study (NASCIS-II) protocol and used propensity score matching to account for age, sex, time of neurological exam, varying neurological level of injury, and baseline severity of neurological impairment. We compared changes in total, upper extremity, and lower extremity motor scores using the Wilcoxon signed-rank test and performed sensitivity analyses using negative binomial regression. Forty-six patients received methylprednisolone and 1555 received no steroid treatment. There were no significant differences between matched participants for each of total (13.7 vs. 14.1, respectively; p=0.43), upper extremity (7.3 vs. 6.4; p=0.38), and lower extremity (6.5 vs. 7.7; p=0.40) motor recovery. This result was confirmed using a multivariate model and, as predicted, only cervical (C1–T1) rather than thoracolumbar (T2–L3) injury levels (p

Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (≥ 70 yr) on treatment decisions and outcomes.We identified patients with traumatic spinal cord injury for whom consent and detailed data were available from among patients recruited (2004-2013) at any of the 31 acute care and rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry. Patients were assessed by age group (70 v. ≥ 70 yr). The primary outcome was the rate of acute surgical treatment. We used bivariate and multivariate regression models to assess patient and injury-related factors associated with receiving surgical treatment and with the timing of surgery after arrival to a participating centre.Of the 1440 patients included in our study cohort, 167 (11.6%) were 70 years or older at the time of injury. Older patients were more likely than younger patients to be injured by falling (83.1% v. 37.4%; p0.001), to have a cervical injury (78.0% v. 61.6%; p = 0.001), to have less severe injuries on admission (American Spinal Injury Association Impairment Scale grade C or D: 70.5% v. 46.9%; p0.001), to have a longer stay in an acute care hospital (median 35 v. 28 d; p0.005) and to have a higher in-hospital mortality (4.2% v. 0.6%; p0.001). Multivariate analysis did not show that age of 70 years or more at injury was associated with a decreased likelihood of surgical treatment (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.22-1.07). An unplanned sensitivity analysis with different age thresholds showed that a threshold of 65 years was associated with a decreased chance of surgical treatment (OR 0.39, 95% CI 0.19-0.80). Older patients who underwent surgical treatment had a significantly longer wait time from admission to surgery than younger patients (37 v. 19 h; p0.001).We found chronological age to be a factor influencing treatment decisions but not at the 70-year age threshold that we had hypothesized. Older patients waited longer for surgery and had a substantially higher in-hospital mortality despite having less severe injuries than younger patients. Further research into the link between treatment delays and outcomes among older patients could inform surgical guideline development.

Background: Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections. Methods: A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process. Results: Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration. Conclusion: Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not.This is a prospective observational study.The sample included participants with cervical SCI included in a prospective Canadian registry.The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality.Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified.Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement.We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.

Study design Retrospective medical record review. Objective To (1) determine if outpatient referrals for low back pain (LBP) and leg pain triaged through a multidisciplinary spine care pathway (group A) were more likely to be candidates for surgery than conventional physician referrals (group B); (2) compare relevant clinical differences in the 2 groups (e.g., diagnosis, pain scores, level of disability); and (3) compare wait times for magnetic resonance imaging and surgical assessment. Summary of background data The Saskatchewan Spine Pathway was introduced on the basis of evidence that a co-ordinated, multidisciplinary, and stratified approach to the assessment and management of LBP may improve quality. During early implementation, some physicians began to refer patients to Saskatchewan Spine Pathway clinics, whereas others continued to refer patients directly to the surgeon through the conventional process. Methods We retrospectively analyzed consecutive new outpatient referrals for LBP and leg pain, June 1, 2011 through May 30, 2012 for 2 surgeons. Results We identified 215 referrals, including 66 (30.7%) in group A and 149 (69.3%) in group B. There was no difference in overall health (mean EuroQol Group 5-Dimension Self-Report Questionnaire visual analogue scale) or lower back-related disability score (Oswestry Disability Index). Group A patients were significantly more likely to be candidates for surgery (59.1% vs. 37.6% for group B; P = 0.0034, χ test), had significantly poorer scores for EuroQol Group 5-Dimension Self-Report Questionnaire mobility, a higher proportion of leg dominant pain, and a lower proportion of back dominant pain. Group A patients also had significantly shorter wait times for magnetic resonance imaging and surgical assessment. Conclusion A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs. Level of evidence 3.

Introduction:With over 44,000 individual farms, farm dwellers account for 11% of the population of Saskatchewan. There is limited data on brain and spine injuries acquired on farms. The objective of this study was to evaluate the epidemiology of head and spine injuries on Saskatchewan farms to assist the development of injury prevention initiatives.Methods:Using the Canadian Centre for Agricultural Health and Safety's Saskatchewan Farm Injury Surveillance Database, farm-related head and spine injuries hospitalized > 24 hours were examined (1990-2007). We collected information regarding the type and mechanism of injury as well as the geographic location of both the injury and treatment.Results:The database captured 390 brain injuries and 228 spine injuries, including 16 spinal cord injuries. The majority of patients were male (73.3% of head injuries and 84.2% of spine injuries). The highest risk age groups were 50-59 years, with 24.1% of the spine injuries, and 40-49 years, with 19.2% of the head injuries. The most common causes of injury were falls and/or machinery-related. The average annual incidence of farm-related spine and head injury were 10.8 and 17.6 per 100,000 farm population, respectively. All patients included in this study were hospitalized for over 24 hours, with 44.7% of spine injuries spending over one week in hospital, and 20% of head injuries spending over three days in hospital.Conclusions:Injury prevention initiatives should be targeted towards males aged 40-59 years residing in the southern areas of the province, with increased awareness towards the dangers of falls and operating tractors.

Study Design Review. Objective To describe a decision framework that incorporates key factors to be considered for optimal treatment of spinal metastasis and highlight how this system incorporates the Spinal Instability Neoplastic Score (SINS). Methods We describe how treatment options for spinal metastasis have broadened in recent years with advancements in stereotactic radiosurgery, vertebral augmentation, and other minimally invasive techniques. We discuss classification-based approaches to the treatment of spinal metastasis versus principles-based approaches and argue that the latter may be more appropriate for optimal patient informed consent. Case examples are provided. Results Scoring systems at best produce an estimate of life expectancy but fall short in incorporating all of the relevant factors that determine which treatment(s) may be indicated. We advocate a principle-based decision framework called LMNOP that considers: (L) location of disease with respect to the anterior and/or posterior columns of the spine and number of spinal levels involved (contiguous or non-contiguous); (M) mechanical instability as graded by SINS; (N) neurology (symptomatic epidural spinal cord compression); (O) oncology (histopathologic diagnosis), particularly with respect to radiosensitivity; and (P) patient fitness, patient wishes, prognosis (which is mostly dependent on tumor type), and response to prior therapy. Conclusions LMNOP is the first systematic approach to spinal metastasis that incorporates SINS. It is easy to remember, it addresses clinical factors not directly addressed by other systems, and it is adaptable to changes in technology.

Object The Saskatchewan Spine Pathway (SSP) was introduced to improve quality and access to care for patients with low-back and leg pain in the province. There is very limited data regarding the efficacy of nonsurgeon triage of surgical referrals. The objective of this early implementation study was to determine how the SSP affects utilization of MRI and spine surgery. Methods The authors performed a retrospective analysis of 87 consecutive patients with low-back and leg pain who were initially referred to a spine surgeon but were instead redirected to the SSP clinic between May 1, 2011, and November 30, 2011. The SSP clinic triaged patients into 2 groups: Group A (nonsurgical management) and Group B (referred back to the spine surgeon). The SSP classification was modified from the classification proposed by Hall et al. Pain and disability were scored by pain-related visual analog scale, modified Oswestry Disability Index, and EuroQol-5D. Results Sixty-two patients (Group A, 71.3%) were discharged after patient education, self-care advice, and/or referral for additional mechanical therapies. Although only 25 patients (Group B, 28.7%) were directed back to the surgeon, the final percentage (12.6%) offered surgery was similar to that of historic controls (15%). Total MRI utilization was significantly lower in Group A (25.8%) than Group B (92.0%) (p < 0.0001). Nonsurgeon triage captured all red flags detected by the surgeon. Patients in Group B were much more likely to have a leg-dominant pain (p = 0.0088) and had significantly higher Oswestry Disability Index (p = 0.0121) and EuroQol-5D mobility (p = 0.0484) scores. Conclusions The SSP significantly reduced MRI utilization and referrals seen by the surgeon for nonoperative care. Although this early implementation study suggests potential for cost savings, a more rigorous analysis of outcomes, costs, and patient satisfaction is required.

Privacy legislation addresses concerns regarding the privacy of personal information; however, its interpretation by research ethics boards has resulted in significant challenges to the collection, management, use and disclosure of personal health information for multi-centre research studies. This paper describes the strategy used to develop the national Rick Hansen Spinal Cord Injury Registry (RHSCIR) in accordance with privacy statutes and benchmarked against best practices. An analysis of the regional and national privacy legislation was conducted to determine the requirements for each of the 31 local RHSCIR sites and the national RHSCIR office. A national privacy and security framework was created for RHSCIR that includes a governance structure, standard operating procedures, training processes, physical and technical security and privacy impact assessments. The framework meets a high-water mark in ensuring privacy and security of personal health information nationally and may assist in the development of other national or international research initiatives.

Study design Systematic review. Objective To critically review and summarize evidence on the treatment of cervical adjacent segment pathology (ASP). Summary of background data Clinical ASP (CASP) refers to clinically significant symptoms and signs (radiculopathy, myelopathy, mechanical pain) that correlate with imaging evidence of degeneration at motion segments adjacent to a previous intervention. Despite growing awareness of the long-term risks of ASP, fusion is the most commonly performed type of cervical spine surgery. There are little data regarding the optimal treatment for cervical CASP. Methods A systematic search of PubMed, the Cochrane Library, and Google Scholar for literature published through March 2, 2012, was conducted to answer 2 key questions: (1) What is the comparative effectiveness and safety of operative versus nonoperative treatments for cervical CASP?; and (2) Describe the outcomes of surgical treatment of cervical CASP. Results A total of 5 studies were selected for inclusion. No comparative studies were found to answer question 1. We found 1 comparative study and 4 case series of more than 10 patients that addressed question 2: 2 studies described fusion (1 comparing discectomy with corpectomy), 2 evaluated laminoplasty, and 1 reported on use of artificial discs. No studies on use of laminectomy, foraminotomy, or posterior decompression and fusion were found. Two poor-quality (level of evidence III) retrospective cohort studies compared anterior cervical discectomy and fusion with corpectomy for the treatment of CASP, but 1 study was too small to draw meaningful comparisons and was considered a case series. The other reported a 37.5% risk difference favoring corpectomy; however, most patients in both treatment groups had excellent or good clinical results, and the study had significant methodological limitations that limit comparison of anterior cervical discectomy and fusion with corpectomy (nonrandomized allocation to treatment groups, limited follow-up, small numbers of patients). No studies describing subsequent development or advancement of ASP after reconstructive surgery were found. Conclusion Surgical options to treat cervical CASP include fusion, laminoplasty, and disc arthroplasty. There are no comparative data to guide operative versus nonoperative management. Favorable results are reported for each of these operative strategies, but small patient numbers and largely retrospective methodology limit definitive conclusions. There were conflicting data regarding the risk of single- versus multilevel fusion with respect to arthrodesis rates, and very low evidence that fusions at spinal levels caudal to ASP have a higher pseudoarthrosis risk compared with rostral levels. Consensus statement 1. Arthroplasty, laminoplasty, and fusion for treatment of cervical CASP were described in the studies found. These seem to be effective for treatment of cervical CASP. No studies on foraminotomy, laminectomy, and posterior decompression and fusion were found. Level of evidence Insufficient. Strength of Statement: Strong. Recommendation no.1: Despite the importance of this topic, a dearth of literature was found. We recommend further studies on this topic. Level of evidence Insufficient. Strength of Statement: Strong.

Background Percutaneous remodeling of the ligamentum flavum and lamina (PRLL), commercially known as minimally invasive lumbar decompression (mild technique), relies on fluoroscopy and epidural contrast to direct surgical instruments via a 6-mm cannula. Objective To evaluate the safety and efficacy of PRLL and present, to our knowledge, the first reported imaging findings after PRLL. Methods We performed a prospective study of PRLL for neurogenic claudication. Primary outcomes were Oswestry Disability Index, Short-Form 12 version 2.0 health survey, and visual analog scale for pain at 26 weeks. Analgesic use was also assessed. Postoperative magnetic resonance imaging was performed at 12 weeks. Long-term failure, defined as the poststudy need for secondary surgery, was assessed up to 18 months. Results Ten subjects with an average age of 64 years (range, 41-81 years) were treated between September 2008 and January 2009. There were no major adverse events. Mean postoperative visual analog scale score remained significantly reduced throughout 26 weeks (P =.015, analysis of variance). Mean postoperative Oswestry Disability Index was also improved by 1 week and remained significant throughout 26 weeks (P = .024; analysis of variance). However, there was a trend toward increased reliance on narcotic type medications postoperatively. Imaging studies did not show significant decompression of the spinal canal in any patient. In the poststudy period, recurrent claudication requiring laminectomy developed in 6 patients (60%). Conclusion Throughout 26 weeks, pain and disability scores were decreased; however, PRLL did not improve the degree of stenosis on imaging studies. Although PRLL appears to be safe in this small cohort of patients, poststudy outcomes indicate that the failure rate is unacceptably high.

Study design Systematic review. Objective To determine the correlation of patient-reported pain with physical function and health-related quality of life (HRQoL) after spine surgery and to determine the responsiveness of pain, physical function, and HRQoL after spine surgery. Summary of background data Several validated outcome instruments are available to assess the success of treatment for chronic low back pain. These patient-centered tools include measurements for pain based on numeric scales, validated condition-specific functional outcomes measures, and HRQoL outcomes measures. It is unclear whether these three types of patient-reported outcomes are measuring different constructs and whether all three should be measured after spine surgery. In addition, it is unclear which of these outcomes measures is most sensitive to change after spine surgery for low back pain. Methods A systematic search was conducted in MEDLINE, EMBASE, and the Cochrane Collaboration Library for literature published through December 2010. The correlation between pain (visual analog scale, VAS), physical function (Oswestry Disability Index, ODI), and HRQoL (36-Item Short Form Health Survey [SF-36] and European Quality of Life [EQ-5D]) change scores was performed using the Spearman rank correlation coefficients. To compare the responsiveness of pain, function, and HRQoL scores after spine surgery, we calculated effect sizes by dividing change scores by the SD of the baseline scores. This standardized method allowed us to compare the responsiveness of each outcome measure directly and reported an effect size of 0.2 to 0.3 as a "small" effect, around 0.5 a "medium" effect and 0.8 to infinity, a "large" effect. To determine whether the differences in effect sizes measuring responsiveness were significantly different, we conducted a Wilcoxon signed-rank test between each of the three measurements of pain, function, and HRQoL scores when there was enough data to perform the test. Results None of the correlations exceeded 0.70 using the Spearman rank correlation coefficients, suggesting that these outcomes are measuring different constructs. The strongest correlations were between the VAS back pain change scores and the SF-36 physical composite score change scores (ρ = 0.67) and VAS back pain change scores and ODI change scores (ρ = 0.69). The pooled mean effect sizes for the five studies that reported a pain measure and the ODI were 1.4 ± 0.57 and 1.1 ± 0.39, respectively. Both are considered "large" effect sizes. The pooled mean effect sizes for the three studies reporting the SF-36 physical and mental composite scores were 0.66 ± 0.39 and 0.54 ± 0.36, respectively. Both are considered "medium" effect sizes. The pooled mean effect sizes for the single studies reporting the EQ-5D and SF-36 total score were 0.78 ± 0.12 and 0.34 ± 0.21. These were "medium" and "small," respectively. Conclusion We observed little correlation between the change in pain and the change in HRQoL outcomes measures. The strongest correlation was between VAS pain and ODI but was still not considered strong (0.69). These findings suggest that these three outcomes (pain, function, and HRQoL) are measuring different constructs. With respect to responsiveness, VAS pain and ODI were the only outcomes measures that demonstrated a large effect after lumbar spine surgery. None of the HRQoL tools were as sensitive to the treatment. The EQ-5D, SF physical composite, and SF mental composite outcomes demonstrated a medium effect, while the SF-36 total score demonstrated a small effect. The responsive measure shows that the more specific the outcomes tool, the more sensitive the response. Clinical recommendations Recommendation 1: When surgically treating CLBP, we recommend administering both a VAS for pain and a condition-specific physical measure such as the ODI before and after surgical intervention as these outcomes are the most treatment specific and responsive to change. Strength of recommendation: Strong.Recommendation 2: When evaluating the surgical outcomes for CLBP in the clinical-research setting, we recommend selecting a shorter version for measuring general HRQoL (e.g., SF-12, EQ-5D) to minimize clinician and patient burden. Strength of recommendation: Strong.

"Chronic" low back pain (LBP), defined as present for 3 or more months, has become a major socioeconomic problem insufficiently addressed by five major entities largely working in isolation from one another - procedural based specialties, strength based rehabilitation, cognitive behavioral therapy, pain management and manipulative care. As direct and indirect costs continue to rise, many authors have systematically evaluated the body of evidence in an effort to demonstrate the effectiveness (or lack thereof) for various diagnostic and therapeutic interventions. The objective of this Spine Focus issue is not to replicate previous work in this area. Rather, our expert panel has chosen a set of potentially controversial topics for more in-depth study and discussion. A recurring theme is that chronic LBP is a heterogeneous condition, and this affects the way it is diagnosed, classified, treated, and studied. The efficacy of some treatments may be appreciated only through a better understanding of heterogeneity of treatment effects (i.e., identification of clinically relevant subgroups with differing responses to the same treatment). Current clinical guidelines and payer policies for LBP are systematically compared for consistency and quality. Novel approaches for data gathering, such as national spine registries, may offer a preferable approach to gain meaningful data and direct us towards a "results-based medicine." This approach would require more high-quality studies, more consistent recording for various phenotypes and exploration of studies on genetic epidemiologic undertones to guide us in the emerging era of "results based medicine."

Study design Systematic review of spine care pathways and case study of the Saskatchewan Spine Pathway (SSP). Objective (1) What are the differences between clinical pathways and clinical guidelines? (2) Are there examples of clinical pathways in the management of lower back pain (LBP)? Is there evidence that they are successful? (3) What is the SSP, and what are its key features? Summary of background data Adherence to evidence-based guidelines for LBP produces superior outcomes and may improve efficiency by reducing unnecessary imaging, ineffective treatments, and inappropriate surgical referrals. A clinical pathway is an attempt to bridge the "translation gap" between guidelines and clinical practice. Methods A qualitative review was performed for question 1. For question 2, a systematic review of the English language literature was performed for articles published through March 31, 2011. A case study is provided for question 3. Results (1) Evidence for clinical pathways is mainly derived from guidelines, but pathways are distinguished by several features including the coordination of multidisciplinary care, facilitation of communication among care providers, resources for ongoing quality improvements, and a central focus on the patient experience. (2) Five articles describing four clinical pathways met the a priori criteria, but none tested comparative effectiveness. (3) The SSP is unique in that it is (a) inclusive for all types of LBP, (b) based on a classification system, (c) patient-focused mostly at primary care rather than in specialized clinics, (d) implemented in the health care system of a geopolitically defined region, and (e) includes all of the defining features of modern care pathways. Conclusion Several clinical pathways for LBP have been described, but effectiveness has not been tested. Clinical recommendations Clinical pathways for LBP need to be further developed and investigated as a means to facilitate guidelines-concordant practice and improve patient outcomes. Level of evidence Insufficient. Recommendation Weak.

Study design Systematic review. Objective The objectives of this systematic review were to determine whether fusion is superior to conservative management in certain psychological subpopulations and to determine the most common psychological screening tests and their ability to predict outcome after treatment in patients with chronic lower back pain. Summary of background data Many studies have documented the effects of various psychological disorders on outcomes in the treatment of lower back pain. The question of whether patients with certain psychological disorders would benefit more from conservative treatment than fusion is not clear. Furthermore, the most appropriate screening tools for assessing psychological factors in the presence of treatment decision making should be recommended. Methods Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of psychological factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain. In the analysis of psychological screening tests, we searched for the most commonly reported questionnaires and those that had been shown to predict lower back pain treatment outcomes. Results Few studies comparing fusion to conservative management reported differences in outcome by the presence or absence of a psychological disorder. Among those that did, we observed the effect of fusion compared with conservative management was more favorable in patients without a personality disorder, neuroticism, or depression. The most commonly reported, validated psychological screening tests for lower back pain are the Beck Depression Inventory, the Fear Avoidance Belief Questionnaire, the Spielberger Trait Anxiety Inventory, the Zung Depression Scale, and the Distress Risk Assessment Method. Conclusion Psychological disorders affect chronic lower back pain treatment outcomes. Patients with a personality disorder appear to respond more favorably to conservative management and those without a personality disorder more favorably to fusion. Patients with higher depression and neuroticism scores may also respond more favorably to conservative management. Clinical recommendations Recommendation 1: Chronic LBP patients with depression, neuroticism, and certain personality disorders should preferentially be treated nonoperatively. Strength of recommendation: Weak. Recommendation 2: Consider the use of a validated psychological screening questionnaire such as the BDI, FABQ, DRAM, ZDI or STAI, when treating patients with CLBP. Strength of recommendation: Weak.

Purpose Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS). Methods Clinical and radiographic data from 30 patients with spinal tumors were classified as stable, potentially unstable, and unstable by members of the Spine Oncology Study Group. The median category for each patient case (consensus opinion) was used as the gold standard for predictive validity testing. On two occasions at least 6 weeks apart, each rater also scored each patient using SINS. Each total score was converted into a three-category data field, with 0 to 6 as stable, 7 to 12 as potentially unstable, and 13 to 18 as unstable. Results The κ statistics for interobserver reliability were 0.790, 0.841, 0.244, 0.456, 0.462, and 0.492 for the fields of location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement, respectively. The κ statistics for intraobserver reliability were 0.806, 0.859, 0.528, 0.614, 0.590, and 0.662 for the same respective fields. Intraclass correlation coefficients for inter- and intraobserver reliability of total SINS score were 0.846 (95% CI, 0.773 to 0.911) and 0.886 (95% CI, 0.868 to 0.902), respectively. The κ statistic for predictive validity was 0.712 (95% CI, 0.676 to 0.766). Conclusion SINS demonstrated near-perfect inter- and intraobserver reliability in determining three clinically relevant categories of stability. The sensitivity and specificity of SINS for potentially unstable or unstable lesions were 95.7% and 79.5%, respectively.

The choice of treatment for spinal metastasis is complex because (1) it depends on several inter-related clinical and radiologic factors, and (2) a wide range of management options has evolved in recent years. While radiation therapy and surgery remain the cornerstones of treatment, radiosurgery and percutaneous vertebral augmentation have also established a role. Classification systems have been developed to aid in the decision-making process, and each has different strengths and weaknesses. The comprehensive scoring systems developed to date provide an estimate of life expectancy, but do not provide much advice on the choice of treatment. We propose a new decision model that describes the key factors in formulating the management plan, while recognizing that the care of each patient remains highly individualized. The system also incorporates the latest changes in technology. The LMNOP system evaluates the number of spinal Levels involved and the Location of disease in the spine (L), Mechanical instability (M), Neurology (N), Oncology (O), Patient fitness, Prognosis and response to Prior therapy (P).

Traumatic lateral spondyloptosis is mostly a lateral shearing injury that must be tremendous enough to completely disrupt the strong musculoligamentous and bony structures. This injury has only been described at single levels in the lumbar spine. Lateral expulsion of a vertebral body from the spinal column due to 2-level adjacent spondyloptosis has not been previously reported. This 16-year-old girl was referred to our center for the management of an extremely unusual L2–5 fracture-dislocation. Motor deficits were incomplete and sacral sensation was spared. Three-dimensional reconstructed CT scans revealed a fracture involving the superior L-4 vertebral body and endplate. There was also complete disruption of the L4–5 disc space. The majority of the L-4 vertebral body was expelled to the right of the spinal column, with the collapse of L-3 and a small remnant of the L-4 superior endplate onto L-5. Surgical management involved decompression, reduction, reconstruction of L-4 with a cage, and L1–ilium stabilization and fusion. Only a few attachments of the psoas muscles had to be divided to roll the L-4 vertebral body out posterolaterally, similar to the method of complete en bloc spondylectomy used in oncology. Neurological recovery has thus far included the resumption of normal bladder and bowel function, as well as ambulation with the use of a right leg brace. Perhaps this type of fracture has not been previously described because many patients would be expected to succumb to vascular or visceral injury. The authors believe this is the first case report of double lateral spondyloptosis at adjacent levels, resulting in expulsion of the vertebral body from the spinal column.

Object Convection-enhanced delivery (CED) is a novel intracerebral drug delivery technique with considerable promise for delivering therapeutic agents throughout the CNS. Despite this promise, Phase III clinical trials employing CED have failed to meet clinical end points. Although this may be due to inactive agents or a failure to rigorously validate drug targets, the authors have previously demonstrated that catheter positioning plays a major role in drug distribution using this technique. The purpose of the present work was to retrospectively analyze the expected drug distribution based on catheter positioning data available from the CED arm of the PRECISE trial. Methods Data on catheter positioning from all patients randomized to the CED arm of the PRECISE trial were available for analyses. BrainLAB iPlan Flow software was used to estimate the expected drug distribution. Results Only 49.8% of catheters met all positioning criteria. Still, catheter positioning score (hazard ratio 0.93, p = 0.043) and the number of optimally positioned catheters (hazard ratio 0.72, p = 0.038) had a significant effect on progression-free survival. Estimated coverage of relevant target volumes was low, however, with only 20.1% of the 2-cm penumbra surrounding the resection cavity covered on average. Although tumor location and resection cavity volume had no effect on coverage volume, estimations of drug delivery to relevant target volumes did correlate well with catheter score (p < 0.003), and optimally positioned catheters had larger coverage volumes (p < 0.002). Only overall survival (p = 0.006) was higher for investigators considered experienced after adjusting for patient age and Karnofsky Performance Scale score. Conclusions The potential efficacy of drugs delivered by CED may be severely constrained by ineffective delivery in many patients. Routine use of software algorithms and alternative catheter designs and infusion parameters may improve the efficacy of drugs delivered by CED.

“… Above all do no harm” launches a career in medicine and throughout their career compels the physician to act in the patient's best interest. It can be said that the potential for complication, its anticipation, and need for mutual trust makes the patient-physician relationship, so unique.Comp

Study design Systematic review. Objectives To determine the general feasibility and safety of en bloc resection for primary spine tumors by analyzing (1) the effect of incisional biopsy performed before definitive en bloc resection and (2) the rate of achievement of disease-free margins, morbidity, mortality, and health resource utilization. Summary of background data The feasibility of en bloc resection is determined by careful surgical and oncologic staging, and a key step in this process is obtaining a tissue diagnosis. There is currently good evidence to support the premise that the best chance for surgical cure in primary tumors of the spine is by en bloc resection with disease-free margins; however, the early morbidity of these procedures begs the question of whether they are justified. Methods A formal systematic review with search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews databases was undertaken. Included reports described patients with low grade malignant spine tumors, the method of staging and surgical resection, and the complications. Two blinded, independent reviewers used a standardized study selection worksheet. Results About 89 articles were identified, with 8 selected after excluding small case series and studies that included other pathologies (e.g., metastatic disease). Weinstein, Boriani, Biagini staging accurately predicted the attainment of wide or marginal en bloc resection in 88% of cases. There was a clear increase in tumor recurrence when intralesional procedures were performed before the definitive en bloc resection. Tumor recurrence significantly shortened patient survival. Surgical complication rates ranged from 13% to 56% and mortality ranged from 0% to 7.7%. Conclusion (1) Incisional biopsy or intralesional resection significantly increases the risk of local recurrence, therefore, transcutaneous computed tomography-guided trocar biopsy is recommended. When there is a suspicion of primary spine tumor, the surgeon who performs the definitive surgery should ideally perform or direct the biopsy procedure. (2) En bloc resection is achievable if staging determines that it is feasible. The adverse event profile of these surgeries is high even at experienced centers. Therefore, experienced, multidisciplinary teams should perform these surgeries. (3) Grade of Recommendation can be "strong recommendation, low-quality evidence."

In an effort to reduce the burden of harm that our treatments cause to our patients, there has been a trend toward the minimalization of spine surgery. We review the minimally invasive procedures used in the treatment of spinal tumors, including minimally invasive diagnostic techniques, vertebral augmentation, radiofrequency ablation, endoscopic/thoracoscopic spine surgery, and minimal access open spine surgery.

Study Design. Reliability analysis based on expert panel case series review and grading per the Enneking and Weinstein-Boriani-Biagini classification systems. Objective. To assess the reliability of the Enneking and Weinstein-Boriani-Biagini classification systems. Summary of Background Data. The Enneking and Weinstein-Boriani-Biagini (WBB) classifications were developed to stage and facilitate treatment planning in patients with primary spine tumors. To date, their interobserver and intraobserver reliability has not been assessed‐a fundamental step in facilitating broader clinical and research use. Methods. Clinical information, imaging studies, and biopsy results were compiled from 15 selected patients with primary spinal tumors. Eighteen spine surgeons independently estimated and scored the cases for Enneking grade, tumor and metastasis categories, Enneking stage, Enneking-recommended surgical margin, WBB zones and layers, and WBB-recommended surgical procedures, with a second assessment performed after random resorting of cases. Interobserver and intraobserver reliability of each category were assessed by percent agreement or proportional overlap. The Fleiss, Cohen, and Mezzich statistics () were then applied, determined by the type of variable analyzed. Results. The statistics for interobserver reliability were 0.82, 0.22, 0.00, 0.57, 0.47, 0.31, 0.58, and 0.54 for the fields of Enneking grade, tumor and metastasis categories, Enneking stage, Enneking-recommended surgical margin, WBB zones and layers, and WBB-recommended surgical procedures, respectively. The statistics for intraobserver reliability were 0.97, 0.53, 0.47, 0.82, 0.67, 0.63, 0.79, and 0.79 for the same respective fields. According to Landis and Koch, the ranges of values of 0.00 to 0.20, 0.21 to 0.40, 0.41 to 0.60, 0.61 to 0.80, and 0.80 imply slight, fair, moderate, substantial, and near-perfect agreement, respectively. Conclusion. Results indicate moderate interobserver reliability and substantial and near-perfect intraobserver reliability for both the Enneking and WBB classification in terms of staging and guidance for treatment, despite a less than moderate interobserver reliability in interpreting the Enneking local tumor extension and WBB sector. Before incorporating the classifications in the clinical practice and research studies, further work is required to investigate the validity of the classifications.

The authors describe a patient who underwent orthotopic cardiac transplantation after an undifferentiated cardiac sarcoma was diagnosed. While receiving immunosuppressive therapy, the patient developed spinal column metastases and cauda equina syndrome requiring surgical decompression and stabilization. This occurred despite an exhaustive search for metastatic disease prior to the transplantation. To the authors' knowledge, this represents the first reported case of an undifferentiated cardiac sarcoma metastasis to the spine. This previously healthy 18-year-old woman presented with a myocardial infarction. Investigations revealed a left atrial tumor, which was resected. Following local recurrence, the patient underwent extensive studies to rule out systemic disease. Orthotopic heart–lung transplantation was then performed. While receiving postoperative immunosuppressive therapy the patient presented with cauda equina syndrome secondary to metastatic tumor compression at the L-5 level. Despite a comprehensive screening process to exclude metastatic disease prior to transplantation, spinal metastases occurred while this patient was receiving immunosuppressive therapy. This represents a previously unreported and clinically significant complication for undifferentiated cardiac sarcoma.

Object:Routine histopathological examination of intervertebral disc specimens is commonly performed in North American hospitals, but recent studies have questioned the utility of this practice in cases where the indication for surgery is a benign process such as degenerative disc disease. In this study, we have performed a cost-benefit analysis of this practice.Methods:We performed a cost-benefit analysis of routine histopathological examination of 1775 routine (non-neoplastic and non-infectious indications for surgery) and 70 non-routine (suspected neoplastic or infectious indications for surgery) discectomy specimens obtained over an eight-year period (1996 and 2004). Chart reviews were used to determine if any histopathology findings were clinically significant (i.e., affected subsequent patient care). Total costs were calculated. A literature review was conducted to compare our results with other published series.Results:We found four unexpected histopathology results among 1775 specimens obtained from routine cases, one of which was clinically significant. We calculated costs of $42,165.25 per unexpected histopathological finding and $168,625 per clinically significant histopathological finding. For non-routine surgeries, the cost per abnormal pathological finding was $116.67.Conclusions:In routine cases, histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be based on the surgeon's judgment.