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The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding.We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( -)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL.One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p 0.05; OR 3.38) and performing a PSO (p 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p 0.05; OR 2.48) and higher BMI (p 0.05; OR 2.15) were associated to a more significant post-operative HBL.With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.

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 Previous prognostic scoring systems are becoming out of date and inaccurate.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

BACKGROUND: The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database. METHODS: The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed. RESULTS: A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%. CONCLUSION: We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable. ispartof: ACTA NEUROCHIRURGICA vol:162 issue:4 pages:943-950 ispartof: location:Austria status: published

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 Rapidly progressing extrinsic spinal cord compression syndromes are rare, especially when the compression is associated with the supine position. Purpose This work presents a case of extrinsic thoracic spinal cord compression related to the supine position and describes our approach from diagnosis to the technical therapeutic creation of a spinal protection shield. Study Design One case of a patient suffering from extrinsic spinal cord compression syndrome is reported. Patient Sample We report the case of a Coptic priest patient who, as a result of Pott disease sequelae, underwent several decompressive and stabilizing surgeries for major kyphoscoliosis. Consequently, he developed extrinsic thoracic spinal cord compression caused by the supine position. Outcome Measures After each instrumentation device removal, we noticed progressive severe paraparesis when the patient was supine. Imaging assessment confirmed spinal dynamic and intermittent compressions triggered by the supine position, which was facilitated by the exposure and vulnerability of the thoracic spine cord. Methods We implanted a tailored titanium mesh spinal protection shield and a trapezius flap for spine coverage. This work presents the diagnostic aspects as well as several surgical technique options. Results At the 6-year follow-up, the patient's neurologic conditions were significantly improved. We report neurologic improvements, no sphincter disorder, persistent spasticity, and lower limbs weakness not affecting full ambulation. Conclusions To our knowledge, no other case of spinal protection shield in compressions caused by the supine position have been studied. The surgical and technical management therefore remains innovative.

Resume Objectif Evaluer les resultats en termes de qualite de vie chez les patients subissant une chirurgie curative extensive pour tumeur rachidienne et les comparer a la population francaise generale. Introduction L’esperance de vie n’est pas le seul critere de resultat apres des resections tumorales massives. La qualite de vie residuelle est egalement cruciale. L’indication de chirurgie majeure pour tumeur rachidienne doit prendre en compte le statut fonctionnel a long terme du patient, or seule une litterature limitee se penche sur la question. Patients et methodes Vingt-cinq patients vivants issus d’un groupe de 120 operes ont ete evalues. Tous furent operes par le meme chirurgien entre 1984 et 2007. Le suivi moyen est de 9 ans (intervalle : de 3 a 25 ans). L’âge moyen a l’operation etait de 49 ans. Les patients ont complete differents questionnaires fonctionnels et de qualite de vie : Oswestry Disability Index version 2 (ODI), Prolo, Karnofsky Index of Performance Status (KI), Eastern Cooperative Oncology Group Performance Status (ECOG), Short Form-36 Health Survey (SF-36) et EuroQoL-5 Dimensions (EQ5D). De plus, chaque patient a ete evalue cliniquement et radiographiquement. Des sous-groupes ont ete identifies en considerant le nombre de niveaux reseques et l’histologie. Leurs resultats au SF-36 ont ete compares avec ceux de la population generale francaise. Resultats En moyenne, le PCS (composante physique du SF-36) etait a 52,4, le MCS (composante psychique du SF-36) a 47,7, l’ODI a 18,2, le Prolo a 7, l’ECOG a 1 et le KI a 80 %. Les resections de trois niveaux sont associees aux moins bons resultats de qualite de vie mais, dans l’ensemble, les resultats etaient similaires aux donnees de la population generale francaise pour toutes les categories du SF-36. Conclusion Les indications appropriees de resection rachidienne massive donnent de bons resultats oncologiques et fonctionnels. Si c’est l’esperance de vie attendue qui justifie cette chirurgie agressive, la qualite de vie postoperatoire montre qu’elle peut egalement constituer un succes sur le plan fonctionnel. Niveau de preuve Niveau IV, etude clinique retrospective.

Taking into account the various parameters of sagittal spinal imbalance is paramount to treat a symptomatic deformity and restore balance. Pedicle posterior wedge osteotomy is a technically demanding procedure. There are significant potential complications. Pedicle impaction osteotomy may alleviate those complications. Late complications such as nonunion often lead to further challenging surgery.

BACKGROUND:Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery.OBJECTIVE:To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases.METHODS:In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival.RESULTS:The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001).CONCLUSION:Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.ABBREVIATIONS:ASA, American Society of AnesthesiologistsCI, confidence intervalQoL, quality of life

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.

We studied a consecutive series of 40 patients presenting a septic knee arthritis, with a mean age of 49 +/- 20 (range 19-81) years. The aetiologies were: 18 postoperative arthritis, 12 haematogenous infections, 7 arthritis following aspiration or infiltration, and 3 articular wounds. The most common organisms were Staphylococcus aureus and epidermidis (23 cases). Surgical procedures consisted in 20 arthroscopic debridements, 6 open debridements, 14 synovectomies. According to Gächter's classification, there were 8 stage I, 18 stage II, 11 stage III and 3 stage IV cases. Fifteen patients had to be reoperated after the index procedure at our institution: one open debridement, six open synovectomies, one open arthrolysis, one arthrodesis and six total knee arthroplasties (TKA). Final examination was performed after 22 +/- 26 (range 12-96) months. All cases were considered free of infection. Good functional result was present by 19/33 cases (excluding arthrodesis and TKA). The delay between the onset of symptoms and surgery was the major prognostic factor of success (P=0.023). This delay was correlated with Gächter's staging of the intra-articular lesions. The diagnosis of septic knee arthritis must be suspected at the early stage of the disease, and diagnostic joint aspiration must be immediately performed when the diagnosis is suspected. We suggest that the treatment should be more aggressive than generally advocated. Needle aspiration should be only performed at the very early stages. Arthroscopic debridement should be the routine treatment. Synovectomy should be considered even as a primary procedure when significant synovial hypertrophy is present (Gächter stage III and IV) or when a more conservative treatment did not lead to a fast improvement.

Disadvantages of thoracic posterior implants and developments in rod contouring in situ led to the design of a new spinal implant: the bipedicular spinal fixation device (BSF). The BSF is composed of two bifid hooks linked by a compression transverse connector and inserted into the costo-vertebral and costo-transverse joints. The aim of this biomechanical study was to determine the loading tolerance of the BSF. Three strength tests-a pull-out test, a lateral load-to-failure test and a uniaxial transversal compression test to failure-were performed using six human thoracic spines on an Instron testing device. Specimen evaluation consisted of: bone mineral density (BMD) measurement with the dual-energy X-ray absorptiometry (DEXA) technique, cortical thickness measurements and a morphometric study. The mean values for load-to-failure in the posterior and lateral tests were 324 N and 400 N respectively. The mean value of the uniaxial compression was 988 N. The mean BMD estimated by DEXA was 0.557 g/cm(2). The BSF loading tolerance was compatible with the in situ rod contouring technique requirements when we considered posterior and lateral pull-out tests. The transversal compression test determined the appropriate and efficient BSF tightening force.

STUDY DESIGN This biomechanical study using cadaver thoracic spines evaluated the initial stiffness of two different fixation constructs using a new spinal implant: the bipedicular spinal fixation device (BSF). OBJECTIVE To compare the biomechanical stiffness of a new construct using BSF with a regular construct using pedicular and laminar hooks. SUMMARY OF BACKGROUND DATA Disadvantages of thoracic posterior implants and developments in in situ rod contouring led to the creation of a new implant for spine deformity surgery that would provide immediate stiffness to preserve spine correction, allow efficient postoperative rehabilitation, and obtain a good fusion rate. METHODS Two age-paired groups of six human thoracic spines each (T3-T12) were compared: a regular group whose construct was in accordance with the Cotrel-Dubousset technique and the BSF group. In both groups, the spines were tested intact and then after injury. An injury was induced by transections of interspinous and anterior longitudinal ligaments and anterior discectomies. A three-dimensional ultrasonic measurement device, the Zebris 3D Motion Analyzer, was used to record the motion of the T6 relative to the T8 vertebra under loads, and to determine the ranges of motion (ROMs) between intact spines and the spine construct. RESULTS In flexion-extension, the regular construct showed a significantly greater mean of relative ROMs than the BSF construct for principal rotation (88% and 69% respectively, P = 0.015). However, no significant differences were demonstrated in any of the other motions. CONCLUSION The BSF construct showed stiffness similar to that of the regular construct, encouraging clinical investigation.

Since the first pioneering work in the area of tumors of the spine, medical professionals have sought to determine the proper role of spine surgery in the management of spinal tumors. Experience has proven that spine surgery is effective in the treatment of spinal cord compression for decreasing pain and improving quality of life with low rates of surgical complications. We use several staging systems to assess the patient's prognosis, to determine the best type of tumoral resection in preoperative surgical planning, and to provide guidance as to the best therapeutic option for the patient. In the surgical treatment of spine tumors, one of two opposing strategies must be chosen: (1) palliative surgery with cord decompression and spine stabilization or (2) curative surgery with en bloc radical resection of the tumor and stabilization. In this article, we describe indications and surgical techniques related to cervical spinal tumors: fixation and laminectomy of the upper and lower cervical spines, corporectomy, and partial and total vertebrectomy. For tumors of the cervicothoracic region, the most frequent level of spine metastasis and thoracic spine tumors, we describe the fixation and laminectomy technique, en bloc tumor resection, and partial and total vertebrectomy. The last part of the article addresses outcomes following spinal surgery, including outcomes related to en bloc Pancoast Tobias tumor resection, malignant dumbbell schwanomas, and metastasis.