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Osteoporotic vertebral compression fractures (OVCF) are common in elderly patients and may cause local kyphosis due to the vertebral collapse and wedging. Balloon kyphoplasty (BKP) with polymethyl methacrylate is widely used to relieve back pain and restore the height and kyphosis of the destroyed vertebra Johnell (Osteoporos Int 17(12):1726-33, 2006); Wasnich (Bone 18: 179S-183S, 1996); Finnern (Osteoporos Int 14:429-436, 2003). However, the influence of BKP on global sagittal alignment (GSA) in patients with OVCF remains unclear.To systematically evaluate the relevant literature regarding the influence of BKP on the global spinal sagittal alignment using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spinosacral Angle (SSA). Visual Analogue Score (VAS) was also recorded.A systematic review of the English language literature dating up until August 2022, was undertaken utilising the PRISMA guidelines.Of a total of 548 articles, 4 studies met the inclusion criteria (4 level III evidence) and were analyzed. Overall, 201 patients of mean age 73.8 years (69-77) had acute OVCF of one or more vertebra. The male to female ratio was 51:128. The number of fractured vertebrae was 235 (average of 1.17 fractured vertebrae per patient). Their pre-operative radiological parameters on standing x-rays showed a mean PI of 56°, PT 24.1°, LL 44.4°, TK 42.3°, PI-LL 11.7°, SVA 4.9 cm, LL/TK 1 and SSA 114.8°. The average VAS was 7.6 (2.6-10). All the patients underwent BKP and their radiological parameters on standing x-rays post operatively showed a mean PI of 55.3°, PT 23.1°, LL 45.1°, TK 41.4°, PI-LL 10.3°, SVA 4.29 cm, LL/TK 1.07 and SSA 116.8°. Their average VAS post BPK was 2.36 (0-4.8).A statistical analysis comparing the pre/post-operative GSA (111 patients, 3 studies with standard deviations) showed no statistical difference in PT (24.1° vs. 23.5°, P = 0.93), TK (42.3° vs. 42.4°, P = 0.57), PI-LL (14.4° vs.12.4°, P = 0.4), SVA (6.1 cm vs. 5.5 cm, P = 0.19) SSA (114.8° vs. 116.7° P = 0.36). VAS was significantly reduced post BKP (7.1 vs. 2.5 P = 0.004).Performing BKP procedures does not significantly affect the global sagittal alignment in patients with osteoporotic vertebral compression fractures. There was however, a significant improvement in pain scores in patients undergoing BKP at 1 or more levels.

Despite the heterogeneity of chronic lower back pain aetiologies, cluneal nerve entrapment remains underdiagnosed and poorly understood with few studies discussing the efficacy of its surgical release.The current study opts to conduct a systematic review reporting on the efficacy of cluneal nerve surgical decompression in patients with an established diagnosis who fail conservative treatment. We aimed to systematically evaluate the literature regarding the clinical outcomes, recurrence of symptoms and revision rates of surgical intervention.A systematic review of the English language literature dating up until May 2022 was undertaken according to the PRISMA guidelines. Isolated case reports were excluded.Of a total of 54 articles, 4 studies met the inclusion criteria (three were level IV evidence and one level III evidence) and were analyzed. Overall, 98 patients of mean age 61 years, (range 17-86) underwent cluneal nerve release with a mean follow-up of 25.5 months (6-58 months). There was significant improvement in symptoms post operatively in the 4 studies. No systemic or local complications were encountered during the surgeries. Four articles reported on revision surgery for recurrent symptoms in 8 patients out of 98 with a rate of 8.2%. Of the reoperated patients, 7/8 had new branches released that were not addressed initially and 1 had neurectomy for an adhered pre-released branch.This systematic review demonstrated that cluneal nerve decompression has been performed in a total of 98 patients with significant clinical improvement, zero systemic and local complications and revision rates of 8.2% of the cases.

Fusobacterium nucleatum is part of the commensal flora of the oral cavity, frequently associated with periodontal infections. We describe the case of a 49-year-old woman, on immunsuppressive therapy for multiple sclerosis, who presented with a 3-month history of debilitating back pain. She had a recent episode of periodontitis, and was under regular dental review. Her MRI scan demonstrated findings suggestive of L2–L3 spondylodiscitis. Her CT-guided biopsy yielded negative cultures and the patient failed two courses of empirical antibiotic treatment. With clinical and radiological disease progression, she underwent a percutaneous disc washout and biopsy, which subsequently grew F. nucleatum. Treatment with clindamycin and metronidazole was commenced orally for 6 weeks. She improved gradually, and at 1 year follow-up was asymptomatic. The diagnosis of spondylodiscitis caused by F. nucleatum is challenging. The perseverance on identification by surgical biopsy, minimally invasive washout and targeted antibiotics are the mainstay of effective treatment.

A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK). Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior–posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature. 51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed. The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10–16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p

Study designA systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS.ObjectiveTo systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS.Summary of background dataERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published.MethodsA systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with ResultsOf a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy.ConclusionThis systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups.Level of evidence3.

The goal of this study was to review the incidence of complications and unplanned re-operations after surgery for metastatic spinal tumors. The spinal column is the most common osseous site for metastatic spread. The goals of the treatment of spinal metastases are largely palliative. The surgical aims include establishing a diagnosis, providing stability, relieving neurological compression and deterioration, decreasing pain and increasing patient independence. Patients with spinal metastases who undergo surgery are considered high risk, with higher morbidity and mortality rates. A systematic review was undertaken; PubMed and Embase databases were searched between (2010–2020) for relevant publications in English language with the following search items: metastasis OR metastases AND spine AND surgery AND complications OR revision. Using a standard PRISMA template, 2293 articles were identified. Full-text articles of interest were assessed for inclusion criteria of greater than 30 patients. A final number of 19 articles fully met the search criteria. Four were level II evidence, and the remaining were level III/IV. Surgical site infection 6.5% (135/2088) was reported as the main complication following surgery for spinal metastases followed by neurological deterioration 3.3% (53/1595) and instrumentation failure 2.0% (30/1501). Re-operation rate was 8.3% (54/651), with SSI (27.8%) being the most common reason for revision surgery. Patients with spinal metastases frequently present with complex therapeutic challenges requiring multidisciplinary team assessment. Surgical site infection (6.5%) was the main reason for a re-operation in patients undergoing surgery for spinal metastases.

Surgical approaches to pathologies of the L5 vertebra constitute a significant challenge. Our aim was to review the efficacy and safety of the surgical approaches to L5 corpectomy and reconstruction across the range of presenting pathology. This systematic review was conducted according to PRISMA guidelines, and databases were searched from 1970 to January 2020. The search inclusion criteria were L5 Corpectomy AND/OR Spondylectomy AND/OR Vertebrectomy. The outcome measures studied were length of surgery, blood loss, fusion or failure of fusion/instrumentation, complications and mortality. Initial 36 articles were identified, and final 6 studies met our inclusion criteria. The mean reported blood loss was 2265 ml (400–4700 ml) and was higher for the two-stage posterior–anterior surgery group than the posterior-only surgery group (mean 3230 mls vs. 1260 mls) but not the operative time. All surgical approaches shared high fusion rates (94%) and relatively low complication rates (11.7%). However, surgical strategies incorporating an anterior approach were notable for vascular complications (4–7%), as well as perioperative mortality (9%) not seen in the posterior-only surgery group. Where there is clinical and circumstantial equipoise regarding the choice of surgical approaches for a L5 corpectomy, this review indicates a reported mean blood loss of 2265 ml (400—4700 ml), high fusion rates (94%) and relatively low complication rates (11.7%). It is difficult to make direct comparisons between approaches due to small case series, the variability in primary pathology, clinical intent and surgeon experience.

A case report. It is important to achieve optimal sagittal balance in spinal deformity surgery by matching LL to PI. A Lumbar osteotomy to increase lordosis is often the method used to achieve this in adult patients. However, in patients with high PI with compensatory lumbar hyperlordosis, providing further lordosis does not address the root cause. The paper will describe a technique of lumbosacral osteotomy to address sagittal malalignment with associated coronal imbalance and pelvic incidence (PI)—lumbar lordosis (LL) mismatch. A 16-year-old female patient presented with low back pain and right leg pain. Standing anteroposterior X-ray showed scoliosis with a Cobb angle of 34o and 5.7 cm of coronal imbalance. Lateral X-ray showed a sacralized L5 with a PI of 85o and LL of 47o. Pedicle subtraction osteotomy through the sacralized L5 addressed the malalignment secondary to a high PI-LL mismatch of 38o. Following alar resection, an osteotomy was performed below the L5 pedicles. The cranial parts including the superior endplate and intervertebral disc were removed. Osteotomy closure was achieved using the central rod technique. L5 incidence was reduced from 59o to 33o with reduced coronal malalignment. Back pain was significantly improved and PI-LL mismatch was improved to 10o two years post-operatively with no local loss of sagittal correction. A lumbosacral osteotomy at the lumbosacral junction is useful to improve high PI – LL mismatch in patients with abnormally high PI with compensatory lumbar hyperlordosis.

A systematic review and meta-analysis. The purpose of this study was to evaluate the clinical outcome and safety of sacroplasty for patients with secondary metastatic lesions to the sacrum. Several databases, including the Cochrane library, PubMed and EMBASE, were systematically searched to identify potentially eligible articles in English language. All the above databases were searched until December 2019. The search strategy was based on the combination of the following keywords: sacroplasty AND secondary tumours OR metastasis OR metastases. The reference list of the selected literature was also reviewed and a standard PRISMA template utilised. From a total of 102 articles initially identified, a final seven studies were identified as meeting the inclusion criteria. A total of 107 patients from these studies were included. The follow-up ranged from immediate post-operatively to 30.5 months. The mean preoperative VAS was 8.38 (range 6.9–9.3), which improved significantly to 3.01 (range 1.12–4.7) post-operatively (p

Study design Cadaveric study on fresh unprocessed, nonpreserved, undyed specimens which have not previously been reported. Objective We aimed to perform surgically relevant exposures of the anterior cervical spine with particular attention to observing the potential vulnerabilities of the RLN on right and left. Summary of background data Vulnerability of the RLN in the anterior cervical spine approach on the right versus left is the subject of ongoing debate. Although most cadaveric studies focus on course variations, structural relations of RLN, they have been done in preserved (fixed) cadavers without relevance to the needs of spinal exposure. Methods Twelve fresh undyed cadavers had extensive layer by layer dissections by 2 surgeons (one with extensive experience as anatomy dissector). Both sides were explored for vulnerability during cervical spinal procedures. Each dissection was carried out in a phased approach and deliberately explored beyond what can be afforded in live surgery to allow the reader to conceptualize a better view of the structures. Results In all specimens, we consistently demonstrated that the right surgical corridor involved manipulation of the nerve and its branches especially below C5 to achieve optimum midline access: in the right corridor, the RLN is on its oblique course to the tracheoesophageal groove. On the left, RLN is already in the tracheoesophageal groove and out of the surgical field involving minimal direct mobilization of the nerve. Conclusion RLN surgical anatomy photographed here is novel in using fresh unprocessed cadaveric specimens which has previously not been reported.Right surgical corridor, below C5, involves retraction/manipulation of RLN for achieving optimum spinal midline access, highlighting potential surgical vulnerability of right RLN. Level of evidence 3.

Degenerative cervical myelopathy (DCM) is the most common cause of adult spinal cord dysfunction worldwide. However, the current incidence of DCM is poorly understood. The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise surgical activity for DCM in England.The HES database was interrogated for all cases of DCM between 2012 and 2019. DCM cases were identified from 5 ICD-10 codes. Age-stratified values were collected for 'Finished Consultant Episodes' (FCEs), which correspond to a patient's hospital admission under a lead clinician. Data was analysed to explore current annual activity and longitudinal change.34,903 FCEs with one or more of the five ICD-10 codes were identified, of which 18,733 (53.6%) were of working age (18-64 years). Mean incidence of DCM was 7.44 per 100,000 (SD ± 0.32). Overall incidence of DCM rose from 6.94 per 100,000 in 2012-2013 to 7.54 per 100,000 in 2018-2019. The highest incidence was seen in 2016-2017 (7.94 per 100,000). The median male number of FCEs per year (2919, IQR: 228) was consistently higher than the median female number of FCEs per year (2216, IQR: 326). The rates of both emergency admissions and planned admissions are rising.The incidence of hospitalisation for DCM in England is rising. Health care policymakers and providers must recognise the increasing burden of DCM and act to address both early diagnoses and access to treatment in future service provision plans.

Introduction Medical malpractice litigation is a major concern for all spine surgeons. Our aim was to evaluate the incidence and burden of successful litigation relating to the management of spinal disorders over 12 years within a UK NHS tertiary-level spinal unit and compare these litigation costs with those of other specialties. Methods We obtained all data held by our claims department from its inception in January 2008 to December 2019. We also obtained costs for the total financial burden incurred by our Trust during this period. Results In total, there were 83 closed claims involving spinal pathologies. Over 80% of these comprised negligent surgery (n = 28, 34%), delay to diagnose/treat (n = 25, 30%) and negligent care (n = 18, 22%). The vast majority of claims were withdrawn without incurring any cost to the hospital (n = 59, 71%) and only 24 (29%) resulted in successful litigation for the claimant. The total cost of damages for these 24 successful claims was just over £8 million, including legal costs of £2.5 million, out of total litigation costs of £381 million over this period. Discussion Fewer than 30% of initial claims against a tertiary spinal surgical referral unit resulted in a successful financial outcome for the claimant. The total costs incurred were just over £8 million, with one-third apportioned to high legal costs, reflecting the complexity of resolving spinal litigation. Our entire legal expenses accounted for only 2% of the total legal bill paid by our hospital over a 12-year period.

ObjectivesTo assess the reporting of study design and characteristics in multi-level degenerative cervical myelopathy (DCM) treated by posterior surgical approaches, and perform a comparison of clinical and radiographic outcomes between different approaches.MethodsA literature search was performed in Embase and MEDLINE between 1995-2019 using a sensitive search string combination. Studies were selected by predefined selection criteria: Full text articles in English, with >10 patients (prospective) or >50 patients (retrospective), reporting outcomes of multi-level DCM treated by posterior surgical approach.ResultsA total of 75 studies involving 19,510 patients, conducted worldwide, were identified. Laminoplasty was described in 56 studies (75%), followed by laminectomy with (36%) and without fusion (16%). The majority of studies were conducted in Asia (84%), in the period of 2016-2019 (51%), of which laminoplasty was studied predominantly. Twelve (16%) prospective studies and 63 (84%) retrospective studies were identified. The vast majority of studies were conducted in a single centre (95%) with clear inclusion/exclusion criteria and explicit cause of DCM. Eleven studies (15%) included patients with ossification of the posterior longitudinal ligament exclusively with cohorts of 57 to 252. The clinical and radiographic outcomes were reported with heterogeneity when comparing laminoplasty, laminectomy with and without fusion.ConclusionsHeterogeneity in the reporting of study and sample characteristics exists, as well as in clinical and radiographic outcomes, with a paucity of studies with a higher level of evidence. Future studies are needed to elucidate the clinical effectiveness of posterior surgical treatments.

Background: Pubic rami fragility fractures are common in older people and result in significant morbidity and increased mortality. Co-existing fractures of the sacrum are common, but routinely missed. The aim of the study was to explore the perceptions in the assessment and treatment of pubic rami and sacral fragility fractures amongst healthcare professionals. Methods: We interviewed 14 participants about their experience in the assessment and treatment of patients presenting with pubic rami fragility fractures. Data was analyzed using an inductive thematic approach. Results: The majority of patients presenting with a pubic rami fragility fracture were managed by geriatricians. However, many of the geriatricians were not aware that these fractures have a high association with co-existing sacral fragility fractures. Furthermore, they were not aware of the limitations of standard x-ray imaging, nor of the potential benefits of surgical intervention for sacral fragility fractures. Spinal surgeons recommended that early, more specialist imaging in patients with pubic rami fragility fractures failing to mobilize, would change clinical management, if found to have a coexisting sacral fragility fracture, amenable to surgical intervention. Conclusions: The awareness, assessment and management of sacral fragility fractures in patients presenting with pubic rami fragility fractures is poor amongst healthcare professionals in geriatric medicine. Spinal surgeons in this study advocate early further imaging and surgical intervention in patients confirmed to have a concomitant sacral fragility fracture who are failing to mobilize.

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

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

OBJECTIVE The goal of this study was to evaluate the comparative accuracy and safety of navigation-based approaches for cervical pedicle screw (CPS) placement over fluoroscopic techniques. METHODS A systematic search of the literature published between January 2006 and December 2019 relating to CPS instrumentation and the comparative accuracy and safety of fluoroscopic and intraoperative computer-based navigation techniques was conducted. Several databases, including the Cochrane Library, PubMed, and EMBASE, were systematically searched to identify potentially eligible studies. Data relating to CPS insertion accuracy and associated complications, in particular neurovascular complications, were extrapolated from the included studies and summarized for analysis. RESULTS A total of 17 studies were identified from the search methodology. Eleven studies evaluated CPS placement under traditional fluoroscopic guidance and 6 studies addressed outcomes following navigation-assisted placement (3D C-arm or CT-guided placement). Overall, a total of 4278 screws were placed in 1065 patients. Misplacement rates of CPS were significantly lower (p < 0.0001) in navigation-assisted techniques (12.51% [range 2.5%–20.5%]) compared to fluoroscopy-guided techniques (18.8% [range 0%–43.5%]). Fluoroscopy-guided CPS insertion was associated with a significantly higher incidence of postoperative complications relating to neurovascular injuries (p < 0.038), with a mean incidence of 1.9% compared with 0.3% in navigation-assisted techniques. CONCLUSIONS This systematic review supports a logical conclusion that navigation-based techniques confer a statistically significantly more accurate screw placement and resultant lower complication rates.

The goal of this study was to review the incidence of complications and unplanned re-operations after surgery for metastatic spinal tumors.The spinal column is the most common osseous site for metastatic spread. The goals of the treatment of spinal metastases are largely palliative. The surgical aims include establishing a diagnosis, providing stability, relieving neurological compression and deterioration, decreasing pain and increasing patient independence. Patients with spinal metastases who undergo surgery are considered high risk, with higher morbidity and mortality rates.A systematic review was undertaken; PubMed and Embase databases were searched between (2010-2020) for relevant publications in English language with the following search items: metastasis OR metastases AND spine AND surgery AND complications OR revision. Using a standard PRISMA template, 2293 articles were identified. Full-text articles of interest were assessed for inclusion criteria of greater than 30 patients.A final number of 19 articles fully met the search criteria. Four were level II evidence, and the remaining were level III/IV. Surgical site infection 6.5% (135/2088) was reported as the main complication following surgery for spinal metastases followed by neurological deterioration 3.3% (53/1595) and instrumentation failure 2.0% (30/1501). Re-operation rate was 8.3% (54/651), with SSI (27.8%) being the most common reason for revision surgery.Patients with spinal metastases frequently present with complex therapeutic challenges requiring multidisciplinary team assessment. Surgical site infection (6.5%) was the main reason for a re-operation in patients undergoing surgery for spinal metastases.

Systematic review and meta-analysis. Three-column osteotomies (3-CO) have gained popularity in the last decade as part of the armamentarium for the surgical correction of sagittal imbalance in patients with adult spinal deformity (ASD). Three-column osteotomies in the form of pedicle subtraction osteotomy (PSO) may be necessary to achieve adequate correction for severe and rigid spinal deformity. Studies reporting improvement in health-related quality of life (HRQOL) with validated outcome measures after PSO surgery are sparse and currently consist of small series. Evaluate the improvement in HRQOL measures following PSO for adult spinal deformity. Two independent reviewers conducted a systematic review of the English literature between period 1996 and 2019 for articles reporting outcome of PSO in patients with ASD according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Inclusion criteria were studies consisting of patient-reported outcome Oswestry Disability Index (ODI) and Scoliosis Research Society 22 or 24 (SRS) outcomes after PSO surgery for adult spine deformity patients (18 years or older) with a minimum follow-up of 1 year. Eight studies with 431 PSOs were included in the meta-analysis. The results showed a statistically significant improvement in ODI in PSO (P

MRI is the established gold standard for imaging acute spinal cord injury (SCI). Our aim was to identify the prognostic value, in terms of neurological outcome, of extradural and intradural features detected on MRI performed acutely following traumatic cervical SCI. Several databases were systematically searched to identify potentially eligible articles until December 2019. Using a standard PRISMA template, 2606 articles were initially identified. A final 6 full-text articles met the inclusion criteria and were analyzed. An extradural factor, namely the maximal spinal cord compression, was associated with poor neurological outcome and statistically significant (P = 0.02 and P = 0.001 in 2 out of 3 studies). The intradural factors of length of the cord edema (P = 0.001, P = 0.006, and P

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

Most of the literature on infection after surgery for spinal metastases focuses on incidence and risk factors for surgical site infection (SSI). To the best of our knowledge, there is no report on the influence of infection on neurological outcome and survival in patients undergoing emergent surgery for metastatic spinal cord compression (MSCC). Our aim was to establish if SSIs adversely affected the neurological outcome and survival in patients with MSCC. We reviewed 318 consecutive patients admitted for surgical intervention for MSCC from October 2005 to October 2012. Morbidity (neurological outcome, length of hospital stay and additional procedures) and survival rates were analysed. During this study period, the incidence of infection was 29/318 (9.1%). The median length of stay in hospital in the infected group was 25 days compared to 13 days in the non-infected group (p = 0.001). Twenty out of the 29 (69%) infected patients underwent an additional procedure (29 procedures in total) compared to 9/289 (3%) non-infected patients (p = 0.001). There was no statistical difference between the two groups with regard to neurological outcome (p = 0.37) but the survival rate was statistically different between the two groups [infected group: median survival 131 days (19–1558) vs. non-infected group: 258 days (5–2696; p = 0.03)]. Surgical site infection increased the morbidity with considerably longer hospital stay and requirement for additional procedures. Although there was no difference in neurological outcome, the infected group of patients had a significantly shorter survival. These slides can be retrieved under Electronic Supplementary Material.

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

Most spinal metastases are detected late, and thus, the impact of treatment on the health-related quality of life (HRQOL) is an important consideration. This study investigated the HRQOL following surgery for spinal metastases. A prospective study of patients operated for symptomatic spinal metastases, at a single tertiary referral spine centre (2011–2013). Data were collected pre-operatively and up to 2 years following surgery (if alive). The HRQOL assessment was performed using recognised systems including the Frankel score (neurological status), EQ-5D, and the Oswestry Disability Index. A total of 199 patients were studied (median age 65 years, 43% (86) F; 57% (113) M). The Frankel score improved significantly after surgery in 69 patients (35%), worsened in 17 (8%), with 20/39 patients regaining the ability to walk (51%). All the HRQOL scores improved significantly following surgery. The complication rate was 27% and median survival 270 days, and 44 patients (22%) survived at 2 years. This large prospective study showed that surgical treatment for spinal metastases significantly improved the HRQOL.

Multicenter, ambispective observational study.To quantify mortality and local recurrence after surgical treatment of spinal Ewing sarcoma (ES) and to determine whether an Enneking appropriate procedure and surgical margins (en bloc resection with wide/marginal margins) are associated with improved prognosis.Treatment of primary ES of the spine is complex. Ambiguity remains regarding the role and optimal type of surgery in the treatment of spinal ES.The AOSpine Knowledge Forum Tumor developed a multicenter database including demographics, diagnosis, treatment, mortality, and recurrence rate data for spinal ES. Patients were stratified based on surgical margins and Enneking appropriateness. Survival and recurrence were analyzed using Kaplan-Meier curves and log-rank tests.Fifty-eight patients diagnosed with primary spinal ES underwent surgery. Enneking appropriateness of surgery was known for 55 patients; 24 (44%) treated Enneking appropriately (EA) and 31 (56%) treated Enneking inappropriately (EI). A statistically significant difference in favor of EA-treated patients was found with regards to survival (P = 0.034). Neoadjuvant and postoperative chemotherapy was significantly associated with increased survival (P = 0.008). Local recurrence occurred in 22% (N = 5) of patients with an EA procedure versus 38% (N = 11) of patients with an EI procedure. The timing of chemotherapy treatment was significantly different between the Enneking cohorts (P 0.001) and all EA-treated patients received chemotherapy treatment. Although, local recurrence was not significantly different between Enneking cohorts (P = 0.140), intralesional surgical margins and patients who received a previous spine tumor operation were associated with increased local recurrence (P = 0.025 and P = 0.018, respectively).Surgery should be undertaken when an en bloc resection with wide/marginal margins is feasible. An EA surgery correlates with improved survival, but the impact of other prognostic factors needs to be evaluated. En bloc resection with wide/marginal margins is associated with local control.3.

Background Stand-alone anterior interbody fusion (STALIF) with poly-ether-ether-ketone (PEEK) cages could offer a treatment option in olisthesis cases. The fixation of the PEEK-cage at the L5/S1 inferior endplate with long divergent screws however might endanger neural sacral structures, especially the S1 nerve root. If shorter screws are used, the achieved bony purchase might not be sufficient to resist the pull out and shear forces at the lumbosacral junction. The aim of the present investigation was to evaluate the use of long screws in PEEK-cages for olisthesis cases at the L5/S1 segment and its neurological complications. Material and methods 11 Patients (6 males) with a mean age of 47(± 15.1) years between 2013-2015 designated for an STALIF at the L5/S1 level were consecutively included in the present study. All patients had a Grade 1 or 2 slippage according to Meyerding. PEEK cages (SynFix-LR®, Depuy Synthes) were implanted with 30mm screws at the baseplate of L5/S1 in all patients. Perioperative and postoperative long-term complications were evaluated. Furthermore, radiological follow-up was performed (CT-scan at 6 months, X-ray at 6, 12 and 24 months). Results 6 patients suffered from an isthmic, 1 from a degenerative olisthesis. 4 patients with iatrogenic spondylolisthesis were included. Pre-operative radiculopathy was noted in 10 patients. 9 patients with pre-operative radiculopathy showed relief of symptoms until the last follow-up after 24 months. Fusion was achieved in all patients after 6 months. No screw-displacement, breakage or violation of the neural foramen was noted. Furthermore, no implant failure or pull-out fractures were seen. Conclusion In this investigation, no complication due to the use of long divergent locking screws was noted. In addition, the majority of patients showed permanent relief of radiculopathy symptoms at the 2 years follow-up. This study demonstrates the safe usage of long divergent locking screws in the baseplate of L5/S1 in anterior interbody fusion at the L5/S1 level.

STUDY DESIGN Multicenter, ambispective observational study. OBJECTIVE The aim of this study was to quantify local recurrence (LR) and mortality rates after surgical treatment of spinal giant cell tumor and to determine whether en bloc resection with wide/marginal margins is associated with improved prognosis compared to an intralesional procedure. SUMMARY OF BACKGROUND DATA Giant cell tumor (GCT) of the spine is a rare primary bone tumor known for its local aggressiveness. Optimal surgical treatment remains to be determined. METHODS The AOSpine Knowledge Forum Tumor developed a comprehensive multicenter database including demographics, presentation, diagnosis, treatment, mortality, and recurrence rate data for GCT of the spine. Patients were analyzed based on surgical margins, including Enneking appropriateness. RESULTS Between 1991 and 2011, 82 patients underwent surgery for spinal GCT. According to the Enneking classification, 59 (74%) tumors were classified as S3-aggressive and 21 (26%) as S2-active. The surgical margins were wide/marginal in 27 (36%) patients and intralesional in 48 (64%) patients. Thirty-nine of 77 (51%) underwent Enneking appropriate (EA) treatment and 38 (49%) underwent Enneking inappropriate (EI) treatment. Eighteen (22%) patients experienced LR. LR occurred in 11 (29%) EI-treated patients and six (15%) EA-treated patients (P = 0.151). There was a significant difference between wide/marginal margins and intralesional margins for LR (P = 0.029). Seven (9%) patients died. LR is strongly associated with death (Relative Risk 8.9, P

To date, no reliable method is available to determine the parameters of bone density based on the routine spinal computed tomography (CT) in the emergency setup. We propose the use of fractal analysis to detect patients with poor quality of bone before urgent or semi-urgent spinal procedures.This study aimed to validate the hypothesis that the CT-based fractal analysis of the trabecular bone structure may help in detecting patients with poor quality of bone before urgent spinal procedures.This is a retrospective analysis of prospectively collected data.Patients in whom the dual-energy x-ray absorptiometry (DEXA) scan and lumbar spine CT were performed at an interval of no more than 3 months were randomly selected from a prospectively collected database. Diagnostic axial CT scans of L2, L3, and L4 vertebrae were processed to determine the fractal dimension (FD) of the trabecular structure of each spinal level. Box-count method and ImageJ 1.49 software were used. The FD was compared with the results of the DEXA scan: bone mineral density (BMD) and T-score by mean of correlation coefficients. Receiver operating characteristic curve analysis was later performed to determine the cutoff value of FD.A total of 102 vertebral levels obtained from 35 patients (mean age 60±18 years; 29 female) were analyzed. The FD was significantly higher in the group of patients with decreased bone density (DBD) (T-score-1.0) (1.67 vs. 1.43; p.0001) and negatively correlated with BMD (R Spearman, -0.53; p.0001) and T-score (-0.49; p.0001). Receiver operating characteristic curve analysis revealed that a cutoff value of FD1.53 indicates DBD (p.0001; area under the ROC curve [AUC], 0.84; 95% confidence interval [CI], 0.76-0.91).This study shows that fractal analysis of the lumbar spine CT images may be used to determine bone density before spinal instrumentation (eg, metastatic or traumatic cord compression). Further prospective studies comparing results of the fractal analysis of CT scans with quantitative CT (qCT) are warranted.

Background Context Spinal osteoid osteomas are benign primary tumors arising predominantly from the posterior column of the spine. These "osteoblastic" lesions have traditionally been treated with intralesional excision. Purpose The purpose of the present study was to review the treatment and local recurrence rates for symptomatic spinal osteoid osteomas. Study Design/Setting Multicenter ambispective cross-sectional observational cohort study. Patient Sample During the study period, a total of 84 patients (65 males, 19 females) were diagnosed with a spinal osteoid osteoma and received surgical treatment. The mean age at surgery was 21.8 ± 9.0 years (range: 6.7–52.4 years) and the mean follow-up was 2.7 years (13 days–14.5 years). Outcome Measures Local recurrence, perioperative morbidity, and cross-sectional survival. Methods Using the AOSpine Knowledge Forum Tumor multicenter ambispective database, surgically treated osteoid osteoma cases were identified. Patient demographic, clinical and diagnostic, treatment, local recurrence, perioperative morbidity, and cross-sectional survival data were collected and retrieved. Descriptive statistics were summarized using mean/standard deviation or frequency/percentage. Results In our study, most of the tumors were localized in the mobile spine (81 of 84 [96%]); all patients reported pain as a symptom. According to the postoperative assessment, 10 (12%) patients received an en bloc resection with marginal or wide margins, whereas two (2%) patients received en bloc resections with intralesional margins, 69 (82%) patients were treated by piecemeal "intralesional" resection, and three (4%) patients were not assessed. A total of six patients (7%) experienced a local recurrence, all of which occurred in patients who had received an intralesional resection. Conclusions Benign bone-forming tumors of the spine are uncommon. Most patients in our series underwent a piecemeal resection with intralesional margins. This remains safe with a low local recurrence rate. En bloc excision may provide more chance of complete excision of the nidus but is not mandatory. The importance of complete excision of the nidus cannot be overemphasized.

IntroductionPelvic fragility fractures (PFF) are common in older people and associated with a significant burden of mortality and morbidity. This is related to the challenges of appropriate pain control and early mobilisation. The current standard for treatment of PFF is non-surgical management. Minimally invasive surgical techniques for sacral fracture stabilisation have been shown to improve outcomes in terms of pain control and mobility, and they are safe. Randomised controlled trials are required before recommendations can be made for surgical management of PFF to become the new standard of care. This feasibility study will explore several uncertainties around conducting such a trial.Methods and analysisASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation) is a single-site randomised controlled, parallel-arm, feasibility trial of surgical stabilisation versus non-surgical management of acute sacral fragility fractures in people aged 70 years and over. Patients will be randomised to either surgical or non-surgical group on a 1:1 ratio. Follow-up of participants will occur at 2, 4 and 12 weeks with safety data collected at 52 weeks. Primary objectives are to determine feasibility and design of a future trial, including outcomes on recruitment, adherence to randomisation and safety. This will be supplemented with a qualitative interview study of participants and clinicians. Secondary objectives will inform study design procedures to determine clinical and economic outcomes between groups, including scored questionnaires, analgesia requirements, resource use and quality of life data. Data analysis will be largely descriptive to inform outcomes and future sample size.Ethics and disseminationEthical approval was granted by the North East Newcastle and North Tyneside 2 Research Ethics Committee (reference 18/NE/0212). ASSERT was approved and sponsored by Nottingham University Hospitals NHS Trust (reference 18HC001) and the Health Research Authority (reference IRAS 232791). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals on study completion.Trial registration numberISRCTN16719542; Pre-results.

Fusobacterium nucleatum is part of the commensal flora of the oral cavity, frequently associated with periodontal infections. We describe the case of a 49-year-old woman, on immunsuppressive therapy for multiple sclerosis, who presented with a 3-month history of debilitating back pain. She had a recent episode of periodontitis, and was under regular dental review. Her MRI scan demonstrated findings suggestive of L2–L3 spondylodiscitis. Her CT-guided biopsy yielded negative cultures and the patient failed two courses of empirical antibiotic treatment. With clinical and radiological disease progression, she underwent a percutaneous disc washout and biopsy, which subsequently grew F. nucleatum. Treatment with clindamycin and metronidazole was commenced orally for 6 weeks. She improved gradually, and at 1 year follow-up was asymptomatic. The diagnosis of spondylodiscitis caused by F. nucleatum is challenging. The perseverance on identification by surgical biopsy, minimally invasive washout and targeted antibiotics are the mainstay of effective treatment.

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

Study design Systematic literature review and expert survey OBJECTIVE.: The aim of this study was to determine factors associated with neurologic improvement in patients with neurologic deficits secondary to metastatic epidural spinal cord compression (MESCC). Clear understanding of these factors will guide surgical decision-making by helping to elucidate which patients are more likely to benefit from surgery and how surgeons can increase the probability of neurologic and functional restoration. Summary of background data Surgical spinal cord decompression has been shown to improve neurologic function in patients with symptomatic MESCC. However, prognostication of neurologic improvement after surgery remains challenging, owing to sparse data and complexity of these patients. Methods PubMed and Embase databases were searched for relevant publications. PRISMA Statement guided publication selection and data reporting. GRADE guidelines were used for evidence quality evaluation and recommendation formulation. Results Low-quality evidence supports the use of the duration and severity of neurologic deficit as predictors of neurological recovery in patients with MESCC. Low-quality evidence supports the use of thoracic level of compression and previous irradiation as adverse predictors of neurological recovery. Nearly all of the AOSpine Knowledge Forum Tumor members who responded to the survey agreed that ambulation with assistance represented a successful surgical result and that duration of ambulation loss and the severity of weakness should be considered when trying to predict whether surgery would result in restoration of ambulation. Conclusions Review of literature and expert opinion support the importance of duration of ambulation loss and the severity of neurologic deficit (muscle strength, bladder function) in prediction of neurologic recovery among patients with symptomatic MESCC. Efforts to reduce the duration of ambulation loss and to prevent progression of neurologic deficits should be made to improve the probability of neurologic recovery. Level of evidence 2.

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.

Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status

Case A 33-year-old woman underwent C5-6 anterior cervical discectomy and fusion for progressive cervical myelopathy using an intergrated cage screw construct. Five weeks postoperatively, she presented with neck pain, worsening gait, and weakness after a slight jerk, with imaging showing peri-implant transverse fracture in the C6 vertebral body across the site of Caspar distractor pins and tips of the integrated cage screws. She was treated conservatively with hard collar with close observation, and at 6 months, she was asymptomatic with complete fracture union on imaging. Conclusion Peri-implant fracture in a cervical integrated cage screw construct is a rare complication, with biomechanical implications to the pathogenesis, which shows good clinical outcome to conservative treatment.

Purpose: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. Methods: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1–3 and 7–9). Results: Appropriateness outcomes showedclear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. Conclusions: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material. [Figure not available: see fulltext.].

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

Objective Evaluate the cost-effectiveness of minimally invasive surgery (MIS) compared with open surgery (OS) techniques for one- or two-level lumbar spinal fusion in the treatment of degenerative lumbar spinal conditions in the United Kingdom and Italy. Methods A health economic model was developed on the basis of results from a systematic literature review and meta-analysis to determine the cost-effectiveness of MIS compared with OS for lumbar spinal fusion. The analysis was conducted from a health care payer perspective. Parameters included in the model were surgery, blood loss, duration of hospitalization, postoperative complications, and health-related quality of life (HRQOL). Cost-effectiveness was determined by the incremental cost per quality-adjusted life-year gained. Results MIS was the dominant strategy compared with OS (i.e., yielding both cost savings and improved HRQOL). Cost savings were driven mainly by shorter length of hospital stay, reduced blood loss, and fewer complications such as surgical site infection. The total cost saving per procedure was €973 for Italy and €1666 for the United Kingdom, with an improvement of 0.04 quality-adjusted life-year over 2 years in HRQOL. One-way sensitivity analyses and predefined scenario(s) analyses confirmed the robustness of the model. Conclusions MIS is a less expensive and a more effective treatment compared with OS for spinal lumbar fusion in both Italy and the United Kingdom. Lower downstream costs and increased HRQOL in the MIS group compensate for potential higher upfront costs of MIS implants and surgery equipment.

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

The Scoliosis Research Society traveling fellowship was conceptualized in 1970, repeated in 1972, and, after a pause, restarted in 1993. International traveling fellows visiting North America first commenced in 2000 and have since alternated annually with the North American fellows. Although a senior fellow had always traveled with them, in 2012 the first senior international fellow traveled with the group. This year, the senior fellow was Daniel Chopin from the Neuro-Orthopedic Spine Unit, Lille University Hospital, France, and past Director of the Spine Center, Institut Calot Berck sur Mer (succeeding Dr. Cotrel). The junior fellows were Meric Enercan from the Florence Nightingale Hospital, Istanbul Spine Center, Turkey; J. Naresh-Babu from Mallika Spine Centre, Guntur, Andhra Pradesh, India; and Nasir A. Quraishi from the Centre for Spine Studies and Surgery, Queen's Medical Centre, Nottingham, UK. The host centers were initially suggested by Dr. Chopin, the senior fellow; after some minor tweaking and extensive planning from the Scoliosis Research Society office, the itinerary was confirmed. The researchers were to visit 7 centers in just over 3 weeks. All of the international fellows were going to have an extraordinary adventure although they had not met each other previously. As it turned out, the trip was indeed sensational—professionally stimulating and socially endearing. The following is a short report on this unforgettable experience.

Ankylosing spondylitis (AS) can result in severe cervico-thoracic kyphotic deformity (CTKD). Few studies have addressed the relationship between cervico-thoracic osteotomies in AS and health-related quality of life scores. The aim of this study is to evaluate the impact of cervico-thoracic osteotomy (CTO) on improving quality of life for patients with fixed CTKD. A database of all patients who underwent a CTO for CTKD in patients with AS was created. Data entered into the database consisted of patients’ demographics and comorbidities, as well as surgical, clinical and radiological data. The outcome measures used in our study were Neck Disability Index (NDI), EuroQol 5D-5L (EQ-5D-5L) and Visual Analogue Scale. We also measured the following radiological parameters: chin-brow to vertical angle (CBVA), C7-Slope, C2–7 angle, Regional Kyphosis Angle, C2–C7 sagittal vertical axis (SVA) and C7–S1 SVA. A total of 13 male patients with AS were included in our study. The mean age was 57.5 years (40–74); and mean follow-up was 37.6 months (12–78). Following the C7–T1 osteotomy (10 Smith Peterson Osteotomies and 3 Pedicle Subtraction Osteotomies), NDI improved from a mean of 65.54 (SD 8.95) to a mean of 22.09 (SD 6.99). The EQ-5D-5L improved from a mean of 0.41 (SD 0.16) to 0.86 (SD 0.088). Pre-operative CBVA was on average 54° (40°–75°) and post-operative was 7° (2°–12°). There were no major complications, 1 superficial infection and 5 minor nerve root irritations. Cervical osteotomy for the management of fixed flexion deformity of cervical spine in ankylosing spondylitis is a safe procedure and can result in restoration of horizontal gaze and sagittal balance with significant improvement of the patient’s health-related quality of life. These slides can be retrieved under Electronic Supplementary Material.

Multicenter, ambispective observational study.The aim of this study was to quantify local recurrence (LR) and mortality rates after surgical treatment of spinal giant cell tumor and to determine whether en bloc resection with wide/marginal margins is associated with improved prognosis compared to an intralesional procedure.Giant cell tumor (GCT) of the spine is a rare primary bone tumor known for its local aggressiveness. Optimal surgical treatment remains to be determined.The AOSpine Knowledge Forum Tumor developed a comprehensive multicenter database including demographics, presentation, diagnosis, treatment, mortality, and recurrence rate data for GCT of the spine. Patients were analyzed based on surgical margins, including Enneking appropriateness.Between 1991 and 2011, 82 patients underwent surgery for spinal GCT. According to the Enneking classification, 59 (74%) tumors were classified as S3-aggressive and 21 (26%) as S2-active. The surgical margins were wide/marginal in 27 (36%) patients and intralesional in 48 (64%) patients. Thirty-nine of 77 (51%) underwent Enneking appropriate (EA) treatment and 38 (49%) underwent Enneking inappropriate (EI) treatment. Eighteen (22%) patients experienced LR. LR occurred in 11 (29%) EI-treated patients and six (15%) EA-treated patients (P = 0.151). There was a significant difference between wide/marginal margins and intralesional margins for LR (P = 0.029). Seven (9%) patients died. LR is strongly associated with death (Relative Risk 8.9, P 0.001). Six (16%) EI-treated patients and one (3%) EA-treated patients died (P = 0.056). With regards to surgical margins, all patients who died underwent intralesional resection (P = 0.096).En bloc resection with wide/marginal margins should be performed when technically feasible because it is associated with decreased LR. Intralesional resection is associated with increased LR, and mortality correlates with LR.3.

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

Giant herniated thoracic discs (GHTD) remain a surgical challenge. When combined with calcification, these discs require altered surgical strategies and have only been infrequently described. Our objective was to describe our surgical approaches in the management of calcified GHTD. This was a retrospective cohort study of all patients with calcified GHTD operated between 2004 and 2012. Data were collected from review of patients’ notes and radiographs and included basic demographic and radiological data, clinical presentation and outcome, operative procedure and complications. During the study period, there were 13 patients with calcified GHTD, including 6 males and 7 females (mean age 55 years, range 31–83 years). The average canal encroachment was 62 % (range 40–90 %); mean follow-up 37 months (12–98). All patients were treated with anterior thoracotomy, varying degrees of vertebral resection, removal of calcified disc and with or without reconstruction. The average time for surgery was 344 min (range 212–601 min) and estimated blood loss 1,230 ml (range 350–3,000 ml). Post-operatively, 8 patients improved by 1 Frankel grade (62 %), 2 improved by 2 grades (15 %) and 3 did not change their grade (23 %). The complication rate was 4/13 (31 %; 3 patients with durotomies (2 incidental, 1 intentional) and 1 with recurrence). Calcified GHTD remain a surgical challenge. Anterior decompression through a thoracotomy approach, and varying degrees of vertebral resection with or without reconstruction allowed us to safely remove the calcified fragment. All patients remained the same (23 %) or improved by at least 1 grade (77 %) neurologically, without radiographic failure at final follow-up.