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A prospective cohort study To determine a classification system for cone of economy (CoE) measurements that defines clinically significant changes in altered balance and to assess if the CoE measurements directly impacts patients reported outcome measures (PROMs). Preoperative functional data is a crucial component of determining patient disability and prognosis. The CoE has been theorized to be the foundation of biomechanical changes that leads to increased energy expenditure and disability in spine patients. PROMs have been developed to quantify the level of debilitation in spine patients but have various limitations. A total of 423 symptomatic adult patients with spine pathology completed a series of PROMs preoperatively including VAS, ODI, Tampa Scale for Kinesiophobia (TSK), Fear and Avoidance Beliefs Questionnaire (FABQ), and Demoralization (DS). Functional balance was tested in this group using a full-body reflective marker set to measure head and center of mass (CoM) sway. PROMs scores were correlated with the magnitude of the CoE measurements. Patients were separated by the following proposed classification: CoM coronal sway > 1.5 cm, CoM sagittal sway > 3.0 cm, CoM total sway > 30.0 cm, head coronal sway > 3.0 cm, head sagittal sway > 6.0 cm, and head total sway > 60.0 cm. Significant differences were noted in the ODI (

Background Few studies have described rates of proximal clinical adjacent segment pathology (CASP) after posterior cervical decompression and fusion (PCDF). Objective To investigate rates of proximal CASP at C2 vs C3 in PCDFs for degenerative spine disease. Methods A retrospective review of 380 cases of PCDF for degenerative disease with proximal constructs ending at C2 vs C3 was performed. Minimum follow-up was 12 mo. The primary outcome was proximal CASP requiring reoperation. Variable analysis included demographic, operative, and complication data. Results There were 119 patients in the C2 group and 261 in the C3 group with no significant differences in age, gender, comorbidities, presenting symptoms, or complications. Vertebral artery injury rates were 0.8% in the C2 group and 0.0% in the C3 group (P = .12). No patients in the C2 group had reoperation for proximal CASP, while 5.0% of patients in the C3 group did (P = .01). Patients with arthrodesis up to C3 had an increased risk of proximal failure when the fusion construct crossed the cervicothoracic junction (P = .03). Multivariate logistic regression analysis showed no factors that were independently associated with re-instrumentation for proximal CASP. Conclusion Instrumenting to the C2 level reduces the risk for proximal CASP compared to fusion only up to C3. The type of instrumentation used at these 2 levels, form of ASP disease at C1-C2, and natural motion of the relevant proximal adjacent joint may contribute to this difference. Furthermore, within the C3 cohort, fusion across the cervicothoracic junction increased the risk for proximal CASP.

Background Patients with far lateral disc herniation (FLDH) experience more severe pain and sensory symptoms compared with those with paracentral disc herniation. In addition, surgical intervention has both been more challenging and resulted in poorer outcomes. Methods We report our experience with intraoperative computed tomography (iCT) navigation-assisted minimally invasive tubular microdiscectomy via a paramedian approach with electrophysiological monitoring for precise 3-dimensional anatomical localization and early electrophysiological identification of the exiting nerve. Results Five patients presenting with weakness and pain refractory to conservative management underwent iCT navigation surgery for lumbar FLDH with electrophysiological monitoring. The mean decrease in the visual analog scale pain score was −7.1 and the modified MacNab criteria outcomes were good in 1 patient and excellent in 4 patients. Conclusions These results from a small group of patients suggest this is a safe approach with the potential for improved outcomes in the surgical treatment of FLDH.

BACKGROUND CONTEXT Cervical spondylotic myelopathy (CSM) tends to produce a progressive decline in function characterized by gait disturbance, worsening balance and loss of upper extremity dexterity. Traditionally, the goal of decompressive surgery for CSM was to arrest neurological deterioration and prevent further disability rather than to provide functional recovery. In recent years, studies utilizing functional outcome measurements (FOMs) have demonstrated objective improvements in gait and balance dysfunction out to three months after surgery for CSM, but 1-year follow-up has yet to be reported. PURPOSE To determine whether the trends in improvements in gait, balance, pain levels, and psychological profiles observed at three months after cervical decompression for CSM continue out to one year postoperatively. STUDY DESIGN/SETTING Prospective, concurrent control cohort study. PATIENT SAMPLE The study included 22 symptomatic CSM patients, 20 age-matched healthy control volunteers (C). OUTCOME MEASURES Gait and balance parameters, neck disability index (NDI), Visual analog scale (VAS) neck, and psychological measures – Tampa Scale for Kinesiophobia (TSK) and Fear Avoidance Beliefs Questionnaire (FABQ). METHODS Patients performed gait and balance evaluations prior to surgery (Pre) and at 3 months (Post3) and 12 months (Post12) postoperatively. Functional data were recorded and analyzed using human motion capture and dynamic surface EMG. Patients also completed outcomes questionaries at the same time points. Repeated measurements and one-way analysis of variance (ANOVA) were used to analyze data. RESULTS Continued improvement in multiple gait parameters was observed out to one year postoperatively: faster walking speed (Post3: 0.92 vs Post12: 0.99 m/s, p=0.048; C: 1.02 m/s, p>0.050), shorter step time (Post3: 0.44 vs Post12: 0.42 s, p=0.041; C: 0.42 s, p>0.050), and longer step length (Post3: 0.52 vs Post12: 0.55, p=0.048; C: 0.57, p>0.050). Additional gains in balance occurred between 3 and 12 months: head total sway (Post3: 57.70 vs Post12: 51.35 cm, p=0.045 cm; C: 46.42, p>0.050) as well as cone of economy (CoE) dimensions in the coronal plane for both the head (Post3: 3.14 vs Post12: 2.55 cm, p=0.037 cm; C: 2.19, p>0.050) and center of mass (Post3: 2.11 vs Post12: 1.85 cm, p=0.034 cm; C: 1.64, p>0.050). There were significant improvements in all PROMs after surgery: VAS neck (Pre: 5.4, Post3, 2.1, Post12 1.3, p CONCLUSIONS This study reports objective functional measures and psychological outcomes in addition to standard patient-reported outcome measures for CSM patients out to one year postoperatively, thereby providing a comprehensive global assessment of their recovery. Select measures of gait and balance improved at all time points postoperatively and ultimately resembled those of the healthy controls at one year. These results provide important insight regarding the continued recovery that occurs between 3 and 12 months after surgical decompression for CSM. In turn, this information enriches the discussion surgeons can have with patients before and after surgery. FOMs provide both clinicians and patients with a more detailed and sensitive assessment of overall treatment outcomes and the timeframe of functional recovery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Changes in balance are common in individuals with spinal disorders and may cause falls. Balance efficiency, is the ability of a person to maintain their center of gravity with minimal neuromuscular energy expenditure, oftentimes referred to as Cone of Economy (CoE). CoE balance is defined by two sets of measures taken from the center of mass (CoM) and head: 1) the range-of-sway (RoS) in the coronal and sagittal planes, and 2) the overall sway distance. This allows spine caregivers to assess the severity of a patient's balance, balance pattern, and dynamic posture and record the changes following surgical intervention. Maintenance of balance requires coordination between the central nervous and musculoskeletal systems.To discern differences in balance effort values between common degenerative spinal pathologies and a healthy control group.Three-hundred and forty patients with degenerative spinal pathologies: cervical spondylotic myelopathy (CSM), adult degenerative scoliosis (ADS), sacroiliac dysfunction (SIJD), degenerative lumbar spondylolisthesis (DLS), single-level lumbar degeneration (LD), and failed back syndrome (FBS), and 40 healthy controls were recruited. A functional balance test was performed approximately one week before surgery recorded by 3D video motion capture.Balance effort and compensatory mechanisms were found to be significantly greater in degenerative spinal pathologies patients compared to controls. Head and Center of Mass (CoM) overall sway ranged from 65.22 to 92.78 cm (p 0.004) and 35.77-53.31 cm (p 0.001), respectively in degenerative spinal pathologies patients and in comparison to controls (Head: 44.52 cm, CoM: 22.24 cm). Patients with degenerative spinal pathologies presented with greater trunk (1.61-2.98°, p 0.038), hip (4.25-5.87°, p 0.049), and knee (4.55-6.09°, p 0.036) excursion when compared to controls (trunk: 0.95°, hip: 2.97°, and knee: 2.43°).The results of this study indicate that patients from a wide variety of degenerative spinal pathologies similarly exhibit markedly diminished balance (and compensatory mechanisms) as indicated by increased sway on a Romberg test and a larger Cone of Economy (CoE) as compared to healthy controls. Balance effort, as measured by overall sway, was found to be approximately double in patients with degenerative spinal pathologies compared to healthy matched controls. Clinicians can compare CoE parameters among symptomatic patients from the different cohorts using the Haddas' CoE classification system to guide their postoperative prognosis.

Metastatic spinal disease is a source of significant morbidity in patients with cancer. Recent advancements in adjuvant oncologic therapy has led to increased survival for many patients who harbor neoplastic disease. As a result of this, the chance of developing metastatic spinal disease over the course of a cancer patient's lifespan has increased. Symptomatic metastatic spinal disease can cause significant morbidity including severe pain, neurologic deficit, and loss of ambulation. Current treatment of these patients typically involves the use of multiple modalities, including surgery, radiation, and chemotherapy. Areas covered: An extensive literature review was performed to support the author's opinion on the matter of surgical management of spinal metastatic disease. Pubmed was utilized as a primary search engine. Expert commentary: Despite advances in chemotherapy and radiation therapy, surgery remains a mainstay in many of these patients, particularly with those with either significant metastatic spinal epidural compression or spinal instability. This review discusses the surgical management of metastatic spinal disease including a framework for decision making and technical considerations when deciding to operate on these patients.

Retrospective comparative study.To compare clinical and radiographic outcomes between the S2-alar-iliac (S2AI) and the iliac screw (IS) techniques in the adult population and clarify the clinical strength of S2AI screws.S2AI screws have been described as an alternative method for lumbosacropelvic fixation in place of ISs. The S2AI technique has several advantages with lower prominence, increased ability to directly connect to proximal instrumentation, less extensive dissection of tissue, and enhanced biomechanical strength over the IS technique. However, the clinical significance of these advantages remains unclear.A single-center retrospective review of patients who underwent lumbosacropelvic fixation yielded 25 IS group patients and 65 S2AI group patients. Baseline demographic information, postoperative complications, pain and functional outcomes, and screw-related outcomes were collected.The S2AI group had lower rates of reoperation (8.8% vs. 48.0%, P 0.001), surgical site infection (SSI) (1.5% vs. 44.0%, P 0.001), wound dehiscence (1.5% vs. 36.0%, P 0.001), and symptomatic screw prominence (0.0% vs. 12.0%, P = 0.02) than the IS group, whereas rates of L5-S1 pseudarthrosis, proximal junctional failure, and sacroiliac joint pain were similar in both groups. Statistically significant pain relief and functional recovery were achieved in both groups without any significant intergroup differences. On multivariate analyses, age [odds ratio (OR) = 0.91, P = 0.004] and S2AI instrumentation (OR = 0.08, P 0.001) were protective of reoperation, whereas diabetes mellitus (OR = 10.9, P = 0.03) and preoperative diagnosis of tumor (OR = 12.3, P = 0.04) were associated with SSI, and S2AI instrumentation (OR = 0.09, P 0.001) was protective of SSI.The use of the S2AI technique over the IS technique was an independent predictor of preventing reoperation and SSI, while achieving similar clinical and functional outcomes.4.

STUDY DESIGN A prospective cohort study. OBJECTIVE Quantify the extent of change in dynamic balance and stability in a group of patients with cervical spondylotic myelopathy (CSM) after cervical decompression surgery and to compare them with matched healthy controls. SUMMARY OF BACKGROUND DATA CSM is a naturally progressive degenerative condition that commonly results in loss of fine motor control in the hands and upper extremities and in gait imbalance. Whereas this was previously thought of as an irreversible condition, more recent studies are demonstrating postoperative improvements in balance and stability. MATERIALS AND METHODS Thirty subjects with symptomatic CSM and 25 matched asymptomatic controls between the ages of 45 and 75 years underwent functional balance testing using a 3D motion capture system to gather kinematic and spatiotemporal parameters. CSM subjects underwent testing 1 week before surgery and again 3 months postoperatively. RESULTS Patients with CSM exhibited markedly diminished balance as indicated by increased sway on a Romberg test and requiring significantly more time and a wider stance to complete tandem gait tests. The surgical intervention resulted in improved balance at the 3-month postoperative time point; however, kinematic and spatiotemporal parameters did not completely normalize to the levels observed in asymptomatic controls. CONCLUSIONS Human motion video capture can be used to robustly quantify balance parameters in the setting of CSM. Compared with healthy controls, such patients exhibited increased standing sway and poorer performance on a tandem gait task. The surgical intervention resulted in significant improvement in many of the measures of functional balance, but overall profiles had not completely returned to normal when measured 3 months after surgery. These data reinforce the importance of operative intervention in the treatment of symptomatic CSM with the goal of halting disease progress but the expectation that balance may actually improve postoperatively.

Pathology of the craniocervical junction (CCJ) is challenging to treat due to the complex bony, ligamentous, and neurovascular structures that comprise this region. There are many unique pathologies of the CCJ, including spine tumors, arthritides, and fractures, each of which requires comprehensive treatment strategies, which often include surgery. Determining the optimal surgical approach to the CCJ is based on the goals of surgical intervention and location of the pathology. In general, the approach is dictated based on whether the pathology is ventral or dorsal to the spinal cord, its location within the CCJ, and the extent of involvement of adjacent neurovascular structures. The transmandibular approach, despite its associated morbidity, is a useful technique in the surgical armamentarium to address ventral CCJ pathology. We describe the indications for this approach, how to successfully perform the procedure, and the associated intraoperative and post-operative risks.

Background In sacropelvic fixation, the iliac screw technique offers biomechanically strong constructs, but its disadvantages include screw prominence, wound dehiscence, and postoperative pain secondary to the high profile nature. To overcome this drawback, S2-alar-iliac (S2AI) screws were developed as an alternative technique for sacropelvic fixation. This study aimed to compare the S2AI screw technique with the iliac screw technique in terms of postoperative symptomatic screw prominence. Methods A retrospective review of the records of sacropelvic fusion procedures performed at a single institution between October 2010 and January 2015 identified 32 patients with 72 iliac screws and 68 patients with 148 S2AI screws, and clinical and radiographic data were collected. If a patient had wound dehiscence and/or tenderness in the buttock immediately overlying a pelvic screw head postoperatively, it was defined as symptomatic screw prominence. The minimal distance from screw head to skin (MDSS) on postoperative computed tomography scans was measured for each patient to clarify the relationship between symptomatic screw prominence and MDSS. Results Mean follow-up period was 22.0 months. There was significantly more symptomatic pelvic screw prominence in the iliac screw group (11.1% vs. 1.4%, P = 0.002). MDSS ≤23 mm was the strongest predictor of symptomatic pelvic screw prominence, which yielded sensitivity of 100%, specificity of 94.1%, positive predictive value of 47.6%, and negative predictive value of 100%. Conclusions The use of the S2AI screw technique resulted in a reduced rate of symptomatic screw prominence. MDSS ≤23 mm was the strongest predictor of symptomatic screw prominence.

Objective The objective of this study is to analyze time to surgery as both a continuous and discrete variable to determine its association with outcomes in cauda equina syndrome (CES). Methods Patients at a single center whose medical record allowed precise calculation of time to surgery were included. CES was defined as at least four of the following: bladder dysfunction, saddle anesthesia, lower extremity weakness, lower extremity sensory disturbance, bowel dysfunction, or acute lower back or leg pain. Time to surgery was analyzed as a continuous variable using logistic and ordered logistic regression, and as a discrete variable by comparing patients treated before and after set thresholds. Results Forty-five patients were identified. Analysis of time as a continuous variable did not reveal any significant association with outcomes. A parsimonious model with adjustment for age, sex, race, acute onset of CES, saddle anesthesia, motor deficit, and bowel dysfunction at presentation was used to analyze the continuous influence of time to surgery on bladder dysfunction and an aggregate outcome of symptoms. Neither time to surgery nor any of the covariates were significantly associated with either outcome. Discrete analysis of outcomes across thresholds of 12, 24, 36, 48, 60, and 72 hours did not reveal prognostic time points. Conclusion In this single-center CES series, time to surgery did not have a convincing continuous or discrete relationship with outcome. Future prospective studies are needed to determine the best timing for surgery in patients with CES.

Pseudarthrosis occurs after approximately 2-20% of anterior cervical discectomy and fusion (ACDF) procedures; it is unclear if posterior or anterior revision should be pursued. In this study, we retrospectively evaluate the outcomes in 22 patients with pseudarthrosis following ACDF and revision via posterior cervical fusion (PCF). Baseline demographics, preoperative symptoms, operative data, time to fusion failure, symptoms of pseudarthrosis, and revision method were assessed. Fusion outcome and clinical outcome were determined at last follow-up (LFU). Thirteen females (59%) and 9 (41%) males experienced pseudarthrosis at a median of 11 (range: 3-151)months after ACDF. Median age at index surgery was 51 (range: 33-67)years. All patients with pseudarthrosis presented with progressive neck pain, with median visual analog scale (VAS) score of 8 (range: 0-10), and/or myeloradiculopathy. Patients with pseudarthrosis12 months compared to12 months after index surgery were older (p=0.013), had more frequent preoperative neurological deficits (p=0.064), and lower baseline VAS scores (p=0.006). Fusion was successful after PCF in all patients, with median time to fusion of 10 (range: 2-14)months. Eighteen patients fused both anteriorly and posteriorly, two patients fused anteriorly only, and two patients fused posteriorly only. Median VAS neck score at LFU significantly improved from the time of pseudarthrosis (p=0.012). While uncommon, pseudarthrosis may occur after ACDF. All patients achieved successful fusion after subsequent posterior cervical fusion, with 91% fusing a previous anterior pseudarthrosis after posterior stabilization. Neck pain significantly improved by LFU in the majority of patients in this study.

OBJECT Spinal metastases from gynecological cancers are rare, with few cases reported in the literature. In this study, the authors examine a series of patients with spinal metastases from gynecological cancer and review the literature. METHODS The cases of 6 consecutive patients who underwent spine surgery for metastatic gynecological cancer between 2007 and 2012 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by change in Karnofsky Performance Scale and the American Spine Injury Association (ASIA) score during follow-up. A systematic review of the literature was also performed to evaluate outcomes for patients with similar gynecological metastases to the spine. RESULTS In this series, details regarding metastatic gynecological cancers to the spine are as follows: 2 patients with cervical cancer (both presented at age 46 years, mean postoperative survival of 32 months), 2 patients with endometrial cancer (mean age of 40 years, mean postoperative survival of 26 months), and 2 patients with leiomyosarcoma (mean age of 44 years, mean postoperative survival of 20 months). All patients presented with pain, and no complications were noted following surgery. All patients with known follow-up had stable or improved neurological outcomes, performance status, and improved pain, without local recurrence of tumor. Overall median survival after diagnosis of metastatic spine lesions for all cases in the literature as well as those treated by the authors was 15 months. When categorized by type, median survival of patients with cervical cancer (n = 2), endometrial cancer (n = 26), and leiomyosarcoma (n = 16) was 32, 10, and 22.5 months, respectively. CONCLUSIONS Gynecological cancers metastasizing to the spine are rare. In this series, overall survival following diagnosis of spinal metastasis and surgery was 27 months, with cervical cancer, endometrial cancer, and leiomyosarcoma survival being 32, 26, and 20 months, respectively. Combined with literature cases, survival differs depending on primary histology, with decreasing survival from cervical cancer (32 months) to leiomyosarcoma (22.5 months) to endometrial cancer (10 months). Integrating such information with other patient factors may more accurately guide decision making regarding management of such spinal lesions.

Background Posterior atlantoaxial fusion is an important armamentarium for neurosurgeons to treat several pathologies involving the craniovertebral junction. Although the potential advantages of recombinant human bone morphogenetic protein-2 (rhBMP-2) are well documented in the lumbar spine, its indication for C1-C2 fusion has not been well characterized. In our institution, we apply rhBMP-2 to the C1-C2 joint either alone or with hydroxyapatite, locally harvested autograft chips, and/or morselized allogenic bone graft for selected cases—without conventional posterior structural bone graft. We report the clinical outcomes of the surgical technique to elucidate its feasibility. Methods We performed a single-center, retrospective review of data from 2008 to 2016 and identified 69 patients who had undergone posterior atlantoaxial fusion with rhBMP-2. The clinical records of these patients were reviewed, and the baseline characteristics, operative data, and postoperative complications were collected and statistically analyzed. Results The average age of the 69 patients was 60.8 ± 4.5 years, and 55.1% were women. With an average follow-up period of 21.1 ± 4.2 months, the C1-C2 fusion rate was 94.3% (65 of 69), and the average time to fusion was 11.4 ± 2.6 months (range, 5–23). The overall reoperation rate was 10.1% (7 of 69), with instrumentation failure in 7 patients (10.1%), adjacent segment disease in 2 (2.9%), and postoperative dysphagia and dyspnea in 2 patients (2.9%). No ectopic bone formation or soft tissue edema developed. Conclusions Although retrospective and from a single center, our study has shown that rhBMP-2 usage at the C1-C2 joint without posterior structural bone grafting is a safe and reasonable surgical option.

Background: Transforaminal lumbar endoscopic discectomy is a minimally invasive surgical procedure that can be performed in awake patients through an incision less than 1 cm. The procedure requires very little bony removal to access the herniated disc material because the approach is through the foramen, and only a small amount of the superior articulating process is removed to access Kambin’s triangle. This study describes our experience with transforaminal endoscopic lumbar decompression (TELD) for the treatment of lumbar disc herniation. We evaluate the risk for reherniation in the first year after surgery and the characteristics of the patients who experience reherniation. Methods: We describe the technique for the transforaminal endoscopic approach to treat lumbar disc herniations. Retrospectively, a series of 141 consecutive patients, who were operated on with lumbar radiculopathy, was analyzed. We excluded patients who had previous surgery at the lumbar level, surgeries done for disease adjacent to a fusion, and surgeries done for spondylolisthesis. A total of 84 consecutive patients were included who had single level lumbar non-revision surgery and at least 1-year follow up. Results: A series of 46 consecutive male and 38 female patients with an average age of 57.4 years (range, 28–87 years old) who underwent transforaminal endoscopic treatment for lumbar disc herniations between 2014 and 2016 is presented. Four patients required microdiscectomy due to reherniation at 5 months, 8 months, 9 months, and 10 months postoperatively. All the patients in the series improved immediately following their endoscopic procedures, and no patients presented with symptoms suggestive of reherniation until 5 months after their initial endoscopic surgery. Patients with reherniation tended to be young: 31, 45, 48, and 49 years of age: all less than the average patient age who underwent endoscopic surgery. Conclusions: Transforaminal endoscopic surgical access to lumbar disc herniations is an ultra-minimally invasive approach for the treatment lumbar degenerative disc disease. It allows for neural decompression by removing disc and foraminal pathology with minimal bone removal. This minimal bone removal prevents iatrogenic destabilization. However, the 1-year reherniation rate presented here is 4.7%. This suggests that the benefit of this technique may be that it is ultra-minimally invasive, but it may only be equal, not superior to microdiscectomy in its rate of reherniation.

Transforaminal endoscopic spine surgery is an emerging technique in spine surgery, but it offers 2 distinct challenges to spine surgeons looking to adopt it: 1) targeting spine pathology and 2) understanding the endoscopic anatomy visualized through the endoscope. Intraoperative computed tomography (CT)-guided navigation is also an emerging technique in spine surgery that is becoming widely adopted for its benefits in assisting surgeons in localizing pathology and guided spine instrumentation placement. In this technical note, we describe a technique that uses intraoperative CT-guided navigation concomitantly with a transforaminal endoscopic approach to decompress a L4-L5 foraminal heterotopic bone formation after an oblique lumbar interbody fusion. The addition of intraoperative CT-guided navigation proved beneficial in targeting the pathology during the procedure and ensuring that the pathology was resolved by offering postoperative CT visualization of the decompressed neural foramen.

BACKGROUND CONTEXT Cervical spondylotic myelopathy (CSM) is a neurologic condition resulting from spinal cord compression due to degenerative narrowing of the spinal canal. It is the most common cause of spinal cord dysfunction in patients older than 50. Symptoms of CSM may include numbness or weakness in the extremities, loss of fine motor dexterity, and difficulty with balance and gait. The natural history is typically one of progressive decline in neurologic function, so surgery to decompress the spinal cord is generally indicated to prevent progression in symptomatic patients. Despite the prevalence of this condition, relatively little quantitative kinematic information is available on the effect of surgical intervention on the gait of patients with CSM. PURPOSE To evaluate for changes in the spine and lower extremity range of motion (RoM) during gait in patients with CSM before and after surgical intervention. STUDY DESIGN/SETTING Non-randomized, prospective, concurrent cohort study. PATIENT SAMPLE Thirty-eight patients with symptomatic CSM. OUTCOME MEASURES Lower extremity and spine range of motion (RoM), spatiotemporal parameters, and pain level. METHODS Clinical gait analysis was performed one week before surgery (Pre) and three months after surgery (Post). Fifty reflective markers (9.5 mm diameter) attached to the patients; bodies were utilized to collect full body three-dimensional kinematics using 10 cameras (VICON) at a sampling rate of 100 Hz. Each patient performed a series of over-ground gait trials at a comfortable, self-selected speed. Neck and mid-back visual analog scale (VAS), Oswestry Disability Index (ODI), and Neck Disability Index (NDI) scores were also collected at both time points. Repeated measurements ANOVA was used to analyze data. RESULTS When comparing preoperative to postoperative gait parameters, significant increases in walking cadence (98.28 vs 103.37 steps/minutes, p=0.004), stride length (1.02 vs 1.07 m, p=0.018), and walking speed (0.86 vs 0.94 m/s, p=0.001) were observed. The amount of time spent in double support decreased after surgery (0.37 vs 0.32 s, p=0.032). The only significant difference in spine and lower extremity joint RoM measures was a decline in coronal RoM of both the knees and ankles postoperatively. VAS neck and mid-back as well as ODI improved significantly postoperatively, while the reduction in NDI did not attain statistical significance. CONCLUSIONS Despite conventional teaching that the goal of surgical intervention for CSM is to halt symptomatic progression, the data presented here demonstrate that significant improvements in gait are frequently observed after surgical management of CSM. Postoperative patients walk more quickly as a result of increased stride length and cadence. Furthermore, they lift their knees and dorsiflex/plantarflex their ankles less, consistent with a more efficient gait pattern. While surgeons should remain conservative with respect to how they counsel patients and set expectations preoperatively, cautious optimism regarding improvements in gait may be warranted in the setting of surgery for CSM. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT The sacroiliac joint (SIJ) is an underappreciated pain generator in 15-30% of patients with low back pain. The SIJ functions as a primary structure which transfers loads of the upper body to the lower extremities. Sacroiliac joint dysfunction (SIJD) is characterized by SIJ laxity with symptoms manifesting primarily as low back and lower extremity pain. Additionally, there is growing evidence that gait patterns may also be affected by SIJD. Although there is still much controversy, minimally invasive sacroiliac fusion (SIF) is gaining interest as a procedure for SIJD patients with unremitting pain. SIF aims to reduce SI pain by stabilizing the SIJ and improving structural support between the sacrum and ilium. While positive outcomes for improved pain and reduced opioid consumption have been associated with SIF, there is a lack of research concerning the effects of SIF on functional biomechanics such as gait performance. PURPOSE To quantify the effects of SIF on biomechanical gait parameters of SIJD patients at three months postoperative follow-up compared to their preoperative state. STUDY DESIGN/SETTING Non-randomized, prospective, concurrent cohort study. PATIENT SAMPLE Twelve symptomatic SIJD patients. OUTCOME MEASURES Spatiotemporal parameters, gait range-of-motion (RoM) parameters, and patient-reported outcomes. METHODS Clinical gait analysis was performed one week before surgery (Pre) and three months after surgery (Post). Each patient performed a series of over-ground gait trials at a comfortable, self-selected speed. Data were collected using a motion capture system and three force plates. Back and leg Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Fear Avoidance Beliefs Questionnaire (FABQ), Tampa Scale for Kinesiophobia (TSK), and Demoralization Scale (DS) scores were also collected at both time points. RESULTS Patients showed increased cadence (Pre: 98.39 vs Post: 106.95 steps/min, p=0.018) and walking speed (Pre: 0.87 vs Post: 1.03 m/s, p=0.013). Patients also showed decreases in stride time (Pre: 1.28 vs Post: 1.14 s, p=0.015), step time (Pre: 0.65 vs Post: 0.58 s, p=0.015), and double-support time (Pre: 0.37 vs Post: 0.29 s, p=0.024). Patients show significant decreases in both knee RoM (Pre: 15.25 vs Post: 10.79°, p=0.02) and head motion (Pre: 4.80 vs Post: 3.18 °, p=0.045) in the coronal plane. VAS leg pain score (Pre: 4.25 vs Post: 2.69, p=0.032) improved significantly postoperatively. CONCLUSIONS SIJD patients treated with SIF showed significant improvements in functional gait and leg pain at their three-month follow-up. The results suggest that SIF provides improved lateral stability which in turn results in more efficient knee motion and improved cadence and step efficiency. The improved leg VAS scores reflect this notion as well. The lack of more pronounced improvements in gait and reported outcomes may be due to insufficient follow-up time to account for a full recovery following SIF. This study may serve as a basis for future diagnostic techniques which utilize gait pattern evaluation as an indicator for early development of SIJD. The findings of this study highlight the impacts that SIJD can have on patients daily lives and reinforces the importance of recognizing the SIJ as a contributor to the functional ability of an individual. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Incidental durotomy is one of the most common intraoperative complications in spine surgery, including deformity surgery. Unrecognized tears or tears that fail to seal in spite of treatment may result in cerebrospinal fluid (CSF) fistula formation and leak. In turn, CSF leaks may lead to severe postoperative headache, back pain, fluid accumulation and increased risk of infection. In this chapter, the authors present a case of a patient who underwent surgery for spinal deformity and developed a postoperative pseudomeningocele. Additionally, the causes, diagnosis, management, complications, and outcomes of CSF leak are discussed.

Background context A persistent challenge in spine surgery is improving screw fixation in patients with poor bone quality. Augmenting pedicle screw fixation with cement appears to be a promising approach. Purpose The purpose of this study was to survey the literature and assess the previous biomechanical studies on pedicle screw augmentation with cement to provide in-depth discussions of the biomechanical benefits of multiple parameters in screw augmentation. Study design/Setting This is a systematic literature review. Methods A search of Medline was performed, combining search terms of pedicle screw, augmentation, vertebroplasty, kyphoplasty, polymethylmethacrylate, calcium phosphate, or calcium sulfate. The retrieved articles and their references were reviewed, and articles dealing with biomechanical testing were included in this article. Results Polymethylmethacrylate is an effective material for enhancing pedicle screw fixation in both osteoporosis and revision spine surgery models. Several other calcium ceramics also appear promising, although further work is needed in material development. Although fenestrated screw delivery appears to have some benefits, it results in similar screw fixation to prefilling the cement with a solid screw. Some differences in screw biomechanics were noted with varying cement volume and curing time, and some benefits from a kyphoplasty approach over a vertebroplasty approach have been noted. Additionally, in cadaveric models, cemented-augmented screws were able to be removed, albeit at higher extraction torques, without catastrophic damage to the vertebral body. However, there is a risk of cement extravasation leading to potentially neurological or cardiovascular complications with cement use. A major limitation of these reviewed studies is that biomechanical tests were generally performed at screw implantation or after a limited cyclic loading cycle; thus, the results may not be entirely clinically applicable. This is particularly true in the case of the bioactive calcium ceramics, as these biomechanical studies would not have measured the effects of osseointegration. Conclusions Polymethylmethacrylate and various calcium ceramics appear promising for the augmentation of pedicle screw fixation biomechanically in both osteoporosis and revision spine surgery models. Further translational studies should be performed, and the results summarized in this review will need to be correlated with the clinical outcomes.

Study Design Retrospective study. Objective Our objective was to identify preoperative prognostic factors associated with survival in patients with spinal metastasis from lung carcinoma. Methods A retrospective analysis of 26 patients diagnosed with lung carcinoma metastatic to the spinal column was performed to determine factors associated with survival. We used 3 months survival as the clinical cutoff for whether surgical intervention should be performed. We analyzed patients who survived less than 3 months compared with those who survived more than 3 months. Demographic, preoperative, operative, and postoperative factors including functional scores were collected for analysis. Results The median survival for all patients in our study was 3.5 months. We found a statistically significant difference between the group that survived less than 3 months and the group that survived greater than 3 months in terms of extrathoracic metastasis, visceral metastasis, and average postoperative modified Rankin score. Conclusion Determining which patients with lung cancer spinal metastases will benefit from surgical intervention is often dictated by the patient's predicted life expectancy. Factors associated with poorer prognosis include age, functional status, visceral metastases, and extrathoracic metastases. Although the prognosis for patients with lung cancer spinal metastases is poor, some patients may experience long-term benefit from surgical intervention.

A 3-dimensional-2-dimensional (3D-2D) image registration algorithm, "LevelCheck," was used to automatically label vertebrae in intraoperative mobile radiographs obtained during spine surgery. Accuracy, computation time, and potential failure modes were evaluated in a retrospective study of 20 patients.To measure the performance of the LevelCheck algorithm using clinical images acquired during spine surgery.In spine surgery, the potential for wrong level surgery is significant due to the difficulty of localizing target vertebrae based solely on visual impression, palpation, and fluoroscopy. To remedy this difficulty and reduce the risk of wrong-level surgery, our team introduced a program (dubbed LevelCheck) to automatically localize target vertebrae in mobile radiographs using robust 3D-2D image registration to preoperative computed tomographic (CT) scan.Twenty consecutive patients undergoing thoracolumbar spine surgery, for whom both a preoperative CT scan and an intraoperative mobile radiograph were available, were retrospectively analyzed. A board-certified neuroradiologist determined the "true" vertebra levels in each radiograph. Registration of the preoperative CT scan to the intraoperative radiograph was calculated via LevelCheck, and projection distance errors were analyzed. Five hundred random initializations were performed for each patient, and algorithm settings (viz, the number of robust multistarts, ranging 50-200) were varied to evaluate the trade-off between registration error and computation time. Failure mode analysis was performed by individually analyzing unsuccessful registrations (5 mm distance error) observed with 50 multistarts.At 200 robust multistarts (computation time of ∼26 s), the registration accuracy was 100% across all 10,000 trials. As the number of multistarts (and computation time) decreased, the registration remained fairly robust, down to 99.3% registration accuracy at 50 multistarts (computation time ∼7 s).The LevelCheck algorithm correctly identified target vertebrae in intraoperative mobile radiographs of the thoracolumbar spine, demonstrating acceptable computation time, compatibility with routinely obtained preoperative CT scans, and warranting investigation in prospective studies.N/A.

Objective To present diagnosis and surgical management of postlaminectomy spondylolisthesis in patients without preoperative instability and a review of relevant literature. Methods Medical records and radiographic studies of 105 patients who underwent first-time bilateral 1- to 4-level open laminectomies for degenerative lumbar disease at a single academic institution were reviewed. Patients who initially presented with listhesis and had additional discectomy or fusion procedures were excluded. Results Of 105 patients with laminectomies across 1–4 levels, 10 patients (9.5%; 5 men and 5 women with average age of 63.0 ± 11.2 years) developed subsequent iatrogenic spondylolisthesis at the same operative levels that required reoperation. New or worsening low back pain and lower extremity pain were reported over an average period of 19.0 ± 17.5 months postoperatively. Imaging studies showed new spondylolisthesis that was not present before the index surgery, most commonly at L4-L5 level. All patients were treated surgically with posterior instrumented fusion. The average period between the first and second surgery was 32.6 ± 19.9 months. Surgical reduction of spondylolisthesis resulted in significant clinical improvement of patients' symptoms. Conclusions In patients without overt pre-existing instability, laminectomy for lumbar stenosis can disrupt spinal stability and result in iatrogenic spondylolisthesis. The extent of decompression of the facet joints, number of levels decompressed, and preoperative disc space height can help assess the risk of postoperative spondylolisthesis. Patients who develop recurrent radiculopathy after decompressive lumbar laminectomy should be evaluated for potential iatrogenic spondylolisthesis.

Study Design: Retrospective cohort study. Objective: The S2-alar-iliac (S2AI) technique has been described as an alternative method for pelvic fixation in place of iliac screws (ISs) in spinal deformity surgery. The objective of this study was to analyze the impact of S2AI screws on radiographical outcomes, including spinopelvic parameters. Methods: A retrospective review of 17 patients receiving ISs and 46 patients receiving S2AI screws for correction of adult spinal deformity between 2010 and 2015 with minimum 1-year follow-up was conducted. Patient data on postoperative complications, including reoperation rates and proximal junctional kyphosis (PJK), and radiographical parameters was collected and statistically analyzed. Results: With mean follow-up of 21.1 months, the overall reoperation rate was significantly lower in the S2AI group than in the IS group (21.7% vs 58.8%, P = .01), but the incidence of PJK was similar (32.6% vs 35.3%, P > .99). Moreover, the time to reoperation in the IS group was significantly shorter than in the S2AI group (P = .001), and the S2AI group trended toward a longer time to reoperation due to PJK (P = .08). There was a significantly higher change in pelvic incidence (PI) in the S2AI group (−6.0°) compared with the IS group (P = .001). Conclusions: Compared with the IS technique, the S2AI technique demonstrated a lower rate of overall reoperation, a similar rate of PJK, longer time to reoperation, and possible reduction in PI. Future studies may be warranted to clarify the mechanism of these results and how they can be translated into improved patient care.

To investigate the prognostic value of preoperative Nurick grade and time with symptoms for gait improvement and recovery in patients with ataxia secondary to cervical myelopathy.A retrospective chart review of all adult patients who underwent surgical decompression for cervical myelopathy between 1996 and 2013 was performed. Only adults with a Nurick grade of at least 2 or worse were included. Outcome measures included gait improvement and recovery.A total of 170 patients were identified. Gait improvement and gait recovery occurred in 57.7% and 45.9% of patients, respectively. Time to improvement occurred as early as 1 month up to 24 months postoperatively. A greater preoperative Nurick grade was associated with lower odds of gait improvement (odds ratio 0.74; 95% confidence interval 0.53-0.99, P = 0.048) and gait recovery (odds ratio 0.27; 95% confidence interval 0.17-0.43, P0.001). The proportion of patients with symptoms for 12 months or less that experienced gait improvement was 71.2%, compared with 36.4% for patients with symptoms for over 12 months (P0.001). Patients with symptoms for 12 months or less had a 59.6% gait recovery rate, compared to 24.2% in patients with symptoms for over 12 months (P0.001). Having symptoms for over 12 months was independently associated with lower odds of improvement and recovery.Patients with a greater preoperative Nurick grade and symptoms for more than 12 months may have significantly lower odds of experiencing gait improvement or gait recovery after surgery for cervical myelopathy. This study's conclusion favors early intervention in patients with cervical myelopathy.

Pain is very common in patients with spine tumors. It is multifactorial and can be subdivided into neurogenic, mechanical, and oncologic biological pain. Understanding the type of pain can guide the clinician in regard to selecting the appropriate treatment. Furthermore, spinal tumors have three general locations: (1) intramedullary-intradural; (2) extramedullary-intradural; (3) extra-dural. The location of these tumors influences the surgical approaches and strategies.

As the number of elderly continues to increase in the USA, the number of people affected by adult deformity is expected to rise. In the USA, as many as 60 % of the elderly demonstrate some degree of adult spinal deformity (ASD) [1]. Adult spinal deformity, including scoliosis and sagittal plane deformities, is a relatively common finding [1–3] and is broadly classified into two subgroups, adult idiopathic and adult degenerative, defined by the primary etiology of the deformity [1, 4, 5]. One of the characteristic features of adult deformity in comparison to adolescent deformity is the increased prevalence of axial pain and radicular pain in adult deformity [6–8]. Adolescent deformity typically presents with cosmetic concerns or deformity progression, while adult deformity presents with pain and disability [9–11]. A combination of degenerative disc disease, facet arthropathy, trunk imbalance, and muscle fatigue is involved in the pathogenesis of pain in adult deformity [12]. Trunk imbalance and muscle fatigue are primarily influenced by sagittal and to a lesser degree coronal imbalance, and degenerative disc disease, facet arthropathy, and central and foraminal stenosis are more likely to directly cause signs and symptoms of nerve root and thecal sac compression such as radicular pain or neurogenic claudication.

OBJECTIVE The purpose of this study was to report the long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion (ACDF). METHODS A retrospective review of all adult neurosurgical patients undergoing elective ACDF for degenerative disease at a single institution between 1996 and 2013 was performed. Patients who underwent first-time 3- or 4-level ACDF were included; patients with previous cervical spine surgery, those undergoing anterior/posterior approaches, and those with corpectomy were excluded. Outcome measures included perioperative complication rates, fusion rates, need for revision surgery, Nurick Scores, Odom's criteria, symptom resolution, neck visual analog scale (VAS) pain score, and persistent narcotics usage. RESULTS Seventy-one patients who underwent 3-level ACDF and 26 patients who underwent 4-level ACDF were identified and followed for an average of 7.6 ± 4.2 years. There was 1 case (3.9%) of deep wound infection in the 4-level group and 1 case in the 3-level group (1.4%; p = 0.454). Postoperatively, 31% of patients in the 4-level group complained of dysphagia, compared with 12.7% in the 3-level group (p = 0.038). The fusion rate was 84.6% after 4-level ACDF and 94.4% after 3-level ACDF (p = 0.122). At last follow-up, a significantly higher proportion of patients in the 4-level group continued to have axial neck pain (53.8%) than in the 3-level group (31%; p = 0.039); the daily oral morphine equivalent dose was significantly higher in the 4-level group (143 ± 97 mg/day) than in the 3-level group (25 ± 10 mg/day; p = 0.030). Outcomes based on Odom's criteria were also different between cohorts (p = 0.044), with a significantly lower proportion of patients in the 4-level ACDF group experiencing an excellent/good outcome. CONCLUSIONS In this study, patients who underwent 4-level ACDF had significantly higher rates of dysphagia, postoperative neck pain, and postoperative narcotic usage when compared with patients who underwent 3-level ACDF. Pseudarthrosis and deep wound infection rates were also higher in the 4-level group, although this did not reach statistical significance. Additionally, a smaller proportion of patients achieved a good/excellent outcome in the 4-level group than in the 3-level group. These findings suggest a significant increase of perioperative morbidity and worsened outcomes for patients who undergo 4- versus 3-level ACDF.

Spinal malignancies historically had been treated with piecemeal excision or curettage of vertebral tumors because of a lack of more sophisticated techniques. The obvious disadvantage of this approach is the high risk of tumor cell contamination of surrounding structures and the tendency to get subtotal resection because of the inability to sometimes distinguish between normal tissue and tumor. Multiple studies have reported excellent clinical and oncological results with the use of spondylectomy for en bloc resection of tumor. Spondylectomy for en bloc resection of tumor is an important skill set for a spinal oncologist to have in his armamentarium. Spondylectomy is derived from the Greek spondylos, which means vertebra. Thus, spondylectomy means to remove an entire vertebra or segment of the spine, including the vertebral body, pedicles, pars, transverse processes, lamina, spinous process, and superior and inferior articulating processes. Resection of an entire spinal segment in a single en bloc manner in the thoracic spinal region is not feasible given the presence of the spinal cord in the bony confines of the spinal canal. However, spondylectomy for en bloc resection of tumor can be performed as two pieces: (1) the posterior elements to allow a window for the spinal cord to pass and (2) the rest of the vertebra.

Tel: 401-793-9136 Fax: 401-444-2781 Lumbar discectomy for lumbar disc herniation is one of the most common spine procedures performed. The incidence of symptomatic herniated lumbar discs is estimated to be between 1-2% [1] and over 480,000 lumbar discectomies are performed annually in the United States [2, 3]. Lumbar discectomies are effective in relieving back and leg pain [4] and patient outcomes and satisfaction after discectomy have been reported in 7580% of patients receiving surgery [5-7]. However, a common complication after lumbar discectomy is recurrence of herniated disc which has been reported to occur in the range of 3-18% [8, 9]. Recurrent lumbar disc herniation is usually treated with open technique with wider exposure for discectomy, or in cases of significant instability and/or loss of disc height, lumbar interbody fusion [10]. This complication results in increased patient hospitalization and cost as well as missed work days. All of these contribute to an increased economic burden on the United States health care system [8, 9]. It has been estimated that reoperation for recurrent herniated discs in the lumbar spine resulted in a normalized cost of $298,797 per 100 primary discectomies in the setting of a recurrence rate of 12% [11].

Metastases to the spine from non-hepatocellular carcinomas, such as cholangiocarcinoma and angiosarcoma, occur rarely. With improvements in oncologic care, the number of patients diagnosed with metastatic cancer is expected to increase. We performed a systematic review of the literature to assess the clinical presentation, treatment, outcome and survival of patients diagnosed with non-hepatocellular carcinoma spinal metastasis using PubMed, Embase, CINAHL, Cochrane Library and Web of Science. We identified 19 cases of spinal metastases from non-hepatocellular carcinomas that fit our pre-specified criteria. The mean age at presentation was 62.3years and cholangiocarcinoma was the most common subtype. Patients frequently presented with pain, weakness or paraparesis and at the time of diagnosis, most of them had multi-level involvement of the spine. A majority of patients with spinal metastasis were treated either with radiation or chemotherapy or received no treatment. A minority of the reports included information on survival, which revealed a median survival of 1.5months following diagnosis of the spinal metastasis. Although there is a paucity of published literature on non-hepatocellular carcinoma spinal metastasis, this systematic review provides descriptive clinical characteristics of these patients.

OBJECT Surgical procedures and/or adjuvant therapies are effective modalities for the treatment of symptomatic spinal metastases. However, clinical results specific to the skin cancer spinal metastasis cohort are generally lacking. The purpose of this study was to systematically review the literature for treatments, clinical outcomes, and survival following the diagnosis of a skin cancer spinal metastasis and evaluate prognostic factors in the context of spinal skin cancer metastases stratified by tumor subtype. METHODS The authors performed a literature review using PubMed, Embase, CINAHL, and Web of Science to identify articles since 1950 that reported survival, clinical outcomes, and/or prognostic factors for the skin cancer patient population with spinal metastases. The methodological quality of reviews was assessed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) tool. RESULTS Sixty-five studies met the preset criteria and were included in the analysis. Of these studies, a total of 25, 40, 25, and 12 studies included patients who underwent some form of surgery, radiotherapy, chemotherapy, or observation alone, respectively. Sixty-three of the 65 included studies were retrospective in nature (Class of Evidence [CoE] IV), and the 2 prospective studies were CoE II. Based on the studies analyzed, the median overall survival for a patient with a spinal metastasis from a primary skin malignancy is 4.0 months; survival by tumor subtype is 12.5 months for patients with basal cell carcinoma (BCC), 4.0 months for those with melanoma, 4.0 months for those with squamous cell carcinoma, 3.0 months for those with pilomatrix carcinoma, and 1.5 months for those with Merkel cell carcinoma (p < 0.0001). The overall percentage of known continued disease progression after spine metastasis diagnosis was 40.1% (n = 244/608, range 25.0%–88.9%), the rate of known recurrence of the primary skin cancer lesion was 3.5% (n = 21/608, range 0.2%–100.0%), and the rate of known spine metastasis recurrence despite treatment for all skin malignancies was 2.8% (n = 17/608, range 0.0%–33.3%). Age greater than 65 years, sacral spinal involvement, presence of a neurological deficit, and nonambulatory status were associated with decreased survival in patients diagnosed with a primary skin cancer spinal metastasis. All other clinical or prognostic parameters were of low or insufficient strength. CONCLUSIONS Patients diagnosed with a primary skin cancer metastasis to the spine have poor overall survival with the exception of those with BCC. The median duration of survival for patients who received surgical intervention alone, medical management (chemotherapy and/or radiation) alone, or the combination of therapies was similar across interventions. Age, spinal region, and neurological status may be associated with poor survival following surgery.

Object Chordoma is a malignant bone neoplasm hypothesized to arise from notochordal remnants along the length of the neuraxis. Recent genomic investigation of chordomas has identified T (Brachyury) gene duplication as a major susceptibility mutation in familial chordomas. Brachyury plays a vital role during embryonic development of the notochord and has recently been shown to regulate epithelial-to-mesenchymal transition in epithelial-derived cancers. However, current understanding of the role of this transcription factor in chordoma is limited due to the lack of availability of a fully characterized chordoma cell line expressing Brachyury. Thus, the objective of this study was to establish the first fully characterized primary chordoma cell line expressing gain of the T gene locus that readily recapitulates the original parental tumor phenotype in vitro and in vivo. Methods Using an intraoperatively obtained tumor sample from a 61-year-old woman with primary sacral chordoma, a chordoma cell line (JHC7, or Johns Hopkins Chordoma Line 7) was established. Molecular characterization of the primary tumor and cell line was conducted using standard immunostaining and Western blotting. Chromosomal aberrations and genomic amplification of the T gene in this cell line were determined. Using this cell line, a xenograft model was established and the histopathological analysis of the tumor was performed. Silencing of Brachyury and changes in gene expression were assessed. Results The authors report, for the first time, the successful establishment of a chordoma cell line (JHC7) from a patient with pathologically confirmed sacral chordoma. This cell line readily forms tumors in immunodeficient mice that recapitulate the parental tumor phenotype with conserved histological features consistent with the parental tumor. Furthermore, it is demonstrated for the first time that silencing of Brachyury using short hairpin RNA renders the morphology of chordoma cells to a more differentiated-like state and leads to complete growth arrest and senescence with an inability to be passaged serially in vitro. Conclusions This report represents the first xenograft model of a sacral chordoma line described in the literature and the first cell line established with stable Brachyury expression. The authors propose that Brachyury is an attractive therapeutic target in chordoma and that JHC7 will serve as a clinically relevant model for the study of this disease.

Leptomeningeal carcinomatosis (LC) is a devastating complication of cancer. Intrathecal administration of cytotoxic chemotherapy adds little to survival which is measured in weeks. The potential toxicities and efficacy of intrathecally administered anti-angiogenic agents in this setting have not previously been explored. A well-characterized animal model was used to evaluate the neurotoxicity of intraventricularly administered bevacizumab (BCM). Thirty-three New Zealand White Rabbits were studied. Subcutaneous reservoirs and ventricular catheters (SRVC) were placed in eight rabbits, which were randomized to receive weekly intraventricular saline with or without BCM for four weeks. These rabbits were euthanized on day 36 and the brains were examined by a blinded neuropathologist. Twenty-five additional rabbits underwent cisternal injection of VX2 carcinoma cells with or without a single dose of BCM and were followed for survival. No clinical manifestations of neurotoxicity were noted in rabbits treated with intraventricular BCM. Similarly, no evidence of BCM neurotoxicity was identified in autopsied animals. The median survival of evaluable rabbits with LC treated with intraventricular saline (N = 13) was 15 days compared to 18 days for the animals receiving VX2 and one dose of BCM (N = 12). Conclusion: Intraventricular BCM can be administered to rabbits without clinical or pathologic neurotoxicity. Survival following one dose of BCM in rabbits with LC should be cautiously interpreted given uncertainties regarding the dose, schedule, and limited expected benefit of this non-rabbit antibody. This neurotoxicity study provides safety data to allow phase I/II studies in humans with treatment refractory LC.

Object Patients harboring anaplastic astrocytomas (AAs) typically have a poor prognosis, with median survival times of approximately 3 years following resection. However, a significant variability in individual outcomes remains, with some patients surviving for a few months and others for several years. The ability to predict patient outcomes based on preoperative variables would help prognosticate survival and may also guide treatment strategies. The prognostic implications of a preoperative contrast-enhancing AA remain poorly understood. Methods The medical records of all patients who underwent a craniotomy for a hemispheric AA from 1996 to 2006 at a single institution were retrospectively reviewed. Multivariate proportional hazards regression analysis was used to identify independent associations with recurrence and survival. The Kaplan-Meier method and log-rank analysis were used to plot and compare outcomes for patients with and without preoperative contrast enhancement. Results One hundred sixty-five patients were available for analysis. The AAs were contrast enhancing in 102 patients (62%), and nonenhancing in 63 patients (38%). There were no significant differences in clinical and treatment-related variables between patients with and without contrast enhancement. After multivariate analysis, contrast enhancement was independently associated with decreased survival (p = 0.02) and increased recurrence (p = 0.04). The 5-year overall survival rates for patients with contrast-enhancing versus nonenhancing tumors were 31 and 38.5%, respectively. The 3-year rates of progression-free survival for patients with contrast-enhancing versus nonenhancing tumors were 32 and 56%, respectively. Interestingly, heterogeneously enhancing tumors appear to result in poorer outcomes as compared with other types of enhancement (such as ring enhancing, nodular, and others). Among patients with contrast-enhancing AAs, gross-total resection significantly delayed recurrence (p = 0.05) but did not significantly prolong survival (p = 0.52). Conclusions This study may provide insights into risk-stratifying patients with AAs, and most specifically those with AAs that enhance with contrast administration.

Chordomas are rare tumors that arise from the sacrum, spine, and skull base. Surgical management of these tumors can be difficult, given their locally destructive behavior and predilection for growing near delicate and critical structures. En bloc resection with negative margins can be difficult to perform without damaging adjacent structures and causing significant clinical morbidity. For chordomas of the upper cervical spine, surgical options traditionally involve transoral or submandibular approaches. The authors report the use of the image-guided, endoscopic, transcervical approach to the upper cervical spine as an alternative to traditional techniques for addressing upper cervical spine tumors, particularly for tumors where gross-total resection is not feasible.

ObjectiveSurgery remains a common form of treatment for sellar and parasellar tumors involving the pituitary gland and adjacent structures. Studies have suggested that pituitary surgery procedures performed at high-volume centers are associated with less adverse outcomes, yet it remains unclear which types of patients are more likely to be admitted to such centers. We set out to determine which factors most influenced admission to these high-volume centers.MethodsA retrospective analysis of the National Inpatient Sample over an 18-year period was linked to socioeconomic and environmental data contained within the Area Resource File. Only patients undergoing transsphenoidal surgery in the United States, >18-years-old were included. The primary outcome was admission to a high-volume (>25 pituitary surgeries/year) hospital.ResultsOverall, patients' odds of admission to a high-volume center increased over an 18-year time period. However, African–Americans (odds ratio, OR=0.46), Hispanics (OR=0.28), and Asians (OR=0.49) experienced declining odds of admission over time. Patients from high-income brackets (OR=1.53) and from areas with higher neurosurgeon density (OR=1.61) were more likely to be admitted to high-volume centers. Conversely, patients coming from counties with higher poverty (OR=0.92) were less likely to be admitted to high-volume centers.ConclusionRacial and socioeconomic factors play a significant role in the admission of patients to high-volume pituitary surgery centers. This study demonstrates potential key policy areas for meaningful intervention to help ease disparities in access to quality care for surgical pituitary disease.

With the advent of the cancer stem cell hypothesis, the field of cancer research has experienced a revolution in how we think of and approach cancer. The discovery of “brain tumor stem cells” has offered an explanation for several long-standing conundrums on why brain tumors behave the way they do to treatment. Despite the great amount of research that has been done in order to understand the molecular aspects of malignant gliomas, the prognosis of brain tumors remains dismal. The slow progress in extending the survival of patients with malignant CNS neoplasms is very likely due to poor understanding of the cell of origin in these tumors. This review article discusses the progress in our understanding of brain tumor stem cells as the cell of origin in brain cancers. We review the different proposed mechanisms of how brain tumor stem cells may originate, the intracellular pathways disrupted in the pathogenesis of BTSCs, the molecular markers used to identify BTSCs, the molecular mechanisms of cancer initiation and progression, and finally the clinical implications of this research.

In addition to stem cells providing a better understanding about the biology and origins of gliomas, new therapeutic approaches have been developed based on the use of stem cells as delivery vehicles. The unique ability of stem cells to track down tumor cells makes them a very appealing therapeutic modality. This review introduces neural and mesenchymal stem cells, discusses the advances that have been made in the utilization of these stem cells as therapies and in diagnostic imaging (to track the advancement of the stem cells towards the tumor cells), and concludes by addressing various challenges and concerns regarding these therapies.

Primary spinal neoplasms are rare tumors that can lead to significant morbidity secondary to local bone destruction and invasion into adjacent neurological and vascular structures. These tumors represent a clinical challenge to even the most experienced physicians and require a multidisciplinary approach to ensure optimal patient outcomes. This review will discuss the most common primary bone tumors and focus on recent surgical, medical, and radiation treatment advances.

Spinal metastasis from colorectal cancer occurs rarely. However, with increasing incidence of colorectal cancer in the setting of improved therapies, physicians are more likely to encounter such patients. We performed a retrospective review of patients who underwent spine surgery for metastatic colorectal cancer from 2005-2011. Preoperative, operative and postoperative factors; functional outcome as determined by Karnofsky Performance Status (KPS) and modified Rankin scale (mRS); and survival were recorded. Univariate analysis was performed, with patients stratified into two groups based on the position of the primary cancer, either proximal (colon) or distal (rectum) to the rectosigmoid junction. Fourteen patients, with a median age of 52 (interquartile range [IQR] 48-66)years, underwent 21 spine surgeries for metastatic colorectal cancer. Pain was the common presenting symptom (n=11, 79%), followed by motor weakness (n=8, 57%). Twenty-seven postoperative complications occurred in 11 (52%) patients. Baseline KPS and mRS remained stable in four (29%), improved in two (14%), worsened in six (43%), and was unknown in two (14%) at last follow-up. Patients with spinal metastasis from a rectal primary (n=6) had a significantly longer survival compared to those with a colon primary (n=8), with a median survival of 84 (IQR 56-103) versus 26 (IQR 19-44)months after primary diagnosis (p=0.002), 19 (IQR 13-27) versus five (IQR 3-9)months after spine metastasis diagnosis (p=0.010), and six (IQR 4-14) versus three (IQR 2-4)months after surgery (p=0.030). Patients with spinal metastasis arising from rectal primary lesions display longer survival compared to colon lesions. Consideration of these factors is essential to appropriately assess surgical candidacy.

Study Design Retrospective review. Objective To describe the surgical outcomes in patients with high preoperative Spinal Instability Neoplastic Score (SINS) secondary to spinal giant cell tumors (GCT) and evaluate the impact of en bloc versus intralesional resection and preoperative embolization on postoperative outcomes. Methods A retrospective analysis was performed on 14 patients with GCTs of the spine who underwent surgical treatment prior to the use of denosumab. A univariate analysis was performed comparing the patient demographics, perioperative characteristics, and surgical outcomes between patients who underwent en bloc marginal ( n = 6) compared with those who had intralesional ( n = 8) resection. Results Six patients underwent en bloc resections and eight underwent intralesional resection. Preoperative embolization was performed in eight patients. All patients were alive at last follow-up, with a mean follow-up length of 43 months. Patients who underwent en bloc resection had longer average operative times ( p = 0.0251), higher rates of early ( p = 0.0182) and late ( p = 0.0389) complications, and a higher rate of surgical revision ( p = 0.0120). There was a 25% (2/8 patients) local recurrence rate for intralesional resection and a 0% (0/6 patients) local recurrence rate for en bloc resection ( p = 0.0929). Conclusions Surgical excision of spinal GCTs causing significant instability, assessed by SINS, is associated with high intraoperative blood loss despite embolization and independent of resection method. En bloc resection requires a longer operative duration and is associated with a higher risk of complications when compared with intralesional resection. However, the increased morbidity associated with en bloc resection may be justified as it may minimize the risk of local recurrence.

Spinal fusion is one of the most commonly performed procedures for the treatment of spinal instability caused by a multitude of pathologies. However, despite significant advances in spinal instrumentation, failed fusion, or pseudoarthrosis, remains a significant challenge. Therefore, other additives such as bone graft extenders and growth factors have been explored as a method to augment fusion rates. Platelet-rich plasma (PRP) represents an additional approach, as it has shown some promise in bone regeneration. While the general use of PRP in orthopedic applications has been reviewed previously, its use in spinal fusion has not been systematically analyzed. The objective of this review is to systematically discuss the role of PRP in augmentation of bone regeneration for the purpose of spinal fusion. Background information on PRP, including a discussion of its preparation, activation, and growth factors, is included. Additionally, data from in vitro studies utilizing PRP in bone tissue engineering strategies is analyzed, and the available animal and clinical studies are systematically reviewed in order to provide guidance on future research pathways as well as the potential role of PRP in spinal fusion surgery.

Rheumatoid patients may develop a retrodental lesion (atlantoaxial rheumatoid pannus) that may cause cervical instability and/or neurological compromise. The objective is to characterize clinical and radiographic outcomes after posterior instrumented fusion for atlantoaxial rheumatoid pannus.We retrospectively reviewed all patients who underwent posterior fusions for an atlantoaxial rheumatoid pannus at a single institution. Both preoperative and postoperative imaging was available for all patients. Anterior or circumferential operations, non-atlantoaxial panni, or prior C1-C2 operations were excluded. Primary outcome measures included Nurick score, Ranawat score (neurologic status in patients with rheumatoid arthritis), pannus regression, and reoperation. Pannus volume was determined with axial and sagittal views on both preoperative and postoperative radiological images.Thirty patients surgically managed for an atlantoaxial rheumatoid pannus were followed for a mean of 24.43 months. Nine patients underwent posterior instrumented fusion alone, while 21 patients underwent posterior decompression and instrumented fusion. Following a posterior instrumented fusion in all 30 patients, the pannus statistically significantly regressed by 44.44%, from a mean volume of 1.26cm(3) to 0.70cm(3) (p0.001), over 8.02 months. The Nurick score significantly improved from 2.40 to 0.60 (p0.001), but the marginal improvement of 0.20 in the Ranawat score did not reach significance (p=0.312). Six patients (20%) required reoperations over a mean of 13.18 months. Reoperations were indicated for C1 instrumentation failure in four patients and pseudoarthrosis in two patients.Following posterior instrumented fusion, the pannus radiographically regressed by 44.44% over a mean of 8.02 months, and patients clinically improved per the Nurick score. The Ranawat score did not improve, and 20% of patients required reoperation over a mean of 13.18 months. The annualized reoperation rate was approximately 13.62%.