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Okai BK, Lipinski LJ, Ghannam MM, Fabiano AJ. Expected motor function change following decompressive surgery for spinal metastatic disease. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 15:100240. [PMID: 37457395 PMCID: PMC10345847 DOI: 10.1016/j.xnsj.2023.100240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Background Motor function in patients with spinal metastatic disease (SMD) directly impacts a patient's ability to receive systemic therapy and overall survival. Spine surgeons may be in the challenging position to advise a patient on expected motor function outcomes and determine a patient's suitability as a surgical candidate. We present this study to provide this critical information on anticipated motor function change to spine surgeons. Methods Consecutive patients undergoing spinal surgery for SMD at a National Cancer Institute-designated cancer institute were prospectively enrolled. Patient motor function status before and after surgery was assessed using the standard 0 to 5 five-point muscle strength grading scale. The difference in presurgical and postsurgical motor function (proximal and distal) was used to assess motor function changes following surgery. Results A total of 171 patients were included. The mean age was 62.7±10.46 years and 40.9% (70) were female. Common primary malignancy types were lung (49), kidney (28), breast (25), and prostate (23). The average proximal and distal motor function difference was 0.38 (standard deviation=1.02, p<.0001) and 0.32 (standard deviation=0.91, p<.0001) respectively showing an improvement following surgery. Patients with proximal presurgical motor function of 2, 3, and 4 had an improved motor function in 73%, 77%, and 73% of the patients. Patients with distal presurgical motor function of 2, 3, and 4 had an improved motor function in 80%, 89%, and 70% of the patients. Conclusions Most patients undergoing surgery for SMD have a modest improvement in motor function following surgery. The degree of improvement in most instances is less than 1 point on a 0 to 5 motor function scale. This is critical knowledge for a spinal surgeon when evaluating SMD patients with significant preoperative motor function deficits. These results aid spinal surgeons in setting expectations and evaluating the need for rapid spinal decompression.
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Affiliation(s)
- Bernard K. Okai
- Department of Neuro-Oncology, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, 14263, United States
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 955 Main St, Buffalo, NY, 14203, United States
| | - Lindsay J. Lipinski
- Department of Neuro-Oncology, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, 14263, United States
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 955 Main St, Buffalo, NY, 14203, United States
| | - Moleca M. Ghannam
- Department of Neuro-Oncology, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, 14263, United States
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 955 Main St, Buffalo, NY, 14203, United States
| | - Andrew J. Fabiano
- Department of Neuro-Oncology, Roswell Park Comprehensive Cancer Center, Elm & Carlton St, Buffalo, NY, 14263, United States
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, 955 Main St, Buffalo, NY, 14203, United States
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Munim MA, Berlinberg E, Federico VP, Nolte MT, Prabhu M, Pawlowski H, Patel KS, Colman MW. Usage Trends and Safety Profile of Recombinant Human Bone Morphogenetic Protein-2 for Spinal Column Tumor Surgery: A National Matched Cohort Analysis. Global Spine J 2023:21925682231194248. [PMID: 37542521 DOI: 10.1177/21925682231194248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort Analysis. OBJECTIVE The purpose of this study is to investigate national rates of rhBMP-2 utilization in spinal tumor surgery and examine its association with postoperative complications, revisions, and carcinogenicity. METHODS All patients diagnosed with primary or metastatic spinal tumors with subsequent surgical intervention involving a spinal fusion procedure were identified in PearlDiver. Patients were 1:1 matched into 2 cohorts according to rhBMP-2 usage. Postoperative complications and revisions were examined at 1 month, 3 months, 6 months, and 1 year after fusion. New cancer incidence following spinal tumor surgery was assessed until 5 years postoperatively. RESULTS A total of 11,198 patients underwent fusion surgery after resection of spinal tumors between 2005 and 2020, with 909 cases reporting the use of rhBMP-2 (8.1%). An annualized analysis revealed that the proportion of spine tumor fusion procedures utilizing rhBMP-2 has been significantly decreasing (R2 = .859, P < .001), with the most recent annual utilization rate at 1.1%. At least 3 months after surgery, significantly increased incidences of surgical site (11.4% vs 3.3%, P = .03) and systemic infections (8.1% vs 1.6%, P = .02) were observed in patients who underwent fusion with rhBMP-2. Across all time points, no significant differences were observed in survival, implant removal, revision rates, or new cancer diagnoses. CONCLUSION This analysis demonstrated significantly declining national utilization rates. Spinal tumor cases utilizing rhBMP-2 sustained greater rates of surgical site and systemic infections. rhBMP-2 usage did not significantly reduce the risk of mortality, implant failure, or reoperation.
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Affiliation(s)
- Mohammed A Munim
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Elyse Berlinberg
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Vincent P Federico
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael T Nolte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael Prabhu
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Hanna Pawlowski
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Karan S Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew W Colman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Popov A, Petrenko D, Kutsenko V, Lazarenko I, Bondarenko S, Popsuyshapka K, Maltseva V. DEVELOPMENT OF A MATHEMATICAL MODEL OF SELECTING THE EXTENT OF A SURGICAL INTERVENTION IN SPINAL TUMOR. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1627-1635. [PMID: 37622507 DOI: 10.36740/wlek202307117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVE The aim: To develop a mathematical model of selecting the extent of surgical intervention in the spinal tumors. PATIENTS AND METHODS Materials and methods: The retrospective study included 237 patients with spinal tumors who underwent the following surgeries: vertebroplasty (V); vertebroplasty and spinal fixation (F+V); posterior spinal decompression and spinal fixation (F+F); vertebrectomy and replacement of vertebra by a cage with posterior spinal fixation (F+F+K). The mathematical model is based on the modified Spine Instability Neoplastic Score (SINS). The patients were divided into two clusters. Cluster analysis was used to build a diagnostic decision tree model. RESULTS Results: The difference between two clusters is determined by the extent of surgical intervention, the grade of the vertebral lesion, epidural compression, and local kyphosis, and neurological signs as well. The cluster 1 included 115 patients with higher values of SINS compared to the cluster 2. All cases of vertebroplasty belonged to the cluster 2. In the cluster 1 cases of surgery of large extent: F+F; F+V; F+F+K. Analysis of the decision tree model for cluster 1 showed that a type of surgery was determined for 97 patients from 115 that relates to 84.3% of overall accuracy. The decision tree model have a high predictive accuracy for the surgery F+V and better indicators of coverage and predictive accuracy for the surgery F+F+K. CONCLUSION Conclusions: Our study developed a decision tree model to optimize spinal neoplasm surgery, achieving 84.3% accuracy based on significant prognosis criteria. The model considers surgical type, neurological signs, vertebra lesion grade, and stage of epidural compression, potentially improving clinical outcomes.
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Affiliation(s)
- Andrii Popov
- SYTENKO INSTITUTE OF SPINE AND JOINT PATHOLOGY, KHARKIV, UKRAINE
| | - Dmytro Petrenko
- SCIENTIFIC TRAINING MEDICAL COMPLEX "THE UNIVERSITY CLINIC" OF THE KHARKIV NATIONAL MEDICAL UNIVERSITY, KHARKIV, UKRAINE
| | | | - Iurii Lazarenko
- MILITARY MEDICAL CLINICAL CENTER OF THE CENTRAL REGION, KYIV, UKRAINE
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Orenday-Barraza JM, Cavagnaro MJ, Avila MJ, Strouse IM, Dowell A, Kisana H, Khan N, Ravinsky R, Baaj AA. 10-Year Trends in the Surgical Management of Patients with Spinal Metastases: A Scoping Review. World Neurosurg 2021; 157:170-186.e3. [PMID: 34655822 DOI: 10.1016/j.wneu.2021.10.086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spinal metastases are present in approximately 20% of patients with cancer, giving a risk for neurologic dysfunction and instability. In already frail patients, surgeons strive to improve quality of life. Our goal was to review a 10-year trend in the surgical management of spinal metastases. METHODS A scoping review was performed systematically using PubMed to assess trends in surgical treatment for spinal metastases. The search terms used were: metastas∗, "neoplasm metastasis"[Mesh], "Spine"[Mesh], spine, spinal, "vertebral column," "vertebral body," laser, robot, radiofrequency, screws, fixation, "separation surgery," corpectomy, vertebrectomy, spondylectomy, vertebroplasty, kyphoplasty, surgery, "open surgery," "mini open surgery," "minimally invasive surgery," endoscopy, thoracoscopy, corpectom∗, vertebrectom∗, spondylectom∗, "en bloc," and MIS. The variables of interest were neurologic improvement, tumor recurrence, reoperation, and overall survival. RESULTS A total of 2132 articles were found within the primary query. Fifty-six studies were selected for final review. The results were organized into main surgical practices: decompression, mechanical stabilization, and pain management. For separation surgery, clinical outcomes were overall 1-year survival, 40.7%-78.4%; recurrence rate, 4.3%-22%; reoperation, 5%; and complications, 5.4%-14%. For corpectomy, clinical outcomes were overall 1-year survival, 30%-92%; reoperation, 1.1%-50%; and recurrence rate, of 1.1%-28%. Complications and reoperations with spinal instrumentation were 0%-13.6% and 0%-15%, respectively. Cement augmentation achieved pain reduction rates of 56%-100%, neurologic improvement/stability 84%-100%, and complication rates 6%-56%. Laser achieved local tumor control rate of 71%-82% at 1 year follow-up, reoperation rate of 15%-31%, and complication rate of 5%-26%. CONCLUSIONS Minimally invasive techniques for decompression and stabilization seem to be the preferred method to surgically treat metastatic spine disease, with good outcomes. More research with high level of evidence is required to support the long-term outcomes of these approaches.
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Affiliation(s)
| | - María José Cavagnaro
- Department of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mauricio J Avila
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Isabel M Strouse
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Aaron Dowell
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Haroon Kisana
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Naushaba Khan
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Robert Ravinsky
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Ali A Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
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Bao WD, Jia Q, Wang T, Lou Y, Jiang DJ, Yang C, Yang X, Huang Q, Wei HF, Xiao JR. Factors Related to Instrumentation Failure in Titanium Mesh Reconstruction for Thoracic and Lumbar Tumors: Retrospective Analysis of 178 Patients. Cancer Manag Res 2021; 13:3345-3355. [PMID: 33883946 PMCID: PMC8055544 DOI: 10.2147/cmar.s294616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/29/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate risk factors for instrumentation failure (IF) in titanium (Ti) mesh reconstruction for thoracic and lumbar tumors. Patients and Methods The clinical data of patients with thoracic or lumbar tumors who received Ti mesh reconstruction via the posterior approach in our hospital from 2013 to 2018 were analyzed retrospectively. The observation indexes included sex, age, BMI, the vertebra resection mode, the number of resected vertebral segments, application of bone cement, radiotherapy, chemotherapy, revision or primary surgery, and primary tumor metastasis. Correlations between these factors and IF were analyzed by Kaplan–Meier survival and logistics regression analyses. Results The 178 patients included 108 males and 70 females with a mean age of 48.09±16.21 (6–78) years and a mean follow-up period of 51.18 (24–90) months. The data showed that 17 patients (9.55%) were inflicted with IF, involving the thoracic vertebra in 11 cases, thoracolumbar vertebrae (T12–L1) in 2 cases, and lumbar vertebrae in 4 cases. The mean interval between surgery to IF was 35.18±14.17 (14–59) months. Univariate analysis showed that total vertebral body resection, the number of resected vertebral segments, radiotherapy and multiple tumor resection were potential factors for IF, while multivariate analysis showed that only total vertebral body resection, the number of resected vertebral segments and radiotherapy were independent factors. Conclusion Total vertebra resection, the number of resected vertebral segments (≥2) and radiotherapy before and after operation were significant risk factors related to IF.
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Affiliation(s)
- Wei-Dong Bao
- Department of Orthopedics, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, People's Republic of China
| | - Qi Jia
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Tao Wang
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China.,Department of Orthopeadics, Second Affiliated Hospital of Anhui Medical University, Hefei, 230000, People's Republic of China
| | - Yan Lou
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Dong-Jie Jiang
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Cheng Yang
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Xinghai Yang
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Quan Huang
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Hai-Feng Wei
- Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Jian-Ru Xiao
- Department of Orthopedics, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, People's Republic of China.,Department of Orthopedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
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Chou D. Commentary: Survival Trends After Surgery for Spinal Metastatic Tumors: 20-Year Cancer Center Experience. Neurosurgery 2021; 88:E138-E139. [PMID: 32970159 DOI: 10.1093/neuros/nyaa394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/12/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, California
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Yee TJ, Saadeh YS, Strong MJ, Ward AL, Elswick CM, Srinivasan S, Park P, Oppenlander ME, Spratt DE, Jackson WC, Szerlip NJ. Survival, fusion, and hardware failure after surgery for spinal metastatic disease. J Neurosurg Spine 2021; 34:665-672. [PMID: 33513569 DOI: 10.3171/2020.8.spine201166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompression with instrumented fusion is commonly employed for spinal metastatic disease. Arthrodesis is typically sought despite limited knowledge of fusion outcomes, high procedural morbidity, and poor prognosis. This study aimed to describe survival, fusion, and hardware failure after decompression and fusion for spinal metastatic disease. METHODS The authors retrospectively examined a prospectively collected, single-institution database of adult patients undergoing decompression and instrumented fusion for spinal metastases. Patients were followed clinically until death or loss to follow-up. Fusion was assessed using CT when performed for oncological surveillance at 6-month intervals through 24 months postoperatively. Estimated cumulative incidences for fusion and hardware failure accounted for the competing risk of death. Potential risk factors were analyzed with univariate Fine and Gray proportional subdistribution hazard models. RESULTS One hundred sixty-four patients were identified. The mean age ± SD was 62.2 ± 10.8 years, 61.6% of patients were male, 98.8% received allograft and/or autograft, and 89.6% received postoperative radiotherapy. The Kaplan-Meier estimate of median survival was 11.0 months (IQR 3.5-37.8 months). The estimated cumulative incidences of any fusion and of complete fusion were 28.8% (95% CI 21.3%-36.7%) and 8.2% (95% CI 4.1%-13.9%). Of patients surviving 6 and 12 months, complete fusion was observed in 12.5% and 16.1%, respectively. The estimated cumulative incidence of hardware failure was 4.2% (95% CI 1.5-9.3%). Increasing age predicted hardware failure (HR 1.2, p = 0.003). CONCLUSIONS Low rates of complete fusion and hardware failure were observed due to the high competing risk of death. Further prospective, case-control studies incorporating nonfusion instrumentation techniques may be warranted.
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Affiliation(s)
| | | | | | | | - Clay M Elswick
- 2Brain and Spine Specialists of North Texas, Arlington, Texas
| | | | | | | | - Daniel E Spratt
- 3Radiation Oncology, University of Michigan, Ann Arbor, Michigan; and
| | - William C Jackson
- 3Radiation Oncology, University of Michigan, Ann Arbor, Michigan; and
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Silva A, Yurac R, Guiroy A, Bravo O, Morales Ciancio A, Landriel F, Hem S. Low Implant Failure Rate of Percutaneous Fixation for Spinal Metastases: A Multicenter Retrospective Study. World Neurosurg 2021; 148:e627-e634. [PMID: 33484887 DOI: 10.1016/j.wneu.2021.01.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate incidence and types of implant failure observed in a series of patients with spinal metastases (SM) treated with minimally invasive stabilization surgery without fusion. METHODS In this multicenter, retrospective, observational study, we reviewed the files of patients >18 years old who underwent surgery for SM using percutaneous spinal stabilization without fusion with a minimum 3-month follow-up. The following variables were included: demographics, clinical findings, prior radiation history, SM location, epidural spinal cord compression scale, Spinal Instability Neoplastic Scale, neurological examination, and surgery-related data. Primary outcome measure was implant failure rate, as observed in patients' last computed tomography scan. Multivariable analysis was performed to identify baseline factors and factors associated with implant failure. RESULTS Analysis included 72 patients. Mean age of patients was 62 years, 39 patients were men, and 75% of patients had an intermediate Spinal Instability Neoplastic Scale score. Tumor separation surgery was performed in 48.6% of patients. Short instrumentation was indicated in 54.2% of patients. Three patients (4.2%) experienced implant failure (2 screw loosening, 1 screw cut-out); none of them required revision surgery. In 73.6% of cases, survival was >6 months. No significant predictors of failure were identified in the multivariate analysis. CONCLUSIONS A low implant failure rate was observed over the short and medium term, even when short instrumentations without fusion were performed. These findings suggest that minimally invasive stabilization surgery without fusion may be an effective and safe way to treat complicated SM.
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Affiliation(s)
- Alvaro Silva
- Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.
| | - Ratko Yurac
- Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Alfredo Guiroy
- Spine Unit, Orthopedic Department, Hospital Español de Mendoza, Mendoza, Argentina
| | - Oscar Bravo
- Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | | | - Federico Landriel
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Hem
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Di Perna G, Cofano F, Mantovani C, Badellino S, Marengo N, Ajello M, Comite LM, Palmieri G, Tartara F, Zenga F, Ricardi U, Garbossa D. Separation surgery for metastatic epidural spinal cord compression: A qualitative review. J Bone Oncol 2020; 25:100320. [PMID: 33088700 PMCID: PMC7559860 DOI: 10.1016/j.jbo.2020.100320] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
Separation surgery is a new concept for metastatic spinal cord compression treatment. Stereotactic radiosurgery increased local control, overcoming radio-resistance’s idea. The surgery goal shifted towards creating targets for radiations avoiding cord damages. Minimal invasive strategies could allow quick return to systemic therapies.
Introduction The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease’s local control. Discussion In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration. Conclusion Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.
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Key Words
- CTV, Clinical tumor volume
- Carbon fiber/PEEK cement
- ECOG PS, Eastern Cooperative Oncology Group Performance Status Scale
- ESCC, Epidural Spinal Cord Compression
- Epidural spinal cord compression
- GTV, Gross tumor volume
- KPS, Karnofsky Performance Status
- LC, Local Control
- LITT, Laser Interstitial Thermal Therapy
- MAS, Minimal Access Spine
- MESCC, Metastatic Epidural Spinal Cord Compression
- MIS techniques
- MIS, Minimally Invasive Surgical
- NSCLC, Non-Small Cell Lung Cancer
- NSE, Neurologic Stability Epidural compression
- PEEK, Polyetheretherketone
- PLL, Posterior Longitudinal Ligament
- PMMA, Poly-Methyl-Methacrylate
- PRV, Spinal cord planning risk volume
- PTV, Planning target volume
- SBRT, Stereotactic Body Radiation Therapy
- SINS, Spinal Instability Neoplastic Score
- SRS, Stereotactic Radiosurgery
- SS, Separation Surgery
- Separation surgery
- Spinal metastases
- Stereotactic body radiation therapy
- cEBRT, conventional External Beam Radiation Therapy
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Affiliation(s)
- Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
- Spine Surgery, Humanitas Gradenigo, Turin, Italy
- Corresponding author at: Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Via Cherasco 15, 10126 Turin, Italy.
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Serena Badellino
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Nicola Marengo
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Ludovico Maria Comite
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Palmieri
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Fulvio Tartara
- Neurosurgery Unit, Istituto Clinico Città Studi, Milan, Italy
| | - Francesco Zenga
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin and Città della Salute e della Scienza Hospital, Via Genova 3, 10126 Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini”, Neurosurgery Unit, University of Turin, Turin, Italy
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10
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Wong YC, Chau WWJ, Kwok KO, Law SW. Incidence and Risk Factors for Implant Failure in Spinal Metastasis Surgery. Asian Spine J 2020; 14:878-885. [PMID: 32693440 PMCID: PMC7788377 DOI: 10.31616/asj.2020.0034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/03/2020] [Indexed: 12/26/2022] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE To investigate the incidence of symptomatic and asymptomatic implant failure in spinal metastasis surgery and identify potential risk factors. OVERVIEW OF LITERATURE Surgical stabilization with instrumentation is an established method for the treatment of spinal metastasis. However, very few studies have investigated the incidence and risk factors for implant failure after spinal instrumentation surgery for the treatment of spinal metastasis. METHODS This study recruited 88 patients who received surgical stabilization with instrumentation for the treatment of spinal metastasis. Their medical records and postoperative X-rays were reviewed for evidence of implant failure. Statistical analysis with logistic regression was performed to assess nine potential risk factors for the development of implant failure, including patient's age at operation, gender, survival, primary tumor, spinal level involved, construct length, decompression levels, fusion material utilization, and radiotherapy application either before or after surgery, to identify potential contributing risk factors. RESULTS Implant failure was identified in nine out of 88 cases (10.2%) with two cases requiring implant removal: one case included a progressive kyphosis that resulted in nonhealing sore and the other involved a deep-seated wound infection that spread to the implants. Another case required wound debridement due to superficial wound infection. The remaining six cases were asymptomatic, despite postoperative X-rays demonstrating evidence of implant failure. No patient required implant revision. Logistic regression analysis demonstrated that patients who received radiotherapy either before or after surgery were less likely to develop implant failure. CONCLUSIONS The development of radiological implant failure following surgical treatment of spinal metastasis is common. However, symptomatic implant failure leading to revision surgery is uncommon. Our findings suggest that radiotherapy, either before or after spinal surgery, is not associated with the development of implant failure.
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Affiliation(s)
- Yu Chung Wong
- Department of Orthopedics and Traumatology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Wai Wang Jacky Chau
- Department of Orthopedics and Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kin On Kwok
- Department of Orthopedics and Traumatology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Sheung Wai Law
- Department of Orthopedics and Traumatology, Prince of Wales Hospital, Hong Kong SAR, China
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Open Kyphoplasty for Metastatic Spine Disease: A Retrospective Clinical Series. World Neurosurg 2019; 127:e751-e760. [PMID: 30951918 DOI: 10.1016/j.wneu.2019.03.258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Symptomatic metastatic spine disease (MSD), is a challenging disease involving 3%-20% of patients with bone metastases. Different surgical options are available and must be tailored to the general and neurologic conditions of the patients. Open kyphoplasty (OKP) refers to decompressive hemilaminectomy, associated with a contralateral percutaneous kyphoplasty, and in some cases, to a posterior stabilization. The aim of the study was to critically review our experience during the last decade with OKP in patients with cancer. METHODS Fifty-three patients with cancer underwent OKP for symptomatic MSD. The Tokuhashi score and Spinal Instability Neoplastic Score were calculated for each patient. Length of hospital stay, perioperative complications, incidence of adjacent-level fractures, and median survival after surgery were evaluated. Karnofsky Performance Status, visual analog scale, and Dennis Pain Score were calculated preoperatively, postoperatively, and at last follow-up. RESULTS Median Tokuhashi score and Spinal Instability Neoplastic Score were 10 and 10, respectively. The mean volume of filling material inserted was 3.6 mL. Median operative time was 180 minutes. Complications included 8 leakages (15%), 2 permanent motor deficits (3.8%), and 2 asymptomatic pulmonary embolisms (3.8%). Mean length of hospital stay was 7 days. A significant improvement was observed in Karnofsky Performance Status, visual analog scale score, and Dennis Pain Score (P < 0.0001). Median follow-up was 16 months and overall survival 22 months. CONCLUSIONS OKP was an effective treatment of symptomatic MSDs in selected oncologic patients with low Tokuhashi scores. It relieved lateral epidural compressions, expanded indications of palliative surgery in patients who were not otherwise surgical candidates, and rapidly dealt with cement leakages.
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