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Kumar N, Hui SJ, Lee R, Athia S, Rothenfluh DA, Tan JH. Implant and construct decision-making in metastatic spine tumour surgery: a review of current concepts with a decision-making algorithm. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1899-1910. [PMID: 38289374 DOI: 10.1007/s00586-023-07987-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 06/18/2024]
Abstract
STUDY DESIGN Narrative Review. OBJECTIVE Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Increase in MSTS has been due to improvements in our oncological treatment, as patients have increased longevity and even those with poorer comorbidities are now being considered for surgery. However, there is currently no guideline on how MSTS surgeons should select the appropriate levels to instrument, and which type of implants should be utilised. METHODS The current literature on MSTS was reviewed to study implant and construct decision making factors, with a view to write this narrative review. All studies that were related to instrumentation in MSTS were included. RESULTS A total of 58 studies were included in this review. We discuss novel decision-making models that should be taken into account when planning for surgery in patients undergoing MSTS. These factors include the quality of bone for instrumentation, the extent of the construct required for MSTS patients, the use of cement augmentation and the choice of implant. Various studies have advocated for the use of these modalities and demonstrated better outcomes in MSTS patients when used appropriately. CONCLUSION We have established a new instrumentation algorithm that should be taken into consideration for patients undergoing MSTS. It serves as an important guide for surgeons treating MSTS, with the continuous evolvement of our treatment capacity in MSD. LEVEL OF EVIDENCE IV
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore.
| | - Si Jian Hui
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Renick Lee
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Sahil Athia
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Dominique A Rothenfluh
- Centre for Spinal Surgery, CHUV University Hospital Lausanne, Rue du Bugnon 46, 1005, Lausanne, Switzerland
| | - Jiong Hao Tan
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
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Wu Y, Xu LJ. Incidence of Cement Leakage and Potential Risk Factors in Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 184:e95-e110. [PMID: 38246530 DOI: 10.1016/j.wneu.2024.01.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVES The current meta-analysis was performed to gather available evidence regarding the incidence and risk factors of cement leakage (CL) in patients undergoing surgical procedures for spinal metastasis. METHODS Two authors independently searched the PubMed, Embase, and CENTRAL databases. Clinical studies reporting the incidence or risk factors of CL were included for analysis. The primary outcome analyzed was the incidence of various types of CL. Random-effects or fixed-effects single-proportion meta-analyses were conducted to pool the available evidence, based on the heterogeneity test. Subgroup analyses were conducted based on surgical procedures (percutaneous vertebroplasty, percutaneous kyphoplasty, and others). Risk factors of CL were synthesized narratively to identify the most commonly accepted factors. RESULTS A total of 26 studies, involving 2551 patients, were included. The number of operated spine segments was reported in 23 studies, accounting for 4101 vertebrae. The pooled incidences of general, intradiscal, paravertebral, spinal canal, and intravascular CLs were 0.18 (95% confidence interval [CI], 0.11-0.28), 0.14 (95% CI, 0.08-0.21), 0.13 (95% CI, 0.06-0.21), 0.11 (95% CI, 0.05-0.19), and 0.12 (95% CI, 0.08-0.17), respectively. Subgroup analyses revealed significantly different incidences of general CL (0.37 vs. 0.06 vs. 0.09, P < 0.01), intradiscal CL (0.22 vs. 0.06 vs. 0.12, P < 0.01), paravertebral CL (0.25 vs. 0.03 vs. 0.06, P < 0.01), and vascular CL (0.14 vs. 0.03 vs. 0.15, P < 0.01) among the three groups. Posterior wall disruption, pathologic fracture, and the number of treated vertebral levels were the most commonly identified independent risk factors for general CL. Posterior wall disruption was determined as a common significant risk factor for spinal canal CL. CONCLUSIONS This review provides insights into the incidence and risk factors associated with CL in surgical procedures for spinal metastasis. Understanding these risk factors can contribute to the development of tailored strategies aimed at minimizing CL occurrence and optimizing surgical outcomes for patients undergoing spinal metastatic surgery.
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Affiliation(s)
- Yong Wu
- Department of Neurosurgery, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Hubei, China
| | - Li-Jun Xu
- Department of Orthopedics, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Hubei, China.
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Thalambedu N, Kamran M, Al-Hadidi S. The Role of Vertebral Augmentation Procedures in the Management of Multiple Myeloma. Clin Hematol Int 2024; 6:51-58. [PMID: 38817694 PMCID: PMC11086997 DOI: 10.46989/001c.92984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 06/01/2024] Open
Abstract
Approximately 90% of patients with multiple myeloma experience significant pain from osseous involvement during their lifetime. Untreated osseous involvement results in vertebral compression fractures, leading to negative consequences for quality of life. Vertebral augmentation procedures, including percutaneous vertebroplasty and kyphoplasty, offer better and faster pain control and likely lower morbidity compared with non-operative interventions. Our review provides an up-to-date summary of the indications, contraindications, timing, outcomes, and potential complications of vertebral augmentation procedures to guide practicing oncologists in effectively managing bone disease in patients with multiple myeloma.
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Affiliation(s)
| | - Mudassar Kamran
- Interventional RadiologyUniversity of Arkansas for Medical Sciences
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Wang T, Wang J, Hu X, Hao K, Xiang G, Wu Z, Ma Z, Li T, Chen Y, Zhao X, Zhang Y, Ma T, Ren J, Lei W, Feng Y. Diabetes-related Screw Loosening: The Distinction of Surgical Sites and the Relationship among Diabetes, Implant Stabilization and Clinical Outcomes. Orthop Surg 2023; 15:3136-3145. [PMID: 37853938 PMCID: PMC10694010 DOI: 10.1111/os.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVES Diabetes mellitus (DM) is correlated with poor clinical outcomes in spinal surgery. However, the effect of it on screw stabilization has not been investigated. The aim of this study was to evaluate the screw loosening rate and postoperative outcomes in diabetic patients and to identify potential risk factors associated with loosening. METHODS This was a retrospective study. Two hundred and forty-three patients who received cervical or lumbar internal fixation between 2015 and 2019 were enrolled. Screw loosening was assessed on radiography, and clinical outcomes were evaluated by the improvement of visual analogue scale (VAS), Oswestry disability index (ODI) or Japanese Orthopaedic Association (JOA) scores. The relationship of DM, screw loosening and clinical outcomes were analyzed with chi-square tests and regression analyses. RESULTS One hundred and twenty-two patients (50.2%) with diabetes were included in this study. Diabetes led to the increase of the rate of screw loosening in the lumbar spine, while the loosening rate did not vary significantly in the cervical spine. The occurrence of screw loosening in the lumbar spine was more likely to be associated with clinical outcomes for motor performance including walking and sitting. However, no significant effect on JOA and VAS scores in the cervical spine of screw loosening was found. Moreover, the history of DM affected the outcomes of the patients who underwent spinal surgery. CONCLUSION DM had an adverse effect on screw stabilization. The impaired improvement of clinical outcomes in diabetics after spinal surgery was related to screw loosening. In addition to the direct effects on operative wounds and neural function, the impact on the screws due to DM was also worth noting.
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Affiliation(s)
- Tianji Wang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Jing Wang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Xiaofan Hu
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Kaili Hao
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Geng Xiang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Zixiang Wu
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Zhensheng Ma
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Tianqing Li
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Yu Chen
- Department of Critical Care MedicineXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Xiong Zhao
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Yang Zhang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Tiancheng Ma
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Jingjuan Ren
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Wei Lei
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Yafei Feng
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
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Morimoto T, Kobayashi T, Hirata H, Tsukamoto M, Yoshihara T, Toda Y, Mawatari M. Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020407. [PMID: 36837608 PMCID: PMC9964565 DOI: 10.3390/medicina59020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023]
Abstract
Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.
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Biomechanical Comparison and Three-Dimensional Analysis of Cement Distribution Patterns for Different Pedicle Screw Designs. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8293524. [DOI: 10.1155/2022/8293524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/16/2022] [Accepted: 09/29/2022] [Indexed: 11/17/2022]
Abstract
The purpose of this study to explore strategies for reducing cement leakage during cement-augmented pedicle screw fixation, we compared the cement distribution patterns and biomechanical strengths of different types of cement-augmented fenestrated screws and traditional cement-augmented techniques. We compared five screw groups in this study: (1) Cannulated screws (Cann); (2) distal one-hole screws (D1); (3) distal two-hole screws (D2); (4) middle two-hole screws (M2); and (5) traditional screws with a traditional cement injection technique (Trad). The screws were inserted into cancellous bone blocks using a controlled, adequate cement injection pressure (1.6–2.0 kg), and an appropriate cement viscosity. Center to screw tip distance, three-dimensional distribution, and pull-out strength for cement were compared between groups. The average distance between the cement center and the screw tip was highest in the M2 group, suggesting a higher risk of cement leakage into the spinal canal. The Trad group had the highest migration distance in the z-axis, also reflecting a higher risk of leakage into the spinal canal. The D1 group had the highest pull-out strength (
and
) in bone blocks representing different degrees of osteoporosis, and the D2 group had the second highest pull-out strength in the severe osteoporosis model. Overall, D1 screws appeared to be the best option for optimizing biomechanical function and minimizing the risk of cement leakage into the spinal canal in patients with osteoporotic bone undergoing spinal surgery.
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Jaipanya P, Chanplakorn P. Spinal metastasis: narrative reviews of the current evidence and treatment modalities. J Int Med Res 2022; 50:3000605221091665. [PMID: 35437050 PMCID: PMC9021485 DOI: 10.1177/03000605221091665] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The treatment for spinal metastasis has evolved significantly during the past decade. An advancement in systemic therapy has led to a prolonged overall survival in cancer patients, thus increasing the incidence of spinal metastasis. In addition, with the improved treatment armamentarium, the prediction of patient survival using traditional prognostic models may have limitations and these require the incorporation of some novel parameters to improve their prognostic accuracy. The development of minimally-invasive spinal procedures and minimal access surgical techniques have facilitated a quicker patient recovery and return to systemic treatment. These modern interventions help to alleviate pain and improve quality of life, even in candidates with a relatively short life expectancy. Radiotherapy may be considered in non-surgical candidates or as adjuvant therapy for improving local tumour control. Stereotactic radiosurgery has facilitated this even in radioresistant tumours and may even replace surgery in radiosensitive malignancies. This narrative review summarizes the current evidence leading to the paradigm shifts in the modern treatment of spinal metastasis.
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Affiliation(s)
- Pilan Jaipanya
- Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand.,Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pongsthorn Chanplakorn
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Hussain I, Goldberg JL, Carnevale JA, Hanz SZ, Reiner AS, Schmitt A, Higginson DS, Yamada Y, Laufer I, Bilsky MH, Barzilai O. Hybrid Therapy (Surgery and Radiosurgery) for the Treatment of Renal Cell Carcinoma Spinal Metastases. Neurosurgery 2022; 90:199-206. [PMID: 35023875 PMCID: PMC9508965 DOI: 10.1227/neu.0000000000001780] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The management of spinal metastatic renal cell carcinoma (mRCC) is controversial regarding extent of resection and radiation dosing. OBJECTIVE To determine outcomes in patients treated with hybrid therapy (separation surgery plus adjuvant stereotactic body radiation therapy [SBRT]) for mRCC. METHODS A retrospective study of a prospectively collected cohort of patients undergoing hybrid therapy for mRCC between 2003 and 2017 was performed. SBRT was delivered as high-dose single-fraction, high-dose hypofractionated, or low-dose hypofractionated. Extent of disease, clinical and operative outcomes, and complications data were collected, and associations with overall survival (OS) and progression-free survival were determined. RESULTS Ninety patients with mRCC with high-grade epidural spinal cord compression (ESCC grades 2 and 3) were treated. Metastases were widespread, oligometastatic, and solitary in 56%, 33%, and 11% of patients, respectively. SBRT delivered was high-dose single-fraction, high-dose hypofractionated, and low-dose hypofractionated in 24%, 56%, and 20% of patients, respectively. The 1-yr cumulative incidence of major complications was 3.4% (95% confidence interval [CI]: 0.0%-7.2%). The median follow-up was 14.2 mo for the entire cohort and 38.3 mo for survivors. The 1-yr cumulative incidence of progression was 4.6% (95% CI: 0.2%-9.0%), which translates to a local control rate of 95.4% (95% CI: 91.0%-99.8%) 1 yr after surgery. The median OS for the cohort was 14.8 mo. CONCLUSION These data support the use of hybrid therapy as a safe and effective strategy for the treatment of renal cell spine metastases.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Jacob L. Goldberg
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Joseph A. Carnevale
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Samuel Z. Hanz
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
| | - Adam Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel S. Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Mark H. Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA;
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA;
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Massaad E, Duvall JB, Shankar GM, Shin JH. Commentary: Hybrid Therapy (Surgery and Radiosurgery) for the Treatment of Renal Cell Carcinoma Spinal Metastases. Neurosurgery 2022; 90:e35-e36. [PMID: 34995270 DOI: 10.1227/neu.0000000000001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Yagi M, Ogiri M, Holy CE, Bourcet A. Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis. Expert Rev Med Devices 2021; 18:995-1022. [PMID: 34503387 DOI: 10.1080/17434440.2021.1977123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures. AREAS COVERED A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009). EXPERT OPINION This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Japan
| | - Mami Ogiri
- Division of the Chief Medical Officer, Johnson & Johnson K.K. Medical Company, Chiyoda, Tokyo, Japan
| | - Chantal E Holy
- Medical Devices, Johnson and Johnson Limited, New Brunswick, NJ, USA
| | - Anh Bourcet
- Health Economics & Market Access, Johnson & Johnson Medical Asia Pacific, Singapore, Singapore
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