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Chanbour H, Chen JW, Bendfeldt GA, Gangavarapu LS, Ahmed M, Chotai S, Luo LY, Berkman RA, Abtahi AM, Stephens BF, Zuckerman SL. Earlier Radiation Is Associated with Improved 1-Year Survival After Metastatic Spine Tumor Surgery. World Neurosurg 2024; 187:e509-e516. [PMID: 38677650 DOI: 10.1016/j.wneu.2024.04.118] [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: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE In patients undergoing metastatic spine surgery, we sought to 1) report time to postoperative radiation therapy (RT), 2) describe the predictive factors of time to postoperative RT, and 3) determine if earlier postoperative RT is associated with improved local recurrence (LR) and overall survival (OS). METHODS A single-center retrospective cohort study was undertaken of all patients undergoing spine surgery for extradural metastatic disease and receiving RT within 3 months postoperatively between January 2010 and January 2021. Time to postoperative RT was dichotomized at <1 month versus 1-3 months. The primary outcomes were LR, OS, and 1-year survival. Secondary outcomes were wound complication, Karnofsky Performance Status, and modified McCormick Scale (MMS) score. Regression analyses controlled for age, body mass index, tumor size, preoperative RT, preoperative/postoperative chemotherapy, and type of RT. RESULTS Of 76 patients undergoing spinal metastasis surgery and receiving postoperative RT within 3 months, 34 (44.7%) received RT within 1 month and 42 (55.2%) within 1-3 months. Patients with larger tumor size (β = -3.58; 95% confidence interval [CI], -6.59 to -0.57; P = 0.021) or new neurologic deficits (β = -16.21; 95% CI, -32.21 to -0.210; P = 0.047) had a shorter time to RT. No significant association was found between time to RT and LR or OS on multivariable logistic/Cox regression. However, patients who received RT between 1 and 3 months had a lower odds of 1-year survival compared with those receiving RT within 1 month (odds ratio, 0.18; 95% CI, 0.04-0.74; P = 0.022). Receiving RT within 1 month versus 1-3 months was not associated with wound complications (7.1% vs. 2.9%; P = 0.556) (odds ratio, 4.40; 95% CI, 0.40-118.0; P = 0.266) or Karnofsky Performance Status/modified McCormick Scale score. CONCLUSIONS Spine surgeons, oncologists, and radiation oncologists should make every effort to start RT within 1 month to improve 1-year survival after metastatic spine tumor surgery.
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Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey W Chen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Mahmoud Ahmed
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leo Y Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Richard A Berkman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Lazarus D, Wang B, Jenkins S, O’Donnell J, Jenkins AL. Intramedullary spinal cord metastasis treated with prophylactic laminoplasty prior to radiation to the spinal cord: a case report. JOURNAL OF SPINE SURGERY (HONG KONG) 2023; 9:493-498. [PMID: 38196726 PMCID: PMC10772656 DOI: 10.21037/jss-23-27] [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: 03/08/2023] [Accepted: 11/01/2023] [Indexed: 01/11/2024]
Abstract
Background A cervical laminoplasty is a surgical procedure used to treat moderate-to-severe cervical stenosis resulting in cervical myelopathy. It is performed to widen the spinal canal and reduce compression on the spinal cord and surrounding nerves. Though often performed electively on patients presenting with varying degrees of neurologic dysfunction including weakness and imbalance, it may also be used prophylactically when spinal cord inflammation or edema is anticipated. Radiotherapy in the spinal cord is known to produce radiation-induced damage leading to radiation myelopathy. Case Description We present the case of a 62-year-old male diagnosed with both cervical stenosis and an intramedullary cervical spinal cord metastatic tumor. This patient presented with significant symptoms including limited mobility, numbness, lower back pain, paresthesia, and spasms in both legs as well as worsening sexual function. Given that the patient was to undergo radiotherapy, a cervical laminoplasty was performed to eliminate ongoing spinal cord compression as well to prevent future neurologic decline resulting from post-radiation inflammation and edema. Conclusions This case highlights that cervical laminoplasty can be performed safely and effectively with significant improvement in patients with metastatic disease. By treating the underlying symptomatic stenosis, and protect the patient from the potential for spinal cord edema from radiation to a spinal cord lesion in an already narrow spinal canal.
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Affiliation(s)
- Daniella Lazarus
- Department of Neurosurgery, Jenkins NeuroSpine, New York, NY, USA
| | - Brian Wang
- Department of Neurosurgery, Jenkins NeuroSpine, New York, NY, USA
| | - Sarah Jenkins
- Department of Neurosurgery, Jenkins NeuroSpine, New York, NY, USA
- Department of Neurosurgery, Icahn School of Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - John O’Donnell
- Department of Neurosurgery, Jenkins NeuroSpine, New York, NY, USA
| | - Arthur L. Jenkins
- Department of Neurosurgery, Jenkins NeuroSpine, New York, NY, USA
- Department of Neurosurgery, Icahn School of Medicine, The Mount Sinai Hospital, New York, NY, USA
- Department of Orthopedics, Icahn School of Medicine, The Mount Sinai Hospital, New York, NY, USA
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Chanbour H, Suryateja Gangavarapu L, Chen JW, Bendfeldt GA, Younus I, Ahmed M, Roth SG, Luo LY, Chotai S, Abtahi AM, Stephens BF, Zuckerman SL. Unplanned Readmission After Surgery for Cervical Spine Metastases. World Neurosurg 2023; 171:e768-e776. [PMID: 36584895 DOI: 10.1016/j.wneu.2022.12.106] [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: 11/03/2022] [Revised: 12/25/2022] [Accepted: 12/25/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Patients undergoing surgery for cervical spine metastases are at risk for unplanned readmission due to comorbidities and chemotherapy/radiation. Our objectives were to: 1) report the incidence of unplanned readmission, 2) identify risk factors associated with unplanned readmission, and 3) determine the impact of an unplanned readmission on long-term outcomes. METHODS A single-center, retrospective, case-control study was undertaken of patients undergoing cervical spine surgery for metastatic disease between 02/2010 and 01/2021. The primary outcome of interest was unplanned readmission within 6 months. Survival analysis was performed for overall survival (OS) and local recurrence (LR). RESULTS A total of 61 patients underwent cervical spine surgery for metastatic disease with the following approaches: 11 (18.0%) anterior, 28 (45.9%) posterior, and 22 (36.1%) combined. Mean age was 60.9 ± 11.2 years and 38 (62.3%) were males. A total of 9/61 (14.8%) patients had an unplanned readmission, 3 for surgical reasons and 6 for medical reasons. No difference was found in demographics, preoperative Karnofsky Performance Scale (P = 0.992), motor strength (P = 0.477), or comorbidities (P = 0.213) between readmitted patients versus not. Readmitted patients had a higher rate of preoperative radiation (P = 0.009). No statistical differences were found in operative time (P = 0.893), estimated blood loss (P = 0.676), length of stay (P = 0.720), discharge disposition (P = 0.279), and operative approach (P = 0.450). Furthermore, no difference was found regarding complications (P = 0.463), postoperative Karnofsky Performance Scale (P = 0.535), and postoperative Modified McCormick Scale (P = 0.586). Lastly, unplanned readmissions were not associated with OS (log-rank; P = 0.094) or LR (log-rank; P = 0.110). CONCLUSIONS In patients undergoing cervical spine metastasis surgery, readmission occurred in 15% of patients, 33% for surgical reasons, and 67% for medical reasons. Preoperative radiotherapy was associated with an increased rate of unplanned readmissions, yet readmission had no association with OS or LR.
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Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jeffrey W Chen
- Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
| | | | - Iyan Younus
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mahmoud Ahmed
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven G Roth
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leo Y Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Akinduro OO, De Biase G, Goyal A, Meyer JH, Sandhu SJS, Kowalchuk RO, Trifiletti DM, Sheehan J, Merrell KW, Vora SA, Broderick DF, Clarke MJ, Bydon M, McClendon J, Kalani MA, Quiñones-Hinojosa A, Abode-Iyamah K. Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis? J Neurooncol 2022; 156:329-339. [PMID: 34993721 DOI: 10.1007/s11060-021-03915-3] [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: 10/26/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.
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Affiliation(s)
| | - Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Anshit Goyal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jenna H Meyer
- Department of Neurosurgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | | | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Winocour SJ, Agrawal N, Wagner KM, Davis MJ, Abu-Ghname A, Shekher R, Raber MR, Bohl MA, Ropper AE, Reece EM. Vascularized Rib Bone Grafting: Indications, Techniques, and Clinical Outcomes. Semin Plast Surg 2021; 35:31-36. [PMID: 33994876 DOI: 10.1055/s-0041-1725985] [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: 10/21/2022]
Abstract
Pseudarthrosis is a difficult complication often seen in patients with complex spinal pathology. To supplement existing neurosurgical approaches to cervicothoracic spinal instrumentation and fusion, novel vascularized rib bone grafts can be utilized in patients at high risk for failed spinal fusion. In this article, we discuss the indications, benefits, surgical technique, feasibility, and limitations of using rib vascularized rib bone grafts to augment spinal fusion.
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Affiliation(s)
- Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nikhil Agrawal
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kathryn M Wagner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Rohil Shekher
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michael R Raber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael A Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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Viezens L, Dreimann M, Eicker SO, Heuer A, Koepke LG, Mohme M, Krätzig T, Stangenberg M. Posterior vertebral column resection as a safe procedure leading to solid bone fusion in metastatic epidural spinal cord compression. Neurosurg Focus 2021; 50:E8. [PMID: 33932938 DOI: 10.3171/2021.2.focus201087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cancer is one of the leading causes of death and greatly decreases a patient's quality of life. Vertebral metastases often lead to epidural spinal cord compression (ESCC) requiring surgical therapy. It has previously been shown that in patients with metastatic ESCC (MESCC), a surgical intervention leads to an improved outcome. Although the treatment paradigms in spinal metastases have changed and separation surgery followed by stereotactic radiosurgery is considered the best strategy, there are still cases in which 360° decompression with stabilization is indicated. In these patients, a proper bone fusion should be the treatment goal to guarantee good clinical results in extended survival times through progressions in oncological therapies. The aim of this study was to examine the safety and feasibility of posterior vertebral column resection (pVCR) in everyday clinical practice, achievement of bone fusion, and midterm outcome in patients with MESCC. METHODS All patients treated with pVCR due to MESCC between 2013 and 2020 were enrolled in this observational single-center study. Demographics, outcome parameters, numeric rating scale (NRS) score, Frankel grade, and Karnofsky Performance Scale (KPS) score were evaluated. Radiological images routinely acquired during follow-up were reviewed and screened for the presence of bone fusion. RESULTS Sixty-six patients were treated by eight surgeons. The mean follow-up period was 549 ± 739 days. At baseline, the average age was 64.4 ± 10.9 years. Reported NRS scores (preoperative 6.2 ± 1.7 vs postoperative 3.4 ± 1.6) and segmental kyphosis as measured on sagittal CT images (preoperative 13.5° ± 8.6° vs postoperative 3.8° ± 5.4°) decreased significantly (p < 0.001). In only 2 patients (3%), the Frankel grade worsened postoperatively, whereas in 12 patients (18.2%) an improvement was documented. The KPS score remained constant during the observation period (preoperative 73.2% ± 18.2% vs 78.3% ± 18% at last follow-up). Bone fusion was observed in 26 patients (86.7%) receiving CT more than 100 days after the index surgery. CONCLUSIONS pVCR is a reliable surgical technique in daily clinical practice, which proves to be beneficial in terms of short- as well as midterm outcome, as judged by the KPS and NRS. The overall improvement in the Frankel grade shows patient safety. A bone fusion was observed regularly in oncological patients undergoing pVCR. The authors therefore conclude that pVCR is a safe, fast, and efficient strategy to achieve stability and pain relief by achievement of bone fusion in cancer patients.
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Affiliation(s)
- Lennart Viezens
- 1Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, and
| | - Marc Dreimann
- 1Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, and
| | - Sven Oliver Eicker
- 2Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Heuer
- 1Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, and
| | - Leon-Gordian Koepke
- 1Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, and
| | - Malte Mohme
- 2Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theresa Krätzig
- 2Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Stangenberg
- 1Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, and
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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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8
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An Overview of Decision Making in the Management of Metastatic Spinal Tumors. Indian J Orthop 2021; 55:799-814. [PMID: 34194637 PMCID: PMC8192670 DOI: 10.1007/s43465-021-00368-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/29/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors. METHODS A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed. DISCUSSION Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment. CONCLUSION The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.
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9
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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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10
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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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11
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Sankey EW, Park C, Howell EP, Pennington Z, Abd-El-Barr M, Karikari IO, Shaffrey CI, Gokaslan ZL, Sciubba D, Goodwin CR. Importance of Spinal Alignment in Primary and Metastatic Spine Tumors. World Neurosurg 2019; 132:118-128. [PMID: 31476476 DOI: 10.1016/j.wneu.2019.08.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 12/12/2022]
Abstract
Spinal alignment, particularly with respect to spinopelvic parameters, is highly correlated with morbidity and health-related quality-of-life outcomes. Although the importance of spinal alignment has been emphasized in the deformity literature, spinopelvic parameters have not been considered in the context of spine oncology. Because the aim of oncologic spine surgery is mostly palliative, consideration of spinopelvic parameters could improve postoperative outcomes in both the primary and metastatic tumor population by taking overall vertebral stability into account. This review highlights the relevance of focal and global spinal alignment, particularly related to spinopelvic parameters, in the treatment of spine tumors.
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Affiliation(s)
- Eric W Sankey
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Christine Park
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth P Howell
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Isaac O Karikari
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Brown University, Providence, Rhode Island, USA
| | - Daniel Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA.
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12
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Ahmed AK, Pennington Z, Molina CA, Xia Y, Goodwin CR, Sciubba DM. Multidisciplinary surgical planning for en bloc resection of malignant primary cervical spine tumors involving 3D-printed models and neoadjuvant therapies: report of 2 cases. J Neurosurg Spine 2019; 30:424-431. [PMID: 30660123 DOI: 10.3171/2018.9.spine18607] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022]
Abstract
Effective en bloc resection of primary spinal tumors necessitates careful consideration of adjacent anatomical structures in order to achieve negative margins and reduce surgical morbidity. This can be particularly challenging in the cervical spine, where vital neurovascular and connective tissues are present in the region. Early multidisciplinary surgical planning that includes clinicians and engineers can both optimize surgical planning and enable a more feasible resection with oncological margins. The aim of the current work was to demonstrate two cases that involved multidisciplinary surgical planning for en bloc resection of primary cervical spine tumors, successfully utilizing 3D-printed patient models and neoadjuvant therapies.
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Affiliation(s)
- A Karim Ahmed
- 1Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Zachary Pennington
- 1Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Camilo A Molina
- 1Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - Yuanxuan Xia
- 1Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and
| | - C Rory Goodwin
- 2Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel M Sciubba
- 1Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and
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13
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Drakhshandeh D, Miller JA, Fabiano AJ. Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease. World Neurosurg 2018; 111:e403-e409. [PMID: 29275052 PMCID: PMC6022282 DOI: 10.1016/j.wneu.2017.12.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Spinal stabilization surgery is an integral part of the treatment of spinal metastatic disease. Bony fusion is the hallmark of spinal stabilization in non-oncology patients. Spinal oncology patients are unlikely to achieve bony fusion because of their overall prognosis and concurrent therapies. Stabilization surgery without fusion may be a reasonable approach for these patients. Literature evaluating the effectiveness of this approach is limited. The object of this study was to investigate the rate of instrumentation failure in patients undergoing posterior spinal instrumented stabilization without fusion for spinal metastatic disease. METHODS Data from consecutive cases of spinal surgery at our institution during an 81-month period were reviewed. Demographics, clinical notes, and computed tomography findings were recorded and used to evaluate instrumentation failures. Patients who underwent separation surgery that included laminectomy and posterior spinal instrumentation without fusion for spinal metastatic disease and had follow-up computed tomography scans >3 months postoperatively were selected for the study. RESULTS Twenty-seven patients were included in the study. Mean age was 64.85 ± 6.53 years. Nine patients were women. A mean of 1.61 ± 0.96 laminectomy levels was performed. A mean of 8.26 ± 1.48 screws was inserted. The mean postoperative discharge date was 5.07 ± 1.47 days. Mean follow-up duration was 12.17 ± 11.73 months. None of the patients had a change in instrumentation position, pedicle screw pullout, change in spinal alignment, or progressive deformity. No patient required reoperation or instrumentation revision or replacement. CONCLUSIONS Our experience suggests that instrumented spinal stabilization without fusion is an acceptable approach for patients with spinal metastatic disease.
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Affiliation(s)
- Dori Drakhshandeh
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - James A Miller
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, USA; Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Andrew J Fabiano
- Department of Neurosurgery, Roswell Park Cancer Institute, Buffalo, New York, USA; Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.
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14
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Kumar N, Patel R, Wadhwa AC, Kumar A, Milavec HM, Sonawane D, Singh G, Benneker LM. Basic concepts in metal work failure after metastatic spine tumour surgery. 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 2017; 27:806-814. [DOI: 10.1007/s00586-017-5405-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 11/07/2017] [Accepted: 11/19/2017] [Indexed: 02/07/2023]
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